Health, Sickness, Society and the Mind
This 3rd edition of Psychology and Sociology in Nursing aims to address a few key issues:
- Want is the importance of sociology and psychology in health care?
- What can medical sociology and the social sciences generally do to help health professionals?
- How does studying psychology and sociology help us to understand the definition of health?
- Why do we undertake the health behaviours that we do?
- To what degree are we responsible for our health?
This book explores sociology and psychology relevant to nursing and explains why it is so important to understand these disciplines in order to be a good nurse. It is written specifically for nursing students, and clearly explains the key concepts using nursing case studies and examples. Chapters move from individual and personal issues onto society as a whole and explore the psychological and sociological basis that underpins all aspects of nursing practice.Click To Tweet
- All content linked to the sociological and psychological requirements in the NMC standards of proficiency for registered nurses
- Activities to help build critical thinking, independent learning and decision-making skills
- Case studies and scenarios that link sociological and psychological theory to nursing practice
In this blog, I’d like to discuss some of the key thinking that supports the book.
Why do we do what we do? The poverty of individualist explanations.
We all like cake don’t we? Oh, and beer…and yes wine…and…and….
Responsibility for Health
In common talk around health issues, we hear and read a great deal about ‘taking individual responsibility for health’ or the need for ‘helping people to make better choices’ and we hear explanations for ill health based on people’s choice of unhealthy lifestyles. Papers like the Daily Mail like to focus unhealthy working class ‘chav’ cultures in a bid to promote outrage and to garner support to reduce the Welfare State. Every New Year, gym membership rises, dry January is embarked upon and resolutions to quit smoking are made. Failure often follows. The UK population is getting fatter, it drinks excessively and takes little exercise. We are also a nation consuming antidepressants as if they were smarties.
Some individuals of course are ‘paragons of virtue’ in terms of health and the question is asked “if they can do it, why don’t the rest of us?” Often this is framed within personal success stories as “I did it, so you can too (you fat lazy bastard)”. Celebrities are often promoted as role models for a “leaner, fitter, healthier you”.
Most people probably know that eating better and taking more exercise is better for health. So why do we see continuing patterns of chronic ill health, patterns which show social class differences, i.e. the ‘social gradient’, and unequal health outcomes. Those in the lower socio economic groups die younger, experience more chronic illness and have fewer disability free years. Is it really all down to individual moral failure? Why don’t millions of us get up off our fat arses, do something positive and take responsibility for health? Why don’t we as a population exercise our agency to act for better health? After all, we are all free autonomous people able to choose courses of action.
The complete freedom to think and act may be more complicated than adherents of the ‘autonomous sovereign individual’ may have us believe. The model of the ‘free sovereign individual’, so beloved by libertarians, neoliberals and most hues of conservatism in their political stances, is a flawed and incomplete model of human behaviour. It is a model of human behaviour that arose in Enlightenment modernity, and results in the creation of ‘homo economicus’, the free instrumentally rational being, who weighs up the pros and cons of action independently of social or cultural influences or internal psychological drivers, and is 100% responsible therefore for the consequences of their action.
Max Weber – Rationality
Max Weber introduced the word ‘Verstehen’ (German for understanding, perceiving, knowing) to describe the sociologists’ attempt to grasp both the intent and context of human action. While the ‘man of modernity’ developed by the thinking of Enlightenment philosophers, was increasingly thought of as using instrumental rationality to guide action, Weber described 4 ‘types’ of social action that might have been neglected in this new model of ‘being human’:
- Zweckrational – action based in means/ends rationality (the dominant explanation ‘modernity’)
- Wertrational – action based in values based rationality
- Affective action – emotion based action
- Traditional action – action based in custom and practice.
