Mothers' accounts of healthcare encounters: Negotiating culpability and fulfilling the active mother...

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published online 1 May 2013Discourse SocietyNina V Gunnarsson, Helena Hemmingsson and Lars-Christer Hydén

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Discourse & Society24(4) 1 –15

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Mothers’ accounts of healthcare encounters: Negotiating culpability and fulfilling the active mother role

Nina V GunnarssonJönköping University, Sweden

Helena Hemmingsson and Lars-Christer HydénLinköping University, Sweden

AbstractThis article explores mothers’ accounts of initial interactions and encounters with healthcare professionals and the outcomes where questions about their children’s problems are concerned. A case-based storyline was reconstructed as part of the analysis, focusing on when and how mothers claimed to be responsible parents. The outcomes of these encounters were presented by the mothers in this study as a drawn-out process, with disagreement between mothers and healthcare providers, resulting in different performances of moral agency. Some mothers portrayed themselves as dependent on healthcare expertise and made moral claims by attributing and deflecting blame, negotiating back and forth about their own and the healthcare professionals’ culpability, restoring moral agency. Other mothers did not generally defend or justify their actions or place blame, but appealed instead to fulfilment of the active mother role where they controlled the interaction and claimed full responsibility for their child’s care, hence presenting their moral agency as indisputable.

KeywordsChild allergy, healthcare interactions, moral agency, motherhood, narrative accounts, narrative/discourse analysis, negotiating culpability, parent responsibility, performances of self, Sweden

Corresponding author:Nina V Gunnarsson, Department of Behavioural Sciences and Social Work, School of Health Sciences, Jönköping University, 551 11 Jönköping, Sweden. Email: [email protected]; [email protected]

482069 DAS24410.1177/0957926513482069Discourse & SocietyGunnarsson et al.2013

Article



2 Discourse & Society 24(4)

Introduction

When mothers in Sweden seek professional medical help for their children, they do so within a particular socio-cultural setting of values that assumes individual autonomy, independence and rational control of life, including health and illness (Michailakis and Schirmer, 2010). In such a context, it is up to the individual to take action to make the right choices concerning their children. As a consequence, risks of everyday life may then be accentuated (Tulloch and Lupton, 2003), as people are held responsible for the outcomes – particularly concerning their children. When children fall ill, parents are placed in a special position where their responsibility to care for their child is put under the spotlight by others, especially healthcare professionals. This is particularly true for mothers who are the primary caregivers (Elvin-Nowak and Thomsson, 2001; Hays, 1996; Miller, 2005). It is usually the mother’s job to care for the sick child and to take the child to a doctor (Harden, 2005), and mothers are known to feel ultimately responsible for their children’s upbringing and health (Cunningham-Burley and McKeganey, 1990; Hays, 1996; Lauritzen, 1997).

As responsibility of care is gendered, mothers have explicit expectations to live up to, in the sense that normative gendered attributes are particularly connected with giving good care (Hays, 1996). There are widespread beliefs about what makes a good mother and that a woman’s mothering abilities are naturally endowed (Hays, 1996; Miller, 2005). In addition, an essential part of being a woman refers to the need for expert medi-cal guidance in reproduction, childcare and mothering practices (Hays, 1996; Miller, 2007). Thus, women who become mothers are expected to be able to ‘instinctively’ dis-cern good care from bad, but at the same time they are also expected to accept, need and, thus, seek advice and guidance from childcare experts in order to be able to fulfil their mothering roles.

If such good caring is assumed of mothers, they will also be held socially and cultur-ally accountable for these expectations, and a potentially ‘bad’ mother or a mother who has not successfully shown herself to be a ‘good’ mother may not be able to claim a moral self (Liamputtong, 2006; McCarthy et al., 2003).

In this article, we aim to explore mothers’ accounts of healthcare encounters and out-comes where questions about their children’s (allergy) problems are in focus. Specifically, we aim to show how mothers use the interview situation to present, defend and sustain their identities as ‘good’ mothers – when and how they make claims of being responsible parents (moral agency). Although there are specific gendered and generally widespread moral imperatives in good parenting, as found in different social and cultural contexts (Liamputtong, 2006; McCarthy et al., 2000, 2003), variations that can be related to parents’ social belonging also appear in moral tales and accounts of parenting and parenthood (see e.g. Edwards and Gillies, 2005; McCarthy et al., 2003).

Methods

The origin of this research was a 2001 quantitative study, describing allergy-like condi-tions and healthcare contacts among 230 children (215 parents were interviewed) on exclusion diets at a school in a municipality south of Stockholm. The majority of people living in this municipality are Swedish-born and middle-class.



