Symbolic Interactionist Analysis of Health & Medicine
In the first quarter of the twentieth century, British and American sociologists became increasingly interested in health, disease, and medicine. The origins of the sociology of health and medicine (or, as it was initially known, medical sociology) lie in studies of medicine as scientific work and as a professional occupation, studies of illness as social deviance (as in the work of Talcott Parsons), and concerns about social patterns of disease and illness. While much of this work in the 1970s focused on the political economy of health and disease, at the same time, an interest emerged in the social experience of health, illness, and disease. Studies began to focus on the perspective of patients, medical encounters, and doctor-patient communication using the perspective of symbolic interactionism and phenomenology. In this framework, successful interaction with others depends on impression management, information control, and being ever attentive to what our bodies and faces are telling others. However, such management and control is not always possible, and sometimes bodily disruptions and differences such as illness and impairment present interactional challenges. These negotiations and challenges have implications for social relationships and self-identity.
Keywords Actual Social Identity; Biographical Disruption; Disability; Impairment; Political Economy of Health; Stigma; Symbolic Interactionism; Virtual Social Identity
Symbolic Interactionist Analysis of Health
The Origins of Medical Sociology
In the first quarter of the twentieth century, British and American sociologists became increasingly interested in health, disease, and medicine. The origins of the sociology of health and medicine (or, as it was initially known, medical sociology) lie in studies of medicine as scientific work and as a professional occupation, studies of illness as social deviance (as in the work of Talcott Parsons), and concerns about social patterns of disease and illness. While much of this work in the 1970s focused on the political economy of health and disease, at the same time, an interest emerged in the social experience of health, illness, and disease. Studies began to focus on the perspectives of patients, the experience of medical encounters, and doctor-patient communication, using interpretative approaches such as symbolic interactionism.
Symbolic interactionism, especially as developed in the work of Erving Goffman, shows how knowledge of nonverbal communicative norms (e.g., socially appropriate facial expressions and bodily gestures) and control are crucial to the competent presentation of self in everyday life. In this framework, successful interaction with others depends on impression management, information control, and being ever attentive to what our bodies and faces are telling others. However, such management and control is not always possible, and sometimes bodily disruptions and differences such as illness and impairment present interactional challenges. These negotiations and challenges have implications for relationships and self-identity.
Symbolic interactionism, developed in the work of Erving Goffman, G. H. Mead, and C. H. Cooley, builds on Georg Simmel's analysis of how people are bound together through the various encounters, sensual experiences, and glances that are exchanged in everyday life (Frisby & Featherstone, 1997). From this analytic perspective, visual information (facial and bodily appearance through dress, expression, and gesture) and the accurate interpretation of it is critical to successful interaction. We look for visual information when we enter into encounters with other people, and we use this information to make judgments, form opinions, and decide how to speak and act. We use gestures and images to interact with others, or, as Goffman puts it, to perform roles in the ways that are expected of us (1971).
The symbolic interactionist perspective provides a window into the way that the social meaning of people's actions and behaviors cannot be taken for granted, as such meanings are always a matter of dispute, and reminds us of the significance of the micro dimensions of social life (Barry & Yuill, 2002). Ritzer identified three critical points that underlie the symbolic interactionist perspective:
• A focus on the interaction between the actor and the world;
• A view of the actor and the world as dynamic processes;
• The importance of the actor's ability to interpret the social world (1992).
The Patient's Perspective
Symbolic interactionism is concerned with how people view and understand the world they occupy. It is an interpretive approach that seeks to understand human behavior in terms of how people interact with each other and their environments and has been used in studies that focus on how people respond to the experience of illness in their lives.
A change in health status can create both upheaval and opportunity and disrupt not only the physical body but also one's sense of self. Bury refers to this sense of illness experienced as a break in one's self-trajectory as a biographical disruption, or an illness narrative, which can challenge a person's self-narrative (1982; Kleinman, 1988). Accordingly, many studies have examined the experience of illness, the impact that health changes make on people's sense of self-identity, and the meanings and interpretations that are attributed to illness.
For instance, one study of the experience of chronic illness showed how people's sense of identity and self-worth is bound up with an intact, functioning body (Kelly, 1992). Ulcerative colitis is an inflammatory condition that affects the mucus production of the large bowel and sometimes requires surgery to remove the bowel and create a special opening in the skin (a stoma) that allows the patient to eliminate waste into a bag. This study revealed that people who suffer from colitis develop coping strategies that help them deal with the uncertainty of the condition's symptoms. It was important for patients to downplay the significance of the surgery and its impact in order to "pass" as normal and healthy because of the way the bowel is symbolically associated with dirt, pollution, and loss of control (Annandale, 1998). In a sense, they felt they had to manage and control their bodies because they anticipated the responses of others if they did not, and those responses would no doubt cause them embarrassment and shame.
Hence, studies of illness experience show that changes in health status have an impact on people's sense of self, are characterized by considerable uncertainty, and engender coping strategies to deal with the potential for bodily betrayals. The impact on sense of self is a consequence of both the actual and imagined reactions of others to the person who is ill. This relationship is especially sharp in studies of disability. For instance, Charmaz's study of people with various kinds of chronic disability explored definitions of suffering (1983). She found that a narrow, medicalized view of suffering (mainly, physical discomfort) obscured other forms of suffering, especially what she refers to as "loss of self." The experience of chronic disability for these study participants was that their previous sense of self "crumbled away," leading to restricted lives, social isolation, feeling discredited, and feeling like a burden to others.
These studies highlight how the presence of illness in a person's life presents a challenge to the presentation and experience of self and, indeed, can create stigma. Goffman refers to the relation between virtual social identity and actual social identity: the former expresses normative expectations of whom and what a person should be in a given encounter or context—for example, the patient might be expected to be deferential—while the latter refers to the social, cultural, and physical attributes actually possessed by a person (1968). Given that we tend to see ourselves as others do (as argued by the symbolic interactionist perspective), when there is a difference between external expectations or norms and the actual characteristics we possess, we might expect some interactional trouble. Such trouble, created by a gap between virtual and actual social identity, is stigma, which carries moral consequences because people may be reduced in the eyes of others to a social or physical attribute associated with their illness or impairment. Hence, these studies of the illness experience suggest that people work hard to avoid such trouble, often by trying to conceal their illness or any evidence of it, but...
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