Hum Stud DOI 10.1007/s10746-017-9430-z EMPIRICAL STUDY/ANALYSIS

Help-Search Practices in Rehabilitation Team Meetings: A Sacksian Analysis Hiroaki Izumi1

 Springer Science+Business Media Dordrecht 2017

Abstract Using Harvey Sacks’s concept of membership categorization devices (MCDs), this article examines the help-search sequences in which Japanese rehabilitation team members use a set of categories to locate the availability of stroke family caregivers. Specifically, based on an analysis of audiovisual data from rehabilitation team conferences in Japan, the article illustrates the ways in which participants at the meetings: (1) evaluate the expectable behaviors of various category incumbents; (2) classify which category of person is proper to turn to for help; and (3) arrive at the conclusion that no one is available, and so the patient must be institutionalized. Analysis shows that participants routinely choose co-resident family members to fulfill the caregiver position. However, the position is not guaranteed unless the selected incumbent can satisfy additional criteria, especially physical strength and time availability. By exploring the ways in which participants use categories to negotiate discharge destinations, the article adds to Sacks’s analysis by illustrating methodical activities for deciding whether someone is unavailable to help. Moreover, it considers the applicability of Sacks’s notion of MCDs to Japanese data. Keywords Membership categorization devices  Category  Time formulation  Medical team meeting  Japanese

Introduction In a classic study, Sacks (1967) examined telephone conversations between suicidal callers and staff members at a suicide prevention center in California. His main aim was to investigate ‘‘how the conclusion a suicidal person may reach (that he has no one to turn & Hiroaki Izumi [email protected] 1

Department of Anthropology, University of Hawai‘i at Ma¯noa, 2424 Maile Way, Saunders Hall, Honolulu, HI 96822, USA

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to) may be reproducibly provided for’’ (1967: 203) by elucidating the methodical ways in which suicidal callers and staff members use a set of categories to locate the availability of the potential helper. In the process of investigating the search for help in American culture, Sacks was led inevitably into a consideration of kinship, noting that the ways of locating potential helpers might be different in other cultures, such as the Bemba of Zambia (see 1967: 209). However, unlike traditional anthropologists, Sacks was not interested in the cognitive nature of kinship but in the observability of kinship practices; or, in other words, he was interested in how participants use a set of categories to locate potential helpers in actual situations of talk. Drawing on Sacks’s study of the search for help and on membership categorization analysis (MCA) studies in help-seeking (e.g., Broadhurst 2007; Hunt 1991; Paoletti 2001; Watson 1986), this article investigates help-search sequences in which Japanese rehabilitation team members use a set of categories to locate the availability of stroke family caregivers. Specifically, based on an analysis of audiovisual data from rehabilitation team conferences in Japan, this article systematically illustrates the methodical procedures in which participants at the meetings: (1) evaluate the expectable behaviors of various category incumbents; (2) classify what category of person is proper to turn to for help; and (3) arrive at the conclusion that no one is available, and so the patient must be institutionalized. Through exploration of the ways in which Japanese rehabilitation team members use categories to negotiate discharge destinations in actual situations of talk, this article adds to Sacks’s analysis by examining a short series of case discussions that illustrate the methodical procedures used for deciding someone is unavailable to help. Moreover, it considers the applicability of Sacks’s (1967) membership categorization devices (MCDs) to Japanese data. The data used in this article are based on 65 audiovisual recordings (a total of approximately 19.5 h) of rehabilitation team conferences, which I collected during my 12-months of fieldwork at a convalescent rehabilitation ward located in a rural area of Japan during 2010–2011. All the data were transcribed according to the standard conversation analysis transcription system developed by Gail Jefferson (2004). In addition, I used the three-tier format (see Hepburn and Bolden 2014). The first line is an original language transcription. The second line shows word-for-word glosses and abbreviations for various types of grammatical particles (see ‘‘Appendix’’ section). Finally, the third line is a rough English translation. To protect privacy, I changed all private information concerning participants in the transcriptions. Before turning to analysis of audiovisual data, I first provide background on management of stroke patients in Japan, which is relevant to the data presented in this study. I then present Sacks’s (1967) MCD analysis, especially his notions of ‘‘category collections’’ and ‘‘rules of application,’’ which are the primary methodological aspects of this study.

Background: Management of Stroke Patients in Japan Stroke is a leading cause of severe long-term disability worldwide (Donnan et al. 2008). In Japan, it is the foremost cause of people entering a condition of needing care (Ministry of Health, Labour, and Welfare 2013). Although the effects of stroke depend on the

