‘Trust’ and Power: Towards A Social Theory of Self
Dr. Tony Gilbert, University of Plymouth
Dr. Jason Powell, University of Liverpool
Introduction
This article sets out to delve into the relationship trust and professional authority in the context of health care. Understood in its micro-political terms and conceived as impacting on individual identity and agency at a number of levels: intrapersonal, personal, interpersonal, systems or organisational levels and the socio-political; this relationship stands at the interface of competing pressures working to produce the increasing complexity of social life. "Trust" is inextricably linked with uncertainty and complexity while professional authority rests on the specialist knowledge claimed by the range of experts and technologists that inhabit the spaces through which social life is governed and complexity managed. Spaces: at once both hidden and visible, which provide opportunities across the social landscape for the agency of individuals to be exercised and worked on; producing the self-managing citizen central to neo-liberal forms of government. In this context the strategies of trust become linked with rival programmes that come armed with a range of technologies charged with competing and contested truth claims. As a consequence contradictory positions are provided where selfish desire and selfless obligation are placed together sharing the same space, thus adding to the potential for anxiety and provoking searches for predictability, confidence, faith and ontological security.
It is in these spaces that expertise works upon the dual project of managing both its conduct and the conduct of others. A reflexive process where expertise is involved in maintaining systems that do not require personal knowledge of any other individual in the system but which do require an overall level of confidence in order to function. In managing systems expertise engages techniques of impression management, deploying a range of systems of mistrust designed to both reassure the population of the integrity of the system and the authority of the expertise embedded there. At the same time this expertise claims the right to accredit and provide the necessary symbols of authority.
Trust and Health Care
There are increasing attempts to conceptualize the notion of ‘trust’ in social theory as a pivotal dimension of modernity (Giddens, 1991). However, the early statement that ‘social science research on trust has produced a good deal of conceptual confusion regarding the meaning of trust and its place in social life’ (Powell, 2005: 74) seems to be still valid especially as applied to ageing studies. Trust is on the one hand incompatible with complete ignorance of the possibility and probability of future events, and on the other hand with emphatic belief when the anticipation of disappointment is excluded. Someone who trusts has an expectation directed to an event. The expectations are based on the ground of incomplete knowledge about the probability and incomplete control about the occurrence of the event. Trust is of relevance for action and has consequences for the trusting agent if trust is confirmed or disappointed. Thus, trust is connected with risk (Giddens, 1991).
Up to now there have been few attempts to work out a systematic scheme of different forms of trust in between older people and individuals, health institutions or policies that impinge on their identity performance. Social trust tends to be high among older people who believe that their public safety is high. Since the erosion of public trust in institutions like the government and the media trust attracts more and more attention in social sciences
Powell (2005) distinguishes between trust in contracts between people and State such as pension provision, trust in friendships across intergenerational lines and trust in love and relationships and trust in foreign issues associated with national identity. However, sociological theories which suppose a general change in modernity assume that with the erosion of traditional institutions and scientific knowledge trust becomes an issue more often produced actively by individuals than institutionally guaranteed.
Independent from the insight that social action in general is dependent more or less on trust there empirical results in the context of risk perception and risk taking indicate:
Trust seems to be something that is produced individually by experience and over time and cannot be immediately and with purpose be produced by organizations or governments without dialogical interaction with older people on issues affecting their lifestyles and life-chances such as care, pensions, employment and political representation (Lewis 2004).Trust is much easier to destroy than to built.
If trust is once undermined it is more difficult to restore it.
Familiarity with a place, a situation or a person produces trust.
Persons will develop trust if a person or situation has ascriptive characteristics positively valued.
