Walking in the rain, thinking about illness as an action orientation

The past few days we have been on vacation in the West of Scotland. The back end of September is no time to expect sun, but we saw plenty of rainbows and walked the length of Glen Orchy in some of the heaviest rain I have ever been drenched by. We rented a wing of Bonawe House (left) and ate at two really good restaurants – the Airds Hotel at port Appin (a temple where food is not so much enjoyed as worshipped), and Coast in Oban, which does pretty spectacular Scottish contemporary cooking.

Although I was supposed to be on holiday I was actually emailing back and forth, and reading transcripts, about three really interesting and closely interconnected projects in which we’re using normalization process theory to explore the work of being sick, our starting point is a piece written for a book edited by Graham and Sasha Scambler. The collection won't be published until next May, so I have put the chapter up on my academia.edu page.

First of all, a group led by Chris Dowrick, and including Carolyn Chew-Graham, Linda Gask, Jane Gunn, Anne Rogers, and I are using NPT to examine the work of being depressed. The aim here is to explore depression from an action orientation and to locate novel points of therapeutic intervention. This is really interesting and we’re shortly off to workshop through a set of transcripts and start building testable hypotheses in the splendid surroundings of Chris Dowrick’s hacienda at Molina Canario. This international group has its counterpart in a group led by Victor Montori at the Mayo Clinic, who is leading a programme of work that explores the burden of work in chronic illness and comorbidity, again using NPT, but combining it with our work on Minimally Disruptive Medicine. Being involved in this group is very interesting, the aim is to identify ways of measuring treatment burden and thus enable clinicians to respond to structurally induced non-adherence to treatment regimens. Finally, Frances Mair and I are working with Katie McGrath – a really interesting early career research in general practice – to develop an NPT based analysis of the interaction between burden of illness and burden of treatment in people with chronic heart failure. These three studies all seek to analyse the experiences of sick people from the perspective of their active engagement with healthcare systems and their experiences of doing the work of healthcare for themselves. It's a really interesting application of NPT, which I originally envisaged as a theory of socio-technical change. But now, one of the possibilities that it raises is a rigorous and theoretically informed of the implementation and integration work that people do when they engage with their own illness as active participants in processes of sense-making, cognitive participation, and collective action. It's very exciting.

About Social Systems - just briefly

For reasons I shan't trouble anyone with, I am working my way through Niklas Luhmann's grand opus Social Systems (trans J Bednarz Jr & D Baeker, Stanford University Press: Stanford CA, 1995). Luhmann is unique amongst European social theorists in that (i) he owned a pub, and (ii) he owned a brewery. But, God alone knows, he found it hard enough to write an engaging sentence.

I bought Social Systems last week in the wonderful Munro's Books on Government Street in Victoria, BC. There are some things to be said about Social Systems, however. It's not so much a book about social theory as a giant casting press, imposing its great weight on smaller more fragile objects and crushing them into unwilling shapes.

Against Luhmann, Parsons on The Social System and Habermas on Communicative Action both seem to be formed from satirical and succinct prose (which they are very definitely not, incidentally). Even Foucault pales into simplicity next to the violent disregard that Luhmann has for the reader. Luhmann's book is utterly relentless; incomprehensible in some parts; grindingly dull in others. Trying to make sense of it is like working a large and very heavy electric polisher over an uneven strip of parquet flooring.

The value of social media

The Mayo Clinic has just put video of its 2009 Transform Symposium on line. This includes talks by Maggie Breslin and Victor Montori - Victor gives a great presentation of our ideas about Minimally Disruptive Medicine, as discussed in earlier blogs. One of the things that my collaboration with Victor and his colleagues in the Knowledge and Encounter Research Unit has brought home to me is the value of different social media - YouTube, Web 2.0, and even Twitter - in ensuring public and professional engagement with their work. Mayo has an incredibly perceptive and effective social media guru in Lee Aase, and he provides an extraordinary free resource for people interested in developing social media skills and capability.

On the Pacific Rim

For the past week I have been in Victoria, British Columbia, participating in a workshop that ought to lead to major centre for health services research on the Pacific Rim. Led by Mary Ellen Purkis and Lynn Stevenson the workshop focused on how a university and a health authority can build a genuine partnership to answer questions that have both a scholarly and a policy edge. In lots of ways, it was a thrilling meeting because of the Vancouver Island Health Authority’s initiative to redesign patient care . This is a major, data driven, enterprise founded on more than 30,000 hours of observational work, and recording about 1.5m episodes of patient care. It’s a very exciting resource for research and it will be at the centre of the new centre.

