A caring interview: Polar questions,epistemic stance and care in examinations of eligibility for social benefits

Introduction

Interviewing plays a central role in the professional work of welfare administration. In different agencies, interviews are conducted to investigate clients’ perceptions of the services provided to them, to identify clients’ problems and needs, to obtain information for actions and treatment and to assess and decide on eligibility for services (Antaki, 2002; Antaki et al., 2002; Antaki and O’Reilly, 2014; Heritage and Clayman, 2010; Iversen, 2012; McCabe et al., 2017; Raymond, 2006; Summerson Carr, 2010; Suoninen and Jokinen, 2005). This study focuses on the latter. Determining eligibility for services and economic support is a professional task involving assessments in the application of rules, the results of which often have serious consequences for clients in difficult life situations. This study builds on telephone calls in which officials at the Swedish Social Insurance Agency interview individuals who have applied for benefits within two areas of compensation: sickness compensation (a form of disability pension) and childcare allowance (a compensation for parents with a child with serious diseases or disabilities).

The study has two aims, interrelated to form one general argument. The first aim is to investigate central practices in what we describe as a caring interview. Previous research has shown how interviewers, for example, reframe scripted questions and deviate from neutral interviewing in orientations to interactional sensitivity and care (Antaki et al., 2002; Houtkoop-Steenstra and Antaki, 1997). How actors in the design of their talk display a ‘sensitivity to the particular other(s) who are the co-participants’ (Sacks et al., 1974: 727) is a general object of study in conversation analysis (CA) (Heritage and Clayman, 2010). We use the concept of caring interview to refer to particular forms of sensitivity and care in interviews with clients in institutional settings. More specifically, we explore three different forms of caring: (1) helpful treatment of clients in their participant role as interviewees, referring, for example, to how questions are designed to consider clients’ difficulties in answering; (2) care for the client as a person with troubles, given that through the framing of questions professionals can show attentiveness and understanding to a client’s circumstances and problems and (3) enactment of the professional’s expertise in care because in the context of the interviews studied, professionals not only asked questions from unknowing positions, but also displayed expert knowledge about care and health issues.

Second, the aim is to add to the research on epistemic stance and question design in institutional interaction (Heritage, 2012; Heritage and Clayman, 2010: 140; Heritage and Raymond, 2012; Raymond, 2006, 2009). Epistemic stance here refers to how participants in interaction display and manage their relative access to knowledge and their rights and responsibilities to know (see also Drew, 2018). The design of question turns index what Heritage (2012) describes as the ‘epistemic gradient between an unknowing (K-) questioner and a knowing (K+) recipient’ (p. 6). A declarative question format that invites confirmation is, for example, different from an interrogative polar question or a q-word question in indicating more knowledge regarding the matters asked about. As Drew (2018) emphasizes, in CA epistemic is about attributions of knowledge (not what individuals actually know), that is, how participants ‘attribute (states of) knowledge to themselves and one another’ (p. 165). In interviews, the epistemic stance is central to how the questioners manage their own responsibilities of knowing (or not knowing) and what they can expect (or not expect) the interviewee to know (and tell).

In the case investigated, we observed an intriguing discrepancy between institutional guidelines and actual practices of interviewing. The guidelines recommend that ‘open’ (q-word) questions should be given priority in the examination of eligibility: ‘[a] basic principle of the conversations is to use open questions as far as possible, that is, questions that cannot be answered with only yes or no’ (‘Guidelines for the examination of sickness compensation’). However, in measuring the 1473 questions from 43 interviews included in our study, we found that 68% are polar questions (based on definitions in Stivers and Enfield (2010)), many of which are designed for confirmation of information. These are questions in which the questioner invokes knowledge and takes a knowing stance (Heritage, 2012; Heritage and Clayman, 2010: 140). Several studies have observed the centrality of polar questions (interrogatives designed to favor a particular answer and declaratives inviting confirmation) in institutional contexts (e.g. Houtkoop-Steenstra and Antaki, 1997; McCabe et al., 2017; Thompson et al., 2016). In our study, the interviewers’ tendency to prioritize confirming polar questions is indicated not only in the frequency of such questions, but also in the actual design of question turns and sequences. We found frequent cases of q-word questions reformulated into polar questions within the question turn. These are question turns in which the interviewer’s epistemic stance and the related epistemic gradient is amended (Drew, 2018; Heritage, 2012). We became interested in the role of confirming polar questions in the context of the interviews. In our data, polar questions are used, for example, in follow-ups to clarify the information given in clients’ answers (cf. Antaki, 2002). However, in this study, we focus on the epistemic stance displayed in caring interviewing.

