Tag: Goffman

Down and Out

In the spring of 1928, aged about 24, Eric Blair (aka George Orwell) moved to Paris, a city in which the cost of living was very low. He tried to earn a living by writing and giving English lessons, but it hardly paid. He was then stripped of his possessions and money by “a little trollop he’d picked up in a café” leaving him with very little cash. His parents back home in England were spared the knowledge of his predicament, possibly due to his concern for their middle class sensibilities. He could have returned home to Southwold, but having previously chosen to leave a career in the Imperial Indian Police in Burma, that was not an attractive path. He had little option but to work in the foul kitchens of the Hotel Lotti on the Rue de Rivoli. His final impecunious 10 weeks in Paris provided the material for his book, Down and Out in Paris and London, the first draft of which was completed in 1930. This was no journalist’s assignment, research or a gimmick.

 

The following are observations on poverty in the early chapter of the book and reveal something of the life he led.

 

“…it is altogether curious, your first contact with poverty….you thought it would be terrible, it is merely squalid and boring. It is the peculiar lowness of poverty that you discover first…the shifts it puts you to, the complicated meanness, the crust wiping.

 

You discover, for instance, the secrecy attaching to poverty…you dare not admit it, you have to pretend that you are living quite as usual.

 

You discover what it is like to be hungry…everywhere there is food insulting you in huge wasteful piles…a snivelling self pity comes over you at the sight of so much food.

 

You discover the boredom…you discover that a man who has gone even a week on bread and margarine is not a man any longer, only a belly with a few accessory organs…

 

…but you discover the great redeeming feature of poverty: the fact that it annihilates the future…

 

And there is another feeling that is a great consolation in poverty. It is a feeling of relief, almost of pleasure, at knowing yourself at last genuinely down and out. You have talked so often of going to the dogs – and well, here are the dogs, and you have reached them, and you can stand it. It takes off a lot of anxiety”.

 

(Chapter 3, Down and Out in Paris and London 1933)

 

 

Squalor, boredom, secrecy, hunger, future discounting and relief from anxiety were the key features, for Orwell, of poverty. In 1930 in Paris there was no system of welfare benefits to fall back on. In London , the casual wards (‘The Spikes’) provided some refuge, although the conditions were far from salubrious. Orwell went hungry, and at times had absolutely no money. One lack, which was sorely felt, was that of tobacco, something he again experienced on the front line in Spain when he later joined the POUM militia (Partido Obrero de Unificación Marxista, or Worker’s Party of Marxist Unification) in the civil war in Catalonia. The privations in the front line caused by the conditions and the absolute lack of resources for the militia was another form of poverty.

 

“In trench warfare five things are important: firewood, food, tobacco, candles and the enemy. In winter…they were important in that order” (Homage to Catalonia 1938, p23).

 

Winter in the Catalan trenches, Spring in Paris, but in this list we can note the reduction of human need to Maslow’s base of his hierachy of need. Apart from the ‘enemy’ in Spain the similarity is of course there to see. Orwell in both books mentions the centrality of tobacco, and of course of alcohol, in daily life.

 

It might be tempting to dismiss Orwell’s observations as belonging to another age and therefore of little relevance to the experience of poverty today in modern Welfare States. That I think would be a mistake. The psychosocial sequelae of poverty remain the same; what it does to self, self esteem and the setting of priorities.

 

The ‘secrecy’, the ‘dare not admit it’, alludes to what Erving Goffman called ‘passing’ in his theory of Stigma. People with a stigma try to ‘pass’ as normal to avoid oppressive acts.

Poverty was and is a stigmatising condition. Orwell tells of sitting in parks in Paris but being very aware of the distaste expressed by women particularly, towards him.

A source of stigma, for Goffman, arises out of an actual or perceived ‘character blemish’. Another source is membership of a ‘tribe’. Poverty provides both sources. Currently, many believe the poor to be at fault for their poverty due to their poor moral choices and character weaknesses. The Moral Underclass Discourse emphasises that the fault lies within the individual. The poor may also be seen as members of a ‘tribe’ who live apart from the deserving and hard working families; they are the chavs, the skivers, the welfare scroungers.

