A Pragmatic Analysis of Power in Arabic Doctor-Patient Interactions

Research Paper (postgraduate), 2021

19 Pages


Table of contents


Statement of the Problem

Aim of the Study



Brown and Levinson's Politeness Theory (1978-1987)


Language and Power


Data collection Method



Sample Size

Method of Analysis

Findings and Discussion




The present study investigates the notion of power in Mosuli Arabic doctor-patient encounters from a pragmatic point of view. It does so by studying the interface of power and politeness in interaction. The theoretical framework adopted in the study is Brown and Levinson's (1987) politeness theory. Naturalistic observation method is the method used to collect data from 10 doctors and 38 patients in different public and private medical settings. The study hypothesizes that doctors aren’t inclined to use politeness strategies dueto their "expert", "referent" and "legitimate" power whilst patients are inclined to use politeness strategies when they interact with their doctor to lessen the influence of FTAs.The study finds that doctors(both males and females)exercise power when they interact with their patients as they do FTAs baldly-on-record in most cases.Italso finds thatpatients (both males and females) of different ages use politeness mitigation strategies when they interact with a doctor to lessen the influence of an FTA.

In addition, the study finds that doctors don’t exercise power when they use redressive strategies, due to certain situational factors such as the seriousness of patients' illness and the socio-demographic factor of social status. More academic research in this particular area is recommended to be able to understand power and its impact on society in general and the medical settings in particular.

Keywords: power, politeness, politeness strategies, doctor-patient interactions, Face threatening act - FTA


Language is considered the main tool by which people communicate with each other in a particular speech community. Scholars in a variety of disciplines investigate what interlocutors say in what communicative and strategic goals they attempt to achieve and the linguistic means they use to the establishment of the different social relations.

Power is one of the different social relations realized in daily face-to-face interactions. Cameron (2001:161) indicates that language "is among the social practices through which people enact relations of domination and subordination". Power as a social phenomenon which is evident in all social relationships is closely tied to politeness since both politeness and power are vital phenomena in the face-to-face communication. Additionally, power is observed in many approaches to politeness (e.g. Brown and Levinson 1987; Leech 1983; Culpeper 1996).

Research on power in medical contexts is a relatively recent area of study and which attracted researchers 'attention in the last few decades. Mullany (2009:1) says that "overall, there is a real necessity for an empirical investigation to be produced in a wide variety of health care context ". The doctor-patient interview as one type of medical contexts, in which the concept of power is said to manifest as a result of doctor interacting with patients, is the focus of the present study.

Statement of the problem

Based on the claim that there is no interaction without power (Bousfield and Locher, 2008: 8), power is a universal concept and is always present and can't be uprooted completely from society but one which is dynamic and negotiated in interaction (Foucault, 1980: 93). Thus, power constitutes an integral part of all social relationships; including doctor-patient interaction which is the focus of the present study. It is assumed that a powerful individual doesn’t use politeness strategies when doing face threatening acts (Brown and Levinson, 1987). Accordingly, doctors aren't expected to use means of mitigating the influence of FTAs due to their social status, profession and medical knowledge. Furthermore, patients are expected to use politeness strategies to lessen the influence of threat to doctors' face. Yet, it isn't always the case that doctors and patients use power following their position in the social hierarchy which will sometimes cause problems as a result of their nonadherence to politeness norms.

Aim of the study

The present study aims at investigating the concept of power, its nature, and dynamics in Arabic doctor-patient encounters from a pragmatic point of view in relation to Brown and Levinson's (1987) politeness theory.


In order to achieve the aim of the study, it is hypothesized that:

1. A powerful individual doesn’t have to use politeness strategies to lessen the impact of FTAs. Thus, doctors (both males and females) due to their "expert", "referent" and "legitimate" power don’t use linguistic politeness strategies when they interact with their patients.
2. Patients (both male and female) of different ages use politeness mitigation strategies when they interact with a doctor to lessen the influence of an FTA.


