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Health Psychology and Social Action MICHAEL MURRAY Memorial University of Newfoundland, Canada
Journal of Health Psychology Copyright © 2006 SAGE Publications London, Thousand Oaks and New Delhi, www.sagepublications.com Vol 11(3) 379–384 DOI: 10.1177/1359105306063308
BLAKE POLAND University of Toronto, Canada
Abstract This article reviews the main epistemological approaches within health psychology. It considers the approach based on critical realism and various strategies for linking health psychology with social action. It argues that critical health psychology has a distinct contribution to make in promoting public health as part of the broader movement for social justice and health.
AC K N OW L E D G E M E N T S . We would like to acknowledge the contribution of Geoff Nelson, Eleanor Maticka-Tyndale, Lorraine Ferris, Roy Cameron and Ken Prkachin who were members of the working group on Training in community health psychology. COMPETING INTERESTS:
None declared.
ADDRESS.
Correspondence should be directed to: of Community Health, Memorial University of Newfoundland, St John’s, NL, A1B 3V6, Canada. [email:
[email protected]]
M I C H A E L M U R R AY , Division
Keywords ■ ■
critical health psychology social action 379
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JOURNAL OF HEALTH PSYCHOLOGY 11(3) Two things only are wicked: to be helpless when you could be free, to be hungry when you could be fed. (Gwyn Thomas, 1913–1981)1
health psychology is more than a critique of mainstream health psychology it is an attempt to develop new psychological ways of conceptualizing health and illness and strategies for participating in the transformation of an unhealthy world. Hepworth (this issue) traces one of its roots to the International Conference held in St John’s, Newfoundland in 1999 (http:// www.med.mun.ca/health99; Murray, 2000), which she generously describes as a landmark event. This conference was a coming together of many ideas that were circulating in the 1990s. It marked a growing frustration with what seemed to be the complacency and barrenness of the emergent discipline of health psychology that had sucked into its orbit scholars from a range of psychologies but especially from social psychology with its long history of critique and social action. There was frustration at the complacency of a discipline that had as its focus human suffering yet seemed to lack the theoretical and methodological approaches to grasp the character of the phenomenon. This was especially apparent in the connections established with medicine and the aping of medical language and methods. There was frustration at the barrenness of its theoretical approaches that had become fixated on limited social cognitive models of human behaviour and ignored the sustained debate about theory within the social sciences, in particular around issues of language and power. There was frustration about methodology that seemed to focus on refining measurement and statistical techniques rather than increasing understanding and enabling personal and social transformation. Not least there was frustration at the ignorance of the broader social, cultural, political and historical context within which health and illness are enmeshed and a disinterest in contributing to social change in an unjust world. There was no clearly defined alternative programme of research but rather the development of a variety of different critical perspectives. This plurality of views reflected the excitement that was present within the broader critical psychology that Collins defined as:
CRITICAL
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an attitude—and, let it be said, a bad attitude: a disrespect for authority, an uneasy suspicion that something is wrong. And no matter how often we are told that things are not so bad, that it is all on the verge of being fixed, that all we need to do is complete the proper research or perfect the necessary technique, the unshakeable feeling remains that something is seriously amiss. (2004, p. 22) One of the consequences of the 1999 conference was the establishment of a working group on Training in Community Health Psychology that received funding from the Canadian Institutes for Health Research. The aim of this working group was an attempt to take the debate about the nature of critical psychology forward through an examination of the ways it could connect with community psychology. The latter sub-discipline had been historically connected with issues of social solidarity and social justice although it too had become dominated by the theories and methods of positivist psychology. The membership of that working group was deliberately interdisciplinary to ensure that it was informed by the broader debates about social theory. The group attempted to define what was meant by community health psychology. Being informed by a critical perspective it explored issues of epistemology and methodology. A report on that working party is available (Murray et al., 2001). In addition, two articles were subsequently published. One (Murray, Nelson, Poland, Maticka-Tyndale, & Ferris, 2004) explored the values and assumptions underlying community health psychology while the other (Nelson, Poland, Murray, & MatickaTyndale, 2004) considered models for graduate programmes. Unfortunately, a central part of this report has yet to be published. Since it deals with issues germane to those raised by Hepworth (this issue) we thought it would be useful to summarize some of them in this commentary. The report distinguished between critical thinking as intellectual rigour and critical thinking as deepening the social analysis. The former is largely an intellectual exercise that should inform any attempt to explore the assumptions underlying various theories and methods. The latter is premised on the assumption that all