Poverty can be a discrediting stigma as it might have an outward appearance, or it could also be a discreditable stigma as an internal invisible ‘mark’ known only to the poor themselves. It can, of course, be a felt stigma and an enacted stigma as society exercises certain sanctions and behaviours towards the poor. Family members and friends of those on hard times may feel courtesy stigma on their behalf.

Thus, as a highly stigmatising condition, those who today are in poverty may wish to hide away or use ‘maladaptive coping mechanisms’ such as smoking, drinking or drug taking. Orwell’s continual descriptions of the need for and centrality of tobacco illustrates this point. Many today would see tobacco as a dangerous luxury. His fixation with food illustrates the shifting of priorities, and the collapse of time to orientate to the present. Future discounting might explain why the dangers of smoking and the future threats to health just do not impact on present behaviour.  It also clearly illustrates is the exercise of one’s personal agency being highly mediated by (and mediating) the culture and the social structures one lives in. It may seem to today’s sensibilities that tobacco use would or should be resisted if poor. However, Orwell makes it plain to see how one’s psychological state gets reduced and focused in both time and space. His ‘annihilation of the future’ and ‘boredom’ are telling. It might explain why we make what seems to be irrational decisions in the face of hardship. Orwell of course would have a way out, but if one believes that the future is set, the discounting of the future to deal with the present may be a highly rational strategy.

The fear of poverty disappearing, because one is actually poor, is another seemingly irrational mind set. But if the dogs have turned up you at least know you can sink no lower. There is no such thing as status anxiety, or keeping up with the Jones’. The ‘psychosocial comparison’ thesis of poor health outcomes no longer applies to you because the fear of being compared and of comparing has been assuaged by the surety of the lowliness of status. What is left is survival today, not tomorrow, because tomorrow never comes.

Before we thus rush to judgment on the choices the poor make, or provide theories of why there is poverty based on individual failure, Orwell’s exposition provides a window into their world and might make us think twice.

 

 

 

 

 

 

 

 

 

Stigma – a narrative.

“ Hello, my name is John , and I am an alcoholic”

John (aged 46) lives alone in a bedsit in a less than salubrious part of town. He looks in the mirror each morning and thinks to himself …nothing. He just feels numb. Divorced, he does not know where his children are and now isolated as his employer now reckons he can do “without his services”. His previous landlord had given him notice to quit about 3 months ago.

The landlord had stated at that time that John was not quite what he expected, his demeanour and appearance had deteriorated from when he first moved in. John had  Undesired different-ness from what I had anticipated when I first took him in as a tenant”.

John had carried his few belonging to the new place feeling that now as far as anyone else was concerned he was now “reduced from a whole and usual person to a tainted, discounted one”.

John as was drinker. When drunk his alcoholism was out there for all to see, it became a visible discrediting condition. Those around him could see and avoid him. In the mornings before his first drink he carried his alcoholism inside. He used to be able to function at work quite well, his drinking was invisible known only to John (if he thought about it) as a discreditable condition that he was able to pass off.

Throughout his life he had struggled with feelings of self hate and worthlessness. The drink was a friend. However, he knew it was not the friend it once was. He felt different, unwanted, alone. As life got more difficult he could see the stares even when pissed. Being turned down for jobs and housing when his condition became known was increasingly hard to take. Employers and landlords saw him and acted according to the label ‘alcoholic’. His wife eventually had left him unable to take the shame of having a pissed husband turn up at parties making a fool of himself. She had the courtesy of feeling the shame on his behalf.

It was not as if he had visible skin disfigurements or limbs missing, what some have called ‘abominations’ of the body’ this was not why he felt different. After all when sober he had been fairly well presented and in his younger years quite a good looking man. No, the issue now was that others thought of him as weak, unable to control himself, a laughable character, with a character blemish. It was all to do with who he was as a person, it was not his family’s fault and he could not even argue he faced ethnic discrimination living as he did among his own tribe.