The reciprocal relationship between hospitals and the personal lives of patients is central to the analysis of the role and performance of public services. In a mutually constitutive process, the social experience and identities of individual patients are produced, in part, through engagement with services which are then affected by the actions of those patients (Fink 2004, Lewis 2004). The fact that experiences of mental health services impact on different spheres of people’s lives implies that the exploration of trust also has to explore these different domains, but in an integrated multi-disciplinary way that enables comparison between the different criteria upon which trust is established, maintained or lost. Such an approach to trust is aided by the existence of similar concerns across domains. These include: trust as future orientated, trust that occurs without the guarantee of reciprocity, trust that requires the placing of expectations with the agency of others, trust that works to reduce complexity and anxiety, and trust that involves risk and uncertainty. At the same time the observation that mistrust operates as the functional equivalent to trust provides a means of considering the complex interplay between expectations and sanctions (Luhmann 1979, Shapiro 1987, Dasgupta 1988, Gilbert 1998)
The decline in the hegemony of the rational choice models of economic and social behaviour, the limits of the post-emotionalism thesis and the apparent weakening of community bonds in the late twentieth and early twenty-first centuries has provoked increasing academic and political interest in the role and function of trust in contemporary societies (Luhmann 1979, Giddens 1990, 1991, Putnam 1993, Lane 1998, Seligman 1997, Uslaner 1999, Taylor-Gooby 1999, 2000, Dean 2003). However, trust is a complex idea which can be explored theoretically and empirically on different levels: politically in relation to social capital and social norms; sociologically in relation to abstract systems, complexity and risk; and inter-personally in relation to characteristics of trustworthiness such as competence. Trust can be conceived as generalised, e.g. through the level of trust based exchanges between members of a community; or particular, as in personal relationships. Moreover, there are important definitional problems concerning the relationship between trust, confidence, faith and familiarity (Seligman 1997).
Conceptually there are tensions but also interesting theoretical possibilities between late [high] modern and post-modern conceptions of society. Both identify the fragmentation of traditional forms of authority and expertise, and acknowledge the increasing complexity this produces through the availability of multiple sources of information and different lifestyle choices. This uncertainty gives rise to an increasing reliance on trust in the agency of others (Seligman 1997). Late [high] modern conceptions of trust tend to point to the failure of rational choice theories to account for human behaviour as evidence for the existence of a range of social norms that promote altruistic behaviours, obligation and responsibility (Seligman 1997; Dean 2003). Post-structuralists, in particular governmentality theorists, have discussed risk and uncertainty at length (Osborne 1997, Petersen 1997), but leave the discussion of [social] ‘trust’ to an observation that the trust traditionally placed in authority figures has been replaced by audit. Concerns about social norms could be reframed within a post-structuralist lens by locating the debate about trust with those relating to ‘ethics’ and ‘technologies of the self’ (Davidson 1994).
As stated earlier, trust and responsiveness are assumed to be the issues of central concern with transparency and targets providing supporting technologies through which trust is promoted and maintained. The discussion will now turn to explore the relationship between trust and targets, transparency and responsiveness. For the purpose of this section Luhmann’s (1979) definition of trust as ‘managing expectations and reducing complexity’ is assumed.
In considering the performance of public services the National Consumer Council (2004) [NCC] (Wisniewski 2004) identify transparency and responsiveness as core values for public services, arguing that a balance of consumerist ‘choice’ and participatory ‘voice’ is essential to the quality and performance of public services. Responsiveness becomes a blend of choice and voice at both individual and organisational levels, with the proposition that consumers will participate in the setting of organisational targets and contracts, while individual consumers will be able to modify services to meet individual needs. In the context of disabled people the functioning of the Direct Payments Act (1997) (Powell, 2005) provides a key example of responsiveness. Targets and official ratings e.g. star ratings become the external measures of performance on which people are assumed to be able to make judgements, with transparency the key to trust in this process (Shaw 2001, Stewart and Wisniewski 2004, McIvor et al. 2002).
