ILLNESS AS RELATIONSHIP

by
MICHAEL G. TERPSTRA, Ph.D.

ABSTRACT:
A post-modern world requires an approach to language that is sensitive to the increasing complexities of global social interaction.  An initial step toward increasing sensitivity is to describe an alternate approach to language and social interaction. Through Niklas Luhmannís theory of differentiation, I develop an idea that includes a sensitivity to language in its relationship to social interaction.  I extend Luhmannís concept of interpenetration to the analysis of dialogue.

I describe how the theme of "illness" unfolds as a relationship between the patientís self awareness and the clinical encounter that comes alive through the language exchanged between physician and patient. The emotion, anger, is the patientís adaptation to the interdependent relationship he and his physician have within their encounter which is the particular social system under analysis.  In this paper, I analyze the clinical encounter as the social system in where illness is the system of interpenetration.

 ILLNESS AS RELATIONSHIP

Describing todayís modern world requires an approach to language that is sensitive to the increasing complexities of global social interaction. In this paper, I propose that the description of the relationship between language and social interaction be grounded in the work of the German sociologist, Niklas Luhmann.

Post-modernism and post-industrialism are reactionary movements to previous attempts at describing societal and economic problems. The term post-modernism conveys ambiguous concepts and ideologies.  Rather than belaboring the meaning of this concept, I will simply use the term to identify problems the global community is currently communicating.  I use post-modernism to refer to social interactive problems resulting from the increase complexities of our society.   I believe that Niklas Luhmannís theory of social interaction will help to address the information age and the complex issues surrounding it.  Luhmann's theoretical insight takes us away from reinventing old solutions and toward applying current theoretical innovations to complex problems.
Some post-modernists think it is necessary to liberate and free people from their bondage.  The source of  knowledge (information) need not be in the exclusive domain of the expert.  If wielding knowledge creates oppression, then "emancipation" is necessary in order to obtain freedom.  In the information age, there is no longer the need for "emancipation" since information can be accessed by anyone.  The control of information is no longer the exclusive purview of the expert.

Branko Horvat (1982) describes the climate in which the  postmodernist approaches social and economic issues. The coordination necessary for the operation of an information regulatory mechanism requires "organized information diffusion" and an "enormously increased speed and precision of information gathering and processing" (Horvat, 1982).  David Prychitko goes a step further to describe a problem of the information age as "the knowledge problem" of social planning (1991).  The problem centers on the conscious allocation of scarce resources complicated by the multiple demands for a commodity.  The destination for a scarce commodity is decided on the basis of information received.  Prychitkoís summary illustrates the problem: "The assumption of complete knowledge of the relevant factor, production functions, and equilibrium prices does not solve the knowledge problem, but in fact obscures it" (1991, p.88).  A system based on the concept of equilibrium faces the knowledge problem because it ignores the problems of the transmission of that knowledge.  The information age requires assessments of the validity and usefulness of the superabundance of information.  It is a knowledge problem because the information is not being efficiently utilized.

My argument is that in the postmodern world, social systems need to intensify efficient information advantages in order to meet the requirements for maintaining a viable position.  Luhmann's system of self-reference is the theoretical tool needed to meet the needs of the postmodern world.  The postmodern agenda must include an exploration of the theory of differentiation, especially the distinction Luhmann makes between system and environment (1982, p.230).  This distinction is at the heart of what I am discussing as communication and the relationship between language and social interaction.  For Luhmann, human beings do not communicate; social systems communicate.  At the core of this concept, communication requires the synthesis of three selections: information, utterances (Mitteilung) and a need to "understand it all" (Luhmann, 1990a, p.3).

The critics of post-modernism identify one of its failures as holding on to an inadequate notion of subjectivity, one that puts the subject (actor) in an isolated position, one without meaning (Kellner, Best, 1991).  When focused on the problems of communication in the global community, Luhmannís approach to analyzing the social domain is especially relevant to serious considerations for an analysis of interaction that begins with a subject-free approach.
Although I argue for Luhmann's position on the "subject-free" concept, Luhmann recognizes modern philosophy's need for a reinvigorated concept of the "subject."  If the "subject" is a requirement for better understanding, then Luhmann expands its foundation to be inclusive of "all processes and systems within which 'meaning' plays an essential role" (Luhmann, 1982, p. 325).

