At some point in life, we’ve all reaped the benefits of milking an illness. Maybe it facilitated skipping school or work, being coddled, avoiding jury duty or just reveling in hibernation. There are some folks, however, who go above and beyond occasionally attaining advantages from being infirm. They are invested in the sick role. Under these circumstances being ill becomes a socially marginalized identity defined by resistance to taking action towards recovery.
Embellished by American sociologist Talcott Parsons (1951) and influenced by psychoanalytic theory, the sick role is viewed as that which garners useful advantages in the larger context of societal norms. Parsons elaborated on a ‘subculture of the sick’ or what is referred to as malingering. A condition that derives external benefits from exaggerating or falsifying a physical or mental illness, malingering is linked to character pathology.
Also called advantage by illness, alignment with the sick role is motivated and reinforced by secondary gains, such as gleaning attention, sympathy or receiving special concessions and latitude from others.
In fact, there was a time when I derived secondary gains from my mental illness. Deluged by complex trauma symptoms I wore my torment like a badge of superiority. A self-proclaimed martyr I railed at life for my plight. The pain I endured and the abysmal circumstances I navigated became emblematic of the ultimate sacrifice. Like the victims of the Holocaust who absorbed my thoughts, I too felt persecuted and marginalized.
The narrative I composed from my suffering reflected a need to make meaning out of my helpless impotence and outrage. This same narrative afforded me a tenuous container for a fragile sense of self. In a perverse way, this reframed my torment as something exceptional.
As self-indulgent and irascible as this posturing may seem, it was an honest conveyance of my struggle. In spite of my demanding a Divine apology and some much-needed attention, my identification with being ill didn’t stop me from doing what was necessary to stabilize and heal. True, I was defiantly sick, but it was my contract in life to deal with it as best I could. So I embraced it, railed against it and in some ways even extracted certain privileges from it, like financial support and housing.
Cultural anthropologist Ernest Becker wrote in The Denial of Death, “Man cannot endure his own littleness unless he can translate it into meaningfulness on the largest possible level.”
Becker conveys our response to the innate terror of annihilation, of mortality, is a codified hero system. It is through our heroics that we attempt to transcend the fragility of our human condition, most pointedly our dread of death. We must aggrandize whatever is within reach. If all that is within reach are our afflictions then that becomes the source of glorification.
Often I asked myself, ‘who am I beyond my suffering?’ How will I make it in the world based on merit as opposed to being cared for as an emotional cripple? These are not consoling, esteem-building thoughts. To mitigate the anxiety of my impotence and imbue meaning into my life I had to somehow engage with the sick role as a heroic predicament. Lacking a traditional hero system I managed threats of annihilation, by imbuing my fate as a sick person with purpose and significance.
Unlike Parsons, who might view this as a pathological retreat into social deviance I view this as a life-affirming stance. Although I certainly appreciate how an unhealthy need to be absolved of responsibility can fuel an intractable and even unfounded reliance on being sick, or even how Munchausen’s syndrome, a skillful manipulative and exploitive use of sickness exists, these conditions and motivations are few and far between.
Hence as a clinician and survivor of complex trauma and a daughter of a schizophrenic mother, I take umbrage with the paternalistic, accusatory tone of Parson’s sick role perspective. The torment of being assigned a deviant social role as a sick person needing tight monitoring fails to consider how being mentally and physically sick is far more complicated than a refusal to comply with normative behavior.
French Philosopher Jean-Paul Sartre asserted that human behavior involves choices, that we are responsible for what we will do with and about our behavior. He staunchly upheld that one does not have to be a slave to one’s existence. Sartre, like the father of depth psychology, Carl Jung, conceptualized the unconscious as being monitored by the conscious. This perspective implies that just as certain behaviors that lead to a deviant label are voluntary, so is one’s decision to alter one’s psychological state.
Unfortunately when proclamations of free will are absolutist the complex limitations imposed by mental disorders are trivialized. There are some things in life we simply do not choose.
Likewise, a critical element of sociological truth also fails to be considered. Namely, once one is tagged as mentally ill, a social role has been assigned to the labeled individual. Consequently, if a person diagnosed with mental illness tries to rejoin the world of the sane they will likely encounter social hostility and stigma. Obviously, society’s antagonistic position makes the situation worse. As sociologist Edwin Lemert believes, there would be fewer problems for the ‘deviant’ individual if society’s reaction was not so hostile.
Hence, upon discovering that the rewards that are generally available to sane people are denied to him, he might choose to live out the role of the mentally ill person. By accepting the assigned role he is ostensibly offered a number of rewards such as pampering, sympathy and a life free of responsibility. This immersion in the sick role label can become a self-fulfilling prophecy that ignites an identification with being disadvantaged.