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location of damage in the brain, many stroke survivors suffer from serious physical and cognitive problems, such as inability to walk effectively because of lower-limb paralysis, swallowing difficulties due to paralysis of the throat muscles, and difficulties producing and understanding language due to aphasia. Not only do such severe conditions have a profound impact on patients’ lives, they can also place an enormous burden on family caregivers; including physical demands, depression, time spent on caregiving, and financial duress (Adelman et al. 2014; Haley et al. 2009; Morimoto et al. 2003). In Japan, about 64% of stroke patients return home after long-term inpatient treatment (Kaifukuki Rehabilitation Ward Association 2006), and their immediate family typically provides care. Traditionally, caregiving in Japan took place through intergenerational coresidence wherein the wife of the eldest son who married into the house of his parents played the sole role in caring for her aged in-laws (Campbell and Campbell 2003; Imamura 2009). Although today such traditional roles and living arrangements are still more commonly practiced in rural areas than urban areas such as Tokyo (Long 2008; Traphagan 2003), such norms are increasingly contested by women and negotiated in family situations (Brown 2003; Jenike 2003; Long 2008; Long et al. 2009; Traphagan 2003). After acute stroke rehabilitation, many patients are transferred to a convalescent rehabilitation ward, where they stay for several months as they seek to restore their reduced activities of daily living1 (ADL) with the help of multidisciplinary rehabilitation teams. Such teams consist of doctors, nurses, care workers, physical therapists, occupational therapists, speech therapists, medical social workers, and dieticians. Together with patients and their families, team members work to maximize patients’ functional independence with the goal of ensuring the patients can safely return to their homes after being discharged. In particular, it is essential for patients to improve their ADL, which require family caregivers’ frequent daily assistance, especially with ‘‘eating,’’ ‘‘transfers,’’ and ‘‘toileting,’’ to expedite their return home (Sakurai et al. 2011; Sugiura et al. 2014; Uematsu and Ikai 2002). Regaining the ability to walk, rather than returning home in a wheelchair, is also an important factor toward achieving home discharge (Sugiura et al. 2013). However, factors influencing home discharge are not limited to patients’ ADL functions. For example, family structure is crucial because it can limit quality of care and number of family members. Ito et al. (2011) show that if a household already contains a disabled person, the chance for a stroke patient to return to home decreases. In such a case, patients may not be able to return home unless they are nearly functionally independent. Alternatively, their families may send the already co-residing disabled person to an institution. In some cases, patients’ home environments may also be a limitation, especially if they live in a rented home, because these likely cannot be modified. This prevents making adjustments to enable daily activities to be safely and independently conducted. Following the convalescent phase of rehabilitation, stroke patients move to the chronic phase, in which they maintain their present physical and cognitive conditions as long as possible by relying on mandatory public long-term care 1

Activities of daily living refer to self-care tasks, such as eating, toileting, and dressing, which people routinely perform in their daily life.

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insurance (LTCI). Such insurance is primarily used to cover institutional and community-based caregiving for elderly people (Campbell and Ikegami 2000). The LTCI scheme was initiated by the Ministry of Health, Labour and Welfare (MHLW) of Japan in April 2000 with the aim of shifting the burden of care imposed on family members to the state; thus providing a range of options for family care. Persons aged 65 years or older are eligible for LTCI.2 To receive its services, they must obtain certification for kaigodo (‘required care level’), which determines what services the person can receive. Kaigodo is composed of a seven-level scale divided into two main categories: needing support (levels 1 and 2) and needing care (levels 1–5). Persons who need support only are not eligible to enter an institution (e.g., care facility). Instead, they are to live in their homes while using kaigo yoboo saabisu (‘care prevention services’), such as home-visit care and rehabilitation, day care, and short-stay daily-life services. In contrast, persons who need care have the right to enter an institution and use kyotaku saabisu (‘in-home care services’), which are similar to kaigo yoboo saabisu. In this article, I focus on the convalescent phase of rehabilitation, wherein Japanese rehabilitation team members participating in multidisciplinary rehabilitation team meetings negotiate discharge destinations when considering the course of action for stroke patients. Specifically, drawing on audio and videotaped medical team interaction, I explicate the practitioners’ use of categories to locate the availability of stroke family caregivers in actual interactive talk. This is done through the application of Sacks’s notion of MCDs, to which I shall now turn.

Membership Categorization Devices Sacks (1967) developed the concept of MCDs to systematically illustrate how suicidal callers and staff members use categories to locate potential helpers on a telephone suicide helpline. The crux of MCDs is ‘‘category collections’’ and ‘‘rules of application’’ (see also Hester and Eglin 1997; Lepper 2000; Schegloff 2007; Silverman 1998). Category collections include: (1) ‘‘a collection of paired relational categories called R’’ (Sacks 1967: 203) and (2) a collection, K (professionals and laymen), which is ‘‘constructed with reference to special distributions of knowledge obtained about how to deal with some trouble’’ (Sacks 1967: 203). The collection R consists of paired relational categories such as ‘‘husband-wife,’’ ‘‘parent–child,’’ and ‘‘friend–friend’’ in which a rule called the ‘‘standardized relational pair’’ (SRP) is applied: ‘‘Any pair of categories is a member of collection R if that pair is a ‘standardized’ relational pair which constitutes a locus for a set of rights and obligations concerning the activity of giving help’’ (Sacks 1967: 203). The collection R is further divided into two subsets, ‘‘Rp’’ (‘Relationship proper’) and ‘‘Ri’’ (‘Relationship improper’). ‘‘Rp’’ refers to ‘‘categories whose incumbents are proper to turn to’’ (Sacks 1967: 205). In contrast, ‘‘Ri’’ refers to ‘‘categories whose incumbents are not proper to turn to’’ (Sacks 1967: 205). Sacks also notes that members of the subset Rp are ranked in an orderly way: ‘‘If there is an incumbent of some ‘first-position’ category, with respect to any incumbent of some 2

Persons aged 40–64 years old may also qualify for LTCI if they are diagnosed as having one of 16 specific diseases (e.g., cerebrovascular disease) as defined by the MHLW.

