Typing yourself healthy: Introduction to the special issue on language and health online*

Miriam A. Locher and Franziska Thurnherr (Basel)**

http://dx.doi.org/10.13092/lo.87.4170

1 Introduction: The rationale for this special issue

This special issue is a contribution to the study of linguistic online health practices. Its starting point is a research project entitled Language and Health Online, which was funded by the Swiss National Science Foundation from 2012 to 2016 (SNF 100016-143286). Over the years, the scholars involved (Locher, Rudolf von Rohr, Thurnherr) built up a network of contacts and ultimately a symposium of the same name was held in 2016 to mark the end of the funding period of the project. The present collection emerged from discussions at this event and further soliciting of research. This introduction positions our joint research.

The fact that computer-mediated communication (CMC) is used to disseminate, find and negotiate health-related content is by now a well-established fact (e. g. Office for National Statistics 2016; Willerton 2008). The special issue spans different health-related computer-mediated practices ranging from email interaction to chat and forum interaction as well as the use of blogs, Facebook status updates and comments, interviews with online support group users and websites. This range already impressively demonstrates the wide use of different computer-mediated practices for health-related purposes and warrants our research endeavors.

Various health topics are examined in the individual contributions. They include questions about parenting, birth settings, smoking cessation, baldness, disability, and specific illnesses such as low metabolism and HIV/AIDS. Additionally, three contributions discuss online mental health practices, an area which has received more attention from a linguistic perspective in recent years (see e. g. Danby et al. 2009; Richards/Viganó 2013).

The collection features papers on several different languages: Arabic, Danish, Dutch and different varieties of American and UK English as well as South African English with phrases from Afrikaans and isiXhosa. While English is still dominantly represented in this research, the collection pays tribute to the multilingual internet.

There is not one single methodology that is best suited for studying health online practices. This fact is convincingly demonstrated by the different research designs present in this special issue that feature a range of different methodological approaches. They are testimony to the rich and interdisciplinary research field. Our scholars draw on conversation analysis, discursive psychology, discourse analysis, Foucauldian discourse analysis, the notion of inter-textuality, participation interviews and content analysis. We also find a number of scholars who have combined methods in order to approach their research questions from different angles.

In what follows we first survey the findings and themes that emerge from our reading of the papers. After that we pay special attention to the methods employed before concluding with summarizing remarks and an outlook.

2 Findings and themes in online health discourse

In this section, we will first introduce the structure of this special issue and give a brief summary of the individual contributions. After this we will introduce the recurrent themes to highlight current research foci in the interface of language, computer-mediated communication and health. This interface resulted in a diverse assembly of research, which confronted us with the challenge of how to best structure the special issue. Possible sequences of the contributions could have been along lines such as language/variety (e. g. Arabic, Dutch, or various varieties of English), thematic constructs (e. g. identity, narratives, expertise), type of medium (e. g. forums, Facebook, websites), or methodological approaches (e. g. discourse analysis, conversation analysis, discursive psychology) to name just a few. We have chosen an approach that allows us to foreground one specific aspect that has been emphasized in all three research fields of the interface, namely the participants in the health practices.

The reason for this choice is that, first, from a linguistic perspective, all contributions deal with actual language in use and, more precisely, with how participants’ linguistic choices are meaningful when talking about health. Second, research in computer-mediated communication has gone through several waves (Androutsopoulos 2006). The third wave, in which we are currently in, foregrounds a user-based approach to study computer-mediated communication. Third, aspects such as patient empowerment and centeredness (Holmström/Röing 2010) have gained prominence in the past few years in health (communication) research, putting the interactants, i. e. patients, clients, or health information consumers, at the center. Following this prominence of the interactants in research, we have ordered the contributions according to the participation framework and the level of interactivity that characterize the studied health practices (see Table 1). We start out with several contributions that focus on peer-to-peer forums, characterized as many-to-many and highly interactive interaction, followed by two contributions that compare such peer-to-peer forums to one-to-many interactions of YouTube videos and websites. Moving further away from many-to-many interactions, two contributions look at Facebook status updates and blogs. The practices examined in these two studies are of a one-to-many nature (in the case of Facebook, status updates are researched), which still allow for highly interactive exchanges. All of these contributions (with the exception of professional websites) focus on lay people’s language use. The last three contributions, one examining a specific aspect of the website Islamweb.net, one a chat counseling service, and one email counseling, focus on professional-lay person interaction. On Islamweb.net, the interaction is carried out by one advice-seeker and one advice-giver. However, the exchanges are posted on the public website. The chat and email counseling services are private and one-on-one exchanges.

Table 1: Overview of data and participation framework of the contributions in the special issue, ordered according to decreasing level of interactivity

In Section 2.2, we highlight some of the common themes that run through several of the contributions. While we can only highlight a number of them here, we will outline how these were approached by the authors and how the findings of individual contributions complement each other to reveal essential aspects of language used in online health interactions.

2.1 From forum interaction to email counseling: A wide spectrum of research

In the first contribution to this special issue, Loukia Lindholm outlines the functions of stories used in a peer-to-peer setting. In her article “‘So now I’m panic attack free!’: Response stories in a peer-to-peer online advice forum on pregnancy and parenting”, Lindholm focuses on response rather than problem messages to shed light on the multi-functional nature of stories when peers aim to give advice. Conducting a thematic narrative analysis, Lindholm highlights two recurrent thematic foci: unresolved problem stories and success stories. She further conducted a content analysis to uncover to what ends peers utilize stories: to give implicit advice, to legitimize advice, to show or support dis/agreement with others, and to give a diagnostic opinion. Lindholm calls special attention to the last function, which has not been a focus in previous studies, and states that in such stories “advice-givers use their personal experience as an interpretive lens to assess others’ symptoms, conditions, and circumstances surrounding a health issue” (2017: 37). Lindholm convincingly shows how stories are used for various interpersonal effects, such as constructing an experience-based expert identity among peers, and concludes that “response stories [...] frame health-related problems as shared issues and create shared situated identities” (2017: 38), adding that “advice-givers use first-hand, personal experience as evidence to show that they are informed about a given health-related issue and its consequences and potential solutions, thus justifying their right to advise, offer assessments, and show dis/agreement” (ibd.). Lindholm’s study adds to previous work on the use of narratives in interactions focused on interpersonal aspects.