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In 2002, a sample of 19 parents (18 mothers and 1 father) was selected to participate in more exploratory studies (see also Gunnarsson and Hydén, 2009). From the informa-tion provided in the previous telephone interviews with parents, 19 parents were selected based on a variety of factors related to the children’s allergy problems such as: type, severity, age of onset and number of different allergies. Factors also included parents’ social and educational backgrounds, where in the municipality they lived, age, marital status and number of children. The parents were thus selected in relation to each other, to cover different combinations of children’s problems and parents’ characteristics that pri-marily ‘represented’ the variations in the population of children on an exclusionary diet at school. These variations are, however, also likely to be found among children and their parents in a general population of children with food allergies.

Only the 18 mothers’ interview accounts were analysed for this article, since we knew from our own (Gunnarsson and Hydén, 2009) and other previous studies (e.g. Elvin-Nowak and Thomsson, 2001; Harden, 2005) that mothers are primarily responsi-ble for their children’s well-being and healthcare, and they are the parent who most often takes their children to the doctor. One mother was born in the USA, one in the UK and one in Chile. At the time of the interviews, the mothers’ ages ranged from 33 to 45 years of age, and six were single mothers. All mothers worked full time, with the excep-tion of two who were self-employed in alternative healthcare: one had taken early retirement due to illness and the other was a university student in her last year. All moth-ers had attended upper secondary school, and the majority had taken a two-year social- or care-oriented vocational training course, which at the time did not qualify for higher studies. During the period between 1970 and 1980, when these mothers attended school, approximately 90% of Swedish pupils attended secondary school (see http://www.skep-tron.uu.se/broady/sec/sec-27-inledn.html). Five mothers in this study had university degrees (additionally, one mother was a university student in her final year).

The data collection was made through narrative-oriented, retrospective interviews by the first author at the parents’ homes or workplaces. When the mothers reported what happened in the initial encounters with healthcare professionals, these past experiences and their outcomes were constructed as responses to the initial interview inquiry posed as: ‘Would you tell me how you discovered your child’s hypersensitivities/problems?’ Narrative accounts are generally explanations given in response to such evaluative ques-tions from the interviewer, and the account focus is based on factual information (De Fina, 2009). Most parents were interviewed twice; interviews were tape-recorded verba-tim and lasted between one and two hours for the first interview. The second interview was done mainly to elaborate on the first interview.

The data analysis followed a case-based approach where each interview was recon-structed as a narrative about how parents understand and respond to children’s emerg-ing problems, as well as experiences and outcomes of the healthcare encounter. First, different episodes in the interviews were identified and arranged in chronological order, representing when actions and events occurred in ‘real time’. This made up a storyline of what parents do before seeking help in healthcare. The focus in this study was on the continuing storyline about encounters with healthcare providers and the quest for professional help (Mishler, 1995). Narratives were compared across cases, and a ‘general’ culturally defined pathway in seeking professional medical help was




thus constructed, resulting in two different outcomes. As events and actions making up these pathways were told in retrospect and reconstructed as part of the analysis, the most interesting aspect of this study relating to how mothers accounted for these events and actions emerged.

Second, the analysis traced how mothers ‘act out a story’ (Riessman, 2008). Mothers’ performances of agency (particularly moral agency) were of interest in the interviews. When and how mothers make claims and justify their actions (and them-selves) to the interviewer (Radley and Billig, 1996) were focused on, by observing how mothers constructed their speech linguistically. Discourse devices were used to interpret the meaning of their words. Examples of these were quotations or footings (Goffman, 1981), meaning that mothers made reference to the reported speech of char-acters (healthcare professionals) in their accounts, also known as double voicing. Other language features analysed included the repetition of words, a change in the placement of pronouns and the use of personal pronouns to signal agency (see e.g. Silverstein, 2003), and, occasionally, expressive sounds that were used by some moth-ers to make a point (Riessman, 2008).

In an interview context, the interviewer’s social position may also become impor-tant in how the interviewees’ stories unfold. The mothers knew that I, the first author, was a mother (31 years of age at the time), who was doing the study at a well-known medical university, although they were informed that I was not a medical professional but a social scientist and that I was interested in their everyday experiences. Still, there is the possibility that some of the mothers saw me as a representative of the medical profession (or as an expert in the field of healthcare/medicine), although in the inter-views I felt that they related to me more as a ‘mother’/researcher than as a medical representative.

