Let us now return to the models described earlier within the sociology of the professions. The neo-Durkheimian approach is rarely visible in the contemporary sociological discourse about
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professional life, although it can still be found in the writings of mental health professionals when they are generating a ‘public relations’ view of their own work. Examples of this can be found in relation to psychiatry (Clare 1976) and clinical psychology (Marzillier and Hall 1987).
Below, we start by acknowledging that many studies have drawn upon more than one theo- retical framework. We then look at some purer sociological frameworks before addressing the influence of theoretical models from the study of deviancy, professional knowledge and patriar- chy. The latter are important in addition to the work of the sociology of the professions because they come at the question of professional practice from a starting point other than the specialists themselves.
In regard to the other groups we have just noted (non-specialists and lay people), deviancy theorists are interested in the negotiation of deviant roles, like that of becoming a psychiatric patient. While professionals are central to this, they are not the only group of social actors impli- cated. Likewise, sociological investigations of the transmission of knowledge start with an interest in knowledge but then look to how professionals are a vehicle for its reproduction, possession and modification. Feminists start from a wider interest in the male domination of women in society and then look to particular sites of this domination, like professional practice.
Eclecticism and post-structuralism
Many of the attempts to understand mental health professionals have drawn upon more than one theoretical base. For instance, the extensive work of Andrew Scull on the development of psy- chiatry during and since the nineteenth century draws heavily upon Marxist ideas. Scull (1979) explains the rise and maintenance of psychiatry in terms of its functional value for economic order and efficiency under capitalism. The segregation of the mad and the delegation by the State of powers to doctors to keep madness under control are central to Scull’s thesis. His emphasis is on the role of psychiatrists as agents of social control employed by the State to contain the threat of one section of a poor underclass – the mad. However, when explaining the finer dynamics of how doctors purged lay administrators from the asylums and sought upward social mobility for themselves, he uses a Weberian notion of ‘closure’.
Similarly, a work which builds heavily on the work of Scull is Baruch and Treacher’s (1978) analysis of the functioning of psychiatry in Britain, which emphasizes the professional dominance of psychiatrists. In the Marxian tradition, they highlight the economic factors which both precipitate mental distress and are consequent upon a person entering the role of psychiatric patient. However, they also draw liberally for the latter purposes on the work of Parsons, albeit with critical reserva- tions. They also refer positively to the post-Marxian social critic Illich, as well as to Scull, in their
‘medicalization’ thesis about the transformation of madness into mental illness by doctors.
Indeed, while Baruch and Treacher, like Scull, could be labelled as ‘Marxist functionalists’, they begin their book with a long quote from Illich’s Medical Nemesis (1974). (The ideological posi- tion of Illich is contested. His antiprofessionalism has given comfort to critics of both right and left, and his alternatives to current forms of social organization contain a mixture of libertarian and authoritarian elements.)
The medicalization of madness thesis and the emphasis on psychiatrists as agents of social control is by no means limited to neo-Marxians. Right-wing libertarian critics from within psy- chiatry have constructed social histories of their profession with these emphases as well. The best example of this is the work of Szasz (1971), who argues that psychiatrists are for the modern State what witch-finders were for the Church in mediaeval times. The work of Szasz also echoes some of the analysis of Foucault, which is described later.
In another analysis of twentieth-century psychiatry, Ramon (1985) looks at services and the professions of psychiatry, psychiatric nursing and psychology. She dubs these for her purposes the
‘psy complex’, echoing a post-structuralist term but at the same time firmly endorsing the political
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economy approach to welfare professionals given by the Marxist Gough (1979) we noted earlier (Ramon 1985: 21).
Turning to the analysis of a different profession – clinical psychology – eclecticism is evident again. Pilgrim and Treacher (1992) describe the historical development of the profession and its recent functioning. The profession in Britain has gone through four phases: psychometrics (1950s), behav- iour therapy (1960s), therapeutic eclecticism (1970s) and managerialism (1980s). When theorizing the meaning of their description, Pilgrim and Treacher endorse the partial advantages of post-structur- alist, neo-Weberian and neo-Marxian models for their data analysis. Psychologists have been mainly concerned with voluntary relationships (see discussion of post-structuralism later). They have tried to usurp the role of a dominant profession (psychiatry) to some extent and they have sought, via a cam- paign of registration, to attain a State-endorsed monopoly over psychological practice. Psychologists have demonstrably served the social administrative requirements of the capitalist State by seeking to regulate the behaviour of children and people with mental health problems and learning difficulties.
