Material Discourses of Health and Illness

Lucy Yardley, Lucy Yardley

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134773817
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Material Discourses of Health and Illness applies discursive approaches to the field of health psychology, in stark contrast to the bio-medical model of health and illness. The discursive approach uses the person's experience and feelings as the central focus of interest, whereas the more traditional models regarded these as coincidental and relatively unimportant.
The book provides an accessible and compelling introduction to social constructionist and discursive approaches to those with limited previous knowledge of socio-linguistic theory and research. It provides practical examples of how these approaches can be applied to the field of health psychology with a collection of sophisticated discursive analyses which demonstrate the distinctive contribution that can be made by psychologists to a field that has been largely dominated by sociologists and anthropologists.

Chapter 1

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Introducing material-discursive approaches to health and illness

Lucy Yardley

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The aim of this book is to explore a variety of ways in which a ‘material-discursive’ approach to health and illness can be implemented. The word ‘discursive’ is used here in a very broad sense to designate a range of approaches which recognise the socially and linguistically mediated nature of human experience. The term ‘material’ simply signals attention to the physical features of human lives, including not only our bodies and corporeal activities, but also our environment, institutions, technology and artefacts.

Discursive approaches ¹ have been rapidly gaining acceptance and exerting increasing influence across a number of disciplines, especially in the social sciences and humanities, and are now becoming increasingly popular within health psychology. These approaches are actually multiple, disparate and constantly evolving, but nevertheless share a central assumption: namely, that human activities and social practices have a profound influence on the nature of reality—both subjectively experienced and scientifically observed reality. It is simply impossible for humans to transcend their own capabilities and context; ultimately, we can only perceive the world around us by means of human senses (even when their investigative capacities are vastly extended by human technology) and in relation to human desires and activities, and we mustexplain it to ourselves and others using human cultural concepts and language. If it is meaningless to conceptualise an ‘objective’ reality which is somehow independent of our activities and understanding, this means that the neutral perspective to which science claims to aspire can never be attained. Consequently, rather than striving for the illusory goal of objectivity, it is more productive to examine the way in which our reality—including the particular version of reality portrayed by scientists—is shaped by the purposes and conventions, aspirations and assumptions, which form an intrinsic part of human life.

While some psychologists have welcomed the opportunities that discursive approaches offer to re-examine our conceptions of health and illness, others have viewed discursive ideas and methods as challenging, or even threatening, the fundamental principles of psychological theory and research. Some fear that abandoning the goal of scientific objectivity leads inevitably to ‘radical relativism’—a situation of intellectual anarchy in which all beliefs and values are treated as equally valid or invalid. This legitimate concern is addressed in Chapter 2, which discusses the alternative methods and standards employed by discursive analysts, and the complex and unresolved problems pertaining to the assertion or negotiation of intellectual authority. Although discursive writers are careful not to assert that their own (or any other) beliefs and values are universal and timeless truths, very few adopt the extreme relativist position that no comparative evaluations are permissible; rather, they seek to debate and elaborate the criteria for deciding the merit and utility of an analysis.

A second objection to discursive approaches is that they privilege the sociolinguistic dimension to such a degree that the material dimension of human lives is denied or overlooked. It is certainly the case that the new appreciation of the importance of culture and language understandably led many discursive analysts interested in health issues to focus initially on the implications of social and communicative aspects of these topics. For example, discursive writers have examined how illness can be accommodated and assimilated by the sufferer by means of narratives (e.g. illness as a turningpoint in life, or illness as an enemy to be fought and ultimately vanquished) which are used to create a viable new identity (Frank 1993; Riessman 1990). Discursive methods have been used to study the impact of dominant representations of health and illness in modern Western society, such as those which characterise people with disabilities as ‘damaged goods’, irreparably defective and unfit for display (Phillips 1990). In order to show how ‘reality’ is created by linguistic and social practices, others have analysed the way in which medical diagnostic practices are used to recast certain behaviours as ‘symptoms’ of mental ‘disorder’ (Harper 1992; Pilgrim 1992; Soyland 1994).