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thought and action is socially located. This approach is explicitly oriented towards social justice. Further, this form of critical thinking is: (a) informed by a historical perspective/analysis; (b) moves back and forward from the personal/ individual to the social/structural to show the dialectical relationship between the two; and (c) looks for root causes of health and social problems embedded in social structures and social practices. A critical health psychology based on this approach attends to the broader sociohistorical context within which health and illness are created and within which we live and work; it connects the illness experience to that context and it develops a strategy for change connecting the personal with the social. Somewhat similar to Bhaskar (1997) and Habermas (1971), we distinguished between three broad research traditions. Since these overlap with Hepworth’s philosophical periods it is useful to provide some further details of these traditions. • Positivist/Empiricist: according to this perspective what is knowable is directly observable, empirically measurable and quantifiable. There is a focus on the testing of hypotheses (laws) based on the study of observable patterns and statistical associations. This is the focus of mainstream health psychology with its emphasis on objectivity and reliability and its concern for prediction and control. Consider the case of smoking, which from this perspective is viewed as the failure of reason (non-rational approach to verifiable evidence). Questions are framed in terms of knowledge and attitudes towards smoking and quitting, as determinants of behaviour, with the focus being on the development of predictive models of factors associated with smoking uptake, cessation and relapse. This approach can be most vividly observed in the form of behavioural epidemiology (Murray & Chamberlain, 1999). • Constructivist: this approach emphasizes that what is known is only in and via the mind. This approach typified some forms of social constructionism that grew in influence during the 1980s and 1990s. There was an emphasis on understanding the world of meanings especially through the use of qualitative methods. From this perspective, smoking is
considered as being concerned with issues of identity and the process of becoming and being. Researchers are concerned with what smoking means to the individual smoker but with limited reference to the broader social context. • Critical: this approach emphasizes that what really exists cannot be ascertained simply through empirical methods except with the assistance of social theory. It emphasizes that reality is contested and shaped by power structures. The purpose of this approach is to participate in the process of human emancipation. This perspective is concerned with exploring the connection between human action and the social and material conditions. Smoking might be seen as a symptom of lack of control over adverse conditions or as a form of social resistance. Researchers ask what agendas are served by framing smoking as a problem of individual ignorance rather than as a consequence of poverty and disadvantage, or perhaps not a problem at all. Research in this tradition may seek to understand the experience of social exclusion, marginalization and suffering caused by social exclusion and inequitable social structures and processes. It may also include studies of hegemony/ideology; and how people make sense of the structures that ‘keep them in their place’. Frustrated at the limitations of the positivism and empiricism of mainstream health psychology, critical health psychology initially turned its focus to the language used to construct health problems. This was part of the broader ‘turn to language’ throughout the social sciences. In this it was informed by ‘light’ versions of social constructionism (Danziger, 1997) that we can locate within the constructivist approach. This approach was not uncommon at the initial conference on critical health psychology. However, awareness of the importance of political context has increased a turn to more critical discourse analysis and to various forms of social action over the past eight years. Those who adopt the latter perspective are located within the critical approach and attempt to connect their work with other psychologists and social scientists engaged in the struggle for social justice. 381
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In answer then to the question as to whether critical health psychology can contribute to promoting public health the answer is yes but not on its own. Rather there is a need to enter into an alliance with other researchers and community members to participate in the movement for social justice. The following are a few examples of strategies that we can follow. We can expose the reductionist assumptions underlying much social and health policy and research. Modern capitalism is based upon an ideology of individual consumerism whereby health status and personal satisfaction are achieved through the acquisition of commodities, lifestyles and services. Baum (2005) has described how in societies where the ethic of social solidarity is valued there is better health compared with similar societies that emphasize an ethic of individualism. Rather than reifying the model of the individual, critical health psychology can expose the role of dominant scientific, social and political discourses, policies and institutions in shaping this role and help to promote and to develop strategies of resistance. We can research the deleterious impact of unjust and oppressive social arrangements on health and well-being and conversely we can highlight the benefits of greater social solidarity. It is now well established that those with greater wealth and power also have fewer health problems and greater life expectancy. Over the past decade many neo-liberal governments in western society have come to power proclaiming a commitment to combating poverty and building social inclusion. However, evidence confirms that social inequalities in wealth and health continue to exist or are even increasing. In the UK it is estimated that 22 per cent of the population live in poverty (Paxton & Dixon, 2004) while in Canada the figure is 18 per cent (Beiser & Stewart, 2005). The classic Whitehall research has clearly shown the relationship between social gradient and health (e.g. Marmot & Stansfeld, 2002). This differential is due not simply to differences in income but to differences in power, wealth and access to resources. Critical health psychologists can help to highlight the pervasive role of power in our lives and how it can be challenged in different domains (Lykes, Banuazizi, Liem, & Morris, 1996). We can engage in research and advocacy to highlight unhealthy living and working 382