Findings

The findings in this article are organised by the factual descriptions of what mothers said happened when they sought healthcare assistance for their children’s problems. This had resulted in two different outcomes: either a quick diagnosis, or a more com-plex and drawn-out process with disagreement between healthcare professionals and mothers. The findings in this study focus merely on the latter, as these outcomes had to be explained and made sense of, and had the potential to affect mothers’ moral selves and identity.

The mothers in this study made claims of adequacy of their actions mainly when there was a disagreement about the diagnosis; consequently, this meant that straightforward accounts were devoid of justifications or claims of accountability. The way mothers made moral claims were either by negotiating culpability for their child’s condition in their accounts or by appealing quite strongly to an active mother role. Negotiating culpa-bility means the way that mothers, narratively and retrospectively, negotiate responsibil-ity for and potential blameworthiness of their own and the healthcare providers’ actions in the interview situation, seemingly a way to restore moral agency in relation to health-care. In the active mother role, there is already a narrative incitement for a moral agent in doing the right thing.



Gunnarsson et al. 5

Accounts of disagreements with healthcare professionals’ views and claims of moral agency

Some mothers’ experiences with healthcare professionals seemed to be influenced partly by what had been found in our previous study, that is, the parents had already defined the problems as medical ones (sometimes specifically allergy-related) through different interpretative strategies and self-diagnosing practices before seeking healthcare assis-tance. The mothers, thus, portrayed themselves as seeking medical aid to find out not if something was wrong, but what was wrong.

An example of the disagreements around diagnosis and treatment that arise in encoun-ters with healthcare providers in the stories is the mother (a single parent with a univer-sity degree, aged 45) who suspected her son’s eczema to be the result of an allergy and who enquired about this at the child healthcare centre. In the example below, she presents herself as offering the child healthcare professional her interpretation of her son’s problems, but is told by ‘one of them’, ‘it’s probably nothing’:

He had eczema on his legs, it was really that I noticed, and I asked at the child healthcare centre if, if that could be some allergy, and then one of them said – noooo, no they said, no but he’s gaining weight, and growing so he’s, there’s probably nothing to worry about, it’s probably nothing.

In the two last lines of her account, she mimics the professional’s response with a slight mocking voice and exaggerated tone. I don’t think that repeating the word ‘prob-ably’ and making expressive mocking sounds is done coincidentally, when quoting the professional’s negation of her direct inquiry about allergy. Her tone is used to reinforce the meaning of the words she uses and to tell us something about healthcare. She presents the professional’s response as tentative and uncertain and far from the kind of authorita-tive statement one would expect from an expert. By downplaying the professional’s authoritative position with her linguistic devices, she redresses the power inequalities between herself and the healthcare professionals (Baruch, 1981). The mother also seems to inexplicitly question the professional’s knowledge and privileged position, by using expressive sounds and mimicking the professional without making any direct or verbal ‘accusations’. In her retrospective account, she is not at risk of being discredited by the listener since I already knew and was further told (how) an allergy specialist had in the end confirmed the allergy diagnosis she put forward to the healthcare professional in her account (see Ribbens and Edwards, 1998 on retrospective accounts).

Most mothers, when making explicit or implicit judgements about healthcare provid-ers’ views and actions, do so about healthcare as an institution rather than about single doctors or nurses. Although the mother in the example above seems to have a specific healthcare professional in mind, it is notable that she moves from ‘one of them’ to ‘no they said’ in the quotation. She creates a socially consequential image of what at first seems to be a specific healthcare professional, but which is really a generalised image of the community of medical experts and medical knowledge.

‘Reassuring’ statements about nothing being medically wrong with the child, such as those made in the extract above, can be contrasted with the experiences of two other mothers who instead depicted these as salient judgements on the parents’ competence




and/or on them as a family, which the mothers position themselves as not being able to disregard. One mother (married, secondary school, age 36) described these experiences as also having made her into a different kind of person, someone that she in her later interview says she ‘did not want to be’. Consequently, in the extract below and through-out the interview, she indicates how her experience of healthcare has affected not only her confidence in ‘doctors’ advice’, but also in herself as a person.

Eh, I can say this, that it has changed me completely as a person. I can’t really ever forgive (healthcare), and I’m very uncertain about the doctors’ advice now, eh, it was a terrible time because this is our second child, and we saw clearly that this wasn’t normal.