Politeness is an interdisciplinary area of study that has been of interest to researchers in pragmatics, sociolinguistics, sociology, anthropology, etc. Leech (2014: 53) claims that despite its disciplinary nature, politeness actually falls within the domain of pragmatics; arguing that "the richest and most specific form of data for studying politeness is what people say in given communicative situations". At the same time, he admits the possible overlap between pragmatics and other disciplines such as psycholinguistics and sociolinguistics since no clear boundaries are separating them. Thomas (1995: 158) argues that politeness belongs to sociolinguistics based on the claim that politeness is a means by which interlocutors create a social balance and that which is manifested in the actual social behavior.

An understanding of the meaning of the term needs to be made at this point. Meier (1995:345) assumes that there is a "disconcerting amount of divergence and lack of clarity concerning the meaning of politeness". That is why notions such as "deference", "appropriateness", "formality", "tact", "etiquette" and "indirectness" have been seen as similar to politeness.

Another source of confusion results from the overlap of "politeness" as an aspect of appropriate behavior and "politeness" as a theoretical framework. An attempt to solve this issue has been made by Watts, Ide and Ehlich (1992) to distinguish between "first-order" and "second-order" politeness. The former could be defined as "a lay person's concept, something that individuals talk about in everyday situations and have an everyday understanding of", whereas the latter is defined as "the technical or theoretically oriented use of the term" (Leech, 2014:41).

Despite the difficulty of defining and studying politeness empirically (Held, 1992: 131), yet many definitions have been proposed. Fairclough (1989:66) says that "politeness is based on the recognition of differences of power, degree of social distance". Thomas (1995:150) defines politeness as "a genuine desire to be pleasant to others or as the underlying motivation for an individual's linguistic behavior". Kádár (2017: 7) indicates that "politeness is a key means by which humans work out and maintain interpersonal relations". The first definition seems more determinate and more concrete, yet there isn't one conclusive irrefutable agreed upon definition of politeness.

The interest in the study of politeness has increased tremendously in the last few decades and the literature grew rich with a large number of theories that have been proposed to investigate politeness such as Lakoff's politeness Rules (1973), Leech's Politeness Principle (1983, 2014), Brown and Levinson Politeness Theory (1987), Sachiko Ide (1989), Spencer-Oatey's Rapport Management (2008).

Brown and Levinson's Politeness Theory (1978-1987)

One of the most influential theories tackling politeness is that of Brown and Levinson (1978-1987). In their work, they adopt what is called the "model person" or MP who is characterized of being "rational" and having "face" (Archer Aijmer and Wichmann, 2012: 85). They base their model on three important concepts, namely: face, face-threatening acts (FTA), and face-saving strategies. The first is the notion of face which they have admitted to derive from Goffman's (1967) work. They classify face into "positive face" which is the desire to be accepted and respected by others and "negative face" which is the desire to be free from imposition. The second important notion that they attend to carefully is face-threatening acts (FTAs). They tackle it in relation to speech acts and assume that certain speech acts are dangerous to face such as advising, ordering, requesting, threatening, etc. Consequently, they suggest several politeness strategies that they claim to be universal and whose function is to reduce the negative effect of FTAs (Brown and Levinson, 1987: 60). It is important to emphasize that these strategies wouldn’t eliminate the FTAs completely but will only redress its effect on the ongoing interaction (Archer et.al, 2012: 85). These strategies are outlined in Figure (1) below:

Abbildung in dieser Leseprobe nicht enthalten

Figure (1) FTA strategies (adopted from Brown and Levinson, 1987:60)

