Sources of Misunderstanding in Interviews With Psychiatric Patients. Sally Swartz. Child Guidance Clinic. University of Cape Town. Rosebank, South Africa.
Prolcssional Psychology Research and Practice 1992. Vol. 21. No. I. 24-29
Copyright 1992 by the American Psychological Association, Inc. 0735-7028/92/S3.00
Sources of Misunderstanding in Interviews With Psychiatric Patients Sally Swartz Child Guidance Clinic University of Cape Town Rosebank, South Africa Sources of communication failure in interviews with psychiatric patients are identified and analyzed. In both research and clinical practice, it is common to attribute these failures to the illness of the patient. The incoherence of some schizophrenic patients is an example. At times, however, communicative nonsuccess may be the result of interviewers' inattentiveness or preconceptions about the patient. Issues of power and control also affect the outcome of interviews. Interactions between clinicians and patients and the contribution of the clinical interview format to communicative nonsuccess in interviews are important points of focus for future research, and their study could be beneficial in clinical training programs.
Interviews with psychiatric patients are often bedeviled by misunderstandings. The incoherent speech of some psychotic patients makes ordinary conversation with them extremely difficult. Delusions create a complex task for the listener, who must try to engage in a world of which she or he has no knowledge. Anxiety and depression also interfere with patients' ability to converse, primarily by affecting concentration. However, misunderstandings in conversations with psychiatric patients are not always the result of mental illness, although this is often how they are explained (Chaika & Lambe, 1989; Swartz & Swartz, 1987). Misunderstandings are a frequent occurrence in all conversations (Grimshaw, 1989). All speakers have moments of incoherence, and remedial work when communication fails is a routine part of everyday talk (Levinson, 1983). There are times when patients' incoherence may reflect the episodes of interactional failure that characterize everyday conversation rather than mental illness. It is also important that cl inicians consider the part they themselves play when conversations go awry (Swartz, 1990). An attempt to elucidate sources of misunderstanding in clinical interviews is by no means a trivial task, because it is often on the basis of these interactions that diagnoses are made and interventions planned. This article will identify the source of some misunderstandings in conversations with psychiatric patients and illustrate these with examples drawn from clinical interviews. The first section identifies the role played by mental illness in patients' inability to communicate clearly, and the second discusses instances of miscommunication in interac-
tion not easily attributable to either clinician or patient. The third section examines conflicting needs of patients and clinicians in clinical interviews and the contribution of this to communication failure. A taxonomy of communicative nonsuccess in psychiatric settings will be constructed using Grimshaw's (1989) schema. Implications for clinical work and training will be explored. Where available, examples from recorded and transcribed interviews with psychiatric patients will be used to illustrate common sources of miscommunication. Unless otherwise stated, all interviews were conducted by me and were recorded during the patient's admission to a local mental hospital. In all cases patients gave permission for the interviews to be recorded and used for research purposes. For those patients considered to be too psychotic to have given informed consent, permission was asked for again at a later date. All identifying details have been eliminated from the examples to ensure anonymity. This article will not explore the complexities of interactions in which patients and interviewing clinicians come from different class or cultural backgrounds and therefore do not consistently have a shared knowledge of contexts (Grimshaw, 1989). The issue of racial and cultural perceptions and their effect on diagnoses made and interventions planned has been discussed by Fisher (1988), Fisher and Groce (1985), and L. Swartz (1991).
The Contribution of Mental Illness to Misunderstandings Incoherence
SALLY SWARTZ, MA (English), MSc (Clinical Psychology) completed her professional training in 1984. She is currently Senior Lecturer in Clinical Psychology at the Child Guidance Clinic of the University of Cape Town, where she trains intern clinical psychologists. She teaches clinical interviewing, psychotherapy, psychopathology and psycholinguistics courses, and maintains a clinical practice. THE AUTHOR THANKS Diana Cowan for access to some of the data used here and Leslie Swartz for technical assistance. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Sally Swartz, Child Guidance Clinic, University of Cape Town, Chapel Road, Rosebank, 7700, South Africa.