The NCC position is underpinned by a model of human behaviour that assumes individuals will balance their own needs with an element of social responsibility, which also reflects a good deal of New Labour’s discourse around encouraging older people into paid work.. In parallel public service organisations behave reflexively to anticipate concerns and changing patterns of need. This benign model is somewhat undermined by evidence that suggests that individuals do not always make rational choices (Taylor-Gooby 1999) and that for some people, particularly vulnerable and dependent groups, choice can be anxiety provoking a position further compounded by the fact that such groups tend to be disproportionately exposed to risks (Taylor-Gooby 2000). At the same time theoretical debate has exposed the complexity of the relationship between public services, fragmented across the statutory and third sectors (, Rose 1999), and a range of public service consumers whose motivation is somewhere between altruistic and totally self-seeking (Le Grand 2000, 2003 Dean 2003).
Complexity in the relationship between health services and consumers is further exposed when the focus shifts from the structural and organisational level to the individual level of personal lives and relationships. A link between trust and coping strategies has been identified by Taylor-Gooby (2000) in the context of financial decision making. Coping is also the central concern of Sheppard’s discussion of the responsiveness of child care agencies and social workers (Sheppard with Gröhn 2004). Drawing on a range of psycho-social models of coping he concludes that responsiveness is evaluated on the basis of the ability of services/professionals to deliver practical support, quickly and efficiently. At the same time it is noted that an important feature of the level of stress is the importance of people’s self-evaluation of their success in coping.
The suggestion in ‘From Care to Citizenship’ (Powell, 2005) that a new status had been achieved could be taken to be somewhat premature if the evidence from the fieldwork is taken at face value. Regardless of which conceptualization of citizenship we might take, people with learning disability have some way to go before it can be claimed that citizenship has been achieved. A level of functional integration in the community is evident but they still experience large scale exclusions, especially in relation to work. At the same time people with learning disability remain largely dependent upon the organisations that provide them with support for their access to and participation in the community. However, if we take the sentiment expressed in ‘From Care to Citizenship’ to be an expression of the discourses circulating through social policy and link this with the analysis of governmentality, a somewhat different picture is produced. The deployment of discourses of citizenship enable the population to be managed. The management of people with learning disability has shifted from large institutions, either hospitals or daycentres, to management through the community. The discourse of normalization which underpinned the move from institutions has been transformed into a discourse of citizenship with people with learning disabilities now managed within specialized spaces in the community which remain supervised by professionals (Rose 1999). The role of professionals is to encourage people to move along a continuum towards self-management while they anticipate and manage the risks involved (1999). These discourses of citizenship provide a number of reference points e.g. work, exercising choices in the community, and obligation to a particular community: but the partial and fragmented way these discourses penetrate both policy and practice means that a number of different, often contradictory positions are established. The differences between the different models of support, residential care and supported living, are evidence of this uneven process. However, the commissioners of services favour the ‘supported living’ model therefore new contracts tend to promote this model.Ethics of the Self
Despite the fragmented nature of the outcomes for older people we can consider the different outcomes in relation to the ethic of the self central to governmentality (Miller 1993, Davidson 1994). This ethic, deployed through the discourses of citizenship, works to construct people with learning disabilities as useful while also identifying those who are greater risk. The latter, experience further segregation and surveillance by professionals with more coercive technologies. As noted earlier this ethic of the self is composed of four dimensions: ethical substance, mode of subjection, self forming activity and telos or end product. It concerns the way bodies are made useful, productive and self-managing. These dimensions will now be considered in relation to choices and opportunities produced for people with learning disabilities. The first dimension, the ethical substance, is that part of the self that is to be worked and subjected to ethical judgement. In this context we can consider the identity formed and the feelings of responsibility and obligation being produced. The identities of citizen-tenant, of worker, as consumer in the marker, as member of the community are suggestive of a new identity for people with learning disability. These identities are formed in opposition to previous identities of dependence. At the same time feelings of responsibility are created as individuals become accountable for their choices and obligation is produced through a ‘felt responsibility’ for a particular community.
