I’m interested in the symbolism of medication. For me the taking in of a chemical substance to the body with the intention of healing an ill obviously holds parallels with the ingestion of food. What is particularly interesting, I believe, is that medication, with its rich symbolism, can take on a representation of the prescriber for the patient / client / consumer.
Psychoanalytic theory, particularly Klein, describes the internalisation of relationships with others as internal objects. That is – we hold representations of others within our mind and relate to them, projecting portions of ourselves into these representations and so separating them into partial objects with varying qualities.
Symbols serve to represent objects – to tolerate the presence of an object whose loss may be unbearable for example. Medication can become a symbol of the relationship between clinician and client, and the accompanying internal object representing the clinician can consist of partial objects of varying qualities – positive and negative. This argument is summed up and expanded by Tutter (2006) – Medication as object. Journal of the American Psychoanalytic Association, 54(3), 781–804 [SagePub paywall].
Building on these ideas I was interested to see a paper this week, in Social Science and Medicine, describing – Moral discourses and pharmaceuticalised governance in households (Dew, K., Norris, P., Gabe, J., Chamberlain, K., & Hodgetts, D. (2014).. Social Science & Medicine (ePub ahead of print) [Science Direct paywall]. Their thesis is that:
…taking substances with active ingredients is saturated with moral concerns relating to issues of responsibility, identity, stigma, agency and power.
The authors recruited 55 households in New Zealand. They then asked to be shown any form of medication within the home and collected field notes and images of these objects. Family members were then interviewed in relation to each medication disclosed. Illicit substances were excluded from the discourse. Images were used to prompt discussion.
Analysis was conducted during meetings between authors including during writing retreats (I’m particularly taken with this idea!) Interview transcripts were assessed for any form of moral discourse in relation to medication – they then developed repertoires of meaning:
a resource to justify understandings and achieve something
Their findings were then presented as a series of discussions relating to the four identified repertoires.
This refers to the idea that medication represents an unnatural state within society. The pharmaceutical industry is portrayed as deliberately manufacturing concern in consumers in order to further their own ends. Consumers are then embodied as agents with the power to resist, or accept, the influence of medications. The medications served to distance the recipient from a more natural world order – illness is described as emerging from societal influence that can be resisted.
In this argument medications as seen as representing some form of failure in self. Taking medication represents a necessary crutch to overcome limitation – an inconvenience that can not be considered in too much detail. The acceptance or declining of medication can represent a form of moral strength or weakness, for example refusal of painkillers by one male participant was portrayed as an example of “manning up”. The taking of medication can also be a form of external stigma – to be hidden from others, for example HIV medication may be refused owing to the stigma perceived as being associated with the diagnosis.
This repertoire presents medications as a form of necessary evil – a highly complex relationship where medication is perceived as necessary, but there is conflict in that accepting it is not necessarily a morally neutral act. There is a need to adopt the sick role only when it is appropriate – that is if one is truly ill then medication should be taken, but there are other situations when it must be refused. This situation is further complicated by the effects of medications themselves – here medication can be disorientating, addictive or sedating. This can lead to medication being accepted as essential but with accompanying concern regarding its impact on the individual’s ability to fulfil social roles; a mother taking, necessary, but sedating medication and therefore unable to wake in the night would be seen as failing in her role should her children need her, for example.
Here medication represent the restoration, and maintenance, of order. They are beneficent in nature and representative of a supportive pharmaceutical industry, or prescriber. Medications become integrated into the sense of self, allowing normal social functioning to continue. The interpretation of side-effects here is also of interest – medications continue to be taken despite troubling side-effects and the impact of these effects is minimised.
The authors conclude:
People express themselves through their everyday activities (G. Williams, 1993), and the consumption of medication is an everyday activity for many people. Our relationship to pharmaceuticals is thus tied to our identity, what we want to show of ourselves, what sort of person we want to be seen as, and what sort of world we want to live in. As a consequence of changing states of health and illness these relationships are not static, and this fluidity is further eddied by pharmaceuticals not being treated as a single fixed category, but different pharmaceuticals being evaluated in different ways. Evaluations of pharmaceutical use are an outcome of the roles available to us and the responsibilies associated with those roles within systems of pharmaceuticalised governance.
For me this was an interesting piece of research – demonstrating the range of experiences and interpretations of the role of medication. I am interested also in what these findings represent regarding relationships between those taking medication and clinicians – how much are these beliefs informed by relationship with clinician and how much are societal? In the UK where, through the NHS, we have health care generally free at the point of access (for the moment…) how prevalent are discourses relating to the role of the pharmaceutical industry’s influence on us? Are clinicians in the UK seen as expanding their own power through the use of medication?
As usual – far more work to be done!
I think though that this is something that needs to be given a great deal of thought by prescribers – medication is clearly a powerful symbol, prescribing therefore, to me, represents an act far more powerful than merely an effort to correct pathological disruption. I’ve shared these thoughts briefly with some medical students that I supervise – as could be expected, sadly, they became somewhat distressed at my suggestion that as well as learning the pharmacology of substances they should also consider its moral career. Still, I tried…
An apology to end with – if anyone with analytic training makes the mistake of reading this then I’m sorry for the mangling of theory in the introduction. My understanding is based on personal reading and opportunities for discussing with like-minded individuals are, sadly, rare…