The choice of the strategy is dependent upon three sociological factors. The first is the social distance (D) which is the degree of familiarity or frequency of interaction between interlocutors. The second is social power (P) that refers to an asymmetric relation in which the more powerful has the right to impose certain plans or evaluations on the less powerful party. The third sociological dimension is the degree of imposition (R) which they define as "a culturally and situationally defined ranking of impositions by the degree to which they are considered to interfere with an agent's wants of self-determination or approval"(ibid. : 77). They disregard gender and ethnicity for they argue that P, D, and R "subsume all others" (ibid: 80). Their famous formula for assessing the weightiness of an FTA suggests that "The greater the imposition of the act, the more powerful and distant the other is, the more face-damaging the act is likely to be" (Culpeper, 1996: 357). Concerning the dimension of power, Brown and Levinson (1987) claim that there are three different interpretations of an evaluation of power. The first view assumes that power is an absolute value attributed to individuals in relation to other individuals; mistakenly eliminating the role of any contextual factors on the estimation of power. The second view assumes that power is assigned differently according to different roles enacted by individuals (e.g. between employer-employee, doctor-patient). A third view, which is adopted by Brown and Levinson, claims that such fixed social assessments of power are in fact one of a combination of elements that affect the dimension of power; including situational factors

Each super-strategy and their respective strategies will be elaborated on with some details as follows:

a. Bald on record: is used in situations where the risk to face is minimal, such as in emergencies and in cases where power differences between the speaker and addressee are so obvious, (e.g. shouting "fire" to get people to leave a burning building).
b. Positive politeness: is used when the risk to face is higher than before and is directed towards the wants of the "positive face" of the hearer. Its goal is to make the hearer feel as an in-group member or claim a common ground with him. Seeking agreement, joking and exaggerating interest in the hearer, using in-group identity markers, promising, assuming reciprocity, giving reasons, and being optimistic are some of the strategies of positive politeness.
c. Negative politeness: is also used as an on-record strategy with redressive action but is oriented to negative face wants of the hearer. Examples are apologizing, giving deference, using questions, being pessimistic, using hedges, and minimizing the imposition.
d. Off-record: is used when an on-record strategy has a high potential of risk to face and when the speaker wants to convey more than one meaning. The off-record strategy is employed in a way "that it is not possible to attribute only one clear communicative intention to the act"(Brown and Levinson, 1987: 211). It means that the actor can't be held accountable for only one interpretation of the communicated act. Such as giving hints, overstating, being ambiguous, using ellipsis, being ironic, using rhetorical questions or metaphors, over-generalizing and and presupposing.
e. Don’t do the FTA: is a super-strategy used in situations where the damage to face is too great and the sustaining of face is of crucial importance (Brown and Levinson, 1987:91,214)

Despite the influential role of Brown and Levinson's theory in the study of politeness, many have criticized their model. Some have accused them of having an "Anglo-centric" viewpoint; disregarding cultural differences in their application of the model. For example, they claim that certain speech acts are inherently threatening to face and in all cultures. This claim has been proven to be false, take the speech act of inviting for example which isn't threatening to face in the Chinese culture (Chen, 1993:69). Others have claimed that Brown and Levinson's theory hasn’t given adequate attention to the social and interpersonal features of face and that they have heavily concentrated on the concepts of autonomy and freedom (Matsumoto1988 and Gu 1998)

Despite the many limitations of the theory, it remains one of the most influential and adapted theories of politeness that many researchers over the years have found it to be a useful framework in understanding politeness .


Power appears to be closely linked to politeness, given the way it is treated in the literature as a prominent concept in many approaches to politeness (e.g. Brown and Levinson1987; Leech 1983; Watts 2003; Locher 2004). In relation to impoliteness, Bousfield and Locher (2008:36) argue that "impoliteness always involves power" based on the claim that impoliteness leads to "conflict and clash of interests" and restriction of an individual's action-environment, which are both referred to in Locher (2004: 39, 100) concerning power:

1. The restriction of an interactant’s action-environment often leads to the exercise of power.
2. The exercise of power involves a latent conflict and clash of interests, which can be obscured because of a society’s ideologies.

The concept of power has been of interest to scholars in every discipline of social science, such as sociology, economics, philosophy, etc. Russell (1938:10) even claims that "the fundamental concept in social science is power, in the same sense in which energy is the fundamental concept in physics".

