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what it means to be ‘unprofessional’ – to behave incompetently, inefficiently or unethically. As for sociologists, they largely agree on some basic characteristics of professionals:
1 Professionals have grown in importance over the past 200 years and expanded massively in number during the twentieth century.
2 Professionals are concerned with providing services to people rather than producing inanimate goods.
3 Whether salaried or self-employed, professionals have a higher social status than manual workers.
4 This status tends to increase as a function of length of training required to practice.
5 Generally, professionals claim a specialist knowledge about the service they provide and expect to define and control that knowledge.
6 Credentials give professionals a particular credibility in the eyes of public and govern- ment alike.
However, beyond this rough consensus, there is much debate about how professions might be understood sociologically. Here we look at some of the main frameworks used within sociology to understand professions.
The neo-Durkheimian framework
Overviewers of the field of the sociology of the professions (Saks 1983; Abel 1988) emphasize a certain version of the progression of events. At first, as has been mentioned, sociologists tended to simply categorize the professions and describe their work uncritically. Claims of special knowl- edge and altruism were taken at face value. This sociological depiction of positive qualities was dubbed the ‘trait’ approach to the professions. A parallel and equally uncritical approach to the professions was provided by the structural functionalist accounts, which saw the professions as a static or stable social stratum that offered a socially cohesive role (Parsons 1939; Goode 1957).
Durkheim saw professions as providing a disinterested integrative social function. They were one of the social forces that counterbalanced the tendency of egotistical individuals to fragment soci- ety. For the Durkheimian tradition, professions are a source of community for one another and stability for the wider society they serve. They regulate their own practitioners, ensuring good practice by establishing codes of conduct and punishing errant colleagues. They regulate their clients in their interest and in the interest of their host society.
The neo-Weberian framework
Those in the Weberian tradition (Freidson 1970; Abel 1988) emphasize that the professions develop strategies to advance their own social status, persuade clients and potential clients about the need for the service they offer, and corner the market in that service and exclude competitors. Two notions in particular emerge from this picture for those following Weber.
Social closure
Collective social advancement rests upon social closure. By cornering the market, professionals offer a service that is closed off from others. A monopoly is gained to work in a specialized way with a particular group of clients (e.g. medical practitioners treating sick people) so that other occupational groups seeking a similar role are excluded. This closing off also means that only those inside the boundaries of the profession can scrutinize its practices – others are denied access and are kept in a state of ignorance. In order for professionals to maintain their social status they must convince those on the outside of their boundaries that they are offering a unique service and so they develop various rhetorical devices to persuade the world at large of their special qualities.
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To do this they must justify a peculiar knowledge base that has a technical or scientific rational- ity on the one hand, but that, on the other, is not so easy to understand that anybody can use it.
Medicine as a whole can be seen to provide such accounts to the world. However, this persuasion is precarious. The growth of alternative medicine (Saks 1992) is testimony to this, as are the doubts about the coherence and credibility of psychiatric knowledge that we examined in Chapter 1.
Professional dominance
The second main feature of this Weberian picture is that of professional dominance. Professionals exercise power over others in three senses:
1 They have power over their clients. The latter, convinced of the need for the service they are offered or seek, are dependent on professionals. An imbalance of specialized knowledge keeps the client in a state of ignorance, insecurity and vulnerability. This power imbalance is reinforced if the professional operates on their own territory rather than that of their client, for instance by treating people in hospital rather than their own home.
2 Professionals exercise power over their new recruits. Thus, a dominance hierarchy is common in professions, with senior practitioners and trainers exercising control and dis- cipline over their juniors. Power enjoyed in the upper ranks of a profession can only be secured by submission and deference in earlier junior days, as trainees are dependent on their superiors for career progression.
3 Professionals seek to establish a dominant relationship over other occupational groups working with the same clients. Professionals may seek to exclude existing equal com- petitors or they may seek to usurp the role of existing superiors. In medicine, in addition to excluding competitors (e.g. orthopaedic specialists who have kept chiropractors and osteopaths out of official health service practice) they also subordinate them (obstetri- cians directing the work of midwives) or limit their therapeutic powers to one part of the body (e.g. dentistry and optometry).
Thus, power relationships are of central importance to neo-Weberians. These are about gaining and retaining power over clients, new entrants and other occupational groups working with those clients. One way of thinking about the neo-Weberian focus is in terms of horizontal relationships between professionals and those they work with, as colleagues or clients, in order to sustain or extend the material advantages, status and comforts of middle-class life in society.
The neo-Marxian framework
When we look to the Marxian tradition, power relationships are also important, but now the focus is on vertical structural relationships. The question to be answered by neo-Marxians is: ‘where do pro- fessionals fit into a social structure which is characterized by two main groups: those who work to produce wealth (surplus value) in society (the working class or proletariat) and those who own the means of production and exploit these workers and expropriate surplus value as profits (capital- ists, the ruling class or the bourgeoisie)?’ Marx gave scant attention to the third group of interest to us: those functionaries or ‘white collar’ workers who were neither exploitative capitalists who owned the means of production nor workers who produced goods and profits for their bosses in exchange for wages. Consequently, those sociologists upholding a Marxian tradition of analysis have had a number of conceptual difficulties with the professions.
