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Reinventing
Therapeutic Expectations
in Silicon Valley
Dr. Jan English-Lueck
Professor San Jose State University
Research Affiliate, Institute for the Future |
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I
am Dr. Jan English-Lueck, Professor San José State University and
Research Affiliate, Institute for the Future. I am revisiting a topic
that I began at the beginning of my career as a doctoral student at UC
Santa Barbara, which examined medical epistemologies—how people
think about health, their models of well-being and illness, and their
understandings of appropriate therapeutic action. |
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New Age
Long, Long Ago (in the 80s) |
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Syncretism between
naturalistic traditions
(within a coherent
set of assumptions)
• energy,
not physicality
• balance
• use
and interaction of elements
• being
as a whole system |
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In the early 1980s I conducted long-term participant-observation among
holistic healers, going to workshops, and going through a practitioner
training program. I collected life histories of experienced and novice
practitioners and applied a new methodology, ethnographic futures research,
eliciting scenarios of the plausible best, worst and most probable futures
of alternative healing. The focus was on the practitioners and their work.
I was particularly intrigued by their creative syncretism between naturalistic
traditions from Ayurvedic, Chinese and Hippocratic/Unani traditions—blended
with humanistic psychology and various spiritual ideas, particularly from
the new religious traditions of the 19th century. Underlying the apparent
fragmentation was a cohesive worldview based on common assumptions. What
mattered was energy, not physicality, restoring balance, thinking about
the interaction of elements, whether drawn from the Chinese or ancient
Greek traditions, and treating the person as a integral whole system,
being synthetic not analytic. |
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| Silicon
Valley Cultures
Project (1992-2007) |
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• Health as tool
• Self as project |
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I took a long detour in my own research into the anthropology of work
and technology, and developed, along with my colleagues Chuck Darrah and
James M. Freeman, a 15 year project broadly looking at the cultures of Silicon
Valley. Part of everyday life here is, of course, issues of health. It was
striking that the logic of everyday life, highly instrumental and pragmatic,
often includes many features of the new age worldview I had documented among
the holistic healers. Indeed, during the more halcyon days of affluence,
we noted that the personal assistants and lifestyle coaches of the industrial
elite were former holistic health practitioners. In this context, health
was seen as a tool for productivity, being healthy meant being productive.
Indeed, writ large, beyond the high-tech workers themselves, life was discussed
as if it were a project and working on self—ones
education, ones skills, ones network, included working on ones self—making
a healthier self, or at least mitigating the detrimental effects of workaholism. |
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| Fast
Forward to 2003 |
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Institute for the Future,
Health Horizons
(Research for corporate
and non-
profit clients in the health
sector)
• Personal
Health Ecologies
of “consumers”
(Rod Falcon,
Leah Spaulding from
IFTF, Jan
English-Lueck, Erika
Jackson and
Leah Cook from SJSU) |
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I had long collaborated with the Institute for the Future,
a non-profit think tank located in Menlo Park near Stanford University on
emerging patterns of work, technology, innovation. They had long housed
a Health Horizons program (doing research and forecasting for corporate
and non-profit clients in the health sector, ranging from pharma companies
to HMOs). Much of their work had been quantitatively and economic in focus.
Then in 2002, they began to take a more anthropological approach, looking
at the experiences, relationships and choices of “consumers,”
people who are defining health and seeking strategies for managing their
own health. Having been sensitized to the role of networks as information
agents, they began to think about individuals’ Personal Health Ecologies.
In the second year of this study Rod Falcon, and Leah Spaulding brought
me on board along with two SJSU student interns, Erika Jackson and Leah
Cook. This work is continuing in 2004 with a focus on adult onset diabetes
and coronary artery disease. |
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| The
“Findings” |
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Identified ranges of
strategies
(ranging
from “mainstreamers”
to “integrators” and “holistics”)
• Identified use of networks
• Identified choices
(consequences and costs of
“empowerment”)
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That Personal Health Ecologies project focused on exploring
how people managed information and relationships in their personal health
ecologies, especially in the lives of people managing chronic illness, involved
developing an ethnographic interview and observation protocol. We sampled
25 people, ranging in age, culture and health status. In addition, the Institute
conducted an online survey of 1000 adults representatively sampled nationwide—knowing
that would bias the survey toward the computer literate, but also understanding
that such computer literacy was integral to the phenomena of being an “engaged
health consumer.” In the qualitative portion of the project we collected
health histories, all placed in the context of other life events, even projected
the trajectory of their lives into the future. We asked people to take us
on tours of their household, so we could discuss and document spaces, artifacts
and activities related to health. We also collected network maps, trying
to establish the roles of people, organizations, websites, even pets, in
shaping health definitions, choices and actions. The Institute was able
to take the data, both qualitative and quantitative and identified a number
of strategies people employed based on their access to resources and their
fundamental health beliefs. We were able to identify how networks were used
and how people managed the onslaught of information relating to health,
often couched as empowerment but experienced as overwhelm. |
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| The
Anthropological Insight |
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• A shift in the “rules
of engagement”
• From
adherence to agency
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The clients, again ranging from insurance companies to hospitals,
were stunned by seeing a point of view that they rarely had gotten from
other researchers. We were able to communicated that there had been A shift
in the “rules of engagement” so that, from the consumer/patient/
person’s point of view, the issue was less a matter of adherence (complying
to the orders of the health professionals) to one of agency, taking control
of a broad series of activities that they, not the health establishment,
defined as healthy. |
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| Talcott Parsons
Revisited |
| Old rules of
engagement
(Still seen as valid descriptor from within health care institutions) |
Click image to enlarge |
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Although this model has faded from the academic scene in
anthropology and sociology as being entirely too normative to be useful,
especially in a health-care universe characterized by lack of access and
chronic disease, it is still very much the way health industry professionals
view the therapeutic process—symptoms, diagnosis,
treatment and management, with the locus of knowledge and trust clearly
with the practitioners, so that adherence, once called compliance is the
primary duty of the patient. Individual agency in defining health, understanding
illness, determining treatment and management are severely constrained.
