‘What should a woman do and imagine to have bulimia?’: Co-constructing patient expertise in psychotherapy with bulimia patients


  • Joanna Pawelczyk Adam Mickiewicz University
  • Małgorzata Talarczyk Klinika Psychiatrii Dzieci i Młodzieży UMP




psychotherapy, bulimia, co-construction, discourse analysis, conversation analysis


One of the goals of psychotherapy with bulimia patients is identification of the functions of the eating disorder in their lives. Thus, as in any psychotherapeutic approach, the therapist should facilitate the patient’s disclosure of his or her experience of living with bulimia. Talking about one’s dysphoric experiences and, particularly in the case of bulimia, symptoms and experiences that commonly deprive people with bulimia of dignity, constitutes an emotional challenge for the patient and an equally challenging interactional task for the therapist. Using the example of one therapy session with a female bulimia patient, we examine how the therapist and the patient interactionally engage in co-constructing the patient’s expertise – involving epistemics of experience as well as epistemics of expertise – concerning the illness in the interactional here-and-now. Applying tools and insights from discourse and conversation analysis, we examine the sequences in which the patient shifts the topical focus from a general observation concerning bulimia to her personal experience, to be further pursued interactionally by the therapist. We also discuss how the therapist downgrades her epistemic position and (concurrently) foregrounds and bolsters the patient’s voice as expert to accomplish the session’s therapeutic goals.

Author Biographies

  • Joanna Pawelczyk, Adam Mickiewicz University
    assistant professor Department of Sociolinguistics and Linguistic Pragmatics
  • Małgorzata Talarczyk, Klinika Psychiatrii Dzieci i Młodzieży UMP
    Małgorzata Talarczyk holds a PhD in clinical psychology. Her doctoral dissertation was devoted to eating disorders. She has earned certification to conduct systemic therapy and has published extensively on eating disorders.


Antaki, C. (2008) Formulations in psychotherapy. In A. Peräkylä, C. Antaki, S. Vehvilainen and I. Leudar (eds) Conversation Analysis and Psychotherapy, 26–42. Cambridge: Cambridge University Press.

Antaki, C. (2011) (ed.) Applied Conversation Analysis: Intervention and Change in Institutional Talk. Basingstoke, UK: Palgrave.

Antaki, C., Barnes, R. and Leudar, I. (2005) Diagnostic formulations in psychotherapy. Discourse Studies 7–6: 1–22. https://doi.org/10.1177/1461445605055420

Atkinson, J. M. and Drew, P. (1979) Order in Court: The Organization of Verbal Interaction in Judicial Settings. London: Macmillan. https://doi.org/10.1007/978-1-349-04057-5

Bartesaghi, M. (2009) How the therapist does author­ity: Six strategies for substituting client accounts in the session. Communication & Medicine 6 (1): 15–25. https://doi.org/10.1558/cam.v6i1.15

Beckwith, A. and Critchton, J. (2010) The negotiation of the problem statement in cognitive behavioural therapy. Communication & Medicine 7 (1): 23–32. https://doi.org/10.1558/cam.v7i1.23

Beckwith A. and Crichton, J. (2014) Homework setting in cognitive behavioral therapy: A study of discursive strategies. Communication & Medicine 11 (2): 91–102. https://doi.org/10.1558/cam.v11i2.16169

Bercelli, F., Rossano, F. and Viaro, M. (2008) Clients’ responses to therapists’ re-interpretations. In A. Peräkyla?, C. Antaki and S. Vehviläinen (eds) Conversation Analysis and Psychotherapy, 43–62. Cambridge: Cambridge University Press.

Bercelli, F., Rosano, F. and Viaro, M. (2013) Supra-session courses of action in psychotherapy. Journal of Pragmatics 57: 118–137. https://doi.org/10.1016/j.pragma.2013.08.001

Burns, M. (2009) Bodies as (im)material? Bulimia and body image discourse. In H. Malson and M. Burns (eds) Critical Feminist Approaches to Eating Dis/orders, 124–134. London and New York: Routledge.