Today, many downplay, ignore or forget all but ‘zweckrational’ in their condemnation of unhealthy behaviours, assuming that is our only way of thinking. We know from experience however, that we choose courses of action not because they are always meeting a certain goal, but because of a mixture of all 4 types of reasoned action. Many also think about these types (if at all) as existing independently of society. Weber’s insight was to link these types to changing social conditions. He argued that modern societies differed from those of the past because of the shift to zweckrational thinking rooted in the growth of bureaucracy and industrialism. This might explain why today, in bureaucratised, industrialised societies, that instrumental, technical, means ends thinking came to dominate. The error for many is that the ‘is’ of the dominance of zweckrational becomes the ‘ought’, the only way to think and it becomes the assumed method of human thinking. I suggest that those trained in scientific, technical and logical (means-ends) occupations are apt to think using ‘zweckrational’ but assume that is how everybody else does and ought to think. They then become one dimensional in their own thoughts, unable to grasp the complexity of human decision making. If we actions are based in means/ends rationality, that we have weighed up pros and cons of smoking, then we are responsible for those decisions. We have no one to blame for subsequent illness.
It is the assertion throughout the book that this is a partial understanding of human choices and behaviour at best.
Margaret Archer – Modernity’s Man
The social theorist Margaret Archer also describes the Enlightenment’s ‘man of modernity’ as “a being whose fundamental constitution owes nothing to society” (2000 p 51) and (following Weber) who is increasingly driven by instrumental rationality or ‘means-ends’ thinking. This is the ‘ready-made man’ who turns up out of nowhere to impose his own order on the world and applies rational thought to social concerns. It is a view of humanity that believes that our ‘self’, our individuality, exists totally separate from society, that it is not constituted at all by society or culture. The free acting self is an ‘independent of society and culture’ free thinking and rational being. We will hear echoes of this man’s voice when we hear such statements as “only the individual should and can take responsibility for health”, “there is no such thing as society, just individuals and families” and “eat less – move more” injunctions to reduce weight. Any idea of social structure, cultures or ‘social forces’ is completely denied. In this view there are no social or psychological mechanisms operating ‘behind our backs’ that might be guiding ‘free’ choices.
The theory underpins libertarian political views which frequently denies the existence of society promoting the individual to the throne of consciousness. This model of the self assumes the primacy of agency devoid of social structure or cultural or language contexts. It not only assumes the primacy of agency, but elevates it into a core aspect of a political project (neoliberalism) to reduce any action on poverty or welfare beyond that of individuals, families and charities. If there is no society, then there is nothing society can or should do.
Those who adhere to this model might think that obese and overweight people merely freely choose to eat more than they need, that their inability to lose weight is down only to their weak moral character and lack of will power. The obese should “just say no” to a second pork pie. Against this I suggest that they eat and move within the structures and cultures of the ‘obesogenic environment’ (Foresight 2007) and within cultural practices around food that becomes aspects of who they are, that they build into their self-concept. Veganism for example has been seen as the preserve of a slightly effete minority and for many men especially, just cannot be built into their own notions of self as ‘red meat eating males’. Their self-concept as a man excludes this food choice as viable. They are of course free to act as a vegan but the structural and cultural context militates against men many doing so. Some men will be able to draw upon their material, psychological, biological, social, cultural, spatial and symbolic assets to exercise their agency to become vegan. Many others will not be able to exercise the same degree of freedom to do so.
There is not the space to fully explore this idea of the ‘free, pre-existing, independent from society’ view of self, other than to suggest that extricating human agency and the ‘self’ completely out of the effects of language, culture and social structure is erroneous. I emphasise however, the pernicious persistence of this idea in current culture, politics and health policy as it underpins much understanding of, and pronouncements about, human behaviour towards health.
I also suggest that those whose knowledge is non-existent, or superficially grounded, in philosophy, the humanities or social sciences cannot exercise their agency to begin to understand this argument. Their ‘ways of knowing’ and sense of self is in violent opposition to it. They will be so embedded in certain social structures and cultural assumptions and values that the self they experience is unable to grasp the concepts. They will read the words but will feel an instant visceral hatred of the challenge to sovereign individuality because it shakes the very foundations of who they think they are and the basis for success and failure. Current ideal types would be Boris Johnson, Peter Thiel the PayPal billionaire, Rupert Murdoch, Donald Trump, many in Silicon Valley and the alt-right. In fact most of the powerful world leaders would fall into this category including Putin, Erdogan and Modi. They all feature varying degrees of narcissism and the assumptions of what Graham Scambler calls the ‘Greedy Bastards’.