His felt socially worthless life was his fault. He was seen as responsible for his drinking. If he could just put the booze down things could be better. However, some had seen him get worse over the years and though there was nothing that could be done, the drinking was progressively worse and possibility incurable. Many friends and work colleges had of course heard about alcoholism and many had drinking habits of their own which may be problematic. However, few had really understood what alcoholism actually was, how it arises, how it affects people beyond seeing the drunk, and of course being drunk was often hard to conceal.

John sat among the group feeling shame for his past behaviour and a little concerned about how this group would judge him. He had enough experience of how other people had treated him recently and so felt apprehensive about the value judgments they would make and actions that this group would take. He was new to AA and had no idea how this worked, he hoped that as the others had been (or still were) drinkers then maybe they would not judge him so?

His last employer, Mark Taylor, had been particularly hard on him. John’s fellow workers had felt however that Mark had some issues of his own which made the relationship between the two even more difficult. Some had even suggested that Mark was a little self obsessed and was difficult to work with. It was felt that he found it difficult to put the needs of others before his own. This only made his attitude towards John even worse. Mark’s narcissistic personality, it was felt, had just made issues worse. Mark’s stigmatization and harsh treatment of John involved dehumanization, threat, aversion and depersonalization into stereotypic caricatures. For Mark, this served to increase his own self esteem, enhanced his control and allowed “anxiety buffering”, through downward-comparison, i.e.comparing himself to John. This process increased his own subjective sense of well-being and therefore boosted his already over inflated sense of self-esteem.

 

John’s illness experience was being constructed in quite a negative way. His appearance and behaviour singled him out as socially deviant, subject to discrimination, prejudice and stereotyping. His alcoholism was a condition of societal deviance as most people accepted that this was apersonal failing, a sign of moral weakness and lack of control. This was only slightly ameliorated by it being also being seen as a disease. However Johns experience was not that of a patient with an illness that needs medical care, he felt outcast, alone and dirty. It was as if society had two definitions: alcoholism as disease for which John should play the sick role, and alcoholism as deviant behaviour that requires punishment or avoidance.

 

John thus felt ostracized, devalued, rejected, scorned and shunned. He experiences discrimination, and only thinly disguised insults. He began experience psychological distress expressing suicidal ideation as a result of viewing himself with contempt. The drink paradoxically made that feeling go away. It was both savior and nemesis.

 

John’s experiences over the past few years had an effect on his behaviour in that he often started to act in ways that others expect of them. In social situations he learned to withdraw as a result of the avoidance behavior of others. This therefore it not only changed his behavior, but it also shaped his emotions and beliefs. Thus his experiences put his social identity into threatening situations, such as low self esteem. He became more aware of the label alcoholic and thus began to act as he though alcoholics were expected to act. He had nothing to lose, people expected it anyway. He knew that he was not being treated the same way as ‘normals’ and knew he would probably be discriminated against.

 

Post script

Alcoholism – a fault with self?

Not everyone is comfortable with the term stigma or its connotations.  Critics have argued that stigma focuses too much on the characteristics of the stigmatized, and not enough on the social and structural mechanisms that create discrimination and entrench social oppression. http://stigmaj.org/announcement/view/5

To what extent is alcoholism a personal trouble? To what extent is it a public issue? What social structures are involved in ‘creating’ this as a personal and social problem? What is occurring in the 21st century in certain societies that frames the alcoholic experience in particular ways? What discourses are used to describe alcoholism – biomedical. psychiatric, criminal justice, public health, social? How does each discourse frame the issue? Is there a nursing discourse on alcoholism?

 

© Benny Goodman 2011

Goffman on Stigma

“Undesired different-ness from what we had anticipated”.

“reduced in our minds from a whole and usual person to a tainted, discounted one”

1. Medical conditions which give rise to stigma can be:

·         Discrediting conditions (visible).

·         Discreditable conditions (invisible).

2. The experience of stigma can be:

·         Felt – your subjective experience.

·         Enacted – when discrimination takes place, moral judgments made.

·         Courtesy – when friends and family are involved and feel the discrimination or stigma.

3. Sources:

·         ‘Abominations’ of the body.