Elisabeth Muth Andersen also tackles peer-to-peer interaction in a forum in her contribution entitled “Typing yourself accountable: Objectifying subjective experiences in an online health forum”. Andersen analyzes the interaction in a specific Danish forum thread in which participants are faced with the difficulty of explaining their “painful and disturbing bodily experiences” (2017: 44) that have not been diagnosed and therefore have not been successfully treated by medical professionals. In other words, she highlights how participants in an online forum try to objectify subjective experiences in order to make their suffering accountable. Andersen reports on strategies that forum participants use to further objectify subjective experiences and therefore align with each others’ diagnoses. The strategies employed are: (1) to present a medical history of symptom discovery; (2) to present a list of symptoms using medical terms, extreme case formulations and elliptic constructions; (3) to provide a candidate medical cause supported by evidence and sources; and (4) to present objective facts and other sources as the expected solution. Andersen’s conversation-analytic approach uncovers that participants collectively construct the advice-seeker’s perceived medical issue – which the thread initiator proposes is due to low metabolism – as an objective medical problem. Andersen concludes that the interactants in her study have their subjectively experienced medical problem acknowledged and validated by other interactants, which is in stark contrast to their negative experiences in health encounters with professionals. Andersen stresses the importance of being heard and understood when being faced with a difficult medical problem, which in this case is achieved through peer interaction rather than by professionals. She further highlights the possibilities conversation analysis offers when researching health interactions.

The hospital birth setting takes center stage in Antoinette Fage-Butler’s contribution “Hub of medical expertise or medicalised conveyor-belt? Sharing meanings online on the hospital birth setting”. Fage-Butler utilizes a Foucauldian discourse-analytic approach to reveal how mothers discursively construct the hospital birth setting in an online forum in which expecting mothers seek advice from peers. By uncovering ideological arguments for and against the hospital birth setting, Fage-Butler reveals, on the one hand, how specific discourses can be evoked for either both ideological positions, such as the discourse of “risk” (2017: 78), or for only one side, such as the “lack of patient empowerment” (ibd.) in the hospital setting. On the other hand, Fage-Butler also highlights that, in this specific forum, the negative constructions outweigh the positive ones. In other words, her study uncovers the reasons why mothers might have been dissatisfied with their experiences of hospital births. This is especially relevant as Fage-Butler notes that previous studies have over-reported satisfaction with the hospital birth setting. The focus on emic perspectives of the hospital birth setting foregrounds the patients’ perspectives. Her contribution thus not only presents findings that seem to be more balanced with regards to reporting on dis/satisfaction with the hospital birth setting than findings from previous studies, but also allows health professionals to better understand mothers’ preferences for a specific birth setting and what arguments mothers seem to take into account during the decision-making process.

Marie-Thérèse Rudolf von Rohr presents findings from a study about smoking cessation online in her contribution “‘If you start again, don’t worry. You haven’t failed’ Relapse talk and motivation in online smoking cessation”. Her focus lies on how motivation is interactionally constructed in relapse talk among participants in a peer-to-peer forum and on professional websites concerned with smoking cessation. Rudolf von Rohr identifies discourse strategies that were used by relapsing members of the forum interaction to position themselves as authentic advice-seekers who merit being supported further in their “quit journey”. One such strategy is to position oneself as having received previous advice from other forum members in the past. Similarly, advice-givers who aimed to re-motivate the relapsing members used face-enhancing discourse strategies to, on the one hand, normalize relapses as common steps in the quit journey, and, on the other hand, reframe relapsing not as failure but as an important step in succeeding to stop smoking. Rudolf von Rohr notes that professional websites put less emphasis on the topic of relapsing than the forum members and made more use of numerical evidence rather than personal experience to normalize a relapse. Both forum members and website providers made an effort to present relapsing as part of the quit journey and thereby motivated relapsing smokers to continue with their efforts to stop smoking. Rudolf von Rohr convincingly shows how much interpersonal work is invested by the parties she examined and sheds light on how such relational work is linked to motivation and persuasion.

The next contribution, written by Elizabeth Sillence and entitled “Having faith in the online voice: Exploring contemporary issues of trust, language and advice in the context of e-health”, focuses on the construction and recognition of trustworthy accounts of health information online. Sillence works with interviews conducted with forum members, on forum data, and YouTube video blogs including their comments. She highlights the complex nature of credible and trustworthy sources of health information and advice. In her study on the assessment of a credible source in a forum, Sillence foregrounds the importance of homophily in the sense of similarity matching. Participants of an online peer-to-peer support group reported on more trusting accounts that were personally meaningful to them when the posters are close in age, of the same gender, and whose stories resonate with them “in terms of experience, attitude or decision-making” (2017: 121). When looking at the construction of credibility of YouTube vloggers, on the other hand, Sillence notes motivation as the most important aspect to establish trust. The posters aim to construct a genuine and personal voice, especially distancing themselves from gaining financially through their videos. Sillence highlights how the medium, and specifically its interactivity and its duration, influence the ways trust needs to be established. The embeddedness of individual exchanges of information within an online support group allows for trust to be established over time and is enhanced by various characteristics of the community, such as its ethos and participants’ continued interaction. In contrast, the relative free standing of a video on YouTube requires posters to “create an authentic voice from the outset” (ibd.). Sillence’s multi-faceted approach to research trust in online health settings thus advances our understanding of the complex nature of trust. This is especially relevant since trust and expertise are interactional achievements, accomplished, in this case, through the use of multi-modal channels.

