Week 9 Flashcards
Changes in how we view death and bereavement
Huge impact of social media: informed about deaths 24/7 news, able to immediately respond, memorials are different
Increasing wish for openness and candour
-death cafes and discussion groups
-many recent books by health practitioners
Sociological approaches to death
‘Medicalisation’ and institutionalisation
Death and funeral as a social event
Exploring the concept of the ‘good death’ in society
Observational and qualitative research in hospitals, hospices, ICU units
Sociological approaches to bereavement
Social expectations related to bereavement (who counts as bereaved and how are they meant to behave)
How does society interact with the bereaved
What are the influences of wider patterns (inequalities, gender roles)
Qualitative research on experience of bereavement
Strong interaction with practitioners
Medicalised death
Death moves from home to hospital
Decreasing importance of religious rituals
Increasing taboo
‘Power grab’- doctors make decisions
Society values youth and health; carries on by marginalising the dying and bereaved
Hospice movement/palliative care concept as a response
‘Biological’ vs ‘social’ death Sudnow 1967
Biological death- the end of the biological organism
Social death- the end of the persons social identity
Social death Lawton 2000
Ceasing full membership in active society- retirement
Loss of autonomy- moving into institutional care
Chosen by the dying person
When the body cant be controlled- the dying person is avoided or avoids others
3 types of death Walter 1996
Traditional- at home, priest, prayer, ritual, communal mourning, religious
Modern- hospital, doctor, medical intervention, crematorium, private grief, medical
Postmodern- hospice, range of practitioners, palliative care, range of option, celebration of life, personal
Glaser & strauss: awareness of dying/ time for dying
Invention of grounded theory
Interaction between the dying, clinical staff and relatives with focus on expectation and awareness of death
Timeframes and trajectories related to dying
Awareness of dying
Different dynamics around awareness between hospital staff, patients and their relatives
Closed awareness- only staff aware
Suspicion- patient suspects but not told
Mutual deception- both know but don’t talk about it
Open awareness- both know patient is dying and discuss openly
Relatives may or may not know and also ‘shield’ their family
Not knowing means patients and relatives cant make decisions; uncertainty and guilt
Awareness can fluctuate between belief and disbelief
Time for dying
Development of ‘trajectories of dying’
People die at different paces often not as expected by relatives and clinical teams
Gradual slant- long slow decline
Downward slant- rapid decline
Peaks and valleys- remission and relapse
Descending plateaus- periods of decline and stabilisation
Unexpected developments can lead to conflict or upset
Kubler-Ross 1970: stages of grief
People who know they’re dying typically pass through 5 stages:
-denial
-anger
-bargaining
-depression
-acceptance
But not necessarily linear
Similar dynamics with carers and bereaved
Advantages: helps those in a supportive role to understand how the person is feeling, why they might respond differently eg wanting support/pushing people away
Disadvantages: when used prescriptively, rushing towards acceptance/ moving on
Concepts of the ‘good death’ Hart 1998
Concept emerges in late 60/70s
Powerful with practitioners/ in popular culture
Critique of bureaucratic, institutionalised care
In practice good death is the aim but who is to blame for a bad death
Patients and carers may struggle in absence of wider support/ resources
Expectations of a good death
Do family members/nurses etc expect the patient to conform to the good death to make the experience easier for them
Avoidance of anger/depression
Others might want the dying patient to show a brave face
The hospice movement 1960s
Specialised places for palliative care including but not exclusively care in the last days of life
Care focused on comfort, personhood, family, dignity
In some ways like a hospital, in some ways like home
Can be perceived as white, middle class, Christian institution
Reliant on charitable funding- based in more affluent areas
Where do people want to die
The ‘preferred place of death’ is usually at home or hospice
Depends on who you ask, when you ask
Also understood people change their mind during course of a terminal illness
Concept of palliative care
Dying acknowledged as part of life
Dying people can/should be enabled to live as well as possible
Autonomy of the dying person
Support for family/bereaved
Main focus is improving the quality of life
Enabling good deaths; right place, comfort, with fight/acceptance
Aspects of experiencing loss
Bereavement: situation of those who have experienced significant loss
Grief- range of emotions felt by the bereaved
Mourning- visible signs of grief or the period of time in which this happens
All have social conventions attached
Social consequences of bereavement Parkes 1996
Bereaved at greater risk of:
-depression
-social isolation
-alcohol misuse
-use of prescribed and OTC drugs
-self harm
Impact of social inequality Bindley 2019
Awareness of palliative care services
Financial impact of the death adds to grief and distress
Lack of support in interaction with statutory services and bureaucracy
Lack of support from employers/ ability to take leave especially in precarious jobs
Lack of cultural competence by care providers
Social expectations bereaved
Ideal is for the bereaved person to re-engage with society/ become a well-adjusted person
Different ideas about how long this process will take
How society views the relationship between the bereaved and the deceased
Not necessarily a partner/spouse/parent
Right to grieve and have grief validated and accepted
Worden’s 4 tasks for the bereaved 1983
Steps towards a new and fulfilling life
Implies that this needs to be actively done rather than being an effect of time passing
-accept the loss
-work through grief
-adjust to a new environment
-to find an enduring connection with the deceased
Moving on vs staying connected
What is healthy grief and mourning opinions differ depending on time and place
Some warn of the danger of being stuck in the past or socially isolated
Filling the emptiness, keeping busy,, helpful or not over long term?