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| New
Rules of Engagement |
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Increased
complexity
• Shift in locus
of trust
• Increased
modularity |
Click image to enlarge |
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This graphic represents the rules of engagement as viewed
from the users. It is far more complex, involving multiple complementary,
contradictory or even competing understanding of health and illness. What
causes disease may be contested. Multiple sources of information need to
be found, and integrated. Diverse people and organizations take information
and see if it can be negotiated into the person’s models and practices.
These entities, who may include practitioners, but may also peers, brands,
websites, and organizations become the locus of trust and knowledge. The
process is very much more complex than the streamlined normative model of
the past. A striking feature of this process is that the information is
fragmented, existing in modules, packets of information, that move, are
transformed and reintegrated into a customized understanding. Herein lies
an interesting point in cognitive anthropology. |
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• “breaks
complex wholes into
elementary units
that are under-
stood
to be recombinable into
a
variety of different patterns.”
Bradd
Shore, 1996,
Culture in Mind
• “Chunking
and Recombining.
A common strategy is to take
longer sequences of activities
and decompose them into
smaller chunks...”
C. N. Darrah, J.
A. English-Lueck,
and J. M. Freeman,
2000 “Living in
the Eye of the
Storm: Controlling the
Maelstrom in Silicon
Valley”
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Modularity, as a cognitive style, has been noted as a feature
of American information processes. Rather than see uniqueness, or synthetic
wholes, the cognitive approach is to break a process into diverse bits and
reassemble them—this style is integral to mass
production, and the concomitant value of efficiency. Bradd Shore noted this
in the mid-nineties, using evolving American furniture styles as an example,
as did the Silicon Valley Cultures Project team in their study of work and
family life. We can chunk work spaces, family tasks, and whole educational
processes. American have created a University system based on ticking off
interchangeable courses, rather than the rapidly fading British system based
on mastery of whole bodies of knowledge. In a similar way, health can be
broken into diverse symptomatic bits, chunks of diagnosis and treatment
modules. Once this cognitive modularization occurs, it can be recombined
in ways that practitioners, who have been enculturated into a common set
of epistemological assumptions, could never have anticipated. |
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| Chunking
of Diagnostic, Therapeutic and
Management Processes |
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Debbie Miller
Complex Personal Health
Ecosystem
• Combines:
• Chinese medicines,
• homeopathic remedies
and
pharmaceuticals,
• even non-formulary
medicines
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I am going to focus on one particular case, given the constrain
of time, to illustrate this process of health chunking. Debbie’s health
world is complex. She manages her own health, and those of her adult sons,
her second husband and her cat. Her health network is an amalgam of past
and current work-related friends, family, HMO professionals, and complementary
alternative medical practitioners that she met through a women’s spirituality
network. She manages her own chronic conditions including ADD with depression,
extreme chemical sensitivity, migraines, menopause, chronic fatigue. She
typically takes her diagnoses, obtained from physicians at the HMO, and
aggressively vets diagnoses and treatments through her naturopath. She uses
the Internet competently to piece together information and deals for herself,
her family and her aging parents. |
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• depression, extreme chemical
sensitivity, migraines, menopause,
chronic fatigue
• Obtains diagnoses at HMO
• Vets diagnoses and treatments
through naturopath
• Web
literate
• Roots
in women’s spirituality
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She maintains files on each health transaction, organizing
records, pharmaceutical information and noting consequences, maximizing
her physical and spiritual well-being to the best of her ability. Her medica
materia is drawn from diverse traditions—Chinese,
homeopathic and pharmaceutical. She is adept at pushing her HMO into proscribing
non-formulary medicines, which she views as more predictable and higher
quality than generic medicines. A reaction to a medicine, increased fatigue
or loss of sexual desire, will trigger a new effort to obtain a diagnosis—perhaps
decreased testosterone levels—that can then
go through the process of evaluation by Kim, her naturopath, and treatments
from diverse traditions. Debbie has increased her level of control, her
agency, by using her networks to provide a wider universe of information
drawn from different medical epistemologies. She can then recombine the
treatments from one tradition, spirituality or Chinese herbalism, with the
conventional diagnosis from her HMO. She has found a way to chunk and recombine
each aspect of the therapeutic process. |
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| Implication |
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Consider investigating how the
cognitive concept of modularity
changes therapeutic expectations
• As a function
of increased pluralism
• As
source of patient agency |
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Such instrumentality among health care consumers has long
been noted in the way indigenous health care is combined with “Western”
medicine opportunistically, especially in Asian medical pluralism. Yet,
it is a new frontier for applied anthropologists working with the medical
industrial establishment. In urban arenas, even ones considerably far removed
from alternative lifestyles, the proliferation of culturally different medical
choices abounds. Increased demographic pluralism and the Internet make the
health market more global. Feng shui may be part of the urban planning process
in the Bay Area, that comes as no surprise. However, when midwestern Safeway’s
stock herbs and remedies, then OTC alternative medicine is not so exotic.
Given this environment, the medical establishment is now alert to the possible
reinvention of therapeutic expectations. It is our job to help them understand
the phenonena. |
Karl
Lueck Designs. . . karl.lueck@att.net.