Moving away from peer-to-peer interaction in forums or online support groups towards other online platforms, the following two contributions deal with data obtained from Facebook and blogs. Nadine Chariatte examines the use of graphic signs employed by Facebook users in small stories. Her study “HIV/AIDS in South Africa: Graphic signs countering the stigma and silence” focuses on Facebook status updates and their comments that deal with the taboo topic of HIV/AIDS. The status updates were written by residents of the Cape Flats in Cape Town, South Africa and are in English, Afrikaans and/or isiXhosa. Chariatte examines the meaning of the graphic signs as well as their social function within the small stories in which they are presented. By collaborating with some of the Facebook users she researched, Chariatte establishes a detailed description of the graphic signs used in the status updates and the comments. She reports that these signs are used to avoid talking about HIV/AIDS openly by substituting words that describe the physical, mental and social effects of HIV/AIDS, the ways of transmission, and everyday life with HIV/AIDS. By highlighting the social functions, Chariatte uncovers that the graphic signs are used to display solidarity and sympathy, to label and blame, and to distance oneself from other people affected by the illness. Through numerous examples for each function, Chariatte highlights the interpersonal work that the Facebook users carry out with the help of the graphic signs. Chariatte’s work is especially relevant as it opens the door for health professionals to utilize the sufferers’ own language in order to overcome the stigma and silence of HIV/AIDS. Additionally, she adds to work on graphic signs and their sociolinguistic functions in interaction.

In “An imagined community of practice: Online discourse among wheelchair users”, Leslie Cochrane proposes that bloggers with a disability can be seen as a linguistic discourse community although they do not interact locally. By demonstrating through a close discourse analysis how wheelchair users construct their identities within a community, define said community by disability practices and engage in shared sense-making, Cochrane compellingly argues that people with disabilities belong to an “imagined community of practice”. In the three examined blogs written by users of wheelchairs, Cochrane focuses on practices (i. e. repeated social behavior) and positionings to explain how the bloggers construct their identities. Her findings show that “the bloggers position themselves in terms of their disability practices” (2017: 160) but that they also “expand their practices to take up positions beyond those related to having a disability” resulting in “constellations of identities” rather than a one-dimensional identity as a disabled person. Cochrane further illustrates that the bloggers imagine a community of disability as they, for example, refer to the community with “in-group collective terms” (ibd.). They thereby engage in shared-sense making and define the imagined community of practice. Cochrane’s social constructionist approach to disability and identity is a further step away from medical models of disabilities and highlights the possibilities and opportunities the Internet affords to its users in terms of discussing health. Finally, Cochrane advances our understanding of a community of practice by combining it with the notion of an imagined community. She provides empirical evidence how these two notions can be brought together to accurately describe the practice she examines.

“Mental health and religion on Islamweb.net: An intertextual analysis”, written by Najma Al Zidjaly, reports how professionals on a popular Islamic website that provides advice on a range of topics utilize intertextuality to permeate religious discourses into medical advice concerning mental health problems of advice-seekers. Analyzing four consultations written in Arabic that take the form of a problem question and an advice response, Al Zidjaly demonstrates how consultants evoke Islamic authoritative discourses by either overtly quoting from the Quran and hadiths or by covertly referencing religious ritualistic discourses. Religious and cultural discourses that are brought forth in this way are, for example, that mental illness is caused by supernatural forces, that Muslims should submit to God’s will, and that the family knows what is best for an individual, pointing towards the collectivism in Islamic culture. Through uncovering the religious underpinnings in the advice provided to advice-seekers with mental health issues, Al Zidjaly manages to highlight ideological beliefs about mental illness in Islamic culture. Al Zidjaly concludes that mental illness is presented as needing religious intervention rather than or alongside medical/psychological treatment on Islamweb.net. Her work is not only highly salient for practitioners in Muslim countries, but also increasingly for practitioners elsewhere. Counseling services at Western universities with Muslim students, for example, can gain an insight into how mental health is perceived in Islam and can better understand clients’ attitudes and beliefs about mental health and provide more appropriate mental healthcare for Muslim students.

The last two contributions deal with private rather than public interactions between one advice-seeker and one advice-giver. Margot Jager and Wyke Stommel look at how counselors deal with trouble in chat counseling sessions in their contribution “The risk of metacommunication to manage interactional trouble in online chat counseling”. Through conversation analysis, the authors outline the interactional trouble counselors encounter in 29 chat counseling sessions from two different services in the Netherlands. Jager/Stommel identified three metacommunicative strategies that counselors use when they run into interactional trouble: self-criticizing in terms of not having been able to provide the help desired, accusing the client of not taking up the advice provided, and explaining the responsibilities or limitations of the institutional service. All three of these metacommunicative strategies have different implications for the interpersonal aspect of the exchanges and influence the nature of the closing of the chat sessions in different ways. Jager/Stommel explicitly point out the risks of the metacommunicative strategies, such as the face-threatening potential of accusing the client of not taking up advice. They argue that the rather brief duration of chat counseling and its limited amount of time to establish a positive therapeutic alliance might be the reason why such me-tacommunicative strategies are risky in chat counseling. They thus advocate to abstain from using metacommunication in chat counseling. Jager/Stommel’s contribution highlights the merits of conversation analysis of empirical data to uncover interactional patterns in online health practices.

The last contribution in this special issue deals with the question of how interactants in email counseling initiate the process of ending the counseling. In “‘As it’s our last exchange next time...’ The closure initiation in email counseling”, Franziska Thurnherr utilizes an interpersonal pragmatic approach and takes relational work and positioning into account when researching how interactants in email counseling negotiate the therapeutic alliance and construct their own as well as the other interactants identities at a specific time within the counseling process. Thurnherr discusses three types of metacomments used to initiate the closing: to announce a last session, to inquire about a last session, and to inquire to take stock. Thurnherr shows that the counselor does not randomly select one of the metacommunicative types, but that collaborative interpersonal work from both the counselor as well as the client guides the counselor’s choice of closure initiation. She provides insight into how the counselor carries out specific relational work within these metacomments to position the client in specific ways. For example, the counselor praises a client’s progress and thereby provides the client with an opportunity to self-praise. Both praise as well as self-praise aim to enhance the client’s face and to position her/him as an active self-helper rather than an advice-seeker. Thurnherr further provides insight into the implications the choice of metacomment has on the overall closing of the counseling exchanges. Her study complements previous research on closings (in health encounters) by providing an interpersonal pragmatics perspective. She also provides further empirical evidence how relational work is used to construct interactants’ identities in health interactions.