This leads us to our general argument: indicating knowledge and reducing the epistemic gap between interviewer and interviewee are central to the practices of a caring interview. These characteristics render the caring interview a form of institutional interaction that is different from standardized and bureaucratic interviewing. While the questioner in standardized interviewing tends to (and is expected to) design questions from an unknowing position, in caring interviewing the questioner invokes knowledge and manages and corrects their epistemic stance as a resource to (1) be helpful to the interviewee (caring 1), (2) be attentive and understanding to clients’ problems and circumstances (caring 2) and (3) be an expert regarding the problems involved (disorders, illness, etc.) (caring 3). The distinction between a standardized and caring interview does not refer to two distinctive activities, but rather orientations in the design of questions, shaping more or less bureaucratic or caring relationships with clients (cf. Raymond, 2006).

By fulfilling the two aims of the study, we also seek to contribute to applied CA. Knowledge regarding how orientations to care shape practices of interviewing is of considerable relevance for professionals. CA provides an understanding of how tasks and social relations are managed in question design, with great potential to facilitate professionalization and improvements in institutional practices. We discuss the applied aspects of the study, including some concrete initiatives, in the concluding section. In this context, we address the more general issue of how officials have to balance professional roles and tasks in interaction and the tensions between caring forms of interviewing and specific institutional requirements and needs of information (cf. Antaki, 2002; Antaki and O’Reilly, 2014; Thompson et al., 2016).

The next section briefly presents previous research. We then provide information concerning the institutional context, method and data, before proceeding to analyze the three forms of the caring interview.

Previous research: Caring and epistemic stance

Several studies have shown how interviewing in institutional settings is adapted to the sensitivity of the interviewee when institutional goals and guidelines are transformed into practice. Helpful interviewing was observed and analyzed by Houtkoop-Steenstra and Antaki (1997) in a study focusing on how interviewers reformulated questions and deviated from the script of a standardized Quality of Life questionnaire. More complex questions were reformulated into yes/no questions. This general practice was applied in different situations in the interviews. When interviewees displayed difficulties in answering, the interviewers reformulated the initial question in the third turn and provided yes/no questions making the task of answering easier. The simplified polar question was also provided in first turn positions when respondents displayed difficulties in answering the scripted questions in the prior interaction. Houtkoop-Steenstra and Antaki (1997: 302) also show how reformulated questions tend to project a positive and optimistic answer.

In a study of interviews with people with learning disabilities concerning the service they receive at a publicly funded agency, Antaki et al. (2002) provide further examples of how polar questions are used in ‘treating the respondent “helpfully”’ (p. 452) by offering what Pomerantz (1988) describes as ‘candidate answers’, that is, questions that specify a particular information to be confirmed (or not) by the respondent. This study also highlights practices of interviewing that embody care for the individuals and their personal situations. In analyzing comments and advice in interviewers’ third turns, Antaki et al. (2002) identify a shift in footing from impartial interviewing to a more personal form of talk enacting a role as a caring professional. They explain the interviewers’ practices as an indication of a ‘dilemmatic choice between treating her or his interlocutor as a simple interviewee or a person for whom they have a duty to care’ (Antaki et al., 2002: 444).

In another study of interviews in this institutional context, Antaki (2002) shows how epistemic access is invoked in practices of helpful interviewing. Examples demonstrate how interviewers insert sequences in response to what is deemed an inadequate answer, revise more general questions and provide candidate answers that indicate that ‘the interviewer “knew better” than the respondent what the proper answer to the question ought to be …’. The context makes sense. The interviewers are care staff who know their respondents. Antaki also identifies distinctive practices in how shared knowledge is invoked in the question design. For instance, interviewers refer to episodes from respondents’ lives as well as information that respondents have reported that, as Antaki (2002) notes, makes it difficult for them not to confirm.