Her statement here about how this was their second child becomes a way for her to defend and uphold her own, as well as her spouse’s, moral adequacy in the interview situation – that they were capable and experienced parents, who really knew at the time that ‘this wasn’t normal’. The mother creates and indexes a certain identity using per-sonal pronouns specifically to refer to interactions with healthcare professionals (and the effect it had on her as a person). The disappointment in and doubts about doctors’ advice that she expresses are notably made in the present tense, thus pinpointing these experiences/feelings as being a present reality, having persisted over time.

The mother’s discursive strategy may also be interpreted as she enters into a dialogue with the healthcare community by embodying their judgements and by making health-care a subject of her internal conversation. This use of the generalised other in the accounts (Holdsworth and Morgan, 2007) seems to create a way for mothers in her situ-ation to restore their competent parent identity and/or their ‘personal’ self (Frank, 1997). The mother in the above example blamed the professionals (‘I can’t really ever forgive’) for their inadequacies and their failure to listen to her, and the situation for having ‘changed (her) completely as a person’.

Thus, accounting for professionals’ views and the rejection of their explanations were done quite differently by the mothers in these two examples. The latter mother may have had more ‘problematic’ encounters with healthcare providers due to situational factors we do not know about. However, when considering social position in relation to educa-tion, for example, it is the mothers with university degrees that discursively create their experiences, as in the former mother’s account.

In summary, the mother in the first example does not experience the healthcare pro-fession’s rejections of her candid diagnosis as a judgement about her mothering or joint parenting abilities, nor does she depict any doubt in her own self-worth, parenting com-petence or the healthcare professional’s advice in the present. She portrays herself from the outset, and even more fervently so throughout the interview, as being self-sufficient and as having had full control of the situation in finding the correct diagnosis and remedy for her son, mainly on her own. The mother in the second example, in addition to two other mothers, expressed very strong resentment and distrust of the medical profession and could vividly describe, through both her voice and forceful words (often stated in the present tense), initial encounters that had taken place 13 to 16 years ago. It was a similar situation in the example from a mother whose daughter was diagnosed with a milk pro-tein allergy at the age of 18, having had symptoms since the age of 2. The mother ends a



Gunnarsson et al. 7

longer narrative about the healthcare profession’s inability to make a correct diagnosis and the consequences it had on their family life with the following quote: ‘So you, I and the whole family plus (omitted: name of the daughter) feel cheated (by healthcare).’

The negotiation of culpability – managing guilt and blame

Looking at mothers’ stories of their encounters with doctors and other healthcare profes-sionals, it is clear that the mothers strive to uphold a sense of a moral ‘self’ in how they present and portray themselves as competent and responsible parents. At the same time, this means that accounts of possible feelings of guilt (and attribution of blame) from the mothers may also come into play. This was especially true, in this study, when the moth-ers reflected on how doctors or other healthcare professionals did not find anything wrong with their children, often despite several consultations. As such, the mothers then raised questions in their accounts about whether they should have done something differ-ently. The mother in the story below (married, upper secondary school, aged 40) ponders about being more persistent, and whether she should have ‘forced’ the healthcare profes-sion to give her a second opinion. She starts off her account, in response to my question about what symptoms the child had when he was little, as if to justify herself to me, by saying ‘of course, one isn’t stupid’.

IP: Would you, eh, tell me about his symptoms at first, when he was little?

IP: Eh, a very upset stomach, and of course, one isn’t stupid, one has read up on it, it was colic he had, and it was very intense colic, but we fought on, did everything you should, contacted the doctors and were rejected, it was colic, and it would go away and so on, and then you believe the doctor, and I’m not as stubborn as I maybe should have been either, you want to trust the doctors (laugh). But now, of course, afterwards, perhaps we should have persisted and forced them into more, into asking other doctors, but you didn’t do that.

Questions about possible guilt and who is to blame are managed in this mother’s account by negotiating culpability. Her account is both an answer to my question and an internal conversation she has with herself and with the healthcare profession regarding who is to blame for what had happened in the encounter. She starts her account by pass-ing the blame on to the doctors, saying ‘we . . . did everything you should, contacted the doctors and were rejected’, and ends it by pondering on her own blameworthiness. But is it her own or a joint parental blameworthiness she contemplates in her account? As in previous discussions, and also characteristic of these mothers, they refer to a joint paren-tal responsibility and assertive/active parenting (doing the right thing) in their accounts. In fact, in the above extract the mother uses ‘we’ twice and ‘I’ only once. Nevertheless, when she offers an actual explanation for their parental/patient faith in the doctor’s knowledge (‘you believe the doctor’), she switches to a first-person discourse (‘I’m not as stubborn as maybe I should have been’), thus positioning herself as the potentially blameworthy party. She acknowledges that it was she who was not the kind of person that she perhaps should have been and that the situation may have called for.

