48 Symbolic interactionism

There has been enormous interest in people’s ‘struggle to make meaning’ ^[1] from health and illness over the last 30 years. Central to this struggle has been the search for meaning in people’s everyday experiences, interpersonal relationships, and the everyday small acts of social formation. Combined with an abiding interest in those who had long been marginalised by society, some social action theorists have turned away from the grand sociology of Marx, structuralism and critical theory, and turned, instead, towards sociology on a more human scale.

Healthcare has been a particularly fertile field for this work. Alfred Schutz (1899-1959) was one of the first sociologists to explore the sociology of lived experience, using the phenomenology of Martin Heidegger, Edmund Husserl, and Maurice Merleau-Ponty to argue that modern science had treated people like inanimate objects, and what was needed was an understanding of the ways in which people made sense of the world ‘as themselves’ ^[2][3]. ‘People are desperate for stories they can call their own’ Frank argued, ‘because the medical complex chews up individual identities’ ^[4]. Once again, medicine became a particular focus for sociologists, who recognised that it somehow ‘manages the extraordinary feat of homogenising people while reproducing and accentuating inequalities between them’ (ibid).

All relational acts of meaning-making are profoundly complex; what Harold Garfinkel called ‘interactional accomplishments’ ^[5]. So, it is perhaps not surprising that it takes decades for people to develop personal attributes and skills necessary for professional practice. Sociologists have become fascinated by the ‘peculiar and distinctive character of interaction as it takes place between human beings’ ^[6], and much of this work developed in a field known as symbolic interactionism.

Herbert Blumer — who, along with his mentor George Herbert Mead, and Erving Goffman, pioneered symbolic interactionism at the University of Chicago in the middle decades of the 20th century — suggested that human interactions were peculiar because people did not have direct access to other things, people, events, ideas, and actions. Rather, people act on the basis of the meaning that they, and others, give to things. Everything we think, know, and experience, they argue, is mediated by symbolism and our interactions rather than detached and objective truth (hence, symbolic interactionism, or SI). Mead, for instance, argued that we can only talk about people having ‘minds’ because we interact with one another ^[7].

Symbolic Interactionists argue that we develop our self-image by incorporating others’ views of us into our own sense of self; what Charles Horton Cooley called a ‘looking glass self’ ^[8]. People are ‘skilled interpreters of their world’ ^[9], and use these interpretations to make meaning from the world around them. SI sees people as much more active social entities, shaping the world around them, rather than passive biological entities bumping into, or reacting behaviourally to other entities in the course of everyday life. Perhaps understandably, this approach has become hugely important in the development of narrative inquiry, reflective practice, qualitative inquiry, person-centred care, and other relational approaches to health over the last 30 years.

SI focuses especially on theories of action; ‘individual behavioural creativity and micro-level social processes’ ^[10], rather than the structures governing social life. ‘Social roles, institutions, and power’, Ryan argues, ‘are all understood as being the result of a ‘negotiated order’’ ^[11]. SI is concerned with the ways ‘different groups of workers with diverse skills negotiat[e] with each other and secur[e] each other’s cooperation or consent’ ^[12].

Edgar Burns suggested that one of the reasons for the rapid rise to prominence of SI was the fact that ‘Science with its strong, modernist claims to knowledge and truth had for the most part forgotten that knowledge is held by people and groups. It does not exist on its own in some metaphysical library or cosmic-virtual database’ ^[13]. Medicine, and some structural sociologies too, had forgotten the agency of individual actions, behaviours, interactions, and relationships ^[14]. People had become pawns in a grand chess game played by hegemonic forces like the state, doctors, and ‘patients’. SI, in contrast, ‘accords priority to the individual choosing his or her social behaviour’ ^[15].

A number of landmark studies emerged from SI in the 1950s and 60s, including Hughes’ work on the social drama of work ^[16][17], which argued that professional expertise only exists as a function of social interaction, and there can be no definition of expertise that stands in and of itself. But perhaps the best known and most far-reaching example of SI came from Erving Goffman’s studies of labelling theory and stigma.

Labelling theory argued that health and illness have no innate biological basis, nor are they the product of one’s class or gender. Rather, they exist because the sufferer violates certain social norms; norms that emerge from people’s interactions, conversations, thoughts, and everyday practices. Thomas Scheff argued that societies created certain codes of conduct and ways of behaving that he called ‘residual rules’ ^[18]. These were informal social conventions that go largely unnoticed. But when someone breaks one of these residual rules, they are prone to be labelled as a troublemaker, disruptive, or even ‘deviant’. Importantly, it is not the behaviour of the individual, per se, but people’s reaction to the social breach that defines the issue.

In his 1961 study Asylums ^[19], Goffman argued that in Western societies, the development of mental illness concepts and labels had served as a useful construct to help explain rule-breaking behaviour, and manage anxieties about people who deviate from society’s residual rules. The negative consequences for those who have fallen outside of social convention can be severe, however. Not least because the rule breaker is thrown into an almost impossible position. Accepting a label of being deviant, psychotic, backward, handicapped, needy or malingering, can lead to the person being exposed to social judgement, unpleasant and humiliating treatments, isolation, toxic medication or other invasive therapies, loss of work, and humiliation. But resistance to the label can be used as proof of the person’s deviance, resulting in even worse treatment.

Two years later, in a separate body of work, Goffman concentrated on the problem of social stigma. He argued that there was a profound difference between our ‘real’ selves, and what he called our ‘virtual social identity’, or the image we present to the world ^[20]. Goffman argued that some people’s real social identities came with certain traits that were known to be embarrassing or unappealing, shameful or unpleasant. People felt stigma when they had to try to present a different image to society to avoid others’ negative judgements. He argued that we experience stigmas because not only are our social identities bound up with how society sees us, but because we know it too. And so in order to develop a sense of self-esteem, we must constantly work on how the world sees us, through what Goffman called ‘impression management’ (ibid). This is a form of performance acting that becomes necessary because of the perceived distance between our real and virtual selves.

There are clear parallels here to healthcare, but also for health professional practice because one’s virtual social identity — the image we project to the world — may often be derived from the meaning we attach to our professional work. And so, feelings that one is a different person in reality to an idealised professional identity is a significant issue, not least because many professions rely on their ability to project a spuriously homogenous professional identity, in order to maintain their occupational closure ^[21]. Perhaps for these reasons, many professionals feel at odds with their virtual professional identities. The process of taking up a virtual professional identity begins as soon as students enter training ^[22][23]. Key to this process is the work of socialisation.