Sincronía Summer 2004
Rethinking Gerontology: Foucault, Surveillance and the Positioning of Old Age
Research on the community care needs of older people has tended to concentrate on levels of service satisfaction in US, UK and Europe (Challis 1991; Henwood 1990, 1995). A Foucauldian perspective is proposed as an alternative gerontological theory which focuses on formal and informal discourses. It is argued that Michel Foucault offers a set of strategies for understanding how the discourses on community care construct both older people's experiences in the mixed economy of welfare and their identities, as constructed subjects and objects of managerial power and knowledge. The work of Foucault has significance and importance to the study of gerontology. This significance is twofold: firstly, his analyses of punishment and medicine have high relevance to the experiences of older people. Foucault describes how the 'patient', the 'madman' and the 'criminal' are constructed through disciplinary techniques, for example, the 'medical gaze' (1973: 29). Historically, older people needs could said to be constructed by bio-medicine in similar ways. This has been done through the rise of the bio-medicine via clinical definitions of 'decay' (Stott 1981). Secondly, Foucault offers a set of tools which makes it possible to analyse both the official discourses on older people and those operating within professionalized care: care managers.
In the past 15 years, social policy in USA, UK and Australasia have focused on the management of old age with particular emphasis on the reform of the health and welfare apparatuses. In the case of the UK, the process of reform was imposed by central government backed up by alarmist demographic arguments (Warnes 1996). Similarly, such reforms offered the promise of greater choice and autonomy for both welfare workers and service users through the introduction of market ethos into areas traditionally directly controlled and subsidised by central government such as community care.
Indeed, the philosophy of care provision for older people have been the cornerstone in academic debates within Gerontology. The continuing passionate debate of this question, in gerontological consciousness, and the powerful emotions which it generates, is inextricably linked to the perceived role of the professional social worker as a bulwark against an encroaching tide of 'dependency'. Indeed, a distinctive feature of the welfare state in the 1990's has been the systematic introduction of managerialism throughout the public sector.
The social policy rhetoric of the 'mixed economy of welfare' sees, as mentioned, the introduction of managerial techniques. Managerialism is a technology put in place to challenge 'structured dependency' (Townsend 1981) by promoting choice of services and instigating social relationships of partnership and trust between professionals and older people (DoH 1989). Coupled with this, the outcomes of choice have relied heavily upon informal care and residential care (Henwood 1990; White Paper Caring for People 1989).
Such social phenomenon arises partly because the mixed economy of welfare embodies a diversification of political aims: the control of financial resources; the improvement of services and promotion of choice; changing the role of local authorities; a reduction in public sector provision; a focus on social relationships between professionals and service users. Indeed, the Department of Healths (1991) policy rhetoric has highlighted the contradictions of the role of the care manager: 'The guiding principle of implementation should be to achieve the stated objectives of the care plan with the minimum intervention necessary. It should, therefore, seek to minimise the number of service providers involved' (DoH 1991: 71). At the same time, professional managers should be 'tailoring services to individual needs (p.14) and 'promoting wider choice' (p. 16).
There is a reliance upon care assessments made by care managers. The rationalities and technologies of care management becomes a strategic space for the surveillance of older people. It is argued here that such a mechanism is not of empowerment and human development, but of a strategy for individual regulation and collective control. Hence, there are two dimensions which are particularly important to this paper. Firstly, there is the use of a Foucauldian perspective to locate the continuities and discontinuities in the relationship between professional power and older people (See also Katz 1996). Secondly, there is the question of power itself and its relevance to the emergence and consolidation of a discourse articulated by professional managers who assess, probe and increasingly audit a distinct populational group: an elderly population.