Current ideal is to stay emotionally connected while still being able to carry on living
There may be unhelpful pressure to move on from other people
Role of the doctor with those who are dying or grieving
Treating, curing, averting death
Breaking bad news
Symptom control
Discussing patient wishes
Completing death certificate
Differences between groups of people
Human beings are complex creatures
One aspect of this is our tendency to organise into groups and consider ourselves as part of those groups
We also consider how other group are different
This phenomen has been studied as social identity theory
Social groups
Social groups will often develop ways of being that allow identification of other group members
The phenomenon is known as habitus:
The way they present themselves to others
This might include the way they dress
They way they talk- accent, language, tone of voice
The way they walk or stand
This habitus of a group reflects the aesthetic preferences of those who have power within the group
Doctors social group
A lot of your credibility as a professional relies on your ability to seem like a doctor
Look right, act right, talk right
Social identity theory posits that the more doctor-y you seem the easier you will find it to find acceptance, power and influence within the group
Traditional doctor habitus in UK: firmly upper middle class, white, male
Identity dissonance Yang Costello 2015
This poses no problem at all for those who are already from the correct background
But other people have to learn to act the right way
Professional identity doesn’t just happen
It takes time to see oneself as a member of the new group
It’s not just about looking the part, sounding the part
It’s not even just about being accepted as a member of the group
It’s also about successfully internalising the values of the new group
Values and behaviour
Values and beliefs are about what’s important and how things should be
We all hold multiple values across contexts
Values are of interest to psychologists and sociologists because they are one of the most important determinants of behaviour
Explicit professionals values
The GMC and other bodies provide us with professional values
Honesty, probity, reliability, responsibility
Medical schools council list the values expected of applicants:
Respect for others, responsibility, integrity, empathy
Values of humanistic care: whole person care, respect for peoples intrinsic value, considering others perspectives, suspending judgements, recognising universality, relational focus
Possible trajectories
Adapted from coulehan and Wilson 2001
Students: explicit professionalism, cognate professionalism, tacit professionalism
Cognate professionalism
Coulehan and Wilson 2001
When asked many doctors say they espouse professional values
They are able to behave accordingly to prescribed professional values when they are thinking about it
However when watched the behaviours they display when they are not thinking about it are anchored in a quite different set of values
Tacit professionalism ‘the hidden curriculum’
Coulehan and Wilson 2001
A position of self interest with values based around objectivity, detachment and wariness
Informal and procedural knowledge- how things are done Hafferty 2015
Consequences of hidden curriculum
Loss of idealism and acceptance of hierarchy (Sinclair 2020)
Neutralisation of emotions (hellman 1991)
Detachment and entitlement (coulehan and Wilson 2001)
Hidden curriculum borgstrom et al 2010
Conflict between old and new professional values
The hidden curriculum as lag in medical culture as medicine shifts from a paternalistic to a patient centred model
Professional identity coulehan and Williams 2001
Three possible outcome:
Narrow to being a technician adopt tacit
Non reflective professionalism
Internalise professional virtue adopt explicit
Values determine behaviour subconsciously
Cognate professionalism does not lead to the right behaviours most of the time
The system
The other thing we need to consider here is the system doctors work in
High pressure
Understaffed and under resourced
Punitive when things go wrong
Competitive
Traumatic
Little or nothing in the way of psychological support
Loss of sense of community
Professional values are expensive
Difficult to meet the needs of others when own needs aren’t met
The vast majority of unprofessional behaviour is seen in highly pressured stressful situations
Overworked and overstretched People will experience burnout
System must be revised and resources allocated improved to prevent circumstance undermining professional behaviour
Role models
Many medical students have role models for their professional behaviour
We will often internalise the values of role models easily and without deeper consideration
Think about professional behaviour you’re seeing rather than simply accepting it
In-groups and out-groups
Social groups to which a person does/does not psychologically identify as being a member
Individuals belong to many different in groups and out groups
In groups give use a sense of social identity
Important source of pride and self esteem