A common cause of communicative nonsuccess in psychiatric settings results from psychotic patients' incoherence or "thought disorder." This can be regarded as a deficit in speaker communicative competence, which implies the speaker's failure to produce interpretable signals, irrespective of the listener's competence and motivation to make sense of them (Grimshaw, 1989). Although clinicians occasionally produce incoherent sentences (Dahl, Teller, Moss, & Trujillo, 1978), they are likely to attempt to make themselves clear following cues from a puzzled audience. Psychotic patients remain incoherent 24
MISUNDERSTANDING IN PSYCHIATRIC INTERVIEWS
over extended periods of talk and also fail to repair when signaled to do so by the listener (Chaika & Lambe, 1989; Rochester & Martin, 1979). The following is an example of a psychotic woman speaking incoherently. This interview took place 3 days after B.'s admission to the hospital during an acute manic episode, and she is talking to me about a gynecologist she had wished to consult. (For ease of reading, conventional punctuation has been used throughout the examples used, with the following exceptions: italicized words indicate overlap; double parentheses indicate words that are indecipherable; and single parentheses indicate omitted text.) Example 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
B.: I wanted to see him desperately, so I rang him once, and I rang him twice, and I rang him three times. Did he come, he should have come, he should have made time, shouldn't he? S.: I don't know. Can you tell me a bit about B.: You 're interested in part of my story, aren't you? S.: Hmm B.: Shall we write it down now? S.: When was that? B.: Let's try and write it down. Let's try and write it down. ((. . .)) S.: Would you like to write on this? (gives B. paper and pen) B.: Alpha, beta, gamma, delta (writes this down), epsilon, epsilon, epsilon, bactrim, bactrim, bactrim. (B. writes her signature)
It is impossible to trace the connection between the failure to make contact with the gynecologist, which opens the dialogue, and the Greek alphabet and the antibiotic, bactrim, with which it ends. One can speculate that B., cued by my question "Can you tell me a bit about. . . ," imagines that I want to take a history from her and that she makes the connection between that and writing notes in a file. Once she has been given paper to write on, she scribbles, and then draws the letters of the Greek alphabet as she names them. Her request that we should write her story down seems to be directed at me: I should be taking notes, as other clinicians do.
Delusional Content of Talk Most ordinary conversational topics are structured in familiar ways, and this makes it possible for listeners to miss parts of what is being said and yet be able to predict what is coming (Levinson, 1983). If conversation becomes unpredictable for any reason and very little of it is redundant, the listener's task becomes difficult. Communicative nonsuccess may therefore arise when topics of conversation have unpredictable or bizarre content. This is all the more likely because delusional subject matter is often emotionally highly charged for the speaker and may hinder his or her ability to communicate clearly about it. The communicative nonsuccess of the following interchange illustrates these points. A fourth-year speech therapy student (P.) is interviewing a man with a long history of schizophrenic breakdowns (C.).
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Example 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
C.: I've been belittled right in the eye coz my mother can't get boyfriends. P.: Mmm. C.: She can't get a boyfriend and now because she can't get a boyfriend I mustn't get a girlfriend. P.: Mmm why what does she say to you? C.: Uh so close last time through the girl I was thinking about her eyes still and it happens every day, it happens uh every day. P.: What about her eyes? C.: It happens every day as soon as you make contact with the eye it has to ha- lose its contact. P.: (0.2) What about her eyes though? C: Her eyes? P.: Ja, you said you knew something about her eyes. C.: Yes—I said she had beautiful eyes. P.: Mmm C.: And (0.2) she put me uh and she put a habit in me. I then looked at her and it was all got uh uh it was all over—she jus' looked at me how she was still interesting. P.: Mmm B.: Look I can't be interviewed or anything, I can't.
In this interchange, C. makes a statement that appears to be part of a delusional system (Lines 13-15). P. does not ask for clarification of what C. has said, but repeats her preceding question, adding "though" to the end, as if C. has strayed from the topic without attempting to answer her. It seems likely that the content of Lines 13-15 was processed by P. as "noise" rather than a proper turn-at-talk, and this is the reason why she disregards it. C. buys time with the hearing check in Line 17 and appears to decide not to talk further about a subject that probably is anxiety laden for him. Line 20 is not truthful and is used to block P. from questioning him further about his beliefs. The interchange then becomes incoherent, perhaps as a result of anxiety, a hypothesis that seems to be confirmed by C.'s expressed wish to end the interview at that point.
Hallucinations Hallucinations are often a silent partner in conversations with psychotic patients. Auditory hallucinations affect concentration and turn-taking by interrupting. When they produce a verbal response, hallucinations also generate talk, the meaning of which is often obscure to the listener.