However, there is now a growing awareness of the need—which is particularly acute in the field of health and illness—to consider how the sociolinguistic aspects of experience relate to our material existence. To give just one example: in what way do the practical consequences of visual impairment (e.g. the inability to recognise and greet friends in the street or corridor) feed into the identity and social relationships of blind people?² Conversely, how do beliefs about the material aspects of blindness (e.g. that visual aids eliminate visual impairment, or alternatively that someone who carries a white stick is unable to see anything) influence the activities and opportunities of those with visual impairments? As soon as questions such as these are posed, it seems obvious that the socio-cultural and material aspects of human experience are intimately linked and that, while each can be studied separately, it is also useful to explore their reciprocal influence.

It is clearly important for health psychologists to include the material dimension of human lives in their theory and investigations, but how this can best be combined with socio-linguistic analysis remains a difficult question. One solution is to retain traditional methods of researching the physical and behavioural aspects of health and illness, but to also consider the impact of cultural and communicative factors, using discursive techniques. But for many discursive analysts, it is not enough simply to add a socio-linguistic angle to a traditional biopsychosocial analysis if this entails treating certain health-related phenomena as real (e.g. clinical test results) and others as socially constructed (e.g. illness perceptions). The problem is that, in practice, life cannot be simply dichotomised in this way. For example, an ‘illness perception’ may draw on embodied self-knowledge, such as an awareness of serious disease prior to medical diagnosis. Conversely, medical students soon discover that convention and interpretation are involved in determining the significance of even an X-ray (see Radley 1994), and that X-rays can serve a primarily symbolic function by reassuring the patient or affirming the expertise of the doctor. It is for this reason that a ‘material-discursive’ approach is adopted in this book, presenting a range of illustrations of the varied and complex manner in which the sociolinguistic and physical dimensions of health and illness are intertwined.

The second half of Chapter 2 outlines some theoretical perspectives that appear compatible with a material-discursive approach, and then considers the diverse ways in which the chapters following apply these perspectives to health-and illness-related topics. However, as a prelude to discussion of the possibilities for material—discursive approaches, it is useful to consider first the nature and origins of existing discursive approaches to health and illness. The next section sketches a brief outline and history, therefore, of biomedical, biopsychosocial and discursive perspectives on health and illness.

CHANGING PERSPECTIVES ON HEALTH AND ILLNESS

Development of the biomedical model

Over the past three centuries during which modern medicine has developed, its success has been attributed (at least by the historians of the medical profession) almost entirely to advances in the understanding and control of biological processes. Improvements in health and longevity are credited to the victory of medical science over nature: the conquest of invasive disease, the correction of physical malfunction, the repair of accidental damage, and the management of risky events such as childbirth. These triumphs are in turn attributed to ever-expanding scientific knowledge about the mysteries of anatomy, physiology, biochemistry, and (most recently) molecular genetics, together with increasing technological capabilities relating to procedures such as diagnostic testing and surgery.

In this biomedical account of how ill-health is conquered, the achievements of biomedicine are typically somewhat overestimated. Despite the undeniable, and often wonderful, power of modern medicine to cure, prevent or alleviate many physical ills, reduced morbidity and mortality rates in Western populations are actually due in large part to socio-economic and life-style factors such as improved diet, housing, hygiene and safety (Lewontin 1993; Fitzpatrick 1991). But the rhetoric of biomedical supremacy seems persuasive because it forms part of a larger discourse which has dominated Western thinking since the birth of the industrial era (Gordon 1988)—a discourse which asserts that by means of accurate observation and rational deduction human beings can attain an objective knowledge of the nature of reality that will enable us to predict and control nature (including our own bodies).

One of the fundamental premises of this ‘realist’ or ‘objectivist’ view is that facts about the world can be empirically ascertained by an objective observer (ideally, a trained scientist), and that these facts are independent of the sociocultural context in which they are determined and untainted by the assumptions, goals, activities or previous experience of the observer. Subjective phenomena such as attitudes, beliefs, values and emotions are considered to be potential nuisance factors which can obscure or misrepresent the true state of affairs. From a realist perspective, biological phenomena, which are regarded as objective facts, therefore tend to be seen as more reliable and fundamental (and also more controllable and commercially useful) than the psychosocial context and meaning of these phenomena (Benton 1991). The result has been the emergence of a dominant biomedical model of health and illness which is based on ‘biological reductionism’—in other words, a belief that bodily events are best explained exclusively in terms of objective physical processes, and that these must be distinguished from the psychological and social factors which might bias or distort how physiological events are perceived. Consequently, whereas physicians and healers in previous and non-Western cultures might see the social, subjective or spiritual significance of illness as an intrinsic and significant part of the phenomenon (a view often shared by the afflicted person and his or her associates), modern Western diagnostic practices are designed to exclude, or at least isolate, these aspects of illness in order to focus more clearly on the biological processes, which are regarded as of primary importance.

