Symbolic Interactionist Analysis of Health and 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

Overview

The Origins of Medical Sociology & Symbolic Interactionism

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 & Early Classic Studies

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).

Further Insights

The Patient's Perspective & the Illness Experience

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.

Virtual & Actual Social Identity

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 suffer in doing so.

Similarly, a recent study of women's experience of depression extends these observations and highlights how the meanings of experiences, rather than being intrinsic, are developed through interaction between the "I" and the "me." Schreiber, the study's author, observed that the women in her study spoke about internal dialogues concerning societal or significant others' expectations of them and the moral judgments contained within (2001). Such expectations contrasted with the women's own sense of coherence. When the women became aware of the competing voices within, they were able to reflect critically on how the "me" (societal expectations) overwhelmed the "I." Moving from depression toward recovery involved sifting through these internal messages and questioning the legitimacy of the moral judgments contained in societal expectations, which they came to feel had constrained them and prevented their full selves from emerging. Hence, Schreiber argues that a symbolic interactionist analysis of depression highlights how women are socialized to invalidate their needs in favor of the needs of others, with the result that they become alienated from their own needs (Schreiber, 2001).

Health Behavior

Modern Western societies are characterized by messages that urge people to adopt healthy lifestyles and take responsibility for their health. Yet symbolic interactionist studies reveal the contradictions between, on the one hand, what people say they believe or do to keep healthy or pursue a healthy lifestyle and, on the other, how those beliefs and actions are played out in everyday life. Indeed, health issues typically have a moral component, from the ways that disease categories are used to create boundaries between normalcy and deviance to the victim blaming of individuals who fail to participate in practices deemed essential for the production and maintenance of health (Katz, 1997; Crawford, 1979). This perspective is sharply emphasized in relation to behaviors that have health implications and that are seemingly irrational.

For instance, in the late 1980s and early 1990s, Hilary Graham studied patterns of tobacco consumption among low-income mothers in the UK (1994). She found that these women spent a large proportion of their income on cigarettes, despite the relatively high financial and health costs. Viewed from the perspective of economists and health professionals, such behavior seems irrational, since it is damaging to both the household purse and personal health. By talking with and listening to the women in her study however, Graham discovered that smoking, while acknowledged as a health hazard, offered them "time out" from the demands of routine caring and domestic work and a way of reconnecting with their sense of self. As such, this study suggests that irrational and health-damaging behaviors, viewed from the perspective of the people themselves, can be a coping strategy in the wider context of structural social and economic disadvantage that helps to sustain a sense of self.

Viewpoints

Disease Categories & Interventions

Disease refers to pathological changes in the human body that are expressed in various signs and symptoms that trained practitioners can interpret and use to diagnose. Diseases have conventionally been understood as natural entities that have been discovered by medical scientists. However, some sociologists argue that disease categories are socially constructed; that is, they emerge as the product of interactions and exchanges between different social groups and from new emergent ways of seeing the human body and its processes. For instance, in their study of the development of the Pap smear as a screening tool for cervical cancer, Casper and Clarke (1998) "argue that a tool's rightness for the job is an outcome of processes of negotiation in which everything is up for grabs: what the tool is and does, what criteria are used to judge its efficacy and efficiency, and indeed what the job is," because "meanings are generated through interactions" such that they "can only be understood in relation to one another" (Guillemin, 2000, p. 192). A more recent example of this approach, a study of menopause as a disease category, suggests that it is difficult to understand what menopause is without also taking into consideration the technologies and practices that are associated with it, such as hormone replacement therapy, bone scans, and mammograms, and how they interact to create the category "menopause" (Guillemin, 2000). That is, there is nothing discrete about menopause as either a social or a biological category. Instead, it is a category that is shaped, or co-constructed, via the symbolic interactions of material bodies, technologies, experiences, and cultural understandings.

Symbolic Interaction & the Social Context of Health Care

Where political economists and structural-functionalists focus on the significance of organizational and system characteristics of hospitals, clinics, and other institutions in explaining how patterns of disease emerge, how health care is distributed, and how humans behave, symbolic interactionists focus on social order, or the social rules and rituals that govern social interaction (Goffman, 1967). A number of studies demonstrate this concern with social order.