In addition, Pilgrim and Treacher draw attention to questions of gender and race in under- standing some of the features of the profession being white and male dominated (see later). These examples of eclecticism reflect that the earlier advice of Turner (1987) about the need to integrate Weberian and Marxian frameworks has been anticipated by a number of sociologists.
Foucault’s (1961; 1965) early writings on mental health began quite close to the Marxian emphasis on social control. However, he diverged from Scull’s analysis on two counts even at this stage. First, he puts the beginnings of segregation at an earlier point, the ‘great confinement’ of the mid-seventeenth to mid-eighteenth century. Scull (1977, 1979) argues that most of the mad were still roaming free in society at the beginning of the nineteenth century and it was not until the mid-nineteenth century that the State asylum system was well established to segregate madness. Second, Foucault empha- sized the moral, not the economic, order. While Scull argued that psychiatry functioned to aid and abet economic efficiency, Foucault argued that psychiatry existed primarily to deal with those who offended bourgeois morality and rationality. For Foucault, segregative psychiatry was not concerned with either medical cure or economic efficiency per se but with moral regulation.
Miller (1986) notes that Foucault’s work is essentially a ‘prehistory’ of psychiatry. It is then extended by Castel (1983) into the period when the profession became more firmly established in the nineteenth century. The moral regulation theme continues about the role of the alienist or psychiatrist. Madness now had to be dealt with within the rules of the emerging bourgeois ‘contrac- tual’ society. During this period the psychiatric profession did not go unchallenged but it retained its central role in relation to the asylum.
The third phase of interest to post-structuralists has been the changes in psychiatry during the twentieth century (Armstrong 1980; Miller and Rose 1988). Here, four interweaving themes can be identified:
• psychiatry as a professional enterprise is no longer restricted only to the asylum;
• its practices are no longer only associated with coercive social control;
• large bands of the population have been induced into an individualized state of psycho- logical mindedness about their existence, via the media and education; and
• following from the last two points, voluntary relationships involving lengthy conver- sations about the self are now sought out by the public and deployed by professionals (versions of counselling and psychotherapy) (Rose 1990).
The move beyond the asylum can be linked roughly to changes in practices during the First World War when the problem of shellshock required a new response to mental distress (Stone 1985). Psy- chotherapy began in earnest at this point: outpatient clinics were set up after the war and centres of excellence, like the Tavistock Clinic, which celebrated the legitimacy of psychoanalysis, were established. Psychoanalysis had been attacked or ignored by psychiatrists before 1914. After the
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war, the Tavistock Clinic became associated with a wider cultural emphasis on the individual and the family: for instance, by promoting explanations of delinquency and mental distress, which were purported to arise from poor mothering.
Of central importance in this account is the rejection of the coercive social control empha- sis of Scull and the ‘anti-psychiatrists’. For instance, Miller and Rose argue that the psy complex has increasingly emphasized a voluntary relationship which is sought out and appreciated by cli- ents: ‘We argue that it is more fruitful to consider the ways that regulatory systems have sought to promote subjectivity than to document ways in which they have crushed it’ (Miller and Rose 1988: 174). De Swaan’s notion of ‘proto-professionalization’, mentioned earlier, also operates with a similar assumption about a cultural consensus between professionals and lay people that their everyday troubles can be solved by conversations (counselling and psychotherapy) which focus on, celebrate and construct the ‘self’.
