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Purpose – To assess labeling and social control of clients in contemporary mental health care organizations.

Methodology/approach – Fifteen months of observation in two multiservice mental health care organizations, interviews with workers and clients, and analysis of organizational documents.

Findings – The organizations used a variety of organizational labels, both official and informal, which served distinct purposes in organizational life and which did not always agree in their construction of the client. Official mental illness diagnosis was a bureaucratic label, while informal labels determined the types of social control to which clients were subjected. Clients who were informally labeled severely mentally ill were subject to integrative social control, while exclusionary social control was applied to those informally seen as not being severely mentally ill. Unlike in classic studies of mental health care, looping processes, in which client behaviors are viewed as symptoms, do not reliably predict the types of labels or social control applied to clients.

Implications – It is important for a sociology of diagnosis to contextualize official diagnosis in the repertoire of organizational labels applied to clients in mental health care, recognizing that it plays a limited but important role in organizational life. Informal labels, which at time conflict with official diagnosis, play a more prominent role in the management of everyday organizational life.

Throughout the late 19th and early 20th centuries, one of the many techniques used by physicians and psychiatrists to diagnose patients involved external and highly public examination. Typically conducted as a lecture to other medical experts and students, the patient was placed in the center of a round room with onlookers arranged in tiered seating to guarantee an unobstructed view. As the lead physician detailed the list of symptoms, using the patient's body as an illustration, observers witnessed the behavioral signs for themselves and discussed the possible underlying conditions or pathologies. This process of consultation and naming worked to increase the relative reliability among experts and bolster the professional reputations of medicine and psychiatry alike (Conrad & Schneider, 1992; Gillis, 2006; Grob & Horwitz, 2010). As researchers have noted (Aronowitz, 2001; Foucault, 1973), this change from focusing on disparate, idiosyncratic symptoms as expressions of individual illness to a system that recognized disease states comprised of symptom clusters marks a historical turning point in the history of medicine. The shift toward a classification scheme that linked medicine with science and technology bolstered medical authority and the power of physicians. In addition to professional credentials, accumulated knowledge, and institutional legitimacy, the authority of modern medicine both rests on and is expressed by medicine's decisive power to name and categorize through diagnosis (Jutel, 2009). Even as medical prestige has eroded, ceding some of its power to other entities,¹ physicians remain the final arbiter of official medical categories (Pescosolido, 2006), judges of what is, and what is not, a “real” diagnosis. In the diagnostic process, one looks within to reveal the nature of disease from without – empirical observation becomes immutable fact. Of course, as critical perspectives on medicine have long pointed out (Conrad & Schneider, 1992; Zola, 1972), the scientific “fact” of one time and place is the mythology or ignorance of another. Diagnosis, as both category and process (Blaxter, 1978), is infused with all manner of things social, historical, and cultural. This volume explores some of these infusions. In so doing, it aims to clarify and contribute to the emerging sociology of diagnosis – an endeavor first called for by Brown (1990), but more recently revived by Jutel (2009).

An inquiry into the constitution of the experience of patienthood. It understands “becoming a patient” as a production of a subjectivity, in other words as a process of individuation and milieu that occurs through an ontology of production. This ontology of production can, of course, also be understood as a political ontology. Therefore, this is, first of all, an inquiry into a mode of production, and, secondly, an inquiry into its relation to the issue of social justice – because of effects of digital divisions. In these terms, it also reflects on how expert discourses, such as in medical sociology and science studies (STS), can (and do) articulate their problems.

An integrative mode of discourse analysis, strongly related to discursive institutionalism, called semantic agency theory: it considers those arrangements (institutions, informal organizations, networks, collectivities, etc.) and assemblages (intellectual equipment, vernacular epistemologies, etc.) that are constitutive of how the issue of “patient experience” can be articulated form its position within an ontology of production.

The aim not being the production of a finite result, what is needed is a shift in how “the construction of patient experience” is produced by expert discourses. While the inquiry is not primarily an empirical study and is also limited to “Western societies,” it emphasizes that there is a relation between political ontologies (including the issues of social justice) and the subjectivities that shape the experiences of people in contemporary health care systems, and, finally, that this relation is troubled by the effects of the digital divide(s).

A proposal “to interrogate and trouble” some innovative extensions and revisions – even though it will not be able to speculate about matters of degree – to contemporary theories of biomedicalization, patienthood, and managed care.