The mode of subjection, relates to the way in which the individual recognises themselves in accordance with particular rules and norms, and puts these into practice. The recognition of oneself as citizen-tenant, worker, consumer, and member of a community requires the individual to actively engage in these processes and through this engagement to demonstrate their compliance with the rules and norms. There are examples of individuals engaging in work and exercising consumer choice . In relation to community based voluntary work the two themes of work and affiliation to a particular community, are brought together clearly paralleling communitarian views of citizenship. Nevertheless, these circumstances remain incomplete and fractured as the relationship with the community and the formation of obligation is mediated, not by the individuals themselves, but through the organisations that manage the individual in the community. In contrast the citizen-tenant achieves a relationship with the community in their own terms i.e. not mediated by an organisation. In this case the modes of subjection are more instrumental with expectations over paying rent and other bills promptly, and maintaining the private space in a responsible way so not to offend other citizens. Work and an affiliation to a particular community are possible but not engineered.
The third element is the self forming activity or ethical work required transform and develop the individual as an ethical subject. This relates to the particular practices individuals engage in to maintain their identity. Discussing governmentality, Miller (1993) Rose 1999), while cautioning against any necessary correspondence, identify a range of techniques where individuals work upon themselves to modify their behaviours, improve their knowledge and develop skills linked to their identity and modes of subjection. Many of these activities relate to reflective and confessional practices. However, in relation to the fieldwork and people with learning disabilities we might identify practices that sustain individual self-discipline i.e. attendance at work, appearance, maintenance of personal space, and relationships with others. In the marginalized spaces that older people occupy these self-forming activities are mediated, encouraged and supported by professionals. Nevertheless, it is clear that there is not an option for older people not to comply with this discipline without having to face the consequences. The final dimension, telos, relates to the aim governmentality: the production of the useful, productive and ethically self managing individual; the role of services and professionals is to encourage and support people towards this goal.
Approaching interpersonal relationships through the medium of ethical decision-taking is seductive because it appears to offer comprehensive solutions to both structural and personal dilemmas at the point of contact between helping professionals and older patients. It is an approach that chimes well with the claim that the medical model should be objective and free from prejudice and also preserves the exclusive context of the patient-physician relationship . Interaction between older people and their doctors and nurses may thereby be driven by a clear ethical code, a clinical examination of need, and respect of the autonomy of the patient. It becomes a matter of technical gate-keeping within the symbolic space of a special, one to one, relationship. Whilst such an approach directly addresses the inequities that arise from explicit decisions, it is less able to digest issues of institutionalised ageism or imbalances of power between patients and health professionals. This implies that the way in which alliances and power imbalances are played out varies between service systems. An example of this variation can easily be seen, by comparing health care systems in the US and the UK. In the United States, with its predominantly commercial system, it is not uncommon for patients to be reportedly distrustful of their doctors. This trend has been intensified with the advent of managed care, a system that attempts to reconcile treatment options with insurance liabilities. Physicians are often seen as being in alliance with the insurance companies when making clinical judgements as the latter determine what can be legitimately prescribed. It is not uncommon for patients to go ‘doctor shopping’ within the US system in order to gain alternative opinions or interpretations of access criteria to clinical procedures. Under the UK system however, Doctors and most notably General Practitioners are most likely to be seen as in alliance with the patient in attempts to secure adequate treatment from a limited state system. However, because patients have to register with one doctor and public services are subject to ‘queue’ systems, doctor shopping is virtually unknown. Thus, when Powell (2005) talk about the ethical ‘responsibilities to third party interests’, speaking from the US context- they are referring to a potential conflict of ethical demands from the patient and from the insurer. In the UK context, this is currently more likely to be interpreted as a debate on the duties to informal carers, mostly relatives, or the implications for wider public health. Further, in state-controlled quasi-markets, increasing politico-economic control of public health services and attacks on professional autonomy are more likely to be engineered through ‘quality’ processes such as monitoring and audit, which are perceived to be a greater threat to professional autonomy than corporate capital. Traditional ethical concern about the relationship between professionals and older people need has tended to focus on issues such as: what to divulge to patients about their own health status and in what form; the need for privacy and confidentiality and its limits, plus the discussion of conflicts of interest. This tends to take the power/knowledge relationship between professional and user as a given, in such a way that discussion hinges on how and whether the former should make information available. To return for a moment to the question of patient autonomy, this is often presented as the deciding factor, whether an individual patient has the where-with-all and sufficient information to make a judgment. Whilst a laudable objective in itself it also uncritically reflects decision-taking within the traditional one-to-one patient-physician relationship where other factors are supposedly more or less equal.Foucault (1977) has argued persuasively that the birth of the medical profession brought with it a different way of seeing illness and well-being. Most notably, the sick other became an object to be modified. Under the ‘medical gaze’, people become their bodies, bodies disaggrogated into a series of dysfunctional parts. This is useful for the scientific analysis of function and remedy but severely limits any perspective that takes into account interpersonal and wider social factors.