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‘second-position’ category, the rules provide that the incumbent of the first position and not the second should be turned to’’ (1967: 205f.). Let us illustrate Sacks’s concepts in his original excerpt below in which the suicidal caller (C) talks to the staff member (S) on a telephone suicide helpline (see also Lepper 2000: 19f.): Excerpt 1 (from Sacks 1967: 207)

In line 01, the staff locates the availability of a potential helper by asking, ‘‘Have you ever been married, Miss M?,’’ thus invoking the SRP ‘‘husband-wife’’. In American culture, if a person is married, his or her spouse is expected to be the primary helper. In line 02, the caller’s response ‘‘no’’ provides the staff to continue to search for the availability of an alternative incumbent. Sacks (1972: 38) introduces the notion of ‘‘programmatic relevance’’ to describe such procedure: ‘‘If a pair of categories with the features of standardized relational pairs is relevant, then the non-incumbency of any of its pair positions is an observable, i.e., can proposedly be a fact. Furthermore, various uses may be made of the facts of the presence or absence of persons to fill the potential pair positions’’. In line 06, the staff asks the caller ‘‘You have no one out here?’’. The caller’s response, ‘‘I have cousins,’’ shows that she heard ‘‘no one’’ as invoking the MCD ‘‘family’’ (line 07). Sacks notes that ‘‘no one’’ indicates ‘‘no incumbent of a pair position in subset Rp’’ (1967: 206). Here, after the initial search fails, the staff expands the help-search sequence to find the availability of the extended family members. Although the caller mentions she has ‘‘cousins,’’ she downgrades the availability of her cousins by specifying ‘‘third or fourth cousins’’ (lines 07–08). By increasing the familial distance, the caller implies that they are not available to turn to for help. In what follows, I apply Sacks’s concept of MCDs to examine the help-search procedures Japanese rehabilitation team members use when dealing with stroke patients. In particular, I add to Sacks’s analysis by illustrating two primary methodical activities for deciding whether someone is unavailable to help. First, I draw on two canonical cases to illustrate members’ methods of ordering the potential incumbents. I then move on to examine how members use time formulations to identify whether family caregivers can manage their work conflicts, which serve as an important factor in deciding on discharge destinations.

Ordering Potential Incumbents Case 1 In the following excerpt, rehabilitation team members, including a doctor (DR), a nurse (NS), a physical therapist (PT), an occupational therapist (OT), a medical

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social worker (MSW), and a case manager (CM), are participating in a rehabilitation team conference where they are talking about a male stroke patient in his 600 s. Just prior to the excerpt, the MSW told the DR that the patient’s wife has to have back surgery around the time of the patient’s discharge. The excerpt begins when the DR tells the MSW that he is not totally sure about what might happen to her back due to the complication of her surgery (lines 01–04). Excerpt 2

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In line 08, the DR interrupts the MSW, indicating that the patient’s wife is incapable of helping the patient with transfers because of her back surgery: toransufaa wa dekin na: (‘She can’t do transfers, you know’). The wife’s physical weakness makes the DR consider sending the patient to a facility (line 12). However, the DR’s proposal meets a series of resistant responses from the other participants. In lines 13 and 18, the MSW, the OT, and the PT form an oppositional coalition to indicate that the wife does not need to use her hands

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because the level of assistance is mimamori (‘supervision’).3 In reaction, the DR produces a worst-case scenario in which the patient falls down while attempting a transfer: koitsu yuka ni shagamikondara doo nan no? (‘What happens if this guy falls to the floor?’) (lines 19–20). Conducting transfers from the floor requires that a caregiver have greater physical strength than would be necessary to conduct wheelchair/bed transfers. Thus, by increasing the amount of assistance needed, the DR challenges the team members by asking if the wife could manage the worstcase situation. In line 22, the PT indicates that it would be impossible for her to manage that situation. Then, the DR asks if anyone can lift the patient from the floor (line 23). The PT answers that daremo oko(h)se(h)nai (‘No one can(h) lift(h) him’) (line 25), which is also overlapped with the MSW’s daremo (‘no one’) (line 26). Here, by choosing daremo (‘no one’), the PT and the MSW indicate that no family members, especially those who co-reside with the patient, are available to lift the patient from the floor. The PT and the MSW further seek an alternative incumbent (lines 31–32). However, when the DR specifically asks dare yonde kureru? (‘Who would they call?’) (line 33), the PT shows trouble responding by delaying his response (line 34). The MSW also shows trouble by asking the PT if there is someone they could call (line 35). When no answer is given, the DR rephrases the previous question with a specific one: dare o yobu tte yuu fuuni shidoo suru no? (‘How do you teach them who to call?’) (line 36). After a delayed response, the PT invokes the SRP ‘‘friend-friend’’ by producing chikaku no tomoda(h)chi(h) (‘frie(h)nds(h) nearby’) (line 38). Here, he apparently jokes about his choice with laugh particles, inviting laughter from the coparticipants (Jefferson 1979). In the next lines (lines 39–40), the MSW and the CM accept this through laughter, thus treating the choice of the ‘‘non-family’’ as problematic. Following 22 lines in which the PT mentions that he actually has not confirmed if the patient has friends who can help (22 lines deleted), he recycles the help-search sequence in which he lists the unavailable incumbents from the MCD ‘‘family’’: okaasan de wa muri ya to omou shi musuko san cchuu wake ni wa ikanai desu shi (‘I think it’s impossible for his mother and it can’t be his son’) (lines 64–65). Here, after the patient’s wife is ruled out, the PT expands his search to choose the other co-resident family members, namely the patient’s mother and son, even though these members are not available (lines 63–65). Consider the excerpt below:

