59 A third way

Bourdieu

An alternative to postmodernism and intersectionality came from a group of social theorists who also sought to develop a ‘third way’, that did not default to agency or structure. The most prominent of these was Pierre Bourdieu. Bourdieu’s work ‘emphasises the external nature of the social world and how that affects individuals’ ^[1]. Bourdieu, like Garfinkel, was interested in theories of practice. But also like Foucault, Bourdieu was concerned with questions of power and privilege. His is a very practical sociology, concerned with what was actually happening in the world.

Bourdieu believed that the social world had a ‘double’ structure. When viewed objectively, it appeared to be structured around hierarchies that privileged some individuals more than others. But when viewed from an individual perspective, the social world seemed to be constructed by the perceptions we hold of people’s power relative to one another. He believed these two perspectives often coexisted, giving the world a sense of natural stability and common-sense obviousness ^[2]. Bourdieu believed that people were totally situated within social structures, but were also agents with ‘capacity to act in their given fields of social action or interaction rather than simply being passive… subjects’ ^[3].

Bourdieu argued that the ‘currency’ that people traded in, as they move through the social matrix that makes up their lives, was what he called ‘capital’. Capital amounts to different resources that ‘social agents can mobilize in pursuit of their projects’ ^[4]. Unlike Marx, whose emphasis was firmly on economic capital, Bourdieu was interested in the many different forms of capital. But the four main types he concentrated on were:

• Economic capital — the income, wealth, and the monetary value of the goods a person or group possesses;
• Social capital — the value inherent in networks of social relations between people, but also the value of the network itself;
• Symbolic capital — the status we hold within a specific community;
• Cultural capital — culturally valued resources in the form of objects (books, paintings, clothes, etc.), institutions (going to the right school, gaining degrees and professional qualification), and embodied competencies (being well-read, dressing fashionably, etc.).

The key to these forms of capital for Bourdieu was in their exchange value. If a person goes to a prestigious school and uses their connections to obtain a high-paying job, they have exchanged cultural and social capital for economic. For many of the orthodox health professions, affinity with biomedicine has brought high levels of prestige through the same process of exchange. Bourdieu believed that society was organised by the ongoing play of different forms of capital. Forms of capital endure, and are often inherited from one generation to another, ensuring that the conflicts and achievements of the past are not forgotten by future generations. Indeed, some forms of capital, as physiotherapists and others well know, take generations to accumulate.

The kinds of cultural capital that health professionals work hard to acquire have particular value because of their ability to be exchanged for economic capital (or higher pay). This is because cultural capital is a reflection of a person or group’s practiced affinity with something (i.e., balance assessments or the management of chronic pain), and something that society at large finds to be of value ^[5]. Bourdieu saw this practiced affinity — or ‘habitus’ — as particularly important.

In many ways like socialisation, habitus refers to the way we are civilised into certain ways of thinking and behaving, and then internalise these lessons so that they become second nature. There is a ‘positive’ aspect to this, in that we learn ways to ‘get along’ with each other. But habitus also recognises that ‘control mechanisms’ ^[6] mould us into suppressing urges that some may see as uncivilised. Most importantly for physiotherapists, perhaps, Bourdieu argues that habitus manifests most clearly in people’s bodies. Kate Cregan suggested we ‘learn to train, restrict, dispose and quarantine’ our actions, and through this, shape the world we live in;

‘We embody our habitus through the way we walk; the way we conduct ourselves with others and in different spaces; why we are disposed to particular ways of dress and a rejection of others; the places we do and don’t go; the way we regulate our behaviour in certain areas of homes and in different public spaces; the way we act depending on whether we are adults or children, male or female, young or old, etc., etc.’ ^[7].

Bourdieu was heavily influenced, here, by the work of Marcel Mauss, who developed the concept of bodily hexis, or the way that societies expressed their differences through the way people moved ^[8][9][10]. The way we swim, walk, sit, and so on, reflects social changes like attitudes to seeing bodies in public, cultural styles, and inventions like the mobile phone and personal computers. Habitus concerns everything from ‘Ways of walking or blowing one’s nose, ways of eating or talking’, to grand social distinctions ‘between the classes, the age groups and the sexes’ ^[11]. Importantly then, when we think we are acting autonomously, we are actually only demonstrating another facet of our habitus ^[12].

