(HEA1c) Sociology of Medicine, Health, and Illness III: Expert, health professionals, and access to care

This session focuses on the theoretical, methodological, and empirical issues pertaining to the sociology of health and health care. Papers explore health inequities, individuals’ experiences of illness and/or interactions with health care services, intersections between work and health, health care professions, and organization of the health care system. Tags: Égalité et Inégalité, Politique, Santé et soin

Organizers: Elena Neiterman, University of Waterloo, Michael Halpin, Dalhousie University; Chair: Claudia Chaufan, York University

Presentations

Michael Slinger, University of Ottawa

The Many Faces of Mental Health: How Practitioners Enact Mental Health in Psychotherapy

In this paper, I explore how practitioners of psychotherapy enact or “do mental health”. I take a social constructionist approach to mental health and mental illness, seeking to understand how practitioners construct conceptualizations of “mental health” through the practice of psychotherapy. Despite psychotherapy’s growing popularity in recent decades, practitioners’ enactments of mental health remain poorly understood in both sociology and the clinical literature. While “mental illness” is defined through a combination of the Diagnostic and Statistical Manual (DSM-5-TR) and clinical training manuals, the concept of “mental health” is not articulated nor critically examined. Traditionally, the elimination of illness and disease was seen as the central goal of medicine, with many theorists—including Talcott Parsons, Erich Fromm, and Georges Canguilhem—arguing that “health” is primarily understood as an absence of symptoms. Several sociologists—notably Adele Clarke, Peter Conrad, and Nikolas Rose—have since challenged this view. These scholars argue that understandings of “health” have changed from the mid-1980s onwards, with patients, health care professionals, and governments increasingly orienting towards the optimization of well-being, evoked through concepts such as “flourishing” and being “better than well”. My paper builds on these theoretical frameworks, uncovering how practitioners enact “mental health” in their everyday work to examine whether psychotherapy conforms to the optimization trend observed in other areas of medicine. Using a grounded theory approach, I conducted 15 semi-structured interviews with two groups of practitioners in Ontario: clinical psychologists—who have completed a graduate program culminating in a PhD dissertation and year-long clinical internship—and MD psychotherapists—who have complete medical school, residency, and a year-long fellowship in medical psychotherapy. My investigation focused on how these practitioners attempt to produce changes in the patient’s condition—i.e., interventions—and evaluate when change has been successfully achieved—i.e., setting and monitoring goals. I argue that practitioners do not have a single, rigid enactment of mental health. Rather, practitioners flexibly enact four models of health—restoration, enhancement, management, and stabilization—with different patients at different points in therapy. Through restoration , practitioners aim to eliminate the patient’s symptoms and return them to “normal”. Practitioners alternatively define “normal” in reference to conformity to broader normative social roles or the patient’s personal values and sense of self, thus actively encouraging deviance or acting as agents of social control depending on the situation. Through enhancement , practitioners aim to improve patient well-being, often by attempting to enhance the patient’s social skills, mood, or sense of meaning. Through management , practitioners aim to maintain the gains made in therapy, teaching patients how to “become their own therapist” so they can stay healthy. Practitioners add a temporal dimension to health, encouraging extended self-surveillance to “treat” the patient’s susceptibility to imagined future symptoms and possible recurrences of mental illness. Finally, through stabilization , practitioners aim to prevent the patient from getting even worse, focusing on “stopping the bleeding”. Health is again seen as precarious, with practitioners seeking to reduce the patient’s potential for future dysfunction. However, the patient is still noticeably dysfunctional rather than “restored”, with practitioners considering that dysfunctional state a therapeutic success. In sum, enactments of mental health in psychotherapy are complex and context specific. Themes of enhancement and optimization do appear in psychotherapy, however, these practices are not recent additions but largely continuations of 1950s humanistic psychology. Furthermore, practitioners are often critical of optimization-oriented practices, preferentially enacting and endorsing other understandings of “mental health”. I propose that practitioners of psychotherapy are best thought of as possessing ambivalent attitudes towards the different enactments, alternatively endorsing and criticizing each approach depending on the patient and situation at hand.

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The paper associated with this presentation has received the Sociology of Health Research Cluster's 2024 Best Student Paper Award.