The foundational accomplishment of postmodernism is its recognition that subjectivity needs reconstruction.  Several authors recognize this contribution in a variety of expressions (Knodt, 1994, Jameson, 1991, Kellner, Best, 1991).  Knodt points out that "the binary logic of classical ontology is exhausted" (1994, p.93).  This means that the logic which maintains a separation between the subject and object no longer holds.  In a discussion of literary style, Jameson demonstrates how an author is postmodern by identifying the emptiness of the subject (1991, p.133).

Communication is made possible only as a self-referential process.  This means that communication takes place within the social system and not between the social system and environment.  In one of his books, Love as Passion (1986c), Luhmann defines love as a system of interpenetration.  By arguing that love is a system, Luhmann states that in order to understand "love" one must see it as a medium for the formation of personal relationships.  By extending the concept to "illness" and applying Luhmannís theory of distinctions, I analyze the clinical encounter as the social system where illness is the system of interpenetration.  In the clinical encounter,  illness defines the systemís (clinical encounterís) boundaries and goals.  The environment for this social system includes the two participants (patient and physician) and everything else that is not part of the system.

First, a distinction is made between the environment (including the psychic system of patient and the psychic system of physician) and the social system of illness.  Information is a result of the process of the system differentiating between itself and its environment.  Elaborating further, differentiation includes the first distinction mentioned above and the reproductive process of the social system (discussed later under Autopoiesis).  Differentiation results from the distinction between the self-perpetuating activity of the social system (autopoiesis) and accomplishments (language) of the relationship between the participants and the social system that facilitated their interactions.

The patient and physician, because their psychic systems are part of the environment and a condition of differentiation, form a temporarily reciprocal interdependent relationship with the social system (clinical encounter).  The evidence for this interdependent relationship is language.  The adaptation to the interdependent relationship just described is emotion.  The emotional responses expressed by the patient are the effect of language transferring social complexity into psychic complexity.  The transference of social complexity into psychic complexity is the driving force behind the concept of interpenetration.
Differentiation is a meaning-based processing of experience.  The process functions in a cyclical manner by both reducing and preserving complexity (Luhmann, 1990a, p.27).  The reduction of complexity allows us to comprehend extremely complex concepts while the preservation of complexity prevents us from reducing a complex world to a mere simplistic perception.
The experience of the patient unfolds during the clinical encounter.  Luhmann reminds us that the "concept of meaning refers to the way human experience is ordered" (1990a, p.25).  Through the communication between the AIDS patient and his physician, the patient's illness is given meaning.  As we shall see, the system generates meaning through the process of differentiation that functions by combining three different selections: information, utterance and understanding.

Communication is the medium from which social systems operate. Communication differentiates and the difference is "thematized as the unity of what is different, as communication and non-communication, that is, as a paradox" (Luhmann, 1994b, p.25-26).   When the patient (speaker) is talking about his illness, these utterances are evidence of a process of internal observation (self-observation).  As far as the experience of the patientís illness, the physician (receiver/participant) responds as an external observer of the illness.

The language spoken during the clinical encounter provides partial evidence of a patientís construct of "self ."  Pursuant to Luhmannís terminology, (without the notion of a efficient subject or actor), language provides evidence from the communicating social system of the knowledge we have of others and ourselves. The following case study illustrates a very small part of a patientís construction of his system of illness.   The patientís personal system of illness is only one of many systems of interpenetrations that contributes to the knowledge of "self" and contributes to societyís knowledge of illness.
In order to set the stage, I need to identify what is environment and what constitutes the social system we are observing.  The environment, using Luhmann's vocabulary, includes the psychic systems of the AIDS patient and the physician.  The social system is the clinical encounter.

The emotion of anger as it occurs in my case study is easily identifiable.  The dialogue permits identification of discernible landmarks for the presence of this emotion.  The tracking of anger provides the opportunity to observe the results of interpenetration.  Interpenetration is the relationship between the patient's consciousness and the encounter. Communication is a process resulting from the clinical encounter (social system) and not the act of the patient.  Emotion is the "internal adaptation to internal problem situations of psychic systems" (Luhmann, 1995/1984, p.559 fn# 26).