Interpreted in a structural context, this underpins the gendered aspects of parenting and a woman’s caring responsibilities as tightly intertwined with her self/identity (Miller,




2005, 2007). As it was the mothers who interacted with the doctors and other healthcare professionals, it also follows that it will be the mothers’ competence that is at risk of being thrown into question, and particularly the mothers’ moral self and agency that are potentially threatened when interactions with (child) healthcare experts go awry. Thus, what these mothers do is take on accountability for potentially ‘bad’ and non-assertive (joint) parenting. Nevertheless, there are twists and discursive acts of ‘counter- accountabilities’ in their self-performances that are made to ‘save’ face (moral self) (Goffman, 1967). In light of the responsibility they put on themselves narratively, these counter-narratives become ‘necessary’ in order to be able to claim a moral self and uphold the good mother identity in interactions with others (Liamputtong, 2006; McCarthy et al., 2003).

Examples of these counter-narratives are the reflections of possible guilt in the moth-er’s last sentence, but she also expressly evades feelings of guilt or the ‘blame victim’ position by referring to what they should have done today. She ends her account by refer-ring to an intersubjective world of ‘but you didn’t do that’. By using the word ‘you’ several times, she tells me that her actions are something she depicts as being generally acceptable patient/parent behaviour in contact with healthcare providers, and perhaps something I, as a mother, and other parents would agree with. Putting trust in the doctors is a legitimate action for lay people, which she seems to acknowledge, although she still keeps justifying this action to me.

It seems that this mother is dealing with conflicting embodied views that make her uncertain about the ‘right’ action in this situation. The conflict may very well be between having to present as a socially expected assertive mother (which I may expect of her) and at the same time showing that they had been good patients who trusted and listened to healthcare authorities (Sayer, 2005). Saying ‘I’m not as stubborn as I maybe should have been either, you want to trust the doctors’ with a laugh may also reveal a social position (a deferential attitude), although the mother does what people often do in west-ern individualised cultures: she puts her inability to be assertive down to individual attributes.

However, by actually blaming her inability to be ‘stubborn’, she effectively manages any possible symbolic threats to her identity as a mother. Thinking that her failure to show assertiveness in interactions with healthcare professionals may indicate that she is an irresponsible mother, she directs the ‘blame’ away from her mothering self, placing it instead on an inherent personality trait that she cannot be judged for, thus avoiding a pos-sible threat to her identity as a mother. By presenting her behaviour in terms of being an individual deferential trait that is perhaps less ‘harmful’ for the social self and thus mor-ally risk-free to acknowledge, she resourcefully rescues her mother identity from being affected and judged by her inaction. This may be an example of how a woman manages class-related aspects of morals and values, where the behaviours and demeanours of inactivity in terms of motherhood may be seen as a sign of irresponsible parenting and lack of parenting engagement, although it may very well be a respectable working-class (patient) position (Sayer, 2005).

The mother’s final negotiation, ending her account by defending the appropriateness of her passive deferential actions by using the past tense in saying ‘you didn’t do that’, may also be interpreted as a reference to the healthcare context at this time (in 1989,



Gunnarsson et al. 9

when the active and autonomic patient was at least not as politically and socially endorsed as at the time of the interviews), and thus perhaps as a reference to a different parent and patient reality.

Morality is about doing the right thing (and being a morally good person), but there is seldom a single right thing available in most situations (Frank, 1997). Thus, there is often an uncertainty in mothers’ stories about what was done and what could have been done instead. Mothers’ negotiations back and forth on what was the right thing to do is a way to evaluate and make sense of what being a responsible parent in this situation really entails.

As such, negotiating culpability is a narrative practice that mothers perform as part of showing their moral agency to the interviewer, and in balancing their own and the health-care professional’s culpability. It should not be confused, however, with general negotia-tion (Sandman, 2009), as some mothers do not depict themselves as having been in a position where they felt empowered, independent or in control of their encounter with healthcare professionals.

Appealing to the fulfilment of the active mother role

Another way of presenting how mothers dealt with disagreements about diagnosis was found primarily in stories told by those with higher educational levels, but also by the two mothers who worked as alternative therapists. These accounts did not nor-mally include negotiations of culpability or other apparent blame attributions. They appealed in their accounts to having been successful in fulfilling the active mother’s role in their encounters with healthcare providers. These are accounts of how they challenged professional explanations of their children’s problems or the medical treatments recommended, for example by searching for and finding ways of defining and treating the problems elsewhere, primarily by seeking more specialised medical help on their own.