Power isn't an easy concept to understand and define due to its many changeable features, such as its instability and changeability (Foucault 1994:12). Yet, many definitions in the literature on power have been proposed. Brown and Gilman (1960:255) in their influential work on forms of address and power define the latter as "a relationship between at least two persons and that it is non-reciprocal in the sense that both can’t have power in the same area of behavior". Power has also been defined as "the ability to control resources, own and others', without social interference" (Galinsky, Gruenfeld and Magee, 2003: 454). A classical definition of power is put forward by Weber(1947:152); he defines power as" the probability that one actor within a social relationship will be in a position to carry out his own will despite resistance, regardless of the basis on which this probability rests"

There have been many influential accounts that shaped the understanding of the nature of power in the literature. Machiavelli (1532) who tackles the strategies people use in order to exercise and maintain power. Weber (1947), Dahl (1957), Bachrach and Baratz (1970), Foucault (1977) onward, Fairclough (1989), Wartenberg (1990) and onward are only some of the vast number of scholars of the Twentieth Century who have dealt with power

Language and Power

An understanding of what holds power and language together needs to be made at this point. It is indicated that language is one of the most prominent tools through which the notion of power is exercised (Locher, 2004:34). Thus, power is realized through the use of language whether written or spoken. For example, political power is demonstrated through politicians' speeches, public debates, and elections' campaigns and laws are demonstrated through written language (Thomas and Wareing, 2005: 10). In addition, Holmes and Stubbe (2015:3) claim that language is a substantial means of exercising power and a considerably necessary element in the creation of social reality. Since power is " the force in society that gets things done, and by studying it, we can identify who controls what, and for whose benefit" (Moore and Hendry, 1982: 127), it is argued then that language mostly benefits the interests of the more powerful groups of people since these are the people who are in charge and have authority over it (e.g. politicians, lawyers, and even parent, etc.) (Thomas and Wareing, 2005: 10). Fairclough (1989) has also pointed to the close relationship between language and power. His work gives important insights into power through language. He examines how the means in which individuals communicate are controlled by the structures and forces of the public institutions within which people live and function.


The present research mainly adopts a qualitative method because the phenomenon under investigation is compounded and social in nature and partly implements a quantitative method as the researcher integrates numerical data in the research.A qualitative research design is characterized by certain features, such as:

1. The research takes place in natural settings, such as in school, hospital…etc.
2. The researcher is the main tool for collecting data.
3. The data are descriptive, i.e. they take the form of words rather than numbers.
4. A qualitative research's main emphasis is on people's perceptions and experiences.
5. Researchers are concerned with understanding the process as well as the outcome.
6. The profoundness of the collected data is more valuable than the amount or size of the samples collected.(Creswell, 2012)

Data collection method

In the present study, naturalistic observation has been chosen as the method of collecting data. Observation is done by "systematically watching and recording people's behaviors, clothing, expressions and interaction in a particular location or several settings". It can be carried out either in public locations or in a private location where permission must be requested beforehand (Rice and Ezzy, 2004:104,105). Research studies use naturalistic observations in situations where participants' accounts of their experiences aren’t precise or liable to selective filtering. In the same vein, it should be noted that observation is also liable to the researcher's elucidation and subjective analysis. (Vanderstoep and Johnson, 2009: 238)

Observation can be carried out either in public locations or in a private location where permission must be requested beforehand (Rice and Ezzy, 2004:104,105). In the present study, collecting data takes place in different Mosul's private and public medical clinics where permission was requested from all participants.

Of the questions that the researcher should answer when using this method is "how the observation should be recorded?" In the current study, an audio-recorder has been used to record the interactions.


The population represents all items or members in any field of inquiry (Kothari, 2004:55). It represents the entire group of people that the scholar is concerned with and from which a sample is chosen (Hammond and Wellington, 2013). In the present study, the population represents all Mosuli people, both doctors, and patients, from which the researcher will select a sample. The choice of patients and doctors as informants isn't restricted to a particular age range, gender type, social class, or educational background.


An important component of empirical linguistic study is to make a decision not only about the kind of data to collect (e.g. interview data, experimental data, natural data), but also to decide what kind of people to aim at when collecting data. Since choosing a suitable sample design is based on the aim of the study (Marshall, 1996:523) and the present study is mainly a qualitative one, thus the researcher chooses a non-probability sampling procedure. Non-probability sampling is also referred to as "purposive sampling" or "judgment sampling" and is considered the most common sampling procedure used in qualitative studies. Marshall (1996:523) indicates that in purposeful sampling "The researcher actively selects the most productive sample to answer the research question".