Michel Foucaults philosophical work has been acclaimed as the most important event in thought of our century (Merquior 1985: 33). Throughout his many works, he has attempted to develop perspectives on psychiatry, medicine, punishment and criminology. Despite this, Foucault never analysed the topic of age. In turn, only a handful of people who can be pin-pointed as Foucauldian gerontologists have recently recognised the validity and importance of his theories, methodologies and concepts in relation to old age (Katz 1996). Katz has identified that aging is not a static process and for this reason cannot be singularly analysed via any particular discipline. By utilising Foucault's 'box of tools', Katz 'digs into the past' to 'escavate' the rise and dominace of bio-medicine and sociological insights to an contemporary understanding of the 'aging body'. By use of Foucault's work, Katz demonstrates that the challenges to 'age disciplines' impinges upon the 'power/knowledge' axis. Crucially, such an axis permeates all formal and informal discourses, their language, logic, forms of domination and classification, measurement techniques and empiricism as essential elements in the technology of discipline and the process of normalization. 'Professionals' such as gerontologists and geriatricians are key interventionists in societal relations and in the management of social arrangements pursue a daunting power to classify with consequences for the reproduction of knowledge about 'ageing' and simultaneous maintenance of power relations. Katz's work demonstrates that the challenges to mainstream 'age disciplines' have adopted the agendas of these traditions, taking their historical and contemporary as legitimate points of departure. While starting with 'knowledge as it stands', that which is 'known', Katz reconstructs such knowledge at the interpersonal level of professional and humanistic 'agency'.
Yet whatever the quality and implications of professional agency, their recognition and legitimacy are rooted firmly in the determining contexts of 'structure' and their manifestation in the professional ideologies of control, regulation and power/knowledge. This article seeks to draw upon the insights of Foucault (1965, 1976 and 1977) and Katz (1996) and critically engage with complex sites of the disciplinary web of surveillance, professional power and normalisation and how these triangular forces impact upon older people.
Foucaults (1977) work has significance to the analysis of old age in two aspects. First, his analysis of punishment and discipline and medicine and madness have relevance to the experiences of older people. Foucault describes how subjects of knowledge such as the stereotypical elderly', 'criminals', and 'mentally ill' are constructed through disciplinary techniques, for example, the notion of the expert 'gaze' (1973: 29).
Secondly, Foucault (1977) makes it possible to analyse both the official discourses embodied in social policies and those operating and implementing within society: managers and older people:
'It was a matter of analyzing, not behaviours or ideas, nor societies and their 'ideologies', but the problematizations through which being offers itself to be, necessarily, thought - and the practices on the basis of which these problematizations are formed' (Foucault 1985: 11).
The varied works of Foucault (1967, 1970, 1976 and 1977) have problematised issues of madness and illness, deviance and criminality, and sexuality. These issues are conceptualised as socially constructed 'problems'. In these specific social issues, Foucault has problematised the role of the 'expert', social institutions, social practices and subjectivity that seem 'empowering' but are contingent socio-historical constructions and products of power and domination. The relevance to 'old age' is the recognition that social practices 'define a certain pattern of 'normalization'' (Foucault 1977: 72). Such social practices are judged by professional 'experts'. In the era of the 'mixed economy of welfare' such experts are labelled as 'managers' who problematise older people via a process of 'assessment' for services. Such social actors are pivotal to Foucault's analysis of 'panoptic technology'. In addition, they probe and 'normalise judgement' on older people via differential discourse as 'service users', 'consumers', or 'clients':
For Foucault (1977) 'normalizing power' involves the dimensions of physical and biological discourses and how these are inserted on the human body. The 'ageing' individual is located in a political field saturated with power relations which 'render it docile and productive and thus politically and economically useful' (Smart 1985: 75). Hence, the care manager '... take(s) responsibility for ensuring that individuals needs are regularly reviewed, resources are effectively managed...(DoH 1989: 21).