The specific context in which a person’s habitus operates was called a ‘field’ by Bourdieu. These are a ‘structured space of social forces and struggles’ ^[13]. Within each field, actors (which might include small or large groups of professionals, consumers, governments, communities, and so on), negotiate and compete with each other to decide what matters and what is at stake for people in the struggle. Each party brings its own presumptions and taken-for-granted beliefs (what Bourdieu called doxa: that which goes without saying, and what we do without thinking), and their habitus is reflected in each group’s specific histories, tastes, preferred ways of doing things, values, and shared experiences. If a group’s habitus does not position them well to convert different forms of capital into economic advantage, they often seek to challenge the doxa, and disrupt what others take-for-granted. This is one of Bourdieu’s formulae for understanding professional boundary tensions.

Like all of his postmodern compatriots, Bourdieu was skeptical of those who saw professions as having a solid identity. He believed that formal legalistic definitions of professions had largely ignored the power dynamics that shaped professional groups ^[14]. Nick Crossley suggests that simple trait-based definitions of the professions have made us all ‘unwitting conspirators’ in granting some groups in society enormous prestige on the basis of their claims to different forms of capital ^[15].

Bourdieu showed that the power of the professions had become self-fulfilling because we have accepted the ‘rules of the game’ that the professions, themselves, have put in place (ibid) — what Bourdieu called ‘illusio’ ^[16]. We have been convinced that without such rules and systems, people might mis-recognise a charlatan, or an authoritative voice for a true professional. What this makes possible is the myth that only a true professional can know what it takes to achieve professional status, so only they can define the criteria that the rest of us should use to distinguish the quack and sham practitioner from the ‘real thing’. And so ‘certain social agents are empowered, in part, by our belief that they are powerful’ (ibid). The social capital held by the professions, then, has become ‘particularly useful for reproducing existing power dynamics’ ^[17].

Social capital refers to ‘the resources, tangible and intangible, that we can access by virtue of our place in the social world’ ^[18]. These resources are often described by Bourdieusian scholars in the form of a network of social relations that a person or group is enmeshed within. The value of the network lies both in the relationships between the various actors, and the value of the network itself ^[19]. Rather than seeing professional entities as stable and autonomous, Bourdieu argued that all social fields were structured around quite arbitrary and fluid conventions and principles ^[20], and there was no authentic reality that was not in some way mediated by even the most basic rules, principles, or social conventions. A similar approach to social reality can be seen in the work of Anthony Giddens.

Giddens

Giddens’ structuration theory proposed that structure and agency must co-exist, and neither precedes the other. For Giddens, social structures are not concrete phenomena, like physical objects, but their effects are no less ‘immanent’. They provide resources that shape our agency. But, at the same time, they have no meaning without people’s agency reproducing them through their daily habits and routines, forms of work and play, institutions and beliefs. Giddens called this the ‘duality of structure’, in which agency ‘reproduce[s] the conditions’ that make such structural effects possible ^[21].

Giddens’ work on relationships offers a useful example of how he believes agency and structure co-exist. Giddens argues that relationships depend on the resources that people bring to the encounter, and those with the most resources to bring, carry the greatest transformative capacity to influence social structures. In this way, actors and society can be seen to be interwoven and interdependent, inseparable from one another. Social structures are reproduced only through people’s interactions, and people’s agency is a condition of people’s access to social resources. Social structures are not constraints on people’s actions, as is often argued by Marxian and critical theorists, but rather enable action ^[22].

Although sociologically grounded, Giddens’ approach is also rooted in everyday realism. He has argued that radical social change can come from rejecting traditional binaries. Like Ivan Illich, he has criticised social welfare and the power of the professions for inducing dependence and passivity in people, and trapping people in need in cycles of poverty. He has chastised sociologists for their grand theories, and followed Garfinkel and others in arguing for much more attention to everyday praxiological approaches ^[23]. He has also been a fierce critic of governmental regulation for stifling innovation.