conditions, especially of those who are most oppressed and marginalized. For example, critical health psychologists can expose the effects of poverty on the health and health care of individuals and families. Such work is not completed in a descriptive manner but placed clearly within its social and political context to expose the contribution of reactionary government policies and the nefarious role of multi-national corporations (Steinitz & Mishler, 2001). We can engage in various forms of community and collective action to transform unhealthy living and working conditions. At all times we are aware of the potential of radical action and language being co-opted by those in power to provide a cover for more reactionary policies. For example, the appropriation of the concept of community by New Labour in the UK conceals a strategy to nourish individualism (Fremeux, 2005), or as a cover for the retrenchment of the welfare state (Bullock, 1990). By engaging with these different strategies, critical health psychologists are breaking out of the limitations of the positivist model of science and participating in the development of a more socially activist approach (Murray & Campbell, 2003). A socially activist health psychology participates in the broader movement to combat these growing inequalities and to create a more socially just society. In this they connect with those community and liberation psychologists who have been engaged in movements for social justice (Martin-Baro, 1994). An important aspect of this approach is the flexibility in methods. As Mishler and Steinitz emphasized: The basic issue in regard to whether or not our studies can be useful in the struggle for social justice does not have to do with the reliability or validity of our methods, nor [. . .] with whether we do qualitative or quantitative research. Rather it has to do with whom we ally ourselves, the nature of our collaboration with them in carrying out our studies, and how we negotiate ways to combine our different interests to make our findings useful and relevant to our shared political aims. (2001, p. 2) It is not that rigour becomes irrelevant within a critical paradigm, but rather that additional dimensions of rigour are required (social/ community relevance, emancipatory/transformative potential, empowerment and capacity
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building, unintended consequences, etc.). Underlying critical health psychology is a moral project2 of personal and social transformation. It is not content with merely describing reality, but rather seeks to transform reality. As agents of change critical health psychologists define themselves not as scientist-practitioners but rather as scholar-activists. We are aware of the values underlying our approach (Murray et al., 2004). We challenge oppression in its many forms and we participate in movements for social justice. It is through this broader work that we can expose the impact of social inequities on health and can contribute to the building of a healthier society. Lest we leave the reader with the impression that critique is to be applied only to others, we underscore the importance of reflexivity in critical research (Eakin, Robertson, Poland, Coburn, & Edwards, 1996). That is, an awareness of one’s own social location (class, race, gender) and its implications for how we see the world, how research questions are framed and investigated, the theoretical orientations we bring to our work. We work to make these explicit, just as we encourage others to do the same.
Notes 1. Quotation taken from Rodgers (1999). 2. Term used by Hank Stam at the Third Annual Conference of Critical Health Psychology, Auckland, New Zealand.
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Eakin, J., Robertson, A., Poland, B., Coburn, C., & Edwards, R. (1996). Towards a critical social science perspective on health promotion research. Health Promotion International, 11, 157–165. Fremeux, I. (2005). New Labour’s appropriation of the concept of community: A critique. Community Development Journal, 40, 265–274. Habermas, J. (1971). Knowledge and human interest. Boston, MA: Beacon Press. Lykes, M. B., Banuazizi, A., Liem, R., & Morris, M. (Eds.). (1996). Myths about the powerless: Contesting social inequalities. Philadelphia, PA: Temple University Press. Marmot, M. G., & Stansfeld, S. A. (2002). Stress and heart disease. London: BMJ Books. Martin-Baro, I. (1994). Writings for a liberation psychology. In A. Aron & S. Corne (Eds.), Cambridge, MA: Harvard University Press. Mishler, E. G., & Steinitz, V. (2001). Solidarity work: Researchers in the struggle for social justice. Paper presented at the 14th Annual QUIG Conference on Interdisciplinary Qualitative Studies, Athens, Georgia, USA, January. Murray, M. (Ed.). (2000). Reconstructing health psychology. Special Issue of Journal of Health Psychology, 5(3). Murray, M., & Campbell, C. (2003). Living in a material world: Reflecting on some assumptions of health psychology. Journal of Health Psychology, 8, 231–236. Murray, M., & Chamberlain, K. (1999). Health psychology and qualitative research. In M. Murray & K. Chamberlain (Eds.), Health psychology: Theories and methods (pp. 3–15). London: Sage. Murray, M., Nelson, G., Poland, B., Maticka-Tyndale, E., & Ferris, L. (2004). Assumptions and values of community health psychology. Journal of Health Psychology, 9, 323–333. Murray, M., Nelson, G., Poland, B., MatickaTyndale, E., Ferris, L., Cameron, R., & Prkachin, K. (2001). Training in community health psychology. Report submitted to Canadian Institutes for Health Research, Ottawa, Canada. http://www.med.mun. ca/tchp Nelson, G., Poland, B., Murray, M., & Maticka-Tyndale, E. (2004). Building capacity in community health action research: Toward a praxis framework for graduate education. Action Research, 2, 389–408. Paxton,W., & Dixon, M. (2004). The state of the nation: An audit of injustice in the UK. London: Institute for Public Policy Research. Rodgers, G. (1999). A settlement of memory. St John’s, NL: Killick. Steinitz, V., & Mishler, E. G. (2001). Reclaiming SPSSI’s radiacl promise: A critical look at JSI’s ‘Impact of welfare reform’ issue. Analyses of Social Issues and Public Policy, 1, 163–173. 383
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Author biographies M I C H A E L M U R R AY is Professor of Social and Health Psychology at Memorial University of Newfoundland.
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is an Associate Professor of Public Health at the University of Toronto.
BLAKE POLAND
