The Institutional Gaze and Disciplining on Smoke-Free Website - Case Study Example

The “Institutional Gaze” and “Disciplining” The modern Western world is characterized by well structured systems which regulate human behaviour. This means that every individual, from the moment of birth onwards, is categorized, labelled and subjected to all kinds of observation and control, starting with health care institutions and parental behaviour and moving on to school, work, politics, and all the different “institutions” which have evolved to cater for every conceivable eventuality. Some of these “institutions” are formally constituted, with laws and procedures which explicitly govern their remit and conduct, such hospitals or prisons, while others have more implicit rules, which we perceive as conventions or habits, such as theatre going or sports fandom. Most of the time people unconsciously abide by the rules set in these institutions, or willingly submit to the rules that they can clearly see, and this compliance is regarded by the majority as “normal” behaviour, while those who do not display compliance are labelled in some way “sick”, “abnormal”, “deviant” or even “criminal”. Throughout the twentieth century scholars in different disciplines began to unpick this dynamic and look for ways to explore what is going on here, why it is happening, and how these patterns are created and maintained. It was recognised by linguists that many of these issues are expressed in the way that people and organisations communicate with each other. A method called “discourse analysis” was developed in the field of linguistics which allows close examination of individual pieces of communication between people, whether in daily speech, in writing or in television programmes, instruction leaflets or any other context. This method provides “rather powerful, while subtle and precise, insights” and allows us to “witness the realization of the macrosociological patterns that characterize our society” (Van Dijk, 185, 7). In this paper we shall use a discourse analysis approach to investigate a portion of communications from the field of healthcare : the “Smoke Free” website from the UK National Health Service. In particular we shall look at how participants are recruited into this programme, how the programme sets behaviour codes, monitors the individuals, and keeps records on them. Close analysis of the actual communications will only take us so far, however, and as Van Dijk realised, there are also “macrosocial” factors to consider. One of the most influential scholars in this, as in other fields, has been Michael Foucault. His many books and articles on the underlying power relations that exist in institutions (Foucault, 1984, 1997 etc) have inspired many further interpretations and expansions (see for example, Smart, 1995). Foucault’s ideas originate in Marxist political theory and one of his basic assumptions about contemporary Western society is that “human beings have been constituted as subjects and objects of knowledge” and this has led him to concentrate on “the inter-relationship between forms of knowledge and power” (Smart, 1985, p. 19). In his work Discipline and Punish (1997) Foucault traces this phenomenon back to the period of the Enlightenment when European cultures began to adopt the so called “scientific” method and embark on the logical positivist trajectory that has produced highly regulated, industrial and technological society that we have today. This insight about the link between “knowledge” and “power” can be used as a key to unlock the secrets of dominance and control that modern institutions exert over individuals. Following on from this starting point, Foucault explored what he called the “institutional gaze”. Using the example of prisons, he reflected on the “Panopticon” (Foucault,1984), an idealised model of confinement and correction which was first suggested by the philosopher Bentham in 1785. What interested Foucault was not so much the historical details of prison structures and processes, but the notion that the organization observes the inmates and in so doing exerts power over them. The “gaze” in this case of a prison institution is extreme, but Foucault detects its existence in greater and lesser amounts in all organisations. In particular he suggests that people are subjected to this all-seeing institutional gaze precisely because it is the way that power relationships are maintained in our apparently free society. His view is that an establishment such as a hospital, or a modern version of that in our present case study, the “Smoke Free” NHS website, provides knowledge which is weighted towards those in power, and designed to “discipline” the consumers of that knowledge. This concept of “discipline” is not intended to be understood as punishment, but as a way of guiding and controlling behaviour, often in a way that the subject perceives as positive, towards a goal that is defined by the organization. The institutional gaze in modern society is not just the video camera attached to the wall when we park our car in the supermarket, but a) the whole network of processes and methods that organisations use for surveillance, data collection, monitoring and controlling, and b) the force that makes us internalize all of these guidelines and modify our behaviour so as to comply with this gaze and become increasingly more “governable” by the authorities. We shall examine this website now in the light of these concepts. The institution in our case study is the UK National Health Service’s (NHS) Smokefree organisation, as presented via its website. The umbrella body (the NHS) is government funded and charged with carrying out government policies on the population’s health. Traditionally a reactive service, meeting people at their point of need, the NHS has ambitions to become a proactive force in changing the culture of the UK and the behaviour of the population. In line with other Western countries, the UK has embarked on a programme of legislation to limit people’s freedom to smoke in public places. Smoking