2.2 Recurrent themes

The previous section has shown how diverse the papers are with regards to discussed health concerns, utilized medium, or thematic focus. This diversity reflects the richness that the interface of language and health in computer-mediated settings provides. Nevertheless, the emphasis on language in e-health also results in several themes emerging as central throughout the special issue. We want to draw the reader’s attention to some of these themes by discussing how individual contributions shed light on them from different perspectives. While we cannot give an overview of all the recurrent themes of this special issue, the ones we selected will provide the reader with a web of connections that highlights the importance of the research niche, but also the possibilities it provides for further research. We will first discuss some aspects of computer-mediated interaction such as the participation framework and medium affordances. In a second step, we will closely look at the health aspect of the papers, such as discovering an emic perspective of health issues, uncovering health ideologies, and the theme of patient empowerment. Third, we want to review some of the linguistic foci that emerge within the special issue, such as identity construction and narratives. Concluding this section, we will broaden our discussion to elaborate how the special issue is not only relevant for researchers concerned with language and the Internet, but also for health professionals and practitioners.

Findings on computer-mediated interaction

Several factors of the online aspect of the research presented in this special issue can be explored. We want to briefly discuss findings related to the participation structure, the a/synchronous nature of interactions, the anonymity that some types of online interactions allow, and the embeddedness of practices. Herring (2007) cites the participation structure of computer-mediated communication as a social factor. We have highlighted above how diverse the individual practices are with regards to the participation structure and their interactive possibilities, ranging from peer-to-peer interaction in forums that are public, often anonymous and structured as many-to-many interactions (e. g. Lindholm; Rudolf von Rohr), to professional-lay person interaction on an advice-giving website (public; Al Zidjaly) or from a counseling service that have a one-to-one participation structure (private; Jager/Stommel; Thurnherr). Participants in these various practices take advantage of the participation structure and other participant and medium characteristics for very specific purposes. Many of the contributions dealing with peer-to-peer forum interaction report on the solidarity and empathy that peers display towards each other. They further note how peers tailor their posts towards an audience that has members at different stages of an illness, of recovery, or might not suffer from the same illness/disability, clearly showing that peers engage in recipient design. The interactivity of forums also influences participants’ linguistic choices. Interactivity allows interaction to occur over a longer period of time. Forum members can come back, for example, after a doctor’s visit and update other members about progress. Similarly, clients in multiple-sessions counseling can report on applied advice and progress. Several of the papers show how this continued interactivity supports a sense of community building or identity shift of interactants. In contrast, as Jager/Stommel argue, more ephemeral interaction in chat counseling cannot build up on past histories. They therefore show that meta-pragmatic comments are risky in the investigated context, while comparable meta-pragmatic comments are successful in the email counseling discussed by Thurnherr. The participation structure and interactivity clearly influence the interaction taking place in the practices, and the participants take advantage of these aspects in very specific ways that support them in their journey to better health.

The Internet allows for some interactions to take place in anonymous form, another factor in Herring’s (2007) classification scheme, which has implications both on the technical and the social side of interaction. Previous studies have highlighted that anonymity might be beneficial in interactions concerning health, because it can foster self-disclosure due to the disinhibition effect (see e. g. Barak et al. 2009). Fage-Butler highlights this aspect by shedding light on mothers’ perceptions and experiences of hospital births. Fage-Butler’s report on an overwhelming number of negative statements compared to positive ones emphasizes mothers’ dissatisfaction with the hospital birth setting. This finding is in stark contrast to previous studies in which mothers were, for example, interviewed, i. e. where the disinhibition effect was not present but social desirability bias was more likely to occur. The anonymous nature of forum interaction allows for a more accurate description of mothers’ perspectives to come to the fore. Chariatte, on the other hand, provides us with a study in which a taboo topic (HIV/AIDS) is the focus in non-anonymous interaction on Facebook. Rather than the users being anonymous, the content of the messages is kept covert to a certain degree. The users in the study resort to graphic signs to talk about HIV/AIDS to avoid being directly associated with a stigmatized illness that would result in their social marginalization/ostracism. Chariatte demonstrates how users make use of technical affordances to stay covert with respect to the content of the interaction as anonymity is not easily achieved on Facebook. Both contributions highlight how users take advantage of certain technical characteristics of a specific medium to talk about health issues that might not be discussed in an open format, because revealing their identity or their illness would result in negative consequences for them.

Another factor in Herring’s (2007) classification system is asynchronicity. Various online mediums, such as forums, emails, or websites are asynchronous, i. e. users must not be logged in at the same time to receive messages. Naturally, the asynchronous nature of a medium has an influence on the interaction that ensues between participants. Thurnherr, analyzing email counseling, elaborates how the closing of the counseling process is initiated in an asynchronous medium. While she outlines that the asynchronous nature of the interaction poses certain challenges to this endeavor, she demonstrates how the clients and the counselor work collaboratively to achieve a satisfactory closing for both sides. In the peer-to-peer forums analyzed in several papers in this special issue (see e. g. Andersen; Fage-Butler), the asynchronous nature of the forums permits advice-seekers to pose their question and return later to a range of advice provided from various parties, allowing advice-seekers to choose the advice most appropriate for their personal situation. Cochrane further elaborates how an imagined community of practice can be established even in asynchronous blog interactions as bloggers engage in shared sense-making through, for example, displaying disability practices.

There are also interactional challenges to be met in synchronous interactions. Examining chat sessions, Jager/Stommel report that a client can simply leave the session in case of dissatisfaction with the provided advice. The synchronous nature of chat in this case makes it difficult for interactants to realize what the other interactant is up to. For example, Jager/Stommel elaborate how counselors have difficulties interpreting a lack of a response. A range of reasons need to be considered: the chat is lagging, the client does not know what to write, the client does not agree with the advice provided but does not want to overtly state it, or the client has simply left the chat for whatever reason. Both asynchronous as well as synchronous interaction provides interactants with certain affordances, but also poses certain problems for them. These are, however, often dealt with collaboratively and creatively.

A further recurrent theme is the embeddedness of the practices researched. Sillence especially highlights the difference of forum members and YouTube vloggers. The forum members continuously interact with each other and establish trust and credibility through their continued presence. In contrast, YouTube vloggers often have just one shot of presenting themselves as credible advice-givers due to the lack of embeddedness of single standing YouTube videos. Rudolf von Rohr similarly highlights the fact that relapsing members of smoking cessation forums position themselves as credible advice-seekers and as deserving of further support by showing that they have had continuous interaction with members on the forum. The affordance of interactions being embedded in a broader context allows for several interpersonal aspects to come into being, such as creating an expert identity that appears credible and trustworthy, a point we will take up in our discussion of the linguistic foci of the contributions to this special issue below.

