Sociology of Health & Illness Vol. 21 No.6 1999 ISSN 0141–9889, pp.

797–819

Is anybody there? Critical realism, chronic illness

and the disability debate
Simon J. Williams
Department of Sociology, University of Warwick

Abstract Taking as its point of departure the contested nature of the body,
in mainstream theory and the sociology of health and illness
alike, this paper seeks, albeit tentatively, to chart a critical realist
alternative to these debates using the controversial terrain of
chronic illness and disability as a case study. A critical realist
approach, it is suggested, enables us to: (i) bring the biological
body, impaired or otherwise, ‘back in’; (ii) relate the individual to
society in a challenging, non-conflationary or non ‘uni-
directional’ way; and (iii) rethink questions of identity, difference
and the ethics of care through a commitment to real bodies and
real selves, real lives and real worlds. Within all this, it is argued,
modern medicine does indeed, contra disability theory and
postmodern calls for the pursuit of so-called ‘arche-health’, have
a continuing role to play in the mitigation of human pain and
suffering, including the realities of chronic disabling illness
conditions and the associated ‘greying’ of Western populations.

Keywords: body, society, chronic illness, disability, postmodernism, critical

realism

Introduction

We live, it is said, in a world of uncertain times. Modernity itself, some

argue, has ‘collapsed’ under the weight of its own contradictions, giving way
to a new postmodern world of nomadic signs and symbols which ‘float’, so
to speak, in a hyperreal world with no ultimate grounding or referents
(Lyotard 1984, Baudrillard 1988). For others, in contrast, modernity and
the self are far from redundant themes. Rather, we are simply facing up to
contradictions which have long been apparent, but only now fully realised
(Giddens 1991, Bauman 1992). Modernity’s obituary, in short, has yet to be
written.
© Blackwell Publishers Ltd/Editorial Board 1999. Published by Blackwell Publishers, 108 Cowley Road,
Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.
798 Simon J Williams

The body too, hitherto viewed as a biological ‘given’ or extrinsic factor,

has also become increasingly uncertain in recent years, partly as a conse-
quence of the very upsurge of interest in corporeal matters both inside and
outside the academy, but also through the rapid growth of new technolo-
gies—from plastic surgery to organ transplants and the new genetics—
which render its seemingly immutable features increasingly ‘malleable’
(Williams 1997). This is perhaps most graphically captured in recent post-
structuralist thought where bodies are radically reconfigured as fluid, multi-
ple, fragmented and dispersed.
The body, in short, is everywhere and nowhere today: the more it is
talked about and studied, the more elusive it becomes; a fleshy organic
entity and a natural symbol of society; the primordial basis of our being-in-
the-world and the discursive product of disciplinary technologies of
power/knowledge; an on-going structure of lived experience and the founda-
tional basis of meaning, imagination and reason; the wellspring of human
emotionality and the site of numerous ‘cyborg’ couplings; the physical vehi-
cle of personhood and identity and the basis from which social institutions,
organisations and structures are resisted or reproduced. At best this has
served to capture the multifaceted nature of the body in society. At worst it
has led to a fragmentation of perspectives and a dispersal of approaches
which, for the most part, continue to talk past rather than to each other
(Williams and Bendelow 1998a).
These debates, in turn, have been reflected and reproduced within medical
sociology itself. From the dominance of Foucauldian influenced social con-
structionist approaches to medical knowledge (Armstrong 1983) and the
‘abyss of relativism’ to which it gives rise (Bury 1986) – to current debates
over chronic illness and disability (Bury 1997), including the attempt to
bring ‘impairment’ back in through a more ‘relational’ approach – the terrain
of health and illness has never been more hotly contested. To be sure, a
more integrative, less antagonistic phase of theorising and debate is now
being reached, one in which the physical and social, material and cultural,
experiential and representational are being brought together in promising
new ways. Yet these rapprochements are still somewhat embryonic and
much still remains to be done before these current impasses are successfully
overcome.
It is in this theoretical context that the present paper is located. Taking
the chronic illness and disability debate as a paradigmatic case study, a criti-
cal realist perspective is advanced as a possible ‘way forward’ in these and
many other body/society, structure/agency debates, both inside and outside
the domain of health itself. Critical realism, I venture, with its commitment
to deep underlying structures and mind-independent generative mecha-
nisms, offers us a promising way out of these dilemmas, bringing the biolog-
ical body back in, so to speak, without stripping agency of agency or
structure of structure. This, coupled with the current demise of postmod-
ernism, suggests that the time of critical realism has indeed arrived. It is
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with this claim in mind—a claim which, as we shall see, becomes an onto-
logical warrant—that my arguments proceed.
Essentially, the paper falls into two main parts, in the first section I seek
to contextualise these debates further through a focus on the contested
nature of the body within both mainstream theory and the sociology of
health and illness, focusing in particular on the chronic illness and disability
debate. Having done so, I then proceed to ‘flesh out’ what a critical realist
approach to these issues and debates entails, including a rethinking of the
biological, an emphasis on the ‘emergent’ nature of disability, and a reasser-
tion of modernist medicine as a critical resource in the biographically
embodied lives of the chronically sick and disabled—themselves a heteroge-
neous population with diverse needs, identities, values and wishes. Given
the lack of previous work of this nature, what follows is necessarily tentative
and provisional. It does, however, I suggest, offer us a glimpse of what criti-
cal realism has to offer, not simply as an alternative to ‘personal tragedy’
and ‘social oppression’ models of chronic illness and disability, but also to
social constructionism and postmodernism more generally. It is to the first
of these issues that I now turn.