It follows, as the founding father of modern sociology Robert Merton theorized, that when a group of people experience themselves as disadvantaged a state of anomie or normlessness ensues. These disadvantaged groups feel that since society’s rewards are not available to them by any legitimate means, neither do the society’s notions of what is legitimate apply to them. Consequently, they just go after what they want without consulting any system of rules or values. This mindset and behavior is considered characteristic of antisocial personality.
All things considered, although every individual certainly has a responsibility to be productive within parameters commensurate with aptitude, marginalizing attitudes and conditions towards those who fall short of baseline societal standards of normalcy ignites a retreat into lethargy or active defiance. It’s interesting to note that this response is a source of contention for the very key agents of social control who establish power differentials and enforce social stratification.
In Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1961) sociologist and social psychologist Erving Goffman wrote about how those who are mentally impaired and can’t seem to cope with societal norms and rules of conduct are removed from society, placed in mental hospitals and labeled sick.
In the process of becoming a regimented patient, a process called ‘the mortification of self’ strips away personal identity and replaces it with an institutional identity. Goffman conveys that these patients are groomed and instructed to conform to bureaucratic rules and regulations. Such individuals become dependent on and managed by the medical-industrial complex. Their chronic misfortune is a profitable venture for the present-day corporatized medical establishment.
Indeed, as unaffordable services and medicine, racial and gender disparities in healthcare, and exorbitant health insurance premiums continue to escalate it’s obvious that the healthcare industry is not necessarily concerned with the needs of the sick, but more concerned with creating an indecently lucrative market in which private enterprise motivations extinguish the mission of public health.
Considering the vast terrain of health, culture and disease it seems those who glean the most secondary advantages from physical and mental illnesses are not those afflicted as Parsons contended, but those medical and pharmaceutical institutions that are owned by private equity firms.
Consequently, the repercussions are disastrous.
According to the Organization for Economic Co-operation and Development (OECD), “compared with other developed and many developing nations, the United States continues to rank at or near the bottom in indicators of mortality and life expectancy while continuing to exceed other countries in health spending.”
Similarly, a 2016 National Survey of Children’s Health data estimated that, “as many as one in six U.S. children between the ages of 6 and 17 has a treatable mental health disorder such as depression, anxiety problems or attention deficit/hyperactivity disorder (ADHD).”
Most disturbing is that of the estimated 7.7 million U.S. children with a treatable mental health disorder, approximately 50% do not receive treatment from a mental health professional.
Furthermore, medical bankruptcy, almost unheard of outside of the United States, is responsible for two-thirds of all bankruptcies in America (APHA). This trend has remained unchanged since the inception of Obamacare in 2010 and continues to worsen as medical costs soar beyond the rate of inflation and standard incomes.
British writer and theologian C.S. Lewis imparted, “Hardships prepare ordinary people for an extraordinary life.”
Yet when those hardships are caused by physical and psychiatric disorders necessitating humane competent treatment, the potential for an extraordinary life may be derailed by the under-prioritization of mental health and well-being. This tragic inevitability is evidenced in the current reality of mental health financing and barriers in accessing competent, affordable and culturally affirming care.
Although America is currently beset by an opioid overdose crisis and overall mental health is worsening, colossal military spending and ensuring the interests of big donors and special interest groups like Big Pharma, as opposed to financing public health, continues to take precedence.
Hence, it’s no surprise that President Joe Biden’s new COVID relief plan , comprised of initiatives recommended by insurance lobby groups, benefits the healthcare industry’s record profits while Americans face claim denials, and either lack coverage completely or struggle with substantial out-of-pocket costs from deductibles, copays, and coinsurance.
Although the Congressional Budget Office recently analyzed how Medicare for All could actually save the country up to $650 billion annually, U.S. policymakers loyal to free-market capitalism clearly serve the interests of the medical-industrial complex over wellness.
Moreover, a recent study (Journal of the American Medical Association) revealed ACA marketplace health care coverage costs 83% more than Medicaid coverage. Additionally, ACA plans leave patients with ten times the amount of out-of-pocket costs.
I am left to wonder if we can ever find a rational middle ground between the neoliberal emphasis on individualism that characterizes homeless addicts and mentally ill consumers as partaking in an alternative lifestyle and the callous condemnation of those who are ill. Neither enabling or ostracism effect positive change.
Yet perhaps there is a method to this madness, as these polarized perspectives are exactly what is required to ensure that neoliberal capitalist reforms and policies prevail with promoting profits over people. Until we collectively see through the smoke and mirrors, as usual, Wall St. and moguls politically connected to privileged corporate interests will continue to glean the secondary gains from illness.