Findings on health discourse

We want to link some of the findings concerning health with each other and draw the reader’s attention to the following recurrent themes: discovering an emic perspective of health issues, uncovering health ideologies, and the theme of patient empowerment. One of the more prominent recurring themes concerning health is the fact that researchers can gain access to an emic perspective of health issues when researching online data. Two contributions that foreground the patients’ voice are Chariatte’s study on Facebook users who are affected by HIV/AIDS and Fage-Butler’s study on the hospital birth setting. Chariatte’s work not only uncovers how people affected by HIV/AIDS circumvent the stigma of the illness through the use of graphic signs, but she also provides a description of the graphic signs that were used. Such a descriptive classification of graphic signs could open up opportunities to tailor health interventions more accurately towards a specific target audience that might otherwise not be reached. Fage-Butler, additionally, highlights how mothers who are or have been faced with the decision of choosing a specific birth setting talk about their expectations and experiences. As we pointed out above, Fage-Butler convincingly argues that the online peer-to-peer setting fosters a more balanced view of the hospital birth setting. Fage-Butler’s study revealed, among other things, how mothers critically talk about the risk of a hospital birth. Both studies illustrate how their findings uncover patients’ linguistic choices within a specific health context.

Further, three contributions pay special attention to health ideologies with regards to three different topics: mental health, birth settings, and disability. All three authors highlight the discourses that are evoked in specific practices and how these discourses can influence users’ attitudes and beliefs about certain health issues and reflect what treatment they desire, receive or struggle with. Al Zidjaly uncovers how mental illness is perceived in Arabic Islamic culture. We have highlighted above how important it is to understand mental health from various cultural backgrounds to be able to provide interventions that can take such ideological underpinnings with regards to mental health into account. Al Zidjaly’s intertextual analysis revealed that mental health is viewed as supernatural and is therefore also treated with religious intervention rather than only with medical treatment. Fage-Butler’s Foucauldian discourse analysis of a peer-to-peer forum concerned with the hospital birth setting showed which discourses are used to depict the hospital birth setting either in a positive or negative light. And Cochrane demonstrates how disability bloggers actively combat the inspiration discourse of disabled persons and instead evoke various other discourses through their identity work to construct “constellations of identities” (De Fina et al. 2006: 2; cited in Cochrane 2017: 163). While these three papers specifically deal with ideologies and discourses that evoke certain ideological underpinnings with regards to health issues, other contributors implicitly highlight ideologies as well, one of them being patient empowerment, which we will discuss next.

Patient empowerment, i. e. the active participation in health decisions by patients and clients, has been a prominent feature in health research and is taken up by our authors as well (for an overview on patient empowerment see Holmström/Röing 2010 or Segal 2009). The research presented in this special issue provides empirical evidence that patient empowerment does not need to be a hierarchical process between health professionals and patients/clients. Rather, many of the authors describe how peers empower each other by providing each other with support, information, advice, and a community in which patients/clients can foster their knowledge, their confidence with regards to health decisions, and a sense of belonging. Fage-Butler states how present the term and the concept of patient empowerment is not just in health research, but also among lay people as she uncovers patient empowerment as being one of the discourses that mothers evoke when discussing the positive and negative aspects of the hospital birth setting. Andersen mentions not only how much medical knowledge peers have gained in discussions in forum interaction about low metabolism, but also foregrounds the fact that it is the peers who acknowledge and validate the posters’ persistent medical problem. All in all, the contributors compellingly show that patient empowerment is not only desired by many of the users, but is also fostered and performed in the online health practices they research.

Linguistic findings derived from the study of the e-health practices

We want to draw some conclusions with regards to linguistic foci in the contributions. While the authors have chosen many different topics, some are touched upon in several papers from different perspectives. We want to discuss three specific aspects here: the construction of identities, the construction of shared experiences, and the use of narratives. Constructing various types of identities is topicalized in many of the papers in this special issue and highlights the importance of the interpersonal aspect of health discourse online. Several papers make use of the notion of “positioning”, derived from work by Davies/Harré (1990) and Bucholtz/Hall (2005). These authors propose that identity is “the social positioning of self and other” (Bucholtz/Hall 2005: 586). In this constructionist approach, identity is not a fixed category, but is rather established in interaction. Many of our authors highlight this by researching various types of identities users construct. Cochrane, for example, shows how bloggers who live with a disability construct not only a disability identity, but a plethora of other identities through their discursive activities in the blogs. The research presented in the papers thus resonates with the interpretation of identity as being emergent in interaction, socially constructed and in flux.

When exploring specific activities within health discourses, such as advice-seeking and advice-giving, corresponding identities are established. Rudolf von Rohr, for example, discusses how relapsing members of an online forum on smoking cessation need to re-establish themselves as credible advice-seekers who, despite their relapse, are deserving of further help. Advice-seekers carry out complex interpersonal work to construct this identity. Responders then proceed to reposition relapsing members not as having failed, but as being on a successful quit journey. Relapsing members’ identities emerge in the interaction highlighting the discursive nature of identities.

Lindholm looks at identity construction of advice-givers on a peer-to-peer forum and discusses how advice-givers position themselves as informed peers who have gained expertise through experience. Utilizing personal experience, these forum members manage to create a credible advice-giver identity through discursive work. In other words, their expert identity is emergent in the interaction and socially constructed.

Jager/Stommel point towards the possibility of having identities discursively contested. In their analysis of chat counseling, some advice-seekers question the validity of the advice they have received and thereby construct the counselors as having failed to fulfill their role as advice-givers. Jager/Stommel demonstrate how identities are socially rather than individually constructed.

Further, Thurnherr explores how identities are in flux by showing clients’ shift from initial advice-seekers towards active self-helpers. She reports on discursive strategies used by both the clients and the counselor to indicate this move towards active self-helpers and thereby allowing counselors to initiate the closing of the counseling process.