Ukeme Eka, Memorial University

Factors associated with the use of dental care among African immigrants in St. John's, Newfoundland and Labrador

Research has indicated that regular access to and utilization of dental care services are crucial to preventing and managing oral diseases (Mehra et al., 2019). For instance, regular utilization of dental care services has been found to improve mental and social well-being (Kisely, 2016; Zucoloto et al., 2016), while lack of use has been linked to several chronic diseases, such as diabetes, chronic lung disease, cardiovascular disease, and cancer (Linden et al., 2013). Werneck and colleagues found that the lack of publicly funded dental care insurance for adult Canadians contributed to the high prevalence of dental disease among immigrants (Werneck et al., 2008). Access to and using dental health care services is essential for optimal population well-being. There is a paucity of research on immigrants, but previous studies have indicated that Canadian immigrants have poorer oral health status than their Canadian-born counterparts (Calvasina et al., 2014; Mehra et al., 2019; Newbold and Patel, 2006). In particular, limited research exist on the dental care use of African immigrants in Canada. In this study, we use the Immigrant Health Services Utilization framework by Yang and Hwang (2016) to explore factors that facilitate or impede African immigrants use of dental health services in St. Johns, NL. To address the objectives of the study, data were collected between June and December 2020 from a cross-section of 272 African immigrants on their dental health access and usage. Complementary log–log regression models were used to examine factors influencing immigrants decision to seek dental health services considering Yang and Hwangs framework. Overall, 43.8% of African immigrants self-reported that they used dental health services in the past 12 months preceding the survey, while 35.7% indicated they had not used dental health services. Our findings demonstrated that socioeconomic variables are strongly associated with dental health services utilization. For instance, respondents’ personal income emerged as the most powerful determinant of dental care use. Immigrants who earned $55,000 and above were about 2 times more likely to use dental health services than those with incomes below this amount. These findings highlight socio-economic barriers to using dental care in NL among African immigrants and question the rationale for private insurance given its negative impact on dental health outcomes.

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Non-presenting author: Eric Tenkorang, Memorial University

Monica Gagnon, University of Toronto

"They would never do it to parents who were not racialized and were not immigrants": Denial of newborn health coverage registration as a bordering practice

Recent Canadian immigration policy has led to an increase in the number of people living in Canada with precarious immigration status, who are disproportionately racialized as non-White, often lack health insurance, and experience discrimination in health care settings. In Ontario, health policy requires that coverage be provided to newborns even if the parents are not covered under the Ontario Health Insurance Plan (OHIP). A parent does not need to have an authorized immigration status in Canada for the baby to be eligible for OHIP as long as their primary place of residence is Ontario. Problematically, despite the fact that newborn citizen residents of the province are immediately eligible for health coverage, this policy is not consistently upheld in Ontario birthing hospitals. I used the concept of bordering to examine how people deemed outsiders to Canada are socially excluded within this health care context. Bordering practices filter people according to who is perceived to belong or not to belong, determining who is included or excluded, who is entitled or unentitled, and who is deserving or undeserving. I analyzed health policy documents and conducted interviews with health care providers, administrators, and researchers about processes of, and negotiations around, denial of OHIP registration. I found that newborns who meet OHIP eligibility requirements may be denied registration in Ontario hospitals due to gaps in provincial policy, restrictive institutional policies, or assessments of deservingness by frontline staff that are based on the parents’ immigration or insurance status. When a parent is without OHIP coverage, questions are raised about their child’s entitlement to OHIP. Hospital OHIP denials make it harder for a newborn to get health care, and some may end up going without coverage indefinitely. I theorize denial of OHIP registration to babies born in Ontario hospitals, and policies that allow for inconsistent application within and across hospitals, as bordering practices that allow gatekeepers to control access to membership and citizenship, differentiating between “us” and “them.” I show how bordering in Ontario health care happens at both the policy and administrative levels and I identify four mechanisms for how it is practiced at each level: omission, devolution, obfuscation, and intimidation. These mechanisms are sometimes practiced independently and sometimes overlap. In omission, the issue is not addressed, or no directive is provided. In devolution, power over decision-making is pushed to lower levels. In obfuscation, the policy is not clearly communicated or the source of the discrimination is obscured. In intimidation, a culture of fear is created, discouraging questioning or resistance. The negative effects of bordering practices in health care are evident in lack of health coverage for eligible newborns, arbitrary barriers to care, undue strain on uninsured parents and their advocates, discrimination and racial profiling in the health care system, stymied advocacy efforts, and the creation of tiers of citizenship. Ultimately, my research argues that unjust denial of access to health coverage threatens the realization of the right to health, marginalizing people deemed to be outsiders. In the context of increasing immigration to Canada, ensuring that the right to health of immigrants with precarious status is not undermined is of utmost importance.