The Politics of Dialogue in a Contemporary Health Care Context.
Socrates interrogates a slave who is destined to remain one. (Ranciére, 1991, s. 29)
The main purpose of this paper is to problematize dialogue, dialogism and person-centering between professionals and patients as a governmental rationality in contemporary healthcare context (Siouta, 2016). The concept of dialogue in education, as an ideal for face-to face relationships, has a long history in Western societies. It can be traced at least as far back as Plato’s Dialogues and the Socratic conversations (Englund, 2012). However, during recent decades the concept of dialogues has become a matter of course and a figure of thought in virtually all areas of society, not only in education, also for instance in health care, work life, career counselling, business marketing, european rural developement as well as in the formation of political spaces as the European Union (Olsson, Peterson & Krejsler, 2014a; Siouta, 2016; Sundelin, 2016). In many of these contexts, dialogue as a practice is regarded as an ideal not only in terms of individuals, but also in terms of groups, organizations, communities and national as well as of transnational political spaces. You might even talk about a dialogical turn in society and that dialogism has been established as a dogma of the talking, writing and thinking in most areas of society. And, as Siouta (2016) emphasize, most of these kinds of dialogues occur within the context of institutional settings characterized by asymmetry power relationships. The dialogic turn can be seen as an expression of a profound political change in how we should perceive society, work, health care and education and of which we as individuals should be and become to be included in society. In this paper, we are not interested in dialogues from a traditional policy perspective, where issues such as objectives, results, resources and organization are in focus. We are instead interested in the politics of dialogue, how the concept operate as a technology in the formation of narratives, in this case, about health care, health professionals, patients and of citizens (Ibid.). Our main interest is to problematize the governmental rationalities that permeate this narrative. In our analyses, we are playing with Focault’s concept of governmentality. We use “play” to signal that we are exploring governmentality as more or less a methodological approach to thinking about conditions that make the present possible, in this case, the formation of contemporary health care system, professionals and patients. This kind of analysis has the advantage that it does not require prior definition of for instance dialogue and person-centering (Foucault, 1994; Olsson, Petersson & Krejsler, 2014b). Instead, it enables us to study how these concepts and other floating signifiers acquire meaning within particular regimes of discourses and practices. Studies on governmentality pay particular attention to the relationships between governance, knowledge and political reasoning in relation to questions such as how to govern those who are expected to govern themselves, and how far to govern (Ibid.).
To carry out the analysis we use a genealogical approach. The purpose is to destabilize notions, in this case notions of dialogue and person-centering, that nowadays more or less are taken for granted in health care (Popkewitz, 2008). In a first step this is done by reflecting the health care narrative of dialogue and person-centering against how similar phenomena are treated in two different contemporary discourses, transnational education (EHEA 2012; Krejsler, Olsson, & Petersson, 2012) and business marketing (Bruhn, 2003). In a second step we are comparing the contemporary narrative against how corresponding notions operates in two different historical contexts. The early 19th century narrative of philanthropy Gerando (1832) and Ranciére´s (1991) philosophical rewriting of the French teacher Joseph Jacotot´s story of education from the beginning of the 1800th. This means that we are mirroring how concepts are constructed and how they operates in health care against how they are constructed and operate in other contemporary an historical contexts in order to deepening the understanding of what is going on within the context of contemporary health care system.
Empirically speaking, in the health care context, we work with document/policy analysis and interviews with health professionals and patients. Contemporary Educational documents selected are White Papers, scripts and memos concerning European educational policy. In this context our main focus is on the rationality of what is called the Open Method of Coordination (OMC), a kind of political dialogue designed to make policy processes move forward even in situations where explicit decision making appears impossible. In the context of business marketing we analysis textbooks and scientific publications dealing with Customer Relationship Marketing (CRM) a dialogic way of marketing designed to get to know the customers and to win their loyalty (Bruhn, 2003; Storbacka & Lehtinen, 2000. For analysis of the narrative of early 19th century we select documents produced by influential philanthropists, for instance, Gerando (1832) and Jacques Ranciére´s (1991) philosophical rewriting of the French teacher Joseph Jacotot’s story of education.