Chafe, N. and Nichols, J. (1986) Evidentiality: The Linguistic Coding of Epistemology. Norwood, NJ: Ablex.

Craciun, M. (2013) Embodied Expertise: The Science and Affect of Psychotherapy. Unpublished Doctoral Dissertation, University of Michigan, Ann Arbor.

Culpeper, J. (2011) Impoliteness: Using Language to Cause Offence. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511975752

Davis, K. (1986) The process of problem (re) formula­tion in psychotherapy. Sociology of Health and Illness 8 (1): 44–74. https://doi.org/10.1111/1467-9566.ep11346469

Dörnyei, Z. (2007) Research Methods in Applied Linguistics. Oxford: Oxford University Press.

Ekberg, K. and LeCouteur, A. (2012) Negotiating behavioural change: Therapists’ proposal turns in Cognitive Behavioural Therapy. Communication & Medicine 9 (3): 229–239.

Ekberg, K. and LeCouteur, A. (2015) Clients’ resistance to therapists’ proposals: Managing epistemic and deontic status. Journal of Pragmatics 90: 12–25.

Ferrara, K. (1994) Therapeutic Ways with Words. New York: Oxford University Press. https://doi.org/10.1016/j.pragma.2015.10.004

Garfinkel, H. (1967) Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice-Hall.

Gerhardt, J. and Stinson, C. (1995) ‘I don’t know’: Resistance or groping for words? The construction of analytic subjectivity. Psycho­analytic Dialogues 5–4: 619–672. https://doi.org/10.1080/10481889509539099

Gröne M. (2000) Wie lasse ich meine Bulimie verhungern. Ein systemischer Ansatz zur Beschreiburg und Behandlung der Bulimie. Carl-Auer-Systeme: Heilderberg.

Heritage, J. (2013) Epistemics in conversation. In J. Sidnell and T. Stivers (eds) The Handbook of Conversation Analysis, 370–394. Chichester, UK: Wiley-Blackwell.

Heritage, J. and Atkinson, J. (1984) Structures of Social Action. Cambridge: Cambridge University Press.

Heritage, J. and Greatbatch, D. (1991) On the institutional character of institutional talk: The case of news interviews. In D. Boden and D. Zimmerman (eds) Talk and Social Structure, 93–137. Cambridge: Polity Press.

Heritage, J. and Maynard, D. (eds) (2006) Com­munication in Medical Care: Interaction between Primary Care Physicians and Patients. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511607172

Heritage, J. and Raymond, G. (2005) The terms of agreement: Indexing epistemic authority and subordination in talk-in-interaction. Social Psychology Quarterly 68 (1): 15–38. https://doi.org/10.1177/019027250506800103

Heritage, J. and Watson, R. (1979) Formulations as conversational objects. In G. Psathas (ed.) Everyday Language, 123–162. Mahwah, NJ: Lawrence Erlbaum.

Jefferson, G. (2004) Glossary of transcript symbols with an introduction. In G. H. Lerner (ed.) Conversation Analysis: Studies From the First Generation, 13–23. Amsterdam: Benjamins. https://doi.org/10.1075/pbns.125.02jef

Labov, W. and Fanshel, D. (1977) Therapeutic Discourse: Psychotherapy as Conversation. New York: Academic Press.

Landqvist, M. (2014) Professional roles in a medical telephone helpline. In E. Graf, M. Sator and T. Spranz-Fogasy (eds) Discourses of Helping Professions, 179–203. Amsterdam: Benjamins.