However, the post-structuralist account still emphasizes the role of professionals in ‘regulat- ing’ the everyday lives of their clients (Donzelot 1979). Thus, differences of opinion between soci- ologists about the regulatory role of professionals seem to hinge on differences of emphasis. The post-structuralists (and Parsons (1951) in his discussion of the sick role) emphasize a process of consensual decision-making, some of it implicit or unconscious, wherein the client either comes to agree with, or already accepts, professional definitions of the nature of their problem. Social regulation occurs by agreement and with actual (or perceived) benefits to the client. By contrast, the Marxian tradition emphasizes the enforced imposition of a view on the client by professionals acting as agents of the state. The first of these suggests that the power to regulate emotional life and norms of conduct is diffuse or dispersed. Power cannot be located ‘inside’ any one particular group of social actors. Rather, it is understood as a relationship or discourse shared by several par- ties. The second account clearly locates power in the hands of professionals who dominate their clients at the behest of their state employers.
Maybe both types of account are credible. Patients do seek out help in voluntary relationships.
In addition, sometimes, professionals impose themselves on patients – they lock them up and give them treatments they do not consent to freely. Because post-structuralist writers about mental health have tended to focus on twentieth-century developments, their emphasis has tended to be on the disciplinary, rather than repressive, power of psychiatric experts. This has led to a skewed post-structuralist interest, with Foucault’s early concern with repressive power being replaced by an emphasis on psychological interventions which are ‘anxiously sought and gratefully received’
(Pilgrim and Rogers 1994). This shift emphasizes the role of the secularized confessional in modern society in Foucault’s later writings:
The confession has spread its effects far and wide. It plays a part in justice, medicine, education, family relationships, in love relations, in the most ordinary affairs of everyday life and in the most solemn rites: one confesses one’s crimes, one’s sins, one’s thoughts and desires, one’s illnesses and troubles; one goes about telling with the greatest precision whatever is most difficult to tell.
(Foucault 1981: 59) This role of the confessional is discussed in more detail in relation to mental health work by Rose (1990). He suggests a number of points in this regard:
1 Psychotherapeutic assumptions can be found to operate now in general medicine, educa- tion, advertising, and journalism and business management. They are not limited to the work of mental health experts.
2 A countervailing discourse has also emerged from some social critics about a ‘modern obsession with the self’ and a ‘tyranny of intimacy in which narcissism is mobilized in social relations’.
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3 Modern psychotherapeutic rituals mimic and displace the older emphasis on religious or spiritual pilgrimages. The growth of Protestantism with its emphasis on individual guilt and responsibility marked a bridge between mediaeval religion and the modern culture of the self and individualism. Alongside this emerged the ‘civilizing process’ (Elias 1978) in which self not State control became important; the growth in importance of etiquette and manners. Thus, a repressive State form of control was increasingly superseded by self-control.
4 New versions of the confession such as counselling and the psychological therapies became means by which identities were inscribed upon their subjects. Mental health work produces ‘the subjectification of work’, ‘the psychologization of the mundane’, ‘a thera- peutics of finitude’ and a ‘neuroticization of social intercourse’. What Rose points to in these phrases is the way in which work, common life transitions, disappointment, death and our intimate relationships are now framed within mental health discourses.
5 Following Foucault, Rose offers a triple aspect on psychological treatments. First there are moral codes in the language and ethical principles of therapy. These imply some notion of ‘the good life’ and are thus implicitly or explicitly normative. Second, there are ethical scenarios which are the sites or contexts in which the moral codes operate – social work practice, the courts, the private consulting room and so on. Third there are techniques of the self, which are developed to codify the exploration, definition and con- frontation of the self in therapy (Foucault 1988). These techniques are not a unitary body of knowledge but a wide range of models which produce narratives of the self – hetero- geneity of approach characterizes the psychological treatments.
6 These features of mental health work are not guided by the hidden hand of capital (cf. the neo-Marxian view of the professions) nor by the conscious collective self-interest pursued by professionals according to the neo-Weberians (see later). Instead, the main orientation of modern mental health work is one of reconciling or aligning the needs of individuals with the social, political or organizational goals which form the social context of therapists and their clients.
Having outlined the post-structuralist perspective of mental health work, we now turn to the appli- cation of an older sociological approach.
The neo-Weberian approach
This has already been mentioned in relation to clinical psychologists seeking a monopoly on psy- chological practice and on their boundary dispute with psychiatry (Pilgrim and Treacher 1992). It was also an important aspect of the study of a psychiatric unit by Baruch and Treacher (1978), in terms of the strategies which consultant psychiatrists used to maintain their dominant position in the mental health team working with inpatients.