How professionals, in the design and framing of questions, display attentiveness and concern for patients or clients’ circumstances have been analyzed mainly in research on medical visits. In a study of questions used by psychiatrist in clinical encounters, Thompson et al. (2016) observe a positive impact of declarative questions on the therapeutic relationships. This is explained with reference to how such questions are used to display empathy, an understanding of the patient’s stance and feelings. Two normative principles have been identified: the principles of optimization and problem attentiveness (Heritage, 2009; Heritage and Clayman, 2010; Stivers, 2007). The first suggests that questions by default ‘should be designed so as to allow patients to confirm favorable framed beliefs and expectations about themselves, their health, and their circumstances’ (Heritage and Clayman, 2010: 144). Orientations to the principle of optimization have been observed in different institutional contexts. For example, in a study of psychiatric assessments, Antaki and O’Reilly (2014) demonstrate how, in the design of alternative questions, practitioners tend to put more negative alternative and serious states of affairs as the first of two alternatives, rendering them less expected and likely answers. However, in questions concerning the health problems that represent the reasons why the patients contacted the doctor, optimizing can be considered inappropriate, and problem attentiveness is instead the default principle (Heritage and Clayman, 2010:145; Stivers, 2007). The principle suggests that questions should be framed so that the problems and reported symptoms are assumed and not questioned.

This research thus provides evidence of different forms of caring in interviews with clients: (1) the interactional care of the interviewee and (2) the care of the client, his or her problems and circumstances. Although these can be interrelated in practices of interviewing, they are sensitive to the individuals in different respects and relate to different norms and moral responsibilities. In the first form, caring is about helping the interviewee to fulfill normative obligations of answering the question asked (Heritage and Clayman, 2010: 23). In caring for a client with troubles, interviewers relate to moral responsibilities and normative principles. The research also highlights examples of what we described in the introduction as (3) the enactment of the professional’s expertise in care. This is illustrated in Antaki’s (2002) observation of how care staff interviewers claim exclusive knowledge in treating clients’ answers as inadequate and suggesting a better answer to the question.

The data and examples referred to in the research described above largely consist of polar questions, often designed with preference for confirmation. We thus have reasons to assume that such questions are of particular relevance in caring interviews. A distinctive feature of polar questions is the way in which the questioner is positioned as more or less knowledgeable in relation to the respondent (Heritage and Raymond, 2012; Raymond, 2006). As Heritage and Clayman (2010: 141) illustrate, for example, in yes/no declarative questions, the questioner takes a knowing stance and invites confirmation of what is assumed to already be known.

The significance of epistemic access and stance in helpful and caring interviewing is indicated in the research illustrated above. As Pomerantz (1988) argues, polar questions typically include ‘candidate answers’ (p. 372) indicating some knowledge about the situation. In providing candidate answers, the questioner can make answering less demanding, display attitudes to the respondent and embody a cooperative relationship. Furthermore, problem attentiveness and an understanding of a client’s circumstances requires the questioner to take shared knowledge – what has been learned about the client/respondent from prior interaction – into consideration in the design of questions (Heritage and Clayman, 2010: 145).

The relationship between knowing stance and caring is further analyzed in this study. Translated into the context of these interviews, we can expect the principle of problem attentiveness to apply in more or less sensitive questioning regarding the client’s problems that constituted the reason why they applied for specific benefits. However, the institutional context is different from previous research. The institutional task of officials is to examine the client’s problems in order to assess his or her eligibility for support and not (e.g.) to promote the health of the patients through providing diagnoses and treatment. It is in this particular institutional context that we explore the three forms of caring in interviews.

The institutional context

This study includes data from two different areas of compensation handled by the Swedish Social Insurance Agency: sickness compensation and childcare allowance. Sickness compensation is intended for people with such permanently reduced work ability that they cannot function in regular work, at least not full-time (Bruhn et al., 2017). Reduced ability should be assessed as permanent. Most often, compensation becomes an option for those who have been on sick leave for a long time and where several measures from different actors have been made for rehabilitation without any progress being made. Childcare allowance is a form of compensation paid to parents who have a child who is sick or has a disability. This includes costs for daily care and medicine, and assistive devices. The child’s need must continue for at least 6 months.

Applications are handled by officials specialized in investigating these cases. In both compensations, a medical certificate must be enclosed with the application. The examination calls analyzed in this study are in most cases required in an official’s investigation of the applicant’s eligibility for compensation. In the case of sickness compensation, it is principally the applicant’s work ability that should be examined, while in childcare allowance it is the care needs.