What is common to all the identities presented above is that interactants try to create them as credible and authentic, be they advice-seeking, advice-giving, or other identities. This foregrounds how important credibility and authenticity is in health interaction. Sillence’s insights from interviewing online support group members provide us with an additional perspective. By pointing towards the importance of credibility and trust in establishing and assessing a trustworthy voice to provide health information online, Sillence indicates the complex nature of trust. Rather than highlighting specific strategies used to create trust, Sillence uncovers underlying notions that influence the perception and construction of trust. The results of the studies from this special issue thus provide further empirical evidence of discursive strategies used to create trust, credibility or expertise, and also highlight certain aspects of the notion of trust. It goes without saying that, in interactions with a sensitive topic such as health, our understanding of trust and other interpersonal aspects is crucial to comprehend individual practices. This field clearly deserves further research.

Another theme that we want to highlight is the construction of shared experiences in online health interaction. Andersen researches patients who experienced doctor-patient encounters negatively. She shows how exchanging shared experiences online can be helpful for such patients. It is the members of the forum who acknowledge and validate the posters’ struggle with their persistent medical problems. The graphic signs in Chariatte’s study also demonstrate how solidarity can be created. Two of the contributions, on the other hand, highlight the opposite side of this coin when demonstrating how language is used to distance oneself from others or to “other” interactants from oneself. Chariatte shows that the Facebook users also use graphic signs to other HIV/AIDS patients. And Cochrane elaborates on how bloggers with disabilities used in-group terms to distance themselves from people without disabilities. This was especially important in order to construct an imagined community of practice that is defined by the bloggers themselves rather than by non-disabled others who label the bloggers as disabled people. Health interactions such as the ones presented here provide rich research settings to analyze various practices that are used to either share experiences, but also to highlight differences.

One such practice of sharing experiences and creating common ground is the use of narratives. Narratives have received attention in the health context in the past, as, for example, highlighted by Gygax/Locher’s (2015) edited collection on Narrative Matters in Medical Contexts across Disciplines. Similarly, narratives used in an online context have also been researched. Dayter/Mühleisen (2016) edited a special issue on personal narratives online in Open Linguistics and in particular the contribution by Thurnherr/Rudolf von Rohr/Locher (2016), which deals with narratives in health contexts. Lindholm, who focuses specifically on the use of stories in a forum, shows how peers create expertise through telling stories of their own health difficulties. By aligning their stories with the advice-seekers’ experiences, peers can share experiential knowledge and provide the advice-seekers with indirect advice. By doing so, peers not only take face-concerns of their interactants into account, but also create shared identities and show agreement. Andersen and Rudolf von Rohr also highlight the interpersonal aspect of (second) stories in their contributions in different health contexts. All three authors add thereby to the analysis of forms, functions, and interpersonal aspects of stories that are used in an online health context.

Transfer to health professionals and practitioners

After having presented some of the recurrent themes that emerge in the special issue with regards to the interface of language, health, and computer-mediated communication, we would like to point out an aspect that some of our contributors have made explicit in their conclusions: the applicability of results in health practices. As much as we are all interested in how language is used in a specific field, namely online health practices, it goes without saying that we do not just research these practices for our own benefit. Rather, we hope that our focus on online health might also benefit the participants of the practices we have studied. Throughout the previous section, we have pointed towards the practice implications of some papers already. Here, we want to highlight this last point by referencing Jager/Stommel’s work on chat counseling. Jager/Stommel’s research illustrates the connection between research and practice especially well. They collaborated with two Dutch counseling services and specifically researched the use of metacommunicative strategies in interactional trouble – a practice that is advocated in a handbook on online counseling. Through their conversation analysis, Jager/Stommel reveal that this specific practice seems to be unsuitable for chat counseling as it can break down communication between a client and a counselor rather than repair it. Jager/Stommel can thereby provide counselors with information as to why such metacommunicative strategies might not work in the interactions the counselors have. Jager/Stommel provide a prime example how linguistic findings can be of use in health encounters. While the research presented here cannot solve medical problems themselves, of course, it can inform health professionals about specific communicative aspects and might help improve communication between health professionals and lay people.

3 Methodologies employed in health-related CMC studies

3.1 Spectrum of methods used in this special issue

The studies reviewed in this introduction display a nuanced set of results, but it is also worth pointing out that these results are derived from a number of different methodologies. The themes identified in Section 2.2 are thus worked out and worked on through different analytical steps. We strongly believe that this heterogeneity of approaches is an asset of the research field and we want to repeat that we do not wish to propagate any of the methodologies employed as more valid than another.

From a step-by-step analysis as conducted in conversation analysis (Andersen; Jager/Stommel), the study of acts of positioning as proposed in discursive psychology (Sillence; Rudolf von Rohr; Thurnherr), discourse analysis and Foucauldian discourse analysis (Al Zidjaly; Chariatte; Cochrane; Fage-Butler; Lindholm; Rudolf von Rohr; Thurnherr), the use of the notion of intertextuality (Al Zidjaly), the study of participation interviews (Sillence) and content/thematic analysis (Chariatte; Fage-Butler; Lindholm; Rudolf von Rohr; Thurnherr), this special issue demonstrates the variation in approaches in this field very well. The list also shows that many of the scholars combine their methods in order to approach their research questions from different angles.

Since the methodology employed in the project Language and Health Online is itself a combination of different methods, we will briefly introduce this in the next section.

3.2       Methodology employed in the project Language and Health Online

Over the years, a methodology has been employed for the project Language and Health Online that combines a number of analytical steps in order to study health discourse (see Locher 2006; Rudolf von Rohr 2017a; Thurnherr in preparation). This methodology is not novel in the sense that the steps are unique or freshly invented, but we believe that the combinations allowed us to approach our individual and joint research questions from different angles in a meaningful way. As Jucker (2009) states, the choice of an appropriate methodology depends on the suitability of the analytical steps to the data and the research question. In the case of our project, our overarching aims are to explore the interface of health discourse, computer-mediated practice and relational work. We are interested in:

While we cannot go into detail here with respect to sharing results on the three research areas just listed, we hope that our outline of methodological steps helps give an idea of how to approach such research questions. The sub-projects on email counseling and smoking cessation e-health practices that are part of the Language and Health Online project explore further nuanced questions. The chapters in this special issue by Thurnherr (2017) and Rudolf von Rohr (2017b) provide a glimpse of these projects. Further insights can be gained from Rudolf von Rohr (2015, 2017a), Thurnherr/Rudolf von Rohr/Locher (2016) and Rudolf von Rohr/Thurnherr/Locher (in press), and Thurnherr (in preparation).