Professional Power and Old Age
Definitions of managerial 'truth' and assessments oriented around older people can be understood as a 'system of ordered procedures for the production, regulation, distribution, circulation and operation of statements' (Foucault 1980: 133). Furthermore, for Foucault (1980: 133) ''Truth' is linked in a circular relation with systems of power which produce and sustain it'. Here we can see his power/knowledge explication. All strategies that attempt to control older people involve the production and social construction of knowledge. Hence, we can discuss the social construction of truth and managerial power in the context of the 'gaze' of surveillance.
A central feature of Foucault's work is the way in which the 'gaze' constructs people as both subjects and objects of power and knowledge. In The Birth of the Clinic, Foucault illustrates how such a 'gaze' opened up 'a domain of clear visibility' (Foucault 1973: 105) for doctors for allowing them to construct an account of what was going on inside a patient, and to connect signs and symptoms with particular diseases. The space in which the gaze operated moved from the patient's home to the institution or the 'hospital'. This became the site for intensive surveillance, as well as the attainment of knowledge, the object of which was the body of patients. Both historically and contemporaneously, older peoples identities have been constructed through expert notions of decay and deterioration (Stott 1981) and the 'gaze' helps to intensify regulation over older people in order to normalise and provide treatment for such notions. Medical discourse, under the guise of science, was part of a disciplinary project orientated to:
create a model individual, conducting his life according to the precepts of health, and creating a medicalized society in order to bring conditions of life and conduct in line with requirements of health (Cousins and Hussain 1984: 151).
In general, medical power took its place alongside gerontology in normalising older people.
Risk, Surveillance and Objectification of Older People
Scientific dominance may have helped shape the construction of identities, though it was not economical enough in its reach. Science has been bound up with 'risk' (Beck 1984) and what Giddens (1991) calls the process of 'reflexivity': this manifests because of the loss of faith in the exercise of scientific power/knowledge. The focus on risk has led to a situation in which 'science' has been slowly supplemented with financial discourses, and what we see, in relation to care provision, is an intensification towards care management models and consumerism. Hence, the pervasive move to a mixed economy of welfare has produced an extraordinarily powerful discourse and impacts upon treatment of older people as 'consumers' moving away from fixed and static conceptualisations of 'deterioration'.
Regulation and surveillance of older people can be seen as economically productive. Recent social policy legislation such as the NHS and Community Care Act (1990) centres upon a 'mixed economy of welfare' which highlights the incorporation of market forces to the construction and delivery of services (Clarke 1994; Lewis and Glennerster 1996; Walker 1993). The surveillance of older people is committed to primarily upholding economic management at the expense of providing empowerment and autonomy.
From a Foucauldian perspective, the mixed economy of welfare arguably fabricates representations of empowerment for older people. For example, many people's needs have not been met due to power relations and ageism (Bytheway 1995). Allen et al. (1992: 35) quote a manager as saying 'It is hard to listen to older people. They are slow in speech and thought'. In this case, services provide schemas for the 'conduct of conduct' (Foucault 1978) dominated by power/knowledge and characterised by the discretionary autonomy of managers of the state. It is within this disciplinary duality of power/knowledge and autonomy that power operates over older people, ultimately reinforcing the fragmentation that surveillance engenders in the broken identities of many older people at the centre of the professionals' gaze. Indeed, in modernity, professionalisation and subsequent power relations relate to the beliefs held and social relationships developed are constructed around barriers of marginalisation and dependency. Similarly, Henwood (1995) found pressures on resources was leading to reduced levels of service and a tightening of 'eligibility' criteria. As the American gerontologist Estes (1979) succinctly points out...
'Service strategies...and those for the aged...tend to stigmatise their clients as recipients in need, creating the impression that they somehow failed to assume responsibility for their lives. The needs of older persons are reconceptualised as deficiencies by the professionals charged with treating them' (Estes 1979: 65).
The relevance to older people is that managerial power can intensify the ordering of identities through the processes of social service institutions and care policies of the state. Allen et al. (1992) found that most older people had only one or two services in their study. In this study, few older people had much choice in what services they received, any say in the time of the delivery, the person who delivered it or how much they received. Hence, this evidence highlights the consequences are 'docile bodies' (Foucault 1977) drained of empowered energy, reinforced by the attitudes of managers to ageing that it is just that, 'your age', which requires an inspecting 'gaze' and assessment of needs from managers to older people.
