Tag Archives: Erving Goffman

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The Rise of Telehealth

Well down the path of protecting health care workers with vaccines and masks, it remains for insurance companies to decide whether to still cover virtual visits.

Just a few years ago most people who studied health communication expressed doubts about the value of remote health “visits.” A phone or video appointment with a professional might be fine for a patient or client isolated in a remote location. But more recently, the more typical telehealth “visit” has gone local, with patients talking to a provider just a few miles away, usuallly via some version of Zoom.  Indeed, no person with symptoms of COVID was really welcome in a typical medical office, especially when vaccines were still months away.  Rates of virtual visits for all types of care are now at about 35 percent.

I certainly was among the skeptics, believing that a live face to face encounter is far preferable. And health professionals note that if they take time to notice, they may learn more about a patient’s condition in the small ways they present themselves during an in-office examination. But COVID obviously made telehealth “visits” a safer alternative.

Now, well down the path of protecting health care workers with vaccines and masks, the question remains for insurance companies whether to continue to fully reimburse health providers for virtual visits. And since states pitch in for federal insurance, many are grappling with what they will reimburse. Some state leaders have expressed concern that virtual visits are easy to abuse, and maybe little more than a glorified phone call. Then, too, it takes some planning and skill  to do exams remotely.

The behavioral health therapists I know bridle at the suggestion that they do any less for a virtual visit. Some argue that they often achieve more because they have to listen closely to a patient’s or client’s descriptions of their world and concerns. Not surprisingly, a face on a flat screen sometimes gives away very little. With video, the work and the payoffs are ironically in the process of active hearing and listening: something we are less apt to do in the presence of a lot of visual stimulation.


The Human Glitch of Required Video

There’s also an unexpected glitch with a mandate that specifically requires video visits. Many older patients  and clients are hardly in the position to use a computer or smart phone to connect with a professional. What is second nature to most of us is often awkward for a senior with limited abilities. They may not be able to pull off a video chat, with all the normal prerequisites of finger dexterity, access codes, Wi-Fi connections, and basic management of the software. And, to be frank, there aren’t enough staff around these folks to stand by and help.

For these seniors, phone visits are often adequate and preferred. They’ve grown up with telephones. So far, through much of the pandemic insurers have usually allowed calls to be counted as full “visits.” But those who pay our healthcare bills have a hard time imagining that seniors would be challenged to manage Zoom calls. Most surely need a more active imagination to understand why what is essentially video conferencing is poorly suited to an assisted living or nursing home situation.

There is also an additional advantage to audio-only visits. They allow a person to give up the natural anxiousness that comes with the offering of oneself to the gaze of others. This is no small matter, as anyone with a teen in the house knows. Almost all of us worry about how we will look to others. It’s part of the human condition. Face to face meetings require, in sociologist Erving Goffman’s perfect phrase, “the presentation of self.” Our presence in the same space with others carries the double burden of trying to meet perceived expectations, and implicitly inviting others to judge the-outer most shell of the self.

To some extent that still happens with voice-only messages.  But the so-called “white coat syndrome” is probably reduced. We can retain more of our personal “front,” making it easier to focus on what we are saying. For now, it remains to be determined how routine medical visits will look in the coming years.

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The Useful Idea of Social Intelligence

A person with high social intelligence has a set of ‘antennae’ that can be a guide for behavior that will give another more comfort than pain.

We are used to thinking of “intelligence” as a single entity.  But it’s not so simple.  To be sure, we have IQ scores and other measures of a person’s capacity for understanding abstract ideas and processing information.  But traditional measures of intelligence are notoriously imprecise. The term itself is difficult to operationalize, something that must happen with “objective” and comparative measures.  It’s thus problematic to saddle an individual with a number that is supposed to stand as a representation of their cognitive skills. It’s not unlike establishing the overall worth of a car by the time it takes it to go from 0 to 60 mph. You can do it, but it misses a lot. By contrast, there is something of greater value in the idea of social intelligence, even though it also will not easily yield to the insistence in most of the social sciences for specific metrics.