Development of the biopsychosocial model

The dominance of the scientific biomedical approach has never been total. One alternative model of the way health should be understood and promoted is the parallel tradition of ‘social medicine’, which in the last century took the form of large-scale interventions to improve public health through measures which ameliorated living and working conditions (Turner 1992). In the early part of the twentieth century, psychoanalytic and psychosomatic theories and research helped to foster an awareness of the contribution of the psyche to ill-health. And during the latter part of this century, as acute contagious disease has given way to chronic illness and disability, and the costs and limitations of scientific medicine have become increasingly apparent, there has been a growing appreciation of the need to consider psychosocial influences on health.

In the 1970s, the application of behavioural principles to health problems gave rise to the interdisciplinary field known as ‘behavioural medicine’, while ‘health psychology’ emerged as a new discipline. At the same time, a psychiatrist named Engel proposed the ‘biopsychosocial model’ as a framework for integrating knowledge about the biological, psychological and social aspects of illness (Engel 1977). Based on systems theory, the model was intended to foster the analysis of developmental processes and the reciprocal interactions between different levels of the human ‘system’, from the biochemical to the socio-cultural (Engel 1982; Schwartz 1982). The model was warmly welcomed by social scientists because it affirmed the importance of psychosocial factors and over the past two decades there has been a vast expansion in ‘biopsychosocial’ research.

As recommended by Engel, most of this research has produced quantitative measures of psychosocial variables such as behaviour, beliefs or perceptions, and then correlated these with signs of the presence, severity or progression of disease. These descriptive studies have been complemented by analysis of the physiological and medical consequences of experimentally or therapeutically induced changes in reported beliefs or behaviour. One major advantage of this approach has been that it has enabled psychological research to win acceptance from medical clinicians and researchers who are familiar with the language and procedures of scientific investigation. Employing methodologies such as laboratory-based experiments, quantitative questionnaire data and statistical analysis, it has been possible to achieve widespread recognition in medical circles that psychosocial factors significantly influence health status. The consequence is that psychology now forms a (relatively small) part of the medical school curriculum, and clinical and health psychologists have been given an increasingly substantial role to play in the promotion of health and care of the sick.

Development of discursive analyses of health and illness

Health psychology has always drawn inspiration from mainstream psychological theory, and especially from social and clinical psychology. While these disciplines were dominated by the behavioural and cognitive paradigms, there was relatively little difficulty in combining psychological and biomedical data; both were considered to have a similar epistemological status as scientifically verifiable facts, amenable to objective and quantitative measurement and analysis. However, the rise of discursive theory and methods in social psychology (e.g. Gergen 1985; Hollway 1989; Potter and Wetherell 1987) and constructivist approaches in clinical psychology (e.g. Mahoney 1993; McNamee and Gergen 1992) has led some critics to question both the objective reality of biomedical and psychosocial ‘variables’, and the suitability of the traditional biopsychosocial model as a framework for understanding and researching human experiences of health and illness (Armstrong 1987; Stainton-Rogers 1991, 1996; Stam 1988).

A key problem identified by these critics is that the biopsychosocial model seeks to assimilate and incorporate non-medical aspects of health and illness while retaining an essentially biomedical perspective. For example, Engel advocated adopting a ‘rational scientific approach to behavioural and psychosocial data’ (Engel 1977:132), in order to create psychosocial variables comparable to biomedical measures. This implies that standardised...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Contents
• List of contributors
• Preface and acknowledgements
• 1 Introducing material-discursive approaches to health and illness
• 2 Introducing discursive methods
• 3 What role does the body have in illness?
• 4 Interpretative phenomenological analysis and the psychology of health and illness
• 5 Social and material ecologies for hearing impairment
• 6 Disorientation in the (post) modern world
• 7 The relationship between representational and materialist perspectives: AIDS and 'the other'
• 8 Discourses and sexual health: providing for young people
• 9 Discourses of pregnancy and childbirth
• 10 Diet as a vehicle for self-control
• 11 Speaking the decorated body
• Index