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Patients with mimamori (‘supervision’) require a caregiver to watch while they are performing activities of daily living because there might be some risks involved with their behavior. However, a caregiver does not need to use his or her hands to physically assist them. Instead, s/he can utilize verbal and gestural cues to instruct them.

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Excerpt 3

In line 66, the DR solicits a reason why, in addition to the wife, the patient’s mother and his son are also not available to help.4 In lines 68 and 70, the PT explains that, according to the patient’s wife, the son is not available because he will be sent to a facility. The MSW further adds that he will be sent to a facility that specializes in mental 4

The excerpt does not explain why the participants do not consider the patient’s mother to be a helper, but the patient’s mother is 90 years old and probably lacks the strength to help with transfers. Such background knowledge might be shared by the participants.

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disabilities, which undermines the son’s potential as a caregiver (line 72). Once the patient’s son is ruled out and no alternative incumbents are selected, the DR announces a medical decision with a preface jaa (‘So’), suggesting that the patient be sent to a facility where capable caregivers are available to look after him (lines 109 and 112). In the following excerpt, participants still resist the DR’s proposal. After 42 lines in which the PT considers whether or not the patient’s wife could change the date of her surgery, he mentions that the amount of care is manageable by saying sonna futan wa okkiku kakaranai (‘There won’t be too much burden’) (line 155). In the next line, the DR recalls that the patient has daughters, thus invoking the SRP ‘‘parent–child’’ (line 156). Excerpt 4

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In line 157, the MSW explains why the patient’s daughters are not available by saying: musume totsuidemasu ne (‘His daughters are married’). The fact that they no longer belong to the patient’s family indicates that they have the right and obligation to serve their husband’s family. Thus, the MSW treats their marital status as making them unavailable for fulfilling the caregiver position. In line 162, the DR asks their geographical proximity: chotto tooi no? (‘Do they live far away?’). The MSW answers that even though the daughters live in the same city, they have work conflicts (lines 164–165). Furthermore, after reading the conference record to confirm that they live in the same city (line 167), she mentions that their availability is limited to the weekend, namely doyoo toka (‘Saturdays and so on’) (line 168). Then, she further downgrades their availability to hannichi (‘half-day’) (line 169), which contributes to ending the help-search procedure. When it is determined that no family members are available, the DR selects a facility in which physically capable caregivers are available (line 193). In summary, participants in the above case choose the potential incumbents from the MCD ‘‘family,’’ especially those who co-reside with the patient. Yet, even though co-resident family members are available, the caregiver position is not filled unless the selected incumbent can physically help the patient. When this criterion is not met, participants expand the help-search procedure to search for an alternative incumbent who can satisfy this criterion. For example, when the first-position candidate, the wife, is not physically capable to help, participants continue to search for other family members such as the son. A departure from their expectation happens when non-kin members such as ‘‘friends’’ are selected.5 Now, I move on to examine a case of another stroke patient for a comparative purpose. In the household, co-resident family members, including the mother, wife, son and daughter, are available as the potential caregivers. Case 2 The following case is based on a young stroke patient in his 400 s. Before the excerpt below begins, the DR asked the PT if the patient is able to get up from the floor by himself. The PT answered that the patient cannot do this without assistance. Immediately after telling the PT to train the patient transfers from the floor, the DR initiates a help-search sequence (line 01).