Coupled with this, Foucault's genealogical analyses of punishment and discipline and of sexuality, Foucault describes how 'techniques of surveillance' which occur in the 'local centres of power/knowledge' (for example, in the relationships between older people and care managers), have an individualising effect. Techniques of surveillance are so calculated, efficient and specific that 'inspection functions ceaselessly. The gaze is everywhere' (1977: 195). Foucauldian ideas can identify two related mechanisms of surveillance:panopticism; normalisation and the probe of assessment. These mechanisms have helped shape and mould many of the experiences of older people.
Panoptic power and aging
In Foucault's (1977) work 'Discipline and Punish', he presents the contrasting example between the execution of Damiens and the timetable activities of 'young' offenders. The description of Damiens devastating and savage death serves to remind us of the strategy of torture upon the 'body' and the multiplicity of pains a body can endure. The timetable, by contrast, is specific, elaborate and a disciplinary technology which trains and organises individuals for their daily routines.
Foucault (1977) sees Jeremy Bentham's panoptican as the dominant example of disciplinary technology. For Foucault, the panoptican integrates power and knowledge, the control of the 'body' and the control of space into a technology of discipline. Bodies of people can be made productive and observable. As mentioned earlier, Foucault remarks 'Is it surprising that prisons resemble factories, schools, barracks, hospitals, which all resemble prisons' (1977: 44).
At the level of discourse, we could add residential care institutions to Foucault's list. The numbing time-tabling narrative of when older people are told when to wake up, eat, sleep, recreate, wash and clean and go to bed is well known and documented by negative imagery (Bytheway 1995: 121-2): the residential 'space' helps control and operationalise disciplinary power over older people.
The perfect disciplinary apparatus, according to Foucault (1977: 173) 'would make it possible for a single gaze to see everything perfectly'. The technique of 'panopticism' was incorporated into social work relationships in the twentieth century so that older people could be observed by professional power. Foucault (1977) views the mechanism of panopticism as both efficient, since surveillance was everywhere and constant, and effective, because it was 'discreet', functioning 'permanently and in silence' (1977: 177). It also provides the scope for the supervision of those who were entrusted with the surveillance of others.
Community care provision for older people has elements of this kind of surveillance. Supervision is hierarchical in the sense that many mature adults are accompanied by management discretionary power which embraces monitoring, assessing and calculating older people. Social service departments need to kept informed of progress of clientele in order to communicate this at formal review meetings to establish resource allocation to service spending planning. The surveillance does not stop at this point, as a network of reciprocal power relationships has been created. Older people who require services are the objects of scrutiny within society, but for such bodies requiring financial services, the gaze reaches further. They are observed, not only during managerial assessment for services, but also post-assessment during the very service they receive in the mixed economy of welfare such as 'residential care'.
The Residential Apparatus and Managing Aging
The way in which people interact with other older people and interpersonal relationships can be brought under the vigilance of care staff in residential regimes (Brooke-Ross 1986). The emotional well-being of many older people in such an environment is a subtle aspect of control and normalisation. This legitimises the search within the individual for signs, for example, that s/he requires intense forms of surveillance and ultimately processes of medicalisation which permeates as an intervention into ageing lives because such practices befit them because of the pathological permeation of 'its your age'.
The emergence of public and private residential care and the groups of care workers who staff them, is built around discipline and surveillance where the bodies of older people are broken down and fragmented into individual cellular spaces thus allowing their control and ordering through routines and time-tables. The consolidation of care knowledge reinforce(s) this fragmentation, surveillance and individualised documentation, thus, this becomes a corner-stone of care practice. The residential regime became a laboratory in which the advice and expertise of the care profession, both managers and care workers, is geared to re-integrating older people back to normality.
