Into conceptions of self and are likely to become a basis for the imputation

of identity by others. The body is central because the biological

bases of experience as perceived by self and others have very important

effects on the construction of self and identity. The relation between self

and identity in chronic illness is a social process which alters through

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Chronic Illness and the Body 249

time, as the bodily contingencies change. These bodily contingencies may

be cyclical, intermittent and unpredictable, or they may be ever downward

as in a terminal illness. Living biological systems are not static.

Neither are their manifestations nor the sensations and experiences of

these manifestations. These experiences are not merely socially constructed,

they are contingencies exercising varying degrees of salience for

self and others through time and place (Strauss et al. 1984).

At one extreme for example, an illness like well controlled diabetes

demonstrates our point (Kelleher 1988). To all intents and purposes this

disease is invisible to all but intimate others. Hence identity may remain

unchanged. However, the individual's sense of self will be intricately tied

into the routines attached to managing the illness with respect to physical

activities like insulin regimes, urine testing and dietary control. So long as

the self-management practices remain private or concealed in ordinary

interactions, the identity of a well person can be maintained. In contrast,

at the other extreme, someone whose condition is visible and cannot be

hidden, for example if they are in a wheelchair, will be in social situations

where, whatever the salience of their impairment for self at any given

moment, their public identity is always constrained by the wheelchair.

The wheelchair gives a physical salience and presence for identity construction.

Between these extremes lie a large number of diseases and conditions

in which the progress may be unpredictable, the intrusiveness of

symptoms may fiuctuate, and the prognosis may be uncertain. The consequences

for self and identity are therefore highly variable. Someone with

psoriasis may be involved in permanent self-care routines at the level of

self which makes the illness highly salient, while their public identity may

change in terms of the obviousness of the disease to others (Jobling

1977). Someone in the early stages of cancer may have had their sense of

self completely shattered as they ruminate on their own mortality but to

their neighbour, their workmates, to their fellow travellers on the moming

commuter train, their identity remains unaltered, until either they

show external signs of deterioration, or other cues are given off intentionally

or unintentionally which signal the need for a revision in identity. In

other illnesses the transformations in identity may not only be highly

salient but also highly stigmatising. External signals deriving from the disease

may be of such symbolic significance, say in uncontrolled epilepsy or

frank schizophrenia, that the identity is overlain by all kinds of other

negative and stigmatising labels (Albrecht et al. 1982, Goffman 1963,

Jones et al. 1984).

Discussion

In a theoretical review of medical sociology Gerhardt (1989) has made a

distinction between two ways in which sociologists have been influenced

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250 Michael P. Kelly and David Field

by the interactionist tradition from which the ideas of self and identity

used in this paper derive. She calls these the crisis model and the negotiation

model. The crisis model is typified by the work of Becker (1963),

Scott (1969) and Lemert (1962). In the crisis approach, becoming ill is

about identity change. The sociological interest is in irreversible status

passage and changes in the person's placement in the social structure. The

negotiation model, in contrast, characterises chronic illness as a process

of loss of self as the individual struggles or works to be as normal as possible.

The negotiation model is exemplified by the work of Strauss et al.

(1984), Charmaz (1983, 1987), Bury (1982) and Williams (1984).

Bringing the body into analytical focus helps to show that these are not

really two separate traditions but rather different ways of dealing with

the salience of the body. In the crisis approach symptoms of body alterations

lead to societal reactions (identity change) which in turn lead to

intemalisation and alterations in the self. The logic of the explanation

runs from body to self to identity. The degree to which interaction is selfdriven

or driven by the social reactions of others depends on the salience

of body to either self or others. An obvious point perhaps, but made the

more obvious when one considers that the crisis model happens to be

derived from studies of blindness (Scott 1969) and paranoia (Lemert

1962) neither of which condition can be easily bracketed out of social

interactions by others. In the negotiation model the illnesses dealt with -

rheumatoid arthritis, colitis, emphysema - do not necessarily make people

look especially unusual. The physical symptoms of this latter group of illnesses

do not always and invariably impinge directly on interactions and

will not inevitably be taken account of by others in interactions. They do,

however, have continuous salience for the sufferer. Differently diseased

bodies therefore affect interaction differentially.

It is also helpful to consider the role of language in these processes. In

a paper considering some of the methodological issues associated with the

validity of accounts of illness produced and analysed qualitatively. West

(1990), following Comwell (1984), draws a distinction between private

and public accounts and the apparent inconsistency between the two.

Public accounts are those produced by subjects which affirm and reproduce

the moral order. These tend to be 'ought' types of expressions of an

approved or an acceptable kind: 'Oh I'm doing fine', 'I can't complain',

or 'Mustn't grumble' are public accounts of this type. Private accounts, in

contrast, refer to meanings dedved from the experiential world - a world

of body experience and pain - often at odds with the public account of

things. They arise out of bodily experience, including all those difficult

and socially unacceptable aspects of body experience and outpourings like

blood, vomit and faeces. In public accounts social order is maintained,

and to echo both Mary Douglas (1966) and Norbert Elias (1994), dirt is

kept in its place and civilisation upheld. In other words, the very nature

of the accounting process, the way people talk about, or are permitted to

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Chronic Illness and the Body 251

talk about illness, reflects the salience and the immediacy of the bodily

experience of self.

Most public accounting practices help direct attention away from the

potentially stigmatising nature of illness, and much social interaction is

geared to repairing or overlooking faux pas, to covering up mis-understanding

and generally making interaction work (Goffman 1961, Schutz