@million Medical Books K

Discourse and Mental Health
This book is the result of years of fieldwork at a public hospital located in an immigrant
neighbourhood in Buenos Aires, Argentina. It focuses on the relationships between
diversity and inequality in access to mental healthcare through the discourse
practices, tactics and strategies deployed by patients with widely varying cultural,
linguistic and social backgrounds. As an action-research process, it helped change
communicative practices at the hospital’s outpatient mental healthcare service. The
book focuses on the entire process and its outcomes, arguing in favour of a critical,
situated perspective on discourse analysis, theoretically and practically oriented to
social change.
It also proposes a different approach to doctor-patient communication, usually
conducted from an ethnocentric perspective which does not take into account
cultural, social and economic diversity. It reviews many topics that are somehow
classical in doctor-patient communication analysis, but from a different point
of view: issues such as the sequential organization of primary care encounters,
diagnostic formulations, asymmetry and accommodation, etc., are now examined
from a locally grounded ethnographic perspective. This change is not only
theoretical but also political, as it helps understand patient practices of resistance,
identity-making and solidarity in contexts of inequality.
Juan Eduardo Bonnin is Researcher at the Consejo Nacional de Investigaciones

Científicas y Técnicas (CONICET) and Professor of Discourse Studies at the
Universidad Nacional de San Martín (UNSAM). His latest book is Discurso
político y discurso religioso en América Latina (Buenos Aires, Santiago Arcos,
2013).
Cultural Discourse Studies Series
Series Editor: Shi-xu
Centre for Contemporary Chinese Discourse
Studies, Zhejiang University
A cultural-innovation-seeking platform in discourse and communication studies,

the Cultural Discourse Studies Series aims to deconstruct ethnocentrism in the
discipline, develop culturally conscious and critical approaches to human dis-
courses, and facilitate multicultural dialogue and debate in favour of research
creativity.
Discourses of the Developing World

Researching Properties, Problems and, Potentials of the Developing World
Shi-xu, Kwesi Kwaa Prah and María Laura Pardo
Israeli Discourse and the West Bank

Dialectics of Normalization and Estrangement
Elie Friedman and Dalia Gavriely-Nuri
Political Discourse as Dialogue

A Latin American Perspective
Adriana Bolívar

Voice, Inequality and Resistance in Medical Settings
Juan Eduardo Bonnin
For more information about this series, please visit www.routledge.com/Cultural-

Discourse-Studies-Series/book-series/CDSS
Voice, Inequality and Resistance
in Medical Settings
Juan Eduardo Bonnin

First published 2019
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2019 Juan Eduardo Bonnin
The right of Juan Eduardo Bonnin to be identified as author of this
work has been asserted by him in accordance with sections 77 and 78
of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval
system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested
ISBN: 978-1-138-57265-2 (hbk)
ISBN: 978-0-203-70192-8 (ebk)
Typeset in Galliard
by Apex CoVantage, LLC
Para Maia, Julia y Sole. Las quiero mucho.
Contents
List of figuresviii
Series forewordix
Acknowledgementsxi
Transcription conventionsxiii
Introduction 1
1 Voice, singularity and emergency: a discursive

perspective on linguistic inequality 12
2 Psychoanalysis in public hospitals: context as a

discursive problem 35
3 Invisible landscapes: diversity and the semiosis of space 66
4 Diagnosis and treatment: sequencing and exclusion 92
5 Resisting exclusion: patients’ tactics of

misunderstanding bureaucratic discourse 113
6 Speaking with the other’s voice: an attempt to

close the gap 132
7 Discourse and activism: dissent, protest and resistance 154
Epilogue 172
Index174
Figures
2.1 Gaze at the public level 43

2.2 Gaze at the private level 45
2.3 Gaze at the intimate level 49
3.1 Private sponsored sign at the Psychopathology building 67
3.2 Limited visibility of the outpatient service of mental health 67
3.3 Struggle of social actors to define the public space 74
3.4 Ideological debates on the hospital’s discursive landscape 75
3.5 Layered communication at the hospital’s landscape 76
3.6 Grassroots language policies at indigenous communities –
Courtesy of Virginia Unamuno and Lucía Romero 78
3.7 Heteroglossic repertoires of street vendors 80
3.8 Intra-linguistic diversity at the street 81
5.1 Statistical-epidemiological form used at Buenos Aires’
public hospitals 115
Series foreword
As globalization deepens into the new millennium, human cultures have not
become less, but more, divided. On the one hand, America continues to dominate
the international order – politically, economically, militarily and in many other
respects as well. On the other hand, most developing nations remain underprivi-
leged, excluded or else alienated, and they feel compelled to change the current
unfair global system and aspire to re-discover, and where necessary, re-invent,
their own voices and identities and to re-claim their own rights. To make matters
worse, the American-led West-centrism and consequently the plight of the rest of
world have more often than not been smoothed over.
At the same time, as multiculturalism spreads across the globe, the human
destiny has not become less, but more, shared, however. Cultural diversification,
the Internet and border-crossing have advanced human interaction, information
flow and above all socio-economic development. Along with these, too, however,
come for mankind all kinds of risks and threats, seen or unexpected. In this one
and the same world, peoples’ interests in well-being become ever more intercon-
nected, intertwined and interpenetrated. And yet the commonality of human
destination is far too often obscured or simply forgotten. Current mainstream
discourse and communication studies, despite its theoretical and methodological
achievements and beyond, have not been fully conscious and competent to take
up common cultural challenges alluded to above. West-centric and binary in the
main, it has too often ignored the cultural complexity, competition and common-
ality of human discourses and as a consequence has not only become an academic
monologue in itself but also overshadowed culturally alternative approaches.
It is with issues such as these that the Routledge Cultural Discourse Stud-
ies Series concerns itself and endeavours to bring them to the centre stage of
discourse and communication research, with a view to forging a culturally con-
scious, critical and creative form of discourse and communication scholarship.
At the meta-theoretical level, this series forays into: (a) how we as academics are
to combat West-centrism in society and scholarship, (b) how we are to enable
and enhance cultural coexistence, harmony and prosperity and (c) how we are
to identify, characterize, explain, interpret and appraise culturally divergent, pro-
ductive or competing discourses – not only of familiar, privileged and dominant
societies, but especially of less known, marginalized or otherwise disadvantaged
communities.
x Series foreword
There are a few theoretical, methodological and topical characteristics of the
series that are worthy of mention here, too. Firstly, it abolishes the conventional
and common binary notions of ‘text’ and ‘context’, ‘discourse’ and ‘society’,
‘representation’ and ‘reality’, the ‘micro’ and the ‘macro’, and re-unifies them
into one of an all-encompassing and dialectic whole. In this way, human discourse
becomes a multi-faced but integrated communicative event (or a class there of
named activity) in which people accomplish social interaction through linguistic
and other symbolic means and mediums in particular historical and cultural rela-
tions and moreover is recognized and highlighted as cultural in nature – cultural
in the sense that human discourses are not simply differentiated but diversified
and, very importantly, divided. Secondly, it is culturally grounded and continu-
ously self-reflexive, its perspectives dialectic and multiple, its data diversified and
historical and its conclusions dialogical and temporary. Thirdly, the series has set
upon itself the cultural-political tasks of exposing, deconstructing and neutral-
izing ethnocentrism on the one hand and developing, practising and advocating
locally grounded and globally minded principles and strategies of communication
research on the other hand.
In sum, this series publishes works that cross linguistic, disciplinary and cul-
tural boundaries and examines social and cultural issues in communication that
are of local and global significance. It aspires to be culturally pluralist, whether in
authorship, in publication content or in approaches. A cultural-creativity-seeking
platform in discourse and communication studies, to be sure, the Routledge Cul-
tural Discourse Studies Series will continue to deconstruct ethnocentrism in the
discipline, develop and practice culturally conscious and critical approaches to
human discourses, and propel intercultural-intellectual dialogue and debate in
favour of research innovation and advancement. Ultimately, it aims to contribute
to human cultural coexistence, harmony and prosperity.
Shi-xu
Acknowledgements
This book would not have been possible without the friendship and profession-
alism of many colleagues who have been supportive and patient with me and
my quirks. I would like to thank the following for their help in the process of
researching and writing:
Mental healthcare patients and professionals who struggle every day to give
the best of themselves against all institutional odds. Although I cannot name the
participants of this research for reasons of confidentiality, I hope that the time
spent together has been as enriching for them as it was for me. I especially want
to thank JD and EF for our long talks and discussions, and for their generosity.
Dr. Shi-xu, for encouraging me to participate in the Journal of Multicultural
Discourses first and, now, in the Routledge Cultural Discourse Series, proving with
his hard work and intellectual commitment that integration and dialogue should
not be limited to geographical comfort.
Adriana Bolívar, Daniela Lauria, Cecilia Magadan, Florencia Rizzo and Mila-
gros Vilar for their patient reading and suggestions on early drafts of the first
chapters of this book.
Virginia Unamuno, whose friendship, erudition and wisdom have accompa-
nied every step of the research process from the beginning.
Colleagues from around the world who helped me to think (and to write)
the ideas and texts presented in this book and, hopefully, to develop a voice of
my own in this strange language: Natalie Schilling, Janet Fuller, Howard Giles,
Srikant Sarangi, Luci Nussbaum, Robert L. Ivie and William B. Ventres. Teun
A. van Dijk and Jan Blommaert have been more supportive and important than
they think.
Other colleagues helped me throughout the process of researching, reading
and writing. In conferences, classrooms and bars, I discussed the concepts and
realities expressed in this book with Elvira Arnoux, Isolda Carranza, Roberto
Bein, Lia Varela, María Laura Pardo, Alejandro Raiter, Martha Shiro, Florencia
Alam, Maia Migdalek, Mónica Baretta, Lucía Godoy, Julia Otero, Cecilia Tal-
latta, Lucía Romero and the whole team of the Centro de Estudios del Lenguaje en
Sociedad, our young CELES at the University of San Martín. I have also shared a
lot with Cecilia Cross, Marta Novick and the rest of the compañer@s of our brave
CITRA at CONICET-UMET.
xii Acknowledgements
Catalina Connon copyedited the manuscript with patience and understanding,
for which I am deeply grateful. Samantha Phua and Katie Peace guided me wisely
through the whole editorial process at Routledge.
On a personal note, I want to thank to my parents, Rolo and Estela, and my
brothers, José, Julio and Santiago, who supported my earlier decisions, no matter
how risky they looked.
Finally, and most importantly, I want to thank the family I am building with
my wife Soledad and my daughters Julia and Maia: their patience and joy for liv-
ing are the main reason to try to understand this world and do our best to make
it better.
Transcription conventions
Adopted from Richards, Keith & Paul Seedhouse (Eds.). (2005). Applying Con-
versation Analysis. New York: Palgrave Macmillan.
[ indicates the point of overlap onset

] indicates the point of overlap termination
= inserted at the end of one speaker’s turn and at the
beginning of the next speaker’s adjacent turn, it indicates
that there is no gap at all between the two turns (3.2) an
interval between utterances (3 seconds and 2 tenths in
this case)
(.) a very short untimed pause
word underlining indicates speaker emphasis
::: indicates lengthening of the preceding sound
– a single dash indicates an abrupt cut-off
? rising intonation, not necessarily a question
! an animated or emphatic tone
, a comma indicates low-rising intonation, suggesting
continuation
. a full stop (period) indicates falling (final) intonation
CAPITALS especially loud sounds relative to surrounding talk
°° utterances between degree signs are noticeably quieter than
surrounding talk
°° °° considerably quieter than surrounding talk
(()) comments on non-linguistic behaviour
(guess) indicates transcriber doubt about a word
Introduction
This book explores the complex and often contradictory relationship between
discourse and inequality in mental healthcare settings. Although the terms
invoked here are frequently used in academic research, I will use a slightly differ-
ent approach from the usual one.
The book also aims to contribute theoretically and methodologically to
re-thinking and imagining new problems for discourse analysis – without adjec-
tives or brand-identifications initials – which are no longer in the mainstream
agenda. I will argue that intellectual workers from non-European, non-(North)
American societies have something new to say, as they have traditionally been pas-
sive reproducers of dominant, ethnocentric theories. Latin American Discourse
Analysis has developed many voices which have only recently begun to participate
as equals in the global scenario of academic research.
Jorge Luis Borges, arguing with traditional nativist writers in Argentina who
demanded gauchos and tangos everywhere, concluded a famous essay on “The
Argentine Writer and Tradition” (1951) as follows:
I repeat that we should not be alarmed and that we should feel that our
patrimony is the universe; we should essay all themes, and we cannot limit
ourselves to purely Argentine subjects in order to be Argentine; for either
being Argentine is an inescapable act of fate – and in that case we shall be so
in all events – or being Argentine is a mere affectation, a mask.
I believe that if we surrender ourselves to that voluntary dream which is
artistic creation, we shall be Argentine and we shall also be good or tolerable
writers.
(Borges 1951/1962: 178)
Just as Borges wrote regarding literature, Latin American researchers too have
been nurtured by many traditions; not just one dominant trend of discourse
analysis, one system of grammatical description or one “school” of social theory.
We have translated, commentated, written and read whatever we have been able
to, sometimes from an orthodox and other times from a heterodox standpoint.
We have communicated with each other a lot through specialized journals such
2 Introduction
as the Revista Latinoamericana de Estudios del Discurso, Signo y Seña and Discurso
y Sociedad.
Nowadays we are increasingly participating in the global dialogue of discourse
analysis, not as accomplished students of dominant theories, but as researchers
with a sense of identity and something new to say regarding language, institu-
tions and – more importantly – speakers. This need to say the unexpected, which
we will call an “act of voice”, can be traced in the recent work of Latin American
researchers in the field of DA.
Discourse analysis in Latin America

We can distinguish two kinds of articulation between Latin America and DA. The
first can be described as “Discourse Analysis in Latin America” and the second
as “Latin American Discourse Analysis”. In the former, the region serves as an
agenda of topics for DA. It is the geographical region where specific issues, prob-
lems and corpora are collected to analyze from mainstream perspectives, either
“Critical Discourse Analysis” (e.g. Wodak & Meyer 2001) or “French School of
Discourse Analysis” (e.g. Maingueneau & Charaudeau 2002). We can say that
these works are Latin American in their topics and political motivations but Euro-
pean in their theoretical-methodological approach.
There are a few available studies in English that review the literature of DA
in LA, such as Bolívar (2015, 2018), Pardo (2010, 2016), Carranza (2015)
and Arnoux and Bonnin (2015). In the latter paper, we observed that the DA
research agenda in our region is intertwined with politics in one of two ways.
The first, which we call analysis of political discourses, considers a sphere of activ-
ity (the exercise of public speech as regulated by institutions which provide a
framework for the democratic struggle for power) and the genres, practices and
strategies produced within it. The second addresses the ideological orientation
of meaning-making through discourse, as it reveals social practices, processes and
actors as positioned within a given social field. It is thus political in nature, but
not in expression.
We have called this approach political analysis of (other) discourses (Arnoux &
Bonnin 2015: 560–561): a perspective on the social use of language which not
only inquires into its specificity (such as pedagogical discourse, religious discourse,
etc.) but also observes how it deals with conflict, shapes social representations,
produces and reproduces identities, regulates the linguistic space or intervenes in
shaping, replicating or transforming both political entities and power relation-
ships. From this perspective, every discourse is linked to the dynamics of the
field in which it is produced, but also to broader social processes and contextual
aspects which are, in one aspect or another, political. We do not distinguish (as
in Fairclough 1992) Critical from Non-Critical Discourse Analysis: as every dis-
course is political, every analysis must be critical to be meaningful. Otherwise, it
is just a clever exercise in textual description.
Introduction 3
Latin American discourse analysis

The research agenda of DA in LA, briefly outlined in the previous section, is not
extensive enough to assume the existence of a Latin American perspective on
discourse analysis. On the contrary, as de Melo Resende (2010) states:
Colonialism of knowledge in Latin America has led to the formation of a

body of researchers competent in understanding and applying theories and
methods but who are petrified at their own ideas, as they always need to be
legitimated by foreign thinkers.
(de Melo Resende 2010: 193)
What defines a Latin American perspective in discourse analysis is not a school,

theoretical framework or shared grammar, but an attitude towards data and the-
ory. On the one hand, with regard to theory, we have an unprejudiced view of
different trends of discourse analysis, text linguistics, sociolinguistics, linguistic
anthropology, conversation analysis, pragmatics, etc. Latin American discourse
analysts converse with worldwide theories, but do not apply them (Raiter &
Zullo 2005; Raiter 2002). Even in cases of apparent application, as is the case of
glottopolitics (Arnoux 2008), there is a systematic and creative “misreading” of
European ideas which achieves legitimation among the conservative local aca-
demia but also dares to create new research agendas and theoretical concepts (de
Melo Resende 2010). On the other hand, with regard to data, there is optimism
of will despite the pessimism of reason, which prioritizes the singularity of data
over the homogeneity and generalization of theory. Bolívar’s (2018) qualitative
approach to large, multi-genre, broad-dialogical corpora is an example of appre-
ciation of data singularity over theoretical-methodological recipes which recom-
mend homogeneity of data.
Latin American Discourse Analysis is not a theoretical framework but a com-
munity. Its influence on the research which led to this book was significantly
outside books or journals: it happened at conferences, seminars and bars. In this
section I will briefly introduce some of the most influential work in this perspec-
tive, not as a systematic theory, but as a climate of ideas and concepts which
helped co-conduct the research presented in this book and, incidentally, are not
well known to non-Spanish speakers.
Glottopolitics
With an interdisciplinary perspective on discourse analysis and a practical orienta-
tion to change situations of inequality in the access to civil rights, E. B. N. de
Arnoux embraces critical analysis of linguistic ideologies in grammars, textbooks
and other academic genres to define inclusive strategies for secondary and higher
education. This articulation of discourse analysis and pedagogical practice, of
description and action towards social change, permeates the work of Arnoux
4 Introduction
and her colleagues not only in the classical research agenda of DA but also in the
definition of a whole new field: glottopolitics.
Glottopolitics studies interventions in the linguistic public space and the lin-
guistic ideologies which they activate, insofar as they are a product of social
relationships and power structures at different contextual levels: local, national,
regional and global. In contrast to classical language policy and planning research,
glottopolitics has a broad scope including non-canonical actors and discourse
spaces which are cornerstones of the establishment, questioning, replication and
transformation of political entities (Arnoux 2011: 162). Data are thus necessarily
heterogeneous: from the creation and semiotic organization of cultural institu-
tions (such as the Museu da Língua Portuguesa in São Paulo, or the Museo del
libro y de la lengua in Buenos Aires), to the networks of public-private economic
and political interests in the promotion, regulation and commodification of Span-
ish and Portuguese, including regional systems of legislation and regulation (Bein
2017). From this perspective, linguistic instruments (orthographies, grammars,
dictionaries, style manuals and rhetoric treatises), teaching texts and discussions
about language are discourses which take part in the process of shaping national
and global identities (Arnoux 2016; Arnoux & Lauria 2016; Lauria forthcoming;
Rizzo 2016, 2017).
Interactional discourse analysis

Although often quoted, Bakhtin’s (1982) interest in dialogism and polyphony
is often reduced to the presence of the other’s voice represented by only one
speaker in his own (written) texts. In this sense, A. Bolívar proposes a change of
focus “from text in contexts to people in events” (Bolívar 2010). For the case of
political discourse analysis, in addition to the foundational distinction between
“us” and them” she proposes the inclusion of “you” as a relationship constitutive
to politics that leaves room for cooperation and dialogue.1
Bolívar defines dialogue as “the primary condition of discourse and human
existence” (Bolívar 2010: 218). As a primary difference with other views on dia-
logue, which draw from Bakthin’s (1982) concept of dialogism, Bolívar is not
only interested in “theoretical” interaction as an abstract possibility, or in a textu-
alist view of “voices” as represented in one speaker’s own texts. Rather, the main
focus in her approach to discourse is on the people who produce, introduce or
evoke those voices. Dialogue is thus not simply a discursive strategy or a theo-
retical need but an effective kind of bond between participants. Influenced by
P. Freire’s (1992) concept of “hope as an ontological need”, Bolívar states that
“only in dialogue with others can we attain autonomy and freedom” (2010: 219).
Her analytical deconstruction of Hugo Chávez’ discourse of polarization and
its effects in the destitutionalization of democracy gained public attention as a
political practice of public criticism and denunciation. Her interactional discourse
analysis does not intend to be a “school” but a source of inspiration for differ-
ent kinds of DA in LA. As one of the founders and main promoters of the Latin
American Association of Discourse Studies (ALED) since 1995, she has taught and
Introduction 5
explained DA throughout our continent. She edited the Latin American Jour-
nal of Discourse Studies (RALED) from 2000 to 2017, thereby participating in
the definition of the research agenda, theoretical discussions and methodological
innovations in the field (cfr. Shiro 2012, 2014; Bolívar & Shiro 2015).
The epistemology of the known subject

Vasilachis de Gialdino’s proposal is to rethink discourse analysis from scratch by
criticizing its epistemological basis and methodological biases. Despite mutual
differences, Vasilachis de Gialdino (2006, 2009) considers mainstream paradigms
in social research as representatives of the same Epistemology of the Knowing Sub-
ject, which makes an ontological difference between the researcher (the subject
who knows) and the researched (the object of study), who is featured as a passive
object under scrutiny, whose own assumptions, values and ideas are valid data but
not legitimate theory.
Vasilachis de Gialdino’s Epistemology of the Known Subject uses a different point
of departure by drawing an ontological distinction between essential and existen-
tial identity. The former is shared by all human beings as the source of personal
dignity, thus guaranteeing equal human dignity to every person. The latter, on
the contrary, is distinct to every individual as she/he is conditioned by her/his
cultural, social and economic context (Vasilachis de Gialdino 2009: 20).
Although this proposal does not take into account cultural difference between
subjects, it enables what Shi-xu (2005) identifies as “aculturalism” to be combat-
ted, because cultural difference is not viewed as a barrier between classes of peo-
ple but as a constitutive feature of identity in its existential dimension. The other
dimension, the essential one, allows for dialogue as an activity between equals,
thus avoiding the view of the other as radically different. Vasilachis de Gialdino’s
discourse analytical practice has therefore focused on recognizing the known sub-
ject’s dignity through different kinds of methodological strategies: ethnographi-
cal interviews with people living in the streets, discourse analysis of written press,
laws, juridical and political discourse (Vasilachis de Gialdino 2003, 2007, 2013).
Co-labour research
Despite its success in other social sciences, collaborative research has had little
impact on discourse analysis. One sensitive area is multilingualism and education,
as research in this field usually seeks to change an unequal state of affairs. V. Una-
muno’s work with indigenous communities focused on this goal through what
she calls “investigación en colaboro”, “co-labor research” (Ballena & Unamuno
2017). Through this terminological innovation, her proposal is to emphasize the
interpersonal commitment among all the social actors committed to the entire
research process, based on three principles: 1) every research project is the result
of a debate among different actors (scholars, indigenous teachers, community
leaders, students, etc.) about why to do the project and what for; 2) teams are
formed of different kinds of researchers (academic, non-academic; indigenous,
6 Introduction
non-indigenous; etc.) with equal status, among whom tasks and responsibilities
are distributed; and 3) direct and indirect benefits from the research are distrib-
uted among the actors involved in it, including co-authorship of scientific articles.
Unamuno’s work on bilingual intercultural communication (Unamuno 2014,
2015) is characterized by an articulation between ethnographic sociolinguistics
(Codó, Patiño-Santos & Unamuno 2012) and critical language policy and plan-
ning (Unamuno & Bonnin 2018). Co-labour research with wichi and qom com-
munities in El Chaco, Argentina, enabled the reformulation of public policies
and institutions thanks to sociolinguistic and discursive data and analysis. From
her perspective, language revitalization is a process which involves an ideological
dimension and an unprejudiced practical approach to literacy, technology and
formal and non-formal education while recognizing the agency and creativity of
local actors in creating, implementing and evaluating their own language policies
and politics of language (Unamuno 2015).
Discourse and poverty

Unlike previously discussed approaches to LADA, Pardo’s (2008) innovation
is theoretical as well as methodological. On the one hand, language is viewed
simultaneously as a replicator of inequality and domination and as a giver of
“the freedom of being conscious of the experience of life. Language is a restorer,
healer and substantial axis of any potential social change” (Pardo 2011: 13, my
translation). From this standpoint, she has analyzed juridical discourse (Pardo
1996), discourses of and from extreme poverty (2008) and discursive features
of psychosis, especially in the case of poor people (Pardo & Buscaglia 2008,
2017). This line of work had an institutional consequence in the creation of
the Red Latinoamericana de Análisis del Discurso de la Pobreza (REDLAD), a
regional network of researchers especially interested in poverty and inequality
(Pardo Abril 2012).
On the other hand, Pardo (2011) developed a descriptive method with a
strong linguistic basis which establishes relationships between grammatical cat-
egories and discourse-semantic categories. This synchronic-diachronic method for
the linguistic analysis of texts has been successfully applied to analyzing discourses
in psychotic patients (Díaz Alegría 2016), legal and administrative discourses
(Marchese 2011, 2016) and life stories of poor people (Marchese 2013)
Perspective and contents of this book

This book is the result of five years’ fieldwork at a public hospital located in an
immigrant neighbourhood in Buenos Aires, Argentina. My research focused on
the relationships between diversity and inequality in access to mental healthcare
through the discourse practices, tactics and strategies deployed by patients with
widely varying cultural, linguistic and social backgrounds. It was conducted as a
co-labour action research, which helped change communicative practices at the
hospital’s outpatient mental healthcare service. The book focuses on the entire
Introduction 7
process and its outcomes, arguing in favour of a critical, situated perspective on
discourse analysis, theoretically and practically oriented to social change.
This book proposes a different approach to doctor-patient communication in
mental healthcare settings, which is usually conducted from an ethnocentric per-
spective which does not take into account cultural, social and economic diversity.
Studies are generally designed from the point of view of conversation analysis,
which does not contemplate structural and contextual conditions for commu-
nication. Other studies adopt a Critical Discourse Analysis perspective which
projects an ethnocentric view regarding meaning and interaction onto different
cultures and values. Here, I will review many topics that are somehow classical
in doctor-patient communication analysis, but from a different point of view:
issues such as the sequential organization of primary-care encounters, diagnostic
formulations, asymmetry and accommodation, etc., are now examined from a
locally grounded ethnographic perspective and historical and cultural discourse
analysis. This change is not only theoretical, but also political, as it helps under-
stand professionals’ and patients’ practices of resistance, identity-making and soli-
darity in contexts of inequality.
The organization of the book is a proposition – an invitation to visit a specific
time, place and people through discourse and interaction. Chapter 1, “Voice,
Singularity and Emergency: a discursive perspective on linguistic inequality”, pre-
sents the general theoretical standpoint of my research. It does not introduce a
“theoretical framework” but three areas of interests which seem to be left out of
the current agenda of mainstream discourse analysis: singularity and difference,
as features which explain the emergence of the unexpected in everyday communi-
cation; voice, as a form of understanding the articulation of individual biographies
with social structures and institutions in the making of every person’s commu-
nicative repertoire; and emergent discourse, as a term which enables meaning-
making to be understood without resorting to structural, over-deterministic
concepts such as “discursive formation”. The aim of Chapter 2, “Psychoanaly-
sis in public hospitals: context as a discursive problem”, is to problematize the
issue of context in professional-patient communication from our perspective on
discourse analysis. Thus, situation appears to be shaped not only by the histori-
cal and political processes of institutionalization of psychoanalysis and psychiatry
in public health in Argentina but also by local professional-patient interaction.
Analysis shows the intertwining of both aspects in the semiotic construction of a
context which is structurally ambiguous to all participants. Chapter 3, “Invisible
landscapes: diversity and the semiosis of space”, analyzes the “silent discourses”
in public healthcare: the silent diversity that is not publicly visible, even though
it is present at hospitals. Through discourse landscape analysis, ethnographic
observation and in-depth interviews, I describe a double process of privatiza-
tion of public communication and invisibilization of linguistic diversity in the
public space even though it exists in indigenous and immigrant people who go to
the hospital. The aim of Chapter 4, “Diagnosis and treatment: sequencing and
exclusion”, is to analyze the conflict between psychiatry and psychoanalysis as it
emerges in admission interviews in an outpatient mental healthcare service. The
8 Introduction
analysis focuses on the development of diagnosis in the conflicting expectations
of professionals and patients regarding diagnosis and treatment, which usually
results in patients being rejected implicitly. Exclusion is thereby not only a matter
of social structure or institutional logic but also an unexpected consequence of
small interactions. Chapter 5, “Resisting exclusion: patients’ tactics of misunder-
standing bureaucratic discourse”, complements Chapter 4. It analyzes the resist-
ance tactics and strategies used by patients to confront the medical status quo and
institutional inclusion and exclusion criteria. Many mechanisms of subordination
and control, such as statistic-epidemiological forms and inquiries about country
of origin and migrant status, among others, are reverted by patients as resources
for resistance by “misplacing” legal categories, answering “more than the ques-
tion”, etc. Chapter 6, “Speaking with the other’s voice: an attempt to close the
gap”, endeavours to understand the efforts made by patients and professionals
(whether psychoanalysts or psychiatrists) to understand each other in an attempt
to accommodate to each other’s voices, sociolects, assumed knowledge and cul-
tural backgrounds. This analysis shows a reciprocal, solidary effort but, at the
same time, prejudices and stereotypes which stand in the way of intercultural
communication. Overall, the aim of this chapter is to show constructive efforts at
building intercultural communicative practices, in both their strengths and their
weaknesses. Chapter 7, “Discourse and activism; dissent, protest and resistance”,
offers an explicit political analysis of current debates in mental healthcare in
Argentina. In a sense, its aim is to argue against some Euro-/(North)American-
centric political theories which place protest in opposition to dissent. I will argue
that in contexts of profound inequality, such as Argentina, protest and resistance
are part of a repertoire of discourse activism. This theoretical definition is based
on different movements and actors that participated in the debate of the New
Law of Mental Health in Argentina and the resistances to its actual application.
Note
1 The relationship between first and second person is much more prominent in FSDA
than in ACD studies. In this regard, the work by Sigal and Verón (1986) and Verón
(1987) has been very influential on political discourse analysis in Latin America.
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1 Voice, singularity and
emergency
A discursive perspective on
linguistic inequality
I believe that once we move beyond thought and enter the “path of action”,
our thinking changes and, hopefully, sharpens. We learn to ask better, more
profound questions. New and better theories and ideas arise because now our
theories are grounded in direct experience and not simply in thoughts about
thoughts.
To me, perhaps surprisingly, the end or goal of theory is no-theory (. . .)
Theories are very much like the Buddhist yana, the vehicle or raft that carries
us across a river. Once we arrive at the other side of the river, Buddha asks,
“Do wise people carry the raft with them – or do they leave it tied to the
shore?” (Eugene Burger, www.magicbeard.com/presentations-essays/a-few-
thoughts-about-theory.php)
I’m a pessimist because of intelligence, but an optimist because of will.
(Antonio Gramsci)
From fieldwork to theory

I will begin this chapter with one of my field notes from 2012:
Excerpt 1. Field notes (2012)

Today’s first interviewee was a young Paraguayan man who spoke Spanish,
but there was something odd about him. In the referral letter, the psychia-
trist writes: “X has difficulties in expressing himself”. X came to Argentina
five months ago because treatment in Paraguay was too expensive and here
it is free.
Y: Are you taking your medication, you don’t forget to do it?

X: I forget a lot of things . . . I get dizzy
Y: Do you forget to take your medication?
X: I feel shaken, no, I don’t forget medication
Y: Who helps you with medication?
X: No, no one, I remember everything
Y: You remember? Do you have a medication plan?
X: No, I remember . . . the paper
Voice, singularity and emergency 13
Y: Do you have a paper?
X: No, in my head
Y: Here the doctor says that you have difficulties speaking
X: ¡El casteiano! (in Spanish!)
(. . .)
Y: How do you feel about getting psychological treatment? (4 or 5 seconds
pause) What do you imagine a psychological treatment is like?
X: Hmm . . . in my head . . . I think about something and it happens ((he
points to his chest, his breath is agitated again))
(Field notes, 2012, p. 6)
In this example, X is a young man from Paraguay who is talking about his first
psychotic outbreak. Like many patients who visit the outpatient service, he often
crosses the border with his family, sometimes living in a villa (urban shanty town)
in Buenos Aires and sometimes in his rural hometown in Paraguay. He cannot
be described as a “migrant” in traditional terms but as a deterritorialized speaker
(Jacquemet 2005). X comes from a small town in north-eastern Paraguay, which
is mainly monolingual in Guaraní (Gynan 2007).
The outcome of the interview can be interpreted as successful from the point of
view of the Hospital’s psychologist, Y: she has identified the event which triggered
the first psychotic break, she has identified his object of fixation (a large bottle of
water that X always carries in his backpack) and she has even identified an interest-
ing personality trait of alexithymia, or inability to describe one’s own emotions.
The latter conclusion is explicitly presented as a quote from a previous physi-
cian, a very frequent diagnostic device which adds new diagnostic information
to the conversation from an indisputable source. As this kind of contribution
has a preference for the agreement, the other participant(s) are strongly inclined
to acknowledge what has been formulated. To disagree with such a diagnostic
device can be perceived as face-threatening, the more so in an asymmetrical con-
text such as a medical encounter. Thus, it requires strong motivation to produce
such an act of voice that attempts to overcome a context which is both unequal
and asymmetrical: doctor vs. patient, professional discourse vs. lay discourse, local
vs. foreign, urban vs. rural, Spanish vs. Guaraní. X’s act of voice is unexpected
because it shows that mental healthcare is based on a monolingual conception of
the population and a monoglossic representation of language: for public health-
care providers, it is unimaginable that someone would demand mental health-
care at a public hospital without being a fully competent Spanish speaker. As
the healthcare system operates on a territorial basis, its imagined geography is
that of the modern Nation-State: the equation between territory, population and
language permeates linguistic policies in healthcare (Unamuno & Bonnin 2018).
To X, in contrast, something different is at stake: the possibility of being admit-
ted as an outpatient. What is at stake is his right to mental healthcare: his right to be
accurately diagnosed and treated. That is why his dispreferred, impolite reply is nec-
essary, though inappropriate. He is pointing out the unequal valuation of his way
of speaking and the dangers of a clinical interpretation of a sociolinguistic reality.
14 Voice, singularity and emergency
This example illustrates the kind of phenomena I analyze here, which include
inequality, monoglossia and power relationships but also heteroglossia, emergent
discourse and voice making. The case of X shows the need to articulate discourse
analysis with sociolinguistics in order to understand new forms of linguistic ine-
quality in public healthcare settings.
A critical stance towards Critical Discourse Analysis

Critical Discourse Analysis (CDA) was severely criticized in its early years for dif-
ferent reasons, mainly because of its extremely dense theoretical repertoire which
has a weak correlate in its “fuzzy” analytical model (Widdowson 1995, 1996,
1998). It has also been accused of being ideologically biassed towards a priori
interpretations of language in context, thereby privileging some interpretations
(usually related to power relationships, domination and ideology) and discard-
ing others which are equally possible (Schegloff 1997). From an epistemological
point of view, this means replacing the ideological frame of other social actors by
the analyst’s own (Verschueren 2001), with the difference that the researcher’s is
presented as objectively truthful (Blommaert 2005: 33). Breeze (2011) offers a
comprehensive summary of critiques to CDA.
From the perspective of Cultural Discourse Studies (Shi-xu 2015, 2016),
the main problem encountered in CDA theory and practice is the pair Univer-
salism/Aculturalism (Shi-xu 2005: 44–48). This means on the one hand that
some key concepts, such as “text”, “talk”, “ideology” or “power”, are treated
as objectively given and universal. Therefore, theory, methodology, descriptive
methods, etc. are presented as general, notwithstanding their particular origins,
within a particular research project, with a particular set of data, in a particular
historic and cultural space and time. The omnipresence of Systemic Functional
Linguistics (SFL) as the default descriptive tool for written, oral or multimodal
discourses in the most heterogeneous cultural contexts is perhaps the best illus-
tration of universalism as a central problem of CDA. Despite Halliday himself
(who explicitly presents his work as a “grammar of English”, cfr. Halliday &
Matthiessen 2004: 4), CDA embraces it as “one of the major contemporary
linguistic theories” (Chouliaraki & Fairclough 1999: 49). By detaching general
theory from specific data that made it possible, SFL and its various developments
(such as the Appraisal Theory introduced by Martin 2004a) are applied non-
critically as universal tools for analyzing intercultural communication, especially
in Latin America. For a more general criticism of the use of SFL in CDA, cfr.
Mathiessen (2012).
On the other hand, Universalist discourse in scholarship entails a lack of inter-
est in culture, which is reduced to a stereotyped, essentialist conception of a
homogenous, static system of representations and beliefs that is homogeneously
distributed among its members. From this perspective, culture is a source of
difference and problems between people and not viewed as a source of mutual
enrichment and learning from and with the other (Shi-xu 2005: 47; Unamuno &
Bonnin 2018).
In a more recent, harsher account of CDA, Shi-xu also includes a political-
academic evaluation of CDA’s practice as a colonialist form of knowledge which
excludes alternative visions and innovations, especially from the developing
world, by consecrating “western worldviews, values, concepts, models, analytic
tools, topics of interest, and so forth, as universal and exclusive standards and,
aided by (US-)western corporate financing and publishing, indexing and market-
ing, international travel and teaching” (Shi-xu 2015: 1).
More polite, but also critical of the lack of cultural analysis in CDA, Blom-
maert (2005) finds three main problems. The first is the “linguistic bias in CDA”
(Blommaert 2005: 34), specifically the use of SFL as guarantee of scientificity.
From a political perspective, this means adopting English grammar to apply it to
every language in any circumstance. In a more general sense, this bias produces a
restricted view of discourse as text, specifically written text, even when discussing
sets of oral data. The second problem Blommaert finds in mainstream CDA is
its closure to particular kinds of societies: “highly integrated, Late Modern, and
post-industrial, densely semiotised First-World societies” (Blommaert 2005: 35).
Such a restricted empirical field is presented as the base for CDA’s universalist
approach to discourse, in a typical example of hegemonic ethnocentrism which
is adopted by many Third-World scholars who should be combatting it instead.
Finally, the third criticism to CDA is its closure to a particular timeframe, the
present. This lack of “sense of history” (Blommaert 2005: 37) produces either
an account of the here-and-now of the analyst’s own society, which appears as an
ever-changing “historical” time, or an isolated analysis of discourse events which
is presented as detached from any historical process.
A third set of criticisms to CDA is provided by Bolívar (2018), who focuses on
the problem of dialogue, both as an object of analysis and as an actual possible
horizon for democratic discourse. In this sense, a detailed analysis of N. Fair-
clough’s work tracks increasing interest in the issue of dialogue both as a theoreti-
cal problem and as an actual exchange between speakers. However, Bolívar notes
that Faiclough (2003) describes dialogue as a utopic normative practice which
has no correlate in actual discourse practices and their actors. A second criticism,
extended to the work of other CDA representatives, refers to the somehow meta-
phorical reading of Bakhtin’s concepts of “dialogism” and “voice”, which are
only analyzed as represented in texts: in empirical terms, dialogue is only analyzed
as it appears in monologue. She proposes to change the focus “from studying
texts, and voices of the people in texts, to the actual people that communicate
expecting a response, and who are responsible for making the choices of the
voices that are included and/or excluded in the dialogue” (Bolívar 2018: 35).
A proposal: singularity, voice and emergent discourse