Allow us to find out things about ourself
Helps us to define socially acceptable behaviour
What is stereotype
“ a widely shared assumption about the personality, attitude or behaviour of a person based soley on their group membership” Hogg and Vaughan 1995
Positive or negative
Based on accident fallacy (sweeping generalisation)
How are stereotypes formed: personal experience, culturally received information, role models/ family members , the media, encoded by language, generalisation, identifying exceptions
Explicit or implicit- implicit association test
Why do we stereotype
Social function: allows us to learn from the experience of others
Cognitive function: simplify and systemise information about the world, reduces processing time, enables us to respond quicker to situations
Out-group homogeneity effect
People tend to perceive members of an out group as similar to eachother
In group differentiation effect
People perceive many differences between members of their own group
Consequences of stereotyping
Stereotyping affects our expectations of others and ourselves
Stereotypes affects social perceptions and behaviour: conformity/labelling, scapegoating, prejudice/discrimination
Stereotype threat, self fulfilling prophecy
Conformity/labelling
An individuals identity and behaviour is influence by the terms used to describe them
Labelling theory (Scheff 1966): labels bring attention to specific behaviours that break societal norms, labels become internalised into a persons identity, self fulfilling prophecy
Modified labelling theory (Link et al 1989), mental disorders
Modified labelling theory
Person is labelled, social meanings of the label become relevant to the person, response: secrecy, withdrawal, educate , negative consequences for self esteem, earning, relationships etc, vulnerable to further episodes of mental distress
Stigma is associated with powerful negative labels
Stereotype threat Steel 1995
Stereotype threat occurs when a person experiences anxiety/concern that they may confirm a negative stereotype linked to their in-group
Negative impact on their performance
Changing stereotypes
Difficult
Counter-stereotypes
Contact hypothesis: Allport 1954, equal status, common goals, inter group cooperation, support of law/customs, imagined contact/ e-contact
Education
Media/social media
Sex and gender
Sex and sexual identity is biologically determined eg genetic makeup, reproductive anatomy and biological function
Gender and gender identity is the social interpretation of sex
Gender role
Behaviours, attitudes, values, beliefs which society expects/considers appropriate to males/females
Gender stereotypes
Widely held beliefs about psychological differences between males and females
Sex typing
Process by which children acquire sex/gender identity and learn gender appropriate behaviours
Biological sex
Sex is a multidimensional variable
Chromosomal sex
Gonadal sex
Hormonal sex
Sex of the internal reproductive structures
Sex of the external genitals
Usually correlate
Intersex individuals
Disorders of sex development DSD
Low correlation of categories of biological sex
Hermaphrodite
True hermaphroditism rare- most cases consist of genital ambiguity (genitals not consistent with chromosomal/gonadal sex)
May influence gender identity or gender roles the effect on sexual orientation is more complex
Androgen insensitivity syndrome
Male develops female external appearance due to insensitivity to androgens
Androgenital syndrome
Female develops male external appearance due to prenatal exposure to high levels of androgens
DHT deficient males
Male develops female external appearance due to deficiency of alpha-reductase
Chromosomal abnormalities
Can lead to abnormal sexual phenotypes and hypogonadism
Eg Turner syndrome Xo:
Short stature, swollen hands/feet, webbed neck, infertility, amenorrhoea, absent/incomplete pubertal development
Eg Klinefelter XXY: gynaecomastia, small testes, less hair, infertility, tall with abnormal body proportions (long legs, short trunk, shoulder equal to hip size
Gender development nature or nurture
Biological
Males and females ‘biologically programmed’ for different roles possibly supported by evidence of structural and functional differences in male and female brains
Empathising-systemising theory Baron-Cohen
Not supported by some human studies eg Daphne Went: female gender identity and roles, XY chromosomes
Feminist theory
Emerged from feminist movements
In the late 20th century, feminists began to argue that gender is socially constructed
Women felt to be imprisoned by their gender role which has been dictated and manipulated by men and should be liberated
Biosocial theories
Money and Ehrhardts critical period of gender identity
AGS females
Males with testicular feminisation
Sociobiological theories
Gender evolved so we can adapt to our environment
Parental investment theory: an investment by a parent in an offspring that increases the chance that the offspring will survive; historically maternal investment> paternal
Social learning theories: learn behaviour though being treated differently, observational learning and reinforcement