Towards a social theory for human behaviour
Part of the answer to understating why we do what we do, will be found by exercising our sociological imaginations to gain a fuller understanding of human behaviour. We need to think beyond the action of an individual, to consider the wider actions of society and culture that provides the context for individual choices at this point in history.
Take the choice to eat insects. In the UK we are free to do so. We could exercise our ‘free agency’ as sovereign individuals. There is no biological reason why we don’t. There is no legal barrier to doing so. There is no trade barrier, tariffs or taxes in importing insects as food. What prevents us eating insects is a combination of cultural barriers with a lack of social institutions that values eating insects, and there are no social institutions providing access to insects. Psychologically we might think that the eating of insects is not part of our ‘self-concept’, there is no social learning going on because no one is doing it, the mental short cuts bypass rational appraisal and go straight to the ‘yuk’ factor. We live in an obesogenic environment and not an ‘insectivorous’ environment.
Why do fat people eat pork pies? Why don’t thin people eat insects?
Graham Scambler in wishing to establish a theory of agency in sociology argues:
I think this means that if you want to know why some people can resist eating the pork pie and most in the UK resist eating insects, you have to think holistically rather than individualistically. You have to avoid the temptation to be reductionist and instead think ‘systems’.
A biologist would focus on physiological processes and raise the importance of body chemicals such as leptin, dopamine, serotonin and endorphins in stimulating behaviour. They might acknowledge the physiological role of sugar and processed carbohydrates in providing very satisfying, but unhealthy, eating habits. This is perhaps the first hurdle that ‘will power’ has to overcome. ‘Willpower’ is of course the ‘go to’ mechanism for those with individualist understandings which some suggest is in any case a poor mechanism.
Psychological Concepts and Health behaviour
A psychologist might explain eating patterns from a variety of perspectives: cognitive psychology might outline the role of mental short cuts that bypass rational thinking; behavioural psychology emphasising the conditioned nature of responses; social psychology which asks us to consider the power of social learning upon choices and psychodynamic psychology which would raise deep seated emotions as drivers for behaviour, e.g. food playing the ‘comfort’ role. All have explanations that downplay the power of conscious instrumental rationality (zweckrational).
Key concepts within psychology which could be linked to why we eat as we do include:
- Body Image.
- Locus of Control.
- ‘What the hell’ effects.
- Future Discounting.
- Classical/Operant Conditioning.
- System 1 and System 2 thinking.
- Self and self-awareness.
- Adult, Child, Parent Ego States.
Both biology and psychology examine the individual body and mind. They seek explanations for human agency within ourselves. For some people, that is enough. Yet both disciplines cast huge doubt on the idea of ‘free thinking sovereign individuals’ who use rational thought, and the exercise of sheer willpower in achieving their aims.
If you have not eaten for three or four hours, and you pass a shop selling freshly baked bread or pasties, or foodstuffs you very much enjoy, your will power to lose weight is severely challenged first by your biology as the body reacts to sight and smell of delicious food and then by your psychology as the ‘what the hell effect’ kicks in supported by ‘future discounting’. Your future self as a slim lean athlete is discounted by your immediate self’s need for food. As you go through your day you are immersed in social and cultural invitations and opportunities to eat and to eat too much. Against this is will power, unless you can actively design your social and cultural environment every single day to support will power, you may well crack. Do you have the material, psychological, social, cultural, spatial and symbolic assets to do this day after day after day for years? For the rest of your life? Some also have poor biological health assets in this regard as in utero processes may well have pre-set a certain weight for you that your body will always want to get to.
We are not completely free autonomous agents beloved of neoliberal ideology. Our lives are highly structured, but not determined. We are the result of a complex interplay of our biology, our psychology and the social. Underpinning much of the common discourse in our media is the idea of the ‘liberal human self’, and failures to live healthy lifestyles are to be found in the individual. This belief, and it is a belief not a scientific fact, often leads to a ‘Moral Underclass Discourse’(MUD) to explain health inequalities. The MUD focuses on cultural and behavioural explanations, rather than sociological, for health inequalities. It is a discourse that leads easily to victim blaming.