The theoretical standpoint of this book emerged from data analysis, dialogue
among peers and extensive reading and writing (another form of dialogue). My
main preoccupation is to understand the regularity of social practices and ideol-
ogy by including – rather than deleting or ignoring – the singularity of people
and events. This tension between structure and event, between regularity and
singularity, is constitutive of my perspective on discourse and the way I position
myself towards other perspectives in DA.
As a perspective, it is not a theoretical framework or “theory” but rather an
epistemological attitude towards the discursive reality and people involved in the
research process. As in Gramsci’s famous expression, it is an act of “optimism of
will” rather than a systematic development of the “pessimism of reason”.
I will develop this attitude in three claims that aim to maintain discursive sensi-
tivity to everyday aspects of communication which are usually overlooked under
the more evident consequences of hegemony and power relationships. These
aspects “redistribute power without necessarily struggling against it” (Martin
2004b: 183) in a constant movement and displacement of meanings which allow
for creativity, community, solidarity and, ultimately, change.
Firstly, I will argue that every discursive event is a potential happening (acontec-
imiento). In other words, every act of communication which follows regular pat-
terns in terms of genre or ideology also contains the possibility of breaking with
this regularity, becoming an extraordinary discursive event. This possibility is not
just an exception, but the condition for regularity; therefore, there is no reason
to privilege ordinary over extraordinary discursive events. On the contrary, the
exceptional utterance often enables better understanding of the regular, expected
discourse.
Secondly, I will maintain that the characterization of participants needs to
consider the individual’s biography, feelings and emotions as they shape their
voice. To CA, participants are defined by interaction as it proceeds, as characters
animated only through the conversation. More recent reflection on institu-
tional discourse adopts only structurally defined roles to characterize partici-
pants (cfr. Heritage & Clayman 2010). To CDA, on the contrary, speakers
are social actors who are equivalent to other social actors in a similar position,
whether by ideological, social structure or institutional reasons. In both cases,
participants are defined by their regularities as belonging to a class of partici-
pants, and individual differences are deleted from analysis. To me, on the con-
trary, individual biographies related to (but not determined by) social structure,
institutional organization and historical processes enable better understanding
of discursive agency and the contingent dimension of social meaning through
voice making.
Finally, I will argue that discourse is an interactional emergent developed
through actual communicative experience. In this sense, the existence of socially
distributed symbolic resources to produce meaning in concrete cultural contexts
(Shi-Xu 2005: 19) does not mean that this distribution is coherent, stable and
over-determinant to the individual. We will argue, following V. N. Voloshinov
(1929), that these regularities are developed by individuals through socializa-
tion and interaction as an emergent repertoire of discursive resources. As a con-
sequence, I will argue with mainstream notions such as “discursive formation”
or “order of discourse” to propose a more dialogical notion of discourse as an
interactional emergent.
Singularity: the unexpected dimension of discursive events
Discourse analysis, in my understanding, is analyzing semiotic data (predomi-
nantly linguistic in my research) as contextualized and embedded in a specific
context. This embeddedness, however, is usually described from a deterministic
point of view which projects over any given situation structural roles and insti-
tutional features defined a priori. Thus, any interaction in a medical setting is
“medical discourse”, “doctor-patient communication”, etc. From this perspec-
tive, every utterance, as a singular emission, is an instantiation, an example of
a pre-existent order of discourse or discursive formation determined by social
structure.
One particularly successful concept coined to link the singularity of the utter-
ance to the regularity of social structure and history is the “discursive event”. The
concept of “discursive event”, as defined by N. Fairclough (1995), comprises
three interrelated components: a text, which is to be described; a discourse prac-
tice of production and interpretation, whose relationship with the actual text is
to be interpreted; and a social practice, whose realization as a discourse process
is to be explained (Fairclough 1995: 96–98). The individual text and the act of
producing it is of little interest, in this proposal, beyond illustrating a series of
similar texts integrated into discourse practice. Even though Fairclough himself
has pointed out repeatedly that “people have a capacity for agency and for act-
ing in ways that are not expected or conventional” (Fairclough 2006: 27; cfr.
Fairclough 1992), this capacity is seen as an exception, not a constitutive dimen-
sion of every discursive event. Furthermore, when describing this “capacity”, it
is understood as “mixing discourses, genres or styles from different orders of dis-
course, or mixing different and conventionally incompatible discourses, genres or
styles from the same order of discourse” (Fairclough 2006: 27). This concept of
“interdiscursive hybridity”, however, assumes the existence of distinct objective
totalities (the “orders of discourse”), on the one hand, and autonomous people
somehow detached from them who are able to discern, adopt and mix (or not)
their components, on the other.
We can read a contradiction in this argument: people disappear from discursive
theory as it focuses on “orders of discourse” and their components, “discourses,
genres and styles” (Fairclough 2006: 26). Each of these terms is defined and ana-
lyzed without reference to the human agents who make them possible, by using
mitigation resources which are usually critically analyzed in CDA studies (Billig
2008). However, when theory appears to be over-determinant in its description
of hegemony, people re-appear as responsible for agency and change. In terms
of the epistemology of the known subject (Vasilachis de Gialdino 2009), people
are objectified when describing the hegemonic effects of orders of discourse and
subjectified as manipulators of those very same orders to leave argumentative
room to hope for a change.
On the other hand, French theories of discourse have studied the single act of
production or enunciation of an utterance because of the contextual parameters
that it involves: an individual act of enunciation deictically anchored in a dialogic
situation of a speaker (me) addressing to a second person (you), within a certain
space (here) in a given time (now) (cfr. Kerbrat-Orecchioni 1981). Maingueneau
(2004, 2014) proposes a discursive model of the relationship between text and
context, distinguishing the communicative situation (which he considers “some-
how exterior to the text” and characterizes through Hymes’ (1972a) SPEAKING
model of speech events) and the enunciative scene (scène d’énonciation). This
concept, which is very influential in Latin America, consists of three components.
Firstly, an “enclosing scene” (scène englobante) which corresponds to regularities
which are typical of a “type of discourse” defined by the social sphere in which it
is produced: political discourse, religious discourse, juridical discourse, etc. Sec-
ondly, these spheres have a distinctive set of institutional discourse genres which
constrain not only choices regarding topic, style and structure but also roles,
legitimate circumstances of use, etc. These constraints are called “generic scene”
(scène générique). However, the two scenes are not directly observable in any
given text, as they are a set of rules that define a class of texts, but not a specific
text. Every concrete text creates a scenography (scénographie) which is the actual
discursive representation an actual text gives of its own conditions of enunciation.
As a consequence, two texts belonging to the same generic scene may stage dif-
ferent scenographies: “preaching in a church, for instance, can be staged through
a prophetic scenography, a conversational scenography, and so forth” (Maingue-
neau & Angermüller 2007: 33).
Although strategies of each text are considered, especially in what Maingue-
neau (1999) calls “self-constituting discourses”, the link between scenography
and both the generic and enclosing scenes remains unclear. The latter two seem
to belong to an abstract set of rules which cannot be observed either directly nor
indirectly, because we only have scenographies in actual texts. As such, they are
supposed to operate in the production and interpretation of texts but from a posi-
tion which seems unsustainable to us. In the first place, because of the interest in
“constrained corpora that are not conversational” (Mainguenau & Angermüller
2007: 33), even in contradiction with the “dialogical principle” of defining dis-
course “by the manifold presence of other discoursers, virtual or effective”. This
idealistic vision of dialogue – extensively criticized by Bolívar (2018) – coincides
with an explicit privilege of theory over data: “ ‘facts’, as a rule, are considered to
be the product of a construction and the emphasis is placed on the conceptual
coherence of the investigation” (Maingueneau & Angermüller 2007: 39).
As a conclusion, both Fairclough and Maingueneau (as representatives of main-
stream discourse analysis – CDA and French school – especially in Latin America)
accept the meaningfulness of singularity in discourse. However, it remains a theo-
retical claim which is subordinated, in practice, either to the regularities of social
practices or to the theoretical consistency of the analysis. When analyzed, the
role of singularity is the exception to the rule, thus accepting the existence of a
set of abstract rules formulated elsewhere, independently of people speaking in
concrete events.
Drawing from these criticisms, in this book I adopt a different angle: discursive
events always have the potential to be exceptional; there is an exceptional dimen-
sion to every event. They are not regular by following a set of rules (either an
“order of discourse” or an “enclosing” and a “generic” scene) but by avoiding
breaking it. What constitutes the rule is not that it is being followed, but that it
is not being broken. Hence the relevance of understanding every event from the
point of view of singularity: although a physician conducts tens of consultations
every day, every patient has a distinct experience of those consultations. Even for
the doctors, the thoughts, looks, feelings and words of every consultation pro-
vide the possibility of an exceptional event, even if that possibility is not realized.
We can track the same intuition to one of the last writings of M. Pêcheux
(1984/1988), who reflected on the problems of integrating discursive events
(événements) into broader social phenomena:
The notion of “discursive formation” borrowed from Foucault has too often
drifted toward the ideas of a discursive machine of subjection fitted with an
internal semiotic structure and therefore bound to be repetitive. At the limit,
this structural conception of discursivity would lead to an obliteration of the
event through its absorption in anticipatory overinterpretation.
One should not pretend that any discourse would be a miraculous aero-
lite, independent of networks of memory and the social trajectories within
which it erupts. But the fact that should be stressed here is that a discourse,
by its very existence, marks the possibility of a destructuring-restructuring of
these networks and trajectories. Any given discourse is the potential sign of a
movement within the sociohistorical filiations of identification, inasmuch as
it constitutes, at the same time, a result of these.
(Pêcheux 1988: 648)
This call for the uniqueness of the event should not draw our attention out of
its common features with other events, because interaction actually (re)creates
those rules. Social sanction of “appropriate” and “inappropriate” communicative
conduct exists, but in the words and actions of participants. And research shows
that these sanctions cannot be interpreted as a stable set of abstract rules, but as a
constant generation and negotiation process (cfr. Chapters 5 and 6).
All too often, discourse analysis tends to maintain an over-determined concep-
tion of discourse that overshadows the exceptions, individualities and counter-
discourses. It is true that these exceptional events are rarely visible, especially in
institutional settings. But when they do emerge, they agitate social discursivity
because they violate the rules of the practice of discourse. They defy expectations
and, in doing so, enable better understanding of them. The singularity of events
leads to deeper comprehension of the regularity of discourse practices (Bonnin
2011, 2012).
We can therefore differentiate between ordinary discursive events, which emerge
through naturalized discourse processes mediating the reproduction of social
practices through actual texts (Fairclough 1995: 133); and extraordinary discur-
sive events which, defying the conventional rules of discourse practices and the
expectations of participants, de-naturalize these processes and draw attention –
both from contemporary actors and analysts – to the construction of meaning in
specific cultural, social and historical conditions.
Discourse analysis of voice
Discourse analysis is imbued with the tensions of certain social science concepts
which are formulated in other fields of research and therefore cannot be mechani-
cally transposed to discourse studies. This puts at risk discourse analysis and, even
more importantly, the kind of contributions it can make. One of these tensions,
inherited from structuralism and already deconstructed by J. Derrida (1967),
opposes society to individual, rule to exception, and structure to event. As rela-
tional terms, each of them helps to define and understand the other, yet under-
standing the relationship between them remains a problem. For example, critics
of some versions of CDA stress the problem that arises when the first term in these
oppositions is focused on. Thus, authors such as Widdowson (1998), Schegloff
(1997) and Slembrouck (2001) accuse CDA of having an overdetermining view
of discourse and society, in which the former is only a tool for dominating and gen-
erating “false consciousness”. On the other hand, critics of the post-structuralist
conversation analysis approach to language, such as Blommaert (2005) and
Chouliaraki and Fairclough (1999), criticize it as an individualistic, spontaneous
post-modern point of view that has no more than merely case-descriptive value.
Between the two extremes, human agency behind discourse and conversation
seems to be obliterated from analysis or lost in the opposition between “text” and
“context”. Following Shi-Xu (2016), I understand discourse as human discourse,
which needs to be addressed both in holistic and cultural terms, thereby integrat-
ing communicative regularities and singularities rather than obliterating one or
the other. To achieve this integration, we need to understand human agents as
both individuals and social actors. The concept of voice will enable us to do so.
There has been much research on this concept in recent years, particularly fol-
lowing Hymes’ (1996) illuminating statement:
In my own mind I would unite the two kinds of freedom in the notion of
voice: freedom to have one’s voice heard, freedom to develop a voice worth
hearing. One way to think of the society in which one would like to live is to
think of the kinds of voices it would have.
(Hymes 1996: 64)
To Hymes, voice enables two forms of freedom: negative, which helps the
individual to overcome denial of opportunities for linguistic (or discursive) rea-
sons; and positive, as language can be the source of creation and satisfaction.
Both dimensions define voice as a product of the tension between individual and
society, or text and discourse, as it is a product of both restriction and creation.
This concept of voice, however, is usually stripped of this creative, singular
dimension. Blommaert (2008), for example, proposes the concept of voice to
explain that:
whenever we open our mouths, we not only use and re-use the words of oth-
ers, but we also place ourselves firmly in a recognizable social context from
which and to which all kinds of messages flow – indexical aspects of meaning,
conventional (i.e. social, cultural, historical, etc.) links established between
communication and the social context in which it takes place.
(Blommaert 2008: 428)
This conception of voice as a series of typifiable semiotic regularities which

index a social context and a social persona enables reconstruction of socially avail-
able representations of both speakers and ways of speaking (cfr. Chapter 5; also
Agha 2005). Although this interpretation is widespread, it is often a consequence
of a restrictive interpretation of Bakhtin (1981, 1986). However, Bakhtin’s origi-
nal text proposes a wider understanding of “voice”, which is much closer to
Hymes’:1
The novel can be defined as a diversity of social speech types (sometimes

even diversity of languages) and a diversity of individual voices, artistically
organized. The internal stratification of any single national language into
social dialects, characteristic group behaviour, professional jargons, generic
language, languages of generations and age groups, tendentious languages,
languages of authorities, of various circles and of passing fashions, languages
that serve specific sociopolitical purposes of the day, even of the hour -(each
clay has its own slogan, its own vocabulary, its own emphases)- this internal
stratification present in any language at any given moment of its historical
existence is the indispensable prerequisite of the novel as a genre.
(Bakhtin 1986: 262–263)
The issue of “individual voices” is usually addressed from the point of view of
social voices.2 Agha (2005), for instance, uses deixis analysis to show that individ-
uals are only “textually individuated discursive figures that are typified through
a system of person deixis as biographic individuals of some kind” (Agha 2005:
45). In a similar vein, the French theory of énonciation (e.g. Ducrot 1984) long
ago established the linguistic nature of the individual in discourse as a mere semi-
otic figure built with words. Following this line of thought, my own work (cfr.
Chapter 5) also relies on voice as an indexical form of constructing social personae.
Yet there still is a place for individualistic understanding of voice as a singular
act of speech, an individual act of agency which is unexpected and yet potential
in every utterance (Bonnin 2011). As Shi-xu (2005: 33) points out, it is an opti-
mistic vision of discourse and, especially, of the people who make discourse their
capacity of agency and will to change.
I understand an act of voice as saying the unexpected: an extraordinary dis-
cursive event produced by an individual thanks to her/his social and personal
biography. This opens at least two possible lines of argument. The first refers
to communicability. These acts of voice are rare, often because they are almost
unintelligible, just as psychotic discourse is unintelligible from outside its own
internal logic. Pure voice – pure individuality – is thus pathological, inasmuch
as pathology is (also) discursive. The second refers to the source of this voice: it
is not a sui generis act of an individual, but the result of an individual biography
which navigates through social practices. This social trajectory is thus what mat-
ters to understand how a repertoire is constructed and, consequently, how a voice
is conformed.
Focusing on the biography of speakers, i.e. their singular trajectories over a
regulated social space, there is no opposition between individual and society,
as the former is social, but the latter only exists embedded in every single per-
son. The individual is thus a point of view on the society in general (Ferrarotti
1991), the result of many networks of relationships which, day after day, human
groups constitute, join and abandon (Mallimaci & Giménez-Béliveau 2006).
The personal experience is thus “a highly individualistic version of collective
experience that does not determine me, but certainly conditions me” (Tognon-
atto 2003: 202).
In this book, the methodological, general focus on people’s voice in discourse
practices helps to keep open the possibility of change from and for the individual
as social actor. At the same time, the modern State governs individuals as mem-
bers of a class. In this tension, in the unequal relationship between voice and
discourse (Bonnin 2012), the individual tends to lose, as voices are differently
valued (Hymes 1996). Therefore, the individual will attempt to enrichen his/her
repertoire with available prestigious social discourses: bureaucracy, medicine, etc.
(cfr. Chapter 5).
In this regard, if we assume that discourse is not merely something pre-existent
to speakers that is just “incorporated”, but a polyphonic and heteroglossic real-
ity in constant movement, we need to examine how it is developed as emergent
discourse.
Emergent discourse is/in interaction

Usual quotes of Bakhtin’s work in DA are often at the service of different –
even contradictory – arguments, especially in some approaches which rely heavily
on the early structuralist work of M. Foucault (notably his 1969 Archaeology of
Knowledge). Much of the deterministic, top-down analysis which is frequent in
this kind of research is built on a Foucauldian view which theoretically recognizes
agency and resistance but only analyzes power and domination. In the same vein,
it usually embraces a dialogic concept of discourse yet analyzes monologic cor-
pora of texts.
As noted by Bolívar (2018), this is a contradiction between theoretical state-
ments and analytical practice. Two of the main names in CDA have made state-
ments which are quite close to my point of view: “[discourse] is constitutive
both in the sense that it helps to sustain and reproduce the social status quo, and
in the sense that it contributes to transforming it” (Fairclough & Wodak 1997:
258). And, more recently, “critical sociolinguistics and discourse studies are
interested in the way discourse (re)produces social domination, i.e. power abuse
by one group over others, and how dominated groups may discursively resist
such abuse” (Wodak 2016: 369). However, when discussing actual sets of data,
only reproduction of dominance and power relationships is shown. Although
there is explicit interest in change and dialogue, few data are systematically ana-
lyzed in this regard (cfr. Wodak 2002; Wodak et al. 2009), and interaction is still
overlooked.
The adoption of Foucault’s (1969, 1970) more structural work is made mainly
through the concepts of “discursive formation” and “order of discourse”. Both
are very close, as they define a set of rules governing what people can say in a
given historical juncture. The former, which is much more usual among French
discourse analysts (cfr. Mainguenean & Charaudeau 2002), is “a system of dis-
persion” defined by its regularity, constituted by of a set of “rules of formation”
of utterances (Foucault 1969/2004: 41–42). The latter, more usual in CDA
studies (cfr. Wodak & Meyer 2001; Fairclough 2006), is defined as “a certain
number of procedures” aimed at controlling, selecting, organizing and produc-
ing discourse (Foucault 1970/1981: 52). In both cases, the concepts of “dis-
cursive formation” and “order of discourse” appear as the top-down explanation
for individual subjection to social rules for producing and interpreting discourse.
Even when human agents are considered, they are also treated as external (and
as such, able to use it as a tool) and, paradoxically, constituted by those orders:
“text producers have nothing except given conventions of language and orders of
discourse as resources” (Fairclough 1995: 8).
I believe this structural conception of the relationship between people and
discourse production may be understood through the same criticisms that were
made in the beginnings of structuralism by V. N. Voloshinov (1929), one of
the less known early modern theorists of language and ideology. Often dimin-
ished as a mere pseudonym of M. Bakhtin, recent research has demonstrated
(in fierce controversies) the originality and force of his work (Bota & Bronckart
2011). Voloshinov’s core critique to Saussurean linguistics can be summed up
as follows:
At the basis of the modes of linguistic thought that lead to the postulation of
language as a system of normatively identical forms lies a practical and theo-
retical focus of attention on the study of defunct, alien languages preserved
in written monuments.
(Voloshinov 1929/1972: 71)
This rejection of language-as-system is a radical point of view which is echoed

by current theories of “emergent grammars” (Hopper 1987) and, more impor-
tantly, critical views on grammar as a complete and fully accessible system avail-
able to speakers. In Hopper’s terms:
we need to question the supposition of a mentally representated (sic) set of

rules, and to set aside as well the idea (. . .) that speakers possess an abstract
linguistic system ready and waiting to be drawn upon – accessed! – in case
they should ever need to speak.
(Hopper 1987: 155)
Following this idea, Ochs, Schegloff and Thompson (1995) directly confront any
traditional grammar (including Halliday’s SFL) as being simply a linguist’s pro-
duction rather than an accurate description of language as it is (in interaction):
“the interactional matrix of grammar requires a different understanding of what
should enter into a linguistic description and/or a different model of linguistic
structure. We do not aim to integrate into them; we aim to transform current
understandings of them” (Ochs, Schegloff & Thompson 1995: 24).
In this regard, the linguistic-textual bias noted earlier privileges “the finished
monologic utterance (. . .) All its methods and categories were elaborated in its
work on this kind of defunct, monologic utterance or, rather, on a series of such
utterances constituting a corpus for linguistics by virtue of common language
alone” (Voloshinov 1929/1972: 72). As a consequence, despite claiming an
empirical approximation to discourse through textual analysis, and a materialist
approach to social reality:
the monologic utterance is, after all, already an abstraction (. . .) Any mono-
logic utterance, the written monument included, is an inseverable element
of verbal communication. Any utterance – the finished, written utterance not
excepted – makes response to something and is calculated to be responded
to in turn.
(Voloshinov 1929/1972: 72)
It is only in this continuous, generalized, social interaction that discourse

exists; not as an abstract discursive formation – a set of rules which dictates “what
can and must be said” (Pecheux 1975) – but as a concrete series of competences
and ideological meanings which on the one hand, are developed through the
individual’s social trajectory, but on the other hand, are regulated, legitimated
and repressed by actual social interaction in actual social contexts. People do not
internalize a discursive formation or order of discourse already structured, just as
they do not internalize an already existent grammar. On the contrary, we develop
our own grammar and repertoire through the process of socialization. We are
born multilingual and develop monolingual (Unamuno & Nussbaum 2017), and
“structural features making up linguistic repertoires bear no inherent linguistic
affiliation but only external cultural labelling” (García & Otheguy 2015: 644).
In the same way, we are all discursively plural and develop ideology through time
and interaction. Over time and interaction, ideological and discursive specializa-
tion occurs, and we become a “subject” both through our individual trajectory
and social criteria of (in)correctness, power, legitimacy, etc. Being “right wing”,
or paraguayo, or speaking “medical discourse” are a posteriori labels of which
the goal is to socially normalize and unify what appears, to actual people, as the
“natural” development of their own lives and ways of speaking (i.e. voice).
Just as the idea of “emergent grammar” argues with a conception of “gram-
mar” as a complete and established system which is “apprehended” and “interior-
ized” by users, the idea of emergent discourse that I propose denies the existence of
an abstract and stable corpus of ideological meanings and enunciative positions,
described as a “discursive formation” or “order of discourse”, which shape what
a given person can and must say and think. Instead, I assume that ideology and
discourse are developed over time and through interaction, following the com-
municative trajectory of speakers themselves. It is not a totality to be interiorized
but an individual development which is socially judged and evaluated through
actual interaction:
Language acquires life and historically evolves precisely here, in concrete

verbal communication, and not in the abstract linguistic system of language
forms, nor in the individual psyche of speakers.
(Voloshinov 1929/1972: 105)
Discourse is thus neither “social” nor “individual”, but interactional: it

is produced and reproduced in actual exchanges between speakers. It is also
emergent: not an abstract, more or less systematic ideological a priori, but an ever-
developing repertoire which only exists through concrete events of interaction.
Every utterance is a potentially exceptional discursive event, as I have defined it.
Unlike mainstream discourse analysis, I argue that change, resistance and
agency are not exceptions but constitutive dimensions of every utterance, as the
unique person producing it has her/his own voice, developed through his/her
biography by constituting his/her own emergent discourse.
This is not a naïve conception of individuals as completely free speakers who
make rationally calculated choices. On the contrary, every early choice and social
response narrows future ones: a child who is told to remain silent while the
teacher speaks will keep that regulation as an interactional rule for that kind of
genre. She/he will also learn about roles in institutions and power relationships.
However, this does not mean that she/he will never be able to talk again when
the teacher is speaking, but it will take a very good subjective reason to break the
silence and to produce such an unexpected act of voice.
In the analysis of empirical data in this book, my focus will be on both aspects
of discourse emergence: the social norms that regulate options, and the acts of
voice that defy, circumvent or play with them.
Sociolinguistics and discourse analysis:

new approaches to inequality
After five decades of strong empirical evidence and several theoretical systematiza-
tions, sociolinguistics has developed a set of well-established claims: language vari-
ation is correlated with sociological variables (Labov 1966). Language use indexes
particular values of one or more contextual dimensions (Silverstein 1976). Mem-
bership in a speech community generates social norms of appropriateness of speech
and social meaning (Hymes 1972b; Gumperz 1972). These statements have
become, at least theoretically, part of (socio)linguistic common sense. As an emer-
gent of a “modern bureaucratic industrial society that increases the importance of
communication processes” (Gumperz & Cook-Gumperz 1983: 2), this theoretical
corpus is also embedded in specific historical conditions. Therefore, there is a seri-
ous risk, pointed out by Blommaert (2009), in the use of a modern repertoire of
scientific knowledge to understand post-modern realities. In the case analyzed by
Blommaert (2009), modern sociolinguistics seeks coherent language varieties tied
to stable identities and territories. However, this approach is scarcely prepared to
understand polyglot repertoires built by mobile subjects through a deterritorialized
world of post-modern (or late-modern) communication (Jacquemet 2005: 261).
During the past decade, a new way of thinking about relationships between lan-
guages and societies – sometimes referred to as “critical sociolinguistics”3 (Blom-
maert 2010) – has questioned some of the assumptions of this doxa. This approach
shares some assumptions with CDA such as attention to discourse as a factor of pro-
duction and reproduction of relationships of power, the need for dialogue between
linguistic analysis and social sciences, and the interest in institutional settings (cfr.
Blommaert 2005: 33–34). Nevertheless, critical sociolinguistics maintains a distant
relationship with CDA based on some of the criticisms reviewed earlier.
I sustain a multidimensional concept of language and discourse, combining
linguistic analysis of written and oral texts with other phenomena such as ges-
tures, sight, paratextual and paralinguistic features of speech, landscape or page
design. I advocate a conceptual blurring of the distinction between language
and discourse, preferring instead the analysis of multilingual, multimodal and
heteroglossic resources employed by actual speakers in contexts of mobility and
change. Special attention is given to the impact of mobility on communication
and its role in the production and reproduction of global social relationships.
Within this framework, language contact becomes a critical issue for discourse
analysis because it is an inherent dimension of globalization, where mobility and
fragmentation of once stable groups are now very frequent.
One of the key interpretative features of this approach to language in society
is a shift in the comprehension of linguistic difference, which is not described as
mere diversity but rather evaluated in terms of inequality.
From diversity to inequality

The term “diversity” has been traced back to the mid-1980s, when the Workforce
2000 Report made a projection of a highly heterogeneous labour force in the
USA, which would later overcome the traditionally higher percentage of White
Anglo-Saxon Protestant workers through the incorporation of more women, eth-
nic minorities and immigrants (Zanoni et al. 2010: 12). Based on this report,
organizations began to see difference as a rare and valuable asset which could
provide a competitive advantage if well managed. This “diversity paradigm”
(Zanoni et al. 2010) became the business rationale for the management of dif-
ference, subsuming class struggle, racism or gender discrimination to a general,
neutral term. Within the field of social sciences, diversity studies allowed for the
expansion of “legitimate” research objects, celebrating multiplicity and multicul-
turalism as a way of introducing “the Other” into academic discourse.
This “management paradigm” (Blommaert & Verschueren 1998) of diversity
entails an instrumental view of culture and difference and objectifies “the other” as an
object of discourse (Thompson 1993: 13). Even “discourse” becomes an umbrella
term that hides the social actors that really stand for and by it: institutions – both
public and private – and political agents who design policies and research agendas
from an ethnocentric point of view which defines the “normality” against which the
“others” (those who are different) are defined and managed. These kinds of ques-
tions address the problem of power relations and domination among “different”
cultures, which remains untouched by many diversity studies (cfr. Hoobler 2005).
Within the field of sociolinguistics and language planning, the study of lan-
guage contact has in many cases become the privileged field for the development
of diversity discourse and the management paradigm. The mere recognition of
6,909 “living” human languages (i.e. languages which are currently spoken or
written by a community or group; cfr. Lewis 2009) says little about the hegem-
ony of five or six of them around the world; the “endangered language” tag usu-
ally hides the fact that the speakers and their social identities are those who really
are in danger, not (only) the languages. Nevertheless, it is auspicious to find high
interest in documenting “nearly extinct” languages (Krauss 2007; Moseley 2010)
and, ultimately, to promote language “revitalization”, not only by providing the
communities with technical support but also by intervening in the social, political
and economic conditions that endanger the speakers and their cultures (Krauss
2007: 13). As Krauss notes, it is a critical task: it involves not only the well-known
mechanisms of linguistic description but it also questions a form of cultural rela-
tivism that lies at the core of diversity discourse, which celebrates the differences
of languages or cultures without wondering how power and economic and sym-
bolic goods are distributed and appropriated by these diverse speakers.
The shift from the managerial paradigm of diversity to the political interven-
tion on inequality raises a new set of questions for social sciences, including socio-
linguistics. In the next section, I will develop some of its theoretical consequences
regarding the concept of linguistic inequality.
Defining linguistic inequality from a discursive point of view

Linguistic inequality can be defined as a specific form of language contact which
is a consequence of the unequal social valuation of languages, varieties or lects (by
region, age, class, etc.) but also communicative styles, repertoires and discursive
traditions spoken or written in a given community. As such, due to the indexical
character of language, linguistic inequality is a producer and reproducer of wider
social, economic and cultural inequalities. At the same time, it creates and strength-
ens inter-subjective bonds, thereby guaranteeing the concepts of identity and
community for speakers. One of the challenges in this asymmetrical relationship
is how to create equal opportunities of access to language and communication-
dependent rights, and another is how to recognize and guarantee legitimate prac-
tices of voice that become discriminated against, stigmatized or under-valued by
dominant varieties and discourse regimes.
This inextricable co-dependence between linguistic and broader social inequal-
ities requires an interdisciplinary approach to a multidimensional phenomenon.
The linguistic side involves leaving aside the traditional notion of “language”
and using a different method of analysis for language contact, by shifting our
standpoint from a “distributional” conception to pragmatics of intercultural
communication (Rampton 2000; Moyer 2011).
Particularly in the context of global diasporas, where national minorities are
also ethnic minorities and victims of social and economic inequality, it becomes
increasingly important to analyze social and sociolinguistic repertoires (cfr.
Hymes 1996: 207, ff.; Blommaert 2009; Becker & Faulkner 2009) as complexes
of heterogeneous semiotic resources used by individuals to interact with other
individuals. The role of the State is key in this regard because it should guarantee
access to basic civil rights, such as healthcare or education, contemplating and
legitimizing the existence of these repertoires.
In fact, in many cases Nation-State institutions face linguistic inequality from a
monoglossic point of view (Del Valle 2000; Silverstein 1998, 2003) that rejects
hybridity (Bauman & Briggs 2003) and “impure” or “mixed” forms of language
(Dreidemie 2011), not only in the case of linguistic minorities but also within
the subordinated varieties, registers and styles of hegemonic languages (Rampton
2006). This monoglossic and normative vision, which chooses between varieties
with different degrees of legitimacy, has even ruled the formulation of policies for
multilingual intercultural communication (Del Valle 2000; Moyer 2011; Huircan
2010; Fernández 2010; Pratt 1991, 2002; Unamuno & Bonnin 2017).
Communicative obstacles for access to human rights thus often arise from the
opposition between impersonal, monoglossic, normative, monologic discourse
and social actors with a repertoire of varieties, discourses and resources based on
strong interpersonal bonds and mobile social networks.
However useful this opposition between modern monoglossic institutions and
post-modern heteroglossic social actors may be, it is schematic and does little
justice to individual agency in the production of voice (Hymes 1996; Blom-
maert 2008). The conceptualization of these realities in terms of inequality – as
systems that prevent the generation of equal opportunities and replicate unequal
opportunities – does not relegate subjects to a passive role of “inadequacy” or
“deficit” (which has been questioned in previous theories, such as Bernstein’s
opposition between elaborated and restricted code; cfr. Bernstein 1971). On the
contrary, the production of voice can be observed, although it requires attention
to different communicative materials and procedures (Blommaert 2009; Ramp-
ton 2011; Bonnin 2011, 2013). The results of this kind of analysis enable alter-
native forms of communication to be proposed based on the dialogue between
discourse theory and the social actors’ own knowledge and needs (Rymes et al.
2017; Ballena & Unamuno 2017).
To sum up, linguistic inequality deals with the inconsistency between a national
monoglossic State, which manages and distributes access to civil rights based on
a traditionally homogeneous conception of language and mobile subjects whose
communicative repertoires are built on everyday evidence of alternative, non-
hegemonic ways of communication. In this sense, the problem of inequality can
be viewed from the fields of both discourse analysis and sociolinguistics and truly
belongs to a “sociolinguistics of discourse” (Blommaert 2009: 425).
Many of the empirical and theoretical issues described herein already have an
established tradition. The concepts of “lectal power” (Chew 1995), “narrative
inequality” (Hymes 1996), and even Bernstein’s classic “restricted”/“elaborated”
code (or “code orientations”, as rephrased by Hymes 1996: 51) have all con-
tributed to our current understanding of the topic. Nevertheless, the realities
and processes studied have changed, and new challenges to old concepts have
surfaced, requiring new perspectives. Hymes (1996), for instance, shows strong
sensitivity to “world-system” problems, understood as macro-scale processes
attached to a new inter-regional and transnational division of labour (Wallerstein
1974). He integrates this concept into communicative repertoires in speakers’
daily lives. However, his examples and the cases he analyzes are firmly anchored
in the classical scope of linguistic anthropology, despite his anticipatory insight
on how “the great process affecting languages has not been one of separation and
diversification, but rather one of contact and reintegration” (Hymes 1996: 211).
The emergence of new global forces and actors since the late twentieth century
has been accompanied by new dimensions of linguistic inequality. Once again, in
the face of new realities, sociolinguistics and discourse analysis need to develop
new theories. In addition to different goals and empirical research fields, we need
to solve problems derived from unequal contact among speakers – prior to contact
among languages. We observe a set of progressively eroded boundaries: between
discourse analysis and sociolinguistics, language and repertoire, written and spo-
ken discourse, and among “national languages”. In sum, the new focus on speak-
ers and the practical problems derived from unequal access to language-based
rights enhances a series of theoretical and methodological innovations that mark
new trends in sociolinguistics and empower new global, multilingual citizens.
From this new set of problems, discourse is not dominant or hegemonic; words
do not have power. Instead, people who use those words are powerful or power-
less; and speakers – not languages – are unequal.
Notes
1 Curiously enough, Hymes (1996) does not quote Bakhtin in his classical book.
2 Morris thinks that the shift from “polyphony” to “heteroglossia” was a “shift of
emphasis towards social languages rather than individual voices which were more
the focus of analysis in the study of Dostoevsky’s prose” (Morris 1994: 113).
3 Not to be confused with Hodge and Kress’ (1979) “critical linguistics” or, more
recently, Kress’ (2001) “critical sociolinguistics”.
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2 Psychoanalysis in public
hospitals
Context as a discursive problem
Doctor-patient interaction and the issue of context

Verbal interaction between doctors and patients in medical settings has been tra-
ditionally described from T. Parsons’ (1951) perspective on social systems and
role assignation (“the sick role and the role of the physician”, Parsons 1975).
Assuming his overall characterization of “the organizing principles” (Heritage &
Clayman 2010: 119) of medical context, ethnographical descriptions are often
missed or even underrepresented in specialized research. As Blommaert (2005:
51–52) notes, the combination of theoretical claims and prima facie ethnogra-
phies often results in an a priori contextualization which situates verbal material
within a static framework of “non-discursive” situation (May 2007). As a con-
sequence, doctor-patient interaction appears framed in rough, schematic terms
which ignore everyday negotiations of these roles, historical developments and
traditions of healthcare, ideological and political heterogeneity within the hos-
pital staff, etc. (Fochsen, Deshpande & Thorson 2006; Fox et al. 2009). Even
information on whether the hospital is public or private is often missing in this
kind of research.1
Important contributions to professional-patient interaction such as Heritage
and Maynard (2006) and Heritage and Clayman (2010: 119 ff.) adopt Parsons’
description of roles. They perform linguistic analysis without questioning the inter-
face between social-structure assessments and interactional data. Cordella’s (2004)
work on participants’ voice during medical consultation finds a similar tendency in a
wide variety of doctor-patient communication studies (Cordella 2004: 30–38). May
(2007) has noted an analogous situation in sociological studies on clinical encounters
which are usually described as a dyadic relationship defined by asymmetrical distri-
bution of power and knowledge. On the contrary, he describes a more dynamic
and multidimensional situation which includes State and corporate actors, locating
the clinical encounter only as a “part of an assemblage of complex organizational,
institutional and disciplinary resources and practices (. . .) where subjectivities are
constructed and worked out in multiple and diverse ways” (May 2007: 41; May et al.
2006). By adopting this kind of dynamic perspective, recent research has shown a
more flexible distribution of roles which are negotiable and subject to change (Foch-
sen, Deshpande & Thorson 2006; Fox et al. 2009) on the basis of socio-economic
backgrounds, gender and race (Peck & Denney 2012; Cordella 2004).
36 Psychoanalysis in public hospitals
From a discursive standpoint, studies on health organizational communica-
tion (Iedema 2005a,b, 2007; Sarangi 2004, 2011; Candlin & Candlin 2003;
Crawford, Brown & Mullany 2005) show the need for ethnographic approaches
to hospitals in order to understand communication in medical settings. Consider-
ing hospital settings as multicultural social sites requiring thorough ethnographic
work (Moyer 2011) enables collaborative research on healthcare (Candlin &
Candlin 2003; Sarangi 2004) which will serve practical ends. In addition, by
shifting away or problematizing the relationship between doctor and patient,
it enables fuller understanding of what constitutes everyday medical practice
(Sarangi & Roberts 1999). Negotiation and reconfiguration of institutionalized
roles and situations thus become not the exception, but a constitutive feature of
medical settings (Cicourel 1999; Sarangi 2011).
Van Dijk (2008) has pointed out that many theories of context have a “deter-
ministic” point of view which considers the situation as an objective crystalliza-
tion of social properties that has a determinant impact on discourse production
and interpretation. He argues that “context is what is defined as relevant in the
social situation by the participants themselves” (van Dijk 2008: 5; cfr. Schegloff
2007). From this perspective, even material/physical properties of situation can
be recontextualized in different terms. For example, the “waiting room” and
the “reception desk” of the mental healthcare service at the hospital are two
areas occupying the same space: same walls, roof, floor and light. Yet after a
patient registers at the table which serves as a reception desk, s/he is told to wait
“outside”. S/he waits in a different space in socio-cognitive terms although it is
the same room in physical terms and the same institutional setting in sociologi-
cal terms. Nevertheless, the patient behaves differently in front of the desk (i.e.
“inside”) and at the side of the desk (“outside”). Following van Dijk (2006:
164): “contexts are not observable, but their consequences are”. This perspective
is especially useful to my research because it enables us to think that two speakers
engaged in conversation may be participating in different mental contexts even
though they are sharing the same space and interacting (acoustically and/or lin-
guistically) with each other.
From this perspective, the context of my research is simultaneously historical
and socio-cognitive; it is a product of power relationships in public policy design,
and an interactional achievement of participants. The aim of this chapter is to
develop both aspects of this claim.
Public health settings: psychoanalysis at the hospital

The healthcare system in Argentina is organized in three sectors: public, private
and mixed (Acuña & Chudnovsky 2002). The private sector includes about 10%
of the population and is financed through a voluntary insurance scheme. The
mixed sector is financed through mandatory insurance schemes and managed by
labour unions and provides health insurance to 20.3 million users (53% of the
total population). Finally, the public sector offers free healthcare to all inhabitants
of the country, financed by the State. About 37% of total population (16 million
Psychoanalysis in public hospitals 37
people), who are not included in the former two sectors, receive healthcare at
public hospitals and primary healthcare centres (Abeledo 2010).
Patients who receive healthcare at public hospitals are not usually included
in the formal sector of economy or do not enjoy full citizenship. Despite the
effort and professionalism of public healthcare providers, structural conditions
are extremely poor and basic resources – from personnel to supplies – are scarce.
Many political and academic activists believe that the lack of resources is part of
a policy to dismantle the public healthcare system, which is no longer considered
a basic human right but now perceived as relief for the poor (Comes & Stolkiner
2005). Most people who receive care at public hospitals have no access to any
other kind of healthcare. I have even observed that healthcare providers at the
hospital reject patients who have medical insurance, arguing that “people who
come here have nowhere else to go for healthcare” (las personas que vienen acá es
porque no tienen ningún servicio para atenderse). In these conditions, the system
is overwhelmed by a demand that cannot be adequately satisfied.
In order to manage the admission (and rejection) of patients to the outpatient
mental healthcare service, a system of “admission interviews” or “first visits” was
implemented the year I began my fieldwork. Once a week, candidates apply for
an interview with two professionals who evaluate whether the interviewees meet
the required criteria to be admitted as patients. These criteria, however variable,
are usually linked to the available slots in the schedules of the different special-
ties (individual therapy, group therapy, addictions, etc.). Approximately fifteen
people are interviewed every week, and about ten of them are admitted to the
outpatient mental healthcare service. Thus, the patient’s performance during the
interview is extremely important, as it is his/her only chance to face institutional
criteria and negotiate his/her admission.
Patients: what they expect and what they get

Outpatient mental healthcare services have been offered at public hospitals in
Buenos Aires since 1957, when progressive movements in the political field
encouraged a critical view of hospices and broadened the object of mental health-
care (Macchioli 2012; Stolkiner 2009). Later, the military dictatorship in Argen-
tina intervened violently in hospitals, universities and other institutions. After the
military regime ended in 1983, many psychiatrists and psychologists with Lacan-
ian psychoanalytic training joined the mental healthcare services (Plotkin 2001;
Vezzetti 1996). At the public hospital where I do fieldwork, there are many
Lacanians, who are critical of other professionals (physicians as well as “medical
discourse”) and are themselves criticized as being non-scientific (Lakoff 2003).
Public hospitals, and especially the one I am referring to here, are overwhelmed
by a demand that cannot be satisfied in their current human and material situ-
ation. Despite the former prestige of the Argentinean public health system, the
neoliberal government during the 1990s conducted a process of dismantling and
privatization which left it in critical condition (Comes & Stolkiner 2005). Today,
16 million people who have no other alternative use different healthcare services
at public hospitals in Argentina (De Almeida-Filho & Silva Paim 1999). In 2011,
the hospital where I conduct research provided healthcare to 37,429 outpatients,
of whom 2,864 received mental healthcare.2
Not only does the mental healthcare service involve a high level of bureaucracy,
but also it is overpopulated and the staff is short-handed. There are only about
ten vacancies a week for new patient admissions, so the purpose of the interview
is both to admit patients and refer them to specific services (individual therapy,
group therapy, addictions, among others) and to reject applicants. About 50% of
the applicants did not make it to the admission interview in 2012, and 35% of
the people interviewed were rejected. As a consequence, admission interviews are
an important link between “outside” and “inside” the mental healthcare service,
and patient performance in the interaction is a major factor in access to treatment.
According to statistics prepared by the outpatient mental healthcare service,
about 20% of the patients who attend admission interviews require psychiatric
attention because of a psychopathological condition. The other 80% receive psy-
chotherapy, specifically psychoanalytic psychotherapy. Nevertheless, 57% of these
patients have not received previous psychotherapeutic treatments, which means
that they do not know what a psychological/analytical treatment is. Neither do
they know about the ambiguous status of diagnosis in psychoanalysis or how
fiercely the same professionals criticize the DSM-IV and other diagnostic manuals
used in the public mental healthcare system (cfr. Chapter 4).
As a consequence, there is a confrontation between the medical expectations
of patients – who expect a diagnosis and treatment to cure their “illness” – and
the psychoanalytic practice of professionals – who offer treatment so that patients
themselves may decide what the problem is.
Psychoanalysis and (public) mental health

Psychoanalysis is extremely popular in Argentina, especially in Buenos Aires.
According to the World Health Organization (WHO), Argentina has the highest
rate of psychologists per capita: 193 per 100,000 habitants. The second place
corresponds to Finland, with 56 per 100,000 habitants (WHO 2014). Tradition-
ally limited to urban middle and upper-middle classes, psychoanalysis in public
hospitals is a recent phenomenon.
Psychoanalysis did not develop early in Argentina. The Argentine Psychoana-
lytic Association (APA) was not founded until 1942, more than thirty-two years
after the creation of the International Psychoanalytic Association (IPA) by Sig-
mund Freud. Although it was not a legitimate specialty in the medical field, it
was indeed a prestigious and lucrative private practice targeting clients from the
higher class (Balán 1992: 114 ff.). Argentine medical associations were highly
suspicious of the APA during the 1940s and 1950s, and therefore kept it away
from public hospitals as long as they could (Plotkin 2001).
The early sixties brought significant change with regard to the relationship
between psychoanalysis, society and medicine. Two processes can be outlined
which began in those days and can be traced to the present. In 1957, the degree in
psychology was created at the University of Buenos Aires. Although the specialty
was reluctant to accept psychoanalysis and intended to train college graduate assis-
tants for psychiatrists, non-medical psychologists were trained and given official
recognition for the first time (Balán 1992). During the sixties, the “mental health
movement” (movimiento de salud mental) was born, which grouped young psy-
chiatrists who opposed the positivist “mental hygiene” paradigm, which proposed
reclusion and medication as the main path for the treatment of mental illness
(Macchioli 2012). The reformers introduced radically new concepts, combining
sanitary, sociological, psychoanalytic and political theory. One of the innovations
of the mental health movement was the introduction of psychoanalysis as a new
experimental tool for treating mental illness at public hospitals (Lakoff 2006: 75).
This introduction was heterodox not only to psychiatrists, but also to tra-
ditional, Freudian psychoanalysts for a number of reasons: “therapy was pro-
vided for free, there was no couch, and transference was potentially hampered
by the difference in social class between therapist and patient” (Lakoff 2006:
75). Within a highly politicized context, new college-trained psychologists/psy-
choanalysts began to gain presence in public hospitals as part of a scientific and
political movement of mental health workers which saw psychoanalysis as a pow-
erful tool for social change (Plotkin 2001: 138). As a reaction against Freudian
orthodoxy, represented by the APA, new psychoanalysts found in Jacques Lacan
(and his rebellious attitude against the IPA) a new mentor to follow in their own
intellectual, medical and political project.
The people who are currently chiefs of staff at the hospital were trained dur-
ing the late sixties and early seventies and therefore participated in this militant
psychoanalytic movement which brought Lacan to public hospitals in a more or
less implicit war against medical psychiatry and traditional psychoanalysis. The
confrontation between “medical” discourse and “psychoanalytic” discourse at
public hospitals is not only asserted by mental health practitioners but has also
been analyzed by social research, as shown in the work of Lakoff (2006).
Although this confrontation is often apparent among healthcare professionals
in their words and attitudes towards each other (cfr. Lakoff 2003), patients are
not usually aware of it. On the contrary, most patients who visit the outpatient
mental health service have never received prior psychoanalytical attention. How-
ever, they have attended public hospitals since childhood and are thus used to the
clinical encounter and its highly structured sequential organization and genres.
The role of admission interviews and

the interactional construction of context
Access to outpatient mental healthcare service is conditioned by an “admission
interview” conducted by two psychologists who decide whether the case deserves
psychological and/or psychiatric treatment at the hospital. Subsequently, the
whole team involved in the admission process makes a joint decision on which
specialty the accepted patients should be referred to (individual therapy, group
therapy, addictions, legal psychology, etc.).
Admission interviews are thus the link between the “outside” and the “inside”
of the outpatient mental healthcare service. Patient performance during the
interaction will be one of the main factors determining access to treatment, in at
least two ways: to the psychologist, it will provide information to diagnose the
patient, and to the patient, it will be an instance of evaluation of the service which
will serve to decide whether or not s/he will accept treatment.
Indeed, resistance to treatment can be conditioned by interaction during the
interview in ways close to primary healthcare encounters (Heritage & Maynard
2006; Peräkylä et al. 2008) and acute medical visits (Koenig 2011). In this sense,
Heritage and Clayman (2010) have proved that although first contact with medi-
cal discourse can have therapeutic value in itself, “this will not be realized if
patients do not feel that their concerns were adequately heard and addressed”
(Heritage & Clayman 2010: 105; cfr. Barry 2002; Moore et al. 2004; Iedema
2005b). This “feeling” can be described as “active listening”, “sympathy” or
“transference” in psychotherapeutic conversation (Peräkylä et al. 2008: 153). In
psychoanalytical terms, in order to ensure continuity of the treatment, there has
to be some kind of transference relationship between the patient and a meaningful
other in the situation, typically the analyst (Fink 2007).
In what follows, I will analyze this reciprocity in terms of mutual adjustment
in the definition of the space of interaction, the activity and the roles of the pro-
fessional. I will also show what happens when there is a maladjustment between
participants and the demand of mental healthcare cannot be satisfied.
Interactional construction of space: the public,

the private and the intimate
Patients traverse three different situational levels during the interview. The first is
the explicitly institutional level of State rationality, which deals with bureaucratic
discourse and registration of the patient in the State system through demographic
information (age, sex, etc.) using an epidemiological-statistical form which is col-
lected to generate quantitative data. The second level is clearly situated, has fewer
active participants and focuses on the patient as the subject of a biography, cre-
ating a private space which favours history taking (Heritage & Clayman 2010:
135–153; Boyd & Heritage 2006: 151–184). Finally, the space of interaction
may be even more restricted at the third level, which focuses exclusively on the
patient’s emotions, which tend to be expressed through crying and volume low-
ering, shaping the intimate level of the interview.
The public level