The ‘contested’ body

The body, as suggested above, is everywhere and nowhere today. Within

social theory, accounts tend to bifurcate on two levels. At the ontological
level this occurs between foundationalism (i.e. an organic, pre-social body as
a material entity beyond discourse) and anti-foundationalism, and at the
epistemological level between social constructionism (i.e. the body as a dis-
cursive product of power/knowledge) and non-constructionist positions
(Turner 1992). These approaches, in turn, relate to other distinctions and
divisions between, for example, the experiential and the representational
bodily order and the embodiment of social action, as well as the body incar-
nate (i.e. the lived body), the corporeal (fleshy shell) and the somatic (i.e. the
medicalised body) (Frankenberg 1990).
Indeed, a panoply of bodies now, quite literally, litter the field, from
Falk’s (1994) ‘consuming body’ to Martin’s (1994) ‘flexible’ body, and from
Barker’s (1984) ‘tremulous’ body to Shildrick’s (1997) ‘leaky’ body. If we
add to this growing corpus of work, other extant writings on bodily themes
and issues such as Foucault’s (1973, 1979) ‘discursive’ body and ‘technolo-
gies of self’ (1988), Merleau-Ponty’s (1962) ‘phenomenological’ body and
Baudrillard’s (1988) ‘hyperreal’ body, one can readily appreciate this recent
burgeoning of corporeal interest within contemporary social theory. Whilst
various attempts at analytical integration have recently been made
(Williams and Bendelow 1998a), we do not, as yet, have a general theoreti-
cal framework with which to satisfactorily address the range of ontological
and epistemological questions surrounding the body and its broader
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800 Simon J Williams