re-classification of experience into symptoms which can then be addressed separately from interpersonal and wider social impacts.
Common-sense assumptions of health service contexts, the history of institutions and social structure, are not questioned. In reality, these service systems reflect the different attention and options offered to different ages and social groups, the use of strategies, routines and masquerades deployed by professionals and older patients in health settings and the complex relationship between the experience of illness, of ageing and the emotional labour of being a patient in care.Frank (1998) argues that the ability to tell ones own story of illness is by no means straight-forward. If as Foucault (1977 claims, the maintenance of existing power relations depends not on the use of force, but on the ability to persuade active subjects to reproduce those relations for themselves, then the telling of narratives will always be suspect. According to this perspective the scope of ideas such as patient autonomy will always be limited and problematic because the frameworks that are used to explain and understand our own illness experience to ourselves are themselves compromised. Frank (1998) poses the almost unanswerable question of when does self-care turn into a technology for producing a certain sort of self ? Personal narratives, particularly for older people in health settings, remain both a means of taking care of oneself and conformity to a restricted legitimising discourse.
The professional’s role as a sort of gatekeeping adviser, itself contains profound interpersonal inequalities in terms of who controls and allows access to scarce medical and social resources, which simultaneously intereact with the economic, social, and cultural capital of the practitioner and the patient both within and beyond the clinic.
Conclusion
This paper has explored the notion of trust in relation to older people and the assumption that policy penetrates into the lives of people in partial, fragmented and locally specific ways. The analysis of the interview material suggested that there was no coherent idea of citizenship operating through the services. Instead there were fragmented approaches leading to contradictory positions of inclusion and dependence or independence and isolation. However, the analysis of trust and governmentality provides a richer picture. Rather than evaluating the adequacy of particular discourses, governmentality identifies strategies that work to make individuals productive and self-managing. First, the marginalised spaces were older people are maintained and subjected to techniques of surveillance and training are identified. The different discourses of citizenship, while producing contradictory positions for older people, do nevertheless provide positions to be had when less than half a century ago no such positions existed. In this sense these discourses are productive and the role of professionals is to move people along the continuum towards self management. The analysis of governmentality enables the identification of a range of techniques that work to make older people useful through a variety of forms of work and opportunities to exercise consumer choices. Consumer discourses become devices which transform real relations - 'older people' become 'consumers', 'social workers' become 'managers', 'social service departments' become 'purchasers' all crystallised by the formation of community care policies. In this case, care services provide schemas for the 'conduct of conduct' in highly professionalised services dominated by power/knowledge and characterised by the discretionary autonomy of social workers. It is within this disciplinary matrix of knowledge, contracts and autonomy that power operates over older people, ultimatley reinforcing the fragmentation that health surveillance engenders in the identities of older people at the centre of the professionals' gaze.
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