Lindström, A. and Weatherall, A. (2015) Orienta­tions to epistemics and deontics in treatment discussions. Journal of Pragmatics 78: 39–53. https://doi.org/10.1016/j.pragma.2015.01.005

Lundren, J. D., Danoff-Burg, S. and Anderson, D. A. (2004) Cognitive behavioral therapy for bulimia nervosa: An empirical analysis of clinical significance. International Journal of Eating Disorders 35 (3): 262–274. https://doi.org/10.1002/eat.10254

McCabe, R. (2006) ‘Conversation analysis’. In M. Slade and S. Priebe (eds) Choosing Methods in Mental Health Research: Mental Health Research from Theory to Practice, 24–46. London and New York: Routledge.

McCabe, R., Heath, C., Burn, T. and Priebe, S. (2002) Engagement of patients with psychosis in the consultation: Conversation analytic study. British Medical Journal 325: 1148–1151. https://doi.org/10.1136/bmj.325.7373.1148

Mondada, L. (1989) Therapy interactions: Specific genre or ‘blown up’ version of ordinary con­versational practices? Pragmatics 8 (2): 155–165. https://doi.org/10.1075/prag.8.2.02mon

Muntigl, P. and Choi, K. T. (2010) Not remember­ing as a practical epistemic resource in couples therapy. Discourse Studies 12 (3): 331–356. https://doi.org/10.1177/1461445609358516

O’Reilly, M., Lester, J. and Muskett, T. (2016) Discourse/conversation analysis and autism spectrum disorder. Journal of Autism and Develop­mental Disorders 46 (2): 355–359. https://doi.org/10.1007/s10803-015-2665-5

Pawelczyk, J. (2011) Talk as Therapy: Psychotherapy in a Linguistic Perspective. Berlin and Boston: Mouton de Gruyter. https://doi.org/10.1515/9781934078679

Pera?kyla?, A. (2004) Making links in psychoanalytic interpretations: A conversation analytic view. Psychotherapy Research 14 (3): 289–307. https://doi.org/10.1093/ptr/kph026

Peräkylä, A. (2013) The conversation analytic approach to transcription. In J. Sidnell and T. Stivers (eds) The Handbook of Conversation Analysis, 551–574. Chichester, UK: Wiley Blackwell.

Peräkylä, A., Antaki C., Vehvilläinen S. and Leudar, I. (eds) (2008) Conversation Analysis and Psychotherapy. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511490002

Pomerantz, A. (1980) Telling my side: ‘Limited access’ as a ‘fishing device’. Sociological Inquiry 50 (3–4): 186–198. https://doi.org/10.1111/j.1475-682X.1980.tb00020.x

Pomerantz, A. (1984) Agreeing and disagreeing with assessments: Some features of preferred/dispreferred turn-shapes. In J. Atkinson and J. Heritage (eds) Structures of Social Action: Studies in Conversation Analysis, 57–101. Cambridge: Cambridge University Press.

Potter, J. (1996) Representing Reality: Discourse, Rhetoric and Social Construction. London: Sage. https://doi.org/10.4135/9781446222119

Poulsen, S., Lunn, S. and Sandros, C. (2010) Client experience of psychodynamic psychotherapy for bulimia nervosa: An interview study. Psychotherapy Theory, Research, Practice, Training 47 (4): 469–483. https://doi.org/10.1037/a0021178

Roberts, C. and Sarangi, S. (2005) Theme-oriented discourse analysis of medical encounters. Medical Education 39 (6): 632–640. https://doi.org/10.1111/j.1365-2929.2005.02171.x

Sacks, H. (1984) On doing ‘being ordinary’. In M. Atkinson and J. Heritage (eds) Structures of Social Action: Studies in Conversation Analysis, 413–429. Cambridge: Cambridge University Press.

Sacks, H., Schegloff, E. A. and Jefferson, G. (1974) A simplest systematics for the organization of turn-taking for conversation. Language 50 (4): 696–735. https://doi.org/10.1353/lan.1974.0010

Sanderson, T. and Angouri, J. (2013) ‘I’m an expert in me and I know what I can cope with’: Patient expertise in rheumatoid arthritis. Communication & Medicine 13 (2): 249 –261.

