The idea that people should take more personal responsibility for their health is nothing new. For more than 40 years now, we have been promoting the belief that self-care is obviously good and necessary, and that people should be less passive and less dependent.
This view has been particularly prevalent in physiotherapy, where the shift away from so called ‘passive’ modalities has been accompanied by an equally powerful set of discourses pushing behaviour change and an activity-is-best agenda.
We’ve written about some of the dangers of this approach elsewhere (Nicholls et al, 2018), but a recent paper published in the journal Sociology of Health and Illness adds weight to the belief that personal responsibility may not be as obvious as it seems.
In the paper titled Pastoral power and the promotion of self-care, Lorelei Jones uses the notion of pastoral power to analyse how health professionals are being asked to take on new and interesting roles in healthcare. Pastoral power draws on Christian notions of the good shepherd as a metaphor for how we might shape people’s moral conduct: in this case, how they might act in their own and, by extension, the rest of society’s interests.
Jones argues that, ‘Applying the concept of pastoral power to healthcare policy, ‘the modern pastorate’ is made up of specialists, experts, and therapists who promote desirable subjectivities’ (p.3).
Through the Foucauldian ethnographic study conducted in the UK across ‘four localities in four different regions of England between November 2013 and August 2015’ (p.5), Jones tracks the strategies used by people to inculcate self-care into a variety of health service providers and users.
The Discussion section of the paper is particularly interesting, because it reveals some of the reasons why discourses of self-care and personal responsibility are failing to gain purchase:
- An overemphasis on homogenous training methods and ways of promoting self care
- Approaches from management that are ‘normative in tone, closely linked to a proposed solution, less theoretical than traditional academic writing, focused on enhancing organisational performance, and addressing ‘hot’ issues in public policy’ (p.12)
- Highly polished and packaged training provided in ‘short sessions on an ad hoc basis, in contrast to professional training where socialisation into professional identities is accomplished through many years of education and apprenticeship’ (p.13)
- Approaches that didn’t confront people’s established views about their professional responsibilities, allowing new ideas to clash with long-held beliefs without the enduring support to bring about significant change
- Emphasising training of lower status staff whilst ignoring the power brokers (especially doctors), who then undermine the message of self-care with directives to ‘fix’ and discharge the patient
- Little attention to personal preferences, family roles or cultural heritage, assuming that people are ‘rational actor[s], neglecting ‘the social life of decisions’’ (p.13)
Most importantly, Jones highlights the underlying motivation of a lot of self-care, that being the kinds of neoliberal economic reforms that drive the shift towards self-care, allowing for the gradual replacement of centralised servises with user pays;
‘Self-care may bring benefits to both patients and professionals, but as a dimension of social policy it is utopian in the belief that re-culturing the public will significantly reduce demand on statutory services, and that organisations in local health and social care markets will respond to a reduction in demand by reducing supply and closing facilities so as to produce ‘significant cost savings’ (rather than, say, lowering access thresholds) (Jones 2018, p.14).
This is not, in itself, a new argument. Rose Galvin in 2002 wrote about the idea of ‘culpability in the face of known risk’, and the idea that the vast volumes of health ‘education’ now available to us can only be understood as a political economic move to shift responsibility from The State to the individual, in order to manage the growing cost of healthcare. Galvin draws the startling conclusion that it will soon be possible to place the blame on you for your poor health – because clearly you didn’t follow all the health advice that’s been available to you for so long – and so it follows that you must be responsible for your bad hip, breast cancer and type II diabetes, ergo you must pay.
Jones and Galvin’s papers remind us that there is always more going on than simply believing that self-care is an obvious good, and more critical attention to questions like ‘why this, why now’ are needed before we jump in behind such dangerous ideas.
Galvin, R. (2002). Disturbing Notions of Chronic Illness and Individual Responsibility: Towards a Genealogy of Morals. Health (London) 2002; 6; 107 DOI: 10.1177/136345930200600201.
Jones, L. (2018). Pastoral power and the promotion of self-care. Sociology of Health & Illness. ISSN 0141-9889, pp. 1–17 doi: 10.1111/1467-9566.12736 (link).
Nicholls, D., Jachyra, P., Gibson, B. E., Fusco, C., & Setchell, J. (2018). Keep fit: Marginal ideas in contemporary therapeutic exercise. Qualitative Research in Sport, Exercise and Health, 0(0), 1-12. doi:10.1080/2159676X.2017.1415220.