‘Trust my doctor, trust my pancreas’: trust as an emergent quality of social practice

Some limits of trust research

The majority of classic writing assumes trust primarily relates to the dyad between a trustee and a trustor–in the health context, between the doctor and patient–although in recent years, this scope has broadened to include more generalised kinds of trust; for example, in entities such as social structures, institutions and organisations [11, 12]. Much of this work has concentrated on what trust means in an abstract sense, whether in terms of its definition, its distinctions with related terms, or by developing a set of analytical principles (see for example [13, 14]). In this literature it is commonly said to be something we can ‘have’ , that can be incrementally increased and built up, or decreased and even lost altogether [15]. It is also said that possessing trust serves as a means to navigate the relationship between expertise and authority, and is frequently conceptualised not only as the basis for co-operation between people, but as a resource to be drawn on [16]. It’s not surprising, then, that many of these arguments draw on an underlying economic model in which trust is a precious form of capital that can be gained, invested, accumulated, given, undermined, earned, received, and so on. Some writers go further, and not only present it as an object of exchange and investment, but also the result of careful calculation, appraisal and management [17]. By reifying and generalising trust in this way, the associated terminology serves to support the idea it is a potentially measurable psychological entity [18], even though there is currently little agreement as to what dimensions to include, and hence no standard metric has been established [19].

However, as the psychologists Harvey et al. acknowledge [20], there is inevitably a difference between what people say about trust and what people actually do in practice (what they term ‘stated’ versus ‘enacted’ trust). A number of sociological studies investigating what is actually enacted in health contexts have consequently served to problematize the overtly mentalist approach of much trust research. Starting with the observation that it can be as much an affective state as a rational one, and that emotions can both guide and influence how trust evaluations are made [21], this work has, in combination, emphasised the complex negotiations that underlie interactions, and hence the plethora of situational factors likely to be significant. More specifically, ethnographic approaches not only reveal the subtle, pragmatic ways in which trust can surface [22] but also modes by which it is can be embodied (see for example [23]). Such work illustrates how conscious deliberations and evaluations of trust are often accompanied by other, less than conscious, processes. This general phenomenological approach highlights how objects and other non-human actors can shape the assumptions and interpretations actors make and that trust is actually a very fluid and varied entity (see for example [24, 25]). By doing so, this empirical work has led scholars to emphasise the contingent, contextual nature of trust [26], and that frequently there are other relevant actors beyond the classic dyad [27].

The renewed interest in care more generally, and in particular a relational approach that emphasises care as interaction rather than something that is simply bestowed on one person by another [28], also serves to illustrate the inherent ambiguity and ambivalence of health-related relationships. Brodwin [29] points out that because of this, care and coercion in health settings cannot easily be distinguished from each other, since the relationship between health carer and patient is invariably unequal and non-reciprocal. Thus, whilst trust might initially be associated with establishing symmetry or mutuality in a relationship, accounts also illustrate the ways in which sometimes trust can actually be produced by such imbalances. For example, some have noted how, in the health context especially, trust can sometimes be the only thing that an individual is left with when they have limited choice but remain dependent on others (see for example [30]). In such situations, both patients and professionals may try to preserve a sense of trust even when doing so is unjustified [31] and, further, that when they do so such attempts may become manipulative and surreptitious attempts to control the situation or the other party [32].

Nevertheless, whilst these primary accounts clearly demonstrate some of the ways in which deliberative evaluations of trust are accompanied by a wide range of other, non-conscious activities and effects, an implicit danger is that by continuing to adopt ‘trust’ as an abstract noun has the potential to reinforce the idea it can be separated from its context and that it consists of some universal properties independent of the situation within which it arises. Part of the problem is that this notion of trust commonly provides the basis on which it can be said to endure over time and in different contexts. Yet, as soon as it is rendered into such a generalised concept, discussion of trust necessarily has to become over-simplified and devoid of the specific details, histories and subjective standpoints that constitute its emergence in any particular instance. In other words, there remains a tension in the literature between, on the one hand, a strong emphasis on the situatedness of trust, and on the other, the use of a generic term that implies it is in some way an intrinsic, a priori, entity.