Phil Strong's (1979) observational study of pediatric clinics in Scotland and the United States examined how certain predictable, repeated rituals that constitute an invariant "ceremonial order" accompany medical encounters. The ceremonial order is constructed by expectations that are entered into and sustained by both doctors and patients in order to make sure that certain outcomes occur—in this case, that mothers are not judged for the decisions they make or actions they take regarding their children's health and that doctors' recommendations are sought and respected. The notion of ceremony alludes to the way that interactional rituals frame medical encounters as a special sort of social occasion and not only structure the encounter but also provide a resource that participants may draw on "to solve whatever problems they have at hand" (p. 13). The rituals on which participants may draw are associated with role formats. For instance, the bureaucratic format is associated with doctors being polite and courteous. While mothers were not openly criticized, doctors nonetheless saw them as ignorant or "technically incompetent" (p. 70), reinforced by their attempts to "interrogate" mothers or control the conversation. The clinical format intensified this view: here the doctors were assumed to be the experts, and mothers deferred to their authority.

In Strong's study, the strongest feature of patient-doctor interaction was the ability of the doctors to control the consultation via tactics such as breaking off conversation, interrupting patients, or excluding patients by writing or talking to others (such as students) while the patients were talking. Although patients sometimes tried to challenge these symbols of expert authority, direct challenges or open conflict were rare, and doctors usually managed to maintain their authority by drawing on their status, training, or other resource (Nettleton, 1995).

However, as Annandale points out, not all medical encounters are as "tightly circumscribed" by an evident ceremonial order (1998, p. 25). Other symbolic interactionist studies of clinical interaction and medical encounters point to "negotiated consensus" as the chief characteristic, which entails each actor defining the situation (as a medical encounter) and interacting in ways that sustain this definition. These studies focus on collecting minute details of the contexts in which interaction occurs and the impact that a different context or awareness has on how people interact or negotiate with each other. For instance, some studies note that health interactions typically entail a form of bargaining. One study of the experience (or the illness career) of tuberculosis examined the importance of timetables for both patients and doctors and for their relative bargaining power (Roth, 1963). On the one hand, timetables provided a monitoring tool that enabled physicians to decide when patients should have certain treatments or interventions; on the other hand, patients relied on their observations of what was happening to other patients as a guide to when they should have a particular treatment. Hence, both groups used the same tool differently and drew on their own awareness contexts to interpret what the next steps in illness management should be.

In such examples, communication between doctors and patients was typically characterized by negotiation between an expert (professional) and a patient (a lay person) in which each participant brought different resources (the power to prescribe treatment versus the power to comply).

Doctor-Patient Communication

While studies of interaction highlight the importance of negotiation and bargaining in doctor-patient communication, other symbolic interactionist studies have examined how power differentials between actors impact the ability to negotiate. Indeed, Nettleton notes that although health care encounters are diverse—they may occur in clinics, in hospitals, or in the home, with physicians, surgeons, or other specialists—such interactions reflect and reinforce wider social relations and structural inequalities, such as gender, race, and class, and as such contribute to social control and regulation (1995). Studies of such interactions have shown how the patient's perspective is typically discounted or undermined by health professionals and how the quality of interaction itself can impact on health outcomes.

For instance, many bodily experiences have increasingly come under the purview of medicine, such as pregnancy and childbirth, which are viewed within obstetric medicine as illnesses rather than, as many commentators claim they ought to be, as natural processes. These distinct perspectives create a power differential between women and their physicians (Graham & Oakley, 1986), which continues to inform the experiences of women in the context of reproductive health care.

However, while power is generally weighted in favor of professionals, patients are able, to some extent, to steer consultations in ways that ensure outcomes that meet their needs. For instance, an early study of patient-professional interaction (Stimpson & Webb, 1975) demonstrated how patients used strategies such as rehearsing their stories, presenting information about only some of their symptoms, and ignoring medical advice in order to extract a particular outcome, such as a treatment or intervention, from their doctors. Similarly, Bloor and McIntosh examined more overt strategies for resisting requests for information by health professionals (1990). They state that when health visitors (community nurse practitioners) solicited information from or dispensed advice to mothers that the mothers did not wish to give or receive, mothers frequently told health professionals only "what they need to know" or agreed to the given advice and "did their own thing" anyway. These findings, and those of other studies (e.g., Fägerskiöld, Timpka, & Ek, 2003), suggest that the lay public is increasingly inclined to challenge expert authority and, moreover, have more resources, such as the Internet, that enable them to do so.

Terms & Concepts

Actual Social Identity: The range of social, cultural, and physical attributes a person possesses.

Biographical Disruption: The personal turbulence and challenges to self-identity created by illness.

Disability: The social and political repercussions and difficulties that may be encountered through impairment.

Impairment: Loss of physiological or anatomical capacity that may be stigmatizing.

Political Economy of Health: An approach that examines how health in capitalist economies is shaped by the pursuit of profit.

Stigma: Discrepancies that may arise between virtual and actual social identity and may threaten the integrity of social encounters.

Symbolic Interactionism: A framework in which 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 present interactional challenges.

Virtual Social Identity: The range of normative expectations associated with who and what a person ought to be in a given social context or encounter.

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