Three positions have been taken up by neo-Marxians about the professions. The latter are deemed either to be part of the ruling class or part of the proletariat, or to constitute a separate and new social class holding contradictory qualities. The first type of claim is made by Navarro (1979),
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who argues that, for instance, the medical profession actually constitutes a part of the ruling class in capitalist society.
By contrast, Oppenheimer (1975) has claimed that the ‘knowledge-based’ professions have had control over their work eroded by the state bureaucracies that employ them (they have been subjected to ‘bureaucratic subordination’). As a result, their control over their specialized skills has diminished (‘deskilling’) and consequently they have become part of the working class (‘proletari- anization’). Oppenheimer understands the collectivist strategies of professions as being no differ- ent from traditional trade union defences of working-class terms and conditions of employment.
This contrasts with the neo-Weberians, who point to such collective action as being about upward social mobility. Thus, the neo-Weberians are clearly much more critical of the professions than Oppenheimer, who treats them with the sympathy implied by their status as an exploited group of workers who are vulnerable to wage erosion and unemployment.
Clearly, Navarro and Oppenheimer cannot both be totally correct if they claim to operate within the same sociological tradition started by Marx. Their apparent opposition is rescued by a third group of neo-Marxians, who argue that they are both partially correct. This group, exempli- fied by the work of Carchedi (1975), Johnson (1977) and Gough (1979), emphasizes the contra- dictory position of professionals in capitalist society. They are not capitalists but they serve the interests of the latter. They are not full members of the proletariat (as they do not produce goods and surplus value) but they are employees and so they share similar vulnerabilities and interests of the working class. For instance, mental health workers would be seen in this contradictory posi- tion as being both agents of social control acting on behalf of the capitalist state and employees of that state and so vulnerable to the same problems of any other group of workers.
Eclecticism and post-structuralism
The above picture of competing views is complicated further by many analysts of the professions drawing liberally on more than one tradition. For instance, Parry and Parry (1977), when discuss- ing the rise of militant trade unionism within the junior ranks of the British medical profession in the 1970s, utilize Weber’s notion of closure and Oppenheimer’s proletarianization thesis. They go as far as arguing that Weber actually anticipated Oppenheimer’s insights and thus they see no dispute between the Marxian and Weberian types of analysis about modern professions.
As we will see later in relation to the mental health professions, it is now common for sociolo- gists to approach their work eclectically – they draw on more than one theoretical tradition. For some this has become an explicit prescription for analysis. For instance, Turner (1987: 140), when discussing health professions, comments that ‘a satisfactory explanation of professionalization as an occupational strategy will come eventually to depend upon both Weberian and Marxian perspectives’.
One important shift in social theory, post-structuralism, now goes beyond eclecticism. One of its main intellectual leaders, Foucault (1980) considers that social analysis entails examining a
heterogenous ensemble consisting of discourses, institutions, architectural forms, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral and phil- anthropic propositions – in short the said and the unsaid.
In particular, Foucault and his followers are concerned to map out discourses associated with particular social periods and places. This notion of discourse includes both forms of knowledge and the practices associated with that knowledge. For this reason, the notion of ‘discursive prac- tices’ might connote more accurately the focus of the post-structuralists when discussing the professions.
The Foucauldians provide a different way of looking at applied knowledge in professional work. They have no notion of a clear or stable power discrepancy between professionals and
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clients or between dominant professions and subordinate ones. Power is dispersed; it cannot be simply and easily located in any elite group. While it is certainly bound up with dominant dis- cursive features of a particular time and place, these may change and they may be resisted. For Foucault and his followers, ways in which the person (the body and mind of the individual) is now described or constructed (measured, analysed and codified) are central features of contemporary society. Medicine and professions close to it have had a central role in this regard with their inter- ests in diagnosis, testing, assessment and observation and the treatment, management and surveil- lance of sick and healthy bodies in society. However, in the post-structuralist account there is a failure to endorse the notion of self-conscious collective activity of professionals, to advance their own interests or to act on behalf of the capitalist state.
As we will see later, the mental health professions have been of particular interest to post- structuralists. This is probably because of the ‘psy complex’ having a chronic surveillance role in relation to mental patients and because it has been associated with two types of discourse. The first of these emphasized segregation and acting on the body (physical treatments) and the second emphasized the construction of the self via a set of psychological accounts (counselling and psy- chotherapy). The attack on the body and the construction of the self represent two key ways of understanding the activities of mental health professionals.
A final point in this section relates to how we understand health professions compared to others. As Starr (2009) has noted, the peculiar organizational context they operate within and the particular expectations the public have of them, about an emotive topic (health and illness), create particular pressures upon them. They are endeavouring to maintain a dominant authoritative posi- tion in relation to patients and colleagues, in a peculiarly emotive and politicized context. Health and illness bring with them substantial intellectual contention about research and clinical priorities and political contention about professional authority.
The above four general sociological frameworks have been the most influential in understand- ing the professions. As we will see below, in relation to mental health work, other sociological approaches have also been influential. These include symbolic interactionism, the sociology of knowledge, the sociology of deviance and feminist sociology. Before we discuss these let us look at the relationships that mental health workers have with other key social actors.