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It should not be assumed that non-family members are always treated as improper. In the following excerpt, participants can and do choose a patient’s neighbors as the potential helper. However, the kinds of help offered by the neighbors seem to be limited, such as giving a ride (see lines 10–12). Excerpt 5

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Excerpt 6

Footnote 5 continued

Par27

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Although it is commonly assumed that if a person is married, his or her spouse is expected to be the primary helper, the DR selects the patient’s mother as the first choice (line 01). The PT replies that the patient needs someone while conducting transfers from the floor because of safety considerations: hitori de wa chotto abunai (‘It is little dangerous to be by himself’) (line 02). Then, the DR further asks if his mother is physically able to lift him from the floor: okaasan nara dekiru n ka? (‘If his mother is there, can she do it?’) (line 03). Again, the DR considers the mother’s physical strength as the selection criterion. In reaction to the absence of the PT’s response (line 04), the DR rephrases his question to deki soona ki ga suru? (‘Does it seem like she can do it?’) (line 05), which is overlapped with the PT’s turn initiation (line 06). While the PT restarts his turn (line 06), the DR reverses the polarity of the question: dekin? (‘She can’t?’) (line 08), which is cued by the PT’s head shake which happens during a 0.3-s pause (line 06). In lines 07–13, the PT provides negative assessments of the mother’s physical condition. Then, he rules out the mother from the caregiver position by concluding that okaasan wa chotto taihen ya to omoimasu wa (‘I think it is difficult for his mother’) (line 13). Yet, he provides an alternative incumbent who could better help the patient: oku(h)san(h) to(h)ka no ga

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mada (‘his wife(h) is still’) (line 12). Immediately after this, the DR recalls the wife’s physical characteristics by referring to her body as chicchai (‘little’), which undermines her ability to serve in the caregiver position: chicchai n ja nakatta kke? (‘I seem to recall that she is little, isn’t she?’) (lines 14–15). Here, the fact that the DR remembers that the wife is physically little explains why he selected the mother at line 01. That is, he accounts for his initial mention of the mother by pointing out that the wife is unsuitable. The PT, the OT, and the NS confirm in a series that the wife is physically small through which they treat the wife as incapable of lifting the patient from the floor (lines 16–21). When the help-search procedure is ended, the PT repeats the mother’s physical problems (lines 22–26), which shows that no further incumbents are available from the MCD ‘‘family’’. When an appropriate caregiver is not found, the DR challenges the PT by producing a worst-case scenario in which the patient falls during a transfer (lines 27–28). Following a short delay (line 29), the PT starts to respond (line 30). However, the DR interrupts his response by providing an example of the worst-case situation (lines 31–33). The PT displays trouble in responding during a 1.5-s pause (line 34). Then, he initiates the helpsearch procedure but fails to provide an alternative incumbent, repeating that the mother is unavailable as a caregiver (line 35). In the next line, the DR asks if anyone else is available to manage the worst-case situation (line 37). Again, the PT’s response is delayed for a 0.8-s pause (line 38) and then he reveals that ‘‘no one’’ is indeed available (line 39), which invites a series of laughter from the DR and the OT (lines 40–43). As mentioned earlier, ‘‘no one’’ indicates no incumbents from the MCD ‘‘family,’’ in particular, ‘‘co-resident family members.’’ In the next excerpt, the PT continues to search for the availability of the alternative incumbents. Specifically, he chooses a set of categories, including the patient’s son, daughter, and the neighbor.

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Excerpt 7

In lines 44 and 47, the PT self-repairs the amount of assistance required to help the patient with transfers from the floor; he first selects a term kai-, which is the first component of kaijo (‘assistance’), but he abandons it and replaces it with sukoshi no kaijo (‘a little assistance’). By specifying only a little assistance, he may be suggesting that it might be possible for a family member to help. Then, he initiates

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the help search by suggesting tasuke o dokka ni motomeru shika nai (‘there is no choice other than seeking help somewhere’). The DR immediately asks him where to seek help (line 48). After a 2.0-s delay, the PT provides a set of candidate incumbents, including the patient’s son and daughter, and his neighbors (lines 50–51). It is noteworthy that the PT lists both inside and outside family members as potential caregivers. In response, the DR displays surprise to the PT by locating a trouble source musuko (‘son’) through other-initiated repair (line 53). The PT momentarily treats the DR’s reaction as a surprise with a stand-alone ‘‘eh’’ (see Hayashi 2008) (line 54). However, he immediately repairs his choice by accounting for the patient’s son’s physical feature: musuko wa chotto chiisasugimasu kedo (‘His son is too small but,’) (line 56). In fact, the patient’s son is 8 years old and is too small to lift the patient from the floor. Thus, the laughter immediately produced by the OT and the NS may indicate that they view the choice of the son as caregiver as inappropriate6 (line 55 and lines 57–59). In line 60, the PT justifies his choice by saying maa sore mo hitotsu kana tto omou node (‘I think that may be one solution too, so’), which is connected with his previous assertion in line 56. However, the DR immediately rejects this by saying iya iya renshuu shite kudasai (‘No, no, please practice that with the patient’). Through negotiation, the participants have decided to train the patient on transfers from the floor for the moment to see whether or not he can learn to do this by himself. If he could not do so, he would be likely to be sent to a facility where physically capable caregivers are available. In summary, the above case seems to be an instance of a violation of the ‘‘spouse first rule’’ because participants select the patient’s mother as the first choice even though he is married. However, close examination of data revealed that it is not an exception. Rather, it is consistent with the rule, given the fact that the DR remembers that the patient’s wife is physically small indicates that he presumably knew this when he first selected the mother at line 01. Now I move on to examine how participants use time formulations to identify whether or not the selected incumbent can manage his or her work conflicts. Specifically, I focus on the ways in which participants identify family caregivers’ occupation categories and organize their work schedule.