We need to think a little more critically about this explanation, particularly as it has a great deal of political and social force in terms of policies we design to tackle health. We need to bring the social (structure) into the individual (agency). We need to ask to what degree are we free agents who can take 100% responsibility for our lives, we need to examine what social structures exist in which that agency operates.
Margaret Archer: Agency Structure and Culture
Margaret Archer has published a series of books on this central problem of structure and agency, i.e. the relationship between our personal actions as free agents and the societies and social structures we are born into.
We know that smoking is linked to illness and disease, we also know there are patterns to smoking which show prevalence is not spread equally across class or age. If we want to more fully understand smoking behaviour we require not only the sociological imagination but also why people as ‘free agents’ continue to smoke despite knowing the consequences. The answer is of course complex, situated in and mediated by a matrix of the biological, social and psychological. Smoking occurs in a social context in which people are enabled or constrained in their behaviours by the structures and cultures of society and mediated by their and others’ ‘reflexive deliberations’ and to a degree, their biology (the ‘substance’ (nicotine) theory of addiction).
Archer’s theory suggests that our individual actions are predated by the existence of social structure of, for example, class relationships. Class structure, and the culture associated with it, are transmitted to individuals. In smoking’s case, the culture of smoking was once widespread across all social classes and therefore to take up the habit was not to be seen as a social pariah. Quite the opposite. George Orwell in both ‘Homage to Catalonia’ and ‘The Road to Wigan Pier’ describes vividly the valued place of tobacco in people’s lives. Today however, smoking has a class characteristic to it, the middle classes apparently are more open to health warnings than those lower on the social scale. This ‘predates’ any individual coming into puberty today. The ‘cachet’ associated with smoking, or its status as a rite of passage, has to be factored in to understanding why some people shun the habit while others embrace it.
Archer however does not wish to over emphasise how such social structures affect action, rather there needs to be a focus on how agents respond and act to those circumstances. There is a causal efficacy to agency, we are not automatons responding to class structures or obesogenic environments. We can make choices to act in certain ways to not buy the pork pie. We do so by having internal conversations which are mediated by our ‘mode of reflexivity’ which at this point in history is particularly salient.
You and I are confronted in our daily lives by social circumstances, and we have a choice of action. We bring to that choice of action our own priorities, our ‘projects and concerns’. What we then do is mediated by the type of internal conversation, or reflexive deliberation, we have. Archer’s thesis is that in the past social structures were such that little self reflexivity occurred. We ‘knew our place’, we knew what our role was and what status we had. However, as societies modernised, cultures and structures confronting us are far more open to change and critique, and are so by the actions of the people involved. Women for example, no longer took for granted that their place was to rear children and to engage in domestic labour. They thought about the franchise and employment and some decided to act differently to ‘break the mould’. Why do some act to challenge social structure and why do others conform and thus replicate social structures?
“The subjective powers of reflexivity mediate the role that objective structural or cultural powers play in influencing social action and are thus indispensable to explaining social outcomes’ (Archer, 2007: 5).
In other words, your inner voice is confronted by the facts of the obesogenic environment or of social class or of gender relationships in the work place, but that fact can be acted upon so that action can for example be fatalistic towards that circumstance or instead might confront it in an attempt to overcome any perceived or actual disadvantage.
Agency is necessarily contextualized, it occurs in a context of social structure and culture. That is the objective fact the people confront every day.
Archer’s (1995, 2003, 2007) way of articulating this is in terms of a three-stage model.
- Structural and cultural properties objectively shape the situations that people confront involuntarily; the structural and cultural possess powers of constraint and enablement in relation to
- People’s own constellations of concerns, as they define them.
- Courses of action are produced through the reflexive deliberations of subjects who subjectively determine their practical projects in relation to their objective circumstances.