has become increasingly a target for state intervention. The website home page adopts the conventions of any non-expert informational page: it has multimedia functions, and a sophisticated linkage between different sections. There are pop ups and revolving messages, with lots of opinions which purport to be general members of the public who have used the site. An interesting feature of the site is the way it identifies its target subjects. A screen on the left flashes a series of messages including one which asks “How addicted are you?... take our quick quiz to find out.” A click on the button “begin quiz” leads the viewer straight into the “Addiction Test” and this not-so subtle change from quiz to test shows that we are entering the world of medical examination. The preamble to the first page of the test begins “Smoking is more than a habit, it is an addiction” and continues to talk about becoming “hooked” and having “cravings”. This blanket definition includes all smokers, without exception, and implies that they are on a par with drug addicts, and that they require medical aid to deal with their problem. At the end of the test the viewer is told that he or she is “highly” or “moderately” addicted, and directed to the “support” services offered by the NHS “in your area” and is given a 0800 telephone number to ring. This is the moment where a viewer is “diagnosed” in a medical sense. Looking at this from the perspective that Foucault suggests, it is clear that the institution wants to log the viewer’s participation in its system and then follow up how he or she progresses. Another option is to order a “quit kit” – again following a registration process with personal details given. Despite the chatty tone, and internet-appropriate presentation, there is a gradual drift in the terminology which draws the viewer more and more tightly into a locked-in relationship with the organisation. There are drop down menus with informative content, but this “information” gives only negative facts about the harm that nicotine does, and stresses the most serious possible consequences of heavy smoking, such as cancer, heart disease, gangrene and death. There is no place for the moderate smoker or the light smoker in this analysis, and so the expert view is decidedly biased. This is an example of the way that a national body appropriates scientific knowledge and applies it to one specific end. Though the viewer may start as a casual surfer, and may even be curious about the “free services” being offered, accessing these services ties the viewer into a formal relationship of dependence. The guidance introducing the the obligatory local registration states: “When you join, a trained adviser will help you to put your plan to stop smoking into action. The group sessions start a couple of weeks before you go smokefree. Your first sessions help you to plan and prepare to quit. After you go smokefree your group will meet each week for advice and motivation.” The disciplinary method, to use the terminology of Tagg, (1993) is a weekly group therapy model and this model is reinforced by the upbeat slogan “when you go smokefree”. The moment of joining the programme, whether by telephone or by sending in an online form, or by turning up at a local advisory centre, is the moment when the participant becomes a case to be followed up by the institution. Further steps, such as setting a quit date, attending one to one or group sessions, attending a follow up and keeping in touch with the group are the means by which the institution monitors participants. The institution operates via these “local advisors”, one of whom is depicted in the introductory video, the transcript of which is below in Appendix 1. The language of this video reveals very clearly how the institution sees and labels all of the participants. Subjects are labelled Q (Successful Quitter) while the representatives of the institution are labelled by complicated acronyms that suggest status. Participants are labelled “clients” and it is made clear that their objective is to achieve “non-smoker” status. A striking feature of all inputs from the clients on the website is their willingness to admit their own incompetence and their utter compliance with the jargon and the medicalization of the process. Possible resistance to the method is mentioned but immediately dismissed “LSSS: People enjoy groups. Sometimes they’re a little bit reluctant to come, but once they’ve been, they see that it’s not what they expected it to be” (Appendix 1 below). The institutional gaze on those who do not comply is not shown openly in the website, but it is hinted at when the local advisor says “You really do see people change. Their self-esteem increases and physically their eyes are sparkling and they really do look a lot better.” (Appendix 1 below) This high praise of the “successful quitter” is a subtle condemnation of smokers (and by implication unsuccessful quitting clients) as people who are dull and lacking in self esteem. The terminology for those who do not maintain their “smokefree” status mirrors that of drug misuse, such as “relapse” and again this connotes negative qualities. Those who “relapse” are simply directed back to an earlier stage, where they either start again from the beginning, or recap a previous step and carry on regardless. “Try again” is a frequent exhortation, and this shows that the institution is not flexible to the needs of individuals, but rather demands subservience to the prevailing “norm” of “smokefree” existence. There is a suggestion, however, that many group leaders are ex smokers and one wonders if perhaps this also is an potential “norm” being held up for participants to follow. In addition to this programme of sessions and follow up there are many brand name products advertised such as the “smokelizer” (a device for measuring gases in a person’s breath), drugs such as NRT, Zyban and Champix, all of which are offered on an NHS prescription basis. For all but the very lowest income brackets this means they are not free. Access to these products