The first level of context takes place when the patient is called by a psychologist
for the interview. Consulting rooms are small cubicles made of moveable panels,
though often there are no rooms available and interviews take place in hospital
corridors. Background noise is constant and interferes with the interaction.
GAZE DIRECTION
The role of gaze in turn-taking allows not only to establish speakership but also
to other-select speakers (Mondada 2007; Lerner 2003). As a consequence, gaze
may work as a resource to designate legitimate interlocutors during interaction.
In the interviews we have observed, the patient faces three other people: some-
one who will lead the interview, whom we call the psychologist in charge (PC);
someone who assists the PC and takes notes in a file (the assistant psycholo-
gist, AP); and someone who stays still, aside from the table, taking notes: the
researcher (R). In this first contact, gaze direction is still exploratory in the case
of the patient, but it is quite directed in the case of the PC:
Excerpt 1
1 PC: buen día señora cómo le va (1)
((levanta la mirada de los papeles y establece contacto visual))
2 A: bien gracias
((mira a los tres, alternativamente, mientras se sienta))
3 PC: bueno (.5) le conta:mos son cole:gas esta es una:
4 primera entrevista de orientación
((acodada en dirección a A, sin perder el contacto))
5 A: sí
((mira al investigador, que toma notas))
1 PC: good morning madam how are you (1)

((raises gaze from papers and makes eye contact))
2 A: fine thanks
((looks alternatively at the three other participants while sitting))
3 PC: well (.5) the:se are co:lleagues this is a:
4 first orientation interview
((leaning forward, looking at A))
5 A: yes
((looks at the researcher, who is taking notes))
The PC tries to narrow the space of interaction as a means to establish her

role as the main interviewer. To do so, she displays a series of postural and gaze
resources during the opening sequence of the interview: leaning her elbows
on the table, physically approaching the interlocutor, and seeking eye contact
(l. 3). The other two participants, who already know the usual development of
the interaction, fix their gaze on the table or the body of the patient or take
notes (the AP to complete the admission form; the R in his notebook), making
their subordinate roles clear at the interview. Nevertheless, the patient does not
know the prearranged roles. In line 2, the patient looks alternatively at the three
interlocutors, looking for some sort of feedback to infer their positions at the
institution or their roles in the interaction. The same happens in line 5, in which
the patient’s gaze addresses the researcher, who will have an insignificant role in
the interaction.
This first level, hierarchically higher and more impersonal than the lower ones,
is also open to the influence of other participants who can be stared at or ver-
bally addressed, broadening the space of interaction. Although due to the spatial
disposition of participants, psychologists are in a more favourable position to
broaden gaze, patients also show a representation of the space of interaction
which is broader than the immediate physical situation. In the next example, a
woman inside the consulting room addresses one of her children, who is staying
outside while the AP is closing the door:
Excerpt 2
1 A: sí: QUEDAte con tu hermana
((mira a través de la puerta))
2 PC: ¿quiere hacerlos entrar?
((mira a través de la puerta))
3 A: (1) no no no gracias
((AP cierra la puerta))
1 A: yes: STAY outside with your sister

((looks across the door))
2 PC: do you want to let them in?
((looks across the door))
3 A: (1) no no no thank you
((AP closes the door))
In this example, the transition from the outside to the inside is made from
within the consulting room, which has permeable boundaries. The momentary
rise in volume, in l. 1, has a pragmatic function (to give an order) rather than a
phatic function, which is why the volume is immediately lowered. On the other
hand, there is a clear distinction between inside and outside, shown by the PC in
l. 2 with the deictic verb “entrar” (“to come in”). This difference is reinforced
by the role of the door, which is closed after the decision to leave the children
outside (line 3).
The diagram in Figure 2.1 shows gaze directions setting the broadest space for
the interaction and the maximum number of participants.
AGENDA SETTING: THE PATIENT AS A DEMOGRAPHIC SUBJECT
The main subject of the interview is always the patient’s particular situation. The
patient is asked to tell his/her story in order to detect meaningful symptoms. At
this first level, however, the patient is characterized only as a demographic entity
and is requested to give demographic-bureaucratic information: name, identifica-
tion number, age, sex, etc. In many cases, professionals already have this informa-
tion, which is provided by the patient to the secretary. Yet it is requested again,
Figure 2.1 Gaze at the public level
as a topical means for establishing the public level of interaction. The interview-
ers’ own roles are vaguely characterized, especially when the researcher is present.
This characterization is made through general categories, such as “professionals”
(profesionales) or “colleagues” (colegas), as seen in Excerpt 1, line 3. On a very few
occasions, psychologists introduce themselves with their own names:
Excerpt 3
1 PC: bue:no (1) te voy a: hacer algunas preguntas para: la
2 estadística
1 PC: well (1) I am going to: ask you some question fo:r the
2 statistical records
This kind of sequence, which introduces a statistical-epidemiological question-
naire, is routinely located at the beginning of the interview. It will be analyzed in
detail in Chapter 5.
The purpose of this first level of interaction is to frame the patient as an emer-
gent of demographic categories such as gender, age and education. This pro-
cedure can be conducted in a series of exchanges which rephrase speech in the
bureaucratic terms of institutional discourse:
Excerpt 4
1 PC: ¿educación? prima:ria, secunda:ria:?
2 A: sí (1) hice hasta: tercer año
3 PC: ah (.5) secundario incompleto entonces
1 PC: education? Pri:mary, se:condary?

2 A: yes (1) I made it to: third year
3 PC: ah (.5) incomplete secondary then
In line 2, the patient answers with a short narrative which characterizes her as
a biographical subject. The PC takes her turn (l. 3) to offer a bureaucratic for-
mulation: “[nivel] secundario incompleto”. The public space is thus inhabited by
the demographic subject and not by the biographical one, which will be the main
character of the private level.
The private level

The second space built in admission interviews is the private one, in which the
biography of the subject as an individual is the main topic. Listening to his/her
story will enable psychologists to diagnose the patient. Without the shift towards
this key level, there cannot be diagnosis or transference.
From the patient’s point of view, this is the space where therapy happens:
s/he can expose private feelings, wishes or frustrations to a professional who is
“supposed to know” (Lacan 1977: 236) and can help him/her solve personal
problems. Within this private space, the subject becomes the protagonist of a
biography, the main character of his/her life story. From the psychologist’s point
of view, this is also a key space because it enables private information to be gath-
ered, which will serve to diagnose patients. As we shall see in the next section,
patients and analysts can move deeper into an intimate space. This move, how-
ever, is not essential; on the contrary, there is often a clear strategy to avoid this
kind of in-depth exchange.
GAZE DIRECTION
My observation of the interviews is not as a participant. This is why, uncon-

sciously at the beginning and consciously later, I kept myself away from the sur-
face of the table. The table is an object that organizes the basic opposition of
roles (interviewer(s)/interviewed) and the distribution of space between two
clear areas. The PC and the AP complete official forms (the epidemiological file
and the admission form) beside each other on the table while I take notes on my
lap. As shown in Figure 2.2, it would require an extra effort by the patient to look
at me once s/he enters the private space.
Therefore, gaze direction closes a space which includes both psychologists and
the patient. The PC immediately assumes a position of authority which allows
him to lead the interview, posing questions and addressing the patient directly,
becoming the individualized interlocutor of the patient.
However, the AP has his/her own role such as assenting, taking notes, and
receiving instructions from the PC. Although subordinated, his/her place in the
interaction is noticeable because s/he is addressed by at least one of the other
participants. Therefore, the space outlined by gaze is semi-closed, privileging a
Figure 2.2 Gaze at the private level

relationship 2/1, excluding the researcher, who does not have an identifiable
role, as shown in Figure 2.2.
AGENDA SETTING: THE PATIENT AS A BIOGRAPHICAL SUBJECT
The main topic discussed at this second level is the patient as a biographical sub-
ject; an individual who emerges from the standardized demographic categories
employed in the previous stage. In fact, the biographical subject being the main
motivation for the visit to the hospital, the patient usually tries to enter private
space during opening sequences and respond to the statistical-epidemiological
form with his/her singular biographic data:
Excerpt 5
1 PC: bue:no (.) decime tu estado civil: (.) EL REAL eh?
2 A: (3) separada
((sonrisa triste; contacto visual con PC))
3 PC: separada entonces?
4 A: no no:: lo que pasa es que: yo me quería separar
5 de mi marido (.) pero él no se quiere ir
1 PC: we:ll (.) tell me your marital sta:tus (.) THE REAL ONE right?
2 A: (3) divorced
((sad smile; makes eye contact with PC))
3 PC: divorced then?
4 A: no no:: the thing is: I wanted to divorce
5 my husband (.) but he does not want to leave
The PC asks for the marital status in line 1 but, taking into account the patient’s
facial expression and the long, 3-second pause, the PC asks for a confirmation in
line 3, thus initiating the repair by the patient, who points out the existence of a
conflict with her husband. In lines 4–5 the patient begins her biographical story
which ends at the consulting room, indexicalized by the change in the verbal
tense: from past (“me quería separar”, “I wanted to divorce”) to present (“no se
quiere ir”, “he does not want to leave”). The life story begins with the emergence
of the first person: “yo me quería separar” (“I wanted to divorce”, line 4).
From this point on, PC’s interventions usually look forward to make the sto-
rytelling easier, asking questions about the patient and the circumstances of the
narrative:
Excerpt 6
1 PC: cuénteme
2 B: mire (.) estoy (realmente) angustiado por
3 una situación que vengo aguantando hace aproximadamente
4 tres años y medio (.) con mi hermana (1.5) que hace como
5 una violencia así familiar (inaudible) hacia las tres (1.3)
6 porque mis padres (.) mayores (.) de ochenta años (1) hacia
7 mí (1) bueno (.) lo hemos hablado me ha: (.) dice vos te
8 Tenés que ir (1) bueno un montón de [cosas
((pasea la mirada por PC y AP))
9 PC: [hacia su persona?
10 viven todos juntos?
11 B: los cuatro (.) sí (1) ahora ella está en pareja y se::
12 qué hace? se va (.5) porque esta persona el señor (.5)
13 dice él que es divorciado y eh: vuelve:: tres de la mañana
14 vuelve a casa (1) todo el día está nerviosa (.) y después
15 se vuelve a ir (.) y vuelve así (1) bueno a ver: es algo
16 que no se soporta
((pasea la mirada por PC y AP mientras habla))
1 PC: tell me
2 B: look (.) I am (really) upset due to
3 a situation that I have been putting up with for about
4 three and a half years (.) with my sister (1.5) who causes
5 say family violence (inaudible) towards the three of us (1.3)
6 Because my parents (.) old (.) about eighty years (1) towards
7 me (1) well (.) we have talked about it and she: (.) says you
8 should leave home (1) well, a lot of [things
((alternatively looks at PC and AP))
9 PC: [to you?
10 Do you all live together?
11 B: the four of us (.) yes (1) now she has a boyfriend and she::
12 what does she do? she goes out (0.5) because this man (0.5) this
gentleman
13 he says he is divorced and eh: she comes ba::ck at three
14 in the morning (1) the whole day she is upset (.) and then
15 she leaves again (.) and comes back (1) we:ll it is something
16 umbearable
((alternatively looks at PC and AP))
In line 1, the PC points out the moment of shift towards the private space by
using the imperative second form “cuénteme” (“tell me”), which builds a deictic
space limited to only two participants (second-person singular in the verb and
first person singular in the clitic pronoun), although the patient’s gaze includes
the AP. Therefore, in line 2, the interviewee answers the psychologist using the
second-person singular (“mire”, “look”, l. 2), while looking both at the PC and
AP (l. 8). The psychologist, on the other hand, encourages the conversation
to develop, adapting her strategies to the narrative style of the interlocutor: in
line 6, the speaker shows his loquaciousness, and then the PC uses only polar
interrogations, receiving elaborated answers about the patient as a biographical
subject.
The intimate level
The last level we have observed is the most difficult to describe because the emo-
tive function dominates the rest, and the audio register is poor due to the patient
crying and lowering his/her voice. Anguish, understood both as a symptom and/
or a clinical diagnosis, controls the speaker’s voice and limits communication to a
minimum space as almost a monologue driven by a somatic subject.
GAZE DIRECTION/AGENDA SETTING: THE PATIENT AS A SOMATIC SUBJECT
By reaching the intimate level, the closing of space between the patient and the
professional prevents the other participants from hearing or understanding. In
the next example, a male patient, who has just lost custody of his children due
to an episode of drug abuse, begins to lower his voice with the PC, ending in an
intimate conversation which leaves the other two participants “outside”:
Excerpt 7
1 PC: hiciste algún tratamiento [de adicciones?
2 B: [no no no (inaudible)
3 PC: no tenías (.3) esto que me decías (inaudible)?
4 B: (inaudible)
5 PC: de los dieciséis años qué tomabas?
6 B: °°marihuana°°
((llorando))
7 PC: ajá:
8 B: (inaudible)
9 PC: (inaudible)
PC: did you follow any treatment [for addictions?

B: [no no no (inaudible)
PC: didn’t you have (.3) this thing you told me (inaudible)?
B: (inaudible)
PC: what did you use since you were sixteen years old?
B: °°marijuana°°
((crying))
PC: ri:ght
B: (inaudible)
PC: (inaudible)
Here, when the patient begins to tell the most emotional part of his biogra-
phy, crying and volume lowering becomes increasingly important. The endings
of lines 2 and 3 (by the patient and the PC), line 4, and the last two turns are
completely inaudible to the tape recorder, the AP and the researcher, but not to
the interacting patient and the PC. This exclusion of the rest of the participants
closes space to a level of intimacy which is qualitatively different from the private
space, as seen in Figure 2.3:
Figure 2.3 Gaze at the intimate level
At this level of interaction, it is practically impossible to distinguish between

dimensions as we have done in previous sections, because gestures and gaze are
a constitutive part of the content of the story. Patients stop talking about crying
and begin to cry. Sometimes a specific gesture replaces the verbal component:
one woman touches her cheek in silence when remembering being battered by
her husband. Body and speech are the form and content of the story because the
intimate space requires a different kind of topic; it is not what attaches a person
to a demographic profile or the unique story of his/her own biography but the
description of a subjective experience that is updated in the speech situation. The
somatic subject is defined non-temporally: s/he shifts the space of institutional
communication to his/her own experience. Actions, such as crying and suffering
a punch in the face, are represented through iconic gestures which not only com-
municate but perform the story being narrated.
Contextual maladjustments
So far, I have shown a series of interactional spaces that represent different levels
on a scale. The broadest space is the public space, where the interaction appears
to open to the outside of the consulting room. Here, the patient is an example
of demographic categories. The second space is the private level, where most of
the interaction takes place, involving the patient, the PC and, in a secondary role,
the AP. Here, the patient is the main character in a biography which will lead to the
establishment of a clinical diagnosis. The last place is the intimate space and is
mainly closed on the patient as an experiencer of physical reactions; the patient is
a somatic subject who cries, lowers his/her voice and gaze, closes his/her eyes and
mimics the story with body language.
In Excerpt 7 we observed what happens when the PC is also in the space of
intimacy: the psychologist and patient together build a closed space that is inac-
cessible even to the other people in the room, whose participation is reduced to a
minimum. In the next example, the patient speaks of her suicidal fantasies occur-
ring at a bus stop. She is closer to the tape recorder than to the PC:
Excerpt 8
1 A: °°me agarré al fierrito de la parada (2) el fierrito°°
((llorando, cruza los brazos sobre el pecho))
2 PC: al qué?
3 A: °°al fierrito°°
4 PC: disculpe pero:: ((alguien dice su nombre fuera del
5 consultorio)) un segundito=
6 A: =°°me abracé al fierrito (.5) del caño de la parada°°
7 PC: deme un segundito que ya vuelvo ((sale))
1 A: °°I held onto the bar at the bus stop (2) the bar°
((crying, folds her arms over her chest))
2 PC: the what?
3 A: °°the bar°°
4 PC: sorry bu::t ((someone calls the PC from outside the
5 consulting room)) just a second=
6 A: =°°I held onto the bar (.5) of the bus stop°°
7 PC: just one second I will be back ((she leaves the
consulting room))
In this example, the patient’s anguish causes her to lower her voice and gaze,
which remains fixed on the table. Emotion is also shown through diminutives,
reiterations (“fierrito”, “bar”), and body language. When a patient uses body
language, he/she not only narrates vocally but enacts the facts as a somatic sub-
ject. The PC, who is not in the same space, asks repeatedly for a repair in lines
2 and 4, which occurs only as a repetition (“fierrito”, l. 3) and does not receive
adequate feedback from the PC. The psychologist is situated in the public space,
which has permeable boundaries to the outside of the consulting room (as seen
in lines 4–5 and 7) and louder volume. The patient, however, is in the intimate
space and does not find an interlocutor at the same level. When the PC left the
room, the patient remained crying while the AP and the researcher stood still,
not knowing what to do.
The expected development of an admission interview is that the patient’s sin-
gularity will gradually be probed in greater depth, enabling the emergence of
symptoms that will be interpreted in order to provide a provisional diagnosis.
However, there is often maladjustment between the space constructed by the PC
and the space inhabited by the patient. As a consequence, both participants are
situated in different imaginary spaces and set different agendas; reciprocity can-
not be achieved, and analytical relationship becomes difficult, if not impossible.
This is the critical issue in my description; even when professionals explicitly
accept new patients and positively recommend their admission to the outpatient
service, scale maladjustment can prevent patients from returning to the hospital
on the basis of not receiving adequate feedback, so their demand for mental
healthcare cannot be satisfied. This is an unintended consequence of communica-
tive action: the patient is formally accepted but communicatively rejected.
Defining the situation: roles, activities

and maladjustments
The situation of the outpatient mental healthcare service at public hospitals in
Argentina is structurally ambiguous due to the unresolved tension between psy-
choanalysis and psychiatry. The situation becomes paradoxical: a discourse which
explicitly challenges “biomedical power” does so from within the “biomedical
device” par excellence, the public hospital. As a consequence, several contextual
maladjustments occur between patients – whose expectations are set to interact
in a medical hospital – and professionals – who think of themselves as outsiders
to the medical setting.
However, professionals often negotiate with medical expectations in order to
help patients to enter treatment. One of the achievements of my research at the
hospital was to identify this conflict and the need for negotiating. In terms of
the chief of the outpatient service of mental health, at an internal seminar where
results were discussed:
cómo recibimos a la gente, con qué suposición. (.) e:h (1) con qué suposición
ingresa y si alcanza la expectativa o ellos venían a buscar un psicofármaco y
resulta que están hablando adelante de un psicólogo.
(chief of the outpatient service of mental health
at an internal seminar, 2014)
how we receive people, under what assumption (.) e:h (1) under what
assumption patients are admitted and whether their assumption is satisfied,
or whether they came in looking for medication and it turns out that they
are talking to a psychologist.
(chief of the outpatient service of mental health
at an internal seminar, 2014)
Some features of this negotiation can be observed in small activities intended

to define the activity currently ongoing and the participants, especially the
professionals.
Negotiating the activity: what are we doing?

Patients have different expectations regarding the activity they will engage in dur-
ing their first interview, but in general terms, they are medical in nature. This can
be observed, for instance, in the sequential organization of the interview, which
usually involves the “reason for attendance” (Bagheri, Ibrahim & Habil 2015) or
“complaint” (Ten Have 2002). From the perspective of the mental health team,
however, this interview is not conceived of as a clinical event but as a “first con-
sultation” or “orientation interview”. Only if accepted as an outpatient will the
patient undergo a proper “admission”.
There is thus maladjustment with regard to the definition of the activity. To
the professionals it is simply an “orientation interview” which does not commit the
outpatient mental healthcare service to conduct any clinical treatment, while to
patients it is an “admission interview” – a clinical instance itself which entitles
them to receive mental healthcare.
We can observe the first case as follows:
Excerpt 9
1 E3: Bueno. (.) esta es una pequeña: entrevista para: (.) de
2 orientación para:, para: (2.0) ver dónde, dónde la derivamos
3 Y primero le voy a hacer unas preguntas, si? Bueno. (1.5)
1 E3: well. (.) this is a small: interview to: (.) of

2 orientation to:, to: (2.0) see where, where we refer you to
3 and first I am going to ask you some questions, OK? well. (1.5)
Excerpt 10
1 E4: =Pero, a ver, está bien. Habrá sido una excepción por
2 una situación muy puntual en ese momento. Pero ahora estás
3 en otra situación. Yo lo que digo es, si vos necesitás
4 medicación podés recurrir- podés ir a la guardia y decir
5 <que viniste a la consulta>, sí?, <que vas a tener en quince
6 días este:: u:n (.) una evaluación, que te van a hacer una
7 evaluación> sí? o que vuelvas a ((nombre de un hospital))
8 P4: [Ah] bueno!= (P4)
1 E4: =but, let’s see, OK. It might have been an exception because of
2 A very particular situation at that time. But now you are
3 in a different situation. what I’m saying is, if you need
4 medication you can resort- you can go to the ER and say
5 <that you had a consultation here>, OK?, <that you are getting, in
two
6 weeks ehm:: a: (.) an evaluation, that you are getting an
7 evaluation> OK? Or you go back to ((name of a hospital))
8 P4: [ah] OK!= (P4)
In Excerpt 9, located at the first part of the interaction, the term “orientation
interview” appears as the preferred term. In lines 1–2, when designating the
activity, E4 self-repairs “entrevista para: (.) de orientación para” in order to keep
the designation of the activity as conventional as possible. In Excerpt 10, P4 is
a young woman who has been visiting the hospital ER sporadically to obtain
medication for her anxiety attacks. Referred by the ER physicians to the outpa-
tient service, P4 asks for the same medication in the understanding that the two
medical contexts are equivalent. However, E4 contrasts the acute treatment of
an urgency (l. 4, “la guardia”) and the chronic treatment of a condition (l. 5, “la
consulta”). Such treatment, however, is not offered by E4: in l. 6 she self-repairs
“u:n (.) una evaluación”, where the masculine indefinite article (“un”) could
have been the beginning of an offer of treatment (“un tratamiento”). Instead,
she repairs with “an evaluation” (“una evaluación”), again postponing a clinical
designation for the activity.
Consultation, interview and orientation designate three activities which,
together with the term admission, express the structural tension regarding what
participants understand they are doing in the situation. Consulting, interviewing
and orienting are different speech acts in which participants – and their roles – are
also different: only the patient “consults”, while the professional “interviews”,
“orients” and ultimately “admits”.
The definition of the activity is not, however, only a matter of professionals. On
the contrary, patients often react against the maladjustment between their clinical
expectations and the disappointing offer made by psychologists at the service:
Excerpt 11
1 Vamos en quince días suponete mas o menos (.) te vamos a
2 llama:r, vos estate atenta al teléfono, te va a llamar un
3 profesional de acá para hacerte una evaluación y ahí te va
4 a indicar lo que (.) este: (.) lo que le parezca a este
5 médico pertinente. Mientras tanto seguí manejándote como
6 te manejaste hasta ahora. SÍ? ↑Bueh (2)
7 P1: Ahora mismo no meno me (apure)=
8 M1: Te estamos atendien[do]=
9 P1: [No]
10 M1: =Esta es una atención. <Esta es una atención porque
11 [te estamos]>=
12 P1: [>Bueno, bueno<]
13 M1: = Ya te escuché y te estamos- <toda la secuencia de lo
14 que viene sucediéndote> y te tomamos el teléfono y en quince
15 días y vas- vas a tener un tri- primera entrevista=
16 P1:=Bueno=
17 M1: =de evaluación
1 We’ll in two weeks give or take (.) we’ll

2 Ca:ll you, you pay attention to the phone, a professional
3 From here will call to conduct an evaluation and then he will
4 Indicate what (.) e:hm (.) what he thinks to this
5 relevant doctor. Meanwhile keep handling it just like
6 You have been doing so far. OK? ↑Well (2)
7 P1: right now don’t do- don’t (rush me)=
8 M1: we are treating [you]=
9 P1: [no]
10 M1: =this is treating. <this is treating because
11 [we are]>=
12 P1: [>OK, OK<]
13 M1: = I Heard you and we are- <the whole sequence of what
14 has happened to you> and we have your phone number and in two
15 weeks and you- will have a tre- first interview=
16 P1:=OK=
17 M1: =of evaluation
Excerpt 11 is taken from the end of the first excerpt analyzed here. Lines 1–6
are a typical closing sequence which repeats the advice of going to the ER to ask
for medication while waiting for a call from the outpatient service (as in Excerpt
2). In l. 6, M1 asks more loudly for confirmation, which is acknowledged with
“bueh”. However, the patient does not take the preferred course of action and,
after a long silence of 2 seconds, explicitly refuses to abandon the activity as
M1’s closing entails. “No me apure”, in l. 7, is interpreted by M1 as a lack of
success in the activity; thus she explicitly designates it as a clinical attention: “te
estamos atendiendo” (l. 8) aims to recontextualize the event in medical terms.
P1, however, does not acknowledge this recontextualization, directly by denying
it: “no” (l. 9).
In confrontation to P1, M1 offers a definition of “attention”: “I heard you”
(l. 13), “and we have your phone number and in a couple of weeks you will
have your first interview” (l. 14–15). This explanation, however, does not satisfy
P1, who simply aligns without affiliating (Stivers 2008) with the psychologist by
overlapping an uncompromising “bueno” in lines 12 and 16.
From the patients’ point of view, however, the activity they are participating is
an admission interview:
Excerpt 12
1 E5: e:h decime. vos llegaste acá:, a psicopatología,
2 derivada por algún otro médico del hospital? o viniste sola
3 por tu cuenta.
4 P5: e:m no. yo vine: se me terminó la obra socia:l, y me
5 agarró una crisis, y vine acá, me atendió el psiquiatra X.
6 E5: m:.
7 P5: e- por guardia. y él me mandó a hacer la admisión.
8 urgente.
9 E5: ahora?
10 P5: no:. me atendió la semana pasada.=
11 E5: =ah! está bien. y te dio alguna notita, algo?
12 P5: no:. no. no. me dijo que venga a hacer la admisión
13 temprano:,
14 E5: sí.=
1 E5: e:h tell me. Did you come here:, to psychopathology,

2 referred by some other doctor at the hospital? Or did you come alone
3 on your own initiative.
4 P5: eh:m no. I came: my insurance en:ded, and I
5 had a crisis, and I came here, and psychiatrist X treated me.
6 E5: m:.
7 P5: eh- at the ER. and he told me to do the admission.
8 urgently.
9 E5: now?
10 P5: no:. he treated me last week.=
11 E5: =oh! OK. And did he give you a note, anything?
12 P5: no:. no. no. He told me to come and do the admission
13 early:,
14 E5: yes.=
P5 is a middle-aged woman who led a typical middle-class life with her hus-
band and daughter until her husband lost his job. During that time, her depres-
sion was treated through the obra social, i.e. the health insurance provided by
labour unions. After losing that benefit, as a last resort, she resolved to go to
the hospital ER during a depressive crisis. As in other cases, she was referred to
begin clinical treatment at the outpatient mental healthcare service. The activity
is mentioned twice (l. 7 and 12) as “doing the admission”. In this case, there is
no repair initiated by professionals to change the designation.
This example shows the importance of point of view to designate the activity
of the outpatient mental healthcare service. Despite the psychologists’ efforts to
avoid the term “admission interview”, the term is used by both patients and doc-
tors, as it is an available designation in hospital settings.
However, the term also appears sporadically in the professionals’ speech, espe-
cially when referring to the institution, either in the administrative term used to
designate the “admission team” or to designate the statistical-epidemiological
forms, “admission forms”:
Excerpt 13
1 E7: ¿Y vas a poder venir acá?
2 P7: Sí, pero por eso yo necesito la constancia, por ejemplo
3 hoy necesité la cons[tancia para]
4 E7: sí, sí, ya (la hacemos).
5 F7: (inaudible) Pregunta. Las hojas de admisión, ¿dónde
6 están?
7 E7: ¿estas?
8 F7: Sí.
9 E7: Eh, en el armario de acá.
1 E7: and will you be able to come here?

2 P7: Yes, but to do so I need the certificate, for example
3 today I needed a cer[tificate to]
4 E7: yes, yes, right now (we’ll make it).
5 F7: (inaudible) question. The admission forms, where
6 Are they?
7 E7: these?
8 F7: Yes.
9 E7: Eh, in the cupboard over here.
Excerpt 14
1 E6: [bueno, escu-] escúcheme, me- escúcheme,
2 ((nombre de la paciente)) (2) me: espera afuera? sí?
3 puede esperar una hora más o menos? sí? que nosotros
4 ahora nos vamos a reunir con el resto del equipo
5 P6: tiene que ser en el hall, acá? porque=
6 E6: = sí, donde estaba
7 P6: porque ahí: bueno voy a ver si consigo dónde ponerme a
8 escribir
9 E6: si no ba- bueno, si no baje un poco abajo, después suba,
10 eh ahora nos vamos a juntar con las personas- con el equipo
11 de: (.) sí? de admisión, para ver a ver cómo- qué respuesta
12 le podemos dar
1 E6: [well, list-] listen to me, will- listen to me,

2 ((patent’s name)) (2) will: you wait outside? ok?
3 Can you wait for an hour, more or less? yes? Because we
4 are meeting the rest of the team right now
5 P6: does it have to be in the hall, here? because=
6 E6: = yes, right where you were before
7 P6: because there: well I’ll see if I can find a place to
8 write
9 E6: otherwise go- OK, otherwise go downstairs, then come back up,
10 eh now we’re going to have a meeting with the peop- the team
11 of: (.) right? admission, to see ho- what response
12 we can offer you
In Excerpts 13 and 14, psychologists use the term “admission” when adopting
an institutional point of view. The most evident case is Excerpt 13: the patient
asks for a certificate of attendance to present at work (l. 2, 3) and the professional
asks for the “admission forms” (l. 5). Excerpt 14 is more complex, as E6 attempts
to find the term to designate the whole team of professionals who work at these
interviews: in l. 4 it is called “the team”, but later there are some hesitations: in
lines 10–11 there are three self-repairs oriented to qualify that team. Thus, in l.
10 they are “the people”; then, “el equipo de:” (“the team of:”) and finally, after
a short but noticeable pause, a third, this time complete, formulation is offered:
“el equipo de admisión” (“the admission team”).
As a part of my collaboration with the outpatient service, I drew attention
to this ambiguity between a preferred, but confusing, non-clinical designation,
and a more extended term which is more familiar to patients but orients them
to a purely medical interpretation of the activity. Then, in an internal seminar,
the chief of the outpatient service began describing the activity in the following
terms:
Excerpt 15
1 B: la idea de hoy es (pedir) un grupo:- el grupo de consulta
2 un grupo de trabajo todavía no es un equipo, (nada más que
3 no hay otra forma de decir), acérquense
4 (ruido de sillas moviéndose)) (59)
5 bueno, les cuento un poco: (6) cuál es la idea, e:h (.)
6 este: grupo de trabajo, de la- que llamamos de consulta y
7 admisión en realidad es de consulta, e:h, pasa que va
8 tomando cada vez más forma de- de equipo y de equipos (1) y
9 la consulta va tomando una especificidad que en el inicio
10 no la tenía, en el inicio, eh, hace unos años
1 B: the idea today is to (ask) a group:- the consultation group

2 A work group is not yet a team, (just that there is no
3 better way to name it), come closer
4 (noise of moving chairs)) (59)
5 well, let me tell you: (6) what the idea is, e:h (.)
6 this: work group, of the- that we call of consultation and
7 admission it is actually of consultation, e:h, the thing is that is
8 more and more taking on the form of- of a team and of teams (1) and
9 the consultation is becoming more specific, with in the beginning
10 it wasn’t, in the beginning, eh, a few years ago
This example is taken from the beginning of an internal seminar on psychiatric

diagnosis for psychoanalysts in response to what I observed as a need for dialogue
between medicine and psychoanalysis. The chief of the service thus begins by
designating the group as the “consultation team” (l. 1) but then makes a more
precise metalinguistic definition, through the hedge “we call” in l.6. “Consulta-
tion and admission” (l. 6–7) is thus an attempt to designate the activity, and its
collective agent, by adjusting it to the patients’ expectations and the profession-
als’ principles. Therefore, the “specificity” (l. 9) of this new team seems to be
associated to this dialogue, in which the seminar took place.
Similar tension is observed when designating the participants in these “consul-
tation and admission interviews”.
‘So, what are you?’ Titles and forms of address

in defining role-identities
Assuming Parson’s (1975) overall characterization of “the organizing principles”
(Heritage & Clayman 2010: 119) of medical context, ethnographical descrip-
tions are often missed or even underrepresented in specialized research. As a con-
sequence, doctor-patient interaction appears framed in rough, schematic terms
which often ignore the everyday negotiation of these roles, historical develop-
ments and traditions in healthcare, ideological and political heterogeneity within
hospital personnel, etc. (Fochsen, Deshpande & Thorson 2006; Fox et al. 2009).
Indeed, there are many differences between public healthcare institutions in
Argentina and the data available on institutions in other countries. In Argentina
there are regularly labour conflicts, and posters bearing announcements from
labour unions and about public assemblies are an everyday sight (in contrast to
Wodak, who reports that “contradiction and conflicts are often concealed and
not discussed or exposed openly”, 2006: 682). Moreover, many health effectors
are anti-status oriented, and patients who belong to the lower classes are often
treated more quickly and more thoroughly than others (in contrast to Wodak
2006: 682: “Institutions are usually status oriented: members of the upper classes
are often treated quicker and more thoroughly”). Many new discourses have
actually obliterated some aspects of the asymmetry between professional knowl-
edge and lay ignorance: from patients demanding psychoactive medications
based on legal arguments to violent revenges which recently occurred, when
friends and family of a patient who died in a hospital broke in and attacked doc-
tors and other personnel.
In the case we are examining here, roles cannot be attributed a priori
because of the maladjustment in the definition of the activity. Although this
ambiguity is apparent in the interaction, it is rarely made explicit by partici-
pants, as in the case that follows:
Excerpt 16
1 E8: nosotros te vamos a derivar a psiquiatría. Te van a
2 estar llamando apenas puedan). (.) Y mientras tanto le
3 a la psicóloga que te haga como un, te haga un pequeño
4 podés pedir informe (2) de tu tratamiento para que cuando
5 la psiquiatra te reciba (1) tenga un poco de idea, cómo
6 te (vio) la psicó:loga, qué pasó en este tiempo. (1)
7 P8: ¿Qué? ¿entonces tengo que esperar a que me llamen?(2)
8 E8: Sí.=
9 P8: =¿Y ustedes qué son?
10 E8:Psicólogas
11 P8: Y yo no estoy para psicólogo. Yo ya estoy en la
12 psicóloga.
13 E8: La entrevista, la primera,
14 P8: Ah, ¿es [con la psicóloga?]
15 E8: [(la hacemos los)] sí, somos todos psicólogos, salvo
16 el jefe que es psiquiatra. Pero en una primera
17 entrevista, así como hoy, (.) no podemos derivar a
18 psiquiatría porque ellos tienen su agenda. Tampoco a
19 psicología. (.) O sea, como que
20 no- que suponete que no está la psicóloga, no podemos
21 salir a ver quién tiene turno=
22 P8: =¿Pero me van a llamar o me van a dejar colgada?
23 E8: =No, no. Te vamos a llamar. (.)
24 P8: Si no busco por otro lado.
1 E8: we are referring you to psychiatry. They will

2 be calling you as soon as they can (.) Meanwhile
3 to the psychologist to make, to do a little
4 You can ask for a report (2) of your treatment so when
5 the psychiatrist talks to you (1) she will have some idea of, how
6 the psychologist(saw) you, what happened during this time (1)
7 P8: What? So I have to wait to be called?(2)
8 E8: yes.=
9 P8: =So what are you guys?
10 E8:psychologists
11 P8: I am not here for a psychologist. I already have a
12 psychologist
13 E8: the interview, the first one
14 P8: oh, is it [with the psychologist?]
15 E8: [(we do it)] yes, we are all psychologists, except
16 the boss, who is a psychiatrist. But in a first
17 interview, like today’s (.) we can’t refer you to
18 psychiatry because they have their own agenda. Neither can we
refer you to
19 psychology (.) I mean, like
20 don- imagine the psychologist is not there, we can’t
21 go outside to see if there is one available=
22 P8: =But are you going to call me or you will let me down?
23 E8: =No, no. We will call you (.)
24 P8: Otherwise I’ll look elsewhere.
P8 is a teenager whose elder brother died beside her during a shooting at the
villa. Left alone with her baby son, she says she spends all day in bed, in a typical
depressive attitude. Although she is currently undergoing psychotherapy at the
local Centro de salud in the villa, her psychoanalyst referred her to the hospital to
receive psychiatric treatment. Thus her surprise in l. 9, when she does not under-
stand who she is talking to or, therefore, what she is doing. This is a consequence
of the maladjustment I have pointed out: E8 differentiates herself from “psychia-
try” (l. 1) and “the psychiatrist” (l. 5). As P8 was seeking a psychiatrist, she infers
(through the causal connector “so”, l. 9) that her interlocutors are not what she
expected and then re-evaluates the whole situation: “what are you guys?” (l. 9).
That is why E8 not only defines her profession (“we are psychologists”, l. 10) but
also the ongoing activity: “the interview, the first” (l. 13) and “a first interview,
just like today’s” (l. 16–17).
The effect of this maladjustment on P8 is mistrust and anxiety: with no audi-
ble pause after the previous turn, in l. 22 she infers from the previous talk that
there are high chances of being left unattended. Against this chance, she counter-
argues with the connector “but”: “are you going to call me or are you going to
let me down?” (l. 22). It is thus extremely important that patient expectations
should be adjusted, since they also affect the patient’s state of mind and trust.
One common way of defining the professionals’ role is through professional
titles and forms of address. In my fieldwork I have noticed the use of the term
“licenciado” (“graduate”) in three different ways. One is a professional cat-
egory, accompanied by the indefinite article (“preguntá por un licenciado que
te atienda”, “ask for a graduate to talk to”). The second is a professional title,
with a definite article (“vas a ver al licenciado Fulano”, “you will see graduate
Fulano”). Finally, used as a vocative, it is a form of address (“buen día, licen-
ciada”, “good morning, graduate”). These three functions of “graduate” are
equivalent to the use of the term “doctor” (when referring to a physician),
although the first (as a professional category) is a marked one, because “gradu-
ate” is a hypernym of “psychologist” (every psychologist is a graduate, but not
vice versa).
The graduates define themselves in opposition to the doctors, especially when
the duties and rights of each profession arise; psychiatrists (as opposed to “psy-
chologists”) are also designated as “médicos”, “doctores” o “psiquiatras”.
Excerpt 17
1 E11: °°permiso°° (2) nosotras somos psicólogas viste no
2 podemos hacerte receta de la medicación porque no somos
3 doctoras no somos médicas psiquiatras
4 P11: sí
1 E11: °°sorry°° (2) we are psychologists you know we can’t

2 write medication prescriptions because we are not
3 doctors we are not psychiatrists
4 P11: yes
As in many other examples, P11 asks for a prescription to continue self-

medicating. This demand entails identification of his interlocutors as belonging
to the professional class of psychiatric doctors, which is explicitly denied by E11:
“we are psychologists” (l. 1), “we are not doctors we are not psychiatric doctors”
(l. 2–3). In this case, the distinction between the two categories is useful for
rejecting P11’s demand for medication.
In other cases, professionals may align with patients as “doctors” in order to
achieve other interactional goals, such as calming down a person in a state of
anxiety:
Excerpt 18
1 E9: bue-=
2 P9: =pero dice si yo no vengo al psicó:logo: no me [dan el:
3 E9: [pero usted: qué cre- qué cree que le pasa a usted=
4 P9: =no SÉ doctora: se ve que yo estaba nerviO:sa ese día=
5 E9: no: quédese tranquila [que ((inaudible))
6 P9: [no SÉ:: por eso=
1 E9: O-=
2 P9: =but he says if I do not come to the psycho:logist: they won’t
[give me the:
3 E9: [but you: what do- what do you think is happening to you=
4 P9: =I don’t KNOW doctor: I suppose I was strE:ssed that day=
5 E9: no: don’t worry [we ((inaudible))
6 P9: [I don’t KNOW:: that’s why=
In this example, P9 failed a series of psychological tests to obtain her driver’s

licence and was sent to receive further examination at a public hospital. In this
example, the patient identifies the practice of “going to the psychologist” (“ir al
psicólogo”) with the activity in which she is participating. However, she designates
her interlocutor as “doctor” (l. 4) instead of “graduate” (“licenciada”), which
is the non-marked form of address in a medical consultation. In this case, as in
many others, E9 decides not to other-repair the medical designation “doctor”,
temporarily acknowledging this attributed role-identity to help the patient settle
down.
In our last example, we will see that even for psychologists, the maladjustment
in the definition of the activity can transpose to the definition of roles:
Excerpt 19
1 F10. =No, la verdad que no podemos. Vamos a hacerle una nota
2 ¿Quién te la::: recomendó a la doctora (.) licenciada X?
3 P10. Eh, mmm, una amiga
1 F10. =No, actually we can’t. We will write a note to her

