Anxious Times: A Discourse Analysis of Women’s and Health Professionals’ Constructions of the Experience of Breast Cancer Linley Elizabeth Stevenson A thesis submitted to Auckland University of Technology in fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) 2014 Faculty of Health and Environmental Sciences School of Health Care Practice ABSTRACT Every day up to seven women in Aotearoa New Zealand are diagnosed with breast cancer. One in eight women will develop it at some time in their lives, and over 600 die each year, almost two a day (New Zealand Ministry of Health/NZHIS, 2014). In a culture where women’s attitudes, thoughts and reactions towards breast cancer are consistently portrayed as having high emotional content, the likelihood that health professionals might experience emotion aligned to their work with women with breast cancer is also high. Although a popular topic for media attention and women’s personal narratives, few research studies have investigated breast cancer from the perspectives of both the women who have experienced the disease, and their health professionals. This study is different therefore, in its inclusion of medical practitioners. While not pairs per se as doctor and patient, the perceptions of 17 health professionals were explored alongside the perceptions of 20 women through their constructions of the same discursive object, breast cancer. Two key questions were central to the study: (1) what were the discourses most predominantly deployed by women and health professionals through which they constructed breast cancer, and (2) what effect did the participants’ positioning in these discourses have on their subjectivities and their discursive practices? The methodology for the study was post-structuralism, drawing on French philosopher Michel Foucault’s concepts of discourse and power/knowledge. The findings showed two dominant discourses by which the women and the health professionals constructed breast cancer – the medical discourse, and the gender discourse. Breast cancer was constructed in medical and gendered ways as problematic, dangerous, and not straightforward. Application of Foucault’s notion of governmentality showed that through their deployment of these dominant discourses, women’s and health professionals’ behaviour was controlled and conforming. As a result, the emotional impact of breast cancer on both parties was not well articulated or understood, and was shut down within medical encounters. The findings showed further that the intersection of these two discourses produced significantly anxious or fearful subjects. These findings have important implications for ii women, and for the education of health professionals who work in the field of breast cancer. This study complements other earlier research which has found that women are fearful of breast cancer and its ramifications, and that there are also associated tensions for health professionals. Two major recommendations for further investigation, and for education, are: (1) permitting women to communicate more openly with their health professionals, and (2) educating professionals in critical thinking and analysis. This might facilitate better understanding of the meaning of breast cancer for each party, thereby steadying the balance of power between the two through a commonality of discursive construction. The significance of the study is that it opened up opportunities for other discourses and discursive practices to be brought into play, thus creating spaces for additional subjectivities to be heard and recognised. iii TABLE OF CONTENTS ABSTRACT ..................................................................................................................... ii LIST OF TABLES .......................................................................................................... x ATTESTATION OF AUTHORSHIP .......................................................................... xi DEDICATION ............................................................................................................... xii ACKNOWLEDGEMENTS ......................................................................................... xiii CHAPTER ONE: INTRODUCTION ........................................................................... 1 My Personal Experience ............................................................................................... 1 Background to the Study ............................................................................................... 4 The Philosophical Approach and Aims of the Study .................................................... 5 Study Outline ................................................................................................................ 7 CHAPTER TWO: PHILOSOPHICAL UNDERPINNINGS ................................... 12 Introduction ................................................................................................................. 12 The Epistemology of Post-structuralism ..................................................................... 13 Discourse ..................................................................................................................... 15 Rules of Formation ..............................................................................................................17 Discursive Object ................................................................................................................17 Subject Position ...................................................................................................................18 Discursive Practices ............................................................................................................19 Foucault’s Theoretical ‘Tool-Box’ ............................................................................. 19 The Archaeology of Knowledge .........................................................................................20 Genealogy ...........................................................................................................................22 History of the Present ..........................................................................................................23 Knowledge .................................................................................................................. 25 The Disciplines ....................................................................................................................25 Normalising Judgements .....................................................................................................26 The Disciplinary or Clinical Gaze .......................................................................................27 Power/Knowledge ....................................................................................................... 28 Power Relations ..................................................................................................................29 Technologies of Power ........................................................................................................31 Surveillance .........................................................................................................................32 Bio-power – Governmentality .............................................................................................35 Technologies of the Self ......................................................................................................36 Subjectivity/Identity .................................................................................................... 38 Summary ..................................................................................................................... 40 CHAPTER THREE: METHODOLOGY AND METHODS .................................... 41 Introduction ................................................................................................................. 41 Post-structural Discourse Analysis ............................................................................. 41 Applying Foucauldian Methods to My Study – How Foucault Fits ...................................43 Methods ....................................................................................................................... 45 Selection of Participants .............................................................................................. 45 iv Participant Groups ...............................................................................................................46 The Women .........................................................................................................................48 The Health Professionals .....................................................................................................49 The Interview .............................................................................................................. 49 Content and Process ............................................................................................................49 The Interviews with the Women .........................................................................................51 The Interviews with the Health Professionals .....................................................................51 Interview Process ................................................................................................................51 Recording of Interviews and Transcription ................................................................