·         Blemishes of character. weak will, domineering or unnatural passions, treacherous and rigid beliefs, or dishonesty. Blemishes of character are inferred from, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, or radical political behaviour.

·         Tribal, e.g. arising from race, nation and religion. beliefs that are transmitted through lineages and equally contaminate all members of a family.

4. According to Goffman, diseases associated with the highest degree of stigma share common attributes:

·         The person with the disease is seen as responsible for having the illness.

  • The disease is progressive and incurable.
  • The disease is not well understood among the public.
  • The symptoms cannot be concealed.

Goffman, E. (1963) Stigma: Notes on the management of spoiled identity. Englewood Cliffs, Prentice Hall.

Society, Socialisation and Culture

Sociology in Nursing

 

This short paper discusses the meaning of three key words:

 

·         Society

·         Socialisation

·         Culture

 

There will be other words in blue and bold which also have specific meanings. These are hyperlinks to Wikipedia which is a useful introduction, however you will have to access books and journals if you wish to discuss these terms in academic writing.

 

 

What does the terms ‘society’ mean?

 

A large group of people who relate to each other. That is to say they work, interact, live in a shared ‘space’ be that geographical, occupational or recreational. They of course are not all in kin or family relationships, with the nature of the relationship often being transactional (‘for a purpose’) rather than emotional. Therefore human societies can be characterized by a shared and distinctive culture and institutions.  A society may be described as the sum total of such relationships among its members. A society can be a particular ethnic group, such as for example those who grandparents may have been from the Indian subcontinent; a nation state, such as Scotland; or a broader cultural group, such as a Western (Anglo-American) society.

From a sociological perspective, a larger society often manifests stratification and/or dominancepatterns among the groups that make it up. For feminist thinkers, many societies are dominated by men and male ways of thinking (Patriarchy), for those of a marxist persuasion societies are dominated by ruling class elites and their ideologies.

In nursing, there is discussion that society is patriarchal. This results in male values and ways of doing things becoming to be seen as more important than female. Also because nursing is female dominated and medicine male dominated these male values often result in nursing being understood as an inferior profession (Goodman and Ley 2012 p36-41).

If it is a collaborative society, the members can benefit in ways that would not otherwise be possible if they remained as individuals. British society since 1948 generally agreed on the social funding, out of personal taxation, of a health care system we call the NHS. Currently British society is showing less cohesiveness (what Zygmunt Bauman calls ‘liquid modernity’) and arguments now arise on how the NHS should be funded or delivered. 

A society can also consist of like-minded people governed by their own norms and valueswithin a dominant, larger society. This is sometimes referred to as a subculture. For nursing we can think of subgroups, especially our professional subgroups, who may have shared norms and values and who may develop quite distinct views, knowledge and attitudes towards health. This means we need to examine our relationship as professionals to our patients and clients and to other professional groups.

In sociology a key issue for understanding how societies work was whether societies arise from the collection of individual actions of ‘free agents’ and therefore if this is the case we need to investigate these social actions at the small group and individual level; or whether societies are characterised as having groups and institutions within them all fulfilling various functions such as child rearing and therefore we need to investigate the functioning of society; or whether societies are riven with group conflict (be they class or gender conflicts) and therefore we need to investigate the nature of this conflict.

From the first viewpoint we could investigate the ‘presentation of self in everyday life’, (see the work of Ervin Goffman) that is to say, how do we go about our daily business ensuring we know what ‘actions’ we need to undertake, for example as a nurse, and how do we manage the impression people have of us? This involves the wearing of uniforms and ways of speaking so as to play the role of ‘professional’. From the second viewpoint we might want to investigate what being sick means for the functioning of society and thus what role should be played by a sick person (see the work of Talcott Parsons). What are the rights and responsibilities of the sick person in a proper functioning society? From the last viewpoint we would want to investigate if health care professionals really serve society as they say they do or whether they actually serve themselves and are in conflict with other groups in society. We would look at the structure of rewards and status in society of, for example, doctors and/or men as doctors (see the work of Ivan Illich).