2 Who di:::d recommend you this doctor (.) graduate X?
3 P10. Eh, mmm, a friend
In Excerpt 19, P10 is undergoing psychological treatment and was referred by

her therapist to psychiatry at the hospital outpatient service. In this context, F10
uses the term “doctor” as a professional title, although she notices that and self-
repairs with “graduate” after a very short pause (l. 2)
This designation somehow imposes itself as a part of a medical discourse which
is often also embodied by the psychologists themselves. We can thus analyze
“graduate” as a term which, at least discursively, is proposed as equivalent to – or
competing with – “doctor”.
Doing mental health: discourse between psychoanalysis

and psychiatry
The aim of this chapter was to understand the context of my research not as a
“framework” for interaction but as constitutive of and constituted by interaction.
As a consequence, context is itself a discursive problem, as it is historical, interac-
tional and socio-cognitive.
The heterodox presence of psychoanalysis in public hospitals and its historical
tension with psychiatry can be observed in the admission interviews and their par-
ticipants. Neither psychoanalysis nor psychiatry are clearly categorized, but they
are constantly defined, redefined and negotiated, with no clear results. Instead
of observing here the hegemony of medical discourse (or the counter-hegemony
of psychoanalytical discourse), what we observe is the struggle of professionals
and patients to make their voices both audible and understandable to each other.
Notes
1 Two important exceptions are Moyer (2011) and Moyer and Codó (2002), who
make a thorough ethnographic and sociological analysis of interaction at a public
hospital in Barcelona, Spain. However, I have not included their work because
their research focuses on migrants as patients rather than on physician-patient inter-
action. In a similar vein, the works by Pardo and Lerner (2001) and Pardo and
Buscaglia (2008) critically contextualize the issue of discourse and mental health,
though not in medical settings.
2 According to data provided by the hospital’s internal statistic service.
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3 Invisible landscapes
Diversity and the semiosis
of space
Introduction
The first obstacle I encountered in my research was to find out where the out-
patient mental healthcare service was located. General hospitals are large com-
pounds of buildings, each of which houses one or more clinical specialties, such as
“Obstetrics and Neonatology”, etc. At the hospital where I conducted fieldwork,
there was a recently painted building on which a sign sponsored by the phar-
maceutical laboratory Roemmers announced “Psychopathology” (Figure 3.1).
Upon asking for the outpatient mental healthcare service, I was sent across the
street to a building with the following signs (Figure 3.2).
At that time (2010), only the painted signs (“Pneumo-Physiology – Allergy
1st Floor” and “Gastroenterology 1st Floor”) (Figure 3.2) were readable on
the wall, so the outpatient mental healthcare service was invisible in the public
space of the hospital. After another sign sponsored by Roemmers was installed,
the service’s visibility is now not only very limited but achieved only through the
medical designation “psychopathology”. The struggle between “mental health”
and “psychopathology” (which I analyze in Chapter 7) has left its marks on the
hospital walls.
This change in the semiotization of space motivated new questions about the
role of language in defining the public space. These questions had tradition-
ally been answered from the perspective of Linguistic Landscape Studies (LLS).
However, the issues raised by Figures 3.1 and 3.2 are not traditionally addressed
by LLS because they present semiotic differences (in colour, design, informa-
tion distribution, etc.) and provide evidence of a discursive struggle (between
ideological positions about mental health), not a “linguistic” (in a restricted
sense) one.
I shall thus propose a different perspective on landscape with the aim of inte-
grating “restricted linguistic” and “restricted semiotic” data in a discursive inter-
pretation of public language(s). In this chapter, I read from a critical point of
view the field of LLS in order to systematize and better understand ethnographic
data – including notes, pictures, interviews and conversations – collected and
generated in my research.1 This chapter is therefore not a study on discursive
landscape but a discursive landscape interpretation of ethnographic data.
Figure 3.1 Private sponsored sign at the Psychopathology building
Figure 3.2 Limited visibility of the outpatient service of mental health

From linguistic to discursive landscape

The term “linguistic landscape” was coined in the mid-nineties (cfr. Landry &
Bourhis 1997) to represent a theoretical and methodological renewal in the stud-
ies of multilingualism in urban settings. The field has grown in the last decade
(a landmark being the special issue 3 (1) of the International Journal of Multi-
lingualism, in 2006), becoming fashionable: it has its own abbreviation (LLS,
Linguistic Landscape Studies), journals (Linguistic Landscape. An international
journal, published by John Benjamins) and controversies (cfr. Blommaert 2016;
Pavlenko 2016). It is a recent and dynamic field of research that sometimes seems
to have too little (and sometimes too much) theory, devoted to an object which
oscillates between empiricism and theoricism (cfr. Sebba 2010).
Since its origins, there has been a preference for phenomena of multilingualism
and cultural diversity (Gorter 2006; Shohamy & Gorter 2008; Shohamy, Ben-
Rafael & Barni 2010; Hult 2009). In methodological terms, there is a dominant
tendency to simply record the presence of written languages and analyze lin-
guistic aspects of their content, paying little attention to its materiality and the
semiotic modes involved. Linguistic landscape studies often risk repeating the
Saussurean gesture of abstracting the “purely linguistic” component of public
literacy, disregarding its interactional dynamics and semiotic complexity (just as
Saussure disregarded speaking, parole, for being “accidental” and “accessory”).
The question about the public presence of languages cannot be separated from
the questions about their semiotic materiality, hierarchy, forms of interaction and
other discursive features that can be registered and analyzed only through eth-
nography and direct observation.
Note: language-as-code and language-as-mode

Unlike other chapters in this book, this one was originally written in Spanish.
One of the challenges it presented was to translate the terms “lenguas” (“lan-
guages” or “tongues”) and “lenguajes” (also “languages”). The former refers
to verbal languages or tongues, which are social constructs attached to a more
or less stabilized linguistic code (which we call “Spanish”, “English”, etc.). The
latter refers to specific semiotic modes involved in every actual communicative
event, including here the language of colour, music, visual design, etc. Although
this difference can sometimes be pointed out (for instance, by using the article,
“a language”, in the former sense but not in the latter – “language”), when we
describe situations of plurality of lenguas and lenguajes, the only possible transla-
tion would be “languages and languages”. In order to maintain the theoretical
difference and the original scope of the research, we can describe the lenguas
as “language-as-code”2 and the lenguajes as “language-as-mode”, at least as an
approximate translation.
In theoretical terms, this distinction entails a difference between “linguistic
landscape” (and its main interest in language-as-code and linguistic diversity) and
Invisible landscapes 69
“semiotic landscape” (interested in language-as-mode and users’ experience). We
propose the term discursive landscape to relate and complement both objects as
they appear empirically: although theoretically different, the linguistic compo-
nent only exists in some sort of semiotic materiality.
Hospital landscape and language policies

in public healthcare
Topics of research in LLS usually fall between sociolinguistics and language pol-
icy and planning (Shohamy 2015). The Spanish term “política” can be translated
either as “policy” or “politics”, thus entailing a double meaning: it can be under-
stood as the process and result of legislating about language from a State point
of view (policy) or as the struggle for power in a given society or community
(politics). Public health is a State institution which is nevertheless fraught with
political tensions, so it is inevitable to articulate both perspectives (cfr. Arnoux &
Bonnin 2015).
Public hospitals are a good example with which to argue against institutional-
istic views on LPP (Unamuno & Bonnin 2018; Tollefson & Pérez-Milans 2018):
they are regulated spaces which should show, a priori, the State’s linguistic ideol-
ogy at its uttermost (cfr. Moyer 2011). However, it is a space fraught with diverse
discourses and logics, which even contradict each other. In the case of the hospi-
tal I am discussing here, what can be observed is not a language policy as much
as its absence (Bonnin & Vilar forthcoming).
This lack of policy regarding language in public health can be attributed to
a specific linguistic ideology based on the modern equation among language,
State, territory and citizenship (Blommaert 2009; Glozman & Lauria 2012). It
can be summarized as a monolingual representation of citizenship and a monoglossic
representation of language. Hence, on the one hand, beneficiaries of public poli-
cies in Argentina are addressed as a homogeneous Spanish-speaking community
through written campaigns, signs and monolingual professionals. On the other
hand, even when linguistic diversity is recognized (as a “handicap” of indigenous
speakers, for instance, in provinces like Chaco; cfr. Unamuno & Bonnin 2018),
language is treated as a transparent, neutral code which can easily be translated
into another. In the latter sense, differences between lects and social varieties are
almost invisible to health policies (but not to health agents, as we shall see in
Chapter 5; cfr. Vilar 2016 for a partial exception).
This is why, at a national level, the few LPP initiatives in healthcare are trans-
lations of Spanish into indigenous and minority languages in specific sanitary
campaigns instead of medical training for bilingual speakers or linguistic training
for professionals. In the case I analyze here, this lack of policies results in deregu-
lation of the linguistic landscape, which in practice enables powerful corporate
actors to appropriate and orient the semiotization of public space.
Linguistic landscape: methodological readings
of a theoretical metaphor
The delimitation of the scope of LLS is sometimes extremely empiricist, as can be
observed in some of its pioneering definitions:
the language of public road signs, advertising billboards, street names, place
names, commercial shop signs, and public signs on government buildings
combines to form the linguistic landscape of a given territory, region, or
urban agglomeration.
(Landry y Bourhis 1997: 25)
Linguistic Landscape is concerned with languages being used on signs

(hence, languages in written form) in public space.
(Gorter 2006: 11)
Although LLS are usually devoted to multilingual objects of enquiry, this is

not necessarily its only purpose. On the contrary, the metaphor of the landscape
can evoke contrasts (cliffs, mountains) but also regularity: the steppe, the sea
horizon. In societies shocked by recent unexpected immigration, such as Western
Europe and the United States of America, the emergence of other languages “in
written form” is both visible and public (Vertovec 2007). In other cases, like
Argentina, linguistic diversity is not necessarily associated to recent migrants but
to originary indigenous populations which have historically been discriminated
against and segregated. On the other hand, the number of speakers literate in
indigenous languages is much lower than the rest of the community, and their
literacy is a matter of politics of language developed over the past decade. In the
case we are dealing with, linguistic diversity is not visible but, on the contrary,
integrated into a semiotic continuum dominated by Spanish literacy. It is some-
how lost in the landscape.
Being invisible, however, does not mean being imperceptible. The issue of
literacy or “languages in written form” has become extremely restrictive in the
interpretation of the “landscape” metaphor. This is because, on the one hand,
languages are present in the landscape without being written: they are heard, they
integrate to the audible landscape and help giving meaning to it; and on the other
hand, because writing is not simply a neutral unequivocal graphic transposition of
sounds but develops simultaneously through different semiotic modes, thereby
producing different meanings. Many studies in mental healthcare settings associ-
ate linguistic landscape to linguistic accessibility, i.e. the degree to which a product
or service is accessible to minority languages speakers (cfr. Schuster 2012). This
kind of work, however, usually measures accessibility as a product of availability
of languages (as written code) in the visible space, not taking into account other
kind of actions that actually work as barriers (or facilitators) to access healthcare
(cfr. Moyer 2011).
From my perspective, language-as-code does not suffice to understand the
meaningful presence of multiple languages-as-modes in the hospital space.
Furthermore, even verbal language does not exist as a homogeneous code regu-
larly distributed within a homogeneous community, but usually appears as dif-
ferent varieties which coexist in the same context or community of practice. In
this sense, the linguistic dimension is only a part (albeit a very important one)
of access to healthcare. Such access also requires a set of communicative com-
petences which are developed through socialization and are therefore unequally
distributed in the social structure (Gumperz 1982; Hymes 1996). This process
of development of communicative competences (which Blommaert 2010 calls
“enskillment”) enables the production and interpretation of meaning through
gestures, clothes, movements and our own transit through the space. Our body –
as social actors, as researchers – becomes a “historical body” (Scollon & Wong
Scollon 2004) shaped by social processes and the individual’s biography, which
condenses experiences, knowledge and ways of speaking, thinking and acting.
This is why I will analyze here less explored spaces of hospital communication
which enable other languages (both as codes and as modes) and forms of interac-
tion to appear in the landscape of public health. This cannot be done only through
the photographic record of the walls. Changes in the organization of the chairs in
waiting rooms, the usual routes of people dressed in coats, the meaning of their
colours, the position of the chipa street vendors at the entrance (but also in the
inner yard and in some waiting rooms), the workshops and artistic activities at the
hospital, the colourful exterior murals and the light-greenish inner walls can only
be registered and analyzed through consistent long-term fieldwork. Other semiotic
modes also help organize the space of the hospital semiotically: the colour of the
robes classify and hierarchize people; the sounds of sirens entering the hospital index
specific kinds of events (either medical urgencies or police intervention); the volume
of voice delimits spaces, allowing louder voices in waiting rooms and mandatory
silences in intensive care locations. They tell us about different ways of appropriat-
ing and (re)constructing the public space, about the diversity of actors and lan-
guages that enter the scene and help design it. In this sense, travelling the landscape
with an ethnographic gaze opens the path to more comprehensive research, able
to observe the interaction between structural processes, local actors and space-time
concrete configurations (Blommaert & Maly 2016; Blommaert 2010).
It is difficult to get to know a place from the point of view of a tourist passing
through, watching through the car window, stopping every now and then to take
a picture or buying handicrafts. The point of view of the traveller is different: he
or she is ready to stay, to walk, to talk. A tourist seeks the exotic, the curious, even
the bizarre, reading space as a text which is necessary to describe. A traveller’s
gaze, instead, endeavours to understand the regularities, beyond the semiotic dif-
ference, which do not appear as a monological text but as a conversation in which
the observer necessarily participates.
Case presentation: the people and the neighbourhood

In what follows, I will present a possible path through the discursive landscape of
Hospital X, looking at both its visible and invisible (yet audible) features. In order
to maintain the confidentiality of the location of the hospital and participants in
my research, the data analyzed here were recorded in three different locations,
looking for equivalent features, especially with regard to a previous study on lin-
guistic landscape in Buenos Aires (Bonnin & Vilar forthcoming).
One of the oldest and largest villas de emergencia in Buenos Aires is located in
the neighbourhood of our hospital. It began in the 1940s with the settlement
of migrants from poorer provinces. Migrants from Paraguay, Bolivia and Perú
currently account for 31% of the population in Buenos Aires City, the Federal
Capital of Argentina. Twenty-eight percent of the city’s population was born
in Argentina, but not in Buenos Aires.3 New population from Africa and China
has recently settled in the neighbourhood, though no reliable updated data are
available.4 The population in Buenos Aires City is much more diverse than usu-
ally represented in media; indeed, for most people, especially those who attend
public hospitals, the local variety of Spanish is not their first language, and many
others do not even speak Spanish at all. In any case, it is a population with hetero-
geneous linguistic repertoires which necessarily contrast with a monolingual and
monoglossic healthcare policy, thereby replicating and heightening the unequal
status of these migratory groups in Buenos Aires (Courtis 2011, 2012). As occurs
for other issues, there are no statistical data on linguistic diversity in the city.
This diversity, which is neither named nor shown by the public healthcare sys-
tem, emerges in the everyday practices of individual social actors, who have to
solve situations or overcome linguistic, social and cultural barriers in order to
access healthcare. What remains visible, instead, is managed by corporate actors
that appropriate public space and take over some typically State-sponsored com-
municative activities, such as sanitary campaigns and hospital signage. The lack of
public policing thereby enables the privatization of the hospital’s semiotic space.
Through direct observation, interviews with users and the record of mul-
timodal texts in the public space, I will analyze the dynamics among actors,
language-as-code and language-as-mode which contribute to creating the hospi-
tal’s discursive landscape. I shall begin with the more visible data (written Span-
ish) to look more in-depth at what is there, although it cannot be seen: minority
languages which “should not be there”, as they are typically associated to other,
modern-State, spaces (peripheral provinces and neighbouring countries with a
recognized presence of indigenous population). This anomalous presence of
unexpected languages and speakers would enable the presence of new kinds of
sanitary agents, who manage linguistic inequality as voluntary, personal work. In
one sense, these grassroots LPP initiatives are the only ones being formulated,
actually put into practice and enabling access to less valued languages, and more
importantly, to their speakers.
The visible landscape: interaction, stratification and time

The visible landscape is observable in different forms and materials of writing in
the public space. There is constant political tension, within the linguistic limits of
Spanish, which enables us to understand the diversity of actors and relationships
which configure it.
From the point of view of the materials, we can trace a continuum that goes
from the offset sign, professionally designed and printed, to the handwritten note
precariously stuck with tape. From the point of view of its discursive dynamics,
there are different degrees of space-time dependency. The offset, for example,
is designed to endure over time. Even if new semiotic layers are added, they
transform, but do not cancel, the previous signs. Some of these have a lower
degree of context dependency: public services (“Wi-Fi”) or general norms (“No
smoking”) not only endure over time but are also relatively independent from
space. Their referential field thus extends to the entire institutional space, not
only the particular place where they are situated. The handwritten sign, on the
other hand, is more ephemeral; its own material suggests spontaneity: “I’ll come
back later” (“vuelvo más tarde”) is fully deictic: in personal (“I”), spatial (through
the deictic verb “come back – here”) and temporal (“later” in this day) terms.
This deixis suggests closeness to institutional agents and everyday dynamism,
especially in cases that show stylization in the handwriting and not just a mere
cheaper substitute to computer-printed signs (cfr. the signature “Dermatología”,
“Dermatology”, in Figure 3.5).
Landscape as interaction
Discursive landscape develops not only in space, but also through time (Blom-
maert 2010). It is the product of actors whose actions leave traces in the environ-
ment. Figures 3.3 and 3.4 show these historical dynamics of interaction among
different social actors in the public space at the hospital:
Both figures show actors and actions in tension in the visible landscape. In
both we observe an example of industrial signage donated by the private labora-
tory Roemmers, which has made such donations to every public hospital in the
city. In the top left corner of Figure 3.3, which is the place where western reading
typically begins (Kress & van Leeuwen 1996), is the donor’s isologotype. How-
ever, there is the trace of a sticker, now unreadable, of a leftwing political party
which has been stuck over the isologo.
Figure 3.4 shows a very similar scenario. An inner wall is vertically divided
into two zones: the upper zone is typically associated to hierarchy and visibility,
and valued as “ideal”, while the lower zone is understood as less important, less
visible and more “real” (Kress & van Leeuwen 1996), associated to concrete
information.
In the higher zone, the offset sign states that it is a donation from a private
laboratory, Roemmers, and the same visual design is used throughout the hos-
pital. The brand seems to support communication from the central, lower posi-
tion, associated to responsibility and reliability. Its presence creates an effect of
identification between the institutional space and the company through the use
of the same colour palette, typography and the isologotype. We can observe here
a process of privatization of the hospital semiotic space, which can only be navi-
gated thanks to the laboratory’s donations.
Figure 3.3 Struggle of social actors to define the public space
Practically as a response to this privatization, we see in the lower-left zone of the

sign a sticker with the logotype used by YPF (“Yacimientos Petrolíferos Fiscales”,
“National Oil Company”) prior to 1992. YPF was a State-owned oil company
deeply intertwined with discourses of national identity, and its privatization in
1992 was widely and critically discussed. In 2012, the president of Argentina at
that time, Cristina Fernández de Kirchner, expropriated 51% of YPF’s shares and
placed them under State control. In this context, the old, pre-1992 logo was used
again as a part of a support campaign for the re-nationalization. Layered over the
privatized sign, a sticker that celebrates nationalization seems to establish a criti-
cal dialogue, an argument, on the wall. This dialogue has a third turn, also visible:
somebody tried to remove the YPF sticker, which is now torn and only partially
visible. Similarly, on both sides of the Roemmers logo are traces of previous stick-
ers, now completely torn away. The same can be observed in Figure 3.3. There
is thus a process of privatization of the semiotic organization of the public space
at the hands of corporate actors of the healthcare industry. However, there is also
contestation and protest confronting and arguing with them.
Stratification and deixis: the (non)institutional mediators

The conflict over Roemmers’ professionally produced signs contrasts with every-
day communication at the hospital, which is left in the hands of non-medical staff.
Figure 3.4 Ideological debates on the hospital’s discursive landscape
Figure 3.5 shows the window where administrative staff talk to patients who
seek care in the dermatology department. It is identified by an offset sign. There
are four other computer-made signs, two of which are corrected in handwriting.
The top left sign shows some typical pragmatic functions of this kind of sign: to
offer information (“For the attention of underage patients, relevant paediatric
Figure 3.5 Layered communication at the hospital’s landscape
referral is required”) and to command (“Please do not insist!!!!”). The latter

function is achieved through reference to previous interactions, using exagger-
ated exclamation marks, which work as a conventional indicator of prosody. The
interactional effect is emphasized by the handwritten signature, “Dermatología”
(“Dermatology”), which does not designate the place, but the author of the sign.
As in other handwritten interventions, this signature seems to create closeness to
institutional agents instead of simply being an institutional marker.
In the centre of the window there is another sign, fully handwritten, which
again offers information (“during the scientific conference week only 16 num-
bers will be distributed”) and commands (“Do not insist”). The latter sign is not
printed by computer, which might be interpreted as an index of its temporary
nature: it will only be relevant this week. However, it is not dated, so its deictic
nature might create greater confusion (as it is usual for handwritten signs to
remain for months or years in the same place). Although both examples include
personal deixis (“no insista – usted-”, “do not insist – you”), only the second is
temporally deictic, referring to the present week. Rather than being informed by
the professionally designed signs sponsored by Roemmers, patients are effectively
guided through the hospital labyrinth by the makeshift handmade signs.
The traces of other signs, their relationship of conflict and competition for vis-
ibility in the hospital landscape, not only illustrate the precariousness of hospital
communication, but also the constant change of the institutional organization:
an organization which cannot be adequately communicated by the stable,
planned signage donated by Roemmers. The zone of the Real – the intervention
of administrative personnel with homemade signs – is temporary, as it is the distri-
bution of available actions at the hospital. The zone of the Ideal – the Roemmers
signs – is durable, because it projects the semiotization of the hospital. However,
it is also the place for politics and confrontation.
The “layered” communication observed in the physical space of the hospital
enables a diachronic reading of the functional dynamics of the institution, which
changes names, uses and behaviours. In this sense, we can say that there is not
a single landscape visible in the hospital but different communicative layers that
occur on different and interconnected scales, generating particular space-time
dynamics: the insistence of patients in performing “wrong” actions motivates
administrative staff to produce handmade signs, thus intervening in the public
space in dialogue with other signs that were already there. In this process, space
is semiotically co-created and formed by different agents in complex interaction.
The invisible landscape: minority languages

at the borders of the hospital
Patterns of distribution of languages (as code) in the public space may index
the linguistic repertoires of the people navigating that space (Soler-Carbonell
2016). Hence the presence of, for example, written Portuguese in Buenos Aires,
which is associated with tourism: bus stations, airports, shopping malls, muse-
ums, restaurants, etc. display signs in Portuguese, Brazilian iconography, etc. As
this population has private health insurance, there is no written Portuguese at
public hospitals, though it can be seen at certain police stations which are closer
to the city’s touristic circuits.
This distribution, however, cannot be seen only as an index of a certain pre-
existent, demographic reality. It is also – and, perhaps, mainly – a political deci-
sion: What population speaks the language the State wants? Which speakers (as
associated to a certain language, following my previous discussion) are the ideal
citizens that the State rules for? The same spaces – for instance, the long-distance
bus station – receive more Guaraní than Portuguese speakers. Guaraní, however,
is invisible, because it indexes a less valued kind of speaker: unqualified migrant
workers rather than middle/higher-class tourists.
If we only observed what is visible at the hospital, i.e. written signs, we would
conclude that it is a Spanish monolingual setting. The Ministry of Health has
implemented health campaigns in indigenous languages, though none in Buenos
Aires. Following the assumption that language is attached to territory, these cam-
paigns have been implemented in provinces with larger indigenous populations,
not taking into account the mobility of people through political borders.
Even in places with a higher presence of indigenous population, language poli-
cies at healthcare settings depend on individual agency rather than State plan-
ning, as can be seen in Figure 3.6.
Figure 3.6 Grassroots language policies at indigenous communities

Courtesy of Virginia Unamuno and Lucía Romero
This photo5 shows the intervention made by an indigenous health agent from
Chaco Province on a national vaccination campaign poster, substituting every
Spanish text for Wichi. This intervention does not work as a sign (because mono-
lingual Wichi speakers are not literate) as much as a signal: its function is to make
visible an indigenous language in its written form. It is not a “communicative”
act as much as a political one, indexing the language rather than communicating
a message, which was maintained in Spanish alongside the other one (cfr. Una-
muno & Romero 2016).
It would be extremely restrictive to say that minority languages are not a part
of the linguistic landscape at public hospitals. Even if they are not visible, they are
audible, especially if we are receptive to them. An ethnographic approximation
to the landscape (that of a traveller instead of a tourist) enables us to see how
minority languages integrate and re-contextualize the hospital setting. Indige-
nous languages do not appear, as in Chaco, in written interventions from users or
professionals; however, they enter the hospital and circulate in a manner that dif-
fers from the State language. Spanish is used in the formal circuits of the institu-
tion (administration, medical consultations, information desks, etc.). Indigenous
languages are used in the interstices of the institution: the entrance door, the
yards, the waiting room and some of the halls.
Indoor and outdoor languages
Linguistic diversity in the hospital landscape can be described by the opposition
between inside and outside spaces. Indoors, the hospital is clearly oriented towards
monolingualism: medical consultations, official forms, public signs, health cam-
paigns, signage, etc. are “Spanish only”. Outdoor languages, on the other hand, cir-
culate through liminal spaces (Rampton 1997; Turner 1982), in transitional zones
between inside and outside the institution, such as yards, halls and waiting rooms.
Street vendors, for instance, offer their products at the entrance of the hospital:
In Figure 3.7, the vendor of chipa (a cheese bread popular among migrants
from Paraguay and Northeast Argentina) is standing at the hospital door. When
I ask him if I can take a picture, he asks me, only half-jokingly, “No me vas a sacar,
no?” (“You won’t kick me out, right?”), implying that I could be working for the
police. We chat for a while, and I tell him that I am researching the languages
spoken at the hospital:
Excerpt 1
V: Un montón hay. De todo. Yo no, yo soy argentino, pero hay un montón
de guarapas.
Y: ¿Y vos hablás algo de guaraní?
V: No, no hablo. Entiendo algo, viste, porque vendo, pero no hablo.
Porque yo vendo de todos los países: el chipa que es guarapa, las bolitas
que son . . . no sé qué son. Lo único que no vendo es tortilla, que es argen-
tina y la vende la peruana. (Field notes, 2014)
V: There are a lot. A lot. Not me, I am Argentine, but there are a lot of
guarapas.
Y: And do you speak any Guaraní?
V: No, I don’t speak any. I do understand some, you know, because I sell,
but I don’t speak. Because I sell things from any country: the chipa that is
guarapa, the bolitas that are . . . I don’t know what they are. The only thing
I don’t sell is tortilla, which is Argentine, and is sold by the Peruvian woman.
His words index a diverse repertoire built up in a neighbourhood of mobile

people and languages with a strong modern imaginary. Thus, he identifies lan-
guage and nationality when, in the first line, he sketches an opposition between
“speaking Guaraní” and “being Argentine”.
Guaraní speakers are designated twice as “guarapas”, an interesting term
which shows traces of several sociolinguistic processes. In the first place, the term
“guarapa” is a Central American word for an indigenous fermented beverage
obtained from fruits, saps and canes. It is also the product of a metathesis by
permutation (that is, permuting the syllables of a word) of the word “paragua”,
an apocopation of the demonym “paraguayo”. This apocopation has a pejorative
Figure 3.7 Heteroglossic repertoires of street vendors
meaning in designating Paraguayan migrants in poor neighbourhoods in Bue-

nos Aires (villas or villas de emergencia), along with other demonyms such as
“chilote” (for someone from Chile) and “bolita” (for someone from Bolivia).
The permutation of syllables, moreover, is a typical word-formation strategy
known in Buenos Aires as “hablar al vesre” (“talk wardsback”, similar to English
“back slang”), which became popular as a lexical process of the lunfardo spoken
in the early twentieth century. When asked specifically about his competence in
Guaraní, the vendor pointed out that he “understands but does not speak”, a
phrase that Gandulfo (2007) analyzes as a consequence of the stigmatization of
that language in Corrientes, Argentina.
Modern and post-modern sociolinguistic processes are intertwined in this
small exchange: a national discourse of monolingualism, a century-and-a-half-
old word-formation process, mobility through national and provincial borders
and yet the perception of a changing reality, as when describing the relationship
between the nationality of the vendor and the origin of the products. When
I went to see “the Peruvian woman” (la peruana), I found her with her home-
made grill next to a tree with the following handmade sign:
The sign at Figure 3.8 was made by her daughter-in-law, who was born in
Argentina of Peruvian parents. It reads “Tortillas/Corner/Turning around (volt-
eando)”. In weaker ink, a previous version read “en la esquina” (“at the corner”)”.
Figure 3.8 Intra-linguistic diversity at the street
However, it was redesigned with an iconic arrow with the word “corner” on it and
a new, thicker and more stylized handwriting. The term “volteando” (“turning
around”), meaning “around the corner”, is marked in the Spanish of Buenos Aires,
but common in Andean Spanish. As a sign of diversity within Spanish, its presence
is also visible right outside the hospital, as an outdoor language, but not inside.
Indoor linguistic diversity, on the contrary, is not written, but it is audible.
However, in order to appear, it requires some privacy. When conducting inter-
views in the waiting rooms, it took some time for patients to feel comfortable
enough to describe themselves as speakers of minority languages, even though
they do show some kind of competence in many of them. The lack of policies
regarding indigenous languages at the hospital as a consequence of the mono-
lingual ideology has an impact on these languages by attributing lower value to
them and tying them to prejudices about poverty, ignorance, cultural backward-
ness, etc. Sometimes they are not even considered “languages” at all:
Excerpt 26
1 G: no hablás guaraní?
2 P: sí
3 M: a::h! (risas) no nos contaste
4 G: sabés otra lengua
5 P: pero la mayorí- siempre me dicen que: el guaraní no es
6 Idioma (.) entonces (risas)
7 G: a::h mirá
8 P: me dicen eso verdad
9 G: y hablás fluido (.) guaraní?
10 P: sí
11 G: y con quién hablás en guaraní?
12 P: y: con alguna gente:: de paraguay también que encuentro
13 acá en la::=
14 M: =(inaudible) con tu familia de paraguay?
15 P: m::
16 G: y acá en el hospital nunca escuchaste gente hablando en
17 guaraní?
18 P: sí escucho
19 G: y a quién escuchás? qué son? pacie:ntes (.) mé:dicos
20 P: sí (.) pacientes
21 G: pacientes
22 P: mh:
23 G: y con ellos no hablaste (.) tampoco?
24 P: no
25 G: los escuchás nada más
26 P: escucho nada más (risas) (. . .)
27 G: y cuando escuchás a otros hablar en guaraní no te da
28 ganas (.) de hablar con ellos?
29 P: sí (.) pero (risas)
1 G: don’t you speak Guaraní?

2 P: yes
3 M: o::h! (laughs) you didn’t tell us
4 G: you do know another language
5 P: but most peop- they always tell me tha:t Guaraní is not
6 a language (.) so (laughs)
7 G: o::h I see
8 P: that is what they say
9 G: and do you speak (.) Guaraní fluently?
10 P: yes
11 G: with whom do you speak Guaraní?
12 P: mm: with people:: who are from Paraguay too that I meet
13 Here at the::=
14 M: =(inaudible) with your family from Paraguay?
15 P: m::
16 G: and here at the hospital, didn’t you ever hear people speaking
17 Guaraní?
18 P: yes I do
19 G: who do you hear? What are they? pa:tients (.) do:ctors
20 P: yes (.) patients
21 G: patients
22 P: mh:
23 G: and didn’t you speak to them (.) either?
24 P: no
25 G: you just listen
26 P: I just listen(laughs) (. . .)
27 G: and when you hear other people speaking Guaraní wouldn’t you
28 like (.) to speak to them?
29 P: yes (.) but (laughs)
Although P answered that she only speaks Spanish, we decided to ask specifi-
cally whether she speaks Guaraní, which is widespread in Paraguay. Her affirmative
answer is received with laughs (l. 2) which seem to show some kind of awkward-
ness on her side in l. 6, 26 and 29. When G formulates her answer as “you do
know another language”, P explains her previous negative answer: in l. 6–7 she
uses a reportative evidential to justify why she did not consider “Guaraní” as “a
language”. The reason is diffuse in its source, but categorical in its content. We
can read here traces of previous normative experiences which repressed the use of
this language by P, a common episode in many biographies of Guaraní speakers
in Argentina (Gandulfo 2007). Although G does not provide any more feedback
on the matter (“oh”, in l. 7, is not continuative in this context), P insists on this
evidence in l. 8 but then abandons the issue to follow G’s agenda. Although P
declares that Guaraní is spoken at the hospital, she does not use it in this context
to talk with strangers. She only uses the language to talk to her family (l. 14–15).
Even though she “feels like” talking to others at the hospital, she does not. The
reason is as undetermined as the source of the evidence that Guaraní is not a lan-
guage (l. 29); the awkward laugh seems to point out, again, that it is a language
only spoken in private, familiar settings.
Indigenous languages are not represented as public languages, but as private
ones, languages that belong to another time and place:
Excerpt 3
1 J: le hago una pregunta (.) usted habla otras lenguas
2 además del español?
3 E: °no°
4 J: ahí en: Corrientes no hablaban guaraní?
5 E: no::: (nah) ya esta pasó ya eso
6 J: por qué ya pasó?
7 E: y porque yo no me crié en Corrientes soy nacida y
8 a los catorce años me vine a Buenos Aires
9 J: pero y en esos catorce años no aprendió nada
10 E: na::h (1) no, además no me gusta
11 J: no le gusta? por qué?
12 E: ts ts (.5) mis hermanos me hablan todo así (.)
13 cuando hablan por teléfono? (.) no: les digo que::
14 que me contesten bien a mí
1 J: tell me(.) do you speak any other languages

2 besides Spanish?
3 E: °no°
4 J: over there in: Corrientes you didn’t speak Guaraní?
5 E: no::: (nah) it’s all over now
6 J: why it is it all over?
7 E: because I wasn’t raised in Corrientes I was born there and
8 when I was fourteen years old I came to Buenos Aires
9 J: but and in those fourteen years, didn’t you learn any Guaraní?
10 E: no::h (1) no, besides I don’t like it
11 J: you don’t like it? why?
12 E: tsk tsk (.5) my brothers speak to me like that(.)
13 When they phone? (.) no: I tell them::
14 You speak properly to me
E is a strong woman who travels once a week from Gualeguaychú to Buenos

Aires to bring her granddaughter to treatment at the hospital. Although she was
born in Corrientes, a province at the north-east of Argentina, on the border
with Paraguay, she left her hometown as a teenager to live in Buenos Aires. Like
P in Excerpt 2, E confronted normative discourses during this process which
repressed her use of Guaraní as a stigmatized language. Hence the reason why she
declares she speaks only Spanish: “ya pasó eso” (“it’s all over now”, l. 5), headed
by a derogatory “nah”. She does not declare losing the language for lack of use
but as an effect of moving from one territory to another.
These derogatory experiences of her adolescence can be traced in both “nah”
in l. 5 and 10, in her dislike expressed in l. 10 (“I don’t like it”) and the presence
of the normative, Spanish-only evaluation in l. 12–13, when E admonishes her
brothers for speaking “like that” (l. 12) and evaluates Spanish monolingualism as
“speaking properly” (l. 14).
Minority languages thus seem to belong to another time and space; not to the
younger but to the older generations, who feel the stigma and do not transmit
the language to their children:
Excerpt 4
1 M: y vos tenés familia acá? O se quedaron en paraguay?
2 E: tengo familia. Tengo acá tres hermanos. Y mis
3 padres que murieron (inaudible)
4 M: y: ellos hablan, con ellos hablás en guaraní
5 E: si:: si
6 M; y con tu hija?
7 E: ella? No porque: como en casa:: mi pareja ess de acá
8 no: ellos noo hablan (inaudible) como yo no ha: blo con
9 mi pareja entonces ellos no entienden
10 M: o sea que ella no sabe: no- nada
11 E: no, no
1 M: and do you have any family here? Or did they stay in Paraguay?
2 E: I have family. I have three brothers here. And my
3 parents who died (inaudible)
4 M: and: they speak, you speak Guaraní to them
5 E: ye::s yes
6 M; and to your daughter?
7 E: to her? No because:: as at ho::me my partner is from here
8 right: they don’t speak (inaudible) as I don’t speak: with
9 my partner so they don’t understand
10 M: so she doesn’t know: no- anything
11 E: no, no
The mediators
We have observed that State deregulation of communication in the hospital
somehow forces healthcare providers to design and intervene in the discursive
landscape themselves. We have seen in the previous section that administrative
staff work as mediators through handwritten signs.
In other cases, patients work as cultural mediators through interaction, either
between languages or between lects:
Excerpt 5
1 J: y vos cuando hablás allá con tus paisanos? sobre qué
2 temas hablás?
3 Abuela: [eh nosotros]
4 J: [porque vos] evidentemente hablas perfecto castellano
5 Abuela: cla::ro, si, y:, yo, eh:- y hablamos, también,
6 sobre, (chasquido) o sea que por ahí, con mis paisanos,
7 por ahí llegaron de allá y:, les cuento de acá::, e:,
8 esas cosas
9 J: claro
10 Abuela: = para tenerlos m:ás al, al día de las cosas de
11 aquí, mayormente hablo en quechua a las personas que
12 llegan de allá y por ahí no no se adaptan mucho, entonces,
13 como yo, eh:, mi mamá nos crió así sin olvidarnos del
14 habla del quechua, entonces yo hablo, (0.1) hablo con
15 las personas mayores más que todo
16 J: con las personas mayores [sobre todo
17 Abuela: [sí]
18 J: = todo, y y tu hijo habla?
19 Abuela: no
20 J: no?
21 Abuela: no, no
1 J: and when you speak over there to your paisanos? what do you
2 talk about?
3 Abuela: [eh we]
4 J: [because you] evidently speak perfect Spanish
5 Abuela: of course:: yes and:, I, eh:- and we speak, too,
6 about, tsk, may be, with my paisanos,
7 maybe they arrived from over there and:, I tell them about here::, eh:,
8 those things
9 J: of course
10 Abuela: = to keep them more: up- updated about things
11 here, mostly I speak in Quechua to people who
12 come from there and maybe they don’t don’t adapt much, so
13 Like me, eh:, my mother raised us like that and didn’t let us forget
14 how to speak Quechua, so I do speak (0.1) I speak to
15 elder people mostly
16 J: to elder people[mostly]
17 Abuela: [yes]
18 J: = and does your son speak?
19 Abuela: no
20 J: no?
21 Abuela: no, no
In this example, the participant comes from Bolivia, and she says that speaking
Quechua is a feature of her upbringing: “my mother raised us like this, she didn’t
let us forget how to speak Quechua”. In her case, the language is associated to
family and the elders, serving as a cultural bridge between the homeland and the
adoptive land: “los que recién llegan de allá”. As seen in the previous section with
regard to Guaraní, Quechua also appears as a private language which is spoken
with the elders but not with the younger generations, who do not know it.
This function of cultural and linguistic mediation is not exclusive of the homes
of migrants. It also appears in the hospital, often between specialized medical
language and the patients. We have observed, and will analyze in the following
chapters, the difficulties that arise from the lack of accommodation between spe-
cialized and non-specialized language at the consultation, where a different kind
of broker is needed. Not being provided by the State, its presence depends on
individual competencies and dispositions.
Excerpt 6
1 M: ah. y vos decís que se sentís acompañada por qué-
2 por consultar con- con tu hermana
3 E: y claro porque las dudas=
4 M: =o venís con ella acá
5 E: no: nono las dudas las =
6 M: =(inaudible entre risas)
7 E: no no no, no. Las dudas las, las evacúo con ellos.
8 M: aah ok, o sea te quedás con lo que, te dice el
9 médico, y después lo consultás con ella
10 E: eeh, varias de las cosas que me dice.
11 M: mhm, y hay alguna: algún ejemplo que te acuerdes de
12 algo que no se entendió bie:n, más allá de esto que decís
13 del tumor, el lenguaje que utili::zan,
14 E: y, los médicos en general utilizan una terminología
15 que entre ellos se entienden, eh y desglosarlo: . . .
16 desglosarlo:: a veces no lo quieren desglosar ellos
17 para pasarlo transformarlo para que llegue al- al común
18 de la gente
19 M: claro
20 E: queda, en el tiempo que tienen e::los en las ga::nas,
21 algunos son más, abiertos y otros no a mí me tocó ver
22 todo tipo de médicos acá
1 M: oh. and you say you feel accompanied for wha-

2 for consulting w- with your sister
3 E: of course because just in case=
4 M: =or you come here with her
5 E: no: no no my doubts I=
6 M: =(inaudible laughing)
7 E: no no no, no. My doubts I talk, I talk to her.
8 M: aah ok, so you just listen to the
9 doctor, and then you consult her
10 E: eeh, many things she tells me.
11 M: mhm, and is there any: any example you remember
12 Anything that was not quite understood: beyond this thing you say
13 about the tumor, the language they use::
14 E: and, doctors usually use terminology
15 that they understand each other with eh and break it down:
16 Break it down:: sometimes they don’t want to break it down themselves
17 To pass it on transform it to reach the co- common
18 People
19 M: of course
20 E: it is left to, the time they:: have whether they fe:el like,
21 Some of them are more, open and other are not I have seen
22 all kinds of doctors here
Here the interviewee is a 45-year-old woman who is at the hospital for her
daughter to be treated. She points out that she is “accompanied, because my
sister is a doctor”. E counts on her sister to “break down” (l. 15, 16), “trans-
form” (l. 17) doctors’ specialized discourse “so it reaches the common people”
(l. 17–18). Although “some of them are more open-minded” (l. 21), the media-
tion between specialized medical discourse and laypeople is left to the good will
or open-mindedness of individual doctors or to networks and available resources
of patients.
When discussing the visible landscape, we observed that signage is left in the
hands of private companies such as Roemmers. It became more and more inac-
curate over time until healthcare workers had to intervene and create new signs
to handle everyday communicative needs.
The role of the mediator is another form of dealing with certain obstacles
linked to the unequal evaluation of languages and varieties at the hospital, with
technical medical Spanish being the most highly valued, while minority languages
and laypeople’s communicative needs are not addressed. Not having access to this
kind of mediation often means not having access to proper healthcare.
Actors and actions in the discursive landscape

The ethnographic perspective has allowed us to navigate the hospital linguistic
landscape limited not only to what can be read but also to what can be heard.
We observed that users’ right to healthcare is conditioned by an institution
that presents itself as monolingual and monoglossic and a State which is absent
in the formulation and implementation of linguistic and communicative policies
in public health.
This situation of linguistic inequality is managed by workers and users them-
selves at the most basic local levels. The obstacles of the semiotization of the
space, due to outdated, under-informative or contradictory signs, are comple-
mented by obstacles in the interaction with medical professionals, which demand
the participation of mediators capable of providing inter- and/or intra-linguistic
management. This management cannot be described in traditional terms of “lin-
guistic accessibility”, a notion that usually assumes a homogeneous community
and not a heterogeneous population with distinctive repertoires, experiences and
needs (Unamuno & Bonnin 2018).
As in other domains of social life, when the State has retreated, corporate actors
step in. Official hospital signage is sponsored by Roemmers Laboratory. Other
kinds of information, such as campaigns, prevention information, etc., also are
left in corporate or NGO hands.
This process of privatization of the semiotic space is limited by time: the prac-
tices and itineraries of workers and users change constantly. This change is only
followed by more or less spontaneous, less formal and less planned forms of
communication which leave their trace on the visible landscape. These responses
have a subordinate place: they correct, complement or update, but do not cancel
previous signs, thus creating a stratified and hierarchized communicative device
that sometimes adds confusion for users.
As a last resort in access to healthcare, users’ diversity is not seen but heard.
Mediators develop competences which allow them to navigate the space. Their
role is the best place to look at diversity and linguistic inequality, as they show
both the contact between languages and between varieties of the same code.
Notes
1 I am grateful for the assistance of Milagros Vilar, who helped collect and analyze
part of the verbal and visual data discussed in this chapter.
2 I use the term “code” only as a simplification and quick characterization of the
object; of course, I do not believe that language is only a stable, normative correlate
between words and stable meanings.
3 Source: “Distribución porcentual de los inmigrantes recientes por lugar de
nacimiento y sexo”, Ciudad de Buenos Aires, año 2014, Dirección General de
Estadística y Censos (Ministerio de Hacienda GCBA), EAH 2014.
4 The most recent data comes from the 2011 census, which counted 8,929 people
born in the People’s Republic of China, of whom 82.76% live in Buenos Aires City
and Buenos Aires Province.
5 I thank Lucía Romero and Virginia Unamuno, who took this picture as a part of
their research project on indigenous language transmission in Chaco, Argentina
(cfr. Unamuno & Romero 2016).
6 I thank Milagros Vilar, Geraldina Fernández and Luz Espain who were part of
the small fieldwork team who conducted these interviews in 2013. The issue of
linguistic diversity was not expected, as our interest was narratives about hospital
experiences and doctor-patient communication.
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4 Diagnosis and treatment
Sequencing and exclusion
Diagnosis in mental healthcare