Giddens’ work emphasises the co-existence of autonomy and dependence. Recalling Hegel’s master and slave dichotomy, and Foucault’s alternative reading of power, Giddens argues that even in situations of oppression, the oppressor still needs the person they are oppressing ^[24]. Giddens argues that such dependence makes it possible for people to resist, boycott, strike, and perform acts of civil disobedience because the person in power does not have complete autonomy, and the oppressor relies on the other having a voice. (Note how, for instance, in the recent study by Lynn Clouder, Mark Jones, Shylie Mackintosh, and Arinola Adefila, on the development of student ‘relational’ autonomy, rather than gradually separating themselves from those around them, the student transfers their dependence on the educator to other forms of dependence, such as more direct client, peer, and service connection. Autonomy can be misleading here then, because it implies a process of distancing, rather than the re-allocation of dependence that takes place through maturation^[25].)

Perhaps most tellingly for health professionals, Giddens saw social groups as distinct entities that could not be understood by looking at their smaller units: their ’genetic code’, so to speak. Nor can they be analysed as the product of social structures. They are unique realities unto themselves, held together by long-lasting relational patterns, enduring in certain places in society over time, defined by particular routines and resources, and by certain characteristic structural features that give the group ‘reproduced permanence’ (ibid). These features are never fixed or permanent, but always shifting in intensity and duration.

Bhaskhar

Roy Bhaskhar’s critical realist work also attempts to bridge the divide between structure and agency. Bhaskar’s approach shares a criticism of Humean empiricism with Stephen Mumford and Rani Lill Anjum’s causal dispositionalism now becoming popular in physiotherapy ^[26][27]. Where Hume believed we could only truly know something by experiencing it (empiricism), but that the causes of events always lay hidden, Bhaskar argues that causes of events are real, whether we perceived them or not ^[28].

Reality for Bhaskar is the capacity to bring about change in material things ^[29]. Causes are more like ’tendencies’ that do not always lead to predictable outcomes. Operating in a complex, open system, the effect of any action will depend on the nature of the interaction as much as any structural factors. In many ways, recalling Durkheim, Bhaskhar sees social causes as similar to natural causal mechanisms like gravity and electromagnetism ^[30]. Social causes are ‘transitive’, however, meaning that they can be ‘altered by humans’ (ibid).

Bhaskar’s critical realism is interesting from a sociological point of view because it makes a serious attempt to resolve the tension between human agency and social structure by essentially ignoring them. Society for Bhaskar is a ‘matrix of structured and relatively enduring relations, rather than a collection of individuals’ (ibid). Individuals may be subject to these relations, but they also have the capacity to shape social structures, depending on their position within this matrix ^[31][32]. A child may well be born into social disadvantage, for instance, but critical realists argue that this, in itself, does not define them. As Sam Porter suggests, ‘agents interpret their position and choose to act on the basis of those interpretations’ ^[33].

Equally, this approach to realist analysis can be applied to a concept that Margaret Archer called ‘morphogenesis’ ^[34]. All too often, we see research and innovation in healthcare that does not take account of the relational matrix that constantly shapes what is possible to do and think. In healthcare reform, for instance, new ideas are promoted as solutions, ignoring the fact that the people working in the system are already embroiled in one reality, and now have to grapple with the old and new systems. Archer argues that our tendency is to oversimplify the current system, in order to minimise the problem inherent in adapting to the change. Critical realism, by contrast, argues that we need to take into account the agential and social mechanisms at play, some of which are latent, and others already recognised (ibid). We see the same thing in clinical trials and RCTs, when we are asked to analyse the findings of studies without considering the ‘social dynamics that result from the constant interplay of structure and agency’ ^[35].

In recent years, Bhaskhar’s critical realism has been used to better understand decision-making in healthcare, arguing that interventions with the greatest rational, empirical evidence behind them, may not, in fact, be the most reasonable, moral, ethical, professional, or human approach to take ^[36]. But where other approaches — including positivist and empirical science, interpretive and structural research — struggle to embrace this kind of realism, Bhaskar’s approach centres on these kinds of context-specific analyses ^[37][38].