Think about the social structures that produce, advertise and market and then distribute food – how that this currently characterised by the industrial production of delicious, tasty and cheap foodstuffs packed with sugar, salt and calories. The objective cultural context might include aversion to walking and cycling as we perceive these as impractical, dangerous or too slow. Think about the culture of eating food and the sociability that surrounds certain foodstuffs. What currently does wine play in the cultural life of many women and beer for men? These objective conditions provide ‘enablements’ to eating easily too many calories. It is made easy to do so. What constraints do we have in eating too much? Well, against the above we have health injunctions not to do so, we have body images that emphasise thinness with attractiveness. If the various constraints to eating too much are not as strong as the enablements, then the individual has to work hard on clearly identifying their ‘concerns’ – one of which is to lose weight. This has to be turned into a project, something that they focus on every day to combat the many opportunities to fail at achieving the goal. People will tell themselves if the daily project of losing weight is achievable given the reality of their working and social lives. They will draw upon their health assets to help them do so. If their health assets are very poor across the board success is not impossible (they are after all free agents) but it will be harder.
Agency operates within certain social and cultural contexts, so consider how agency operated by an A list actress and a struggling in debt mother. What social ‘forces’ propelled them into two very different circumstances and how much is down to personal achievement, luck or circumstance? Consider they now give birth to daughters. What are the chances of either girl using personal agency to radically alter their circumstances. Yes, it happens (e.g. Oprah Winfrey) but who will have the easier path?
It has to be noted that although we retain our agency, we tend to reproduce social structures and cultures rather than radically change them – in Archer’s words this is ‘morphostasis‘
Health Assets – “There but for the grace of God”
The following table are ideal types to illustrate just some of complexity of the interplay between biology, psychology and sociology in understanding health choices and health outcomes. These factors are not be thought of as a simple cause effect relationship, there are feedback loops and emergent properties from the whole. Nothing is predestined, all is possible. The list is not exhaustive either. There may be other confounding variables that will change outcomes. The actress may develop a cocaine habit, Vicky may become an ‘Educated Rita’.
|Asset||A list celebrity Actress||Vicky Pollard “yeah but no”|
Non variant FTO gene
No chronic illnesses
Variant FTO gene
High self esteem
High body image (body reality matches body ideal
Internal locus of control
Emotional and sexual support
Low self esteem
Poor body image (body reality far from body ideal)
External locus of control
Emotional and sexual abuse
Bouts of depression
|Social||Similar looking thin peer group
Network effect positive
Social support for domestic needs
Child care easily affordable
Food prepared by nutritionist
Supportive parents and spouse
Wealthy successful peers
The 0.01% Global elite
Private School and Drama school paid by parents
|Similar looking fat peer group
Network effect negative
No social support for domestic needs
Child care expensive
Food prepared by Greggs
Parents both dead, absent partner
Poor just about managing peers
The local Precariat
Left at 16 with no qualifications.
Health high priority
Emotional, verbal and physical violence common/expected
|Spatial||Beverly Hills, Sunshine, Sea View and palm trees||Concrete high rise, Rain, Industrial Units and burned cars|
This asset is paramount as it feeds into the others
|High Net worth
Where do we go from here?
I think that any definition or discussion of health has to include concepts such as agency, structure and culture, it has to admit the complexity of ‘being human’ in complex consumer societies. We have to shift away from victim blaming, stigmatising, and dehumanising whole classes of people. It requires us to be critically reflexive about our own social and psychological positions and to think about what health and social care policies are appropriate in this context.
This book is a small step in that direction.
References to chase up:
Graham Scambler, emeritus professor at UCL, has written a series of blogs based on the work of Margaret Archer. His work can be found here: http://www.grahamscambler.com/sociological-theorists-margaret-archer/.
Archer,M (1995) Realist Social Theory: The Morphogenetic Approach. Cambridge; Cambridge University Press.
Archer,M (1998) Realism in the social sciences. In Eds Archer,M, Bhaskar,R, Collier,A, Lawson,T & Norrie,A: Critical realism: Basic Readings. London; Routledge.
Archer,M (2003) Structure, Agency and the Internal Conversation. Cambridge; Cambridge University Press.
Archer,M (2007) Making our Way Through the World. Cambridge; Cambridge University Press.
Archer,M (2012) The Reflexive Imperative in Late Modernity. Cambridge; Cambridge University Press.
Archer,M (2014) The generative mechanism re-configuring late modernity. In Ed Archer,M: Late Modernity: Trajectories Towards Morphogenetic Society. New York; Springer
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