Diagnosis in mental healthcare is a process. This process usually involves sev-
eral encounters, tests and questionnaires. It is conditioned by the first contact
between professional and patient and evolves over several clinical encounters
(Bonnin 2013; Woolgar & Scott 2014).
To Lacanian psychoanalysts, diagnosing means identifying an “underlying
structure” that can only be classified as neurotic, psychotic or perverse (Thomp-
son et al. 2006). From this perspective, different types of disorders (usually
understood under the Diagnostic Statistical Manual’s classification) are seen as
superficial phenomena that emerge as “symptomatic features” of these under-
lying structures. Such symptomatic features include, among others, substance
abuse, obsessive-compulsive disorder and conversion disorder. In other terms,
what psychiatrists call “disorder”, psychoanalysts call “symptom”.
Macneil et al. (2012) prefer the term “clinical case formulation” to avoid diag-
nostic labelling promoted by the Diagnostic and Statistical Manual of Mental Dis-
orders (DSM). Clinical case formulations are generally used to avoid categorizing
patients and offer a contextualized approach to their mental health concerns.
Some understand diagnostic formulations differently, especially those employ-
ing a discourse analytical perspective on language and mental health (Pardo &
Buscaglia 2008, 2013). Antaki, Barnes and Leudar (2005) and Antaki (2009)
suggest using the term to signify a specific professional approach to “sharpen,
clarify or refine the client’s account and make it better able to provide what the
professional needs to know about the client’s history and symptoms” (Antaki,
Barnes & Leudar 2005: 627). Thus comprehended, professionals orient the
information they gather towards therapeutic interpretations – “symptom formu-
lations” (Bonnin 2017). They interpret clients’ words and acts as meaningful
symptoms within a diagnostic framework. Formulations (including reformula-
tions and transformations) are cognitively, ideologically or axiologically oriented
(Arnoux 2006); they are never “neutral”. “Therapists work to transform the raw
material of their client’s talk, and get this transformation accepted by their cli-
ent” (Antaki, Barnes & Leudar 2005: 629); as such, diagnostic formulations may
aid or harm the diagnostic process. In order to avoid substituting the clients’
Diagnosis and treatment 93
accounts with their own accounts and definitions (Bartesaghi 2009), mental
health professionals therefore must develop an awareness of how they use diag-
nostic formulations in therapy talk (Bonnin 2017).
When psychoanalysts discuss “diagnoses”, they are specifically referring to the
three above classifications (neurotic, psychotic or perverse). From this point of
view, symptoms take on roles of critical importance: once a structure is detected,
the only possible cure – the only possible way to mitigate suffering – is to treat
the symptom.
However, there has been continuous fluctuation regarding the status of the
analyst as a subject of diagnostic knowledge in the therapeutic relationship. Rub-
istein (1999) states that in the seventies there was an exaggerated rejection of
the analyst’s knowledge, considered as a “subject supposed to know”, in terms of
Lacan. This “confusion between referential knowledge and textual knowledge
of the unconscious” (Rubistein 1999: 120) ultimately led to serious clinical diso-
rientation, especially in the case of psychosis treatments. Later, during the 1990s,
the intervention of Lacanian psychoanalysts at public hospitals brought back the
issue of diagnosis as a clinical need, not only in terms of treatment and therapy for
the patient but also in terms of institutional criteria regarding legitimate health-
care practices (Crowe 2000). Thus, a conflict arose between a psychoanalytical
conception of diagnosis as a process conducted by the patient through treat-
ment, and a medical, psychiatric conception, which considers diagnosis as the
pre-condition to identify the illness and treat it to achieve the cure (Thompson
et al. 2006: 104). As a consequence, every interview is fraught with this tension
between the singularity of the case – which, ultimately, defies the possibility of
diagnosing – and the regularity of the types.
The place to look for these types is a diagnosis chart provided by the Mental
Health Care Department of the City Government, mainly developed on the basis
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; Ameri-
can Psychiatric Association 1994) and the International Classification of Diseases
(ICD-10, by the World Health Organization). To many professionals, however,
this chart is merely a “neoliberal policy” designed to standardize the psychiatric
market and open it to foreign pharmaceutical products (Lakoff 2006: 57).
We have already noticed the maladjustment of expectations between pro-
fessionals and patients regarding the activity that was being carried out as an
“admission interview”. For the healthcare professionals, it is a “first consulta-
tion” designed to classify patients according to the basic psychoanalytic clinical
types. If the patient is identified as psychotic, he/she is referred to psychiatry and
psychotherapy; if the patient is identified as neurotic, he/she is referred to one
of the psychotherapeutic specialties (addictions, eating disorders, family, adults,
youth, etc.). A less explicit purpose is to evaluate and “filter out” patients in order
to match the service’s limited capability. To the patient, however, especially if
she/he has not received prior psychoanalytic treatment, the interview is itself a
clinical instance (cfr. Chapter 2): it is conducted by professionals who call him/
her patient and attend in a consulting room at a hospital. Indeed, being the first
contact of many patients with psychologists, first mental health interviews have
many features in common with primary care encounters (Heritage & Maynard
2006; Peräkylä et al. 2008) and acute medical visits (Koenig 2011). However,
there is a major difference regarding the sequential organization of these inter-
actions: while traditional medical consultation usually presents a diagnosis first,
followed by treatment recommendations, first consultations in psychoanalysis, as
observed in my fieldwork, recommend treatment first and do not offer a diagno-
sis to justify it. On the contrary, the diagnosis is discussed by professionals only
after the patient is gone.
Treating without diagnosis: sequencing as ideology

We have observed that assumptions about the clinical condition of the patient
play a decisive role in formulating one or another diagnostic hypothesis (Bonnin
2017). In this chapter, we will argue that sequence organization of the inter-
view is also ideological and embodies psychoanalytical assumptions about the
relationship between diagnosis and treatment. Not being explained, sequence
order of the interview provokes a new misunderstanding between psychoanalyti-
cal assumptions and the patients’ medical expectations.
We observed in psychoanalysts at the hospital a strong resistance to what they
call “medical discourse” or “biomedical paradigm”, defined by:
an overemphasis on the healing aspects, the centrality of the hospital, the

interest in the organic side of individuals considered alone and with the cen-
tral axis of health professionals, especially doctors (. . .) lay people, within
this scheme, are considered passive, accessory or subordinated objects which
are incorporated only through the logic of professionals. They are simply sick
people, patients or, at best, beneficiaries, users or costumers.
(Mercado & Magalhães Bosi 2007: 52, my translation)
As a response to this paradigm, psychoanalytic mental health services are usu-

ally resistant to adopting features of the medical discourse: they resist using white
coats and clinical terminology, and they try to avoid prescribing psychoactive
medication and admitting inpatients. A new maladjustment occurs: hospital pro-
fessionals reject a biomedical discourse which patients look for.
The sequence diagnosis–treatment recommendation appears, to psychoanalysts,
as typical of medical discourse. As a consequence, they do not meet patients’
demands for diagnosis but, instead, offer psychotherapeutic treatment. The anal-
ysis will be presented in three stages as emergent in the interaction. Firstly, we will
observe how patients try to negotiate a “diagnostic label” (Garand et al. 2009)
and, complementarily, how professionals dismiss self-diagnosis, either implicitly
or explicitly. Secondly, I will draw attention to the offer of treatment by profes-
sionals and the strategies displayed by patients to resist or accept it. Finally, we
will see that patients are diagnosed anyway, using the same kind of labels that
were refused to the patient.
Although I illustrate my argument with different examples, I will follow one of
them, the case of R, to demonstrate the articulation of the three stages through-
out a single interview.
Dismissing self-diagnosis
We will first turn to the interview with R, a 54-year-old male divorcée currently
engaged in a new relationship. He has a small pension and poor social insurance,
and therefore goes to public hospitals for the services not covered by his insur-
ance. He has been receiving psychiatric outpatient treatment, which he finished
four years before the interview, but still self-medicates with Clonazepan and Ser-
traline, which he buys on the black market without a prescription.
Although the first part of the interview is devoted to asking institutional ques-
tions to complete a statistical standardized form, at this time patients usually
present the reasons why they have approached the mental health service (cfr.
Chapter 5). R offers a series of diagnostic labels which are not developed but
dismissed by the professional.
Extract 1: R
1 Psychologist in Charge (PC): no (.) está
2 claro (.) está claro (1) y que: esto lo
3 trae por acá? esto fue::?
4 R: s:í (1) también po:r (2) miedos o
5 pánicos (.) no sé si es igual? (2) a
6 la mañana tempra:no (.) de salir a
7 trabajar o de enfrentar el día (1) °es
8 un pánico° (.) la noche me da pánico
9 no me gusta la noche.
10 PC: con quién vive:?
11 R: con mi:: esposa actual (.)
12 esto::y (.) juntado bah
Translation
1 Psychologist in Charge (PC): no (.) it’s
2 clear (.) it’s clear (1) so wh: this
3 brings you here? this::?
4 R: ye:ah (1) also becau:se (2) fears or
5 panic (.) I don’t know if it’s the same? (2) early
6 in the mo:rning, going out
7 to work (.) or facing the day (.) °it’s
8 such a panic ° (.) the night makes me panic
9 I don’t like night time
10 PC: Who do you li:ve with?
11 R: with my: current wife (.)
12 I:: am (.) cohabiting, bah
In this example, there is explicit metalinguistic activity carried out by the patient
(lines 4–5), who asks a question to introduce the technical term “pánico”, that
leads to the diagnosis of “panic attack”, widely discussed by media in Argentina.
Having had previous experience in mental health interviews, R avoids the direct
use of diagnostic terms, which can be resisted by doctors (as shown by Broom
2005). Rather, in lines 4–5 he tries to establish a terminological agreement on
the synonymy of the non-technical “miedo” (fear) and the technical “pánico”
(panic). As the turn is not taken by the PC at the 2-second pause, R continues
with the description of the symptoms and now uses the term “panic” without
further justification: “it’s such a panic” (lines 7–8), “the night makes me panic”
(line 8). The professional, however, does not give any feedback regarding the
metalinguistic question. On the contrary, when she takes the turn in line 10, she
continues asking the demographic questions of the standard form and ignores the
patient’s attempt of self-diagnosis.
Extract 2: R
1 PC: bueno (.) entonces eh: el motivo
2 por el que lo derivaron acá es su
3 estado de ánimo? podría decirse? lo
4 derivó un médico (.) dijo
5 R: sí: (.5) la ansieda:d (.3) este: (.)
6 depresión o:: no sé qué podría
7 llamarlo (.) [a veces]
9 PC: [desde cuándo?]
10 R: P2: bueno a vece:s (.) a vece:s me
11 acuesto no? y es como que no quiero
12 levanta:rme (1.3) este:: (.) a veces me
13 siento vací:o (.) tengo: (.) un par
14 de amigos pero nunca me vienen a ver.
15 estoy solo. no? está mi esposa al
16 lado pero no es lo mismo (.5) °mi esposa
17 que:: digamos (.) nos llevamos mas o
18 menos°
19 PC: y desde cuándo usted tiene este:
20 estado así que me cuenta? esta
21 cuestión de los pensamie:ntos (.4) esta
22 nosta:lgia?
Translation
1 PC: well (.) then eh: the reason
2 why you were referred here was your
3 mood? could we say? you were
4 referred by a doctor(.) you said
5 R: yes: (.5) anxie::ty, ehrm::: (.)
6 depression or:: I don’t know what to
7 call it (.) [sometimes]
9 PC: [since when?]
10 R: P2: well some ti:mes (.) some ti:mes I
11 go to bed right? and it’s like I don’t want
12 to ge:t up (1.3) ehrm::(.) some times I
13 feel em:pty (.) I’ve got: (.) a few
14 friends but they never come to see me.
15 I’m alone, right?. my wife is with
16 me but it’s not the same (.5) °my wife
17 who:: let’s say (.) we are not on very good
18 terms°
19 PC: and since when have you had this:
20 mood you’re telling me about? this
21 thing about thou:ghts (.4) this
22 nosta:lgia?
In ex. 2, again there is metalinguistic activity by the patient (ex. 2, lines 5–7) and
the professional (ex. 2, lines 2–3). PC offers a gist formulation (Heritage & Wat-
son 1979) which deletes technical terms and proposes a general category: “estado
de ánimo” (“mood”, line 3), as emergent of the “voice of the lifeworld” (Mishler
1984). The patient does not seem to be comfortable with this common-sense for-
mulation of his “panic” and offers, in lines 5–6, technical alternatives: “ansiedad”
(anxiety) and “depresión” (depression). As in the first ex., R proposes an indirect
question on the appropriateness of both terms – as he did before, establishing the
synonymy of “fear” and “panic”. This refusal to adopt the professional’s formu-
lations seeks a clinical interpretation of his “mood”. However, the professional
attempts to dismiss his self-diagnosis and to propose alternative, non-technical
terms, and therefore does not provide any feedback to the patient’s attempts at
diagnosis. On the contrary, PC rephrases “estado de ánimo” (“mood”, line 3) as
“este estado así que me cuenta” (“this mood you’re telling me about”, line 20).
Although she presents this last term as indirect speech of the patient’s prior inter-
ventions (“me cuenta”, “you’re telling me”), she is actually referring to her own
words in line 3. Then, the technical terms “ansiedad” and “depresión” now become
“esta cuestión de los pensamientos, esta nostalgia” (lines 21–22), “this thing about
thoughts, this nostalgia”. Although she dismisses both terms in the interaction with
the patient, later she will diagnose him exactly in these terms (see below, Ex. 7).
In other interviews, the same professional explicitly rejects patients’ self-
diagnosis of panic attack, as in Ex. 3:
Extract 3: V
1 V: empecé el jueves pasado (.) y:::
2 eh (.3) el trayecto del::: viernes
3 sábado y domingo tuve estos ataques
4 de pánico (.) les llamo yo entre
5 comillas (.5)
6 PC: <entre comillas> contanos qué (.)
7 qué:::=
8 V: =más que nada por una cuestión
9 de que yo ya había tenido estos
10 ataques de pánico (.) tuve dos
11 episodios(.) palpitaciones (.) sudor en
12 las manos:::=
13 PC: =bueno (.3) vamos =
14 V: =que me iba a morir (.) o sea:::
15 PC: <vamos despacio> o sea (.) este es
16 tu tercer:
17 V: <exacto (.3) episodios de ataque de
18 pánico>
19 PC: bueno (1) vamos a dejar entre
20 paréntesis esto de los ataques de
21 pánico (.) porque seguramente (.) te
22 lo han dicho si?
23 V: sí
24 PC: vamos- entonces (.) tuv- tuviste
25 una-un tercer episodio (1) <el primero
26 y el segundo (.3) cuándo fue y qué es lo
27 que te pasó?>
Translation
1 V: I started last Thursday (.) and:::
2 eh (.3) the time from::: Friday
3 Saturday and Sunday I had these panic
4 attacks (.) as I call them in quotation
5 marks (.5)
6 PC: <quotation marks> tell us what (.)
7 what:::=
8 V: =more than anything because I
9 already have had these
10 panic attacks (.) I had two
11 episodes (.) palpitations (.) sweaty
12 hands:::=
13 PC: =well (.3) let’s =
14 V: =like I was gonna die (.) like:::
15 PC: <take it easy> so (.) this is
16 your third:
17 V: <exactly (.3) panic attack
18 episode>
19 PC: well (1) let’s leave
20 aside this thing about panic
21 thing (.) because for sure(.) somebody
22 has told you so, right?
23 V: yes
24 PC: let- then (.) you h- had
25 a- third episode (1) <the first
26 and the second .3 when was it and
27 what happened to you?>
21 attacks (.) because probably (.) someone
22 told you that right?
23 V: yes
24 PC: let- then (.) you h- had
25 a- a third episode (1) <the first one
26 and the second (.3) when as it and
27 what happened to you?>
The ex. begins, like the former two, with a metalinguistic reference to the tech-
nical term, “panic attack”. The hedge “entre comillas” (“in quotation marks”,
lines 4–5) is repeated by the professional in line 6, who echoes the hedge and
not the expression hedged. Interpreting this as a confirmation, the patient begins
to use the term as a diagnostic label, justified in lines 11–12 by the enumeration
of symptoms and reinforced with the technical descriptive term “episode”. In
lines 15–16, the professional offers a new formulation to summarize the symp-
toms and elides the diagnostic term, which is again uttered by the patient: “panic
attack episodes” (lines 17–18). Here is where the professional explicitly discred-
its self-diagnosis, discarding it as a non-qualified rumour (Anderson, Rainey &
Eysenbach 2003). To confirm the non-diagnosis, the professional repeats the
expression with no qualifications: “a third episode” (line 25).
In sum, in this section we have observed how R (but also other patients, as
seen in Ex. 3), having some experience with mental health discourse and termi-
nology, already has a series of technical terms which he offers to the professional
to obtain – or confirm – a diagnosis. Patients do not claim technical or theo-
retical knowledge but rather seem to use diagnostic labels loosely as a means of
collaborating with the professional in order to enhance the description of their
symptoms. However, the psychoanalyst refuses to confirm it, either by implicitly
avoiding feedback (Ex.s 1 and 2) or explicitly rejecting it (Ex. 3). In exchange,
PC offers only common sense, lay terminology, referring to “mood”, “nostalgia”
or “episodes” with no qualifications.
Now, what does the professional indeed offer to the patient at the first inter-
view? That is what we will see in the next section.
Offering treatment
Extract 4: R
1 R: °°=que venimos así°° pero hay
2 días (.) sí (.) todo joya (.3) no hay
3 problema (.) todo bien (1) y hay días
4 que: (.) nos ↑ peleamos ↑
5 discutimos
6 PC: bueno (1) y usted está afín de
7 hace:r- quiere hacer un tratamiento?
8 (4) [porque-]
9 R: [yo pienso] que tengo que: (3)
10 tomar algo para la ansieda:d [para-]
11 PC: [sí (.) sí]
12 yo le estoy preguntado otra cosa (1.3)
13 sí. una cosa es que usted tome algo.
14 el tema es (.) que la me- la medicación
15 lo va (a hacer sentir un poco mejor)
16 pero no lo va a curar (1) y aparte
17 bueno (.) el tema es (.) tomarla y
18 tratarse (1.3) sí?
19 R: °°claro°°
20 PC: tanto el control de la medicación
21 como que usted pueda (.) conversar
22 (.) (pida) la palabra de las cosas
23 que le pasan. usted está afín de eso?
24 usted quiere hacerlo? porque una
25 cosa es que uno tenga que hacer algo.
26 que uno puede tener que hacer que:- (.3)
27 no? lo que hay que hacer=
28 R: =sí. o sea (inaudible) qué decir (.)
29 pero uno a veces necesita una ayuda (5)
30 PC: =>NO, NO, NO [por eso (1) sí sí
31 R: [de un profesional (.)
32 digamos=
34 PC:=sí. sí> (.) =pero yo le digo si
35 usted está afín de (.) este: (.) de
36 Hacerlo
37 R: °s:ï°
38 PC: mm: (4) no se lo escucha muy
39 convenci:do eh
40 R: cómo?
41 PC: no se lo escucha muy convencido
42 (3)
43 R: no: (.) no e:s (.) no entendí muy
44 bien la pregunta (1)
45 PC: e:h si usted está afín de hacer
46 un tratamiento y sostenerlo en el
47 tiempo (.3) que usted quiera hacerlo
48 R: sí
49 PC: ah, porque le decía que no lo
50 escuchaba muy convencido (1.3)
51 R: sí (quiero hacerlo)
Translation
1 R: °°=that we are like that°° but some
2 days (.) yes (.) everything is cool (.3) no
3 problem (.) it’s fine (1) and some days
4 we: (.) we ↑ fight ↑
5 Argue
6 PC: well (1) and you are OK with
7 do:ing- do you want to receive treatment?
8 (4)[becaus-]
9 R: [I think] that I should: (3)
10 take something for the anxie:ty [to-]
11 PC: [yes (.) yes]
12 I was asking something else (1.3)
13 yes. it is one thing for you to take something.
14 the issue is (.) med- medication
15 will (help your feel a bit better)
16 but won’t cure you (1) and besides
17 well (.) the issue is (.) taking it and
18 being treated (1.3) right?
19 R: °°sure°°
20 PC: medication control and
21 you being able to (.) talk
22 (.) (start) to speak about what
23 happens to you. are you OK with that?
24 do you want to do it? because one
25 thing is if you must do something.
26 that you may have to:- (.3)
27 right? do what you have to do=
28 R: =yes. I mean (inaudible) what to say (.)
29 but sometimes one needs help (.5)
30 PC: =>NO, NO, NO [right (1) yes yes
31 R: [from a professional (.)
32 so to speak=
34 PC:=yes. yes> (.) =but I ask if
35 you are OK with (.) ehrm: (.) with
36 doing it
37 R: °ye:s°
38 PC: hmm: (4) you don’t sound very
39 convi:nced uh
40 R: what?
41 PC: you don’t sound very convinced
42 (3)
43 R: no: (.) no s:s (.) I didn’t fully
44 understand the question (1)
45 PC: u:h if you are OK with doing
46 treatment and keeping it up over
47 time (.3) if you want to do it
48 R: yes
49 PC: oh, because I was saying that
50 you didn’t sound very convinced (1.3)
51 R: yes (I want to do it)
Right after the history taking, and having avoided any diagnostic label, as seen
in the previous section, the analyst changes the subject abruptly by heading with
a “bueno” (line 6) and addresses the patient to offer him psychotherapy. As she
would later explain, and can be seen in lines 38–39, 41 and 49–50, she thinks the
patient is reluctant to undergo treatment; therefore, she rephrases “estar afín”
(line 6, “to be OK with”) as “querer hacer un tratamiento” (line 7, “to want to
receive treatment”), thus attributing to R a more active role as subject of will. The
expression, however, does not seem to be clear to R, who does not take the turn
at the long 4-second pause (line 8). The brief overlap in lines 10–11 leads to R’s
own proposal, also materialized through a mental process: “yo pienso que tengo que
tomar algo” (“I think that I should take something”). His rephrasing of “treat-
ment” as “taking medication” is quite different to the analyst’s offer of “conversa-
tion”. As the analyst did not give him any chance to participate in diagnosis, this
resistance seems to be a claim for his own voice (as seen by Koenig 2011).
Also, beyond the “empowerment” feature of the patient’s rephrasing, there is
still a key misunderstanding which does not seem to be solved throughout the
interaction: what is the analyst offering? The patient attempts to obtain psychiat-
ric treatment at line 10, repeating the term “anxiety” which worked as a tentative
diagnostic label in Ex. 2, line 5. Refused by the analyst in lines 14–18, the patient
attempts an upshot formulation (Heritage & Watson 1979) drawing the conclu-
sion “one needs help” (line 29). This conclusion is also rejected (line 30) until
the patient completes “of a professional” (line 31), which is confirmed in the
same overlap (line 30). As R requests help and the analyst requests his engage-
ment, the repetition in lines 34–36 of the same question as in lines 6–7 does not
clarify the topic. On the contrary, the patient offered two formulations which
were plainly rejected. Therefore, his attempts at showing understanding of the
offer have failed. The hesitation at line 37, the request for repair at line 40 and the
long pause at line 42 show this failure, which is explicitly formulated: “I did not
fully understand the question” (lines 43–44). However, the analyst in lines 45–46
repeats once again the question asked in lines 6–7, even using the same processes:
“estar afín” and “querer hacer”. The laconic, straight answers in lines 48 and 51
seem to be just an exit, a way to answer affirmatively and close the interaction. In
fact, R did not show up at his first psychotherapy session.
This example is quite different to other experiences – led by the same profes-
sional – at which she assumed a more sympathetic position toward the patient. In
the case of J, who later was to be diagnosed with somatic disorder with impair-
ment of speech, the analyst assumes a pedagogical stance. As a consequence, she
explains what kind of treatment she is offering and is more careful in following
the patient’s reactions:
Extract 5: J
1 PC: bueno (.) ↑ bueno (.3) usted está
2 afín de hacer un tratamiento
3 terapéutico?
4 J: sí
5 PC: sabe de qué se trata?
6 J: no (.) no (.) nunca hice (1)
7 PC: bueno (.) en realidad es esto (.)
8 es como esto con más tiempo de que
9 usted pueda conversar con un
10 profesional=
11 J: = sí=
12 PC: =un terapeuta, un psicólogo o una
13 psicóloga, acerca de (.) bueno, las
14 cosas que le pasan en su vida.
15 J: sí (1)
16 PC: si? por[que]=
17 J: [Sí]
18 PC: =si en principio el neurólogo ya
19 ubicó que no hay nada orgánico
20 J: sí (1)
21 PC: esto (.) es más un tema
22 emocional=
23 J: =sí.
24 PC: sí?
25 J: sí, es emocional
Translation
1 PC: well (.) ↑ well (.3) are you
2 OK with following a therapeutic
3 treatment?
4 J: yes
5 PC: do you know what is it about?
6 J: no (.) no (.) I’v never done it (1)
7 PC: well (.) it’s actually this (.)
8 it’s like this with more time for
9 you to talk to a
10 professional=
11 J: = yes=
12 PC: =a therapist, male of female
13 psychologist, about (.) well, things
14 which happen in your life.
15 J: yes (1)
16 PC: yes? be[cause]=
17 J: [yes]
18 PC: =if the neurologist has already
19 said that there isn’t anything organic
20 J: yes (1)
21 PC: this (.) is a more
22 Emotional issue=
23 J: =yes
24 PC: yes?
25 J: yes, it’s emotional
Because of the mild speech impairment declared – and shown – by J during

the interview, the analyst not only explains what “therapeutic treatment” is but
is constantly seeking confirmations of her explanations. This strategy is useful, as
seen in the first four lines of Ex. 5: the affirmative answer in line 4 does not imply
an understanding of the terms of the question. This is the same problem that
we have seen in Ex. 4. However, instead of extending the misunderstanding for
eighteen lines, here the analyst asks immediately for a confirmation (line 5) and,
receiving a negative answer (line 6), develops a repair which expands the informa-
tion. Although J confirms constantly with “sí” (“yes”) at lines 4, 11, 15, 17 and
20, the analyst asks her again in lines 16 and 24, remembering that “yes” does
not necessarily mean that the patient understood the question. Then, in line 25,
J repeats the formulation of line 22, showing that she is following the analyst’s
reasoning and that she acknowledges with her almost-diagnostic claim: “it’s emo-
tional”. This is not far from the DSM-IV diagnosis produced by the analyst after
the patient was gone: it is somatic.
In this example, in contrast to the previous one, the analyst changes her strat-
egy toward the patient. Thus, she produces pedagogical discourse which includes
a step-by-step development of what “psychotherapy” is, and a diagnostic formu-
lation of the symptoms presented by J: “it’s emotional”. These two elements,
explaining treatment and offering a tentative diagnosis, seemed to be enough to
reassure the patient somewhat, and she is currently undergoing therapy at the
hospital.
Diagnosing anyway
Although psychoanalysts oppose the use of the DSM-IV at public mental health
services in Buenos Aires, it is institutionally mandatory to label every patient
interviewed with the code of one of the disorders listed in the form. Although
patients are not usually diagnosed during the interview, professionals do apply
diagnostic labels after completing the interview, simply by reasoning out loud or
in a conversation with the assistant psychologist or even with the researcher. This
process of diagnosing “properly” is simultaneously discredited and mandatory –
a fiction of clinical work which will later be used for preparing statistics. As a
consequence, these statistics are not accurate at all. During 2008, 43% of patients
were diagnosed within the category of Dysfunctional Behaviour Disorder; dur-
ing 2009, only 1% fell in this category. In contrast, 44% of the patients were
diagnosed as Mental Disorder Not Otherwise Specified, which represented 11%
in 2008. A sudden change in the demography of mental health being highly
unlikely, the most probable interpretation is that there was a sudden change in
the use of default diagnostic categories.
This loose diagnosis, however, is included in the patients’ medical history and,
therefore, affects her/his treatment. We have analyzed elsewhere a diagnostic
mistake which misinterpreted neurological symptoms with neurotic ones, causing
a deeper deterioration in the patient’s condition (Bonnin 2017).
Here is how both the PC and the AP elaborated R’s diagnosis after he left the
room:
Extract 6: R
1 PC: no le vamos a creer que [la
2 esposa] solamente es celosa porque sí
3 ((laughs)) digo es que: no? bueno .3
4 eso (.) es todo pa- está todo para
5 abrir (.) pero (.) eso .3 bueno
6 (inaudible) bueno (14) a ve:r (3)
7 trastorno depresivo (.) sí (5)
8 trastorno depresivo mayor (.) eso no
9 sé(.) porque es bien psiquiátrico es-
10 (.) la verdad no lo sé (6) pero
11 trastorno depresivo no ↑especificado
12 (.) especifica que es por el hijo
13 no? (.) y hay un tema acá que:
14 aparte habría que pensar que es (.)
15 el tema del pa- el tema del padre (.)
16 que él no es el padre (.5) a ver (13)
17 además le pregunté (inaudible)
18 gastrointestinales porque le pusieron
19 (inaudible) no?
20 Assistant Psychologist (AP): lo mandó
21 el (.) gastroenterólogo
22 PC: gastroenterólogo (12) le podemos
23 poner trastorno de ansiedad
24 generalizada?
25 AP: (inaudible)
26 PC: e:h(.3) qué se yo (.) más o menos
27 trastorno de ansiedad(.) de- después
28 hay que- hay que traducirlo esto
29 trastorno (inaudible)(.5) trastorno
30 depresivo> es el treinta y dos
31 nueve< (4) y alguna cuestión de:: (.)
32 la familia (.3) porque habló de los
34 hijo:s (.) de la muje:r
35 AP: (inaudible)
36 PC: sí! (6) y proble- y tampoco se
37 (.) junta con los amigos (.) no? (3)
38 tiene problemas conyugales también
39 AP: sí
40 PC: problemas de relación °no
41 especificado° tiene problemas de
42 relación no?
43 AP: sí
44 PC: Bueno >problemas de relación no
45 especificado<(6) bien (.) ya está
46 (inaudible) °terapia individua:l
47 ansieda:d depresió:n (.) problema:::
48 relación° bueno (.) empecemos con las
49 cuestiones
Translation
1 PC: we won’t believe that [his
2 wife] has no reasons to be jealous
3 ((laughs)) I mean it’s: right? well .3
4 it’s (.) there are so many: things
5 to open (.) but (.) that .3 well
6 (inaudible) well (14) let’s see:: (3)
7 depressive disorder (.) yes (5)
8 major depressive disorder (.) this I don’t
9 know(.) because it’s very psychiatric it-
10 (.) I actually don’t know (6) but
11 ↑unspecified depressive disorder
12 (.) he specifies it’s because of his son
13 right? (.) and there is an issue here:
14 besides we whould think is the (.)
15 issue of the fa- the issue of the father(.)
16 he’s not the father (.5) let’ see (13)
17 besides I asked (inaudible)
18 gastrointestinal because he got
19 (inaudible) right?
20 Assistant Psychologist (AP): the
21 gastroenterologist (.) sent him
22 PC: gastroenterologist(12) we can name
23 it generalized anxiety
24 disorder?
25 AP: (inaudible)
26 PC: eh:r(.3) I don’t know (.) more or less
27 anxiety disorder(.) la- later
28 we ha- we have to translate this
29 disorder (inaudible)(.5) depressive
30 disorder> it’s the thirty two
31 nine< (4) and some issue with:: (.)
32 family (.3) because he spoke about
34 so:ns (.) about his wi:fe
35 AP: (inaudible)
36 PC: yes! (6) and iss- and he doesn’t hang out
37 (.) with his friends (.) right? (3)
38 he’s got marital issues too
39 AP: yes
40 PC: relational disorder °not otherwise
41 specified° he’s got
42 relational disorders, right?
43 AP: yes
44 PC: well > relational disorder
45 not otherwise specified<(6) right (.) it’s done
46 (inaudible) °individual the:rapy
47 anxie:ty depre:ssion (.) relation:::
48 disorder° well(.) let’s begin
49 with the issues
As a transition between the situation of the interview, including the patient,

and the new situation of discussing a diagnosis with colleagues, PC introduces an
inclusive we with a joke at lines 1–3, creating a sense of community and shared
identity with the AP. This is important as a way to shorten the hierarchical distance
between both psychologists, especially after exchanges which usually involve only
two participants: the PC and the patient. The metaphor “está todo para abrir”
(lines 4–5, “there are so many things to open”) is very frequent in this service
of mental health as a way to point out the preliminary function of the admission
interview, which serves to signal those symptoms which shall be later addressed
(“opened”) by professionals during proper therapy sessions. This first turn is very
long and is full, with long pauses which are used by the PC to write her impres-
sions on the patient at the “admission form”. This form includes diagnostic infor-
mation elicited during the interview and is later handled to the therapist who
takes the case. After a long pause of 14 seconds (line 6), the analyst finishes writ-
ing her impressions on the interview and begins to look for the diagnostic label,
following the categories listed in the reverse of the statistical-epidemiological
form. She reads it out loud so as to create consensus with her selection, con-
firms the superordinate category (‘depressive disorder’, line 7) and then begins
to discard the subordinated items: it is not ‘major’ (8–10); it is not ‘unspecified’
(10–13). As she understands that this category does not seem appropriate, the
PC addresses the AP with two questions (lines 13 and 19), starting an exchange
with him. This exchange consists mainly in polar questions made by the PC to
confirm their own judgement; therefore, the AP answers are merely confirma-
tions in lines 39, 43 and probably 25. During this stage of diagnosis, there is an
uncertainty about the criteria, made explicit in line 26, “qué sé yo, más o menos”
(“I don’t know, more or less”), and a metalinguistic comment on “translating”
these labels when the case is orally referred to at the service’s meeting (line 28).
The acceptance of the uncertainty of the categories and their appropriateness
to diagnose the case makes labelling easier. As a consequence, the PC includes
a second disorder (lines 40–41) and produces, at 47–48, a diagnostic brief of
what she wrote and quickly closes the sequence to open a new one, referred to as
bureaucratic issues (lines 48–49, “las cuestiones”, “the issues”).
In other cases, the diagnosis can be faster and less collaborative, although usu-
ally there is a seeking of confirmation by the AP to level up a relationship which
is, in fact, hierarchical:
Extract 7: J
1 J: gracias eh (.3) muchas gracias
2 PC: no (.) buenos días .5 Hasta luego
3 (36) lo que más- (4) trastornos
4 somatomorfos es lo que más se: (.)
5 trastorno de conversión, no?
6 trastorno de somatización
7 AP: m::h
8 PC: no? es lo que más se: acerca
9 (2) (efe cuarenta y cinco cero)
Translation
1 J: thank you (.3) thank you very much
2 PC: it’s OK (.) good morning .5 see you
3 (36) the mos- (4) somatoform
4 disorders is the most: (.)
5 conversion disorder, right?
6 somatization disorder
7 AP: m::h
8 PC: Isn’t it? it’s the most: the closest
9 (2) (F forty five zero)
In this case, the PC assumes a more monological kind of diagnosis. During a

long pause of 36 seconds in line 3, she writes and makes no comments. This is a
clear difference with what we observed in ex. 6, lines 4–19, when she interrupted
her writing several times to discuss the facts with her colleague. In lines 3–6, she
names a series of disorders as a way to involve the interlocutor in her decision, as
in the previous example. Although she receives a discouraging answer in line 7,
reinforced by a gesture of doubt which she interprets as a negative answer (line 8),
she keeps her diagnosis anyway as “the closest thing” and closes the sequence
writing out loud the diagnostic code (line 9).
Confronting psychoanalytic and medical discourses

One of the motivations for this analysis was the perception of a contradiction in
the way psychoanalysts relate to what they call the “medical discourse”, which
supposedly seeks regimentation and disciplining through biologization of sub-
jects, including personality, behaviour, cognition and psyche. I interpret this rela-
tionship as contradictory because, among many other reasons, the institutional
place is itself a hospital which offers mental healthcare just as it offers orthopaedic
surgery. Indeed, a few psychoanalysts in the service are also psychiatrists and per-
ceive this relationship as, if not contradictory, at least difficult to reconcile (Lakoff
2006: 84–85).
Although members of the mental healthcare service are aware of this tension,
many patients are not. On the contrary, medical discourse is the only framework
patients have for understanding what happens at a hospital, no matter what medi-
cal specialty they use. Asking for a diagnosis (“what’s wrong with me?”) and ask-
ing for medication to be cured (“what can I take?”) are the expected actions in
doctor–patient interaction as far as patients know. To Lacanian psychoanalysts,
medication and diagnostic labelling are two characteristic features of medical dis-
course, and therefore resisted, as I pointed out in the first analytical section. Refus-
ing diagnosis is, from their point of view, resisting the biologization of the psyche.
This practice is partially coherent with the psychoanalytic idea that patients
are the ones who “know”, and professionals only “guide” them to elicit this
knowledge (Schafer 2005; Waska 2006), although this guidance is achieved
through diagnostic formulations oriented toward a priori hypothesis (Bonnin
2017; Antaki, Barnes & Leudar 2005; Bartesaghi 2009). In any case, patients’
expectations in medical settings include a diagnosis, i.e. a proposal about their
clinical condition (Maynard 2004). Instead, outpatients at first interviews do not
receive a diagnosis but an offer of treatment, which is often recommended uni-
laterally by the professional. Patients’ self- or other-diagnoses, which fill the need
of knowledge and can empower patients within their asymmetrical relationship
with professionals (Broom 2005; Giles & Newbold 2011), are often dismissed
by psychoanalysts. Indeed, instead of providing alternative formulations (Antaki,
Barnes & Leudar 2005) or other discursive strategies for diagnosing (Maynard
2004), nothing is offered but psychological treatment. In other words, patients
are told that psychoanalysis “cures with words” (Peräkylä et al. 2008), but they
are not told what the problem is that should be cured. The asymmetrical relation-
ship between participants places patients at a disadvantage. They cannot argue
about the treatment offered by the professional but are only allowed to take it
or leave it. As we have seen in the case of R, the patient leaves the hospital: even
though he was explicitly admitted, he was communicatively rejected. This pro-
cess, however, can be different: the case of J shows that explaining psychoanalyti-
cal treatment and offering a tentative diagnostic label can be sufficient to provide
feedback to the patient and encourage his/her adherence.
Resisting medical discourse in medical settings can therefore be contradictory
not only for analysts but especially for patients who find it difficult to under-
stand what is going on. Perhaps professionals could be more flexible towards
patients’ expectations about diagnosis and treatment as a way of ensuring access
and adherence to the mental health service. As seen in Ex. 5, this strategy of
negotiation with medical discourse can be successful in guaranteeing engagement
and continuity in treatment.
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5 Resisting exclusion
Patients’ tactics of misunderstanding
bureaucratic discourse
Introduction
Medical consultation usually includes, as shown in the analysis of primary care
acute visits (Heritage & Maynard 2006), a more or less routine questionnaire
addressing the patient’s “past medical conditions, the health status of parents
and siblings, and psychosocial and lifestyle aspects of the patient’s circumstances”
(Stivers & Heritage 2001: 152). This is a key strategy designed to gather relevant
clinical information during history taking. As it also conveys information about
the physician’s own beliefs, prejudices and attitudes (Heritage 2010), it is not
a unilateral practice of collecting data but an exchange of information during
which patients can adopt different positions and strategies.
One of these strategies is what Stivers and Heritage (2001) describe as
answering “more than the question” during comprehensive history taking.
History-taking questions are designed as a “checklist” that demands only mini-
mal answers which would not move beyond the immediate agenda set by them
(Stivers & Heritage 2001: 153; Raymond 2010). Patients’ responses usually
answer the question as put, as a simple request for unelaborated facts. Each
short answer is usually taken as complete both by the patient and the doctor,
both of whom collaborate in a recognizable routine activity. Therefore, there
has to be a good reason for the patient to depart from the pattern of minimal
responses, volunteering more information than required. Stivers and Heritage
(2001) analyze these expansions as a way to incorporate patients’ concerns with-
out making them explicit. Nishizaka (2011) analyzes response expansion in rou-
tine prenatal checkups (instead of acute medical visits), finding that answering
“more than the question” is one of the few opportunities available to pregnant
women to take the initiative in presenting their concerns at the consultation.
Through different perspectives, response expansion in medical settings seems to
be an act of voice linked to some kind of empowerment or resistance – however
limited it might be – regarding patients’ asymmetrical position (see Gill 1998;
Robinson & Heritage 2006; Stivers 2006; Stivers & Hayashi 2010; Heritage &
Raymond 2012).
Bureaucratic questions and expanded answers

We can distinguish between optimized medical questions, typically designed by
doctors to obtain a “no problem” response during history taking (Boyd & Herit-
age 2006; Heritage 2010), and bureaucratic questions, which refer to an institu-
tionally set agenda and which is, in a sense, ancillary to healthcare (Heritage &
Sorjonen 1994; Heritage & Lindström 1998). Recent study of questioning and
answering in medical settings, however, does not usually take into account the
bureaucratic questionnaires which are routinely applied, especially at public hos-
pitals: written, bureaucratic forms designed to gather statistical-epidemiological
information. As research in this field has a predominantly conversation-analytical
perspective, there is a restricted view of context which does not take into account
institutional and political conditionings of the interaction (Heritage & Lindström
1998; Candlin & Candlin 2003; Iedema 2007; Bonnin 2013). Therefore, the
activity of gathering epidemiological-statistical information is usually seen as alien
to the medical interaction proper not only by analysts but also by professionals
themselves (cfr. Extract 1).
In the case of public mental healthcare in Buenos Aires, clients must respond to
an epidemiological-statistical form with information ranging from name and ID
number to occupation and former treatments (cfr. Figure 5.1).
Although this form is not attached to the patient’s medical history but sent
instead to the City Government Mental Health Office, it plays at least two impor-
tant roles regarding interaction and access to mental health. On the one hand,
it is statistical input for designing public health policies in Buenos Aires City.
As such, it classifies individuals into social-demographic categories such as male,
married, unemployed, schizophrenic, etc. (Bonnin 2013). In this sense, printed
forms are used from a biopolitical point of view, enhancing State governance
through “the mundane administration and surveillance of individual bodies and
the social body” (Ong 2003: 91). The privileged agent of this governance is
modern medicine, “defining and promoting concepts, categories and authorita-
tive pronouncements on hygiene, health, sexuality, life, and death” (Ong 2003:
91). Official forms, statistical questionnaires and printed and written administra-
tive documents become the key input in a State “enterprise of production, repro-
duction and transformation of legitimate [social/epidemiological] problems and
solutions [which produce] the creation and normalization of an order of social
problems’ ”(Pantaleón 2005: 90, my translation).
On the other hand, as these forms are filled by the professional who con-
ducts the interview, they are the main topic of an interaction with an extremely
restricted agenda set by the form’s checklist. Despite its function at the level
of the State, in the local interaction, participants negotiate the activity they are
engaged in and its expected outcome: being admitted to the mental health service
as outpatients. In this sense, bureaucratic interaction may adopt a “restrictive” or
“inclusive” character, following different eligibility criteria (Jean 2004; cfr. infra
Section D) which may result either in the inclusion or the exclusion of the client
in the mental health outpatient service. As there is a limited number of consulting
Figure 5.1 Statistical-epidemiological form used at Buenos Aires’ public hospitals
facilities and very restricted number of personnel to deal with the demand, “they
are not admission, but rejection interviews” (“más que de admisión, son entrevis-
tas de expulsión”), as one psychiatrist once told me. Patients, on the other hand,
are generally not aware of inclusion/exclusion criteria other than availability of
slots (“cupos”) which are filled by order of arrival. Thus, being rejected regardless
of how long they have waited for their appointment may cause indignation: “I’ve
been here since five in the morning and now [mid-morning] they tell me I have
to go to XX [public hospital in the Buenos Aires Province]” (“Estoy acá desde las
cinco de la mañana y recién ahora [media mañana] me dicen que tengo que ir a
XX [hospital público de la provincia de Buenos Aires]”). In other words: locally
managed inclusion/exclusion is conditioned by structurally defined rationing of
public healthcare.
If we adopt a scalar view on context (Blommaert 2007), we can observe how
epidemiological-statistical questions and answers may index, simultaneously, both
semiotic levels: the local, immediate situation of the interview and the higher,
State-administrated biopolitical order. Therefore, answering “more than the
question” may be an individual strategy for raising concerns (as seen by Stivers &
Heritage 2001; Nishizaka 2011), but it also may embody a practice of resistance
towards State-defined classifications and policies regarding mental suffering and
healthcare.
This is the idea we will discuss in this chapter. We will distinguish four types of
expanded answers as they serve strategically to a) display competence in bureau-
cratic discourse; b) move from the sphere of the public to the private; c) deal with
potential face-threats; and d) pre-empt rejection. In the last section, we will dis-
cuss our results from the point of view of the political effects of local interaction.
The epidemiological-statistical form and the organization

of the interview
Every interview is noticeably organized in three distinct parts explicitly designed
to a) gather information to complete the epidemiological-statistical form pro-
vided by the City Government Mental Health Office; b) inquire about the rea-
sons why the patient requires mental healthcare in order to later decide on which
specialty the patient should be referred to; and c) gather personal information to
make contact later and inform the patient regarding the appointment to begin
treatment. These three moments are usually treated as separated activities, as can
be seen in the following extract:
Extract 1
1 Prof: bueno (0.5) mire (.) esta es una pequeña
2 ↑entrevista
3 Pat: sí=
4 Prof: =de orientación (1.0) yo primero le voy a toma:r-
5 (.) le voy a hacer algunas preguntas que son para
Resisting exclusion 117
6 la (2.0) estadística del hospital=
7 Pat: =sí
8 Prof: y después nos cuenta (.) qué lo trae por acá (0.3)
9 le parece?
10 Pat: sí
11 Prof: bueno (0.3) dígame su edad
1 Prof: well (0.5) look (.) this is a short

2 ↑orientation
3 Pat: yes=
4 Prof: =interview (1.0) first I’m going to ta:ke-
5 (.) I’m going to ask some questions for
6 the (2.0) hospital statistics=
7 Pat: =yes
8 Prof: and then you tell us (.) what brings you here (0.3)
9 OK?
10 Pat: yes
11 Prof: well (0.3) tell me your age
The extract begins with a metapragmatic comment by the professional, who

describes the general activity which will take place as “a short orientation inter-
view” (lines 1–4). Due to her position of power as an institutional representative,
she is allowed to “orchestrate” the interaction, determining “when the other
party or parties may speak and receive attention and what they may speak about”
(Dingwall 1980: 156). Therefore, she anticipates the structure of the interview,
differentiating bureaucratic questions – “I’m going to ask some questions for the
hospital statistics” (l. 5–6) – from clinical ones: “then you tell us (.) what brings
you here” (l. 8). Line 11 introduces a bueno-prefaced move into the interview,
with “bueno” being equivalent to “okay” (cfr. Beach 1993). This kind of move
is usually repeated as a transition between the three stages we described earlier, in
all cases projecting the beginning of the new activity.
About 25% of the time of the interview is dedicated to the first of these parts, in
which one of the psychotherapists (usually the more experienced one) introduces
the successive items of the epidemiological-statistical form checklist, rephrasing
them as questions. This rephrasing is orientated by the therapists’ own “best
guesses” (Heritage 2010: 43) about which could be the most likely answer.
In what follows, we will focus on those answers which, contrary to those
observed in previous extracts, do not offer a short, concise and complete
response but an elaborated one, answering “more than the question” to these
bureaucratic, epidemiological-statistical questions. We observed 56 sequences of
expanded answers related to every item of the form, from name to health insur-
ance. We can distinguish four basic types of expansion according to the action the
patient takes: a) displaying competence in bureaucratic discourse (10%); b) mov-
ing from the sphere of the public to the private (41%); c) dealing with potential
face-threats (37%); and d) pre-empting rejection (12%).1
A) Displaying bureaucratic competence

The first kind of expanded responses to epidemiological-statistical questions is,
actually, an over-efficient type of straight answer: it is not designed to move away
from the agenda set by the questions but, rather, to advance rapidly through the
routine steps of bureaucratic questioning. Therefore, the answer to one item
is expanded with information which responds to the usual follow-up question,
which has not yet been asked, in a “nonconforming, yet cooperative” kind of
response (Lee 2011: 905). We will analyze this phenomenon as a potentially
empowering voice adopted by patients in order to level the structurally asym-
metrical roles of the doctor–patient situation (Chapter 6). Here are two typical
examples:
Extract 2
1 Prof: está bien (0.3) e:h (.) tus estudios?
2 Pat: secundario completo
3 Prof: completo (0.3) [iniciaste-]
4 Pat: [acá en Buenos Aires]
5 Prof: algún estudio terciario?=
6 Pat: =no (.) no (.) no porque me fui para XX
7 ((provincia argentina))
1 Prof: OK (0.3) u:hm (.) your education?