The internal guidelines for the examination calls describe the aim of the call, the topics to be included and general recommendations for how the questions should be framed. For example, when it comes to sickness compensation, work ability should be examined through questions concerning work as well as leisure activities. However, there is no standardized script to follow, and the guideline emphasizes that the interviews should be adapted to the particular case. The calls recorded for this study also display clear differences in how the examinations are performed. In some cases, the officials systematically go through question by question on a number of themes, while in other cases a more limited number of questions are asked. It is beyond the scope of this study to explain the differences. The practices analyzed in this article are observed across different interviews.

Method and data

The study follows the methodological practices of CA, thus carefully examining the participants’ design of turns and actions, and the sequential turn-by-turn dynamics of the interaction (Sidnell, 2010). In institutional CA, the method is essentially applied to understand how professional work is carried out and institutional objectives are achieved (Heritage and Clayman, 2010).

The data include 43 examination calls from 4 regional offices and 17 officials, recorded during 2017 and 2018. The length of the calls varies from about 15 to 70 minutes, except a few that were significantly shorter. The total time of the data is about 20 hours. All recordings were first transcribed turn by turn, albeit without detailed indications of pauses, overlapping talk, intonation and other aspects of speech delivery. Based on the first preliminary analysis (using the rough transcripts as well as listening through the calls), a selection of sequences was then transcribed in greater detail according to the conventions of CA. The excerpts presented in the article have been selected to illustrate more general practices identified in the analyses of the data. Thus, for each of these practices, there are many more examples in the data.

The study was conducted with the informed consent of all participants and was approved by the Swedish ethical vetting board. Officials at the four offices were informed at a staff meeting and on paper about the aim of the study, the methods, confidentiality and voluntary participation. Those who were willing to participate notified and signed a consent form. In this regard, the officials are thus recruited through self selection. A recording device was installed on their phone, and they were asked to record calls for about 2 weeks. The informed consent with clients was associated with more critical considerations. It was not possible to inform with a pre-recorded voice before the conversation began, partly because in some cases it was the officials who called the client. We also found it unethical to inform at the end of the call when it has already been recorded. Instead, the officials asked about informed consent in the opening of the call. The disadvantage is of course that this makes the call openings different from an ordinary conversation. All data presented outside the research team have been anonymized, and the data are stored on hard drives protected from intrusion in accordance with the data security routines at the department.

Analysis

Conclusion

We have analyzed three forms of what we describe as a caring interview. First, a helpful form of interviewing is shaped by the interviewer’s reformulation of questions into polar questions that are easy to confirm, taking the interviewees’ displayed or expected difficulties to answer into consideration. Second, the interviewers enact a caring attitude in the framing of questions, showing attentiveness and understanding of clients’ problems and circumstances. Third, in assessments interviewers express professional expertise and knowledge regarding the circumstances pertaining to clients’ disabilities and care needs.

The orientation to helpfulness and care is evident in the design of questions and most clearly in the practices of reformulating the questions within the question turn and in follow-ups. The reformulations demonstrate the role of candidate answers and the related invitations to confirm information in the interviewer’s (the official’s) management of their relationships with the interviewee (client). Epistemic stance is central to how their relationships are managed (cf. Heritage, 2012: 6), and the reformulations of questions provide an example of what Drew (2018) describes as ‘epistemic amendments’ (p. 174) in social interaction. Based on examples from ordinary conversation, Drew concludes that speakers almost always move from K+ positions to K– positions (e.g. from declarative to interrogative constructions) in correcting themselves. In the practices, we have observed as typical for a caring interviewing, the questioners move in the opposite direction, from unknowing to knowing positions. The study adds to observations in previous research regarding the ways in which polar questions are designed to embody a care of the interviewee and client (e.g. Antaki et al., 2002; Pomerantz, 1988). Moreover, the study shows how the normative principle of problem attentiveness, previously observed in care visits, is enacted in a different institutional context: the examination of eligibility for social benefits.

A general argument of the study suggests that epistemic access and epistemic stance in question design and assessments are central to practices of caring interviewing. Relying on findings in the research on epistemic and question design (e.g. Heritage and Raymond, 2012; Raymond, 2006), we have highlighted how the different forms of care involve interviewers’ indications of knowledge based on available documents, prior talk or general assumptions. Knowing about clients’ circumstances is a resource in careful interviewing, enabling the design of questions easy to confirm and attentive to client’s problems. The practices of caring interviewing, at the same time, show how interviewers take their responsibilities of knowing into account when designing questions in interaction (cf. Drew, 2018: 164; Stivers, 2011).

