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.

It's more than a case study

I’m a medical sociologist – which is to say that I am interested in the knowledge, practices, and social relations that underpin medicine as a social institution; and in health care as the matrix in which it is set, and the ways that it is linked to other social institutions. I’m also interested in the history and sociology of technology – hence my focus on the development of explanatory models of socio-technical change, discussed in other posts. My small contribution to this field has been to lead a programme of work that has led to the development of Normalization Process Theory.

From my perspective, one of the interesting features of sociological research around health and illness over the past decade has been the growing significance of the broad field of Science and Technology Studies, or STS. A number of commentaries – of which a paper in Health Care Analysis by Casper Jensen is the most recent – have argued that a shift to the theories and methodological perspectives of STS is necessary to secure the intellectual future of ‘medical’ sociology. My research and writing has certainly been influenced by STS although – it seems – not enough for Jensen. In some ways, STS seems to have a good fit with the ways that Sociologists of Health and Illness construe their own field of research. In the UK, at least, the boundaries between the two fields are getting a bit blurred.

Now, STS is constructionist in its theoretical approach; privileges contingent and relational aspects of social life; focuses on specific incidents or cases of general problems; and is largely conducted through the application of qualitative research techniques – often ethnographies, and increasingly also interview-based research. But, as John Law has argued in a recent position paper in Sociological Review, there is a strong argument within the communities of practice that make up STS that it ought to concern itself primarily with case studies, description and classification, and that it should seek neither causal explanations nor should it attempt quantitative generalisation. Actually Law may go further than this. He seems to say that this is the way that we should think about sociology as a whole discipline. I think this is a counsel of despair; a recipe for empirical fragmentation; and a prescription for the loss of analytic power. The multiplication of small-scale, qualitative, case studies of contingencies and relational processes restricts the development of Sociology as a holistic science of social and material relations. If everything is a case, then nothing is a whole.

As a brief aside, the BiomedCentral papers describing Normalization Process Theory passed 18,000 on-line accesses today.