 

 

 

Case study: Mid Staffordshire NHS Foundation Trust Inquiry March 2010

 

In 2010, Emily Cook (a health correspondent for a daily paper) reported that up to 1,200 patients may have died as a result of “shocking” treatment at Stafford Hospital. This story was based on a report by the Healthcare Commission which stated that Mid Staffordshire NHS Foundation Trust had an appalling and chaotic system of patient care.

The Healthcare commission (now the Care Quality Commission) had a role in examining the quality of care delivered by NHS organisations. The Commissions’ report argued that between 400 and 1,200 more people died than would have been expected during 2005 to 2008.

According to Cook, families described ‘Third World’ conditions in the hospital with some patients resorting to drinking water from flower vases because they were so thirsty.  Some of the conditions reported included filthy, blood and excrement crusted wards and bathrooms, patients being left in pain and needing the toilet, and being left sat in soiled bedding for hours and not given their regular medication. In one ward, 55 per cent of patients had pressure sores when only 10 per cent had sores on arrival.

The health minister at the time was concerned enough to order an inquiry. In a 452 page report, Robert Francis QC outlined the shortcomings in care in and argued “It was striking how many (patient’s) accounts related to basic nursing care as opposed to clinical errors leading to injury or death”. The conclusion was that patients were ‘routinely neglected’ in the context of cost cutting, targets and processes that lost sight of the basic need to provide safe care.

 

Many patients had their basic needs neglected:

 

·      Calls for help to use the bathroom were ignored.

·      Patients were left lying in soiled sheets.

·      Patients were left sat on commodes for hours.

·      Patients were left unwashed – at times for up to a month.

·      Food and drink was left out of reach.

·      Family members had to feed patients.

·      There was a failure to make basic observations.

·      Pain relief was given late.

·      Patients were discharged inappropriately.

·      There were poor standards of hygiene.

·      Families removed dressings and had to clean toilets.

 

 

 

The reasons outlined in the report for these deficiencies in care were as follows:

·      A chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care.

·      Morale at the Trust was low.

·      Many staff did their best in difficult circumstances, others showed a disturbing lack of compassion (my emphasis) towards their patients.

·      Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear or bullying.

 

The Trust’s board was found to be:

 

“ disconnected from what was actually happening in the hospital and chose to rely on apparently favourable performance reports by outside bodies such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients.

The Trust “failed to listen to patients’ concerns”, the Board did not “review the substance of complaints and incident reports were not given the necessary attention”.

 

Quotes are from   http://www.midstaffsinquiry.com/news.php?id=30

See http://www.midstaffsinquiry.com/ for the report into Mid Staffordshire NHS Trust.

 

 

 

Please read the case study above and then think about what this says about our society, how we are socialised and what a culture may mean.

 

Next I will address two key concepts in sociology – socialisation and culture – and relate them to what was going on at Mid Staffordshire and how they apply to your own nursing practice.

 

 

 

What is socialisation?

 

Staff at the Mid Staffordshire NHS FoundationTrust may have been socialised into a particular culture that was detrimental to good care. But what is meant by ‘socialisation’? 

One possible definition is as follows:

We may understand the idea that we are born into a society that has certain rules of behaviour and we, as human beings, learn these rules through a process of socialisation. Socialisation simply means the various ways we learn how to be a human being and are taught the basic rules of society we live in. (Goodman and Clemow, 2008, page 78).

 

Therefore socialisation is the process by which we learn the customs, norms, values, attitudes, beliefs, mores and behaviours of our society, i.e. how we acquire our culture. However, socialisation provides only a partial explanation for the acquisition of culture. People are not blank slates to be written on by our society. We are not robotic social actors blindly learning culture. Scientific research provides strong evidence that people are shaped by both social influences and their hard-wired biological makeup Genetic studies have shown that a person’s environment (socialisation) interacts with their genotype to influence their behavioural outcomes. So, society shapes us through socialisation and we also act as agents to socialise others. Our genes do not determine our behaviour and are in fact affected by the social environment.  

The following activity asks you to consider your own socialisation.