Hence, as Phillipson (1988) points out, it is mythical that residential care enables older people to be in more control and more able to choose the kind of services than in publicly provided services. The dangers are that there may be the manifestation of 'elder abuse' unless standards are monitored and inspection takes place (see Whittaker 1995; Biggs 1993).
Normalizing old age
Foucault observes how the 'norm' entered social science disciplines by 'imposing new delimitations on them' (Foucault 1977: 184). While this standardised social science and promoted the homogeneity of old age, it also had an individualising effect 'by making it possible to measure gaps, to determine levels, to fix specialities and to render the differences useful by fitting them to one another' (1977: 185).
The identities of many older people are defined in relation to issues of abnormality and normality. The 'cut off' point were an old individual is or not deemed to be 'frail' is in no sense clearly defined and variations in levels of assessment is of increasing concern for care managers. In a climate of resource constraints, distance from the norm has become valued amongst older people who do not conform to discourses of 'slow' and 'deterioration' (PSI 1992).
Domination through observation objectifies particular older people as diagnoses began to be made of normality and abnormality and of the appropriate procedures to achieve... to the norm (Smart 1985: 93). In this way studying and examining the body and mind of older people was and is intrinsic to the development of power relationships:
the examination is at the centre of the procedures that constitute the individual as effect and object of power, as effect and object of knowledge. It is the examination which ... assures the great disciplinary functions of distribution and classification (Rabinow 1984: 204).
The 'probing' technique, argues Foucault, combines panopticism and normalisation and 'establishes over individuals a visibility through which one differentiates them and judges them' (Foucault 1984: 184). The 'assessment' is a function of a disciplinary technique. As Foucault (1977) indicates, an individual is established as a 'case' (or client) and may be 'described, judged, measured, compared with others, in his very individuality. This individual may also have to be trained or corrected, classified, normalised, excluded' (Foucault 1977: 191).
Foucault then sees the assessment as central a technique that renders an individual an object of power/knowledge. In the assessment leading the opening for social services, the statement of an 'ageing body' is established in relation to normalised standards of rights and risks. Thus, older people will be probed for social, psychological and economic factors such as 'frailty', 'financial resources' and expected levels of 'supervision'.
Following an assessment, most older people are marked out for surveillance throughout the remainder of his/her service and beyond. Care managers also come under the scrutiny of the continuous review of ageing bodies needs. All are caught by a gaze which is 'always receptive' (Foucault 1976: 89) and the very existence of the discourse of 'frailty' provides a further rationale for the control of the 'elderly population'.
Foucault places great emphasis on the processes of discipline, surveillance, individualisation and normalisation. These processes are key elements in the emergence of managerial power in the 1990s. Despite the surface of community care policy of idealising empowerment, the depth of community care was part of a disciplinary strategy which extended control over minutiae of the conditions of life and conduct (Cousins and Hussain 1984). Within this discourse the care manager became the great advisor and expert (Rabinow 1984: 283) in assessing older people for care services.
The impetus for this Foucauldian excursion derives from the view that older people bear the imprint of dominant modes of regulation both in terms of expert discourse formation and the decrease in resources to empower in advanced capitalist societies. The final epitaph of modernity raises crucial questions as to the social relationships between professionals and consumers of services. As Marx and Engels (1985) recognised in The Communist Manifesto, to discuss social relationships in terms of 'contracts' disguises the wider, often hidden power relationships which underpin and shape observable reality.
Conceptualising social relationships in discourses of consumers of services is problematic; it limits the power of the consumer; it subtly alters the feasible grounds of complaint from collective concerns to the shortcomings of an individual transaction; and it is concerned with differentials rather than with the quality of treatment. Indeed, the notion of the consumer is based on an entirely voluntaristic view of human agency which denies altogether the relevance of social conditions in determining human action.. As we transcend the fin-de-siecle, the metamorphosis of identities of 'older people' into 'consumers' is likely to fracture and consume older people still further, marginalising the social and political context of care experiences and transforming discourses of 'empowerment' into politically neutral and individually safe questions of satisfaction and dissatisfaction with the commodity or service on offer from social service departments and managers.