The expression of anger began after a short rhetorical question by the physician about a previous theme.  The physician's remark triggered the onset.  At this juncture, the emotion of anger contributes significantly to the formation of a new theme.  The physician, by allowing the patient to continue, provides the opportunity for the patient to fully express himself.  The physician gives the patient ample opportunity to change topics.  The expression of anger is initially introduced by the patient in isolation from other anger references.  Initially I sought to identify the agent or cause of the anger portrayed through the patient's descriptions of his current state of being.  The word "anger" drew attention because of its frequency in a word count of the dialogue; the patient used "anger" in one of its forms twelve (12) times during his conversation.  The "diagnosis" topic drew attention because of the variety of ways in which the patient talked about his diagnosis and how he expressed his eventual acceptance of the diagnosis of AIDS.  Although the word "strength" only occurs twice in the patient's talk, it contributes a clue to eventual identification of the diagnosis theme.  The term "space" (seven times) has significance because of the patient's association with a mental (emotional) safe space for retreat and renewal.  The combination, "safe space" (four times) identifies, in the patient's spatial jargon, a secure mental refuge from confrontations and anger.  Once the patient refers to the safe space as meditation.

The patient continues the conversation with occasional physician-assisted extensions of the patient's thought.  The physician attempts to change topics but the patient interrupts.  The physician immediately asks a question to request an elaboration of what the patient was saying.  The next two questions asked by the physician lead to what appears to be a therapeutic resolution for the patient.

The patient's awareness of his illness is reflected through self-observations.  The very nature of the clinical encounter centers on the patient's illness.  The definition of the clinical encounter establishes the boundaries of the social system.  The theme of illness therefore is the only valid theme in the system's communicative process.  It is not plausible nor necessary to have complete knowledge of the patient.  Self-thematization (Luhmann, 1982, p.327) makes the social system accessible to information pertaining to the patient's illness.  Self-thematization is another term that Luhmann uses to refer to the relationship a system establishes with itself.  In other words, the process of self-reference (reflection) the patient connects with the social system, i.e. the clinical encounter.  The patient is in a position of observation.

Metaphorically speaking, this type of language analysis might be compared to paleontology.  Researchers have the fossilized bones, footprints, and eggs of the creatures called dinosaurs.  They have never seen one but they make the best informed guess about the habits and physical appearance.  In the same sense, communication according to Luhmann cannot be observed but residual data reveals that communication has occurred.  The language exchanged in the clinical case study is the product created by the clinical encounter.

Interpenetration is the relationship between the AIDS patient's awareness of his illness and the theme of illness that is accessible through self-reference.  The selected fragment of my case study demonstrates evidence for differentiation between a psychic and social system.

The language uttered by the speaker (patient) on the subject of illness is through internal observation (self-observation).  The receiver/participant in the clinical encounter (physician) respond as an external observer of the illness.  The only valid theme in the system's communicative process is the one emerging through internal observation (Luhmann, 1995/1984, p. 180).  In the case of my clinical encounter, it is the theme of illness.  The paradox is that both the speaker (patient) and addressee (physician) contribute to the knowledge of the illness but the only valid theme comes through internal observation.   Internal observation is the self-observation of a social system.  Luhmann reasons that the system (clinical encounter) is accessible to itself only through communication.

In this illustration (the clinical encounter), knowledge of the patient is communicated through the theme as a "meaning-employing system" rather than the source for the creation of meaning (Luhmann, 1979).  Meaning for Luhmann is not the "conscious actualization of the intentional structures of experience" of the patient (1990a, p.22).  Understanding the clinical encounter is realized through the activity of the social system (clinical encounter) rather than identifying the patient and physician as the source of understanding.