In another study of psychiatrists, their relationship with the police has been analysed in terms of professional dominance. The transactions that occurred between the two occupational groups when people deemed to be mentally disordered in public were taken for psychiatric assessment by police officers (under section 136 of the Mental Health Act 1983) were studied. The same study also found that psychiatrists operated a number of strategies to exert control over how the patient was dealt with. The technical knowledge of the profession was a focus for psychiatrists’ dominance over police officers. Even though police officers identified mental disorder with the same technical efficiency as psychiatrists, the latter insisted on depicting the police as lacking in the credentials to understand or manage the client group. The police were not in fact interested in encroaching on the territory of psychiatric practice. Nonetheless, psychiatrists acted to ward off a form of encroach- ment on their professional power that they perceived to be coming from police officers.
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Sociologists who try to understand specific groups of professions usually find it necessary to appreciate how practitioners perceive their own role and that of others. The next wider sociologi- cal tradition to be discussed highlights this.
Symbolic interactionism
This approach can be found in Goffman’s (1961) classic study of asylum life and of how the patient role is imposed on admitted psychiatric patients. What matters in this ‘microsociology’ are the meanings which are negotiated by various social actors involved in a drama or ritual. Goffman talks of ‘degradation rituals’, when the patient’s identity is removed as they enter the psychiatric patient role (see later); this type of approach was extended by Braginsky et al. (1973).
The symbolic interactionists can also be found in studies of how psychiatrists and other men- tal health workers see and justify their role. Goldie (1977) interviewed psychiatrists in order to understand the meanings they attached to their knowledge base and their perceived superior sta- tus compared with non-medical staff. He also observed and took accounts from other members of mental health care teams about how they understood their particular expertise and powers. From this data he built up a picture of how psychiatrists maintain their mandate of authority in the field of mental health and how subordinate professions both challenge and maintain that mandate.
More recently, another study has examined the different mental models held by different members of mental health teams within this negotiated order (Colombo et al. 2003). While a prag- matic imperative exists to make a service work and to complete daily tasks, it is clear that these contain strains and compromises about implicit models which permeate the intentions and actions of staff. For example, psychiatrists still overwhelmingly operate a diagnostic treatment approach to mental illness. They work alongside others who do not share this view but prefer an alternative model (psychotherapeutic or social).
In another study of a psychiatric team using participant observation and interviews, Emerson and Pollner (1975) investigated the ways in which professionals classified their work with different types of patients. In particular, the investigators were interested in looking at how less acceptable work, such as the compulsory detention of patients in emergency duties, was conceived by work- ers. They found that this ‘dirty work’ or ‘shit work’ was accounted for by workers who preferred the morally superior role of being benign therapists.
The dirty work conception derives from earlier work by Hughes (1971), who sees it as an aspect of all professional activity entailing a practitioner being obliged to ‘play a role of which he thinks he ought to be a little ashamed morally’. For Emerson and Pollner, the dirty work of acute psychiatry is that of social control – involuntary admission to hospital. In order to distance them- selves from this explicit and morally dubious role, practitioners will point out that it is not really typical of their duties, that it is forced on them by circumstances or that they use the opportunity to help the patient as best they can.
The symbolic interactionist approach has been given new relevance, given that mental health service reformers are seeking to take account of the role of lay people in quality improvement pro- grammes (Milne et al. 2004). (We return to the importance of ‘users and carers’ in the final chapter.) The influence of the sociology of deviance
It is not surprising that some investigations of mental health work have started with the social negotiation of psychiatric patienthood, rather than looking at a particular profession. Coulter (1973) studied how social crises in the domestic arena became reframed as psychiatric illnesses.
A similar approach can be found in the work of Scott (1973), who tried to map out the powers available to professionals, prospective patients and significant others to establish or maintain the deviant role of mental patient. Scott talked of the ‘treatment barrier’ to describe the loss of agency occurring once the identified patient was labelled as ill. This process of placing illness inside an