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Conceptualising body work in health and social care
Julia Twigg, Carol Wolkowitz, Rachel Lara Cohen and Sarah Nettleton
Introduction
Body work is work that focuses directly on the bodies of others: assessing, diagnosing, handling, treating, manipulating, and monitoring bodies, that thus become the object of the workerâs labour. It is a component part of a wide range of occupations. It is a central part of healthcare, through the work of doctors, nurses, dentists, hygienists, paramedics and physiotherapists. It is a fundamental part of social care, particularly for older people in the form of personal care and the work of care assistants (Twigg 2000a). Body work is also a central theme in alternative medicine (Sointu 2006). It is at the heart of the body pleasing, body pampering trades such as hairdressing, beauty work, massage, and tattooing (Black 2004, Sweetman 1999), and it extends to other, more stigmatised occupations, such as sex workers (Sanders 2004, Brents et al. 2010) and undertakers (Howarth 1996). The contexts within which these practitioners operate, the knowledge systems they draw on, and the status hierarchies in which they are embedded, vary greatly; however, as we have argued elsewhere (Twigg 2000b, 2006, Wolkowitz 2002, 2006), there are certain commonalities that can be traced across these contexts that make the concept of body work sociologically useful.
This book explores the relevance of the concept of body work for the field of health and social care. The Call for Abstracts followed from a research seminar series organised by the authors in 2007â9 entitled âBody Work: Critical Issues, Future Agendasâ funded by the UK Economic and Social Research Council. The seminars were not confined to the field of health and social care, but brought together social scientists interested in exploring the social relations of body work across a range of occupations that focus on the human body, many of which are far from the conventional areas of health or social care. The series demonstrated how a concept of body work is useful for exploring commonalities and differences in workersâ dilemmas and strategies in what are otherwise widely disparate occupations, in ways that highlight, rather than ignore, the particularities of their work. The concept also provided a vehicle for the collaboration of researchers associated with different specialisms, not only those concerned with health and social care, but also scholars of work and employment, gender, ethnicity and migration, and social policy and sociology. The crossovers and commonalities between these fields were among the most fruitful aspects of the seminars. It is very much in the spirit of these wider collaborations that we approach this book on body work in health and social care. Indeed, one of the gains of the concept for health and social care is its capacity to link these subjects with wider social structures and discourses.
This introduction to the book seeks to elaborate the concept of body work and to specify some of the gains from adopting it as a focus in health and social care. We begin by highlighting the boundaries and intersections between our conceptualisation of body work and that of parallel and different usages, particularly in relation to emotion, work and the body. We argue that one of the benefits of our definition is to foreground the constraints care of the body must deal with, especially as regards the use of time and space. We suggest that by acknowledging the particular character of body work, we are better able to understand the micro-political relations between practitioners and patients and clients, how difficult these are to alter, and how these are shaped by the wider social and economic context. We are arguing, therefore, that the concept not only makes visible aspects of health and social care too often neglected, but also highlights critical dimensions on which comparative research is needed.
Body work, as we have noted, involves direct, hands-on activities, handling, assessing and manipulating bodies. It is often ambivalent work that may violate the norms of the management of the body, particularly in terms of touch, smell or sight. It is sometimes a form of dirty work in both the literal and sociological senses (Emerson and Pollner 1976) as workers have to negotiate the boundaries of the body and deal with âmatter out of placeâ (Douglas 1966). Body work also lies on the borders of the erotic, its interventions paralleling and mimicking those of sexuality; and this further reinforces its ambiguous character. It is gendered work, differentially performed by men and women (Widding Isaksen 2002a). It is practised on both an object and a subject and, as such, involves both a knowledge of the materiality of the body and an awareness of the personhood that is present in that body. It can be linked to pleasure and emotional rapport as well as to abuse and discipline. It is ambivalently positioned in relation to power, caught in dynamics that can tip either way, presenting the worker as either a demeaned body servant or an exerciser of Foucauldian biopower. It can treat the body as a unity, or in terms of discrete body parts, and this has implications for how it is organised and experienced. Whether the work takes place on bodily surfaces, or penetrates the body, whether it involves inflicting pain or producing pleasure, whether it deals with the head or the ânether regionsâ, or appendages rather than the torso may all have implications for the social relations of body work. Body work therefore invokes ontological questions in terms of how the human body is read or known, and how it may be handled, transformed and understood.
Boundaries and Intersections
The relations between the body and work have increasingly been the focus of sociological interest (Wolkowitz 2006, Shilling 2005, Gimlin 2007, McDowell 2009). As a result, the term body work has been used in wide and varying ways. It is helpful therefore to clarify what we are and are not including under the terminology, and how our concept of body work relates to other, parallel, conceptualisations. In order to identify a distinct set of social relations, we define âbody workâ relatively narrowly. For us, body work involves work that focuses directly on the bodies of others, who thereby become the object of the workerâs labour. For reasons of analytic clarity we omit certain areas. Thus work undertaken by individuals on their own bodies, though interesting and increasingly significant, is not included. We omit debates around the self-disciplining of the body as part of the Foucauldian technologies of the self (Foucault 1997), as a requirement for work (Witz et al. 2003) or as a project in High Modernity (Shilling 1993), particularly in relation to norms of appearance and control (Bordo 1993, Gimlin 2002, Davis 1995), though we are, of course, interested in the body work of those who are employed to help others meet those expectations, or whose work practices on their own bodies, as Wainwrightâs chapter in this book shows, are related to their work on othersâ bodies. We also lay aside the current focus within public health on the requirement for citizens to promote their own health through regimes of bodily activity and control. Again this represents a form of working on the self, not othersâ bodies. We also exclude the work-transfer occurring in health systems whereby patients take on technology-related activities on their bodies previously performed by staff.