The clinical encounter represents two distinct and separate worlds, one from the physician's perspective and the other from the patient's experience (Toombs, 1993).  These worlds are known by the language style the participants use.  The language of the patient reflects illness as an inward experience.  The point of reference for the physician is different than it is for the patient.
The problem discussed by Toombs in the following quote illustrates the problem of double contingency.  "In the clinical encounter the body becomes objectified.  With this objectification the unity of lived body disintegrates and the body is alienated from the self.  The alienation from self engenders a profound sense of loss of control" (Toombs, 1993, p83).  This illustration presents a partial picture.  Toombs conclusion about clinical encounter assumes an object and subject dynamic.  Anyone who develops an objective/subjective model avoids the problem of double contingency.  The problem is that oneís conclusions are determined by the object/subject dilemma.  The dilemma is knowing who is the subject and what is object.  Toombsí methodology that created the above conclusion about clinical encounters emerges out of the object/subject duality.
An alternative perspective, such as that of Luhmann, envisions the function of social analysis as the relationship between system and environment.   When Luhmann uses the problem of double contingency as a solution, it becomes part of the social systemís autopoietic characteristics.  A methodology developed along the lines of Luhmannís theory does not emerge from an object/subject duality.  When I use the concept of double contingency, it contributes to the idea of illness as a system of interpenetration.  Luhmann's solution to the problem of double contingency is to utilize its presence where meaning: emerges through the clinical encounter.

"Interpenetration is ... a relationship between autopoietic systems" (Luhmann, 1995/1984, p.218).  Autopoiesis, simply defined, is the process of a system's reproduction through its own network of structures.  "Systems" refers to biological systems, psychic systems, and social systems.  Autopoiesis is applicable to all systems but the single most important characteristic of social and psychic systems is that they are non-living systems.  Without going into detail, the system's ability to maintain closure and openness at the same time requires that these social systems be classified as non-living (Luhmann, 1986a).

Self-reference is a process of autopoiesis that refers something beyond itself and then returns to itself.  Self-reference and external reference are examples of closed and open systems respectively.  The self-referential systems maintain closure with respect to communication (Luhmann, 1990a, p.5).  Because I am using the concept of self-reference in the context of an interaction rather than society at large, the distinction between interactive and social systems requires a refinement in definition.   Social systems are all-inclusive, thus "closure" becomes all encompassing.  On the other hand, interactive systems are both open and closed to their environment.  They are open in the sense that communication with the environment is acknowledged by "the fact that the persons who are present and participate in the interaction have other roles and other obligations within systems that cannot be controlled here and now" (Luhmann, 1990a, p.5).  Interactive systems are also closed "in the sense that their own communication can be motivated and understood only in the context of the system, and if somebody approaches the interactional space and begins to participate, he has to be introduced and the topics of conversation eventually have to be adapted to the new situation" (Luhmann, 1990a, p.5).  Therefore the synthesis of information, utterance, and understanding causes the system to deal with resolution of the difference between closure and openness.

Luhmann defines the input/output schema as a restrictive description  on the relations between system and environment (personal communication, September 20, 1996).  The restriction is limited to social systems that have fixed input and output goals.   What this means is that the methodology for analyzing the interaction between the physician and patient during a clinical encounter must not include an input/output scheme.  The only type of social system that can utilize input/output organization are those systems that have to distinguishes between openness and closure.  The classical example Luhmann sites is the system (firm) which distinguishes between labor markets and product markets.  When following through with Luhmannís theoretical constructs, it is important to return to his applications of system reproduction (autopoiesis) and self-identification (self-reference). [For further study, see summary of conversation with Luhmann - 8/22/96 ]

The complexities of today's global interaction between diverse cultures requires that we maximize the resources of our "informational age."  I do not believe that many doubt the overwhelming impact of the amount of information on the potential for meeting our problem solving needs.  But I think that many still underestimate the impact the "knowledge problem" has on social planning and problem solving.  With the enormous accumulation of information, effective systems for managing knowledge must be found.  I suggest that Luhmann's theory of social interaction addresses this "knowledge problem."  In order to illustrate the potential for Luhmann's theory in the analysis of social interaction, I use language to focus on one of the basic tenets of his theory, interpenetration.  The development of the "illness" theme shows the relationship between what Luhmann defines as the relationship between autopoietic systems.  That is, the language spoken by the patient in my example is the evolutionary result of what  occurs between the patient and his means to understand his illness.  The difference between environment (which includes the patient's psychic system) and the system, the clinical encounter, is at the heart of Luhmann's work.  Illness as a relationship not due to the role played out by the patient but only as that theme of "illness" is communicated by the clinical encounter.

References:

Horvat, B., (1982).  The Political Economy of Socialism.  Armonk, NY:
M.E. Sharpe.

Jameson, F., (1991).  Postmodernism, or The Cultural Logis of Late Capitalism.
Durham: Duke University.