 

Activity

 

a. Think back to your first day at secondary school. How did you know how to behave with other pupils and with the teachers. How did you learn the formal (and informal rules) for being a pupil in class (i.e. how were you socialised as a pupil)?  

 

b. Think about right now and what is happening to socialise you first as a student and secondly as a nurse.

 

c. Now identify just one aspect of your health and how it has been shaped by your socialisation. Consider, for example, your alcohol consumption and the likelihood of developing problems with alcohol.

 

 

Socialisation shapes our behaviour in quite fundamental ways to the extent that we begin to feel that we could not behave in any other way. Take a common student pastime: drinking.  The use of alcohol in western society is seen very differently from that in a Muslim society. People living in Muslim families, in the UK as well as abroad, may well be socialised into very different views on drinking. Young westerners ‘feel’ that going to the pub is very normal and to be expected, whereas their counterparts from a devout Islamic background may not feel the same way. However as this example indicates socialisation is not so strong that behaviour never changes as young British Muslims may feel themselves being socialized into two different cultures and this results in a tension that has to be resolved.

 

A related idea is that of ‘Occupational’ socialisation i.e. how one learns the customs of an occupation. The suggestion here is that many occupations (and professions) have their own ways of speaking, dressing and acceptable modes of behaviour. Melia (1987) described the occupational socialisation of student nurses, while over 30 years old, this study sheds light on how we become the nurses we are and illustrated the tension felt by students as they juggle the demands of education and the service needs of the NHS. The clinical area demands a certain behaviour (doing the work) while the University expects another (studying).

 

As student your focus may be on learning about medications; their administration, prescription, side effects and contra indications and so you may wish to spend time asking about drugs or reading the British National Formulary while you are in practice. Your University may highly value this activity. Your clinical practice setting may also value this knowledge but what may be of more immediate importance is that you assist the qualified staff in actually administering the drugs themselves, time being too short to look up every single one. The university may value knowledge, the practice setting may value ‘getting the work done’.  Of value also is that knowing how to find out a piece of information that is specific to a particular patient or situation is perhaps more important than carrying the complete contents of the BNF around in your head.

 

What is culture?

 

The shared beliefs, norms values, attitudes, mores and behaviours of a society is its culture. This involves language use, the way we dress, the food we eat, what leisure we like, whether work is valued …even what sports we value. Into this mix are ideas about dominant and subordinate cultures, or sub-cultures, within wider culture. Culture is dynamic and subjective. It changes over time (sometimes rapidly). It is defined by those who are experiencing it and will mean different things to different people. Therefore, and from an understanding of how we become socialised into a culture as described above, we may see that culture affects how we behave, our attitudes and our values. At Mid Staffs the organizational culture was described as having elements of:

 

·      Bullying

·      Target driven priorities

·      Disengagement from management

·      Low staff morale

·      Isolation

·      Lack of candour

·      Acceptance of poor behaviours

·      Reliance on external assessment

·      Denial

 

So it can be hypothesised that despite professional codes of conduct some nursing staff were or socialised into accepting poor practice. Although staff did raise concerns, the culture was such that not enough was done to prevent poor quality care.

 

Socialisation and culture can be viewed as strong social ‘forces’ that shape how we go about our business in an organization. We may think we are completely free agents making free choices, but the experiences of nurses at Mid Staffs shows that the culture can very seriously affect behaviour, in this case the reporting of and delivery of inadequate care. Sociology moves us on from blaming individuals as the sole reason for poor care. Instead it asks us to investigate the social processes that affect individuals in an attempt to devise solutions which go beyond the individual and focus as well on the nature and culture of organisations in which people have to work.

 

Benny Goodman. 2012

 

 

 

 

 

Goodman, B. and Clemow, R. (2008) Nursing and Working with other people. p78. Learning Matters. Exeter.

 

Goodman, B., and Ley, T. (2012) Psychology and Sociology in Nursing. Learning Matters. Exeter.

 

Melia K (1984) Student nurses’ construction of occupational socialisation. Sociology of Health and Illness 6 (2) pp 132-151

 

 

 

 

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