We are also excluding from our concept âworkâ that takes place outside the employment nexus, typically in informal, family-based relationships, such as child care or care for frail or elderly relatives, though such activity frequently involves work on the body. Some theorists of care (Ungerson 1997) have argued for the importance of treating it as a unified sector across the public/private divide. Others (Lee Treweek 1996, Twigg 2000a), however, have argued that the distinctive nature of the social relations in which informal care is embedded, and its uncommodified character, mean that it is better analysed apart. For similar reasons we only include voluntary sector body work if organised in ways that mimic paid work. In practice body work tends to be bifurcated in its provision, located either in the informal, family sector or in paid employment. Body work as part of volunteering is an unstable category: too intimate for passing friendship, lacking either the neutrality of paid work or the intimacy and compulsory quality of family relations.
We also exclude work on fragmented bodies and parts of bodies, such as tissue samples or bodily organs. Our focus is on bodies that are whole, and recognisably so. Because of our interest in intersubjectivity, we concentrate on bodies that are alive and, typically, awake to some degree; but we do not exclude work on the dead body, and would include tasks such as laying out the body on the ward, or the work of undertakers in managing and presenting the deceased. In both cases, though the body is dead, the social person is still present in the corpse.
The boundaries of body work are inevitably fluid, and we may on occasion want to work across these boundaries in order to find out when and why they are established and breached in practice. For instance, Rapp (1999) found that when laboratory technicians examining fetal cells found an adverse result they related the sample back to the woman from whom it was taken. We should also note new technologies that enable body work to be conducted âat a distanceâ. Laying out these boundaries is helpful in sharpening our concept and clarifying how it is distinctive.
Our use of body work overlaps with that of other theorists. McDowell (2009) adopts the term body work as a shorthand for all the embodied, interactive work in the consumer service sector that requires co-presence. She includes workersâ management of their own bodies and bodily performances, not only their attentions to the bodies of patients, clients and customers. McDowellâs use of the term is part of her case for bringing the embodied character of many frontline service sector interactions to the fore, and is thus much to be welcomed. In recognising the importance of embodiment in all consumer services encounters she does not, however, adequately distinguish between cases in which workersâ focus on the bodies of the clients/customers is a defining and essential feature of the job and other forms of interactive work where the presence of an embodied worker simply adds extra value, pleasure or authority to the interaction (something that has elsewhere been conceptualised as âaesthetic labourâ (Witz et al. 2003)). As it happens, many of McDowellâs (2009) case studies are examples of body work in our sense, presumably because they best illustrate the usefulness of looking at the corporeality of interactions in the construction of jobs and occupational identities. However, we think that occupations that require touching the patient or clientâs body (or at least close proximity or inspection) are characterised by particular challenges and dilemmas and that these are analysed more sharply by confining the term to those situations.
âBody workâ also overlaps, empirically and theoretically, with the alternative conceptualisation of âintimate labourâ (Boris and Parreñas 2010), a concept rooted in discussions of the increasing commercialisation of intimacy (Hochschild 2003a, Zelizer 2005). This concept, however, is as much concerned with the transformation of the social experiences of consumers as providers; and this has meant that domestic labour, much of which does not involve intimate touch, is included, as it occurs within the intimacy of the consumerâs home. We suggest that our concept of body work has a key advantage over âintimate labourâ, in that the focus on intimacy can elide the bodily nature of the work. If working closely with bodies is simply associated with âintimacyâ, it becomes essentially an intense form of emotional labour (Hochschild 1983), implying a difference of degree rather than kind. This is not to say that emotional and body work are not closely intertwined, but that the bodily aspects of the work need to be analytically distinguished.
As we have noted, body work inevitably involves an interplay of inter-subjectivities. There has already been much written about emotional labour (Hochschild 1983, Bolton and Boyd 2003, Kang 2003) and this literature needs to be incorporated in the conceptualisation of body work. Although the concept of âemotional labourâ was initially developed within the commercial service sectors, sociologists of health and illness have also recognised and demonstrated that working with, for and on bodies in health and social care settings is emotionally draining, laborious and demanding (James 1989, 1992). âEmotional labourâ maps neatly on to the gendered occupational hierarchies of healthcare, with the priviÂleged, predominantly male professions relegating the emotional work, along with the other âdirty workâ, to those lower down the pecking order. There is empirical evidence to supÂport this; though it is important to note that those in the upper echelons of the healthcare division of labour are not immune from emotional âwear and tearâ (Graham 2006, Nettleton et al. 2008). Feelings, both physical and emotional, potentially involve vulnerability, and since the whole edifice of biomedical science, and attendant evidence-based practice, presupposes a form of âdisembeddedâ expertise (Giddens 1990), the viable scope for emotions becomes awkward, and much emotional work involves the suppression, rather than expression, of emotion. Thus, while emotional sensitivity and expressivity are desired and necessary characteristics of medical work, they must be circumscribed lest they are conceived of as âunprofessionalâ and a threat to the abstract system of medicine (Nettleton et al. 2008).
It is important to recognise that not all the emotional aspects of body work are negative. Emotion can also make body work worthwhile, meaningful and rewarding. It is double-edged: a source of satisfaction and frustration. For many, the affective aspects of work constitute an import...