Notwithstanding the huge differences between the narratives studied there are also obvious similarities in the way the relationships between governance, knowledge, and political reasoning are considered. For instance, notwithstanding the contextual preconditions dialogues are, from a governmentality perspective, about moral projects with the purpose of designing human dispositions, willingness, and behavior that accord with the designs of the society and with various institutional rationalities and orders. In the narratives studied the subjects, health personal, patients, teacher, customers etc., are for instance constructed in terms of hopes for the future of the society and for the individuals. In early 19th century, the future for the individual as well as for society was given by nature as ordained by Providence. The contemporary future is everything but given by nature, and must constantly be re-created in the context of a continually changeable world. However in all the narratives studied dialogues and person-centering operates, in different ways, as political technology designed to shape individuals as well as collectives to make them ready for inclusion into some kind of social order. Thus, the concept of dialogue that operates here is something completely different compared to the claims operating in various philosophical narratives of dialogue (Englund, 2012). Instead, in all the narratives studied the dialogues in different was operating more or less as “goal directed machineries”.
Bruhn Manfred, (2003). Relationship Marketing – Management of customer relationships. Pearson Higher Education, London.
Büchs, M. (2007). New governance in European social policy: the open method of coordination. Houndmills, UK, Palgrave Macmillan, 224pp. (Palgrave Studies in European Politics).
COM 2001. European Governance. A white paper. 428 final. European Commission.
EHEA (2012). The European Higher Education Area in 2012. Bologna Process Implementation Report. Bucharest Ministerial Conference.www.ehea.info, Accessed Oktober, 2, 2012.
Englund, B. Dialogen som idé och praktik (Dialogues as idea and practice). Stockholm: Carlssons.
Foucault, M. (1994). Governmentality. In D. Faubion (Eds) Michel Foucault. Essential Works of Foucault 1954-1984 (vol 3), Power. London: Penguin Books.
Gérando, Joseph- Marie de (1846). The visitor of the poor. Boston: Hilliard, Gray, Little and Wilkins.
Krejsler, J.B., Olsson, U. & Petersson, K. (2012). Governing Europe by comparison, Peer pressure and self-interest: on the Bologna stocktaking process as operator of national education policy. In The Bulletin of the Institute of Technology and Vocational Education. Nagoya: Nagoya University.
Olsson, U., Petersson, K & Krejsler, J. B (2014a). On confessional dialogue and collective subjects. In A. Fejes & K. Nicoll. Foucault and a Politics of Confession in Education. London: Routledge.
Olsson, U., Petersson, K & Krejsler, J. B (2014b). On community as a governmental technology. In Barry M. Franklin & Miguel A. Pereyra (eds.). System of Reason and the Politics of Schooling. London: Routledge.
POPKEWITZ T. S. 2008, Cosmopolitanism and the Age of School Reform. Science, Education, and making Society by Making the Child, New York, London: Routledge.
Ranciére, J. (1991). The Ignorant Schoolmaster. Five Lessons in Intellectual Emancipation. Standford: Standford University Press.
Siouta, E (2016). Communication and Patient Involvment in Decision making. Thesis for doctorial degree. Stockholm: Karolinska Institutet.
Stocktaking (2009). Bologna Process Stocktaking Report. Report from working groups appointed by the Bologna Follow-up Group to the Ministerial Conference in Leuven/Louvain-la-Neuve 28-29 April 2009. http://www.ond.vlaanderen.be/hogeronderwijs/bologna , hämtat 28 augusti, 2012.
Stone, M., Woodcock, N., & Machtynger, L. (2000). Customer Relationship Marketing – Get to know your customers and win their loyality, 2:a upplagan Storbritannien: Kogan Page Limited.
Storbacka, K & Lehtinen, J. R. (2000). CRM- Customer Relationship Management. London: Penguin Books.
Sundelin, Å. (2016). Att skapa framtid. En analys av interaktionen i studie-och yrkesvägledande samtal med unga i migration. (Shaping a future. An analysis of interaction in career counselling conversations with young migrants). Thesis for doctorial degree. Stockholm: University of Stockholm.