relationship to the socio-cultural and historical order (Turner 1992). The

body, in short, remains as elusive, if not ‘elusory’, as ever (Radley 1995).
Whilst this may be a source of lament for some, for others it is to be
wholly celebrated. Postmodernism, for example, in its challenge to the dis-
embodied rationalist actor, is paradoxically, at one and the same time, both
a championing of corporeal intimacies and libidinal excesses, including the
transgressive potential of desire itself, and a dissolution of the body alto-
gether. It is a body without organs (BwO), reconfigured in terms of intensi-
ties and flows, fragments and multiplicities, involving an endless process of
becoming (other) (Deleuze and Guattari 1984, 1988). Within post-
structuralist feminism, too, writers such as Butler (1993), drawing on both
Foucauldian and Lacanian ideas, are able to reconceptualise the materiality
of sexed bodies as an effect of power, indeed as power’s most productive
effect. ‘Once sex itself’, as she states, ‘is understood in its normativity, the
materiality of the body will not be thinkable apart from the materialization
of that regulatory norm’ (1993: 2). Sex, in other words, is no longer a ‘bio-
logical given’ upon which gender constructs are artificially imposed. Instead
it becomes a ‘cultural norm’ or ‘regulatory ideal’ which governs the materi-
alisation of bodies themselves. This, in turn, keys into other developments
such as ‘queer theory’, in which the emphasis is placed firmly on ‘identities
which are multiple, or at best composites, with an infinite number of ways in
which “identity-components” can intersect and combine’ (Seidman 1996: 6).
In this way, new opportunities and alliances have ‘opened up’, not simply
surrounding questions of sexual identity and the celebration of ‘perverse
desire’, but also in terms of the ‘transgression of transgression’ itself (Grosz
1995, Grosz and Probyn 1995).
The sociology of health and illness has also proved a fertile terrain upon
which many of these evolving corporeal debates are currently being fash-
ioned, albeit in substantively more grounded ways. Indeed, from social
constructionist accounts of medical knowledge and the metaphorical
nature of disease and illness, to social inequalities in health and the phe-
nomenology of pain and suffering, sickness and death, the body has been
an implicit, if not explicit, theme in medical sociology. To this we may
add other work, both past and present, on the intersections of health, risk
and consumption, the medicalisation of (women’s) bodies, the dilemmas of
high technology medicine, and the gendered/emotional division of labour
in health care. In these and many other ways, medical sociology again
raises, in acute form, the ambiguous status of the body in relation to tradi-
tional nature/culture, biology/society divisions. Medical sociology, in short,
is proving central to the theoretical and empirical elaboration of the rela-
tionship between body, self and society. Indeed, as Turner (1992) boldly
proclaims, given these corporeal trends, medical sociology may prove to be
the ‘leading edge’ of contemporary social theory: a challenging claim
indeed given its, at times, turbulent relationship with medicine over the
years.
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Perhaps the key area where these debates are currently being played out,
is in relation to the sociology of chronic illness and disability. Whilst early
work within medical sociology was taken up with debates over disability as
‘deviance’ (Freidson 1965, 1970), together with the documentation of needs
and numbers in national surveys of ‘impairment and handicap’ (Harris et al.
1971), increasing emphasis has been placed, from the mid-1970s onwards,
on the meaning and experience of chronic disabling illness conditions and
the negotiation of self and identity in everyday life. Theoretically, the impe-
tus for these studies stemmed from the pioneering work of Strauss and
Glaser (1975) in the US concerning Chronic Illness and the Quality of Life,
alongside Blaxter’s (1975) detailed work on the unfolding Meaning of
Disability, both practically and socially, over time. Strauss and colleagues in
particular, within the ‘grounded theory’ tradition (Glaser and Strauss 1967)
looked at the ‘bargains’ people struck and the ‘balances’ they attempted
between their illness, their treatment regimens, and their precarious sense of
selfhood: a ‘negotiation model’ of illness within the interactionist paradigm,
rooted firmly in the context of the chronically ill and their families’ everyday
life (Gerhardt 1989). The largely passive view of individuals succumbing to
stigmatising labels—prevalent in earlier labelling perspectives and ‘crisis’
models of illness—is, therefore, countered through an approach in which
aetiology is seen as a ‘bargaining’ process connected with diagnosis, and
therapy as the ‘work’ of both patient and professional in organisations con-
ceived as ‘negotiated’ orders (Gerhardt 1989).
These perspectives have in turn been carried forward and subsequently
developed in the British context by writers such as Bury (1982, 1988, 1991),
Locker (1983), G.H. Williams (1984), Scambler (1989), Kelly (1991) and S.J.
Williams (1993) on disease-specific, disabling conditions such as rheumatoid
arthritis, epilepsy, colitis and chronic obstructive airways disease (COAD).
In doing so, key concepts and insights have been advanced, including the
biographically disruptive nature of chronic illness, the importance of narra-
tive reconstruction, the negotiation of selfhood and identity, as well as the
positive actions which people take in the face of their adversity: responses
which, analytically, may be referred to as coping, strategy and style (Bury
1991, Radley and Green 1987). To this we may add other more recent work
on pain, gender and emotions (Bendelow 1993, Williams and Bendelow
1998a, b, Williams 1996a), together with that of Kelly and Field (1996) and
Seymour (1998) which calls for a return to the bodily dimensions of chronic
illness in relation to both self and social identity. Biological and physical
facts, as Kelly and Field note, are sociologically significant because they (i)
impinge directly on the self; (ii) provide signals for identity reconstruction;
and (iii) act as ‘limiting’ factors on social (inter)action.1
In documenting the meaning as well as the consequences of chronic illness
(Bury 1988), this work has certainly advanced our knowledge and under-
standing of these conditions, including the reality of coping with them on a
day-to-day basis, and the practical strategies and styles of adjustment they
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call forth. It has also served to articulate the voices and concerns of those
who might otherwise not have been heard.2 Much of chronic illness, as these
studies amply testify, is suffered in ‘silence’, so to speak, behind ‘closed
doors’ (Anderson and Bury 1988). To the extent that medical sociology has
been instrumental in bringing this reality, and the challenges it creates for
people and their families, to the attention of policy makers and service
providers, it has contributed much to the mapping of chronic disabling ill-
ness as an issue which extends far beyond the biomedical remit. These
approaches, however, have themselves come under increasing attack in
recent years from a variety of quarters.
On the one hand, writers such as Fox (1993), from a postmodernist per-
spective, have challenged the modernist readings embedded in this model of
the ‘suffering self’.3 Pain, for instance, although allegedly a ‘private’ or
‘inner’ sensation, has been problematically transformed, according to Fox,
through a modernist model of the ‘fabricated’ human subject within the
sociology of health and illness. For Fox, the anatomical body is not, in fact,
the ‘carapace of the self’. If the self does inhabit such an ‘interior’ location,
then this is seen as a consequence of discourse. In contrast, following
Deleuze and Guattari (1984, 1986), Fox argues that the organism is an
effect—i.e. a ‘pattern of intensities on the Body without Organs (BwO)’, the
latter conceived as a ‘political surface of (de/re)territorialised intensities and
flows of desire’—which in the modern period is exemplified, par excellence,
by medical discourse (1993: 145). From this ‘decentred’ perspective on the
‘postmodern self’, lived experience, including the experience of pain itself, is
simply the:

fabrication of a BwO, a political locus, stratified by discourse, desire and

physical sensation (including pain). Pain—as sensation—has no implicit
meaning. But a territorialization of the BwO as organism (creature of
biomedical and more recently human sciences discourse) provides the
possibility for pain to signify. Once it signifies in relation to the organism,
it contributes to the self, to subjectivity. In this reading, it is not the self
which experiences pain or attributes meaning to it, the self is the pain, the
self is an effect of meaning (Fox 1993: 145, my emphasis).

To put the matter another way, discourses on health and illness within the
medical and human sciences contribute to a particular territorialisation of
the ‘pained’ BwO, organised in terms of the ‘organism’: a biomedical or
biopsychosocial body with organs. Similarly, the modernist focus on issues
such as biographical disruption and the search for meaning and legitimacy,
described above, merely serves, we are told, to ‘fabricate’ a subject who is
effectively ‘trapped’ within her/his ‘pained’ body and is required to ‘adjust’
or ‘adapt’ to the limitation this engenders. As a consequence, the effects of
the disciplines of the body (including sociology) in constituting this kind of
subject remain obscured (1993: 146). For Fox, the solution to these mod-
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 Is anybody there? 803

ernist dilemmas lies in a process he cryptically refers to as ‘arche-health’,

something which, of necessity defies definition, but nonetheless involves a
‘deterritorialisation of the BwO as a perquisite for new forms of ‘nomadic’
subjectivity and the endless process of becoming ‘Other’.
These are issues I shall return to shortly below (see Williams and
Bendelow (1998b) for a sustained critique of this postmodernist position on
pain). For the moment, however, it is to another major challenge to the
sociology of chronic illness and disability that I turn, one stemming from
the disability movement itself and its attempt to ‘write the body out’ com-
pletely from the biology/society equation. Whilst the World Health
Organisation’s (WHO 1980) model of impairment (abnormality in the struc-
ture or functioning of the body), disability (activity restriction) and handicap
(social disadvantage) has implicitly, if not explicitly, underpinned much
sociological work to date in this field (see, for example, Williams and Bury
1989). Writers such as Oliver (1990) however reject this model in favour of
an approach in which disability itself, far from being a result of limitations
caused by impairment or physical trauma, is instead seen as a form of
‘social oppression’. Disablement, from this alternative viewpoint, has ‘noth-
ing to do with the body’, its ills or ailments, and everything to do with soci-
ety, including the prejudices and barriers which ‘mitigate against full
participation on equal terms’ (Swain et al. 1993). Medical sociology, in
endorsing this view of the impaired body is complicit, it is claimed, wittingly
or otherwise, in a medicalised approach to disability which is closer to a
model of ‘personal tragedy’ than it is to an endorsement of ‘social oppres-
sion’. Disability, in short, contra the WHO, is not an outcome of bodily
pathology, but of social (dis)organisation.
To be sure, this represents a deft move on the part of disability theorists,
turning the tables, so to speak, on sociologists themselves through a critique
of their supposedly limited ‘socio-medical’ model. Yet a number of prob-
lems remain, only some of which I will touch on here. First and foremost,
we have the ‘writing out’ of the body from any discussion, deliberation or
debate on the nature of disability itself. In this respect, a number of para-
doxes emerge, not least of which is that the body itself, through this tactic, is
‘conceded’ to medicine, rather than remaining open for sociological discus-
sion and debate (Hughes and Patersen 1997). A form of essentialism, in
other words, not to mention dualism, concerning the body creeps in through
the back door, despite the advocacy of a thorough-going social model of
disability which eschews any discussion of impairment or functional limita-
tion. The sociology of the body and the social model of disability, from this
vantage point, are indeed moving in opposite directions: the former towards
and the latter away from the problem of embodiment. As Hughes and
Paterson state:

In harbouring an essentialist, natural standpoint relative to the body the

social model of disability creates a conceptual barrier to the development
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804 Simon J Williams

of a sociology of impairment and creates a disembodied notion of

disability . . . The distinction between disability and impairment de-
medicalises disability, but simultaneously leaves the impaired body in the
exclusive jurisdiction of medical hermeneutics. While the sociology of the
body seeks to challenge biomedical monopoly over knowledge about the
body, the social model of disability concedes it (1997: 330).

Disability theorists, in short, like their sociological counterparts of yester-

year, seem to be suffering from a peculiar form of what Spelman (1988), in
the context of Western feminist thought, has appositely termed ‘somatopho-
bia’: one involving an ‘overly drawn’ view of society itself. That postmod-
ernists suffer, paradoxically, from the same ailment, despite their linguistic
commitment to corporeal issues, is equally apparent, given their ethereal
commitment to the ‘discursive’ body: one whose matter really doesn’t mat-
ter at all.
It is also somewhat ‘surprising’, given this thorough-going commitment
to the social, that so little attention has been paid to date by disability theo-
rists to postmodernism and post-structuralism. It is surprising in the sense
that both, in their different ways, write the body out, pointing in the process
to how things could be ‘otherwise’.4 If, for example, medical language ‘pro-
duces’ impaired bodies—a problematic contention to be sure—then it can,
as Hughes and Paterson note, also be ‘deconstructed’ (1997: 333). Indeed, it
is only in the context of ‘difference’ and ‘heterogeneity’ within the disability
movement itself, as these authors note, that these perspectives have been
turned to and drawn up, fruitfully or otherwise (1997: 333). Shakespeare
(1996), for example, in discussing the struggles of feminists, black people,
gays and lesbians, draws on post-structuralist writings to explore how dis-
abled people can actively craft and script their own narratives and ‘stories’
and in doing so, construct a new persona or identity for themselves.
‘Disability identity’, he proclaims, ‘is about stories, having space to tell
them, and an audience which will listen. It is also about recognising differ-
ences . . . Some we might choose to change, others to recuperate or cele-
brate’ (1996: 111).
Enough has already been said to suggest that this ‘linguistic turn’, how-
ever muted within the disability movement as a whole, is not without its
problems. Suffice it to say that signs of rapprochement between medical
sociologists and disability theorists are now beginning to appear, including
an opening up of questions surrounding impairment itself. Crow (1996) for
example, herself a disabled feminist who has been active in the disability
movement for over a decade, has cogently argued for the need to bring
‘impairment back in’ to the disability debate. Bury (1996) too, argues for
what he terms a ‘relational’ view of disability which focuses on the interac-
tions between the individual and their social location: something which, he
stresses, moves policy makers away from a narrowly defined medical view-
point (see also Williams 1996, Kelly 1996 and Pinder 1996 for further
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 Is anybody there? 805

variants on this theme). Critical realism, I contend, adds a further voice to

this debate, one which, like these other recent attempts at rapprochement,
offers a fruitful way forward in bridging the chronic illness and disability
divide.
What then does a critical realist perspective entail? How does it build on
previous work in this area? And what limitations does it expose and over-
come in the postmodernist and disability critiques themselves? It is to these
key questions that we now turn.

Bridging the divide?