The methodology employed for the entire project was first developed in Locher (2006), which is a study of a professional American online advice column, Lucy Answers. The results and the context of this study function as a point of comparison for the results of the other two e-health practices (email counseling and smoking cessation). The methodology is a combination of qualitative analytical steps that are quantified at opportune moments in order to substantiate the patterns found with insights on numerical distribution. The employed methodology consists of four steps that are hierarchical in the sense that they build on each other with respect to nuance and granularity. In what follows we will briefly outline each step to explain how this approach works.

Even before moving to the study of linguistic expressions that commonly represent the center of attention for linguists, we propose to establish what the texts are about in step (1) (Saldaña 2013: 88). The reason for this content/thematic analysis is that it may be of interest to establish what topics are being talked about since the choice of topic may serve as an explanation for differences found through later analytical steps (such as the composition and linguistic rendition of texts). While this may sound trivial, we still believe that it is worth spending time on looking more closely at what issues or themes (content) the texts raise.

In the case of the American online advice column Lucy Answers (Locher 2006), this meant that the archive structure of the website was used since the archive was organized according to topic. The counselors classified the advisory exchanges into seven different topics from relationship issues to concerns about fitness and nutrition. In other words, the content structure was system-provided. These topics were then taken into account in the analysis and bundled into two groups according to the emotional/relational or bio-medical nature of the advisory exchanges. Locher (2006) was able to show that the composition of the texts (step (2), see below) and the distribution of hedging strategies (step (3), see below) differed in the two groups established in step (1). Including a content analysis thus allowed a more nuanced picture of the practice.

In the case of the email-counseling and smoking cessation sites, this content analysis was conducted by the researchers themselves in a time-consuming process of coder agreement to establish validity (Guest et al. 2012; MacQueen et al. 2008). Thurnherr found that the five email counseling clients raised concerns about depression, anxiety, stress management, self-esteem, relationship troubles, loneliness, abuse, panic attacks, sexuality and health troubles. Rudolf von Rohr established six foci in her content analysis of UK online smoking cessation sources: facing quitting; inform on quitting; point out bio-medical reasons to quit smoking; point out lifestyle reasons to quit smoking; quitting and nicotine substitutes; support. This thematic analysis can be a result in itself in that it gives an overview of the heterogeneity or homogeneity of a practice with respect to topic choice. Especially from an applied perspective, health practitioners often benefit from knowing what range of topics a collection of texts covers. For example, it is of interest to learn what topics lay people raise or what contradictory points of view emerge (e. g. Fage-Butler 2017; Locher 2017). The results can also serve as a backdrop for further analytical steps, as will be shown again below.

In step (2) we turn to an analysis of the composition of texts. Here we employ the concept of “discursive move”, as proposed by Miller/Gergen (1998: 192), which is defined as “the kind of contribution that the entry made to the ongoing interchange”. The concept of discursive moves differs from a speech act analysis in that a discursive move can go beyond the sentence level and comprise entire textual passages. The texts selected as being the object of further analysis (e. g. a selection according to topic from step (1)) are analyzed exhaustively, i. e. in their entirety. Every text passage is labelled and accounted for. This process of analysis is time-consuming, since the codes for the discursive moves are developed bottom-up and need to be refined in a process of several rounds of establishing coder-agreement (MacQueen et al. 2008). This analysis is still a content analysis and fundamentally qualitative. Quantification begins when this qualitative analysis is repeated on many texts (either all texts in a corpus or a selection of texts). Quantification allows us to establish the set of discursive moves used in a corpus and to know the frequency of each discursive move. In addition, we can explore how they follow each other and thus arrive at insights about patterns of distribution. As such a quantified discursive move analysis has proven to be a useful tool for understanding textual composition. The results can then be used for comparative analysis that wants to understand what discursive moves typically are part of the composition of a particular text type in contrast to other text types. For example, in our project we compared the set of discursive moves, their frequency, and their patterns among the three e-health practices to reveal similarities but also differences between the practices. We want to show a brief selection of results to illustrate such a comparative analysis in the following paragraphs.

Locher’s (2006) study on Lucy Answers showed that a small number of such discursive moves sufficed to comprehensively account for the advisory practice: advice and referral, assessment, disclaimer, explanation, farewell, general information, text-structuring comments, and own experience. Subsequent studies by Morrow (2012) and Placencia (2012) have used the same approach and (also in a bottom-up process) have come up with similar discursive moves for advisory practices. Rudolf von Rohr (2017a) and Thurnherr (in preparation) were able to show how their sets of discursive moves differ since their e-health practices are slightly different in purpose. In the smoking cessation forums, for example, Rudolf von Rohr found that the supportive nature of the forum triggers discursive moves such as “welcoming” new members to the forum or “well-wishing”. Thurnherr found that the goal of email counseling, i. e. to support clients to improve their well-being over a specific period of time, is reflected in the discursive move “request for information”, in which the counselor asks the client for more information on a specific topic or feedback on suggested coping techniques, or the use of “assessments” by clients to evaluate their own progress. “Request for information” highlights the interactive nature of the email counseling practice in particular, which was absent in Lucy Answers, where exchanges were restricted to one problem letter and one response letter. While the discursive move “assessment” was used by the advice-givers in Lucy Answers as well, this move is also used by the clients, i. e. the advice-seekers, in email counseling.