Freud’s psychoanalytic theory
Rooted in the phallic stage of pyschosexual development
Resolution of Oedipus or Electra complex
Cognitive development theory
Children’s discovery that they’re male/ female causes them to identify with and imitate same sex models
Gender labelling age 3
Gender stability age 4-5
Gender constancy age 6-7
Gender-schematic processing theory
Gender identity alone can provide a child with sufficient motivation to assume sex types behaviour
Cultural relativism
Gender is socially constructed
Enormous cultural diversity of male and female roles
More than one gender type in some Native American cultures, social dominance of females in Wodaabe Africans
Transgender issues
Transgender is a term for individuals whose identity, behaviour or sense of self does not conform to their assigned sex
More common in those born male
Recent increase in referrals of young women to gender clinics
Transvestism or cross dressing
Wear clothes of opposite sex but not for sexual enticement nor are transgender
Enjoy cross-dressing to gain temporary membership of opposite sex, not necessarily related to sexual orientation
‘Abnormalities’ of sexual preference
Paraphilias
Sexual urges directed to non-human objects suffering/humiliation of oneself or partner towards others incapable of giving consent
Management of paraphilic disorder
Aversive conditioning
Reconditioning techniques
Cognitive techniques
Psychotropic medication SSRIs
Hormonal treatments
Efficacy of castration and neurosurgery controversial and considered unethical
Problems of desire
Lack or loss of desire
Common
Age, hormones, medical/psychiatric disorders, medications etc
Sexual aversion
Rare, most have sexual abuse
Lack of sexual enjoyment
Problems of arousal women
Results in lack of subjective excitement as well as lack of adequate physiological response
It may be due to a number of factors: psychological, pathological, oestrogen deficiency
Problems of arousal men
Erectile dysfunction
Lifelong or acquired general or situational
Relatively common
Increase in age
Organic and psychological aetiology
Viagra treatment
Problems of orgasm
Women- physical , psychological
Men-inhibited orgasm, ejaculatory pain, premature ejaculation
Other sexual dysfunction
Non-organic vaginismus: involuntary muscular spasm, sexual abuse, relationship difficulties, relaxation techniques, gradual vaginal dilation procedures
Non organic dyspareunia: pain during sexual activity
Sex therapy
Masters and Johnson
Partners treated together
Helped to communicate better about their sexual relationship
Education about anatomy/physiology of sexual intercourse
Graded tasks increasingly intimate exercises concentrating only on sensate focus at first
Asking about sensitive subjects
Be empathic and non judgemental
Pre empt the individuals embarrassment
Reassure that sexual dysfunction is common
Discuss in plain, clear and specific terms
Inclusive language
Start with open questions
Never assume
What is stigma
A mark or spot on the skin
A mark of disgrace or infamy
Visible sign/characteristic of a disease
Goffman 1963:
An attribute that is ‘deeply discrediting’
Reduces the bearer ‘from a whole and usual person to a tainted, discounted one’
Development of stigma as a sociological concept
Impact of what is happening in whole society rather than particular ‘groups’ eg values, fears
Social interaction between the stigmatising and the stigmatised
Social impact on the individual who is stigmatised
Social causes/ effects of stigma
People distinguish and label human differences; some are seen as undesirable characteristics
What is undesirable is decided by society differences between times/cultures
Impact of powerful people and institutions as the effect of labelling will spread faster
People can experience emotional reactions to labelled people- fear, repulsion, disgust
Labelled persons may feel shame, humiliation
Labelled persons experience status loss and discrimination as a consequence
Why is stigma important for healthcare
Important element in the experience of illness
Special care needs for people with visible health condition
Potentially delay in seeking help
Stigma and prejudice can influence health practitioners and policies
Stigmatised health condition
Visible differences
Mental health
Infectious diseases
Feared conditions
Caused by fear of contagion
Major epidemics where illness causes visible marks or disfigurement (plague, leprosy)
Illness seen as coming from outside eg Spanish flu
Contagion linked to deprivation and crowded living conditions
Linked to negative stereotyping- poor people, gay men with HIV
What about stigma of cancer
Incurable disease can lead people to avoid saying the word
Unclear causes makes it more frightening
Can lead to visible difference eg hair loss
Potentially embarrassing outcomes eg impotence
Blaming patients might make others feel safer
Positive impact of better prognosis for many, awareness raising, charities
Three types of stigma Goffman
‘Abominations of the body’: physical disfigurement/ deviation from social norm
‘Blemishes of character’ : a known record eg of alcoholism, long term unemployment seen as character flaw