Identifying Time Availability Whether or not family members can look after their disabled family member at home depends on the time they have available to do so. In the following excerpt, the MSW shows her negative reaction to home discharge by considering the co-resident family members’ work conflicts.

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Here, Sacks’s (1974) ‘‘consistency rule’’ could be extended. That is, when the speaker lists three candidate incumbents A, B, and C, and if A is treated as improper, this applies to B and C even though their capacities are not explicitly talked about.

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Excerpt 8

In lines 11 and 13, the MSW makes the potential caregiver position relevant to the co-resident family members, the patient’s wife and daughter. However, she rules out these incumbents because of their work conflicts: futari tomo shigoto shiteru nde: (‘both of them are working’). In the next line, the DR initiates repair by locating a trouble source shigoto (‘work’) (line 14). Then, by choosing an ‘‘extreme case formulation’’ (Edwards 2000; Pomerantz 1986), minna (‘everyone’), he indicates that it is normal for every family member to work (line 15), thus treating the family’s situation as not a special circumstance. Instead, he suggests home discharge by using day care service when the wife and the daughter are not at home to provide care (line 17). Here, it is important to mention that day-care centers

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usually are open only during the daytime. Therefore, family members with irregular work schedules, such as a late-evening shift, are unable to use the service. The MSW agrees with the DR in line 19, but she shows her consideration of the wife’s irregular work schedule. Consider the excerpt below: Excerpt 9

In line 23, the MSW invokes the identity of the patient’s wife as shisetsu no eiyooshi (‘facility’s dietician’), and then offers a topic, kinmutaikee (‘work schedule’), which is associated with the occupation category (line 24). However, a 1.8-s pause in the next line shows that the MSW does not immediately provide the predicate that follows (line 25). In light of this, an ‘‘anticipatory completion’’ (Lerner and Takagi 1999) takes place: the PT self-selects and volunteers the projected syntactic component, namely fukisoku (‘irregular’) (line 26). The OT repeats this in the next line (line 27). The MSW also provides a confirmation (line 28). By doing so, the PT, the OT, and the MSW collaboratively construct their shared knowledge of the irregular work schedule of the patient’s wife. In line 29, the PT lists a first time formulation to describe the irregular work schedule: nichiyoo ni mo ittari mo (‘She goes to work on Sunday as well’). Nichiyoo (‘Sunday’) belongs to the ‘‘weekend’’ in which people with a regular work schedule are not expected to work. In line 33, the OT adds another time formulation, jikan (‘time’), even though she does not provide the specific irregular work hours at this moment. In the next excerpt, however, the NS appears to recognize that the irregular work schedule does not go together with the wife’s occupation category, namely shisetsu no eiyooshi (‘facility’s dietician’). She locates a trouble source eiyooshi (‘dietician’) through other-initiated repair in line 34:

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Excerpt 10

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In reaction to the NS’s repair initiation, the MSW shows that she does not know if the wife is a dietician or a cook (lines 35–36). The DR indicates that these occupation categories are quite different (line 38) and he explains the differences as follows. First, he points out that ‘‘going to the worksite much’’ is not a categorybound activity of the facility’s dietician (lines 42–43). Moreover, by asking nichiyoobi iku? itte n no? (‘She goes to work on Sunday? Does she go?’) (line 48), he points out a category mismatch between the irregular work schedule and the occupation category. In lines 60 and 61, the MSW offers an additional hint to classify the wife’s occupation. Specifically, she characterizes the wife’s irregular work schedule with a time formulation asa hayai jikan (‘early hours in the morning’). Then, she selects specific irregular work hours: goji toka niji (‘5am and 2am’) (line 63), which provide a resource for participants to identify the wife’s occupation. Finally, the MSW finds critical information in the conference record, namely chuuboo (‘kitchen’) (line 65). Her noticing is displayed with a change-ofstate token a (‘oh’) (Heritage 1984). She then mentions the wife works in the kitchen of a care facility called Konoha (line 67), and explicitly categorizes her occupation by saying chuusboo na nde tsukuru hito ssu ne (‘She works in the kitchen so she’s a person who cooks’) (line 71). Once the wife’s occupation and her irregular work schedule have been clarified, the DR tells the MSW to ask the care facility if it is available to look after the patient (line 72). Following the delay in response (lines 73 and 76), the MSW suggests the decision should be made in consultation with the wife.