2 Pat: secondary, complete
3 Prof: complete (0.3) [did you star-]
4 Pat: [here in Buenos Aires]
5 Prof: any higher level studies?=
6 Pat: =no (.) no (.) no because I left to XX
7 ((Argentine Province))
Extract 3
1 Prof: bueno (.) casa propia (.) alquilada (.) ocu[pada?]
2 Pat: [casa]
3 propia (.) con mis padres
4 Prof: <con tus pa::dres> bien (0.5) obra social?
5 Pat: obra social (0.5) sí
1 Prof: well (.) your own house (.) rented (.) occu[pied?]
2 Pat: [my own]
3 house (.) with my parents
4 Prof: <with your pa::rents> good (0.5) medical insurance?
5 Pat: medical insurance (0.5) yes
Extract 2 addresses the issue of educational level, which is usually followed
up by the specification of the level of completion (complete/incomplete; cfr.
Figure 5.1). As the patient is acquainted with this kind of questionnaire, his
response in line 2 includes not only the required “degree of education” but also
the level of completion. The therapist begins a question in l. 3 about possible
incomplete higher education. The patient regains the turn to add information
about the place where he studied, a question which had not been asked but the
speaker treats as likely. The professional, however, is seeking for a confirmation
to the information given by the patient, who justifies why he did not start higher
studies (an expansion typical of the third type we discuss here, to prevent social
prejudices against under-education).
The answer of line 3, in extract 3, is still more plainly over-efficient. As can
be seen in Figure 5.1, the question on “Dwelling” is followed by that of “grupo
conviviente” (“cohabitants”). Although the therapist only asks for the first item
in line 1, the patient answers both questions, even though the second one had
not been uttered yet.
As a potentially empowering voice which displays competence in bureaucratic
discourse, this kind of expansion also allows moving forward to the second stage
of the interview (hence related to the second type of expansions we analyze here).
However, it is not designed to avoid or circumvent classification but, rather, to
advance willingly through it.
B) Moving from the sphere of the public to the private

The transition from the stage of gathering epidemiological-statistical information
to the account for the reasons of the visit has been described as a passage from
the sphere of the “public” to the “private” in psychotherapeutic interviews (cfr.
Chapter 2). This move is usually proposed by therapists, who have previously
“orchestrated” and anticipated the structure of the interview (cfr. extract 1), but
it also can be initiated by the patient. As the therapist’s questions set an agenda
which discourages moving away, the patients’ preferred strategy is to expand the
answer to some epidemiological-statistical question which can be related to those
private, biographical reasons for the visit:
Extract 4
1 Prof: hiciste algún tratamiento anterior psiquiátrico
2 psicológico=
3 Pat: =sí estaba haciendo y lo abandoné
4 Prof: qué hacías?
5 Pat: porque (.) pasa así (0.5) yo estaba: tan tan tan::
6 depresiva que me quise matar (1.0) [no tenía]
7 Prof: [internada] o
8 tratamiento=?
9 Pat: =sí (0.3) estuve interna:da y todo (.) con
10 trata[miento]
11 Prof: [bueno] ahora después nos (.) nos contás bien
12 (0.5) eh::: llegaste a:::: qué nivel de[::
13 educación]
1 Prof: have you had any previous treatment psychiatric

2 psychological=
3 Pat: =yes I have but I left it
4 Prof: what were you doing?
5 Pat: because (.) the thing is (.) I wa:s so so so::
6 depressive that I tried to kill myself (1)
[I didn’t have]
7 Prof: [inpatient] or
8 outpatient=?
9 Pat: =yes (0.3) I was an inpa:tient and everything (.)
with
10 treat[ment]
11 Prof: [well] you can tell us about it (.) later on
12 (0.5) uhm::: you reached:::: what level of [::
13 education]
In lines 1–2, the therapist asks a yes/no question about previous treatments
together with an alternative question about psychiatric or psychological treat-
ment. The answer, in l. 3, is affirmative and offers the rudiment of a narrative
about the patient abandoning treatment. The therapist does not acknowledge
this small expansion but, rather, follows with a wh- question to differentiate
between psychiatry and psychotherapy. The patient’s response, in lines 5–6,
answers “more than the question” and addresses the non-required background
of the previous treatment. By introducing her attempted suicide, the patient
projects a move towards the sphere of the private, presenting her biography as
the main topic of the conversation (cfr. Chapter 2). However, the professional
overlaps in line 7 to regain the turn and follow the written form – distinguishing
between “outpatient” and “inpatient” treatment. As the patient insists on her
narrative, expanding what began in l. 3, the professional explicitly postpones the
biographic story (l. 11) and continues with the form.
Sometimes the strategy of moving towards the sphere of the private, and thus
commencing the psychotherapeutic conversation proper (Bartesaghi 2009), is
successful, as can be seen in the following example:
Extract 5
1 Prof: bien (.) con quién vivís? °contáme°
2 Pat: ahora estoy: con mi señora
3 Prof: mm
4 Pat: mi señora que es (.) la que está: mal viste? por
5 los problemas que tuve de la adicción ↑mía
6 Prof: ahá >ahora ahora vamos< a::
7 Pat: °por eso ahora estoy-° se arregló todo! estoy
8 bie::n no estoy consumie::ndo (.) (>que es-<
9 vengo a hacer) tratamiento
10 Prof: °sí sí°
11 Pat: [(apar-)]
12 Prof: [bueno ] contanos que: qué te trae por acá
1 Prof: OK (.) who do you live with? °tell me°

2 Pat: now I am: with my wife
3 Prof: hmm
4 Pat: my wife is the one who (.) the one who is: unhappy
you know? because of
5 the problems I had with my ↑addiction
6 Prof: right >now we are going< to::
7 Pat: °that’s why now I’m-° everything worked fine! I’m
8 fi::ne I’m not u::sing (.)(>which is-<
9 I come to have) treatment
10 Prof: °yes yes°
11 Pat: [(besid-)]
12 Prof: [well ] tell us what: what brings you here
In this example, the question about “convivientes” (“cohabitants”) triggers

a narrative through the adverb “ahora” (“now”), emphasized by the patient
(l. 2). This adverb suggests a story of breakup and reconciliation which is encour-
aged by the therapist in l. 3 and expanded by the patient, who introduces his
former drug addiction as the main reason for that breakup (l. 4–5). The profes-
sional tries to regain the turn in l. 6 by postponing the narrative, but the patient
keeps elaborating his previous turn, presenting the reason for the consultation.
The minimally displayed narrative is central to the presentation of these motives
because it leaves the addiction in the past and argues for a psychotherapeutic,
non-drug-related treatment in the present. The professional, despite her attempt
to follow the epidemiological-statistical form in line 6, agrees with the patient
to move to the sphere of the private of therapy and confirms the transition with
‘bueno’ (l. 12).
C) Dealing with potential face-threats

Some expanded responses are designed to deal with potentially face-threatening
inferences which could be triggered by the patient’s straight answer. We will
observe here two examples which involve different types of threats, either legal
or moral:
Extract 6
1 Prof: tenés un número de documento?
2 Pat: tengo carnet=
3 Prof: =mm=
4 Pat: porque: (.) está en trámite mi mi DNI
5 Prof: (quedó) acá?
6 Pat: adelante está
(. . .)
7 Pat: el DNI lo tengo pero::=
8 Prof: ESTÁ BIEN (.) está bien=
9 Pat: =lo tengo en trá[mite]
10 Prof: [no te] preocupes=
1 Prof: do you have an ID number?

2 Pt: I have a card=
3 Prof: =hmm=
4 Pat: because: (.) my my ID is in progress
5 Prof: (did you leave it) here?
6 Pat: it is in the front
(. . .)
7 Pat: I do have the ID but::=
8 Prof: OKAY (.) okay=
9 Pat: =I’ve got it in pro[gress]
10 Prof: [don’t] worry=
This example features a Bolivian patient who lives in Argentina without legal
citizenship or residency. As the “illegal alien” figure entails a strong anti-immigrant
prejudice, especially related to the use of public services,2 the patient refuses to give
a straight answer to the yes/no question of line 1. Instead, he offers an alternative
response, “I have a card” (l. 2), on the nature of which he does not provide any
information. As the professional offers an ambiguous “mm” in l. 3, the patient
argues that his ID card is in process. This answer still does not respond to line 1 and
can actually be seen as one of those lies which happen when addressing “delicate
subjects” in health communication (Vincent et al. 2007: 234), as it may lead to legal
sanctions.3 The weak argumentation, mainly based on repetition (l. 4, 7, 9) is inter-
rupted by the therapist in line 8 and the issue of the ID card is dismissed in l. 10.
Other expansions of this type are designed to face moral prejudices about
unemployment, which assert that “he who doesn’t work, doesn’t want to”
(Buendía 2010: 35). This is the case in the following example:
Extract 7
1 Prof: tu situación actual: de trabajo? trabajá:s (.) °no
2 tra[bajá:s]°
3 Pat: [ahora] no
4 Prof: no=
5 Pat: =ahora no
6 Prof: por el tema de la pierna?
7 Pat: por el tema de la pierna (.) por el tema de la
8 pierna
9 Prof: ahá (.) pero estás de lice:ncia estás sin
10 tra[ba:jo]
11 Pat: [>no no] no< me quedé sin laburo
12 Prof: sin trabajo (.) °bien° (.) e:h la casa donde vivís
13 es pro:pia (.) alquila:da?
1 Prof: your current: job situation? you wo:rk (.) °you

2 don’t [work ]°
3 Pat: [not at the moment] no
4 Prof: no=
5 Pat: =not at the moment
6 Prof: because of the leg problem?
7 Pat: because of the leg problem (.) because of the leg
8 problem
9 Prof: ok (.) but are you on a sick le:ave are you
10 un[employed]
11 Pat: [>no no] no <I became unemployed ((untranslatable ‘laburo’))
12 Prof: unemployed (.) °ok° (.) uh:m the house where you live
13 is it yo:urs (.) ren:ted?
The item in the epidemiological-statistical form is “Job status” (Condición

laboral) and provides the following options: “Employed”, “Unemployed”,
“Underemployed”, “Retired”, “Student”, “Housewife”. The therapist begins
with an open question about the patient’s “current job situation”, which she
immediately rephrases as an alternative one, between the options “employed”
and “unemployed” (l. 1–2). The patient overlaps with emphasis in the adverb
“ahora” (“at the moment”), following a similar strategy to that of Extract 5, line
2, in order to suggest a narrative of former employment interrupted by a com-
plication. The therapist only recalls the negative answer in line 4, so the patient
repairs by repeating the adverb (l. 5). Facing this brief but eloquent expansion,
the therapist inquires about the complication which led to the unemployment
situation, making a “best guess” based on the leg plaster the patient is wearing.
As this reason does not necessarily lead to unemployment in formal work, the
therapist asks in line 8 if the patient’s condition is that of unemployment or if
he is on medical leave. At this point, the patient states plainly his unemployment
condition through an informal expression: “me quedé sin laburo” (l. 11), which
is formally repaired by the professional (“sin trabajo”, l. 12), who now continues
with the rest of the form.
D) Pre-empting rejection
As mentioned above, the public healthcare system is overwhelmed by a demand
that it cannot satisfy in its current structural condition. It is a perverse system in
which the responsibility for actually deciding who will receive medical attention
and who will not is placed on the healthcare providers (Jean 2004). Doctors,
nurses and therapists are implicitly entitled with the power to deny people their
legitimate right to healthcare on behalf of a deficient system. As one psychiatrist
once told me bitterly, “they are not admission, but rejection interviews” (“más
que de admisión, son entrevistas de expulsión”). As there is a limited number of
consulting facilities and very restricted personnel to deal with the demand, pro-
fessionals use rejection criteria which are not explicit.4 The two main rejection cri-
teria which we have found are based on city of residence and medical insurance:
Extract 8
1 Prof: ((inaudible)) terapia (1.0) sí (.) obra social?
2 Pat: y:: sería galeno
3 Prof: galeno (1.0) R (.) escúcheme una cosa (.) esto lo
4 comentó? porque nosotros- el tema es así (0.3)
5 nosotros tenemos una demanda:
6 Pat: grande (.) sí (.) ya sé me doy cuenta
7 ((inaudible))
8 Prof: claro eh: no- los que tienen obra social- las
9 personas que vienen acá es porque no tienen
10 ningún servicio para atenderse
11 Pat: ((inaudible))
12 Prof: usted tiene galeno (0.3) yo le tengo que decir
13 que: tiene que ir a galeno
1 Prof: ((inaudible)) therapy (1.0) yes (.) medical

insurance?
2 Pat: uhm:: it would be galeno
3 Prof: galeno (1.0) R (.) listen (.) did you mention
4 this? because we- the thing is (0.3)
5 we have a demand:
6 Pat: that is huge (.) yes (.) I know I realize
7 ((inaudible))
8 Prof: right uhm: don- those who have medical insuran-
9 people who come here have
10 nowhere else to go
11 Pat: ((inaudible))
12 Prof: you do have galeno (0.3) I have to say:
13 go to galeno
In this example, when the patient admits he does have private medical insur-
ance, called Galeno, the therapist rejects him as a patient on the basis that “people
who come here have nowhere else to go” (“las personas que vienen acá es porque
no tienen ningún servicio para atenderse”, l. 8–10). Many patients, however,
have practical knowledge of these (unspoken) criteria because they regularly use
public services and are thus able to pre-empt rejection and argue for admission.
Extract 9
1 Prof: (1.2) tiene alguna cobertura social?
2 Pat: sí
3 Prof: qué tiene?
4 Pat: eh (0.3) yo (.) eh:::: yo trabajo de bombero para
5 la PFA (((Policía Federal Argentina)) y:: (1.0)
6 Prof: para la policía?
7 Pat: sí (0.5) soy bombero de acá de XX ((barrio))
8 y trabajo acá en el hospital
9 Prof: y qué obra social tiene?
10 Pat: la de::::l churruca (3.0) lo que pasa es que yo
11 (vengo) acá porque si yo planteo los problemas que
12 tengo allá (.) ahí me retiran el arma y: y me
13 sacan: no me dejan trabajar más
1 Prof: (1.2) do you have any medical insurance?

2 Pat: yes
3 Prof: which one?
4 Pat: uhm (0.3) I (.) uhm:::: I work as a fire-fighter
for the
5 PFA ((Argentina Federal Police)) and:: (1.0)
6 Prof: for the police?
7 Pat: yes (0.5) I’m a fire-fighter here at XX
((neighbourhood))
8 and I work here at the hospital
9 Prof: and which is your medical insurance?
10 Pat: the:::: churruca one (3.0) the thing is I
11 (come) here because if I talk about my problems
12 there (.) they will take away my gun and: and get
13 rid of me: they won’t let me work any more
In Extract 9, the item “Social insurance” (and its options, “mixed”, “private”,
“none”) is presented as a yes/no question in l. 1 and answered affirmatively in
l. 2. Although the therapist asks for further information, the patient begins an
expansion in line 4 related to his employment as a firefighter for the police force.
As the professional asks again, in line 9, about his social insurance, the patient
elaborates on the reasons why he does not want to use his social insurance. This
answer could have been considered irrelevant to the question insofar as these
reasons were not inquired about. However, the patient pre-empts rejection based
on social insurance, a practice we have just observed in Extract 8. As he is a police
officer and has a drug addiction, he is afraid of losing his job if he uses the medi-
cal insurance provided by the police department. Therefore, in lines 10–13, he
argues his reasons to seek attention at a public hospital, in order to preserve his
employment in the formal sector.
The other main reason for rejecting applicants is based on the city of address.
As in the previous case, there is no explicit rule to do this, but it may be based
on declarations of the Buenos Aires governor, Mauricio Macri, who in 2007
said that Buenos Aires hospitals should prioritize care for Buenos Aires citizens
over people who come from neighbouring cities.5 Despite widespread negative
response to this opinion, it remained an implicit criterion among healthcare pro-
viders and is a regular argument used to reject patients. As many patients have
already been rejected for similar reasons, they may use expanded responses to
pre-empt this kind of refusal of care:
Extract 10
1 Prof: eh dígame le tengo que hacer ((inaudible)) capital
2 o provincia vive?
3 Pat: no (.) vivo en provincia (.) en XX ((ciudad)) más
4 precisamente ahora estoy viviendo acá por esta
5 situación de esta mujer (.) que no no quiero ir
6 con mis padres pero (.) no- yo estuve en el: me
7 dijeron no hay cupo (0.3) lo comenté acá desde
8 el primer día
9 Prof: sí(1.0) lo vamos a atender pero en realidad yo
10 contaba con que usted era de capital porque no-
11 si el((inaudible)) no tiene cupo nosotros no-
12 (0.5) sí (.) su estado civil?
1 Prof: uhm tell me I have to ask ((inaudible)) capital

city
2 or province do you live?
3 Pat: no (.) I live in the Province (.) in XX ((city))
4 right now I’m living here because of this
5 situation with this woman (.) I don’t don’t want
6 to go with my parents but (.) don- I’ve been at:
7 they told me there are no available slots (0.3)
I’ve been saying so since
8 the first day
9 Prof: yes (1.0) we will take you in but actually I
10 thought you were from the capital because we don-
11 if the ((inaudible)) there is no availability we
don-
12 (0.5) yes (.) your marital status?
The item about city of residence is presented as an alternative question between
the options which determine the admission or the rejection (i.e. “Capital City”
or “Province”, l. 1–2). The patient begins with a confused negative which he
immediately repairs by answering that his address is in XX City, in Buenos Aires
Province. The expansion is confusing. In line 4, he states he is currently living in
the Capital City, but immediately begins a narrative about a previous visit during
which he was rejected (by saying “there are no available slots”, “no hay cupo”,
l. 7). Then the patient argues for his honesty as a positive self-image feature: he
has been saying “since the first day” that he does not live in Buenos Aires. This
implies that he has already been admitted from the first day (otherwise he would
not have made it to the admission interview). This argument seems to be effective
enough for the therapist, who admits the patient (“we will take you in”, “lo vamos
a atender”) as an exception, pointing out that the available slots are intended
only for those who live in the Capital City (l. 9–11).
Bureaucracy and access to healthcare

The issue of doctor-initiated questions is a consolidated line of research in
doctor–patient interaction studies. Most of these studies share two distinct fea-
tures: a) they analyze conversation in biomedical specialties; and b) they focus on
history-taking questions. This chapter endeavours to make a contribution to this
line of research from a different, more critical point of view, regarding bureau-
cratic questions as a mechanism for managing inclusion in and exclusion from
healthcare, and expanded answers as tactics: resisting statistical exclusion criteria
allows clients to negotiate access to mental healthcare. I therefore focused on
bureaucratic, epidemiological-statistical questions from a political point of view.
In this sense, Excerpt 1 shows that the question-answer pair is quite similar
to that observed in comprehensive history taking: optimized to set an agenda
quickly and effectively, the questions are usually responded to with short, precise
answers designed to enter the bureaucratic order and thereby secure psycho-
therapy. This process entails tension: the right to mental healthcare can only be
satisfied if the patient gives up his/her right to privacy, thus providing informa-
tion on his/her relationships (marital status, convivial group), economic activities
(occupation, social insurance), national/local identities, etc. This information is
not used for treating the patient. Instead, the epidemiological-statistical form
is stored separately from the patient’s medical history and collected by the City
Government Mental Health Office to develop statistics and, ultimately, used
to design more restrictive and rejecting health policies. In this sense, patients’
collaborative answers result in an optimization of State biopolitical power “for
achieving the subjugation of bodies and the control of populations” (Foucault
1990: 140). The examples of the first type of expansion, Excerpts 2 and 3, rep-
resent an exaggerated case of collaboration. By answering more than the ques-
tion, patients over-collaborate to fulfil the epidemiological-statistical classification
quickly and fully enter the biomedical order. As poor people who are excluded
from many of the capitalistic rights and institutions, the attempt to answer effi-
ciently and enter the bureaucratic order may be seen as an attempt to enjoy fully
the rights they are entitled to.
Bureaucratic and clinical information are closely linked precisely because psy-
chotherapy looks for the patient’s lifeworld experiences, which are not usually
seen as relevant to other clinical specialties (Mishler 1984; Waitzkin 1989). On
the contrary, the usual biomedical questions “tend to ignore those aspects of
patients’ utterances that report on subjective experience, personal circumstances
and social conditions” (Ten Have 1991/2005: 3). These are matters covered by
the epidemiological-statistical form, which is not usually considered a part of clin-
ical interaction but, rather, as an independent bureaucratic activity. This activity,
however, is an institutional strategy which can be tactically exploited by patients.
Our results show different strategies for gaining access to healthcare through
expanded answers to bureaucratic questions. Type A displays bureaucratic com-
petence and thus cooperates in completing the epidemiological-statistical form
as quickly and efficiently as possible. Not sensing any threats, not fearing rejec-
tion, expansions do not move away but forward in the institutionally defined
agenda. Type B expansions, on the other hand, also move towards the private
clinical interview proper, but not following the institutionally defined agenda.
Rather, biographical narrative expansions attempt to force the move towards the
private sphere, either successfully (as in Excerpt 5) or not (as in Excerpt 4). Type D
responses are the most interesting, as they attempt to pre-empt rejection through
expansion. Patients seem to have practical knowledge about (informal) eligibility
policies and therefore devise interactional strategies to avoid them. Lastly, type C
responses are a sort of borderline case which do not deal directly with access but
with the categories implied in the epidemiological-statistical form. Excerpt 7 deals
clearly with a face threat due to the patient’s situation of unemployment. Excerpt
6, on the other hand, is on the edge of type D: the patient’s expansion faces a preju-
dice which ultimately questions his right to obtain public healthcare in Argentina,
even if this right is not at issue either in legal or interactional terms in the interview.
As these actions involve patients’ self-images and private information about
them, there might be a relationship between mental condition, diagnosis (self- or
other-administered) and response-expansion type. This relationship, however, is
not apparent, at least in the data analyzed herein. Patients in Excerpts 2 and 3,
who are included in the first type of answers, received radically different diag-
noses: while the former was admitted to psychiatric treatment for psychosis, the
latter was admitted as an outpatient for psychotherapy to deal with a small rela-
tionship crisis. Patients included in type B also differ: the woman in Excerpt 4
was diagnosed with severe depression, including previous attempted suicide, and
therefore derived to psychiatry and psychotherapy. The man in Excerpt 5, on
the other hand, who was a former drug addict, was referred to group therapy.
Patients included in type C expansions are equally heterogeneous: the young man
in Excerpt 6 was diagnosed with psychosis (and was actually seeking to continue a
former treatment initiated in Bolivia), while the man in Excerpt 7 was diagnosed
with mild depression. As for type D, the man in Excerpt 8 received psychotherapy
for his relationship issues with his family, while the firefighter in Excerpt 9 was
admitted as an outpatient to receive combined addictions treatment, both psy-
chological and psychiatric.
One relevant feature of the patients analyzed in this chapter is that all of them –
except for the patient in Excerpt 5 – have received previous treatment of one sort
or another at other public institutions. It could therefore be hypothesized that
this experience is not only clinical but also bureaucratic. Previous contact with
medical institutions, implicit or explicit eligibility policies and similar question-
naires helped develop a repertoire of strategies for negotiating or gaining access
to healthcare. Is this experience only a personal, individual one? Is there any shar-
ing of this knowledge among patients, for instance in the waiting room or other
public spaces in the hospital? Or do individualistic strategies prevail in order to
compete for a place in a resource-starved and bureaucratically regulated system?
Notes
1 Percentages are indicative of the quantitative relevance, but they have no theoreti-
cal value in our analysis insofar as our research has been qualitatively designed.
2 As public services are tax-funded, this prejudice asserts that immigrants enjoy pub-
lic services without paying for them. On this argument, and other similar ones, cfr.
http://cuadernos.inadi.gob.ar/ (National Institute against Discrimination, Xeno-
phobia and Racism). It should be noted that, at least theoretically, not being an
Argentine citizen should not be an obstacle to access to public healthcare, which
is said to be universal. This is the reason why this case does not fall into the next
category, type D expansions, which attempt to prevent rejection.
3 The figure of “ID card in process” was used, until five years ago, to designate the
time elapsed between the end of the legal procedures to acquire an ID card and
the analogical assignation of a number by the Ministry of Interior. Since 2009, the
“process” is digital and instantaneous: once the bureaucratic steps are completed,
the ID number is immediately assigned. The patient here uses a figure which no
longer exists, although he shows acquaintance with former procedures.
4 On the contrary, it is said to be free and universal; cfr. the City Government Minis-
try of Health, www.buenosaires.gob.ar/salud.
5 Cfr. “Hospitales: duro cruce entre el gobierno macrista y Scioli”, Clarín,
23/12/2007. http://edant.clarin.com/diario/2007/12/23/laciudad/h-06215.
htm.
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6 Speaking with the
other’s voice
An attempt to close the gap
Introduction: dealing with asymmetry and inequality

This chapter addresses an empirical issue observed during our ethnographical
work: the adoption of characteristic features of the interlocutor’s ways of speak-
ing. Although psychoanalysts claim to do so in order to achieve clinical goals,
we will explore here the wider implications and contradictions of this voicing
strategy as it involves both professionals and patients. In this sense, we attempt to
see the potential and the limitations of this other-oriented strategy (Shi-xu 2009:
34–35) regarding actual mental healthcare practice.
Asymmetry between doctors and patients is one of the most widely acknowl-
edged principles in health communication studies. In the field of conversation
analysis, structurally asymmetrical roles, defined as “the sick role” and “the role
of the physician” (Parsons 1975), are a part of the “organizing principles” (Her-
itage & Clayman 2010: 119) of interaction in medical settings. As Ten Have
(1991/2005) states, the issue of asymmetry has two different aspects: first,
regarding topic (it is the patient’s health condition, and not the physician’s, which
is under scrutiny); second, regarding participants’ task during the encounter. In
the latter, there is a noticeable “biomedical selectivity in that physicians tend
to ignore those aspects of patients’ utterances that report on subjective experi-
ence, personal circumstances and social conditions” (Ten Have 1991/2005: 3).
The exception which Ten Have (1989) notes is, precisely, when physicians look
for psychosomatic aspects of diagnosis and treatment, in which case they usually
ask for environmental and subjective reports. This is one of the key differences
between biomedical discourse and psychotherapy, whose main topic is precisely
subjectivity.
It is possible to locally produce or circumvent (a)symmetrical relationships on
the basis of the activities carried out by participants (Ten Have 1991/2005). In
the case of psychotherapy, asymmetry characterizes the distribution of roles and
tasks – as inherited from biomedical discourse – but on the other hand, needs to
be dealt with in order to achieve therapy goals. Bercelli, Rossano and Viaro (2006:
44) have noticed “a uniform asymmetric pattern” regarding turn type distribu-
tion and turn order in psychotherapy. Vehilläinen (2006) observes, as a mean-
ingful difference with everyday communication, an asymmetrical relationship
Speaking with the other’s voice 133
regarding participants’ knowledge of their own experience. Therefore, the analyst
is seen as the only person able to interpret “the meaning of the client’s talk before
and beyond the client’s awareness of it” (Vehilläinen 2006: 138). In this sense, as
Leudar et al. (2006: 154) point out, the therapist uses the client’s language and
frame of reference, and, thus, the degree of asymmetry between therapist and
client may vary according to different therapeutic schools. That is, in fact, what
many psychoanalysts recommend. In the words of one of the professionals we
observed, the challenge is “to speak with the other’s voice” (“hablar con la voz
del otro”) and, in doing so, to understand the other’s lifeworld. In clinical terms,
reducing asymmetry is important in order to “enhance transference and remove
the barriers between speaker and listener” (Harris 2012: 256).
Asymmetry, however, is not only a local effect of role-identities subject to
interactional negotiation. It is also an emergent of social structure and macro
patterns of inequality which produce social distance between groups. Granovet-
ter (1983) has demonstrated the role of weak ties between groups in producing
and reproducing social distance, especially between people who occupy the lower
and the upper positions in social structure. In Argentina, although public health
services are said to be universal, 37% of the population (about 16 million people)
go to public hospitals on a regular basis. The rest is included either in private
or mixed health insurance schemes. As we have pointed out in Chapter 2, the
population who attend regularly at public hospitals is at the lower levels of the
social structure.
As a consequence, in addition to asymmetry between professionals and
patients, there is also a structural social distance between white, Argentine-born,
post-graduate middle-class professionals of European descent and patients with
partial indigenous ancestry, many of whom have migrated from bordering coun-
tries or poor Argentine provinces, with basic education and no steady job. Both
components of G. Simmel’s 1908 definition of social distance are present: on
one hand, the interlocutor is perceived as unfamiliar, of a different kind in terms
of gender, age, ethnicity or social class. On the other hand, distance is observed
in everyday life through the low frequency and intensity of interaction between
groups and their members (Ethington 1997). The stereotypical identification of
social structure position and sociolect becomes a resource in the management
of social distance: as Giles, Coupland and Coupland (1991) have demonstrated,
intergroup communication is often the result of accommodating to the interlocu-
tors’ perceived way of speaking.
Asymmetry, on the other hand, is a locally observable phenomenon which
depends on the qualification of the individuals to fulfil the requirements of insti-
tutionally defined roles. Medical interaction distinguishes between a subject
who has a specific knowledge and authority, the doctor, and someone who lacks
this knowledge about his/her own body, the patient. The whole process which
begins with a more or less unspecific illness is oriented to the authority which
will transform it in a medically validated disease (Heritage & Clayman 2010:
154). Social distance and asymmetry are close, but different. The former is inde-
pendent, to some extent, of institutionally defined roles. As a consequence, the
134 Speaking with the other’s voice
doctor and the patient may be socially familiar even if, during consultation, they
assume asymmetrical roles. On the contrary, institutional roles may be symmetri-
cally distributed – for instance, to the customers in a store – although participants
may be socially distant between themselves and do not share any other space of
interaction.
In this chapter, we will argue that the attribution of voice1 provides patients and
professionals with linguistic resources to manage asymmetry and social distance.
In the case of the former, patients adopt features of the institutional discourse,
which defines the asymmetrically distributed roles, to level the relationship as
an empowerment resource in front of medical authority (Heritage & Clayman
2010: 154 ff.). On the other hand, professionals, especially psychoanalysts, adopt
some features of the interlocutor’s lect to decrease the perception of social dis-
tance and, as a consequence, enhance transference.
Accommodation, voice and social range

Dealing with asymmetry and social distance can be understood in terms of inter-
group communication in medical settings as physicians and patients attempt to
accommodate to perceived outgroup typicality (Hajek, Villagran & Wittenberg-
Lyles 2007: 294). The Communication Accommodation Theory (CAT) specifi-
cally addresses the “social cognitive processes that mediate a person’s perception
of the surrounding environment and her/his communicative behaviours” (Nuss-
baum et al. 2005: 290). The application of CAT in the field of health commu-
nication has been extensive since its beginnings (Giles, Coupland & Coupland
1991), with special interest in mental healthcare settings (Stabile et al. 2013) and
ageing studies (Lagacé et al. 2012; Ota et al. 2007; McCann et al. 2005).
Although we share many interests with CAT, the research we have conducted
has not been shaped within its theoretical framework due to a number of rea-
sons. In the first place, the phenomena addressed here have not been identified
through a theoretical a priori (i.e. looking for accommodation strategies) but,
rather, have emerged as regularities which we reunited in the concept of voice.
Secondly, our analytical approach to conversation favours direct observation of
interaction in actual contexts. Accommodation research, on the other hand, is
mainly experimental, controlling contextual factors and measuring linguistic
or attitudinal outcomes (Coupland 2007: 63). Thirdly, as Gasiorek and Giles
(2012) have stated, accommodation is a subjective phenomenon, “the recipient’s
perception of a behaviour” (Gasiorek & Giles 2012: 311). In this sense, over-
and under-accommodation are “evaluative assessments made by the recipient of
the communication in question” (id.), the speaker’s actual motive and intent
being irrelevant. What CAT takes into account, instead, is the inferred motive,
i.e. “the motive that a recipient attributes to a speaker” (id.). In this article, in
contrast, we will address the speaker’s representations of the recipient’s social
range and, thus, of his/ her characteristic voice. We have adopted many of CAT’s
conclusions, especially the observation that convergence and divergence do con-
tribute to achieving closeness (Giles et al. 1987) and distance (Nussbaum et al.
2005) between participants. As both strategies involve the speaker’s interpreta-
tion of the receiver’s needs and comprehension, stereotypes about “the other”
play a fundamental role in (mis)communication between health professionals and
patients (Gallois, Ogay & Giles 2005).
In the terms of our research, from the speakers’ point of view, we found that
one of the most important resources participants use to decrease asymmetry
and social distance is related to the adoption of characteristic features associ-
ated to the interlocutor’s “voice”, i.e. “another’s speech in another’s language”
(Bakhtin [1934–1935] 1981: 324). From this perspective, the speaker can stage
two voices as “two exchanges in a dialogue” (Bakhtin [1934–1935] 1981: 325),
evoking different personae engaged in a conversation settled by the speaker.
Evoking another’s voice does not necessarily mean identifying oneself with it,
although it does have impact on the orientation towards the activity being carried
on and its participants. Although the voice is attributed to another character, the
voicing and contents are provided by the speaker him/herself, who speaks “as if”
s/he were the other. The source of this voice, therefore, is the speaker’s expe-
rience: his/her own knowledge, beliefs and prejudices about what the other’s
voice is like. In the terms of Agha (2005: 38), voices are indexed by “social types
of persons, real or imagined, whose voices they take them to be”. Social voices,
therefore, are discursive figures that permit characterization through a metadis-
course of social types of persona attributes. Agha (2005: 39) calls that range of
stereotypic social personae performable through characteristic social indexicals
social range: male, lower class, a lawyer, a bureaucrat, etc. The group of persons
capable of producing and recognizing the figures indexed by these voices consti-
tute the social domain of enregistered voices.
Consequently, “speaking with the other’s voice” means representing some
aspect of the social range of the interlocutor’s voice from the point of view of
the speaker’s own social domain. Specifically within the social domain of register
lies a core interest to our work: domains are not just different, but unequal, as
they receive different social values on a hierarchically organized scale (Blommaert
2007). Thus, speakers not only recognize the different social voices indexed by
(more or less) stereotypical cues but also attribute to them a value within a scale:
social voices have the prestige of their speakers. These kinds of voices produce
an effect of alignment which has impact not only on the speaker but also on the
recipients and, in general terms, on the semiotic activity which involves them
both (Goffman 1981). Therefore, adopting the other’s voice may work as a way
to reorient the activity and thus the relationship between participants.
Now, the questions we will attempt to answer are: how do participants identify
their interlocutor with a social persona? Which features of the other’s attributed
identity do they select as relevant for voicing?
The cases we will discuss here illustrate the diversity of resources deployed by
both patients and professionals to deal with asymmetry and social distance by
adopting some of the interlocutor’s perceived characteristic voice. In the case of
patients, indexing upper-level voices (what Giles, Coupland & Coupland 1991
would call “upward accommodation”) is usually achieved by using bureaucratic and
psychiatric terms. In the case of professionals, downward accommodation depends
on the interlocutors’ perceived social range, which varies according to whether the
selected feature is age, social class, ethnicity, religious beliefs, etc. We have selected
four different examples which illustrate this diversity in actual interaction. Although
they are examples of different types of voice which emerge in different interviews,
the criteria employed for sampling were theoretical and not statistical.
The patients’ point of view: indexing upper-level voices

Outpatients at mental healthcare admission interviews may develop a strategy
to decrease the asymmetry of the situation by displaying knowledge. Relevant
knowledge, assumed as a highly valued, potentially empowering voice, appears
in our corpus either as practical or theoretical. In the first case, its source is the
patient’s own experience as a client of the State apparatus and, as such, evokes
the bureaucratic voice of institutional talk (Prego Vázquez 2006). In the second
case, mass media, Internet and previous treatments help develop folk theoretical
knowledge of psychiatric voice which is observable mainly through specialized
terminology (Giles & Newbold 2011).
Indexing bureaucratic voice

Although public hospitals are institutions with highly standardized procedures,
including communicative ones, mental healthcare professionals in Buenos Aires
tend to react against the impersonal, status-oriented tradition of biomedical dis-
course (Lakoff 2006). There is a tendency to create informal environments which
allow the emergence of biographical, often intimate, information relevant to the
diagnostic process (Bonnin 2013).
Therefore, institutional talk (as described by Heritage & Clayman 2010)
appears as an alien voice, the voice of bureaucracy evoked by clients – not by
professionals – to index competence in these kinds of institutional practices and
reorient the activity towards a more formal register. It is usually adopted dur-
ing the first sequences of admission interviews, designed to gather bureaucratic-
administrative information on patients’ demographic profiles (such as gender,
education, marital status, etc.). As a way of decreasing the level of formality,
professionals seldom read aloud the items on the official form but rather request
the information in a more conversational way:
Extract 1
1 PC: deivi vos vivís (.) en capital o vivís en provincia?
2 Patient (PAT): vivo en capital (yo)
3 PC: en capital (1) estás solte::ro casa::do
4 PAT: en pareja (.) °°con mi cónyuge°°
5 PC: hiciste tratamientos psiquiátricos o psicológicos antes
6 de venir acá?
7 PAT: aquí? sí (.) ya hice dos veces vine
8 PC: viniste dos veces acá al hospital?
9 PAT: sí
10 PC: viniste así a los consultorios o: o: estuviste
11 internado?
12 PAT: no solo vine a los consultorios y estuve internado en:
13 bolivia en la paz
14 PC: ah bien (2) y fueron consultorios de acá de psicología?
15 PAT: salud mental’ era=
16 PC: =salud mental
17 PAT: salud mental (1.5) en (allá) le dicen así creo
18 PC: sí (.) sí sí=
19 PAT: =igual creo que se llama acá (.) (no es)?
20 PC: sí [sí]
21 AP: [sa]lud mental
22 PC: deivi vos hiciste: la escue:la
23 PAT: sí sí (.) secundario incompleto
1 PC: deivi do you live (.) at the capital city or at the Province?
2 Patient (PAT): I live at the capital (I)
3 PC: at the capital (1) are you si::ngle ma::rried
4 PAT: cohabiting (.) °°with my spouse°°
5 PC: have you ever receive psychiatric or psychological treatments
before
6 coming here?
7 PAT: here? yes (.) I did twice I came
8 PC: you came twice here at the hospital?
9 PAT: yes
10 PC: you came like this to outpatient service o:r o:r you were
11 admitted as an inpatient?
12 PAT: no I just came to the outpatient service and I have been an inpa-
tient a:t
13 bolivia at la paz
14 PC: oh right (2) and they were services like this of psychology?
15 PAT: mental health it was=
16 PC: =mental health
17 PAT: mental health (1.5) at (there) they call it like that
18 PC: yes (.) yes yes=
19 PAT: =I think it is called the same here (.) right?
20 PC: yes [yes]
21 AP: [ment]tal health
22 PC: deivi did you atte:nd schoo:l
23 PAT: yes yes (.) secondary incomplete
In extract 1, the interviewer begins with a casual, conversational style through
the informal second-person singular pronoun (“vos”, “you”) and the formulation
of questions instead of reading the items in the form. In line 3, she rephrases the
original variable (“marital status”, “estado civil”) and its options (“soltero [single],
casado/en pareja [married/cohabiting], separado [separated], viudo [widower]”)
as a disjunctive indirect question, selecting only the two options which seem to
be more adequate to the interviewer’s situation. This selection is made on the
basis of assumptions made by the psychotherapist, probably based on age – which
exclude options as “widower” – but also on her own moral prejudices – excluding
“cohabiting” and “separated”, which may be considered illegitimate options. As
the patient actually cohabitates (he lives “en pareja”) with his partner, in line 4
he answers using technical terms which index bureaucratic voice: “en pareja (.)
°°con mi cónyuge°°”. Both “en pareja” (“cohabiting”) and “cónyuge” (“part-
ner”) are technical terms which are present in the form, and the speaker adopts
both as an alien voice, the bureaucratic voice, emphasizing this strategy through
a short pause and perceptible lowering of volume in l. 4.
Something equivalent happens in line 16, when discussing the designation
“mental healthcare” (“salud mental”), in which the nominal phrase is followed
by a noticeable pause which introduces a metalinguistic commentary on the
expression modalized through the verb “[I] think” (l. 17). In this case, the psy-
chotherapist had introduced the issue in l. 13 with a non-technical expression,
“outpatient service here, in psychology” (“consultorios de acá de psicología”)
which can be seen as the “voice of the lifeworld” which prevents the emergence
of the “voice of medicine” (Mishler 1984: 63). However, the patient has experi-
ence in the domain of clinical mental healthcare, and this experience is displayed
as he adopts the bureaucratic voice which technically refers to “mental health-
care”, at first with some hesitation – as we saw in l. 16 – but then seeking confir-
mation on his metalinguistic competence at line 18.
Finally, in line 22 the patient answers “more than the question” (cfr. Chap-
ter 5) by providing information on the “level of completion” of education.
Although the professional asks an indirect polar question, the patient adopts the
bureaucratic voice, adding information typically requested by statistical forms
when asking for levels of education. Although the question on “level of comple-
tion” had not yet been enunciated, the patient is able to anticipate it as a part of
the routine activity of gathering demographic information at social security insti-
tutions (as analyzed by Pantaleón 2005). Facing this activity, the speaker answers
to the bureaucratic voice of the statistical form in the same terms, even if they are
not adopted by the professional.
The psychiatric voice