‘Tribal identities’: negative evaluation of people due to association with a particular group most often via family eg class, ethnicity, religion
Physical stigma
Long history of identifying and classifying physical deformities
-fear and disgust but also fascination
-living/dead bodies displayed as curiosities
Appearance a common focus of teasing in childhood
Visible differences can lead to others staring, avoidance eg on public transport, inappropriate questions
Impact of physical stigma
Can lead to:
Heightened social anxiety
Embarrassment
Depression
Low self esteem
Social withdrawal
Isolation
Stigmatised activities/experiences
Potentially stigmatising attributes are eg
-drug or alcohol
-time spent in prison
-long term unemployment
-prostitution
-mental illness
-‘alternative’ sexualities
Traditionally linked to a persons character
Shame or blame scambler 2009
Historically the attributes above have been seen as innate/genetic by some and as in control of the individual by others
Tribal identities
A person visibly belongs to a particular group: religious groups, racial groups, ethnic groups, chosen tribes
Stigma expresses wider social power structures
‘Courtesy stigma’ : stigma rubs off on people close to stigmatised person
Impact of stigma Goffman
Stigma changes the social identity of a person
A person becomes discredited when they have a sign of a stigmatising condition which cannot be disguised they are forced to deal with their stigma in almost all interactions
‘Discrediting stigma’
A person becomes ‘discreditable’ when its possible for them to conceal a sign of a stigmatising condition
Where an individual is discredited
Enacted stigma:people stare/ avoid/ express disgust
Effects on employment and earning potential
Isolation; people may avoid contact in anticipation of a negative response: felt stigma
Where an individual is discreditable
Concealment strategies which may not work
Passing as normal
Evaluating whether or not to reveal condition
Spoiled idientity
Implies that an individuals social identity is dominated by the stigmatised illness/attribute
People may respond to this by:
-passing as normal
-information control-deciding who to trust
-avoiding all social contact
-trying to avoid blame
-refusing to be ashamed
How is stigma different from stereotype
Both relate to the social phenomenon of people being viewed/treated differently for something that they are rather than their actions
Stereotype focuses on group identity
Stigma focuses on the stigmatised individual and the effect on them
Stigma also includes wider society and power dynamics
Prejudice
Similar to stereotype but more about attitude/negative emotions towards particular groups and individuals
Focuses more on the person holding the prejudice who may never be in contact with the person they are prejudiced against
Can lead to discrimination/scapegoating
Examples:
Race/ethnicity and mental health
Self harm
Prejudice related to race/ethnicity
In providing services to BME communities (especially black men) prejudice and the fear of violence can influence risk assessments and decisions on treatment which are likely to be dominated by a heavy reliance on medication and restriction
This means that service users become reluctant to ask for help or to comply with treatment increasing the likelihood of a personal crisis
Prejudice related to mental health: self harm (owens 2016)
When forced to seek emergency care [young people who self harmed] did so weigh feelings of shame and unworthiness
These feelings were reinforced when they received what they perceived as punitive treatment from A&E staff, perpetuating a cycle of shame, avoidance and further self harm
Positive encounters were those in which they received ‘treatment as usual’ delivered with kindness
Social context of prejudice
Potentially strong impact on how people are treated by health practitioners
However, prejudice needs to be seen in its social context rather than only focusing on the prejudiced individual
Eg on race: media reports, fear of making wrong decision, focus on risk
Eg on self harm: over-stretched service, little time to work with individual, attitudes in workplace
Impact on outcomes/health inequalities
Ongoing debate on whether prejudice in healthcare contributes to inequality in outcomes
Disadvantaged groups have worse outcomes
Reasons for this are complex (eg environment, behaviour, experiencing discrimination)
However the above examples show that negative attitudes discourage people from seeking help)
Stigma
Social interaction sociology
Focuses on the individual who has a visible known difference which causes them to be stigmatised and the effect this has on them
The society doing the stigmatising
Stigmas are always negative
Prejudice
Social cognition psychology
Focuses on the attitudes and emotions that a person holds towards another person or a group of people
Prejudices are always negative
Stereotypes
Social cognition psychology
Focuses on the social expectations that people have about others bases on what group they belong to
Stereotypes can be positive, negative, neutral
