47 Encroachment

Professional boundaries are always being tested: by competitors and superior and subordinate allies who see some advantage in taking over particular professional territory ^[1]; by funders and legislators who want service reform; and by service users and advocates who want more or less from their providers. There are two sorts of encroachment: horizontal and vertical. Horizontal encroachment often comes from other professional groups that have similar social power and prestige. Upwards vertical encroachment, on the other hand, occurs when a subordinate group seeks to take over territory from a more prestigious one. The much less common downward vertical encroachment, occurs occasionally when a dominant group claims an aspect of the work of a subordinate.

It is often thought that the elite professions would rather not have to face encroachment and dislike competition, but neo-Weberians argued that, in reality, territorial disputes are used by professional groups to define and solidify their own position. Valerie Fournier and Caragh Brosnan, for instance, showed that medicine had actively used the idea of charlatans and ‘quacks’ to its advantage ^[2][3]. On the one hand, the quack was vilified as an amateurish corruption of ‘real’ medicine. But, at the same time, medicine relied on quackery to develop and demonstrate its distinctiveness, when little evidence existed for medicine’s own therapeutic efficacy.

Social action perspectives do not see subordinated professions as passive in their subordination, but rather actively involved in their own struggles for prestige and social status. Work on alternative and complementary therapies has been particularly important here. Deborah Lupton considered the ways that alternative therapists had traded on their rejection of Western biomedicine’s reductionism and objective detachment to ‘reconnect the bodily and social worlds and often to effect social transformation’ ^[4]. Being able to claim ‘that their approach offers a viable, non-alienating, more ‘natural’ and less invasive way of promoting health and curing ills’ (ibid), has given non-orthodox practitioners a way to define their distinctiveness without having to default to biomedical concepts and language.

What such contests show is that a whole range of occupational closure strategies have been used by professions to negotiate jurisdictional conflicts and increase the profession’s market value. These include systems of:

• Exclusion — or containment strategies by dominant groups designed to restrict access to people, resources, training, employment, and so on, to allow a select few to have privileged access;
• Inclusion — normally performed by an excluded group involving efforts to be accepted (gaining licence, allowing dominant group control, or adopting a dominant group’s philosophy, etc.);
• Demarcation or limitation — in which a dominant group defines a unique territory for a subordinate that does not impinge on that of the dominant group;
• Usurpation — where a socially inferior group eats into the power of a more dominant group (this can relate to all marginalised groups, but also subordinated professions generally);
• Expulsion — where a socially inferior branch of a dominant group is removed to consolidate the power and status of the majority;
• Subordination — where a dominant group delegates activities and allocates professional scopes to others in order to raise its own prestige and reinforce the subordination of another;
• Mystification — in which the profession alludes to aspects of practice that are hard to define for ‘outsiders’, or deliberately creates social distance ^[5] between the profession and the ‘other’ in order to justify their distinctiveness;
• Dependence and protection — where a dominant group relies on a subordinate group for a specific service, and restricts change by conferring socially advantageous forms of privilege and protection.

Of course, encroachment practices may involve the complex interweaving of many of these strategies at the same time, and their effects can be equally convoluted. Susan Roberts, for example, argued that it was often difficult for marginalised or oppressed groups to take on the norms of the dominant group, but that by adopting the philosophy of the dominant profession, the subordinate could achieve more power, control, and social status ^[6].

Andrew Abbott thought that it was possible to distinguish super-ordinate professions, or professions with greater social prestige, from subordinate professions, by their approach to distinctiveness or similarity. Superior professions, he argued, tended to emphasise their difference from others, while subordinate professions tend to focus on similarities. Different professions can hold different kinds of positions depending on the status of the other profession in question. So nursing, for instance, has moved to show its similarity to medicine by adopting evidence-based practice, diagnostics, and a curative ethos. At the same time, it has used these philosophies to distance itself from low-prestige care and the work of healthcare assistants ^[7]. Such moves can be problematic, however, particularly if they involve a profession turning away from a philosophy of practice that it once used to define itself. Nursing has discovered this in recent decades, with its desire to raise its prestige by adopting ‘scientific’ nursing principles, whilst also feeling the pull of its heritage and the crucial role it plays in caring for patients ^[8][9].

Educational credentialing and legal strategies have long been considered some of the most powerful and effective ways of dealing with jurisdictional disputes ^[10][11]. Educational credentialing because it can control the supply of qualified practitioners into the profession and shape the way professionals are socialised (see later), and legal strategies because these can protect a profession’s claim to a particular knowledge base or skill, protecting it in an otherwise competitive market ^[12]. But the same strategies can be used ideologically to protect privilege in a particular professional ‘territory’, excluding people on the basis of race, gender or religion, for instance, and thus playing a part in the structured inequality of society’ ^[13].

For this reason, Keith Macdonald has argued that strategies of exclusion are often ‘aimed not only at the attainment and maintenance of monopoly’, but also the ‘upward social mobility of the whole group’ (ibid). Rather than choosing to take up a position outside of the mainstream where it can advocate for minorities and vulnerable communities, prestigious professional groups have often chosen to side with a majoritarian position, in order to secure social prestige and ‘improved life chances’ ^[14] for its members. A decision evident in the gendered, racial, and non-disabled profile of most of the Western health professions today.

Crucially, a profession will not be successful in its claim to exclusivity simply on its own terms. Neo-Weberians believe that professional prestige is a relational, trade-and-exchange process, that requires professional groups to provide a service that a controlling interest requires, in return for specific privileges. Neo-Weberians believe many professions have spent too long considering their own autonomy and ability to influence their own prestige, and not enough time on the power they have to influence the autonomy of others. Here neo-Weberians agree with functionalists that a balance of interests will have been met with any process of occupational closure ^[15]. But this also means that the way a profession defines its identity must always be done in relation to others, as a constantly shifting process of negotiation and status claim.

Caragh Brosnan has argued that we should also pay more attention to the divisions and boundaries within professions. Using the chiropractic profession as her example, Brosnan argues that much of the literature on boundaries in the alternative and complementary therapies relate to its sometimes fraught relationship with Western medicine. Many professions, though, also expend considerable energy negotiating significant ethical, jurisdictional, relational, and professional disputes that are internal to the profession ^[16][17][18]. In the case of chiropractic, there remains an ongoing dispute between traditionalists who see the roots of the profession ‘outside’ mainstream healthcare, and reformers who call for a shift in the profession’s ideology to bring it more in line with the orthodoxy ^[19]. These, as much as ‘external’ conflicts, shape the profession’s identity.

Ultimately, Weber believed that all acts of occupational and wider social closure were part of modern society’s drive towards rationalisation. Only in the West, Tony Bilton argues, have we seen rationalisation emerge as a primary cultural orientation for social life ^[20]. Occupational closure plays a crucial role in the rationalisation of society because powerful groups like health professionals have been rewarded with prestige and monopoly control of common human resources, like health and healing work, because of their efforts ‘master[ing] all things by calculation’ ^[21].

Influential though it is, critics argue that Weberian approaches to social action remain largely macroscopic, focusing on the professions as large, impersonal industries. Alternative approaches to social action were also developing in the second half of the twentieth century, however, and these focused much more on the everyday, micro-social lives of the people involved in healthcare.