Broadly speaking, social intelligence is a capacity to “read” others and make adjustments to meet their expectations and norms. In practical terms, this turns out to be mostly a function of a person’s skill in knowing how to use a familiar ‘script’ employed in a given setting.  Opening a door for someone with a heavy load or asking the perfunctory “How are you?” are common scripted behaviors.

Psychologists sometimes talk about ‘theory of mind” as the related capacity to be able to anticipate what is going on in another person’s life, making adjustments that are more empathetic than indifferent. We know it when we see it, as when another person has said what seems like just the right thing to a needy friend.  We have also walked away from a conversation suddenly realizing that we wadded into a topic they consider taboo.

In actual fact, there are assorted ways we can sense another person’s social intelligence: in their abilities to self-monitor impulses that might be awkward, in a general willingness to engage even with strangers, or generally knowing how to listen to another and make appropriate responses. A person with high social intelligence could be said to have a set of ‘social antennae’ that are strong enough to grasp what will give more comfort than pain to another.

The phrase “social intelligence” is perhaps most clearly associated with the psychologist, Daniel Goleman, and his best-selling book under the same name (Bantam, 2006).  The book is a worthwhile study, even if its subtitle oversells the subject as a “science of human relationships.”

My own favorite thinker in this area is the less flamboyant sociologist, Erving Goffman. In his ever-popular Presentation of Self in Everyday Life (1959) he notes that we are actors creating responses appropriate to a given scene.  I don’t believe he ever used the phrase, but he was dogged in reminding us that social relationships are predicated on functional presentational skills. He talked about “impression management” and role taking as capacities that lie at the core of our relational world.  His mode of explanation was based less in survey research, using instead a method of deep description, giving simple exchanges a careful ‘reading’ of what they mean and reveal.

When observers see Donald Trump’s behavior as sometimes “unpresidential,” they are doing a kind of dramatic critique. 

The shift in perspective makes a big difference. Social intelligence is best understood as a function of our ability to perform words and deeds that are a good match for a given situation. There is no single standard or set of norms, effects or skills, but infinite possibilities.

This is why the dominant art form in our lives is film, with all of its variations and platforms.  Seeing individuals act in the presence of others is always a potential touchstone.  Comedy generally lets us see people behaving badly, or at least inappropriately. Our laughter flows from a recognition of violated social codes. And drama puts us in close to see moments when lives can be transformed. It isn’t the transformation itself that grabs us. It’s a character’s response to the problem that precipitated it. Their reactions are how we come to know the features of their character, especially their aptitude for rising to meet social circumstances fraught with complexities.

In a sense we are all critics of performances, using personal preferences and floating standards to assess the responses of others.  This more open-ended dramatic framework gives us the kind of pluralism of potential responses we need to understand the marvels and occasional disasters that unfold in social encounters.  For example, when observers see Donald Trump’s acts as sometimes “unpresidential,” they are doing a kind of dramatic critique.  However smart he is or isn’t, he is mostly graceless around others.  People have favorite examples.  One of mine: refusing to shake hands with Germany’s Angela Merkel during a White House photo-op early in his administration.

A final thought: It’s not unreasonable to expect a challenge to the Goffman view of social dramas on the grounds that digital media that was not around in his day takes us out of public spaces.  We obviously communicate much more via devices, and often with complete anonymity.  In these media we hardly pay attention to polite rules of engagement. Our statements can be all of “us” with little worry about “them.” Current research suggests this may be happening with our youth, who seem to struggle more to willingly meet adults and strangers face to face.  The nominal discomfort most of us felt growing into the adult world has lately grown to levels in the young that approach paralyzing fear.

I suspect that’s our problem more than it was his.  Social norms may change, but the need to match our behavior to them does not.