Mood Mood plays an important role in determining the outcome of conversations, primarily through its effect on attention and cooperative attitude. Patients with paranoid delusions clearly do withhold information at times. Aggression, which may be a response to anxiety and fear, or part of the illness for which the patient is being treated, also affects communicative success. Depression often makes patients give monosyllabic responses to questions intended to elicit elaborated accounts. Anxiety
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SALLY SWARTZ
may cause people to express themselves in ways that are confusing to the listener. Elation, which often goes hand-in-hand with pressure to talk, may also affect concentration and cooperation. For example, the playful intrusiveness of hypomanic patients may be disruptive to communication. The following three examples demonstrate how anxious, depressed, or suspicious mood in patients contributes to communicative nonsuccess. The following conversation took place with a woman who had been hospitalized during a manic episode. She had been interviewed several times before this occasion, but this is the first time she ventured to tell me of an event that affected her deeply. Example 3 1 A.: 1 don't know if you know exactly what I'm 2 getting at, but you know that I got- you 3 see um it's very unfortunate -um- you see 4 did I tell you that—I'm embarrassed, but 5 I'm going to tell you exactly what- um did 6 I tell you, you see that I had an affair 7 with a married ah—well he wasn't 8 married, he was only 25, I was 249 S.: Yes? 10 A.: Did I tell you he was married you see and 11 did I tell you that I got pregnant? 12 S.: No.
The embarrassment surrounding this event for A. disorganized her speech. She also contradicted herself (Lines 7-8), and at this point what she is trying to say is unclear. The prompt I gave her in Line 9 was an indication that I hoped clarity would come as she talked further. This is indeed what happened. Mrs. W. was admitted to the hospital with severe depression. She had difficulty with spontaneous talk. The following is an example of her brief and very general answers to questions. Example 4 1 2 3 4 5 6 7 8 9 10 11 12
S.: Can you tell me first of all, have you been depressed before? Mrs. W.: Yes, several times. S.: When first? Mrs. W.: I can't really remember when. Somewhere. It's so many years now it seems. S.: Hmmm. Mrs. W.: At times (0.2) with ah- with worry you know, about things like the future, the past and that sort of thing is on my mind and I get depressed.
F. was admitted to the hospital during a manic episode and was interviewed on the same day. Although he openly described his power to me at the start of the interview, when I began to question him more directly, he seemed to feel suspicious, and his responses contradicted his earlier statements. Example 5 1 2
S.: Tell me a bit about yourself. How would you describe yourself?
3 F: Ordinary, straightforward, bank um- power, 4 my own power. I'm just an ordinary guy 5 you know, I live my life outside.
F. appears here to have attempted to present himself as ordinary, but perhaps because of his psychotic state he mentions
power in spite of himself. It is an incoherent intrusion into an otherwise rather bland statement.
Interactional Failure and the Clinician's Contribution to Misunderstandings When patients are incoherent, the people with whom they interact are likely to become confused, and this confusion in turn generates further misunderstandings. Example 1 illustrates interactional failure arising initially from a patient's incoherence. My question "When was that?" refers back to the gynecologist and ignores two turns at talk that have introduced new subject matter. I also heard "Let's write it down" as B. wanting to write, and in retrospect this seems to be a misunderstanding on my part. I therefore contributed to the progressive incoherence of the dialogue, as a result of my own confusion. Example 2 illustrates a similar process. However, interactional failure sometimes results from clinician's assumptions about their patients. In the following example, communication breaks down partly because the interviewer assumes that the patient, a schizophrenic man, will attach unusual meanings to words. The context in which the following misunderstanding arose was a discussion of bad temper and physical altercations. Example 6 1 2 3 4 5 6 7 8 9
C.: 'Cos I don't like liberties. P.: Mmm. C: That's a liberty. P.: You don't want a liberty. C.: I don't, I don't like liberties. P.: Why not—don't you think it's nice to be free? C: (0.1) That's a liberty? P.: Mmm
C. is puzzled and confused by P.'s interpretation of liberty as freedom in this context, and given the context, the other common meaning, that of "taking liberties with" people, is more salient. Furthermore, C. says liberties and a liberty, both of which are likely to convey the meaning of personal intrusiveness. If he had meant freedom, he would probably have said "I don't like liberty." It seems that the confusion in this part of the conversation is attributable to the interviewer.
