1 Psychology and human development1.10 Social psychology
1.10.4.2 Social roles of doctors, sick role and illness behaviour
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Written by Resident Doctor Committee · Published
Social roles of the doctor
A social role is the set of expectations, rights and obligations attached to a position, not to the person who holds it.
Doctors act as healer, expert adviser, gatekeeper, certifier of illness, advocate, coordinator and public authority, and these roles can conflict.
Parsons' sick role
Talcott Parsons described the sick role in The Social System (1951), treating illness as sanctioned deviance. A doctor legitimises the illness, and the patient's position is conditional: the rights last only while the obligations are met.
Part | Content |
|---|---|
Right | Exemption from normal duties such as work and family, in proportion to severity |
Right | Not being held responsible for the illness |
Obligation | Wanting to get well |
Obligation | Seeking competent help and cooperating with it |
Failing to seek medical help breaches the help-seeking obligation, whereas time off work, freedom from blame, wanting to recover and legitimation by a doctor are all part of the role.
Modern patient rights are not part of the sick role.
The rights generate secondary gain while the obligations demand recovery, so the role holds a tension between the benefits of illness and the duty to get well.
The model assumes acute, curable physical illness, so it fits chronic, stigmatised, contested and psychiatric illness poorly.
Primary and secondary gain
Term | What it is | Example |
|---|---|---|
Primary gain | Unconscious relief of internal psychological conflict that the symptom provides; the mechanism of onset in functional (conversion) symptoms | Conversion paralysis that removes an intolerable conflict |
Secondary gain | External reward that arrives after onset and may maintain the symptom | Sickness benefit, escape from a distressing job |
Secondary gain does not prove deliberate feigning.
Illness behaviour
Illness behaviour, introduced by David Mechanic around 1960, is the way a person perceives, evaluates and acts on symptoms, whether or not disease is found.
It varies with social, cultural and psychological factors, such as symptom severity, causal beliefs, past experience, emotion, advice from family and friends, stigma and access to care.
Abnormal illness behaviour, defined by Issy Pilowsky in 1969, is persistence in a maladaptive way of perceiving and acting on one's health despite thorough tests and a clear medical explanation.
Pilowsky measured it with his Illness Behaviour Questionnaire.
Abnormal illness behaviour can affirm or deny illness, and negative tests alone do not establish factitious disorder or malingering.
Institutions
Goffman, in Asylums (1961), described the mortification of the self in a total institution.
Role stripping begins on admission: possessions are removed, privacy is lost and the person's outside roles no longer count.
Barton described a clinical syndrome of institutionalisation.
Therapeutic relationship
A lasting therapeutic relationship is best built by attending to the patient's own strengths and interests, a patient-centred focus.