Establishing the set of discursive moves of which a text type is typically composed is one finding; how the discursive moves are combined, i. e. which discursive moves typically start or end a text and follow each other, is a further fruitful path of enquiry. In the case of Lucy Answers, which was a study that particularly focused on advisory practices, the analysis of the sequence of discursive moves revealed that advisory moves rarely start an advisory response. Instead, general information and assessment often couches the ensuing advice and thus makes it more mitigated as well as relevant for readers (this is in analogy to a stepwise entry to advice as established for face-to-face encounters in Heritage/Sefi 1992). Thurnherr (in preparation) found a similar distribution in the advisory moves in her email counseling corpus, where it is more likely for advice to be preceded by assessments of the counselor than to appear directly on its own. Rudolf von Rohr (2017a) also observed a tendency of assessments preceding advice in the forum practices, with the latter scarcely being in initial position. Moreover, other discursive moves with a clear interpersonal function (e. g. welcoming, apology) were also typical initial moves – thus interactants attended to each other’s face needs before giving advice.

Step (3) turns attention to any linguistic form and function that deserves the researcher’s attention in pursuit of answering a research question. The selection of such phenomena can take results from steps (1) and (2) into account. For example, in the case of Lucy Answers, Locher was particularly interested in how advice is linguistically rendered and therefore zoomed in on the discursive moves that were previously identified to contain advice. After a detailed analysis of syntactic and lexical choices, the topics established in step (1) could be drawn on to find out whether the linguistic forms were content-sensitive, i. e. whether specific linguistic patterns were more prone to appear in specific topics. Issues studied in the context of the Language and Health Online project include different types of warranting strategies, syntactical and lexical hedges, boosters or the form and function of narratives. All of these findings are then explored in light of the study of (expert) identity construction and relational work. We ask, for example, which relational work strategies occur in which discursive moves and thus combine steps (2) and (3). More results on how expert identities are created can be found in the two chapters in this special issue by Rudolf von Rohr (2017b) and Thurnherr (2017) as well as our joint work (Rudolf von Rohr/Thurnherr/Locher in press).

While tagging in the discursive move analysis in step (2) was exhaustive (i. e. all text is accounted for by tags), analysis in step (3) is not necessarily so. For example, advisory moves can be exhaustively tagged with respect to the syntactic realization of the advisory sentences (declarative, interrogative, imperative), but the more nuanced relational work strategies that express stance cannot always be exhaustively quantified because of the pragmatic variation in which they occur. In general, it is necessary to include exemplary close readings to arrive at the nuances of relational work. The results of these close readings can then complement the picture derived from quantification in any of the steps mentioned so far.

Finally, step (4) alerts us to the fact that – to widen the scope – any further methodological techniques that help answering a particular research question should freely be combined with the previous steps. For example, in the case of Thurnherr’s study of email counseling, she conducted interviews with the counselor and organized workshops with counseling teams. This allowed her to both validate interpretations and to give feedback to counselors. As in our projects we are dealing with textual digitalized data, we can also draw on established corpus linguistic techniques such as concordances, key word analyses, word clouds, cluster analyses, etc. in order to shed more light on the e-health practices in question. The list of possibilities is open ended.

With respect to technical tools that helped us in employing the methodological steps just outlined, we drew on a number of different programs. For the discursive moves analysis we employed an XML tagger for Lucy Answers and NVivo for the Thurnherr and Rudolf von Rohr sub-projects. For cluster analyses, keyword analyses, the creation of word lists, word clouds and concordances, we used a combination of WordSmith, AntConc and SPSS. Since our analytical units are often functional units and established in a process of qualitative interpretation, we want to stress once more the usefulness of establishing validity by means of coder-agreement. This approach, however, should only be used when quantification of the qualitative analysis is desired and meaningful in answering a research question. In our sub-projects, we found that quantification not only gave our hunches a more empirical base but also yielded interesting results in itself.

4 Concluding remarks and outlook

The purpose of this special issue was to bring together scholars who work on language, health and computer-mediated practices in order to share insights on this unique interface. Our discussion in this introduction has shown that this interface offers many possibilities for avenues of research that are topical and relevant. We have especially highlighted the joint themes that emerged in the ten papers, such as the impact of technical and social affordances of computer-mediated interaction; discovering an emic perspective of health issues, uncovering health ideologies and patient empowerment; the construction of identities, the construction of shared experiences, and the use of narratives.

We have also cast some light on the different methodologies employed. With respect to the section in which we introduce the methodological steps employed in the project Language and Health Online, we reiterate that these steps are intended as an offer for those scholars who perceive one or a combination of the steps may yield meaningful results for their own research endeavors. As the variety of methods employed in the papers of this special issue demonstrates, there is no universally valid approach to the study of e-health practices. Instead the field benefits from the variety of questions asked and methodological approaches offered.

The interest expressed by an interdisciplinary audience during the symposium on Language and Health Online in 2016 convinced us that the research interface outlined in this introduction to the special issue warrants further research. Both scholars who work on basic research as well as those with an applied aim in mind will benefit from continuing the dialogue. We hope that this collection will serve as a meaningful contribution to this research field.

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Bionotes

Miriam A. Locher is Professor of the Linguistics of English in the English Department of the University of Basel, Switzerland. She works on interpersonal pragmatics, linguistic politeness, relational work, the exercise of power, disagreements, advice-giving (in health contexts) and computer-mediated communication. Her publications comprise monographs, edited collections and special issues as well as numerous articles in journals and collections. Recent publications are the edited handbook of the Pragmatics of Fiction (with Andreas Jucker, Mouton de Gruyter) and a monograph on medical reflective writing (Multilingual Matters).

Franziska Thurnherr is a PhD candidate in English Linguistics at the University of Basel. Her research focuses on interpersonal pragmatics in online (mental) health discourse. She researches health interaction especially with regards to relational work and identity construction and how these concepts influence the therapeutic alliance or doctor-patient relationships. She is further interested in an applied approach to health communication research. She has been a research member of the SNF-project Language and Health Online (143286).

Notes

* We thank the Swiss National Science Foundation, which funded our project Language and Health Online from 2012 to 2016 (SNF 100016-143286), and which supported the symposium that was the starting point for this special issue. We thank the contributors and external reviewers for lively and constructive discussions. Special thanks goes to Andrea Wüst, who was instrumental in helping with editing this collection. Finally, we thank Marie-Thérèse Rudolf von Rohr, our Language and Health Online team member, who, while not being able to take part in the editing of the collection due to maternity leave, is very much part of this outcome. back

** At the request of the University of Basel, the affiliation is explicitly mentioned. back