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Let us examine another case in which members use time formulations to identify family members’ time availability. In the following case, co-resident family members, including the eldest daughter, the son-in-law, and the grandson, share care responsibilities in looking after their elderly family member, rather than shifting burden of care to a single caregiver. Excerpt 11 begins where the DR starts to identify the grandson’s occupation category and the availability of his time (line 01). Excerpt 11

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In line 04, the PT answers that the grandson is a biyooshi (‘hairdresser’). Following a 1.7-s delay (line 05), the DR displays a problem of hearing the prior turn through repair initiation (line 06). In lines 08 and 09, the MSW and the PT repair the trouble source by repeating the grandson’s occupation category, namely biyooshi (‘hairdresser’). Immediately after the DR recognizes this (line 10), the MSW adds that the grandson is off on Monday (line 11), which is a typical holiday for hairdressers in Japan. After a 0.9-s pause (line 12), the MSW uses time formulations, especially nicchuu (‘daytime’) and yoru (‘evening’), to organize the management of the patient at home (lines 13–14). Specifically, the patient spends his days at a day care when the eldest daughter is not at home to provide care. In the evening when she comes back from work, she looks after her disabled mother, including tube feeding. Thus, having a regular work schedule is essential in being able to access and use day-care services. In lines 15 and 16, the DR asks if the patient’s son-in-law will also look after the patient. The MSW confirms this in the next line, which puts the husband in the position of shared caregiver (line 17). However, he is not always available because of his irregular work schedule (lines 19–20). Thus, the grandson also shares the care responsibility and he will come to the rehabilitation ward to learn caregiver skills (lines 20–22). In line 24, the DR asks if the grandson will also learn how to change diapers, perhaps because this activity is not typically performed by male caregivers. The MSW confirms this by saying that ichioo zenbu yarashite kudasai tte iwareteru mitai desu (‘It seems that he was told to do everything for the moment’) (lines 26–27). Following this, the DR inquiries about the eldest daughter’s occupation category and her time availability:

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Excerpt 12

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In line 33, the DR looks for the reason why the eldest daughter is busy by asking her occupation: choojo nani ni isogashii n shigoto? (‘With what work is the eldest daughter busy?’). In the next line, the MSW provides an answer with a keamane (‘care manager’) (line 34). However, the DR does not agree that this occupation is a busy job (line 35). In line 37, the MSW casts a doubt on the DR’s assertion with a stand-alone ‘‘eh,’’ which projects a disagreement (Hayashi 2008). The DR immediately counters this with a stand-alone ‘‘eh,’’ and then contradicts the MSW by intensifying the amount of care managers’ free time: dondake demo jikan tsukureru yaro keamane nante (‘They can make as much time as they want, care managers as such’) (lines 38–39). In response, the MSW maintains her oppositional stance by saying isogashii n desu yo (‘She is busy, you know’) (line 42). Here, she defends her claim with a final particle ‘‘yo,’’ which is used as a disagreement marker in Japanese conversation (Hayano 2011). However, the DR still disagrees with her by maintaining his point of view (line 43). In response to this challenge, the MSW lists instances of the eldest daughter’s busy circumstances with toka (‘etc’): (1) doyoobi toka mo shigoto ni nattari toka (‘she has to work on Saturday, even though she is not supposed to’) (lines 46–47); and (2) hitori oyame ni nattari toka (‘one person has quit’) (line 49). Then, she concludes that ippai ippai de yatteru rashii desu Himawari no keamane san (‘it looks like she’s got a lot on her plate as a care manager at Himawari’) (lines 50–51). Here, the MSW specifies the eldest daughter’s occupation as a care manager who works in a care facility, which provides a resource for the DR to recognize her busy circumstances. In line 53, the DR displays a change of his state of knowledge with a (‘oh’) (Heritage 1984): a shisetsu n naka no keamane ka? (‘Oh, is she a care manager inside the facility?’). By categorizing the eldest daughter as shisetsu n naka no keamane (‘care manager inside the facility’), the DR differentiates her from the other kinds of care managers who have time. In lines 55 and 56, the MSW corrects the misperception that the eldest daughter is a care manager inside the care facility, saying that she is a care manager in the in-home care or kyotaku. While care managers who work inside care facilities manage their residents’ care plans, kyotaku care managers create care plans for those who utilize home care services. In the next line, the DR requests a confirmation: kyotaku yaro? dokodemo dearuitoru n yaro? (‘In-home care, right? She goes out everywhere, right?’) (lines 57–58), in which dokodemo dearuku (‘going out everywhere’) is a category-bound activity of kyotaku care managers. When the MSW confirms this in the next line (line 59), the

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DR categorizes kyotaku as those who have time: nara hima aru yaro iya (‘Then, she has time, you know’) (line 60). In summary, it is common for family members to work; therefore identifying their time availability is a key criterion for participants when home discharge is being considered. In the above cases, participants first identify the occupation category of a co-residing family member. They then use time formulations to uncover whether he or she has sufficient time to look after the disabled family member at home. In particular, identifying irregular work schedules is crucial for participants because irregular hours and days, such as ‘‘Sunday’’ and ‘‘early hours in the morning,’’ do not coincide with the opening hours of day-care centers. When family members’ irregular work schedules have been identified, participants alternatively seek institutional care (see Excerpt 10).