The predominance of the “voice of the lifeworld” (Mishler 1984) in psycho-
therapeutic interviews is often resisted by patients. They evoke psychiatric voice
through technical terminology designed to name symptoms and diagnostic
labels. In other terms: something too close to an ordinary conversation (as shown
by Bartesaghi 2009) is driven to the medical field in order to meet the patients’
expectations about medical settings and medical discourse. In such a context,
evoking the psychiatric voice is a way of showing competence in medical dis-
course and, rejecting the voice of the lifeworld, reorienting the activity.
What patients do not know is that psychoanalysts usually reject medical dis-
course as an illegitimate biologization of the psyche (cfr. Chapter 4); therefore,
instead of achieving better empathy, psychiatric voice creates more distance as it
is rejected by professionals. The conflict between psychiatric and psychoanalytical
discourse in admission interviews has been explored in previous chapters. Here
we can observe its emergence as a voicing issue, evoking psychiatric voice and
dismissing it:
Extract 2
1 PC: dígame: hizo::: e: (.) qué nivel de educación tiene?
2 [secundario?] terciario?
3 PAT: [e:::] universitario:: (1)
4 PC: completo?
5 PAT: no incompleto (.5) no porque me agarró ataques de
6 pánico y tenía que dar dos finales obligatorios y no me
7 siento a leer dos reglones (.5) mirá que me encanta leer ↑
8 por miedo de (.) e igual me agarró de nuevo (. . .)
9 PC: cuéntenos por qué vino ahora?
10 PAT: y porque me parece que otra vez me agarraba ataques de
11 pánico (.) viste? esto:y cansa:da (.) no tengo ganas de
12 hacer na:da (.) tristona (.) viste? ahora desde el lunes a
13 la tarde estoy con opresión y palpitaciones (.) pero
14 continuamente
15 PC: ah sí? desde el lunes?
16 PAT- desde el lunes a la tarde (1) igual yo ya venía pero
17 no tanto (.) me agarra viste?
18 PC: pasó algo últimamente? algo que pueda [relacionarlo
19 con eso?]
20 PAT: [no no] nunca puedo enganchar qué es lo que:: (2)
21 (. . .) oy (.5) tengo ganas de llorar (.) mirá que yo (.) no
22 sé qué se me mueve te juro
23 PC: a ver (.) vamos a hablar un poquito (.) usted dice que
24 esto empezó en el 2002 (.) cómo empezó? usted dice ataque
25 de pánico pero vamos a ver qué: a qué:=
26 PAT: =qué eran los síntomas?
27 PC: claro
28 PAT: bueno estaba tri:ste (.) deprimida: (.) tenía
29 palpitaciones (.) sudoración (.) me quedaba (.) viste?
30 eh::: dura (.5) eh: tenía:: (2)
1 PC: tell me: did you::: er: (.) what educational level do you have?
2 [secondary?] tertiary?
3 PAT: [er:::] university:: (1)
4 PC: complete?
5 PAT: no incomplete (.5) no because I started with panic
6 attacks and I had two exams and I can’t
7 sit down to read a line (.5) and I love reading↑
8 because of fears (.) and it happened again (. . .)
9 PC: tell us why did you came now?
10 PAT: because I think I was having again panic
11 Attacks (.) you know? I a:m ti:red (.) I don’t want to
12 do a:nything (.) gloomy (.) you know? now since monday
13 Afternoon I feel opression and palpitations (.) but
14 constantly
15 PC: oh since monday?
16 PAT- since Monday afternoon (1) anyway I was already feeling but
17 not that much (.) it just happens, you know?
18 PC: has anything happened lately? Something you can[relate
19 to that?]
20 PAT: [no no] I can never identify what is it that:: (2)
21 (. . .) oh (.5) I feel like crying (.) and I (.) don’t
22 know why I am so moved I swear
23 PC: let’s see (.) let’s chat a bit (.) you say
24 this began in 2002 (.) how did it begin? You say panic
25 Attack but let’s see wha:t what do:=
26 PAT: =what are the symptoms?
27 PC: right
28 PAT: well I was sa:d (.) depre:ssed (.) I suffered
29 Palpitations (.) sweating (.) I was like (.) you know?
30 eh::: rigid (.5) eh: I ha::d (2)
Extract 2 shows one of the most common self-diagnosis among patients in

the outpatient service, panic attack (lines 5–6, 11–12), which has had extensive
media coverage in recent years. Professionals usually reject patients’ engaging in
self-diagnosis (cfr. Chapter 5; Broom 2005; Giles & Newbold 2011), dismissing
psychiatric terminology either explicitly or implicitly. As in ex. 1, l. 4, the patient
answers more than the question in line 5, adding information to explain the
reason why she had not finished her higher-level education. However, the profes-
sional does not acknowledge this information, which included the “panic attack”
self-diagnosis, ignoring the digression and moving forward to inquire, paradoxi-
cally, about the reason for the visit (the “problem presentation” described by
Heritage & Clayman 2010: 104 ff.). The answer in lines 10–14 offers an elabo-
ration of the previous turn, omitting circumstantial information. After the self-
diagnostic formulation of lines 10–11, there is a first attempt to describe the
symptoms in everyday, non-technical terms. Therefore, the patient uses informal
second-person forms (“viste?”, “you know?”) in lines 11 and 12, and a diminu-
tive in l. 12 (“tristona”, “gloomy”), indexing affective meanings which contrast
in line 13 with technical nominalizations, which mitigate the subjective position
provided earlier, “palpitations” and “oppression”.
The professional does not provide any feedback on the psychiatric voice.
On the contrary, in lines 24–25 there is an attempt to dismiss self-diagnosis by
opposing the patient’s reported speech (“you say panic attack”) to direct obser-
vation (“let’s see”) through the contrastive conjunction “but”. Since this is a
face-threatening act which diminishes the degree of evidentiality that sustains
the patient’s self diagnosis – in other words, it diminishes her credibility or
reliability – she answers by evoking the psychiatric voice again. Thus, in line 26
the patient interrupts the professional with emphasis and repairs the hesitations of
line 25 with the technical term “symptoms” and enumerating technical and non-
technical terms: “deprimida” (“depressed”), “palpitaciones” (“palpitations”),
“sudoración” (“sweating”) among the former; “triste” (“sad”), “me quedaba
dura” (“I was like rigid”) among the latter.
In this extract, the patient uses the psychiatric voice in those cases which require
levelling up the situation among participants: in the first case, at the beginning of
the interview, we can see an attempt to negotiate the activity by showing techni-
cal knowledge on her condition. In the second case, as a reaction to a potential
face threat, the patient fills the professional’s hesitations and, again, evokes the
psychiatric voice to enumerate her symptoms technically.
The professionals’ point of view: speaking “at the patients’ level”

In the previous section we observed the strategies displayed by patients to ori-
ent the activity by adopting/evoking two well-situated voices: the bureaucratic
and the psychiatric. The relevant feature of the interlocutor’s identity is his/her
role in the actual interaction: as a bureaucrat and as a doctor, specific vocabulary
and degree of formality are adopted to show competence and, thus, level up the
patient’s asymmetrical position.
In the case of professionals, on the contrary, we observe an adoption of the
interlocutor’s voice not in terms of the locally defined role of “patient” but in
terms of demographic-social structure. Thus, the position of patients within the
social structure becomes the dominant feature which professionals select in order
to attribute to them a social range and thus a voice to adopt. As a consequence,
social distance is emphasized even when an attempt is made to reduce it.
That is what one of the professionals once meant by saying that “tenés que
hablarles a su nivel” (“you have to speak to them at their own level”). By adopt-
ing these stereotyped, “lower” voices, professionals attempt to decrease social
distance, levelling down their position to the patient’s supposed range. When this
strategy is successful, patients recognize their attributed voice as legitimate and
use it to elaborate further on the topic of the interaction.
The young, middle-class voice
The following example is taken from an interview with a 19-year-old male who
is currently studying software engineering and, despite having access to private
healthcare, is interviewed by a psychotherapist who is a friend of his mother. This
information is relevant because the professional belongs to the same social class
and, therefore, tries to adopt the young man’s chronolect as the other’s voice:
Extract 3
1 PC: =ah. (3) hubo una diferencia para vos=
2 PAT:= sí, sí, [totalmente]
3 PC: [eso estás] diciendo (.5) hubo una
4 diferencia cuando (.) tu novia- charlaste con tu novia
5 profundamente=
6 PAT: =claro (.) sí (.) sí=
7 PC: =como se dice ahora te hizo un click
8 PAT: >sí, sí, sí, sí, sí<=
9 PC: ahá
10 PAT: y me siento- cada día me siento diferente y con
11 ganas de::- o sea (.) siempre me juntaba con- antes de
12 juntaba con (buena) gente este:: (2) siempre salía con
13 chicas mas chicas también
14 PC: esta: (.) novia (que edad tiene)?
15 PAT: la misma edad que yo
16 PC: me pareció que igual me dijiste que se había:- que
17 te habías peleado?
18 PAT: cla::ro (.) sí porque::: salía con mi ex que:::
19 con esta chica (ya llevo) hace tres meses (.) °o
20 cuatro meses° (1) con mi ex la vi un par de veces,
21 después de saliendo con ella este:: (.) pero sí tengo:
22 así contacto corporal digamos a veces no? (inaudible)
23 y yo le decía que no (.) bueno por esa mentira
24 ella se enojó mucho porque es mu::y de ir de frente
25 (2) y creo que también eso fue una inmadurez de
26 no: haber (encarado las cosas de una)
27 PC: uno más
28 PAT: cla:ro, una (cosa más, sí)
29 PC: una más
30 PAT: sí (.) sí (.) totalmente=
1 PC: =so. (3) there was a difference to you=

2 PAT:= yes, yes, [totally]
3 PC: [that’s wat you] are saying(.5) there was a
4 difference when (.) your girlfirend- you spoke to your girlfriend
5 seriously=
6 PAT: =sure (.) yes (.) yes=
7 PC: =something clicked like they say nowadays
8 PAT: >yes, yes, yes, yes, yes<=
9 PC: ahá
10 PAT: and I feel- every day I feel different and
11 Willing to::- I mean (.) I used to hang out with- before
12 hang out (good) people ehrm:: (2) I used to date
13 Younger girls too
14 PC: this: (.) girlfriend (how old is she)?
15 PAT: the same as mine
16 PC: I thought you said that she had:- that
17 you broke up?
18 PAT: su::re (.) yes because::: I dated my ex who:::
19 with this girl I have been (dating) three months (.) °or
20 four months° (1) to my ex I saw a couple of times,
21 after I began dating her ehrm:: (.) but yes I had:
22 like body contact so to speak a few times? (inaudible)
23 And I said I did not (.) well because of that lie
24 She got very upset because she es ve::ry confrontational
((untranslatable: “va al frente”))
25 (2) and I think that was an immature thing I did
26 not: facing (things right away) ((untranslatable: “de una”))
27 PC: the right way
28 PAT: ri:ght, right (away, yes)
29 PC: the way right away
30 PAT: yes (.) yes (.) absolutely=
(((The last four turns are freely translated in order to preserve the
effect of wordplay of the original in Spanish))
In lines 1 and 3–5, the professional attempts to locate what psychoanalysts call
a “turning point” (Böhm 1992: 675), that is, “the sudden change of quality that
plays the part of a forerunner or prerequisite to the slow structural change in psy-
choanalytic treatment”. In order to emphasize the relevance of the fact, for the
third time she refers to it in line 7, adopting explicitly the young people’s voice
through the metalinguistic commentary: “como se dice ahora” (“as they say nowa-
days”). The term “[hubo una] diferencia” (“[there was a] difference”), which
named the turning point in lines 1 and 4, is now rephrased in the chronolect of
the interlocutor as “[te hizo] un click” (“something clicked”), emphasizing its
relevance through the metalinguistic commentary and the emphatic tone. The
adoption of the patient’s voice helps to decrease distance, even in the formal
context of the interaction. As a consequence, the patient also moves towards the
young enregistered voice proposed as his own, using chronolectal expressions
such as “ir de frente” (l. 24, “being confrontational”) and “de una” (l. 26, “right
away”). In both cases there is some sort of prosodic mark which, similarly to
other metalinguistic devices shown previously, indexes voice changes: a hesitation
(“mu::y”, “ve::ry”) followed by a medium pause of 2 seconds in the first case and
a noticeable volume decrease in the second. The competence in the young man’s
voice, however, seems to be insufficient to decode every chronolectal expression
he uses. Hence, the psychotherapist says “uno más” in line 27 (freely translated as
“the right way”, in order to preserve the wordplay) as a recall of the patient’s last
turn, which had employed the expression “de una” (“right away”) which prob-
ably was not understood by the psychotherapist. The patient, in line 28, appar-
ently confirms 27 but, instead, provides a repair cohesive with the item “cosas”
in line 26. Rather than dismissing the misinterpretation of his voice by the psy-
choanalyst, the patient offers a productive “mishearing” in order to contribute to
the interaction, recalled by the psychotherapist in 29 (“una más”, “the way right
away”) and confirmed by the patient in 30.
The echoes of what the professional considers the young patient’s voice, mani-
fested in phrastic units considered characteristic of the other’s lect, allow her to
reach clinical goals. Even if her competence is limited, it enabled the patient to
adopt his own voice and elaborate on the topic under discussion.
The voice of lower-class youth

When social distance is perceived as greater, a more complex voice is embodied
by the professional. In extract 3, as the patient was considerably younger than the
PC but belonged to the same social class, only chronolectal terms were adopted.
But the usual population at the hospital comes from lower classes and requires a
more elaborate strategy. In the following case, the interlocutor is a 21-year-old
young woman who lives in a villa (an extremely poor neighbourhood, equivalent
to “shanty town”, including a pejorative meaning), has basic education and no
steady job. In this case, in order to decrease social distance, the psychothera-
pist adopts the patient’s chronolect in addition to meaningful aspects of lower-
class phonology, dropping voiceless sibilants and dental consonants in word-final
position:
Extract 4
1 PC: =Pero viste esa frase que dice la procesión va por dentro?
2 se- conocés esa frase? (1.2) que parece que está todo
3 bien, pero lo que uno le pasa va por adentro y a veces ni uno
4 mismo se entera (1) se entera (.) porque a veces de repente (.)
5 le a[garra]
6 PAT: [porque, por ej-] sí::: ya sé porque yo a lo
7 primero no caía que mi hijo había fallecido (1) o sea (.) no es
8 que no caía (.) era que yo estaba bien, (1) [este]
9 PC: [claro] triste pero: [máh o menoØ andabaØ] (. . .)
10 AP:[siempre viviste con él?]
11 PAT: sí (.) desde chica
12 PC: o sea vivías vos y tu hermano más grande y este::
13 PAT: y este pibe (.) que es más chico que mi hermano más grande
14 PC: este pibe qué edaØ tiene?
15 PAT: tiene y:: (.) e:: trein treinta
16 PC: ah::! es bastante más grande digamos: o sea:
17 PAT: sí sí sí (.) un tirón me lleva (a mí) :)
18 PC: está bien (.) o sea esto trajo muchos conflictos a nivel
19 familiar y te hago una pregunta Mariela?
1 PC: =but you know that phrase that says still waters run deep?
2 it- do you know the phrase? (1.2) it seems that everything is
3 all right, but important things are going on deep inside you
and sometimes you
4 do not even notice (1) you notice (.) because sometimes all of a
sudden (.)
5 It happ[ens]
6 PAT: [because, li-] yes::: I know because may be at the
7 Beginning it didn’t really sink in that my son had died I mean (.) it did
8 sink in (.) but I felt fine,, (1) [ehrm]
9 PC: [right] sad but: [more or less you kept going] (. . .)
10 AP: you always lived with him?]
11 PAT: yes (.) since I was a girl
12 PC: so it was you and your elder brother and this::
13 PAT: and this guy ((“pibe”)) (.) who is younger tan my elder brother
14 PC: how ol’ is this guy?
15 PAT: he is:: (.) ehr:: thir- thirty
16 PC: oh::! He is quite a bit older let’s say: I mean:
17 PAT: yes yes yes (.) he is much older tan me ((untranslatable:
“un tirón me lleva (a mí)”) :)
18 PC: OK (.) so this brought a lot of conflicts at a
19 familiar level and tell me Mariela?
Extract 4 begins with a traditional idiomatic expression, “la procesión va por

dentro”, whose meaning is metalinguistically topicalized by the professional in
lines 1 and 2. As there is a 1.2-second gap, the professional repairs the idiom,
rephrasing it with a chronolectal voicing “está todo bien” (l. 2–3, “everything is
OK”) and elaborates until the overlap in line 4. In this overlap the patient shows
understanding, confirming with “sí::: ya sé” (l. 6, “yes, I know”) and further
elaborating with her own particular case, related to the death of her child. As
a 1-second gap preludes a hesitation in line 8, the professional overlaps again
and repairs the patient’s turn in line 9. In doing so, she drops three consecu-
tive sibilants in word-final position (l. 9), either by aspiration (“mah”, “more”)
or elision (“menoØ”, “less”; “andabaØ”, “you kept going”). Although aspira-
tion is an extended phenomenon in Buenos Aires, elision is not; indeed, it is a
stigmatized variant identified with lower classes (Aleza Izquierdo 2010: 64). In
lines 13–17 we can observe a similar phenomenon. The patient uses the item
“pibe” (l. 13, “guy”), which can be identified as chronolectal, and, as an identity
marker, is repeated by the psychotherapist in line 14, combined with a lower-
class variant: omitting the voiced dental fricative [ð] in final position at “edaØ”
(“age”). The adoption of the other’s voice, young and poor, proves successful
in decreasing social distance, encouraging the patient to adopt other terms and
expressions characteristic of lower-class young people, as shown in the rephrasing
of “bastante más grande” (l. 16, “quite a bit older than you”) as “un tirón me
lleva” (l. 17, untranslatable, “much older than me”).
The ethnical voice

Almost 50% of the cases we have studied involve people born in Bolivia, Peru or
Paraguay. As these are countries with a strong indigenous component and a wide
variety of contact between Spanish an indigenous languages (mainly Quechua,
Aymara and Guaraní), the “ethnical voice” appears as a way to decrease social
distance, especially with migrants who show traces of language contact.
In the following example we will see an interview with a Bolivian patient who
speaks a typical Andean-Pacific variety of Spanish. The psychotherapist will adopt
an anti-normative expression used by her interlocutor in an attempt of downward
accommodation to the other’s lect:
Extract 5
1 PAT: teníamos () pero:: (.) después ya no él (2) se iba a la calle
2 de la: de la casa salía y: (nosotros) teníamos que ir a buscar=
3 PC: = y no lo acompañaban?
4 PAT: no (1) se perdía
5 PC: y pero no (.) por qué iba solo?
6 PAT: no se perdía de la casa digamos (.) estaba la puerta abierta
7 del hospital se sale y: =
8 AP: = a:: se iba del hospital? (1) eso es lo que,
9 PC: a:: lo acompañaban al hospital y se perdía del hospital?
10 PAT: (1) a: veces pero no: más no (.) pero en la casa ya (.) en la
11 casa ya o sea (.) e:: antes que mejore (.) antes que ahora está
12 mejor (.) cuando no cuando no estaba mejor se i:ba a la calle se
13 sal:ía por (.) o sea (.) sin pedir pedir permiso y se perdía =
14 PC: = no pero lo que yo le pregunto es lo siguiente (.) él estuvo
15 internado en el Borda (.) salió del Borda
16 PAT: sí sí salió (2012–2011–2015 3)
1 PAT: we had () but:: (.) after that he (2) used to go out

2 of the: of the house he left and: (we) and we had to look for=
3 PC: = didn’t you go with him?
4 PAT: no (1) he used to get lost
5 PC: and why didn’t you (.) why did he go out by himself?
6 PAT: he didn’t get lost out of the house ((untranslatable: “no se
perdía de la casa”)) So to speak (.) there was this open door
7 At the hospital and he went out an: =
8 AP: = oh:: he left the hospital? (1) that’s what you
9 PC: ah:: you used to go with him to the hospital and he used to get
lost of the hospital ((untranslatable: “se perdía del hospital”))
10 PAT: (1) some: times but no: (.) but at the house he(.) at the
11 House he I mean (.) ehr:: before getting better (.) because now he is
12 Better (.) when no when he wasn’t any better he used to go: out to
the street he
13 used to go out: (.) I mean (.) without any authorization and he used
to get lost=
14 PC: = no but what I am trying to ask is this (.) he was
15 admitted at the Borda (.) he left the Borda
16 PAT: yes yes he left
In line 6, the preposition “de” seems to be dependent to the verb “perderse”

(“to get lost”). Although it is not “normative”, the professional assumes this rela-
tionship as a trace of language contact proper to the patient’s variety of Spanish.
It is noticeable that the patient used a hedge, “digamos” (“so to speak”), which
can be associated to processes of idiomatization and fixation (Grande Alija 2010)
and, therefore, can be interpreted as a trace of language contact. Although the
AP does not fully understand and asks for a repair in line 8, the PC repeats the
expression in line 9 in order to decrease social distance based on language variety,
here associated to nationality and ethnicity. The patient’s turn, in lines 10–13, is
a confusing attempt to answer both questions, formulated by AP in l. 8 and PC in
l. 9. At the end of line 13, the verb “perderse” (“to get lost”) is used by the patient
in its standard form, without the preposition. After the confusion is disentangled,
the psychotherapist rephrases: “se perdía del hospital” (“he used to get lost out
of the hospital”) as “salió del [hospital] Borda” (line 15, “he left the [hospital]
Borda”). Then, the patient finally confirms emphatically in line 16.
As in extract 3, the professional’s attempt to adopt the interlocutor’s voice
is based on a limited competence and, although it deals with social distance in
order to decrease it, does not favour comprehension. In this case, the voice of the
migrant is identified with the anti-normative Spanish and the feature selected to
evoke it is, precisely, the non-standard relationship between verb and preposition.
As “Bolivian”, in social range, is both a combination of ethnicity and national-
ity (Dreidemie 2013), and ethnicity is associated to language contact, the non-
standard becomes a symbol of voice.
The voice of popular religion

Religion, as a widespread cultural phenomenon, is linked to social structure in
Argentina, not only regarding demographic distribution of beliefs and institutions
but also social representations of them (Heaton 2013; Mallimaci 2013). In this
sense, the association of lower classes with folk beliefs and popular religious
practices is prevalent in common sense, even among social scientists (cfr. Martín
2009). As Semán (2004) points out, popular religion becomes a cultural logic that
assumes the immanence and superordination of the sacred in the world. Hence,
facts which would be considered “miraculous” or “impossible” by a middle-
class Catholic or non-believer are seen as regular (not extraordinary) events for
lower-class, “popular” believers (Martín 2009: 279). Popular beliefs and prac-
tices, therefore, are perceived as distinctive of lower classes. Specific religious
voicings are typically associated to specific social ranges, especially when seen
from a different social domain.
Extract 6
1 PC: entiendo pero me (.) volviendo a esto de: (1) las cuestiones
2 que te pasaron en el cuer:po y que por ahí vos ubicás a esta
3 religión (.) específicamente vos qué pensás de eso? porque como
4 que no me quedó: (2) no no sé (.) no quedó muy claro en relación
5 a ver (.) si vos (.) sentís como que que hicieron al:go como un
6 gualicho no sé cómo se llaman igual (.) esas, =
7 PAT: no no (.) no sé ni idea (.) e: (.) no que me hicieron a mí
8 sino que había quedad algo en la casa (1) y me lo agarré yo
9 PC: (1) algo qué es? (.) porque la verdad que:
10 PAT: (1) no: una: (.) es que yo no sé cómo hablar de la religión en
11 realidad (.) porque no la conozco (.) no me gusta me da miedo
12 °aparte° (1) no:: (.) no sé cómo es (.) pero: viste que traen
13 mucha (1) las malas lenguas dicen que trae mucha mala on:da malas
14 energí:as co (.) te (traen) cosas malas (.) si vos no limpiás la
15 casa (2) yo creo que eso me lo agarré yo
1 PC: I understand but I (.) now going back to this thi:ngs (1) the
things
2 you experienced in your bo:dy which you seem to relate to this
3 religion (.) specifically what do you think of it?
4 I didn’t: (2) I don’t know (.) I didn’t fully understand the relationship
5 let’s see (.) if you (.) feel like somebody did so:mething like a
6 cast a spell ((untranslatable “te hicieron un gualicho”)) I don’t what
these things are (.) called=
7 PAT: no no (.) I don’t know no idea (.) eh: (.) it’s not something that
someone casted on me
8 but something in the house (1) which I suffered
9 PC: (1) what is something? (.) because I really:
10 PAT: (1) no: a: (.) I don’t know how to speak about religion
11 Actually (.) because I don’t know (.) I don’t like it it scares me
12 °besides° (1) I:: (.) I don’t know what it is like(.) but: you know (.)
they bring
13 A lot (1) people say they bring a lot of bad vi:bes ((untranslatable
“mala onda”)) bad
14 energy: li- (.) they (bring) bad things (.) if you don’t clean up
15 the house(2) that’s what I think I’m suffering
In extract 6, the professional explicitly attempts to clarify the terms of the

interaction through metalinguistic activity by pointing out that she did not fully
understand what the patient had said before (lines 3–4). Then she rephrases the
patient’s previous words, evoking the religious voice in the lexical item “guali-
cho” (line 6, “spell”), a popular term which designates an activity of witchcraft.
As in previous examples, there are traces of the adoption of the other’s voice, as
the lengthening in “al:go” (l. 5, “something”, cohesive with “gualicho”, “spell”),
the hedge “como” (l. 5, “like”) to introduce the term, a prosodic emphasis when
pronouncing the word (l. 6) and the metalinguistic commentary “no sé cómo se
llaman igual (.) esas” (line 6, “I don’t know what these things are called”). As
the voice of popular religion is not prestigious – rather, it is stigmatized – the
patient’s first reaction is to reject it, showing a lack of competence in this field
through metalinguistic activity: “no sé ni idea” (l. 7, “I don’t know, no idea”)
and then “yo no sé como hablar de la religión” (l. 10, “I don’t know how to
speak about religion”). However, the effect of adopting the other’s voice, thus
generating confidence, proves to be effective, and the patient elaborates further
on the topic, using herself – once the religious voice is accepted as legitimate –
technical terms of the field such as “mala on:da” (“bad vibes”), “malas energí:as”
(“bad energies”) and “limpiar” (“clean up”). In this case, the identification of
the patient with the voice of popular religion becomes useful to decrease social
distance, thus increasing confidence and encouraging storytelling, which will
eventually lead to formulating a diagnosis.
Voice, asymmetry and social distance from

the participants’ perspective
Although the examples analyzed differ widely, they all share two features: a) they
involve speaker’s adoption of a voice which is frequently marked as alien but
attributed as proper to the recipient; and b) this attribution is a consequence of
identifying the interlocutor with a social persona and its characteristic ways of
speaking.
The analysis allows us to distinguish two distinct strategies: from the patients’
point of view, the professional is identified as a representative of institutionalized
medicine. Patients therefore adopt features of bureaucratic and medical voice.
In both cases we can recognize some aspects of “institutional talk”, especially
regarding participants’ involvement “in specific goal orientations which are tied
to their institution-relevant identities” (Heritage & Clayman 2010: 34). In this
sense, patients tend to identify psychotherapists as bureaucrats (as long as they
request demographic-epidemiological information) and doctors (as long as they
work in a hospital). Thus, patients adopt these voices in order to reduce asym-
metry, displaying what they consider some kind of acquaintance with the other’s
role identity.
On the other hand, professionals index lower-range voices as they identify
their interlocutor with lower levels of social range, either as young middle class
(Ex. 3), young and poor (Ex. 4), Bolivian (Ex. 5), believer in popular religion
(Ex. 6), etc. Speaking “at the patient’s own level” means decreasing the perceived
social distance by adopting some feature of the interlocutor’s attributed lect.
Several metalinguistic markings show, at the same time, acquaintance with the
interlocutor’s social range but not identification with it. Examples in Excerpts
3 and 4 show the impact of social distance in perceiving the “otherness” of the
other’s social position and range: in Ex. 3, belonging to the same social class, the
professional adopts the voice of “youth” as her interlocutor’s main characteristic.
In Ex. 4, on the other hand, as there is also a social class difference, the other’s
voice is identified through age and social class to manage the distance between a
middle-aged professional and a young working-class woman.
To sum up, while patients index locally defined roles to adopt the voice of
the interlocutor and negotiate the activity, professionals index out-of-context
identities to decrease social distance and better develop the psychotherapeutic
conversation. However, structural positions are not abandoned. We observed in
Excerpt 2 how a patient’s attempt to adopt the psychiatric voice was dismissed
by the professional as inadequate, thus reinforcing asymmetry based on roles and
knowledge. On the contrary, Excerpts 3 and 5 show that professionals who fail
to adopt the patient’s voice are not sanctioned because, despite local procedures
to decrease social distance, structural factors still act to replicate the unequal
relationship between participants. Inequality therefore conditions the voicing
options of participants: patients attempt to reduce asymmetry despite social dis-
tance; psychotherapists endeavour to decrease social distance while maintaining
asymmetry.
These results have consequences in the field of mental healthcare prac-
tice. Research in terms of voice and inequality enables us to better understand
professional-patient interaction in terms of inter-group communication. In this
sense, there is still much work to be done in order to understand the intercultural
dimension of psychotherapeutic interviews in the field of public healthcare in
Argentina. However limited, the analysis presented here has impact on the actual
practice of admission interviews as long as representations of the interlocutors’
identities and voices are involved. For the professionals, I have already argued
the need to negotiate with biomedical discourse, at least until the establish-
ment of common ground regarding the participants’ roles in psychotherapeutic
interviews, the relevance of diagnosis, etc. It might therefore be preferable for
professionals to temporarily accept patients’ attribution of a bureaucratic and
medical position (which is directly linked to the ongoing activity) than to adopt
the informal voice of the lifeworld. This dialogue with the other’s own cultural
representations and beliefs is necessary as it allows social distance to be decreased
without reifying cultural differences. Professionals seem to understand this need
and therefore evoke the interlocutor’s voice without identifying with it, as repeat-
edly shown by metalinguistic comments. These results show an attempt to adopt
“the other’s own, local, historical terms” (Shi-xu 2005: 107), although in contra-
diction with the professionals’ own asymmetrical, dominant position.
Note
1 We differentiate here between speaking with one´s own voice (as seen in Chapter 1)
and speaking with the other’s voice.
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7 Discourse and activism
Dissent, protest and resistance
Introduction
Theory is embedded in its local contexts of practice (Shi-Xu 2015), including lin-
guistic ones. Concepts that have been developed to understand central countries,
with their distinctive social organization, political mechanisms, media systems
and discourse traditions, are not equally suited to understanding other realities,
even in a context of globalization (Blommaert 2005, 2010). On the other hand,
natural language terms usually carry with them their previous uses and traditions,
translations and appropriations.
When Ivie (2005) elaborates on the concept of dissent, he somehow proposes
a scale of intensity:
When debate inside and outside of formal channels of deliberation is insuf-

ficiently engaged, dissent defaults to myriad forms of protest that interlace
poetic complaints with provocative speech and that resort to symbolic acts of
resistance and even violence.
(Ivie 2005: 279)
From this perspective, being unable to manage deliberation results in an overflow

of dissent, which escalates in intensity to protest, then to resistance and, finally, to
violence. This concept of deliberation, as I will argue, does not entirely apply to
political culture in Argentina.
Protest in Argentina is not necessarily a faulty form of dissent which cannot be
sufficiently engaged through channels of deliberation. Neither is it a spontaneous
act of political freedom, as understood by Drexler (2007). Massive protest dem-
onstrations are usual and routinely organized, respond to more or less explicit
rules and have their own rituals and their own legitimate agents and actions
(Cross 2008). Although protest exerts some kind of violence on the public space,
it is tolerated. It is in fact a form of performative discourse with its own genres,
styles and meaning-making resources (Cox & Foust 2008: 613–614).1
Finally, I will discuss resistance as a practice of engagement over time which
does not necessarily occur outside formal channels and institutions but, on the
contrary, often develops within those very same institutions. Resistance, as I will
Discourse and activism 155
argue, is the tactical form par excellence, as it develops over time within “an exist-
ing web of power and knowledge” (De Certeau 1984: 269).
Dissent and protest

Gallagher (2016) understands “dissent” as a single limited act of disagreement,
while “dissensus” “suggests less a single concrete action than an abstraction, a
state of affairs; it seems, in other words, to point to the existence of a diffuse
multiplicity of differing viewpoints” (Gallagher 2016: 171).
The verb “to dissent” can be translated to Spanish as disentir. Someone who
disiente (dissents) is basically somebody who can say “I disagree”. This concep-
tion of dissent is thus based on an essentially symmetric conception of partici-
pants: disagreement is only possible among equals. From this perspective, there
are institutional mechanisms which distribute turns for speaking among partici-
pants in a debate, an assembly or a mass media controversy. Elective politics and
its deliberative institutions do not fulfil the needs of democratic political com-
munication. In terms of I. Young,
the social power that can prevent people from being equal speakers derives
not only from economic dependence or political domination but also from
an internalized sense of the right one has to speak or not speak.
(Young 1997: 63)
In a wider context of linguistic inequality, which distributes the right to speak

differentially and evaluates styles, varieties and lects differentially, most citizens
are not considered equals (cfr. Chapter 1). In contexts of inequality and asym-
metrical power balance, protest and resistance are ways of remaining human while
facing dehumanizing discourses (Ivie 2008), becoming agents (and not merely
patients) in public policy-making. The value of this kind of dissent, however,
is not individual but collective. Citizens force their way into the public debate
through numbers and active, public protest (Unamuno & Bonnin 2018).
Ivie (2015: 47–48) describes the state of the art, mainly regarding US social
movements. In these cases, the “rhetoric of war” sustains a strategy of radical
confrontation, a “sustained collective action aimed at achieving basic structural
change”. Thus, these social movements “want big changes. They reject injustices.
They are persistent and impatient. They march, shout, strike and make nonnego-
tiable demands” (Ivie 2015: 48).
In Argentina, however, protest is a routine discourse practice which mobilizes
collective social actors demanding very local and concrete action from the State.
Since political contestation generates legitimacy “because it represents a capacity
to acknowledge power relations” (Rasmussen 2016: 36), protest in Argentina
is not perceived as illegitimate. On the contrary, it is a routine discourse prac-
tice which, as Laclau (2005) states, simultaneously constitutes the demands and
the subject who formulates them. By protesting, (more or less) organized citi-
zens recognize power relationships and the asymmetry which leaves them on the
streets when protesting at the doorstep of corporations or public buildings. Their
goal is not to overthrow power relationships but to be acknowledged by power.
They do not demand to demolish bourgeois institutions but to be included in
them. Dissent, on the other hand, does not gain legitimacy through confronta-
tion, but through the institutional design that makes it possible. There is a sym-
bolic shared ground of equality that allows someone to say “I disagree”.
Protest, as a discourse practice, has two main genres: the marcha and the
piquete (Cross 2008). The marcha is a demonstration in which the actor is
typically massive and heterogeneous. Although it has immediate demands, it
is usually guided by general consignas (“slogans”). It has a beginning and an
end, independent of its success. The marcha is defined by movement, usually
between meaningful symbolic places: protesters march to meet the addressee of
their slogans.
The piquete, on the other hand, is typically a road or street blockade con-
ducted by a smaller but more integrated and homogeneous group with concrete
demands. These blockades last until some agreement is achieved, while marchas
end after a given lapse of time. The piquete is defined not by moving through the
public space but by occupying it. It does not usually move to meet the addressee;
on the contrary, State officials (usually second rank) “bajan” (“go down”) to the
piquete to negotiate.
Protest and resistance

Young (1997) argues that democracy needs inclusion as a way to overcome
unequal opportunities to deliberate as a consequence of cultural differences and
socio-economic inequality. I believe that this is the reason why protest and resist-
ance are necessary as discourse practices which allow for democratic contestation
in contexts of inequality. Drexler (2007) criticized Young as being a moderate
version of the Habermasian deliberative approach, according to which this per-
spective (which explains very well symmetrical forms of contestation, such as
what we call dissent) fails to understand the political nature (and legitimacy) of
protests, blockades and forms of civil disobedience which are not deliberative
practices but are nevertheless political actions. This is the place of protest and
resistance, what Drexler calls “performative political practice”.
Differences in social position and identity are resources, from this perspective;
hence they conform a repertoire of practical discourse genres available for social
and political actors to contest and confront within a context of democratic dis-
course. However, due to their short-term duration, dissent and protest are aimed
at resolution and thus supposed to end in either victory or defeat. Resistance, on
the other hand, learns to live with conflict. It is a silent, indirect, metaphorical
practice which contests dominant discourses or practices from the place of the
subordinate. As M. de Certeau (1984) states, despite repressive aspects of social
order, ordinary people enact tactics of resistance in everyday life choices. They do
not have a proper space, but develop over time, which is the most readily available
resource to the subordinated.
Resistance is the least known side of activism: in typical-ideal conceptualiza-
tions (such as Young 2001), activists are persons who
[often] make public noise outside when deliberation is supposedly taking

place on the inside. Sometimes activists invade the houses of deliberation
and disrupt their business by unfurling banners, throwing stink bombs, or
running and shouting through the aisles. Sometimes they are convinced that
an institution produces or perpetuates such wrong that the most morally
appropriate thing for them to do is to try to stop its business -by blocking
entrances, for example.
(Young 2001: 673)
Activists are characterized by Young as childish persons who make noise and
draw attention from serious, deliberative people. However, she seems to con-
fuse protest – as a discourse repertoire which includes slogans in banners and
stink bombs – with protesters, the individuals who effectively protest. Activists
do not only protest; on the contrary, protest is the most visible form of activism,
but it can only exist thanks to the fact that the activists belong to an organized
community of people bonded by shared meaning developed over time. Drexler
(2007) proposes an excessively homogeneous category of “political performative
actions” to understand activism. Her call to recognize the political freedom of
spontaneous protest fails to understand long-term processes of resistance which
are not visible and refulgent actions but instead secretly build up community and
collective meaning.
Resistance does not foresee an end. Even if the resisters’ goals are achieved,
their practices continue, because they build up community over time. Inter-
twined with history and each participant’s biography, resistance becomes part
of their life. Thus, because it has to semiotize and give meaning to a history of
conflict and contestation, it is indirect and metaphorical. In addition to being
a political practice of contestation, resistance is a practice of identity-building
which integrates biographies even beyond their own participation within a lim-
ited timeframe.
In this sense, resistance is more poetic and metaphorical, combining utopic
long-term goals with concrete, immediate demands. Everyday negotiation with
authorities and institutions is at the same time a success in itself and a step further
towards the community’s ultimate raison d’être. This interplay between long- and
short-term, between utopia and everyday achievements, guarantees the commu-
nity’s sustainability over time as an actor capable of resisting domination from
within its own institutions.
Ethnographic discourse analysis of resistance, dissent and

protest in mental healthcare in Argentina
To illustrate the distinction between resistance, dissent and protest, I will analyze
three moments in the process of development, discussion and implementation of
the National Law of Mental Health in Argentina (NLMH).
The data analyzed herein were collected over several years of ethnographic
discourse analysis and action research in the field of mental healthcare at public
hospitals in Buenos Aires, Argentina. They were not, however, the main data
I was collecting, which involved hospital communication (Iedema 2007) and
professional–client interaction. The issue of the discourse of contestation in men-
tal healthcare contexts arose as additional, somehow secondary, observations dur-
ing my years of fieldwork.
Indeed, one of the main problems I encountered when publishing results of
my research was that discourse at public healthcare institutions in Argentina is
not configured under the general premises observed elsewhere (i.e. Wodak 2006;
Heritage & Clayman 2010). Above all, there is a high level of politicity in every
action and decision taken by healthcare workers in general, and mental health-
care workers especially. Thus, over the years of my ethnographic work, a series of
contestational political practices emerged, which turned out to be a hermeneutic
key to understanding what was happening in the consulting rooms. The data
I analyze herein are drawn from these marginal activities, notes and discourse
practices of contestation which were necessary to my research and yet could not
be published as a part of it.
In this sense, I differ radically from Young’s advice to “keep distance from
democratic practices in existing structural circumstances” (Young 2001: 688).
I believe that research requires social practice. Analysis of the discourses of con-
testation is always made from a standpoint regarding the status quo, which may be
either critical or conformist (to different degrees); therefore I do not believe that
the researcher can be separated from the citizen (as Young 2001: 688 proposes)
but rather that only through engagement can theory be relevant to understand-
ing and changing current practices.
At the margins of social practice, at the margins of theory and methodological
strategies, discourse practices of contestation are, nevertheless, central to under-
standing the political dimension of communication in public healthcare settings.
I will analyze four sets of data: field notes taken at hospitals and demonstra-
tions; Facebook posts, fan pages and profiles set up by individuals or organiza-
tions; and semi-structured interviews with key informants and sessions at the
House of Representatives. I include Facebook as a second ethnography site
because it is a virtual space that is complementary to other spaces.
By including these heterogeneous sources, we can observe contestational
discourse practices as a systemic form of political action and meaning-making,
instead of observing acts of dissent as separate events produced by separate actors.
As they are different discourse practices, they are heterogeneous and cannot be
compared. Instead, I propose a continuum through differences under the politi-
cal problem of contestation and the NLMH.
Resistance, dissent and protest in action: the National