While I was there, I had the opportunity to renew my acquaintance with Chris Ceci of the University of Alberta, as well as Mary Ellen, and ended up writing an Introduction for their edited volume of papers presented at In Sickness and in Health 2009. While I was in Victoria I had a chance to eat at the inestimable Café Brio - one of my favourite restaurants in the world. They served a fantastic Fig and Goats cheese salad to start (it’s going to figure prominently on my Menu this winter) and a truly excellent roast duck on pureed Jerusalem Artichoke.

Theory, Practice, and STS

Working on Chapter 3 of Normalizing Health Technologies, I've been musing on the problem of agreement about fundamental problems of practice in Sociology. For example, we can find representatives of very different perspectives – for example, John Goldthorpe [1], representing rational choice theory applied to large population data-sets; and John Law [2], representing actor-network theory in ethnographic case studies – arguing that the integration of theory and empirical research is a core problem.

Traditionally, STS practitioners have usually been cautious about theory in the form of grand narrative. (…) They tend to speak somewhat austerely, to want to know both what large scale generalisations or theories mean in practice, and about where they apply. Indeed, they are prone to ask whether such generalisations mean anything at all. They also, and in a related way, tend to avoid buying into a theory/data distinction. This is because in STS theory is not first created and then applied empirically. Theory and data are created together. However empirical it may be, everything is already theorised (2008: 629)

This implicit theorisation is both inscribed in the meanings and assumptions that are designed into technologies like telemedicine – in this case that clinical encounters can be lifted out of the clinic, and be made more efficiently and equitably available that are by the people who are implicated in those practices, and in the cognitive and behavioural ‘toolkit’ that those people draw on in their everyday lives. So, one task for sociological analysis is to engage with those implicit cognitive resources and to find ways to make them explicit. But for Law and others, the business of STS is also about breaking down distinctions between data and theory, and saying that STS analysis is about the co-production of theory and data in relation to some empirical topic.

Law wants to avoid social science in which the empirical world is divided off from the world of theoretical development – like many sociologists (me included). He’s also anxious that the methods of sociological research come to constitute the realities that sociologists seem to engage with. Foucault’s dictum, that ‘discourse constitutes its own objects’ [3] applies here. So, to read theory in STS is to read the literature of cases studies. It is in this context that theory is developed as the empirical world is described and understood. An approach in which ‘theory’ and ‘data’ are co-produced and interwoven, then, is at the heart of Law’s analysis of the strengths of STS.

I think this is true of the work of a very small number of theoretical innovators including Law, but also – and especially the astonishing Sociological imagination of Michel Callon [4, 5]and Donald Mackenzie [6-8], both of whom have become interested in the sociology of maths, markets, and machines. However, it is much less clear that this is, in practice, what happens more generally. It's certainly not what I see as a reviewer for journals like Social Science and Medicine. In fact, just as in other areas of theoretically informed social science investigation, we see multiple instances of the transportation of basic constructs of a theoretical perspective from empirical setting to empirical setting. They don’t change much as they move between them, and slowly the socio-technical world becomes framed in relation to such constructs. It's hard to have a sociological conversation now about a new technology without addressing the problem of how the network is stabilized or not.

1. Goldthorpe, J.H., The integration of sociological research and theory - Grounds for optimism at the end of the twentieth century. Rationality and Society, 1997. 9(4): p. 405-426.

2. Law, J., On sociology and STS. Sociological Review, 2008. 56(4): p. 623-649.

3. Foucault, M., Afterword: the subject and power, in Michel Foucalt: beyond structuralism and hermeneutics, H.L. Dreyfus and P. Rabinow, Editors. 1986, Brighton. p. 208-226.

4. Callon, M., C. Meadel, and V. Rabeharisoa, The economy of qualities. Economy and Society, 2002. 31(2): p. 194-217.

5. Callon, M. and F. Muniesa, Economic markets as calculative and calculated collective devices, C.U. New York Conference on Social Studies of Finance, Editor. 2002.

6. MacKenzie, D., Mechanizing Proof: Computing, Risk and Trust. 2001, London: MIT Press.

7. MacKenzie, D., Knowing Machines: essays on technical change. 1998, London: The Massachusetts Institute of Technology Press.

8. MacKenzie, D., Inventing Accuracy: A Historical Sociology of Nuclear Missile Guidance. 1993, Cambridge, Mass: MIT Press.