The appeal to an active role of motherhood can be exemplified by one mother (mar-ried, university degree, aged 45) who described how she sought ideas and help from outside the medical arena. This mother tells how she discovered the cause of her son’s problem: ‘it was thanks to the Internet that I found out that he was allergic and not to the doctors’.

IP: Then it was probably some mailing list or something like that on the parent network that I was looking at and clicking my way through and I found descriptions of children with allergies and then I remembered that they described somewhere a child with sandpaper calves and I thought that it’s exactly like that, very dry skin, and a little irritated sort of and that child had milk protein allergy.

Then (child’s name) was four and a half years old, I think. And then I thought, no, that’s for sure what he has it’s just like that. I called the childcare centre and said, ‘Can I avoid milk for a while, just to see?’.

‘Yes, certainly, you can try that for two weeks.’ And he got much, much better right away. So then I must have looked for a doctor and we could, they agreed then that’s what it was, then we avoided milk and got calcium tablets and such.




Even though the mother argued that it was through her use of the Internet that she succeeded in identifying her son’s problem as an allergy, she did not dissociate herself completely from professional expertise and authority. Instead, she used the professionals for advice, as a ‘sounding board’ for how to act. Her statement ‘so then I must have looked for a doctor’ tells us about her assertive role, which is an active identity that she constructs and performs in the interview, stating, ‘then I must have’, alluding to the fact that she does not fully remember how it ‘really was’ at the time. She explains how she looked for a doctor who could confirm her diagnosis, or, as she says, ‘we could, they agreed then that’s what it was’, suggesting a powerful agent position where she was the one who pursued the actual shared decision-making she refers to (Sandman and Munthe, 2010). She also positioned herself assertively as an expert, equal in a sense to the professionals.

The two mothers working as alternative therapists stretched the active expert position even further, and portrayed their professional knowledge of alternative medicine as ‘above’ that of healthcare and traditional medicine. Positioning themselves as having a superior knowledge of health and illness to that of healthcare professionals, though, is a far riskier business for their identity performance, and more socially questionable. These mothers portrayed themselves throughout their interviews as opposing biomedical val-ues and views in an ideological and explicit way. They also presented justifying accounts in order to defend their actions. One of the mothers explained the difference between her thinking and that of school medicine (in connection with a prescription for cortical balm for eczema) with an illustrative narrative/metaphor:

It is like putting a nail in the head and saying, oh, I have a headache so I think I will take an Alvedon. The nail doesn’t go away just by doing that. The headache may be gone but the nail is still there, it’s a lot with that, one takes the nail away. (pause) Therefore, I don’t want to give the cortison. (pause)

Furthermore, these mothers reported not having to or wanting to consult healthcare professionals again after their initial encounter concerning their children’s allergies. Both these mothers had changed their professions and were at this time self-employed in alternative healthcare and medicine, but they came from different social backgrounds. Throughout the interview, they were extremely aware of their ‘alternative’ views and that their actions went against the norm of behaviour for good mothers. They proceeded with great caution in revealing actions they had taken by means of their own alternative meth-ods to help their children (besides the social aspect, they also stated clearly that it was against the law to treat small children with the kinds of methods they used, mainly homeo-pathic). Their main narrative strategy was therefore different from that of other mothers. They talked about their experiences with healthcare professionals in more general terms and through their professional roles, referring to other patients and their work identity when making controversial statements about healthcare and medical knowledge. In this way, they could protect their moral agency and also uphold their identity as responsible mothers when being judged by others.

One of the mothers had changed her profession to alternative medicine when she was laid off from her previous (blue-collar) job. She states in general terms that she in fact



Gunnarsson et al. 11

‘avoids having contact with doctors’, although she does not attribute blame to the way she was dealt with by the healthcare professionals in her child’s case. The other mother, who had a higher school degree in dentistry but changed her profession to alternative medicine, says that she does not avoid healthcare providers in general (when it comes to broken bones or ‘big things’). She explains her reservations about seeking their help for ailments she can manage herself. Furthermore, she cautiously ends a long statement about her views on school medicine, evaluating her views and justifying her standpoint:

I think that sometimes it can, eh, yes (pause) sometimes, yes, oh, I don’t know, it sounds so stupid – sometimes I know better (says this in an affected way) that’s not really what I mean, but my thinking is a little different.