Clinical Interviews Taking a History Barrett (1988) has drawn attention to the extent to which case records truncate and medicalize information gleaned in interviews as part of the process of transforming people into patients. Throughout the world, admission, assessment, and diagnostic procedures define what is relevant knowledge and delete everything that falls outside of that frame of reference. Patients, however, are not party to the formats guiding assessments and have their own ideas about what is relevant to be said. The resulting confusion of goals often leads to communicative failure. Moreover, in hospital settings, clinicians are often busy and preoccupied with tasks to be completed in specific ways. This makes them potentially, although not invariably, inattentive or determined to impose their own structure on interactions.
MISUNDERSTANDING IN PSYCHIATRIC INTERVIEWS
In the following example, A., a manic patient, wants to talk at length about the origin of her illness. My anxiety to collect basic history data leads me to respond irrelevantly to what she has said. Example 7 1 A.: Because that's what hit me as a child. I 2 was too beautiful. I was born too 3 beautiful. I was the most beautiful 4 little girl, like a little doll. I know 5 one shouldn't rave about themselves but I 6 was always just chortling and laughing and 7 hugging and kissing everybody and my 8 father loved me too much. I think my 9 mother got jealous. She doesn't like 10 competition. She's the kind of woman who 11 can't take competition. So she had 12 competition from the sister from the camps 13 and from me so she stuck us together and 14 she bashed our heads together. Well I 15 didn't really bash the other one's head, 16 she was too strong. 17 S.: Where did you go to school?
The following example further illustrates the way in which conflicting goals in a clinical interview may lead to communicative failure. Mrs. W. makes clear her wish not to be interviewed. I need to interview her and cannot easily return on another day. Example 8 1 2 3 4 5 6 7 8 9 10
S.: How does it feel being here? Mrs. W.: Well it's ah-1 like being here except that I don't, not enjoying all this ah- interrogation that's going on around me. S.: Have you been having a lot of interviews and . . . Mrs. W.: Yes. S.: Does it make you feel worse to talk about it o r . . . Mrs. W.: Yes, I don't want to talk about it really. I just am, am anxious and worried. Everybody's veryS.: Have you got a family?
The communicative nonsuccess in this episode happens in Lines 9 and 10. At this point it becomes clear that Mrs. W. would like the interview to end. Preempting the possibility of her saying anything more specific about her interviewers, I interrupted with an unrelated question.
Mental Status Examinations Patients who have had many admissions to hospitals and who know the routine questions well may enter into the "game" of history taking and mental status examination, particularly questions designed to elicit psychotic symptoms, with sufficient knowledge of the kind of information being sought to be able to maintain some control over the course of the interview. This might be used either cooperatively, giving the clinician what she or he wants to hear, or obstructively. The importance of patients' familiarity with interviewing formats is that it gives them a relationship with an otherwise unseen, unspokenof body of knowledge and audience of scrutinizing clinicians. It gives them an awareness of the "gaze" of the scientist (Foucault, 1975). The following is an example of how this knowledge might be used by a patient to regain control in a situation
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of potential powerlessness. When I interviewed B. and failed to follow the normal interviewing format, she was noticeably disturbed. Example 9 1 B.: Why don't you ask me the right questions? 2 S.: Tell me what they are, then I'll ask you. 3 B.: Find out about orientation, eh.
Patients know that clinical interviews determine aspects of their treatment. Suspicion of staff and fear about both medication and incarceration often create a strong investment in playing down symptoms, and on occasion, this leads to a breakdown in the smooth exchange of information. Withholding information about psychotic symptoms is an obvious source of power for patients, but also a fertile site for the production of confusing communication. Examples 2 and 5 above are illustrations of this. Patients in the hospital settings in which I worked sometimes practiced routine mental-state examination questions with each other to obscure from clinicians the fact that they were deluded or having hallucinations. A., for example, knew what to try to avoid saying, and this is clear from the following comments made during my first interview with her. Example 10 A.: I jus want to get out of here, 'cos I don't feel happy. Not that I'm not well, I'm as well as I've been in my whole life, well, I've been happier of course, but you knowS.: How is your mood? Does it go up and down, orA.: No it's the same. I just want to be out of here.
In a later interview, A. describes her feelings about being in a locked ward of an institution. It is clear that she knows that she has a mental illness, which is not an admission that she was prepared to make while she was in a locked ward. Example 11 1 A.: I felt it was like a loony bin, 'cos half 2 the people are insane, and the other half 3 are almost unbearable. ( . . . ) ! didn't know 4 whose hands I was in, and I didn't know, I 5 thought I was in the government's hands, 6 and I didn't know how long I'd stay there. 7 I used to go to bed at night in a cell, 8 first I was in like a cell, with a 9 terrible fear at night, when will I get 10 out of here, and will they ever think I'm 11 normal, 'cos I'm not really very—I 12 mustn't say this (Laughs)—I'm not really 13 normal. (Laughs) I'm a bit cuckoo.
