Social Constructions of Illness Part I
What does ‘construction’ have to do with it?

Freidson

Freidson is concerned with understanding how medicine creates the role of social illness, or as he puts it, the social possibilities of being sick. He is interested not in the etiology of illness per se, but rather on the label and the meaning given to the experience of illness. Inherent in his argument is Parson’s notion of the sick role: Freidson believes that to take on the social label of ‘sick’ means you have equated sick as the official social role. (notice the crucial role that is played by society)

Medicine as a profession, defines what symptoms/ailments are sick – we see the physicians’ daily activities: s/he defines who is normal and who is not. Thus, Freidson centers his analysis on the very notion of ‘deviance’:

How does medicine create the role of social illness?

How does the social state of illness differ from other social states?

Can we create a social taxonomy that is meaningful in understanding social deviance?

What role does ‘medicine as a profession’ play in this?

 

Brown

Brown is a more comprehensive piece, almost a literature review. He begins an exposition on social construction and then considers what this means for diagnosing illness. He introduces a revised (new) model that takes into account constructivism and the effects of social structure. His argument is centered upon the following:

What does social construction mean for medical sociology as a field?

What is the relationship between social construction and diagnosis?

What are the stages in the social construction of an illness?

What are stages of treatment and outcome for social constructions of illness?

 

Some issues we might consider:

i) Forms of constructivism-

a. Traditional view- social definitions of actors involved in a situation are what matter- not the action or condition itself (Spector/Kitsuse). Based upon various types of social control and settings where control occurs (dr.-patient) or

Contextual (a concern with conditions and how conditions arise) and strict (what matters are the meanings and claims made by actors)

b. Postmodern theory (Foucault based) focus is on deconstruction of language, symbols, structures to gain an understanding of reality

c. Soc. Science- based on local actions and constructions in laboratory setting- how discovery of disease is dependent upon social negotiations and agreements of what exists-Latour. (NB: sociologists of science contend with different meanings of ‘social’ constructivism- a point Brown glosses over)

ii) Meaning(s) of social construction: It’s relation to social causation and diagnosis

social causation- how does it differ from social construction? (define a health status- underlying social cause; proximate social cause; mediating social cause. Versus the meaning that is imputed to a social construction (how we determine there is a condition or disease.

diagnosis reflects difference between disease/illness; process and category; or diagnosis as a tool of medicine (label giving voice to the profession)

iii) Typology that considers both conditions and biomedical definitions- how important is this model in illustrating the dynamic nature of social constructions? (model needs to consider development, or stages of social construction of disease-but what IS this (43)

iv) Social discovery of disease is dependent upon a number of variables: lay perceptions of discovery (initiation); social movements; professional factors; organization and institutional factors.

Questions to consider:

How much of a constructivist is Brown? Consider for example his position (p. 37) on identifying phenomenon and the impact of the underlying social stratification system. Does this position assume that structure, stratification are fixed entities?

Is this new model (symbolic interactionist and structural/political-economic approach) actually new? What does it provide that pure constructivist models don’t?

 

Link et al.

Link introduces the basic precept of epidemiology- the search for identifying individual risk factors in disease. Finding fault with this basic premise, ‘individualist approach provides us with proximate causes of disease’, Link argues for the modification of the model: one that highlights the importance of social conditions in the study of illness.

Social conditions are defined as factors that involve relationships of individuals: among people; with position and status; with structures of society. These conditions are important in that they uncover a pattern of disease. Studies on social conditions help to clarify directional causality, process or mechanisms of disease; effects upon disease. He suggests this can be accomplished by:

Contextualization of risk factors- provide a framework that demonstrates why and how people are exposed to risk factors; identify the social conditions where individual risk factors are related to disease

Identifying ‘fundamental social causes’ of disease: ‘fundamental’ is defined as involving access to resources that can be used to minimize risks or disease.

 

Question:

What is to be gained by contextualization?

Why does Link believe that ‘SES is a fundamental cause of disease’- examine the error of Kadushin study. (87)

 

Segal/Chapell

In this case study, the authors ask the question how it is that people interpret and manage ill health experiences. Much of what they show in this piece exemplifies the points made by all authors, but especially Freidson’s notions regarding lay and professional conceptions of illness. A good example of how one gets at ‘meaning’ and ‘managing’ illness. Some important findings:

Case study finds that lay and professional positions about illness are not mutually exclusive. Individuals can accept ‘science’ and ‘medical definitions’ without summarily rejecting popular health beliefs

The relationship between cause, management, and outcome of disease needs to be further examined- especially if one is to determine how lay belief system works.

Freidson Profession of Medicine, Chapters 10, 11, 13

Consider how biological and social deviance differs?

Illness may indeed by a biological state but an illness is a label (diagnosis) and this has consequences for an individual’s behavior. This is why Freidson argues that the social state of deviance is ‘added’ to the biological sense of deviance. It is the social state that assigns meaning to illness.

Classification of social states

This is a simplified model taken from Parsons’ sick role: the sick role is itself conditional, temporary, and offers legitimacy. This is because the model states a) individual is not responsible; b) individual is exempt form obligations; c) illness is seen as undesirable; d) ill (deviant) seeks competent help. This model equates sick with patient who is under the social control of the physician. However, this model is problematic:

Centering sick role within doctor patient relationship is misleading: ignores societal reaction (this is where absolution of obligations comes from) and only takes into account the reaction from medical field

Exemption from roles/function is dependent upon the seriousness of deviation, and this is determined by society

Assignment of non-responsibility legitimizes behavior-how does this come about?

Understanding the importance of society- imputing deviance:

When faced with societal response, an individual will organize and take on a defensive/offensive role at some point in time. Question: How does the strength of societal response (imputation of deviance) lead the individual to take on the deviant role? For Freidson, it is the social structural societal reaction that is KEY here- it is the seriousness of imputed offense that will lead it to be rationalized away (primary deviance) or organized as a social role (secondary deviance). It is clear therefore that deviance is dependent upon societal reaction to a very large degree- The label ‘deviant’ has numerous outcomes as is most evident by obligations and privileges that are either lost or gained. This is the essence of chart on page 232- deviance as crime or illness.

Lay conceptions of illness:- decided along two dimensions:

Deviance from well being (health

Structure of lay social life

Pain responses: group membership and social meaning of pain is dependent upon social context- differs in expression of pain and attitudes toward pain (complain, worry, drug use or abuse)

Meaning of the perception of pain – how is an illness defined?

Again, this involves imputation of deviation from the norm- how to distinguish health from illness:

Recency of onset/interference of activity

Overall conceptions of health: no symptoms, or high level functioning

Functioning is dependent upon routine experiences- this has consequence for what lay people consider a symptom:

(285) symptom, illness is deviation from everyday experience and is rooted in culture and history of a group.

Meaning of experience of pain – difference between middle and lower class and their understanding of medical knowledge- this is linked to referral system:

Middle: abstract notion of illness- not how I feel but what this may mean

Lower: personal experience- how I feel, pain, and discomfort.

Links to social life, content, structure: kin, family, neighborhood, work place, etc.

Role of others: validates illness/symptom by reactions to my complaints and their beliefs about complaints-important because it is society that releases me from obligations and provides me with privileges

Referral system: entree into health care-

Structure seeks legitimation; seek care and advice, implicit diagnosis, lay referral system. Again, example of middle/lower class as parochial or cosmopolitan referrals.

Referral system says a great deal about the utilization of services- utilization is ultimately affected by:

cultural variation of meaning of illness from professionals and lay people

structure of the community itself- pushes or pulls you toward physicians (consultation room)