Discussion and Conclusion In this article, I have applied Sacks’s (1967) notion of MCDs to examine the methodical procedures in which Japanese rehabilitation team members use a set of categories to locate the availability of stroke family caregivers. Specifically, based on an analysis of audiovisual data from rehabilitation team meetings in Japan, I added to Sacks’s analysis by illustrating two primary methodical activities for deciding whether someone is unavailable to help: ordering potential incumbents and identifying time availability. The data showed that participants routinely choose co-resident family members as the potential caregiver. However, although these members are available, the caregiver position is not filled unless candidate incumbents can satisfy additional criteria, in particular, physical strength and time availability. Here, I focus my discussions on two features of my data: (1) the method of ordering the potential incumbents; and (2) Japanese and Western kinship practices. First, as mentioned, Sacks (1967) notes that members choose the first-position candidate and order the potential incumbents in an orderly way. In his data, for example, if a person is married, his or her spouse is considered the first choice. If this category is not available, other family members are sought as the alternative. The data presented in this article fit into Sacks’s model. In Case 1 (Excerpts 2–4), participants arrange the potential caregivers according to family relationship. First, they select the patient’s wife. However, after considering that she is incapable of helping her husband due to her back surgery, they search for other co-resident family members to serve in the caregiver role. When none of these family members are available, the married daughters who have left their natal household are selected. In Case 2 (Excerpts 6, 7), at first glance, participants seem to order the potential incumbents in order of physical strength (i.e., from the mother, to the physically small wife, and lastly to the physically too small 8-year-old son) rather than the family relationship, and therefore, this seems to be a case of a violation of the ‘‘spouse first rule’’. However, careful examination of data disapproved this. That is, the fact that the DR remembers the patient’s wife’s physical characteristic (i.e., the small-sized body) indicates that he presumably knew this when he first selected the patient’s mother. If no family caregivers are available, participants alternatively

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choose an institution which can deal with various family situations (e.g., work conflicts). This is also consistent with Sacks’s model in which when the suicidal caller has no one to turn to for help, the staff member selects a professional (or K) as the alternative choice. Future studies are invited to add more cases to the body of work initiated by Sacks, and further contribute to uncovering members’ methods of identifying availability of potential helpers. Next, as mentioned in the beginning of this article, Sacks refers to Bemba kinship to consider the ways in which locating the potential helper might be different across cultures. In such a case, the analyst needs to draw on ethnographic knowledge to explain the non-Western kinship system. Indeed, the usability of ethnographic knowledge has been discussed in conversation analysis (e.g., Arminen 2005; Bilmes 1996; Maynard 2003; Moerman 1988) and also in MCA (e.g., Bilmes 2009; Hauser 2011; Izumi 2014). These studies have considered whether or not the utilization of ethnographic knowledge advances the analysis. As far as the data presented in this article is concerned, it is not necessary to explain Japanese kinship because there are similarities between Japanese and Western kinship practices. For example, in Excerpt 4, the MSW treats the patient’s daughters as unavailable caregivers because of their marital status. I said, ‘‘The fact that they no longer belong to the patient’s family indicates that they have the right and obligation to serve their husband’s family’’. Although there may be some differences between Japanese and Western kinship practices (e.g., the American wife has to attend to her husband but not necessarily to his family), they do not seem to affect the analysis of Japanese data presented in this article. One final note: in examining place formulations in classroom talk, McHoul and Watson (1984: 287) point out, ‘‘…in the past, MCD analysis has always tended to focus on references by persons to persons (babies, mommies, boozy boys, men, etc.). How legitimate is a move toward using an MCD analysis (or its analogue) to understand the problem of place reference and its adequacy?’’ More recently, Housley and Fitzgerald (2002, 2015) and also Bilmes (2011, 2015) indicate that there is a need to explore category practices of non-personal categories. Building on studies in this line of research (e.g., Button 1990; Koike 2014; McHoul and Watson 1984; Schegloff 1972), the present article contributes to filling the gap by examining members’ use of time categories to identify family caregivers’ time availability. Acknowledgements I am deeply indebted to Jack Bilmes for his excellent advice and useful comments on earlier manuscripts. My thanks also go to the two anonymous reviewers for their helpful comments and suggestions. Albert Britt Robillard generously shared his social network with me, helping me connect to a Japanese rehabilitation hospital for conducting my fieldwork and data collection. Jack Bilmes and Pamela Runestad provided valuable editing assistance. An earlier version of this article was presented at the International Institute for Ethnomethodology and Conversation Analysis Conference held at the University of Southern Denmark (4–7 August, 2015). I am thankful to the participants for their useful feedback. All errors are my own responsibility.

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Appendix: List of Abbreviations Used in the Interlinear Gloss Adopted from Iwasaki (2013) and Hayashi (2010). ACC

Accusative

NML

Nominalizer

ASP

Aspect

NOM

Nominative

AUX

Auxiliary

PAST

Past

CAU

Causative suffix

PFX

Prefix

CLS

Classifier

POL

Polite suffix

COM

Comitative

POT

Potential suffix

COND

Conditional form

PP

Pragmatic particle

COP

Copula

PSS

Passive suffix

DAT

Dative

PURP

Purposive

EMPH

Emphasis marker

Q

Question marker

FL

Filler

QT

Quotative particle

GEN

Genitive

REP

Representative

HON

Honorific

RP

Retrospective particle

IMP

Imperative form

SE

Sentence extender

INJ

Interjection

SOF

Softener

INS

Instrumental

TE

TE form

LOC

Locative

TL

Title

NEG

Negative

TOP

Topic marking particle

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