Hoffmann Pii, K., Villadsen, K. Protect the patient from whom? When patients contest governmentality and seek more expert guidance (2013) Social Theory and Health, 11 (1), pp. 19-39.
https://dx.doi.org/10.1057/sth.2012.19
Abstract
This article presents findings from an empirical study among patients and professionals involved in a preventive health program at a Danish hospital. It shows how patients enrolled in the program interact with health professionals in ways that challenge assumptions common to governmentality studies of prevention and health promotion. This literature has successfully explored how contemporary health promotion transgresses the public/private boundary by shaping the values of collectivities and individuals to fit better with public health objectives. By exploring the complex co-existence and intertwinements of discipline and biopolitics in preventive practices, this study eschews an interpretation that views the powers of the professional health system as invasive and one-directional. Perhaps surprisingly, the study demonstrates how patients in various ways defy a ‘patient-centered’ and empowering approach and demand to be treated medically and disciplined in a more traditional sense. The blurring of the public/private boundary, then, cannot be straightforwardly described as a result of a professional health system that, more or less subtly, reaches into the private lives of patients. A more complex picture emerges, as patients’ attitude reflect both traditional medicine and rationalities foreign to the health system.
Author Keywords
atherosclerosis; ethnography; Foucault; governmentality; preventive health; resistance
DOI: 10.1057/sth.2012.19
Foucault News 
Hoffmann Pii and Villadsen introduced their research into public health practice, particularly health promotion by posing the following two questions:
‘How should we conceive of recent patient-centered health initiatives for the prevention of “lifestyle diseases” and improvement of life from a Foucaultian perspective? Should they be unveiled as more or less subtle technologies for social control and optimized productivity, or can they be evaluated as offering positive, if ambiguous, potentials?’
These questions are ambiguous. Hoffmann Pii and Villadsen were particularly concerned with patient-centered health initiatives that undertaken as part of a program in a vascular out-patient clinic to prevent atherosclerosis. The program consisted of two components undertaken by nurses with their patients: ‘motivational interviewing’ and ‘motivational counseling’. I suggest that the motivational counseling component can be conceived of from an alternative perspective to a Foucaultian one, the perspective of my concept of ‘“benevolent” scapegoating’. This concept refers to the same phenomenon that William Ryan (1971), the American psychologist, called ‘blaming the victim’. I call the phenomenon ‘“benevolent” scapegoating’ because I consider that this name is a better match for it. (Ryan later admitted that ‘maybe [“blaming the victim”] was an unfortunate phrase.’ [Ryan and Brinton Lykes, 1996: 354]). I hope that both the phenomenon and my preferred name for it will become clearer from the following account.
The concept of ‘“benevolent” scapegoating’ is based upon two concepts: ‘psychological intervention’ and ‘the justifiability of psychological intervention’. I define ‘psychological intervention’ as ‘any action that aims to solve or compensate for the psychological problem of an individual’. Vince Murphy, my former colleague, defined ‘the justifiability of psychological intervention’ as an ethical principle, that psychological intervention should not be undertaken unless it is justified by objective evidence for its necessity. I complemented the principle by creating the practice of ‘psychological auditing’, which aims to prevent unjustifiable intervention and, when relevant, ‘benevolent’ scapegoating.
A psychological audit is undertaken by asking someone who supports a psychological intervention to confirm the basis upon which they rely to justify that intervention. This description might encourage the assumption that psychological auditing is simple. But it is not. Like the concept of ‘“benevolent” scapegoating’, it is based upon the concepts of ‘psychological intervention’ and ‘the justifiability of psychological intervention’.
The desirability of undertaking psychological audits becomes clear when it is realized that undertaking psychological intervention can be fraught with risk. For example, an intervention can invade the privacy and/or the emotions of the recipient. In addition, an intervention can be harmful. When an intervention is unjustifiable, it stigmatizes the recipient as being psychologically inadequate. In some cases, it can also unjustifiably blame them for their plight. Scapegoating can be explicit, as in the case of punitive scapegoating, or implicit, as in the case of ‘benevolent’ scapegoating. Consequently, an intervention can ‘benevolently’ scapegoat its recipient.
To elaborate upon the possibility of a psychological intervention being harmful, even the prospect of one can be harmful. For example, during the 1980s, an unemployed young woman in Wales joined a course on a UK Government Youth Training Scheme to become a hairdresser. As part of the course, she was required to attend a week-long component to learn how to canoe and abseil. In her own reported words, she was ‘terrified of water and heights and … became very worked up just thinking about the week’ (quoted by Gwilym, 1988). Consequently, she sought the help of her family doctor, who gave her a sick note that excused her from the requirement to attend the component.
A journalist on ‘The Independent’ newspaper documented a case of an intervention that caused harm, about her attendance on an Outward Bound course for women. These were her conclusions about the course:
‘Courses aim to bring about “enhanced self-knowledge, changed understanding of others, greater adaptability to change and an increased capacity to learn from experience”. Enhanced self-knowledge? Well, I had long suspected that I had an incurable fear of heights. Having been reduced to tears of frustration and blind terror at one end of a rope bridge, I’m now absolutely convinced of it.’ (Jones, 1989)
This example is, of course, an extreme case of how an unjustifiable intervention went badly wrong, and produced extreme emotional harm. Alternatively, an intervention can be patronizing. Understandably, someone who feels that they have been patronized might hit back at the person who they feel has patronized them. This seems to have happened about the motivational counseling undertaken by one of the nurses in the vascular out-patient clinic. The nurse seems to have discussed with a patient the contents of their fridge, which provoked the patient to ask her whether she had butter in her fridge.
The rejoinder of the patient illustrates the desirability of undertaking psychological audits. Hoffmann Pii and Villadsen referred to the rationality (my emphasis) of the program undertaken in the vascular out-patient clinic. In contrast, the motivational counseling component of the program strikes me as having been unjustifiable. This issue about these two contrasting perceptions of the authors and the current writer could be resolved by asking the managing doctor to confirm the basis upon which they relied to justify the counseling. I would be extremely intrigued by their response, which, I suggest takes precedence over any theoretical concerns.
References
Gwilym, Jayne. 1988. Michelle dropped in YTS abseil shock. South Wales
Evening Post. 19 May. 1-2.
Jones, Judy. 1989. All bound for self-discovery. The Independent. 27 September. 19.
Ryan, William. 1971. Blaming the victim. New York: Pantheon.
Ryan, William and M. Brinton Lykes. 1996. A conversation between William Ryan and M. Brinton Lykes. Section VI in ‘Myths about the powerless: contesting social inequalities’. Edited by M. Brinton Lykes et al. Philadelphia: Temple University Press.
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