Sarangi, S. (2001) On demarcating the space between ‘lay expertise’ and ‘expert laity’. Text 21 (1–2): 3–11. https://doi.org/10.1515/text.1.21.1-2.3

Sarangi, S. (2010) Practising discourse analysis in healthcare settings. In J. Bourgeault, R. Dingwall and R. de Vries (eds) The SAGE Handbook of Qualitative Research in Health Research, 397-416. London: Sage. https://doi.org/10.4135/9781446268247.n21

Sarangi, S. and Candlin, C. (2011) Professional and organizational practice: A discourse/com­munication perspective. In C. Candlin and S. Sarangi (eds) Handbook of Communication in Organizations and Professions, 3–38. Berlin: Mouton de Gruyter.

Sarangi, S. and Roberts, C. (eds) (1999) Talk, Work and Institutional Order Discourse in Medical, Mediation and Management Settings. Berlin: Mouton de Gruyter. https://doi.org/10.1515/9783110208375

Sator, M. and Graf, E. (2014) ‘Making one’s path while walking with a clear head’: (Re-)constructing clients’ knowledge in the discourse of coaching. Aligning and dis-aligning forms of clients’ participation. In E. Graf, M. Sator and T. Spranz-Fogasy (eds) Discourses of Helping Professions, 91–122. Amsterdam: Benjamins. https://doi.org/10.1075/pbns.252.05sat

Schegloff, E. A. (2007) Sequence Organization in Interaction: A Primer in Conversation Analysis. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511791208

Schiffrin, D., Tannen D. and Hamilton, H. (eds) (2001) The Handbook of Discourse Analysis. Malden, MA: Blackwell.

Stiles, W. B. (2007) Theory-building case studies of counseling and psychotherapy. Counselling and Psychotherapy Research 7: 122–127. https://doi.org/10.1080/14733140701356742

Stiles, W. B. (2009) Logical operations in theory-building case studies. Pragmatic Case Studies in Psychotherapy 5 (3): 9–22. https://doi.org/10.14713/pcsp.v5i3.973

Talarczyk, M. (2010). Bulimia. Przepisy, paradoksy i zakl?cia. [Bulimia. Recipes, Paradoxes and Scripts]. Poznan: Media Rodzina.

Thomassen, G. (2009) The role of role-play in medical education: Managing activity ambiguities in simulated consultations between medical students and patients. Communication & Medicine 6 (1): 83–93. https://doi.org/10.1558/cam.v6i1.83

Tsui, A. (1991) The pragmatic functions of ‘I don’t know’. Text 11 (4): 607–622. https://doi.org/10.1515/text.1.1991.11.4.607

van Dijk, T. (2008) Discourse and Context: A Sociocognitive Approach. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511481499

Voutilainen, L. and Peräkylä, A. (2014) Therapeutic conversation. In J.- O. Östmann and J. Verschueren (eds) Handbook of Pragmatics. Amsterdam: Benjamins. https://doi.org/10.1075/hop.18.the1

Weiste, E., Voutilainen L. and Pera?kyla?, A. (2015) Epistemic asymmetries in psychotherapy inter­action: Therapists’ practices for displaying access to clients’ inner experiences. Sociology of Health & Illness. https://doi.org/10.1111/1467-9566.12384

Williams, G. (2014) Lay expertise. In W. C. Cockerham (ed.) The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, 1283–1288. Chichester, UK: Wiley-Blackwell. https://doi.org/10.1002/9781118410868.wbehibs555

Ziebland, S. (2004) The importance of being expert: The quest for cancer information on the internet. Social Science & Medicine 59: 1783–1793. https://doi.org/10.1016/j.socscimed.2004.02.019






How to Cite

Pawelczyk, J., & Talarczyk, M. (2018). ‘What should a woman do and imagine to have bulimia?’: Co-constructing patient expertise in psychotherapy with bulimia patients. Communication and Medicine, 14(2), 135-149. https://doi.org/10.1558/cam.30380