Because of what she says, namely that she knows better than a doctor, she is aware of how this may be judged by the interviewer (‘it sounds so stupid’) and other potential audiences she may have in mind (Riessman, 2008). Consequently, she defends her think-ing and actions and does this by downplaying the meaning of what she says through the use of several linguistic features such as: repeating ‘sometimes’ three times, hesitating throughout her account, making one long pause, using an affected voice and bluntly inserting the phrases ‘it sounds so stupid’ and ‘that’s not really what I mean’. Knowing that I, the interviewer, work at a medical university may contribute to the apparent way in which she downplays her standpoint, together with the fact that she herself was a highly licensed professional in school medicine.

Being professionals in the field of alternative health and illness, these mothers’ posi-tions of being right and knowing what is best for their children are different from the other active mothers. As professionals in alternative medicine, it is expected that their ideas will go against the biomedical view of health and illness. But in being good moth-ers and patients, they are fully aware that their actions and beliefs may be condemned by others, and they also give several examples of having been judged throughout the inter-view. Their narrative strategies are, thus, aimed precisely and primarily at meeting and dealing with judgements and social sanctioning.

Mothers who appealed to the active mother role hence positioned themselves firmly in the discourse of active mothering. They portrayed themselves as being in control of the situation and as having confidence and competence in having done the right thing and in being right. They were also far less discontent with healthcare in general, although they could sometimes ‘mock’, ignore and be annoyed by expert answers. Their creation of moral agency and moral worth as good mothers is less about defending themselves or their actions and more about portraying themselves as good, competent middle-class mothers who can and do make independent and rational choices in interactions with healthcare professionals.

Discussion

In this study, moral agency consists in trying to show that one has done the right thing and, accordingly, that one is a good, responsible mother. Mothers make claims of moral agency in their accounts particularly when something goes wrong, and mothers disagree




with healthcare professionals about their children’s symptoms being signs of illness. Overall, there were two different kinds of performance of moral agency to be traced in the mothers’ accounts.

For some mothers, healthcare professional representatives are presented as either ‘accomplices in blame’ or occasionally as the main ‘blame character’. Nevertheless, the mothers also ponder and evaluate their own blameworthiness in the process. Especially when interactions with healthcare providers go awry because of disagreements and diagnostic difficulties, the dependent social positions that some mothers account for are potentially more vulnerable in terms of having negative consequences for the mothers’ identities.

In order to act as and show that they are competent and responsible mothers, they seem to have to deal with conflicting socio-cultural scripts of a passive patient and an assertive and competent mother. They particularly defend actions of passiveness in their accounts; this is perhaps because passiveness is not compatible with the kind of maternal assertiveness that is the hallmark of good mothering (Elvin-Nowak and Thomsson, 2001; Hays, 1996; Miller, 2005, 2007). Some mothers thus have to combine different narrative strategies in their work of moral agency, and make seemingly incompatible moral positions appear righteous.

As an example, a mother may refer to being an informed active agent who is fully capable of distinguishing between ‘normal’ and deviant child development, either through knowledge they have gained by experience (‘this was our second child’) or by having ‘read up on it’, thereby presenting as an assertive and active mother who is well-informed about ‘correct’ child-rearing and proper childcare. Because these mothers had experienced the healthcare profession’s rejections as implicit judgements of their moth-ering competence, they have to convince the listener that their views about their chil-dren’s health were already well-informed and rational at the time of the encounters, so as not to risk any further threats (from me or other potential listeners) in the interview situ-ation, when disclaiming these judgements. These mothers’ moral performances are, thus, not merely about defending and sustaining their mothering selves in their accounts, but they may also be about having to reconstruct their moral selves and agency in relation to healthcare. Since the mothers knew that the interviewer came from a medical university and thus may represent the world of healthcare and medicine, claims of moral agency are made in dialogue with a generalised past and a potentially present ‘healthcare other’. In making healthcare a subject of internal conversations, restorations of mothers’ self and moral agency may become possible (Frank, 1997; Holdsworth and Morgan, 2007).

Second, in defending passiveness in relation to healthcare providers, the mothers make statements in contradiction of an active and knowledgeable agent, that is, around a lack of knowledge about healthcare and illness in general. They do this to make it clear to the listener that they had no choice but to rely and depend on healthcare professionals’ expertise. As one mother said, ‘I don’t know anything about healthcare’. Blaming health-care thus becomes a rational and morally acceptable performance when one is fully dependent on healthcare to fulfil childcare responsibilities (Baruch, 1981). As such, the mothers make use of their lay position in restoring their moral agency.