Patients may manipulate the course of an interview by withholding information about their symptoms. However, at times assumptions about their mental state, made before the interview place them in a situation of having little choice about how they are seen. In this example, a consultant psychiatrist asks A. how long she has been in the hospital.
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SALLY SWARTZ
Example 12 1 2 3 4 5 6 7 8 9 10 11 12
A.: I've been here for 2 days. Dr. T.: Are you ill? A.: No. Dr. T.: Why are you in a mental hospital if you're not ill? A.: Because my sister got the police to bring me here. Dr. T.: Why would she do a thing like that? A.: Because she wants me to be in hospital. Dr. T.: What are her motives? A.: I don't know. I've still got to find out.
This exchange is "successful" from the point of view of the interviewing consultant, who sought confirmation of "knowledge" he already has, namely, that A. is psychotic and therefore lacks insight into her condition. He knows that she is ill. He wants to know whether she thinks she is ill. Whatever she replies to these questions, she is trapped into confirming his diagnosis of her situation, which she does.
Role Reversals Clinicians have the power to withhold information or to obscure it, to be misleading, impolite, and to ask many personal questions. All these behaviors are routinely in the repertoire of clinicians, and in fact are the customary mode of interaction in many medical settings. Psychiatric patients frequently develop a startlingly similar repertoire, and their "rude," "inappropriate" and "intrusive" behavior is used to confirm a diagnosis. No matter how it is labeled, this inversion of roles in interviews is useful to patients as a source of locally established power, which may compensate temporarily for a more pervasive feeling of powerlessness. Furthermore, the mood of some psychiatric patients, as well as the unpredictable behaviors that result from their illnesses (including both verbal and physical aggression), combines to give them considerable power in interactions. It almost always results in communicative nonsuccess for the clinician, at least in terms of his or her overall goals for clinical interviews. In the next example, T. steps out of his patient role simply by persisting in asking personal questions. He had been hospitalized during a manic breakdown. Example 13 1 2 3 4 5 6 1 8 9 10 11
S.: 1 must just keep an eye on the time. I must leave at quarter past. T: Oh great we've got lots of time. How about talking about yourself some of it? S.: Well I actually T: OK, OKS.: need to find out what you're doing hereT: Sorry. S.: and how long you've been in. T: What's your star sign? S.: Sagittarius.
In this conversation T. succeeded in getting personal information out of me, despite my attempts at redirecting the conversation. He did this by ignoring my request that he talk about himself, even though I said I "need to find out," which implied that my request was related to a specific task. I mentioned
having only a little time to spend with him, and his reaction (Line 3) seemed to be a deliberate misunderstanding of the implication (Grimshaw, 1989). The outcome was successful for him, but not for me. Conclusion: Some Implications for Clinical Research and Practice Implications for Research There is ongoing debate about whether the communication failures shown by psychotic patients constitute a disorder of thought or language (Chaika & Lambe, 1985; Holzman, Shenton, & Solovay, 1986). The language productions of psychotic patients is a major site of research (Holzman, 1986). Identifying sources of communication failure in interviews with psychiatric patients opens a new area of study. This focuses on the interaction between patient and clinician and on its contribution to the genesis of misunderstandings. Narrowly focused research projects that concentrate attention on one aspect of language or thought disorder in psychotic patients and fail to take account of interactive processes are likely to perpetuate circularity in the debate about the nature of the problems involved. It may be useful, therefore, not to focus research too narrowly while basic descriptions of interactions with psychiatric patients are lacking.