Sample Size

After choosing an appropriate method of sampling, the researcher has another decision to make concerning the appropriate sample size. It is believed that linguistic studies draw on a considerably smaller sample size than in other fields of study in the social sciences. It is mostly due to the time-consuming linguistic data collection process and transcription work needed (Podesva and Sharma, 2013: 82). In practice, the required numbers of informants become clearer as the study proceeds, and as new themes seize to unfold from data or what is referred to as data saturation (Marshall, 1996: 523). Thus, the present study involves ten doctors of different specialties, ages and both genders and thirty eight patients from both genders and different ages.

Method of Analysis

The aim of carrying out a study is to yield results, and in an attempt to do so, data must be analyzed in order to transform raw data into findings. The type of analysis to select in a particular study depends on the type of questions asked in the respective study. Thus, the type of analysis to choose is essentially linked to the aims of the study at hand (Liamputtong, 2009: 135). Since the present study aims at revealing themes underlying the different manifestations of power and politeness in Mosul's doctor-patient encounters, thus, an interpretative thematic analysis is appropriate as a type of data analysis within the theoretical frameworks of Brown and Levinson's (1987) politeness theory.

There is a six-phase process of conducting a thematic analysis. First, familiarizing oneself with the data which means that the raw data must be transcribed by the researcher himself and then have to read the data multiple times, and write down initial thoughts and impressions about the data. Second, the researcher should generate codes that would identify the important features of the data related to the research questions.Third, searching for and identifying themes. This step moves the analysis further into a broader level which involves categorizing the codes into possible themes, and collating all the pertinent coded data within the recognized themes. The fourth step involves reviewing the themes since some of them might be combined; others discarded or split, developing a detailed analysis of each theme. The fifth step involves developing a detailed analysis of each theme. The analysis must give a brief, coherent, reasonable, nonrecurring, and vivid account of what the data are about. Finally, relating the themes to existing literature and producing the final analysis (Braun and Clarke, 2006:16, 23).

During the final phase of analysis, the researcher will attempt to compare the findings with data taken from the theoretical frameworks relevant to the study, the literature review in addition to the objectives of the study. This would allow the researcherto see if the findings verify or contradict thetheoretical frameworks of the study. It may even propose new questions that may need the creation of new theories.

Findings and Discussion

Concerning Brown and Levinson's theory (1987) and its interface with the social dimension of power, it has been found that doctors mostly use a bald-on-record strategy when they interact with their patients. This goes in line with Brown and Levinson's assumption that a more powerful individual isn't inclined to use a redressive politeness strategy when they interact with the less powerful individual. It is assumed, according to the researcher's observation and analysis, that what motivate doctors to use a bald-on-record strategy is their desire to always be able to control the encounter and runs it according to their rules and agendas. Another reason is their inherent institutional authority, since doctors have what is called "legitimate power" afforded to them by their institutions that gives them the right to suggest or demand certain things from their patients. Other less influencing situational factors that contribute to the doctors' use of bald-on-record strategy and consequently realization of power are the urgency of the situation at hand and the doctor's desire to be as direct concise and clear as possible. Time-constraints is another contributing factor that results in the doctor's resort to doing an FTA baldly with no consideration of the risk to the patient's face.

As for doctors' use of other strategies, it has been found that doctors use both negative and positive politeness strategies approximately equally. It has been found for instance that doctors use negative politeness strategies in situations where the patient is of equal social status. Thus, it has been noticed that the sociodemographic factor of patients' social status and other contextual factors prevails both age and gender concerning doctors' use of redressive strategies

Another motivation for doctors' use of negative politeness is the doctors' estimation of the seriousness of the situation. Thus, it has been noticed that doctors often use the negative politeness strategy when they report bad news of the patient's condition.