Law of Mental Health in Argentina
The National Law of Mental Health (N° 26.657) (NLMH) was an extraordinary
discursive event (cfr. Chapter 1): on the one hand, the ideas of reducing the
power of physicians in mental healthcare decision-making and actively promoting
the deinstitutionalization of mental health patients were (and still are) strongly
resisted by the medical establishment. This is one of the reasons why resistance
movements take such great pride in this law as an accomplishment of decades of
underground work. On the other hand, however, the bill passed Congress almost
unanimously, with 47 votes in favour and one abstention. This maladjustment
between strong dissent in public debates and evident consensus in institutional
deliberation might explain why, within a context of general approval, the law
has been applied in a very restricted fashion. Moreover, amendments have been
recently proposed to some of the most controversial aspects of the law, leading to
protests in 2016 and 2017 to defend the law and demand its full implementation.
The NLMH is the first national law on mental healthcare in Argentina. It was
preceded by eight provincial laws which, in general terms, are consistent with
what is known as the “human rights perspective” on mental health (Hermosilla &
Cataldo 2012). With the exception of the legislation of the Provinces of San Juan
and Entre Ríos, which adopts a traditional and more biomedical view of “mental
illness”, the human rights perspective refers to “mental suffering” (“padecimiento
mental”) to designate its object, the same expression used in the NLMH.
The new law was applied to the whole country, introducing several innova-
tions with regard to existent provisions in the public healthcare system. Follow-
ing Hermosilla and Cataldo (2012: 136), I highlight five of these provisions:
a) substitution of the term “mental illness” by “mental suffering”; b) emphasis
on interdisciplinary teams, reducing the preeminence of psychiatrists over non-
medical professionals; c) community orientation, forbidding non-consensual
treatment and privileging the patient’s rights; d) new provisions regarding inpa-
tient admission, which is now viewed as a last resort and can be ordered either by
a psychologist or a psychiatrist; and e) creation of an autonomous government
entity to supervise the application of the law by healthcare institutions. Regula-
tory decree 603/2013 included one more novelty: the elimination of mental
hospitals by 2020. Instead, mental health units are to be created in general hos-
pitals, and community treatment should be privileged over inpatient admission.
During the first years of the Macri administration, however, the role of State
has changed, and the political balance is now unfavourable to the application of
the law and the new rights it defines. Ferreyra and Stolkiner (2017) have pointed
out a number of setbacks regarding the NLMH during 2016: a) medical corpora-
tions have begun to gain power at the Ministry of Health regarding maintaining
the old structure of mental hospitals and preventing the integration of mental
healthcare units into general hospitals and community treatment; b) the control
agency is being dismantled, leading to a situation of non-observance of the law at
general hospitals, and new organization charts use the designation “psychiatry”
instead of “mental health”; and c) new regulations favour physicians, whether or
not they are psychiatrists, as directors of mental health interdisciplinary teams,
in express contradiction of the law. Within this context, during the past months,
new organizations, social movement networks and meetings have emerged to
defend the implementation of the law and assert the human rights perspective on
mental health.
The discursive process of emergence of the NLMH in Argentina can be
described from the perspective I have developed herein: long-lasting collective
resistance at the margins of mental health institutions allowed for public debate
and the exercise of democratic dissent which resulted in a National Law. How-
ever, the obstacles deployed by the medical establishment, the change in the
political situation and the lack of active engagement in its instrumentation and
application have recently resulted in practices of protest as a response of weaker
sectors to the omission of the law.
Resistance: demolishing the walls through art

The field of mental healthcare is broad and heterogeneous. Many organizations,
movements, volunteer groups, etc. emerge constantly at the margins of official
institutions, resisting what they call “the psychiatric corporation” and “hegem-
onic medical discourse”. One of the oldest and most respected organizations
is the Borda Artist Front (BAF), an artistic organization created in 1984 at the
Neuropsychiatric Hospital José T. Borda in Buenos Aires.
The Front was part of a wider global movement, commonly known as “anti-
psychiatry”, which denounced mental asylums as violent and repressive “total
institutions” (Goffman 1961). Combining political activism, psychiatry and
psychoanalysis, different groups and organizations called for community mental
healthcare. In this sense, there is a rejection of “hegemonic medical discourse”
(cfr. Lakoff 2006), which is understood as a means for attaining domination
over bodies through a process of biologization of the psyche (Bonnin 2014).
The political agent that is said to reproduce this hegemonic discourse and ben-
efit from it is the “psychiatric corporation”, which does not include all psychia-
trists, but those who oppose an interdisciplinary, community approach to mental
healthcare:
With regard to the law, what happens is that the psychiatric corporation is
against us psychologists gaining any hierarchy. Instead of sharing and think-
ing things over together, they understand the whole business as if they were
being displaced.
(Viviana)2
Movements such as the Therapeutic Communities “combined democratization,

permissibility, freedom of speech and communication [with] the key therapeu-
tic instance (the community assembly)” (Chiarvetti 2008: 175, my translation).
However, military dictatorships as from 1969 were extremely repressive of this
kind of alternative experience, and many of the actors in such movements were
exiled during the last dictatorship (1976–1983). The democratic government of
Raúl Alfonsín (1983–1989) allowed for the (re)emergence of “multiple practices
and discourses which favoured the establishment of spaces for transformation
and development of deinstitutionalization practices” (Ferigato, Sy & Resende
Carvalho 2011: 352, my translation).
Within this new context, in 1984 an artistic workshop experience began at the
Borda, a neuropsychiatric hospital for male inpatients. The concept of deinstitu-
tionalization (“desmanicomialización”) has lain at the heart of the BAF activities
since its inception. The Front carries out its artistic workshops for inpatients and
outpatients “until the walls fall down” (Fava 2008: 6, my translation). It is there-
fore relevant to my analysis of resistance as a discourse practice which develops
over time, rather than space, because the Hospital Borda, as a place, is experi-
enced only as the point of departure for the Front’s activities:
I was lost in the Hospital halls and suddenly saw a sign which read “Artists
Front”. I joined, I felt really good and took it as an exit. I did not use the
Artists Front; it gave me the chance to get out.
(Carlos Almirón at BAF 2008: 9)
We are not artists at the Borda, we are artists from the Borda.
(Javier)
This is a key feature to understanding the use of space as a semiotic resource:

the aim of the Front’s activities is to go beyond the boundaries of the hospital,
both in a symbolic and a material sense. On the one hand, the demand for dein-
stitutionalization (desmanicomialización) is radical and non-negotiable: “The
Borda Artists Front will fight and resist . . . until the walls fall down” (Sava 2008:
6). This kind of slogan is typical of public protest (cfr. Ivie 2015: 48) and helps
give meaning to long-term processes. On the other hand, however, there are
small, everyday negotiations with the hospital authorities to allow workshop par-
ticipants to make temporary outings: musicians would go out to make a concert;
actors to present a play; painters to open an exhibition. Resistance cannot succeed
over time with long-term slogans alone; it also needs short-term, achievable goals
in order to continue. This double temporality of discourse (long-term demands
and short-term goals) helps explain the reason why the BAF has lasted over time.
This perspective sheds light on how the NLMH was understood by the BAF. Pro-
fessionals and artists who participate in the Front’s activities consider that the law was
a major success in the path of deinstitutionalization, as Executive Decree 603/2013
states that psychiatric hospitals should be closed by 2020 and psychiatric inpatient
units be created at general hospitals. Although this goal does not look likely at the
moment, the legislation of a term in which to implement it was perceived as a success.
Although, at least theoretically, implementation of the law would mean effec-
tive deinstitutionalization, its achievement would not imply the end of the BAF.
On the contrary, the metaphorical slogan “until the walls fall down” allows for
fighting other kinds of “walls”, which should guarantee its continuity even if its
historical demand happens to be satisfied. When asked specifically about what will
happen once “walls have fallen down”, one respondent answered:
The walls are not just the asylum’s. Many people at the workshops are outpa-
tients and others are not even patients, but they come anyway, because walls
are mental and social. Besides, you have a lot of ties, you know everybody.
You can’t just quit.
(Fabricio)
This metaphorization of the BAF’s demand, produced in a context in which

deinstitutionalization is foreseeable in the near future, was already a part of the
Front’s discourse about itself:
Deinstitutionalization (. . .) is to prepare society to knock down the mental

walls it has built around mental health issues and, not fearing chaos, to learn
to accept that it also has suffered a psychiatric pathology, just like any other
person who, after an experience of suffering, takes up his original place again.
(BAF 2008: 14, my translation)
In the same way protest is literal in its demands (“No more asylum”, “Regulate
the NLMH now!”), resistance is simultaneously literal and metaphorical. Going
“from the Borda to the world!” is at the same time a material description of
“going out” to do artistic activities but also a symbolic expression which shows
that art:
has three different meanings for them: as a language which is foreign to the
asylum, as a way of living at the asylum, and as a way of being oneself.
(Viviana)
Resistance is thus based not only on slogans and political demands but also on
shared meaning and community belonging, reinforced by interpersonal commu-
nication. Resistance, as a form of organization, is a matter of trust and mutual
knowledge.
Dissent: the politics of disagreement

Dissent rests primarily on space – material and/or symbolic – rather than on time.
It has consecrated places: the Blue Hall, the Congress, the newspapers – places
which have their own names and communicate through a relatively stable code
of political meaning. Time, on the contrary, is accessory: it is scheduled and
limited. Allocutions are also timed, and respecting time for dissent is key to its
functioning.
Dissent is not only a matter of public institutions, such as Congress: it also hap-
pens in a “shared symbolic space” (Ivie 2015: 54) which works as a place. Dissent,
as we understand it, is preferably displayed over space by equals, in a symmetric
relationship.
Although consensus regarding the NLMH was almost unanimous in the House
of Representatives and the Senate, its legislative process included four debates at
the Congress with representatives of professional associations and civil society
organizations (Faraone 2012). These events can be understood as places suitable
for typical deliberative politics, as there is a common ground which guarantees
symmetry between participants, and time and space are scheduled and organized
from an “objective” institutional point of view.
The organization of the debates shows who were considered to be legitimate
participants. The three preliminary events included some human rights organi-
zations (Mothers of Plaza de Mayo and the Centre for Legal and Social Studies)
but no professional associations of social workers, occupational therapists or
sociologists, even though they were part of the “interdisciplinary teams” being
discussed. The final encounter, at the Senate, included only associations of psy-
chiatrists and of psychologists, thereby highlighting which actors were considered
legitimate in the debate.
Although there was no explicit agenda for the debate at the Senate, it soon
became apparent that the most critical points of disagreement were Articles 1
(which defines “mental suffering”3), 13 (which refers to managerial and directive
positions at healthcare institutions) and 16 (which defines which professionals
can admit someone as an inpatient).4 Dissent, as we understand it here, is a strug-
gle for power over a common ground: psychiatrists and psychologists fought
over the right to define mental health (art. 1), to rule institutions (art. 13) and to
make decisions about people (art. 16).
As dissent occurs among equals, it requires comparative analysis. This is not the
case for resistance and protest, which can only be exerted by the weak. Peers can
disagree with each other, but they can not resist or protest against one another.
In this sense, disagreement appears to be the most binary form of contestation
in our corpus.
In a context of equals, dissenters were powerful, i.e. the representatives of
medicine and medical institutions. It is not a paradox, however, as they disagree
with the text of the law: the dominant actors in the public healthcare system were
the dissenters at the Senate.
Unlike the metaphorical demands of resistance and the floating signifiers of
protest, dissent sets an explicit and literal agenda for disagreeing, in this case, with
the text of the bill in discussion. This need to name and designate the topic lies
at the core of the law: the definition of its object:
The aim of this law is to ensure the right to mental healthcare protection of
every person, and the full enjoyment of his/her human rights to every person
with mental suffering residing in national territory.
(LNMH, Art. 1)
In this article, the law defines two kinds of beneficiaries: every person and “per-
sons with mental suffering”. This distinction is made by avoiding the use of
expressions attributed to the “psychiatric corporation” and “hegemonic medi-
cal discourse”: healthy people and sick people; normal people and crazy people
(cfr. Vilar 2016). The term “mental suffering” acts as a substitute for “mental
illness/condition”, but also widens the scope of mental healthcare: it no longer
refers to pathologically defined patients, but to any person who suffers. We see
here a more psychoanalytically than psychiatrically oriented perspective on mental
health, which thus establishes that “every man is a neurotic”. As the bill adopted
this view quite openly, it was explicitly and directly confronted by, among others,
the representative of the Argentine Association of Psychiatrists, who declared:
It should also be noted that mental illness exists, because we should not medi-
calize psychic suffering, which we may all experience. Everybody has suffered
a night of insomnia because of a wounded heart, and we should not medical-
ize that. However, mental illness does exist, and thus requires the best pos-
sible conditions to guarantee social reinsertion of the psychotic patient.
(HCSN 2009a)
The psychiatrist argues against the first article of the law by defying its distinc-
tion: “persons with mental suffering” simply means “every person”. Thus, the
bill would overlook its specific beneficiaries: “people with a mental condition/
illness” and, later, “the psychotic patient”. As we can see, dissent between psy-
chologists and psychiatrists at the NLMH hearings seems to be a zero-sum game
in which each party’s gain is a loss for the other.
Something similar happens with regard to the right to occupy directive posi-
tions at mental healthcare units. Article 13 of the bill reads:
Professionals with a college degree are in equal conditions to access directive

positions at healthcare units and institutions. It will be necessary to evaluate
their qualification for the position and their capability to integrate the differ-
ent kinds of knowledge involved in the field of mental healthcare.
(NLMH, Art. 13)
This article was contested by the representative of the Argentine Association

of Child and Youth Psychiatrists (AAPI), who spoke against it based on a legal
argument:
I think it is very important that whoever has the highest responsibility should
also have certain decision-making roles because he/she is the highest legally
responsible person if there is any problem at a hospital. As you know, physi-
cians are legally responsible and should hold these positions.
(HCSN 2009b)
In this example, also based on the “hegemonic medical discourse”, the power to
rule an interdisciplinary mental health unit is attributed to a physician because
of his/her “legal responsibility”. In this argument, the psychiatrist does not take
into account that the object of the bill is, precisely, legal: its aim is to create a new
legal order, which could also have impact on the previously defined responsibili-
ties. The aim of this argument is to maintain a certain prior medical status quo by
arguing that the new order will not accommodate to the existing status quo. Even
now, six years after the approval of the NLMH, most mental healthcare units are
run by physicians:
You know? The team leaders are psychiatrists, and, if they are psychologists,
they are psychiatrists besides being psychoanalysts.
(Viviana)
To oppose the legal argument against the law, its defenders resort to the “art of
the possible” by arguing that it is a matter of political – not legal – responsibility:
I wonder why such a big deal is made about the directive positions at health
units, if there are hospitals run by accountants, nurses, dentists, etcetera.
There have been ministers of health with no college degree: union leaders,
people with political responsibility. Nowhere does it say that the minister has
to be a doctor, a nurse or a member of a healthcare team.
(Lores, HCSN 2009c)
In his intervention, Lores dismisses professional qualifications as being a neces-

sary condition for access to directive positions at mental healthcare units. Instead
of defining the issue of “legal responsibility” (as did the AAPI representative),
he states that it is a matter of “political responsibility”. As such, the definition
of professional qualifications is not a matter of opinions but of political muscle.
The last issue on the agenda was the legal ability to admit inpatients at general
hospitals. Article 16 states that every hospitalization should be signed by at least
two professionals from the health unit, at least one of whom should be “necessar-
ily either a psychologist or a psychiatrist”. The representative of the Association
of Argentine Psychiatrists argued:
We think that admitting an inpatient, either clinical or psychiatric, should be

an attribution of the physician, especially the psychiatrist, just as it is now and
is stated in the Civil Code. The person responsible for hospitalization is the
psychiatrist. There is a legal problem, that of malpractice, which is why only
physicians are authorized to hospitalize. In addition, there are legal respon-
sibilities. If you are a psychologist and you want to medicate and hospitalize,
you have to be a physician first.
(HCSN 2009b)
Here again, the argument is of legal nature; the same legal status invoked by the
representative of the Federation of Psychologists of the Argentine Republic:
On October 31st, resolution 343 of the Ministry of Education was approved,

which states the responsibilities and limitations of the degree in psychology.
Admitting inpatients is one of our rightful responsibilities.
(HCSN 2009b)
As in the previous case, disagreement is symmetrical: on a given point, the two
positions are exactly opposed. Since both claims have legal support (either the
Civil Code or the Ministry of Education resolution), what would finally tip the
scale is political power.
We see here that dissent among equals at the Congress is not a matter of argu-
mentation, but of power. The Bill passed with almost no modifications after the
debates, and the senators were unwilling to accept any changes to the proposed
text, as stated by the leader of the ruling party, who asked to shorten the opposi-
tion’s interventions simply because:
We have already said that we will not accept any modifications to our bill, so
you needn’t keep reading your intervention.
(Liliana Fellner at HCSN 2010: 106–107)
As Humpty Dumpty said in Lewis Carroll’s Through the Looking-Glass (1872),

what is at stake is not a matter of words and argumentation: “The question is”,
said Humpty Dumpty, “which is to be master – that’s all”.
#YoMePlanto: the empty signifier of protest

The analysis I present in this chapter observes different discourses of contes-
tation as part of a repertoire which is available to social actors who are not
limited to one form or another. On the contrary, they can contest differently
in different settings. This is, however, a sociological issue which cannot be
addressed here.
The same person can thus be an active member of the BAF and, when neces-
sary, participate in protests about the NLMH or any other social or political
demand. That is what non-ethnographical approaches to activism (even opposed
among each other, such as Young 2001 and Drexler 2007) fail to understand by
not distinguishing social actors and discourse practices. The BAF’s fan page on
Facebook, for instance, invites people to sign a petition against the reform of the
law and its decree of regulation. Meanwhile, routine activities continue at the
Front’s workshops.
Following the historic process of the NLMH, after a long phase of resistance,
and finding the right political conditions for dissent at Congress, the law was
enacted in 2010. For three years, however, it was not regulated. Presidential
decree 603/2013 issued terms and conditions to put the law into practice, begin-
ning a difficult process of application which, in turn, was resisted at several public
hospitals.
A new process of dissent began in the media and professional associations
regarding the applicability of the law. Everyone seemed to agree with the need
for reform in the mental healthcare system. However, some of the core changes
were contested: was it possible to eliminate asylums? Was it advisable to do so?
Should non-medical professionals be able to admit inpatients? Were general hos-
pitals ready to admit mental health inpatients?
The slow, conflictive process of applying the law came to a halt during 2016,
when the new government, under the presidency of Mauricio Macri, decided to
reverse many legislative initiatives taken by the former government. Within this
context, different movements, groups and individuals began to protest in the
public space, both on the streets and on social media.
On October 7th, 2016, there was a national demonstration with the slogan “Yo
me planto!”, a play on words which literally means “I plant myself” but is intended
to say something like “I take a stand”. Unlike routine protests in the public space,
there was no big concentration of people blocking streets. Rather, small groups
of mental healthcare workers, mostly psychologists, gathered in public places in
cities all over the country. This protest was intended to generate images and social
media content, rather than immediate visibility in the public space.
The protest was organized by almost fifteen mental health and human rights
groups with different degrees of institutionalization, involving informal associa-
tions like Deheredadxs de la razón (“Disinherited by reason”) and government
departments such as the Comisión Nacional por la Memoria (“National Memorial
Commission”).
Protest works on a relatively balanced equation between time and space. It
works on the chronotope la marcha. A marcha – demonstration – typically fol-
lows a regular, meaningful path (e.g. from Congress to Plaza de Mayo) or stands
in different meaningful places: in December 2016, for instance, we scientists at
CONICET demonstrated at the Ministry of Science, but we also blocked – at
least for a short period of time – the streets nearby. A typical demonstration at the
Obelisco would close any of the streets for at least half an hour.
The #YoMePlanto demonstrations, on the contrary, were small, with about
eighty participants who were not necessarily aware of the organizers or the
demand of the protest:
V: I read about it on Facebook, but we were just a few, less than a hundred
people
J: Why did they organize it?
V: Specifically, I don’t know (. . .) because the national law is not being applied
(Viviana).
The demonstration was locally organized by widely differing institutions. As a

consequence, it needed a slogan polysemic enough to gather them all, as well
as unaffiliated people. Laclau (1996, 2005) explains the effectiveness of politi-
cal demands as a consequence of their being “empty signifiers”: somehow uni-
versal concepts which are semantically empty, thus made up of heterogeneous,
subordinated demands which constitute a chain of equivalencies among them.
#YoMePlanto, as in “I take a stand”, worked as an empty signifier, as it allowed
for different chains of equivalences which, under a shared slogan, articulated dif-
ferent political identities and subordinated demands. Therefore, organizations
which upheld a more professional-oriented defense of the NLMH carried plac-
ards reading “In defense of the Law of Mental Health”, “The Argentine Network
of Art and Mental Health takes a stand”, “Workers and Users of the PREA #Tak-
eAStand for the right to healthcare and the defense of law 26653”. In these
examples, the demand was plain and literal, identifying its immediate aim and the
institutional actors involved.
In other cases, there was stylistic work on the rhetorical formulation of the
demands, such as “Mental Health takes a stand. Let our rights sprout!” (“La
Salud Mental se planta. ¡Que broten nuestros derechos!”) or in “Madhouse never
again” (“Manicomio nunca más”). In the first example, the untranslatable meta-
phor “se planta” (“takes a stand”/“Plants itself”) is projected over the field of
political activism and its effects: our protest is the necessary condition to make
our rights sprout and grow. In the second case, there is a juxtaposition of terms
from two different semantic fields: the “manicomio” (“madhouse”), which is a
pejorative expression to designate mental asylums, and the slogan “never again”,
associated to human rights movements’ struggle for justice regarding human
rights violations by the last military dictatorship in Argentina. In both cases, the
rhetorical work strengthens the relationship between mental health and human
rights, a central innovation of the NLMH.
In other cases, finally, there was a more radical political interpretation of the
demand, which was integrated to a chain of equivalencies with other, more
explicitly political demands. This was the case of groups such as Disinherited
by reason, who demonstrated carrying placards reading “Mental Health is also
having a job”, and “Mental Health means not being arrested for being activist”.
At the bottom of every placard, in a smaller font, was the legend “Let’s defend
the law of mental health 26.657. Say no to emptying the State”. These exam-
ples propose an equivalence between the defense of the NLMH and political
demands which, in general terms, are aimed at the government of Macri and
the current rise in unemployment, political repression (such as the incarceration
of Milagro Sala) and reduction in the numbers of government-hired workers.
Up to this point, we should say that #YoMePlanto was successful, in terms of
Laclau (2005), at symbolically structuring a heterogeneous collection of groups
and individuals as a collective actor. However, the main aim and strength of pro-
test is visibility. Although #YoMePlanto allowed for internal cohesion in an emerg-
ing collective actor, it failed at making this actor and its demands visible locally,
because there were many small demonstrations which did not interfere with the
organization of public space, and globally in social media, because #Yomeplanto
is also a well-established hashtag for Spanish-speaking cannabis activists around
the world. Therefore, the protest was diluted, both on Facebook and Twitter, in
a very different discourse universe.
We could say that #YoMePlanto was not only an empty signifier, but indeed
an ambiguous one: it allowed for two very different chains of equivalences: one
devoted to mental health and human rights, the other to the legalization of mari-
juana. Thus, it succeeded internally as a discourse means to build a collective
identity of mental health activists, but it failed at making their demand visible to
the public opinion.
Contestation in contexts of inequality: the socio-political

limits to democratic dissent
In this chapter I have discussed the concept of “democratic dissent” in the light
of political experiences of resistance, dissent and protest in Argentina. My aim in
doing so was to analyze the limits of democratic disagreement (and deliberative
forms of contestation) in contexts of inequality and asymmetry. A second goal
was to show the need to discuss political theory concepts as they exist in current
political practices, especially by using empirical methods such as direct observa-
tion, participation and in-depth interviews. This empirical approach helps distin-
guish actors and discourse practices, thus showing that the same social actors may
dissent, resist and protest. Hence, we avoid typical-ideal subject categories such
as “the activist”, the “deliberative democrat”, etc.
The three terms, as I understand them, designate forms of the discourse of
contestation which are integrated to a culturally defined repertory. As such, the
continuum of contestation discourses I analyze here is not generalizable. On the
contrary, empirical analysis will no doubt show differences and displacements
among three categories which are intended to stimulate research rather than
close it.
From this standpoint, dissent is a form of direct disagreement between equals
which emerges in well-defined shared places, either material or symbolic.5 Protest
is a form of contestation, direct and literal, which exerts some kind of violence
but is not necessarily spontaneous or disorganized. Under certain genres, such as
blockades and marches, it has concrete demands which develop simultaneously in
time and space, usually under the form of a chronotope. Resistance, finally, is an
indirect, often metaphorical form of contestation which builds up community at
the heart of institutions, developing fundamentally over time.
These categories are not intended to exhaust the forms of democratic dis-
course of contestation, nor are they meant to be absolutely distinct from one
another. On the contrary, they enable me to better understand the discourse
process involved in the NLMH in Buenos Aires and the political dimension of
psychotherapy at public hospitals. I believe that only through participation and
engagement in transformative practices will new theoretically relevant concepts
emerge.
Notes
1 During the last weeks of December 2016, we scientists at CONICET (National
Council for Scientific and Technological Research, in Argentina) protested at the
Ministry of Science against budget cuts. Although the Ministry building was taken
over by protesters and nearby streets were blocked several times, there was no police
intervention or media condemnation. On the contrary, the protest was perceived as
legitimate by general opinion in the mass media, and the Ministry authorities finally
negotiated with us protesters. This is one key feature of protest: although it exerts
some kind of violence outside formal channels, it may still be perceived as legitimate
by both the government and public opinion. In contrast to Young (2001: 673),
“powerful officials” did have motives to “sit down” with us to negotiate.
2 All texts are translated from the original Spanish by me.
3 It is difficult to translate the expression “padecimiento mental” in usual terms in
English, as they tend to emphasize a medical sense, such as in “mental illness” or
“mental condition”. The term “padecimiento” attempts to define a person by his/
her suffering, independently (and prior) to his/her medical condition.
4 Later, Executive Decree 603/2013 would include the issue of effective deinstitu-
tionalization in the agenda of public dissent and protest.
5 This characterization depends on the political culture and the discursive process
analyzed here. As such, it probably will not be suitable for understanding other
political realities.
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Epilogue
Like any ethnographically-based research, this book condenses a journey. It was

a path through a diverse and conflictive reality which was possible thanks to the
effort and commitment of people who helped shape decision-making throughout
the research process. It was also a theoretical and methodological journey: as new
questions emerged from the data, I considered discourse analysis, interactional
sociolinguistics, conversation analysis and linguistic landscape studies, among
others.
The chapters in this book enabled us to understand a specific place, the mental
healthcare outpatient service at a public hospital in Buenos Aires, as it is a part
of realities of different levels. We observed how the situation itself is the product
of historical processes of institutionalization of mental healthcare in Argentina,
but also of interactional negotiation, misunderstandings and maladjustments. At
the core of these issues lies the conflict between psychiatry and psychoanalysis, a
conflict which is apparent at every level of analysis: from discursive landscape –
which invisibilized the mental healthcare outpatient service and privatized com-
munication by placing it in the hands of a pharmaceutical company – to legislative
and political discourse, which postponed the application of the National Law of
Mental Health and was responded by actions of dissent, protest and resistance.
These higher, more general levels, however, do not exist outside everyday inter-
action at the consulting rooms. It is people who actually make discourse exist,
who produce and reproduce (in)equality in everyday communicative practices.
Chapters 4, 5 and 6, devoted to admission interviews, are to be seen in this
contradiction, as they show people struggling between institutional discourses of
medical diagnosing and bureaucratic classification and a genuine attempt to reach
the other and speak with the other’s voice. Agency and voice are not, therefore,
exceptional features, but a systematic property of interaction in medical settings.
Discourse analysts do not usually attempt to reach the actual people whose
discourse they analyze. Interdisciplinary dialogue and collaborative research pro-
vide a way to renew our theoretical and methodological repertoire, but also our
commitment to social change. Changing the focus “from texts in contexts to
people in events” (Bolívar 2010) is an attempt to do so by learning from people
and letting this knowledge help shape the research process, even although it may
affect our narcissistic relationship with knowledge and theory. It may be time to
Epilogue 173
open the dialogue beyond interdisciplinarity, to take discourse analysis outside its
comfort zone and demand it to ask (and answer) new questions, posed by new
speakers, in order to understand new realities.
Reference
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Journal of Multicultural Discourses, 5(3), 213–225.
Index
Note: Page numbers in italic indicate a figure on the corresponding page.
access to healthcare 127 – 129, 129n2 – 3 Blommaert, J. 15, 20 – 21, 26, 35

activism see dissent; protest; resistance Bolívar, A. 2, 4 – 5; on contradiction
act of voice 13, 21 – 22 between theoretical statements and
admission interviews in hospitals 39 – 51 analytical practice 22; on idealistic
agenda setting: private level 46 – 47; vision of dialogue 18; on problem of
public level 42 – 44 dialogue 15
Agha, A. 21, 135 Bonnin, J. E. 2
Alfonsín, Raúl 160 Borda Artist Front (BAF) 160 – 162
Almirón, Carlos 161 Borges, Jorge Luis 1
analysis of political discourses 2 Bourhis, R. Y. 70
Antaki, C. 92 Buddha 12
anti-psychiatry 160 bureaucracy and access to healthcare
Appraisal Theory 14 127 – 129, 129n2 – 3
Archaeology of Knowledge 22 bureaucratic discourse: access to
Argentine Association of Child and healthcare and 127 – 129, 129n2 – 3;
Youth Psychiatrists (AAPI) 164 dealing with potential face-
Argentine Association of Psychiatrists threats in 121 – 123; displaying
164, 165 bureaucratic competence in 118 – 119;
Argentine Psychoanalytic Association epidemiological-statistical form
(APA) 38 and the organization of interviews
“Argentine Writer and Tradition, in 116 – 117; introduction to 113;
The” 1 moving from the sphere of the
Arnoux, E. B. N. de 2, 3 public to the private in 119 – 121;
asymmetry between doctors and pre-empting rejection in 124 – 127;
patients 132 – 134; accommodation, questions and expanded answers in
voice and social range in 134 – 149; 114 – 116, 115
patients’ point of view in 136 – 141; Burger, Eugene 12
professional’s point of view in
141 – 149; voice, and social distance Carranza, I. E. 2
from participants’ perspective Chávez, Hugo 4
149 – 151 Chouliaraki, L. 20
Clayman, S. 35
Bakhtin, M. M. 4, 15, 21 – 23 co-labour research 5 – 6
Barnes, R. 92 Communication Accommodation
Benjamins, John 68 Theory (CAT) 134
Bercelli, F. 132 competence, bureaucratic 118 – 119
Bernstein, B. 28, 29 consignas 156
Index 175
contestation in contexts of inequality 169 doctor-patient interaction:
context: in doctor-patient interaction accommodation, voice and social
35 – 36; role of admission interviews range in 134 – 149; asymmetry in
and interactional construction of 132 – 151; issue of context in 35 – 36;
39 – 51 patients’ point of view in 136 – 141;
contextual maladjustments 50 – 51 professionals’ point of view in
Cordella, M. 35 141 – 149; see also bureaucratic
Coupland, J. 133 discourse; maladjustments;
Coupland, N. 133 psychoanalysis in public hospitals
Critical Discourse Analysis (CDA) 7; doxa 26
accused of having overdetermining Drexler, J. M. 154, 156, 157
view of discourse and society 20;
as colonialist form of knowledge emergent discourse 22 – 25
15; critical stance toward 14 – 15; emergent grammars 23 – 25
linguistic bias in 15 énonciation 21
critical sociolinguistics 26 epidemiological-statistical form and the
organization of interviews 116 – 117
dealing with potential face-threats in epistemology of the known subject 5
bureaucratic discourse 121 – 123 ethnical voice 146 – 147
de Certeau, M. 156 extraordinary discursive events 19
deinstitutionalization 161
de Melo Resende, V. 3 Facebook 158, 167
face-threats 121 – 123
Derrida, J. 20
Fairclough, N. 15, 17, 18, 20
diagnosis in mental healthcare 92 – 94;
false consciousness 20
dismissing self- 95 – 100; loose
Federation of Psychologists of the
95 – 100; treating without 94 – 109
Argentine Republic 165
Diagnostic and Statistical Manual of
Ferreyra, J. 159
Mental Disorders (DSM) 92, 93
field notes 12 – 13
dialogism 4, 15 fieldwork 12 – 14
dialogue 4, 15 Foucault, M. 22, 23
direct experience 12 Freire, P. 4
discourse analysis (DA) 2; emergent French theories of discourse 17 – 18, 21
discourse 22 – 25; Latin American
3 – 6; sociolinguistics and 25 – 29; of Gallagher, M. 155
voice 20 – 22 Gasiorek, J. 134
discursive events, singularity as gaze direction: intimate level 48 – 49, 49;
unexpected dimension of 17 – 19 private level 44 – 46, 45; public level
discursive formation 16, 19, 23, 25 41 – 42, 43
discursive landscape 68 – 69; actors and Giles, H. 133, 134
actions in 88 – 89; see also linguistic glottopolitics 3 – 4
landscape Gorter, D. 70
dismissal of self-diagnosis 95 – 100 Gramsci, Antonio 12, 16
dissent: in action against the National Granovetter, M. 133
Law of Mental Health in Argentina Guarani speakers 13, 79, 84
(NLMH) 158 – 160, 162 – 166;
ethnographic discourse analysis of Halliday, M. A. K. 14
157 – 158; introduction to 154 – 155; hegemonic medical discourse 164
as politics of disagreement 162 – 166; Heritage, J. 35, 113
protest and 155 – 156; socio-political history-taking 113
limits to democratic 169; see also Hopper, P. 23
protest; resistance hospitals: cultural mediators in 85 – 88;
diversity 26 – 27 indoor and outdoor languages and
176 Index
79 – 85, 80 – 81; invisible landscape policies in public healthcare and
of 77 – 88, 78, 80 – 81; landscape and 69 – 71; indoor and outdoor
language policies in public healthcare languages in 79 – 85, 80 – 81; invisible
69 – 71; psychoanalysis in (see landscape and 77 – 88, 78, 80 – 81;
psychoanalysis in public hospitals); methodological readings of theoretical
visible landscape of 72 – 77, 74 – 76 metaphor in 70 – 71; visible landscape
Hymes, D. H. 18, 20, 29 and 72 – 77, 74 – 76
lower-class youth voice 144 – 146
indexing bureaucratic voice 136 – 138
indoor and outdoor languages 79 – 85, Macneil, C. A. 92
80 – 81 Macri, Mauricio 126
interaction, landscape as 73 – 74, 74 Magalhaes Bosi, M. L. 94
interactional construction of context Maingueneau, D. 18
39 – 51; intimate level interview and maladjustments: contextual 50 – 51;
48 – 49; private level interview and mental healthcare services roles,
44 – 47; public level interview and activities and 51 – 62, 93
40 – 44 management paradigm 26 – 27
interactional discourse analysis 4 – 5 marcha 156
International Classification of Diseases May, C. 35
(ICD-10) 93 Maynard, W. 35
intimate level interview 48 – 49 mediators, cultural 85 – 88
invisible landscape 77 – 88, 78, 80 – 81 medical consultation see bureaucratic
Ivie, R. L. 154, 155 discourse
medical discourse: confronting of
Krauss, M. E. 27 109 – 110, 150 – 151; hegemonic 164;
see also bureaucratic discourse
Lacan, Jacques 39 mental healthcare: confronting
Laclau, E. 155, 167, 168 psychoanalytic and medical discourses
Landry, R. 70 in 109 – 110; diagnosis in 92 – 94,
landscapes see discursive landscape; 105 – 109; dismissing self-diagnosis
linguistic landscape in 95 – 100; ethnographic discourse
language-as-code 68 – 69 analysis of resistance, dissent and
language-as-mode 68 – 69 protest in 157 – 158; psychoanalysis in
Latin America 1 – 2 (see psychoanalysis in public hospitals);
Latin American Association of Discourse treating without diagnosis in 94 – 109
Studies (ALED) 4 Mercado, F. J. 94
Latin American discourse analysis moving from the sphere of the public to
3–6; co-labour research in 5–6; the private in bureaucratic discourse
epistemology of the known subject in 119 – 121
5; glottopolitics in 3–4; interactional
discourse analysis in 4–5; poverty and 6 narrative inequality 29
Latin American Journal of Discourse National Law of Mental Health in
Studies (RALED) 5 Argentina (NLMH) 157 – 158;
lectal power 29 resistance, dissent and protest in
Leudar, I. 92, 133 action against 158 – 168
linguistic inequality: defined from negotiating the activity in psychoanalysis
discursive point of view 27 – 29; in public hospitals 52 – 58
diversity and 26 – 27; from fieldwork Nishizaka, A. 113
to theory in study of 12 – 14; Non-Critical Discourse Analysis 2
sociolinguistics and discourse analysis
new approaches to 25 – 29 Ochs, F. 24
linguistic landscape 68 – 69; actors and optimism of will 16
actions in 88 – 89; case presentation order of discourse 16, 19, 23, 25
71 – 72; cultural mediators in 85 – 88; ordinary discursive events 19
hospital landscape and language Other, the 26 – 27
Index 177
Pardo, M. L. 2, 6 through art 158 – 162; see also dissent;
Parsons, T. 35, 58 protest
patients: point-of-view of 136 – 141; Roemmers Laboratory 66, 73 – 77, 88
self-diagnosis by 95 – 100; see also Rossano, F. 132
doctor-patient interaction Rubistein, A. 93
Pêcheux, M. 19
pessimism of reason 16 saying the unexpected, act of voice as
piquete 156 21 – 22
politics of disagreement 162 – 166 scenography 18
poverty and discourse 6 Schegloff, E. A. 20, 24
pre-empting rejection in bureaucratic self-constituting discourses 18
discourse 124 – 127 self-diagnosis 95 – 100
private level interview 44 – 47 Semán, P. 148
protest: in action against the National semiosis of space 66, 67, 88; see also
Law of Mental Health in Argentina linguistic landscape
(NLMH) 158 – 160, 166 – 168; dissent sequencing as ideology in mental
and 155 – 156; ethnographic discourse healthcare treatment 94 – 109
analysis of 157 – 158; resistance Shi-xu 5, 15, 20, 21
and 156 – 157; #YoMePlanto and Simmel, G. 133
166 – 168; see also dissent; resistance singularity 15 – 16; as unexpected
psychiatric voice 138 – 141 dimension of discursive events 17 – 19
psychiatry 62, 159 Slembrouck, S. 20
psychoanalysis in public hospitals social distance 133 – 134, 149 – 151
36 – 39; context in doctor-patient social theory 1 – 2
interaction and 35 – 36; and discourse sociolinguistics and discourse analysis
between psychoanalysis and psychiatry 25 – 29
in doing mental health 62; growth in space, semiosis of see semiosis of space
use of 38 – 39; negotiating the activity status quo 164 – 165
of 52 – 58; role of admission interviews Stivers, T. 113
and interactional construction of Stolkiner, A. 159
context in 39 – 51, 93 – 94; roles, stratification and deixis of landscape
activities and maladjustments in 74 – 77, 75 – 76
51 – 62; titles and forms of address synchronic-diachronic method for the
in defining role-identities in 58 – 62; linguistic analysis of texts 6
what patients expect and what Systemic Functional Linguistics
they get in 37 – 38; see also mental (SFL) 14
healthcare
psychoanalytic discourse, confronting of Ten Have, P. 132
109 – 110 Thompson, S. A. 24
psychopathology, semiosis of space and titles and forms of address in defining
66, 67 role-identities in healthcare settings
public level interview 40 – 44 58 – 62
transference relationships 40
questions and answers in bureaucratic
questions 114 – 116, 115 Unamuno, V. 5 – 6
Universalism/Aculturalism 14
Red Latinoamericana de Análisis del
Discurso de la Pobreza (REDLAD) 6 Van Dijk, T. A. 36
rejection, pre-empting of 124 – 127 Vasilachis de Gialdino, I. 5
religion, voice of popular 147 – 149 Vehilläinen, S. 132
resistance 154 – 155; in action against Viaro, M. 132
the National Law of Mental Health visible landscape 72 – 77, 74 – 76
in Argentina (NLMH) 158 – 162; voice: accommodation, social range,
ethnographic discourse analysis of and 134 – 149; act of 13, 21 – 22;
157 – 158; protest and 156 – 157; asymmetry and social distance from
178 Index
participants’ perspective 149 – 151; Widdowson, H. 20
discourse analysis of 20 – 22; ethnical Workforce 2000 26
146 – 147; indexing bureaucratic World Health Organization
136 – 138; lower-class youth 144 – 146; (WHO) 38
patients’ 136 – 138; of popular religion world-system problems 29
147 – 149; psychiatric 138 – 141;
shaping of 16; young-middle class #YoMePlanto protest 166 – 168
142 – 144 Young, I. M. 155, 156, 157, 158
Voloshinov, V. N. 16, 23 – 25 young-middle class voice 142 – 144

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Discourse and Mental Health

Juan Eduardo Bonnin is Researcher at the Consejo Nacional de Investigaciones

A cultural-innovation-seeking platform in discourse and communication studies,

Discourses of the Developing World

Israeli Discourse and the West Bank

Political Discourse as Dialogue

Discourse and Mental Health

For more information about this series, please visit www.routledge.com/Cultural-

Juan Eduardo Bonnin

1 Voice, singularity and emergency: a discursive

2 Psychoanalysis in public hospitals: context as a

3 Invisible landscapes: diversity and the semiosis of space 66

4 Diagnosis and treatment: sequencing and exclusion 92

5 Resisting exclusion: patients’ tactics of

6 Speaking with the other’s voice: an attempt to

7 Discourse and activism: dissent, protest and resistance 154

2.1 Gaze at the public level 43

[ indicates the point of overlap onset

Discourse analysis in Latin America

Latin American discourse analysis

Colonialism of knowledge in Latin America has led to the formation of a

What defines a Latin American perspective in discourse analysis is not a school,

Interactional discourse analysis

The epistemology of the known subject

Discourse and poverty

Perspective and contents of this book

From fieldwork to theory

Excerpt 1. Field notes (2012)

Y: Are you taking your medication, you don’t forget to do it?

A critical stance towards Critical Discourse Analysis

A proposal: singularity, voice and emergent discourse

This conception of voice as a series of typifiable semiotic regularities which

The novel can be defined as a diversity of social speech types (sometimes

Emergent discourse is/in interaction

This rejection of language-as-system is a radical point of view which is echoed

we need to question the supposition of a mentally representated (sic) set of

It is only in this continuous, generalized, social interaction that discourse

Language acquires life and historically evolves precisely here, in concrete

Discourse is thus neither “social” nor “individual”, but interactional: it

Sociolinguistics and discourse analysis:

From diversity to inequality

Defining linguistic inequality from a discursive point of view

Doctor-patient interaction and the issue of context

Public health settings: psychoanalysis at the hospital

Patients: what they expect and what they get

Psychoanalysis and (public) mental health

The role of admission interviews and

Interactional construction of space: the public,

The public level

1 PC: good morning madam how are you (1)

The PC tries to narrow the space of interaction as a means to establish her

1 A: yes: STAY outside with your sister

AGENDA SETTING: THE PATIENT AS A DEMOGRAPHIC SUBJECT

Figure 2.1 Gaze at the public level

1 PC: education? Pri:mary, se:condary?

The private level

My observation of the interviews is not as a participant. This is why, uncon-

Figure 2.2 Gaze at the private level

AGENDA SETTING: THE PATIENT AS A BIOGRAPHICAL SUBJECT

GAZE DIRECTION/AGENDA SETTING: THE PATIENT AS A SOMATIC SUBJECT

PC: did you follow any treatment [for addictions?

Figure 2.3 Gaze at the intimate level

At this level of interaction, it is practically impossible to distinguish between

3 Invisible landscapes: diversity and the semiosis of space 66

4 Diagnosis and treatment: sequencing and exclusion 92

7 Discourse and activism: dissent, protest and resistance 154

2.1 Gaze at the public level 43