Implications for Training Learning to communicate effectively in clinical interviews with all patients, including those who are psychotic, is a central task for psychologists in training. Clinical interviews have two major purposes: (a) to assess and diagnose the patient's psychiatric disorder and (b) to build a therapeutic relationship. At times, these goals may be at odds with each other and become a source of conflict. For example, a diagnostic skill is to learn to identify "tangentiality" or "loss of goal" in diagnosing schizophrenic thought disorder. The focus on formal aspects of language, rather than on content, has a long history in psychiatric practice (Littlewood, 1990). This may make the task of attempting to follow the gist of what is being said more difficult. The assumption that form is more important than content encourages an observing, rather than interactive, stance on the part of the interviewing clinician, and this may have a detrimental effect on the evolving therapeutic relationship. Moreover, the focus on the patient's speech productions clearly shifts attention from misunderstandings occurring for reasons other than the patient's mental illness and probably discourages remedial work in ongoing conversation. It is important therefore that clinical students be taught to identify the variety of causes for confusion in interviews with psychiatric patients. For this purpose, I have developed the flow chart in Figure 1 to provide a guideline for decision making. It is a modification of Grimshaw's (1989) taxonomy of communicative nonsuccess in ordinary conversation and represents sources of misunderstanding particular to psychiatric interviews. It does not demonstrate the complexities of context, nor does it show the compounding effects of successive confu-
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MISUNDERSTANDING IN PSYCHIATRIC INTERVIEWS Patient Incoherent
YES
Communicative Nonsuccess
NO
Patient Coherent But Deluded
YES
Communicative Nonsuccess
YES
Communicative Nonsuccess
YES
Communicative Nonsuccess
YES
Communicative Nonsuccess
NO
Patient Inattentive: Mood/ Hallucinations Interfere NO
Patient Uncooperative: Suspicion/ Conflicting Goals Interfere
NO Clinician Inattentive: Preconceptions/ Conflicting Goals Interfere NO
Communicative Success Figure 1. Sources of communicative nonsuccess in interviews with psychiatric patients.
sions in interaction. It summarizes the sources of misunderstanding described in this article. There are occasions when the incoherence of a psychotic patient makes effective communication impossible, but there are others in which careful exploration of the misunderstanding will lead to clarity. Furthermore, even incoherent psychotic patients have periods in which they communicate lucidly, and students should be alert to these. Awareness of ways in which interaction contributes to misunderstandings is a neglected diagnostic skill that deserves careful consideration from those involved with the preparation of students for work with psychiatric patients.
References Barrett, R. J. (1988). Clinical writing and the documentary construction of schizophrenia. Culture, Medicine and Psychiatry, 12, 265299. Chaika, E., & Lambe, R. (1985). The locus of dysfunction in schizophrenic speech. Schizophrenia Bulletin, 11, 8-15. Chaika, E., & Lambe, R. (1989). Cohesion in schizophrenic narratives, revisited. Journal of Communication Disorders, 22, 407-421. Dahl, H., Teller, V, Moss, D, & Trujillo, M. (1978). Countertransference examples of the syntactic expression of warded-off contents. Psychoanalytic Quarterly, 47, 339-363. Fisher, S. (1988). In the patient's best interest: Women and the politics of medical decisions. New Brunswick, NJ: Rutgers University Press. Fisher, S., & Groce, S. B. (1985). Doctor-patient negotiation of cultural assumptions. Sociology of Health and Illness, 7, 342-374. Foucault, M. (1975). The birth of the clinic: An archaeology of medical perception. (A. M. Sheridan Smith, trans.). New York: Vintage Books. (Original work published 1963). Grimshaw, A. D. (1989). Collegia! discourse: Professional conversation among peers. Vol. 32. Advances in discourse processes. Norwood, NJ: Ablex. Holzman, P. S. (1986). Thought disorder in schizophrenia: Editor's introduction. Schizophrenia Bulletin, 12, 342-346. Holzman, P. S., Shenton, M. E., & Solovay, M. R. (1986). Quality of thought disorder in differential diagnosis. Schizophrenia Bulletin, 72,360-371. Levinson, S. C. (1983). Pragmatics. Cambridge, United Kingdom: Cambridge University Press. Littlewood, R. (1990). From categories to contexts: A decade of the "new cross-cultural psychiatry." British Journal of Psychiatry, 156, 308-327. Rochester, S., & Martin, J. R. (1979). Crazy talk: A study of the discourse of schizophrenic speakers. New York: Plenum Press. Swartz, L. (1991). The politics of black patients' identity: Wardrounds on the "Black side" of a South African hospital. Culture, Medicine and Psychiatry, 15, 217-244. Swartz, S. (1990). Some methodological issues in the analysis of psychotic speech. Manuscript submitted for publication. Swartz, S., & Swartz, L. (1987). Talk about talk: Metacommentary and context in the analysis of psychotic discourse. Culture, Medicine and Psychiatry, 11, 395-416.
Received Novembers, 1990 Revision received July 24,1991 Accepted July 26,1991 •