is not via the website but via the local general practitioner. The institution is in effect a monopoly and it demands submission to its “smokefree” infrastructure in return for access to these products. Moreover, the general practitioner is the official statistics collector for the whole of the NHS, and by tying the “free services” to this mechanism, the anti smoking programme ensures that the “smokefree” participants are shepherded into the full administrative machine of the national system. In order to have a little insight into the hidden reach of this programme it is necessary to look a little further than the web site, which after all, is only the recruiting gate of the institution. One year after the launch of “Smoke Free” the government’s Department of Health published an Annual Report (2007) which claimed that over half of the 462,690 people who used the service were still “smokefree”at their four week follow up. This document incidentally also reveals that the “smokefree” website of the NHS is a campaigning one, and is deliberately tied to an ongoing tightening of legislation with the ultimate objective of making the whole country “smokefree”. In summary, then, it is clear that the institutional gaze is visible in this website, and it is a rather authoritarian gaze, covered in a jazzy veneer of internet technology. When the participant (or client) interacts with the institution, its true and rather less fashionable nature becomes more evident, and the paternalistic state takes control using its standard medicalisation systems and processes. Bordo, S. (1998) Unbearable Weight. Berkeley: University of California Press. Available at: http://pages.cmns.sfu.ca/daniel-ahadi/files/2010/06/Case_Study_Applying_Foucault.pdf Foucault, M.(1984) “The means of correct training” and “Panopticism” in P. Rabinow (ed) The Foucault Reader. New York: Pantheon Books, pp. 188-213. Foucault, M. (1997) Discipline and Punish. Harmondsworth: Penguin Books. Holligan, C. Discipline and Normalisation in the Nursery: The Foucauldian Gaze. Hoy, P. (ed.) (1991) Foucault: A Critical Reader. Oxford: Basil Blackwell. Rabinow, P. (Ed.) (1984) The Foucault Reader. New York: Pantheon Books. Smart, B. (1995) Michael Foucault. London and New York: Routledge. Smoke Free UK National Health Service Website (2006) available at: http://smokefree.nhs.uk/ Smoke Free: One Year On. Annual Report (2007) UK Dept of Health, available at: http://www.smokefreeengland.co.uk/files/dhs01_01-one-year-on-report-final.pdf Tagg, J. (1993) The Burden of Representation. Essays on Photographies and Histories. Minneapolis: The University of Minnesota Press. Van Dijk, T. A. (Ed.) (1985, reprint 2001) “The Role of Discourse Analysis in our Society,” in Handbook of Discourse Analysis, Vol 4, London, Orlando: Academic Press, pp. 1-8. Appendix 1 : Video Clip transcript (screen on the left of page). Location: http://smokefree.nhs.uk/real-life-quitters/beverley-and-alisha/ The transcript below is taken from the “real life quitters” tab on the front page of the NHS smokefree website. The key to speakers, the video and the transcript, are all provided by the website for downloading. This introductory video is on the left of the page, and a column of followed by a few individual case studies of people who have given up smoking using the NHS smoke free services is available on the right of the page, each with their own video and transcript. Speaker key N Narrator Q Successful Quitter GP Local GP LSSS Local NHS Stop Smoking Advisor HL NHS Smoking Helpline Advisor Clip 1. (Introduction) NHS STOP SMOKING SERVICES IN YOUR AREA Q I stopped smoking through a group session. There were ten of us, all workmates. LSSS Okay, welcome everybody. LSSS The NHS offers a free service, which comprises of a group support programme or one-to-ones with an advisor and the client can choose which they prefer. Q I needed the support. Whatever you’re feeling, if you’ve got a good support worker, you can go and explain those situations to that person. Q If I didn’t have the support, I wouldn’t have known where to turn to or where to start or what to have done. LSSS Clients like to have the support because it’s better than doing it alone, and a lot of people have tried to give up smoking alone and not succeeded. Q I don’t think I could have given up on my own. I’ve tried several times before, whereas in a group you don’t let yourself or the others down. LSSS The first week of a group session, we go through all the different medications that are available and pick a product that will fit in with their lifestyle, because if it’s suits them, it’s much more likely that they will use it. Q I do a physical job. I’m always out of breath. LSSS People enjoy groups. Sometimes they’re a little bit reluctant to come, but once they’ve been, they see that it’s not what they expected it to be. LSSS We use a smokelyzer to measure to carbon monoxide and this is a motivational tool because it will help the client to see the benefit of giving up smoking. Q It was something tangible that we could see. The first time, I think I was showing something like 21. Then I stopped smoking and it went down to 3. Q I have to class myself as a non-smoker as well now. Q 10 of us took part in the course and 9 of us are still non-smokers 3 years on. So I think it’s pretty good. Q Now I’ve given up, I feel much healthier within myself. I can go for long brisk walks, which I couldn’t do before. Q I’ve been able to buy more clothes and that is... I’m just being honest with you, I obviously save... I save a lot of money. LSSS You really do see people change. Their self-esteem increases and physically their eyes are sparkling and they really do look a lot better. Q You’ve got to try it. You really have. Q I wouldn’t have been able to do it just on my own. Q Now we save. Because we smoked 60 a day, we’re saving over £500 a month, which is nearly £6,000 a year. So, we’re actually going to Kenya next year. Q Group sessions work. N To find your local NHS Stop Smoking Service call now on 08800 169 0 169 or visit gosmokefree.co.uk Read More