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31 Health Disparity and Structural Violence- Page-Reeves, et al.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
“There is a powerful, enervating anxiety created by the limits of our control over our small worlds and even over our inner selves. This is the existential fear that wakes us at 3 a.m. with night sweats and a dreaded inner voice that has us gnawing our lip, because of the threats to what matters most to
Organizations are commonly thought of as physical structures, organizational charts, financial assets, and so on.
However, these are outward expressions of a deeper reality.
An organization is, at its most basic level, a continuous dialogue between its employees, leaders, customers, suppliers, neighbors, regulators, and observers—indeed, everybody who comes into contact with it in any capacity.
The discussion focuses on who the organization is, what it does, and how it goes about doing it.
Changes in the organization’s more concrete qualities, such as structures, programs, and budgets, occur as the debate evolves.
Organizational interactions have a vocabulary that includes not only words but also symbols and gestures (meanings implied in behavior); for example,
the conversational procedure (who gets to speak in what way to whom)
the distribution of time and resources, and
the distribution of benefits and perks
Individual participants’ thoughts, feelings, and behaviors are both contained in and shaped by organizational discussions.
Individuals’ brains are routinely integrated into organizational concepts and values—often without their explicit awareness or conscious decision.
To some extent, this is accomplished through modeling and reinforcement, but there is also a more subtle, yet powerful, dynamic at work: organizations deliberately direct our attention toward certain phenomena while ignoring others.
This influences our perceptions, which in turn influence our interpretations, expectations, and conduct.
They influence how others react to us, which in turn influences our views, and so on.
Much of what we consider to be reality is created by this self-reinforcing circularity.3
Although well-being is difficult to describe since it is based on each person’s developing matrix of experiences, values, and meaning, we can gain a feel of it by combining three different techniques.
Individuals have three primary psychological needs, according to self-determination theory: competence, autonomy, and relatedness.
1 These are related to Abraham Maslow’s hierarchy of needs, which includes self-actualization, esteem, “belongingness,” and love.
The highest stages of human growth, according to Erickson, are “generativity” and “ego integrity”—a sense that one’s life has been valuable as a result of constructive effort and contribution to something larger than oneself.
The desire for real selfhood, as manifested in one’s vocation, is described by Parker Palmer as follows:
I must first listen to my life tell me who I am before I can tell it what I want to do with it.
I must search for the truth and values that are at the core of my own identity, not the standards by which I must live, but the standards by which I cannot help but live if I am living my own life.
We can define well-being as a quality that goes beyond physical and physiologic integrity and reflects the degree to which one is and becomes oneself fully and authentically, experiences connection with others and the world, and finds meaning in one’s life and work when these perspectives are combined.
These characteristics are similar to those linked to physician satisfaction and meaning.
We’re now ready to think about how health-care institutions influence people’s well-being.
Given the definitions above, we might ask: How do organizational discussions in health care affect the ability of people who work there to express themselves, grow, connect with others, and contribute meaningfully?
OBJECTIVITY AND DEPERSONALIZATION OBJECTIVITY AND DEPERSONALIZATION OBJECTIVITY AND DEPERSONALIZATION
In health care, organizational conversations favor factual statistics above subjective, personal experience.
Meeting agendas and protocols, the kind of data used in organizational decision-making, and the kinds of comments made — and not made — in official organizational activities all reflect and perpetuate this.
Self-disclosure and other personal utterances are uncommon; most discourse focuses on external, impersonal events.
This is especially true of the debate that the two most influential groups—physicians and administrators—have contributed.
Individuals’ experiences are partitioned by a lack of constant attention to personal, subjective experience—their rational cognitive thinking is prioritized, while their feelings and intuitions are marginalized—preventing them from expressing and developing their whole selves.
Individuals find it challenging to feel fully seen and understood when their subjective experience is muted as a result of depersonalization and objectification.
There is a greater sense of isolation, and there are less opportunities for true interaction.
GO TO THE CONTROL QUESTION
Consistent with broader themes in western culture, organizational conversations in health care accord the highest value to being in control—of disease and clinical outcomes, and of the organization and its members.
The machine metaphor is the most common metaphor for conceptualizing organizations, with senior managers and physicians acting as designers and operators, and the rest of the organization—including patients and families—acting as precision parts, expected to perform their functions consistently, efficiently, and in a standardized manner according to the managers’ design.11
The emphasis on control has a negative impact on everyone’s well-being.
The dynamic of control produces unreasonable expectations for individuals in positions of power (especially physicians and senior managers)—accepting responsibility for outcomes that are beyond anyone’s control.
Individuals who are expected to be in charge by themselves and others but are aware that they are not are faced with feelings of inadequacy and the dread of humiliation.
Asking for assistance and emotional support would make you appear weak and incapable, so it’s not an option.
There are two popular responses instead.
First, people try to retain the illusion of control, which prevents them from being real, increases interpersonal distance, and exacerbates the dread of being discovered—the “imposter syndrome.”
12 Second, they strive even more to assert control over others, straining relationships and raising anxiety levels across the company.
The illusion of control and invulnerability also produces tremendous social encouragement for clearly harmful habits, such as a lack of life balance, neglect of family, and insufficient attention to rest, food, and exercise.
Those in less powerful positions have issues as a result of the control dynamic.
As people are treated like machine parts—told what to do and expected to fit into standardized roles—they begin to internalize a self-image of helplessness, passivity, and relative incompetence. This has been associated with poor self-esteem, low motivation, depression, substance abuse, and disturbances in family dynamics. 1,13
VISIT THE “PATHOLOGIZING” GALLERY
A third aspect of organizational conversations in health care is their tendency to “pathologize”—to view the world in terms of problems and deficiencies. In both clinical and administrative activity, little attention is given to what is working well. Most attention is directed toward what is wrong, and to the process of judgment itself. The identification of problems provokes a search for causes and the assignment of blame, which then elicits defensiveness and fear. The need for safety is more basic than the needs for belonging, competence, and authenticity, so individuals pull back and become less than they could be.
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