Kellner, D.M., Best, S.  (1991).  Postmodern Theory: Critical Interrogations.
New York: Guilford.

Knodt, E., (1994).  Toward a Non-Foundationalist Epistemology: The Habermas/
Luhmann Controversy Revisited.  New German Critique.  61, Winter.

Luhmann, N., (1979).  Trust and Power.  John Wiley and Sons.

Luhmann, N., (1982).  Differentiation of Society.  (S. Holmes,  C. Larmore,
 Trans.)  New York: Columbia University.

Luhmann, N., (1986a).  Ecological Communication. (J. Bednarz, Jr., Trans.)
Chicago: University of Chicago.

Luhmann, N.  (1986b).  The Autopoiesis of Social Systems.  In  F. Geyer.
Sociocybernetic Paradoxes: Observation, Control and Evolution
of Self-Steering Systems.  Beverly Hills: Sage.

Luhmann, N.  (1986c).  Love As Passion: The Codification of Intimacy.
(J. Gaines, D.L. Jones, Trans.). Cambridge: Harvard University.

Luhmann, N., (1990a).  Essays on Self Reference.  New York: Columbia Univ.

Luhmann, N., (1991).  Instead of a Preface to the English Edition: On the
Concepts  "Subject" and "Action." In N. Luhmann, (1995).  Social Systems.  Stanford: Stanford University.  (Original work published 1984)

Luhmann, N., (1994b).  Speaking and Silence.  New German Critique.  61, Winter.

Luhmann, N., (1995).  Social Systems. (J. Bednarz, Jr., & D. Baecker, Trans.).
Stanford: Stanford University.  (Original work published 1984).

Prychitko, D.,  (1991).  Marxism & Workers' Self-Management:  The Essential
Tension.  New York: Greenwood.

Toombs, S.K. (1993).  The Meaning of Illness.  Boston: Kluwer Academic
 Publishers.

APPENDIX A:  SEGMENT OF CASE STUDY DIALOGUE.

The following is brief exerpt of a clinical encounter between an AIDS patient and his physician.
 

==========================================================

Physician:
015  You were taking him to court,
016  last I heard.

Patient:
016                         We both were cited because there
017                         were no witnesses and he said
018                         that I hit him also.

Physician:
019  I didn't hear that part.

Patient:
019                         Oh, yeah.  So the DA threw it out
020                         because it was his word against
021                         mine, so I took him to small claims
022                         court, and an hour before small
023                         claims court started, he called the
024                         bailiff and said that I had
025                         threatened his life, so that threw
026                         the whole court into turmoil
027                         and caused all of us
028                         to be searched and um, in other
029                         words, angered
030                         the, He's not even a judge in small
031                         claims, they are attorneys.
032                         They're called commissioners,
033                         and commissioner is the head one,
034                         who's, I'm sure anti gay, Catholic,
035                         which I was excommunicated from the
036                         Catholic church, and, and let's
037                         see, what else, let's see one
038                         more thing, oh anti union, for the
039                         union.  So, they were all
040                         against me, I lost.

Physician:
041  I wonder why.

Patient:
041                         I know.  So that sort of like has
042                         got me angry and now I have to
043                         appeal to the Superior Court.
044                         Something else, you know, and
045                         also my mother, she's doing very
046                         badly in terms of a lot of
047                         different things, but then she is
048                         focusing on this too.
049                         So even though I'm detaching myself
050                         from that sort of, it's
051                         still difficult in the sense that
052                         we're very close and
053                         I'm sorry that she is sad and
054                         unhappy about it, but that
055                         affects me too.  Not as much as it
056                         might have in the past,
057                         I think I've gotten some strength
058                         from certain things that help me with
059                         it, but still it does affect
060                         me and so,
061                         um, and I have just, as of
062                         September thirteenth,
063                         I was diagnosed a year ago,
064                         which was nice for me,
065                         I mean, a year, but the thing is,
066                         and I plan on more,
067                         but the thing is, so it was sort
068                         of an odd couple of weeks,
069                         the last couple of weeks.
070                         I know that affects
071                         my health too and
072                         I do see this psychologists,
073                         Jxxxxx Mxxxxx who helps me
074                         quite a bit.

Physician:
075  She probably helps you more
076  than we could help you at
077  this point.