As for doctors' use of positive politeness strategy, social status also plays a role in motivating doctors to use a redressive strategy. Other situational factors that can contribute to doctors' use of positive politeness strategies are the severity of the patient's illness, the nature of the needed task, the patient's psychological state. It has also been found that doctors approach sensitive issues by using redressive strategies.

Concerning the off-record strategy, it has been found that doctors rarely use it. This goes in line with Brown and Levinson's assumption that a powerful individual isn't inclined to use an off-record strategy. Yet, it is found that an off-record strategy is used by doctors in situations where the FTA is highly threatening which could cause communication breakdown that would eventually lead to a failed medical encounter. It is also found that doctors address sensitive issues in an off-record manner.

Concerning patients' use of politeness strategies, it has been found that patients usually use negative politeness strategy when they interact with their doctors in an attempt to lessen the impact of FTAs such as when they make certain requests or try to express their concerns and feelings about particular aspects of their condition. Additionally, they often use positive politeness and off-record strategies equally. They do so for the same purpose as with negative politeness, in an attempt to redress the threat to doctors' face that an FTA may cause. It has been noticed that when a patient tries to challenge a doctor's authority by refusing a particular treatment or course of action, the patient uses an off-record strategy because of the high risk to the doctor's face that the patient's FTA causes. This goes in accordance with Brown and Levinson's (1987) theory that low power participants are more probable to use politeness redressive strategies since it will lessen the likelihood of conflict with superiors.

As for patients' use of the bald-on-record strategy, it has been found that there are contextual factors that lead patients to do so such as the psychological state of the patient. Thus, a frustrated patient may not take politeness issues into consideration. Additionally, the seriousness and urgency of the patient's condition is another contributing factor that can motivate a patient to overlook politeness considerations when he interacts with his doctor. The familiarity that a patient has developed with his doctor may also motivate him to not use politeness strategies.

The following two figures give a summary of the results of doctors' and patients' use of politeness strategies

Abbildung in dieser Leseprobe nicht enthalten

Figure (2): The total percentage of the doctors' use of politeness strategies

Abbildung in dieser Leseprobe nicht enthalten

Figure (3): The total percentage of the patients' use of politeness strategies


The present study aims to investigate power, its nature and dynamics in doctor-patient encounters in relation to politeness. It is to see whether the social dimension of power is realized or not in doctor-patient encounters and what are the reasons that can best explain both circumstances

It is concluded that underlying each medical encounter there is a subtle balance between two motivating forces. The first is doctors' pressure to get the task at hand accomplished well and efficiently. The second are certain affective concerns for people's feelings, i.e. politeness. Nevertheless, doctors' power is realized in most cases where doctors choose to use the bald-on-record strategy. This is due to their desire to control the course of action, due to their inherent institutional authority afforded to them with respect to their experience, knowledge and legitimate position in the institutions and which gives them higher social status in society, and other contextual factors related to time-table constraints and the urgency of the situation at hand.

As for the reasons that best explain why those in authority don't always realize their power and choose to appear more polite are mostly reasons related to considerations of context such as when doctors report bad news, approach sensitive issues or the patients' psychological condition assessed by the doctor. Other reasons are the nature of the needed task, the nature of the doctors' relationship with their patients and patients' high social status.

Patients (both male and female) of different ages use politeness mitigation strategies when they interact with their doctors to lessen the influence of an FTA. Yet, they do sometimes use a non- redressive strategy under certain circumstances such as the patients' psychological condition, the seriousness of illness and nature of relationship with their doctors. Thus, doctors' use of mitigating strategies and patients' use of the bald-on-record strategy are better elucidated by situational reasons.


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A Pragmatic Analysis of Power in Arabic Doctor-Patient Interactions
University of Mosul  (University of Mosul/ Iraq)
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pragmatic, analysis, power, arabic, doctor-patient, interactions
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Kamal Hussein (Author)Marwa M. Ahmad (Author), 2021, A Pragmatic Analysis of Power in Arabic Doctor-Patient Interactions, Munich, GRIN Verlag, https://www.grin.com/document/983957


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