So how might one conduct an empirical study of trust in a health setting that resists presenting it as a bankable resource located inside the head or body, and instead presents it as a feature that is continually contingent on the features of specific contexts? By arguing that trust is not a psychological state or the result of deliberative evaluation, but rather something which only emerges from specific practices in particular situations shifts its conceptualisation from being an entity in and of itself, to being a quality potentially attributed by people to particular assemblages of people and things. Such a practice-based approach draws from diverse sources, including Pierce’s pragmatism [33], Tarde’s interactionist sociology [34] and Bourdieu’s notion of habitus [35], to provide an account of human behaviour not through trying to ascertain its antecedents, but rather from examining the ways in which meaning is a consequence of human action [36]. Although variations of practice theory have circulated in the social sciences for a number of decades, there has been a growing interest in them over recent years. In part, this can be attributed to a rejection of the dominance of individually-focused models which attempt to describe behaviour as the linear consequence of a set of internal processes. This can all too easily support an ideology of responsibilisation, by which the imperative on individuals to manage and take control rapidly becomes an expectation that only they are responsible for their health status [37].

Practice theory, in contrast, adopts a somewhat counter-intuitive approach, arguing that it is people’s actions in the world as they connect and co-opt other people and things which create meaning [38]. Rather than reproduce the mentalists’ distinction between what is conscious and what is automatic, a general commitment to embodied disposition and the interaction of ‘background’ [39] is used to highlight that, although we may not be aware of such processes, they are often comprise of very rich and creative processes. Initially this emphasis on how things are achieved or constructed ‘in the present’ may appear to negate the fact that trust has an enduring nature. After all, from the more usual perspective, trust is conceived of in terms of the influence it can have on how people access health care services or respond to them in the future; as such, it precedes in some form or other a particular event, such as choosing to take medication or follow a doctor’s advice. But a commitment to interrogating what gets done and said in specific social situations implies that what might be said to ‘travel’ from one context to another is not ‘trust’ per se, but rather the range of sociocultural and material resources that have the potential to influence its emergence in a new setting through further practices.

Diabetes and trusting relationships

Drawing on observations in a UK diabetes clinic, the remainder of this paper will use excerpts to illustrate ways in which trust arises during everyday exchanges and activities between doctors and patients. Instead of basing interpretations primarily on people’s reflections, attention is placed on the very specific circumstances of practice, including whatever material elements might play an integral role, since all these exert very real influence on shaping how an event is ultimately constructed or ‘achieved’. In order to illustrate the themes introduced– that matters of trust are emergent, always contingent on multiple factors, and remain inherently ambivalent–I draw on instances when matters of trust appear to be foregrounded even if this is not articulated by actors themselves.

The idea of ‘self-management’ has become an increasingly common feature in the care of chronic conditions such as diabetes. It could be said to be derived from two distinct forces: the shift from paternalistic to patient-centred care, and acknowledgement that on-going treatment strategies now require continual attentiveness and adjustment. Accompanying terms such as empowerment and concordance, and the proliferation of so-called shared-decision making tools, the drive to encourage patients to monitor, record and alter their medication, diet and exercise is broadly conceptualised in terms of mimicking the homeostatic feedback that the body lacks in order to achieve biochemical stability. Accompanied by the rise of electronic devices to measure glucose levels, and insulin pens and pumps to adjust different kinds of insulin to provide either a basal or immediate response, patients are being increasingly encouraged to reflect and act autonomously on their metabolism ‘in real time’.

Some commentators have been sceptical that an emphasis on promoting autonomy is in any way emancipating, and have commented that there is an increasing expectation that the idea of the patient as an ‘active’ subject who takes on primary responsibility for their care is merely an extension of disciplinary surveillance [40]. However, from another perspective it is not simply that the person with diabetes now has more things to do, but rather the patterning of who is responsible for doing those things, and when they are expected to be done, is shifting. In order to be able to manage their diabetes daily they must still use and rely upon a wide range of things and other people, just as they had done previously; but new configurations based on self-management refashion the nature of those relationships. In order to try and achieve some kind of blood glucose stability given this new distribution, many different associations not only need to be established and maintained, but need to be trusted.

My starting point, therefore, is adopt the idea of practices in order to concentrate on the details that relate to how matters of trust emerge and are enacted in a diabetes clinic. Using ethnographic vignettes to illustrate some of the breadth of trust practices, the following results serve to exemplify some of the apparently incongruous situations and the multiplicity of actors which fall within their broad scope. These examples are selected precisely because they may well be missed using methods that assume trust is a stable entity, such as a questionnaire prompt or formal interview. Ultimately, this paper presents trust as the degree to which the sense of stability and predictability emerges from a set of relationships between people, physical objects and the material environment, and hence how a quality attributed to such practices may determine, or restrict, opportunities for repetition in the future.