Patient:
077                         Well, I don't know.
078                         I think everyone is pretty equal.

Physician:
079  Yeah, your health has been
080  pretty good, knock on wood.
Patient:
                               It's been, it's been, it's been,
081                         except for the two pneumonias,
082                         yeah it's been great.

Physician:
083  Yeah, yeah.

Patient:
083
                            And I was going to tell you also
084                         that since it was my one
085                         year anniversary, I really
086                         appreciate what you've done
087                         for me, and
088                         I am very grateful.
 

Physician:
089  My pleasure.  Anyway, so you
090  think your main problem right
091  now is ...
 
 
 

Patient:
091                         Mental.

Physician:
092  What kind of mental.
Patient:
092                         Is that what you were
093                         going to say?

Physician:
094  Well, I was going to let you
095  finish that.

Patient:
095                         Uh, kind of, and I think
096                         I would define that
097                         as being angry,
098                         I am angry.  I don't know
099                         whether I've gone through,
100                         I've been diagnosed with
101                         AIDS for a year so I
102                         know Elizabeth Kubler Ross and
103                         all the different things.
104                         I don't think
105                         I'm in the anger stage because
106                         I've gone through anger
107                         a couple of times back,
108                         but you can go in and out of
109                         whatever, but I'm angry about
110                         this Mr. [named] that assaulted
111                         me, I'm angry at the judge
112                         that threw this,
113                         I mean the DA that threw
114                         it out, I'm angry at those kind
115                         and so I think mainly it's trying
116                         to deal with this anger
117                         and of course, live my life
118                         despite the fact that I have
119                         AIDS, and plus, my mother did
120                         something to me.  She called
121                         a couple of my cousins.
122                         I asked her not to tell them.
123                         If the dissemination of information
124                         is going to be done,
125                         it's going to be by me and
126                         that sort of angered me also,
127                         so I'm sort of going through
128                         an angry period.

Physician:
129  How are you dealing with all
130  this?

Patient:
130                         Well, I don't know.  The thing
131                         with this, I was at Dr. Mxxxxx's
132                         today and I said,
133                         How do I deal with it?
134                         Well she said you see
135                         I feel, and I feel fortunate,
136                         I'm thirtyfour years old.
137                         I had a charmed life.
138                         I lived in New York city,
139                         I've been around the world,
140                         I had money in the past and
141                         I've had a very happy life.
142                         And I think a lot of that has
143                         to do with that I was in
144                         this sort of, um space,
145                         a safe space,
146                         that I wasn't affected
147                         by people like this
148                         Mr. [named] or my mother or
149                         things like that.  So it's just
150                         something that I have
151                         to deal with, maybe put myself back
152                         in that safe space, meditation,
153                         whatever.



 


SUMMARY

Phone Conversation with Niklas Luhmann:
8/22/96

Professor Luhmann would prefer to have material in writing before any indebth comments.  His main concern
was that phone conversations would be too expensive. It is O.K. to talk about any material now.  His secretary
is on vacation until next week.  I will call his secretary at the university next week for his E-Mail address.

Brief answers to a couple of queries regarding my dissertation:

After a congenial conversation Luhmann agreed to further contact and conversations.


WRITTEN CORRESPONDENCE

September 20th 1996 Text from Niklas Luhmann

DATE: 20-Sep-96 at 02:56:18

First, the input/output schema is a restrictive description of the
relation between system and environment. The restriction consists in
a presupposed differentiation of the environment according to input
and output. The most famous example is, of course, the firm which
distinguishes between labor market and product market but not all
social systems can presuppose such a distinction, for example not
families.

Second, I do not see action as subject-free. An action presupposes,
of course, an actor. This is part of the concept of action and both,
action and actor are constructions of an observer. Whether we call
the actor "subject" is another question. I hesitate to do this,
because the term subject has historical connotations as a
self-founding entity and I would not say that the concept of action
presupposes such a theoretical construct.

I take the term subject as belonging to a historical tradition which
tries to found the modern individualism on reflexivity. The end of
this tradition is marked by Freud who describes the individuum as
distinguished from itself, namely its unconscious motives. In every
day language the term subject has lost these historical references
but than it can be replaced by individuum.

I hope that this short reply is understandable to you and remain with
all good wishes for your work

yours sincerely,
Niklas Luhmann