Allen, I (1992) Elderly People: Choice, Participation and Satisfaction, Policy Studies Institute, (PSI).
Arber, S and Ginn, J (1991) Gender and Later Life: A Sociological Analysis of Resources and Constraints, Sage, London.
Arber, S and Ginn, J (Eds.) (1995) Connecting Gender and Ageing: a sociological approach, OUP, Milton Keynes.
Beck, U (1994) The Risk Society
Brooke-Ross, R (1986) quoted in Langan, M and Lee, P (Eds.) (1988) Radical Social Work Today, Unwin Hyman.
Bytheway, W (1995) Ageism, OUP, Milton Keynes.
Chau, W.F (1995) 'Experts, networks and inscriptions in the fabrication of accounting images', Accounting Organisations and Society, 20, 2/3, 111-145.
Clarke, J (1994) 'Capturing the Customer: Consumerism and Social Welfare', paper to ESRC seminar Conceptualising Consumption Issues, Dec.1994, University of Lancaster.
Clarke, J (1978) (et al.) Policing the Crisis
Cousins, M and Hussain, A (1984) Michel Foucault, Macmillan, London.
Davidson, A (1986) 'Archaeology, Genealogy, Ethics' in Hoy, D (Ed.) Foucault: a critical reader, Basil Blackwell, Oxford.
Estes, C (1979) The Aging Enterprise, Jossey Bass, San Francisco.
Engels, F and Marx, K (1985) The Communist Manifesto
Foucault, M (1967) Madness and Civilisation, Tavistock, London.
Foucault, M (1972) The Archaeology of Knowledge, Tavistock, London.
Foucault, M (1973) The Birth of the Clinic, Routledge, London.
Foucault, M (1976) The History of Sexuality, Penguin, Harmandsworth.
Foucault, M (1977) Discipline and Punish, Tavistock, London.
Foucault, M (1980) Power/Knowledge: Selected Interviews and Other Writings, 1972-1977, Pantheon, New York.
Foucault, M (1982) 'The subject of Power' in Dreyfus, H and Rabinow, P (Eds.) Michel Foucault: beyond structuralism and hermeneutics, Harvester, Brighton.
Foucault, M (1984) What is Enlightenment? in Rabinow, P (Ed.) The Foucault Reader, Peregrine, London.
Giddens, A (1991) The Consequences of Modernity, Polity, Cambridge..
Katz, S (1996) Disciplining Old Age: The formation of gerontological knowledge, University of Virginia, Charlottesville.
Langan, M and Lee, P (Eds.) (1988) Radical Social Work Today, Unwin Hyman.
Lewis, J and Glennerster, H (1996) Implementing The New Community Care, OUP, Milton Keynes.
Merquior, J (1985) Michel Foucault, Fontana.
Phillipson, C and Walker, A (Eds.) (1986) Ageing and Social Policy: A Critical Assessment, Gower, Aldershot.
Powell, J (1998) The Us and The Them: Connecting Foucauldian and Political Economy insights into ageing bodies, unpublished paper presented British Sociological Associations Annual Conference, University of Edinburgh.
Rabinow, P (Ed.) (1984) The Foucault Reader, Peregrine.
Schrag, P (1980) Mind Control, Marion Boyars.
Shumway, D (1989) Michel Foucault, University Press of Virginia, Charlottesville.
Smart, B (1985) Michel Foucault, Routledge, London.
Stott, M (1981) Ageing for Beginners, Blackwell, Oxford.
Townsend, P (1981) 'The Structured Dependency of the Elderly: A Creation of Social Policy in the Twentieth Century' in Ageing and Society, Vol.1, No.1, pp.5-28.
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