The practices of interviewing observed in this study show a tendency of reducing the information gap between interviewer and interviewee. The information requested is restricted when the interviewer provides candidate answers that (1) consider difficulties in answering and (2) are attentive to client’s circumstances, or (3) when interviewers provide professional assessments in positions of the interaction where a question would be an alternative. The observations reflect more general conclusions in research on information seeking in interaction. Research shows how questions carefully handle the information states between participants and how, in many contexts, the questioner selects a question that asks for relatively small informational increment (Heritage and Clayman, 2010: 141; Pomerantz, 1988; Siemund, 2017). This has been explained in relation to the efficiency in the strategies of obtaining the information needed, a principle of not asking for more than needed, as well as questioner’s avoidance of being ignorant. However, the actual handling of the information states between the participants also shapes the distinctiveness of the professional work within a particular institutional context. The ways in which the officials in our study design questions, indicating knowledge and understanding of the clients’ problems, reflect a professional caring attitude and a professional interviewing markedly different from forms of standardized interviewing typically associated with the asking of questions from unknowing positions.

Helpful and caring interviewing may in some cases reduce the information provided from clients, with implications for the task of making informed and impartial decisions on the eligibility for social benefits. The professional work involves a balancing of a care for the individuals and the institutional requirements of information gathering. This is a challenge that the officials in our study share with professionals interviewing people with social and health problems in various institutional settings. This is not to suggest that caring interviewing generally prevents the fulfillment of information gathering. Sensitivity and care are prerequisites for interviewers to establish relationships that contribute to respondents’ willingness to provide high-quality information. To understand how different practices of interviewing serve the needs of information, we have to analyze the answers provided in the interviews, a task beyond the aim of this particular study. However, orientations to care in interviewing clients should not be understood mainly as strategies in more or less efficient information gathering. In asking questions, officials shape the relationships to clients and balance the enactment of professional roles. And as Zacka (2017) argues, being completely indifferent and uncaring as a professional is considered a pathology in most (if not all) contexts of public administration.

Within our project, we have shared our observations and results in workshops with officials conducting the interviews included in the data, as well as in discussions with managers at different levels. The experiences show how the detailed analyses of interaction contribute knowledge that is largely lacking within the organization. The research informs about how the professional work is carried out in interaction, the conditions involved in the design of questions and the various resources available in order to achieve the institutional tasks. The workshops with officials confirm the benefits of a CA approach that informs about concrete practices, and based on which participants can discuss authentic examples and related challenges that they recognize from experience. The distinction between the three forms of caring provides a basis for organizing the discussions on different practices of interviewing, what is achieved and what is appropriate (or non-appropriate) in specific situations. We are in the process of organizing more workshops, and they will then be evaluated. We do not expect the applied CA to be translated into entirely new practices. Some guidelines might be revised. Most importantly, however, we believe that the workshops contribute in the development of professional identities and expertise (cf. Bruhn et al., 2017).

Finally, the analyses of conversations provide evidence to a broader discussion concerning the policy and ethos of the authority. In recent years, it has been a clear trend within the Swedish Social Insurance Agency to strive for increased standardization and systematic examinations to make assessments and decisions on eligibility for benefits less dependent on variations in circumstances of individuals. This is manifest in internal documents, policy statements, monitoring and control of decisions. Given the ethos of the agency articulated in different documents, officials are at the same time expected to consider people’s life situation and meet people with understanding and empathy. As for many other professionals in the public sector (often referred to as street level bureaucrats), it is absolutely central to their work to translate and adjust general rules in assessments of and interactions with clients in unique situations (Bruhn and Ekström, 2017). CA shows how an ethos of the agency is shaped in situated interactions and becomes ‘real’ for the participants. The practices of caring interviewing and the related design of questions analyzed in this study embody helpful and understanding relationships (cf. Raymond, 2006). It might be possible for the agency to increase the standardization of the examinations through refined guidelines, internal training and so on. However, most importantly, a more straightforward bureaucratic and standardized form of interviewing cannot be implemented without shaping significantly different social relationships to clients.