Third, individual attributions that are possibly formed by the mothers’ social position (although the mothers in the findings state themselves to be individual personalities) thus




work to reconstruct their good mother image in the interviews. The strategies people use in presentations of themselves (Goffman, 1967) are designed, according to Bourdieu (1989), not only for demonstrations of self and one’s self-image, but also to ‘manipulate the image of one’s position in social space’ (p. 20). Making their mothering self-images fit the dominant social and cultural constructions of good mothering (Hays, 1996; Miller, 2005), in order to feel like and show others that they have acted adequately, some moth-ers may have to reconstruct themselves narratively to be able to claim a moral self.

Other mothers (especially those with a university degree) accomplish their moral agency mainly by adapting one dominant narrative strategy of presenting themselves as main active agents throughout their accounts. As these mothers are possibly ‘socially’ closer to healthcare professionals (Boulton et al., 1986), they will perhaps have to instead minimise any structural dependence on and inequalities between themselves and the pro-fessionals in their accounts. Due to the fact that they do not construct, at least narratively, conflicting identity work in being either good mothers or good patients, their identity work is seemingly more about authenticating their moral claims in their accounts. These mothers do not have to justify their actions or defend who they are because they so closely identify with dominant discourses of good mothering (Hays, 1996) and ideolo-gies of patient-centred care (Sandman and Munthe, 2010). Such a mother thus claims her moral agency by embodying this narrative position of an autonomous and competent active mother. The identity work is all about presenting a mother image in which the mothers already seem confident and secure, and about showing actions of responsibili-ties that they seem also to presuppose the (any?) listener would agree with.

For those mothers who do not construct themselves as having the resources to take on the active and independent agent role, their moral selves may perhaps be put at risk and affected in relation to professionals, especially when disagreements about diagnosis and remedy arise in the lay–doctor relationship. They may thus be placed in a position of having to conform to, construct or defend an unrealistic image of a good mother in inter-action with the healthcare profession to be able to claim moral agency.

As all the mothers were in a more powerful agent position at the time of the inter-views, knowing that the professionals had been wrong about their child’s symptoms ‘being nothing’, this may mean that their performances of self and agency became more differentiated. Retrospection in accounts and narratives may perhaps work to especially differentiate the social positions in mothers’ claims of responsible, ‘good’ parenting.

In conclusion, the mothers in this study seem not to be foremost concerned with being given more responsibility for their children’s illness and care in healthcare settings and in interactions with healthcare professionals. In fact, mothers ‘merely’ want to be respected and taken seriously in encounters with childcare experts.

Ideological assumptions and expectations of freedom to choose will increase parents’ responsibility to conform to positions of independence and assertive parenting (Michailakis and Schirmer, 2010). Nevertheless, healthcare encounters will always be more or less constrained by power relationships and other social structures that most lay people would not be able to influence and control (Henwood et al., 2003; Lupton, 1997). Moreover, promotion of patient involvement in care would likely lead to more disagree-ment between lay people and professionals. Perhaps this means that it is of less signifi-cance for patients what model of patient care and healthcare interaction is promoted.




Regardless of the model for patient care, healthcare interactions are a powerful social context wherein individuals’ moral self and agency may be at stake, and in which social positioning takes place and is managed. Lay–professional relationships will, therefore, play a central role for all persons and agencies, but perhaps especially for mothers whose self and identity are usually more closely intertwined with their parenthood and their children’s well-being (McCarthy et al., 2000, 2003).

Funding

This study was funded by grants from Anna and Edwin Berger’s Foundation and the Kempe-Carlgrenska Fund. The grant holder was the first author, who would like to express thanks for this financial support.

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Author biographies

Nina V Gunnarsson received her PhD in humanistic medicine (medical sociology) from Karolinska Institutet, Sweden. Her research interest is in narrative accounts and moral presentations of self and agency. She currently works as an associate senior lecturer in social work at the school of Health Sciences, Jönköping University, Sweden.

Helena Hemmingsson PhD is a professor in Occupational Therapy at the Department of Social and Welfare Studies: Division of Health, Activity and Care, Linköping University, Sweden. Her research and professorship focuses on disability in everyday life, particularly concerning children, teenagers and young adults with disabilities and the opportunities and obstacles they experience at school and in transitions to working life.

Lars-Christer Hydén received his PhD in psychology from Stockholm University. He is currently a full-time professor of Social Psychology in the Department of Medical and Health Sciences, Linköping University, Sweden, and director of the Centre for Dementia Research (CEDER). His research primarily concerns the use of language and narrative, especially in the area of health, ill-ness and disability. He has published extensively in international journals and edited a number of books on narrative research.



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