Variants of realism have been around for some time in sociology. A com-
mitment to mind-independent generative structures and non-observable
causal mechanisms has been an abiding sociological theme. This can be
observed from Durkheim’s assertion of the social as a reality sui generis, to
Marx’s discussion of the deep underlying structures and contradictions of
the capitalist mode of production, and from Sayer’s (1992) Method in Social
Science, to Bhaskar’s (1989a) Reclaiming Reality. Bhaskar, in particular,
has been instrumental in these developments, from his early work on A
Realist Theory of Science (1997 [1975]) to his more recent bold attempt to
diagnose, explain and resolve the ‘problems of philosophy’ in Plato Etc.
(1994).
In recent years, critical realism—Bhaskar’s preferred choice of term—
appears to have gained momentum in social theory, its fortunes seemingly
inversely related to the demise of postmodernism. Whilst realism, critical or
otherwise, remains a relatively underdeveloped perspective within medical
sociology to date, those who have embraced it—from Durkheimian
approaches to society, disease and stress (Taylor and Ashworth 1987,
Mestrovic and Glassner 1983), to Marxist perspectives on the value of
labour power (Blane 1987) and realist challenges to the sociology of scien-
tific knowledge (SSK) (Abrahams, 1995, 1997)—have demonstrated its rele-
vance, not simply as a viable perspective in its own right, but also as a
challenging alternative to the relativism of constructionism itself. What then
can such a perspective offer to the chronic illness and disability debates
described above?

Bringing the biological body ‘back in’

Perhaps the first, and most obvious point of departure, in charting a critical
realist path through these debates, concerns what Bhaskar (1989a) terms the
‘epistemic fallacy’. The nub of the problem here, and the issue to which any
serious critique of a social model of chronic illness and disability must nec-
essarily return, is the conflation of the ontological with the epistemological.
What this boils down to is a situation in which the biological body,
impaired or otherwise, is simply reduced, both by postmodernists and
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806 Simon J Williams

disability theorists alike, to what is known about it—i.e. the belief that ‘ . . .
statements about being can always be analyzed in terms of statements about
our knowledge (of being)’ (1989a: 13).
The epistemological and ontological cannot, Bhaskar maintains, simply
be conflated in this way. Rather, the social and natural world, as he con-
vincingly demonstrates, comprises three key domains. First, we have the
empirical, a domain founded on (observable) experience. Not all events,
however, are experienced. The actual, in contrast, the second of Bhaskar’s
three domains, consists of both events and experiences. Deep underlying
mechanisms or causes, however, insofar as they are not realised, do not
belong here either. They are nevertheless real, whether experienced or not.
As such, they properly belong to a third domain which, perhaps unsurpris-
ingly, Bhaskar refers to as the real: a domain in which mechanisms, events
and experiences can all occur. It is this third domain of the real, including
the generative causal mechanisms it contains independent of our knowledge
or perception of them, which constructionists and postmodernists alike have
most difficulty with, muddying the issue through a conflation of what is
with what is known about.
Disease labels, for instance, to take a medical example, variable as they
are, are merely descriptive, not constitutive of disease itself. Similarly, if soci-
ety has few categories of disability, then this cannot simply be taken to
mean that disability does not exist. If, on the other hand, it has an elaborate
taxonomy of disabilities, it does not (necessarily) follow that it has more dis-
ability. To argue otherwise is to commit, wittingly or unwittingly, an epis-
temic fallacy. The body in short, diseased or otherwise, is a real entity, no
matter what we call it or how we observe it. It also, like all other social and
natural domains, has its own mind-independent generative structures and
causal mechanisms. As such it has an ontological depth independent of epis-
temological claims, right or wrong, as to its existence.
Not only does our embodied nature as a ‘species-being’ constrain who can
become persons, it also, as Archer notes, has direct implications for what
such people can do:

. . . the characteristics of homo sapiens (as a natural kind) cannot be

attributed to society, even if they can only be exercised within it. On the
contrary, human beings must have a particular physical constitution for
them to be consistently socially influenced (as in learning speech, arith-
metic, tool making). Even in cases where the biological may be socially
mediated in almost every instance or respect . . . this does not mean that the
mediated is not biological nor that the physical becomes epiphenomenal
(1995: 288, my emphasis).

Humanity, in short, is never simply a ‘gift’ from society (1995: 285). We

must not, therefore, conflate ‘human beings’ and their capacities with social
beings (1995: 293). Here we return, once again, to the errors of postmod-
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 Is anybody there? 807

ernism, post-structuralism and the like, errors which are effectively resisted
by claiming that we are so much more than society can ever ‘make’ of us
(1995: 293).
Underpinning this, as alluded to above, is an attempt to ‘rethink’ the bio-
logical in terms which do not simply reduce it to the social or vice versa.
Benton (1991), for example, suggests that new ways of understanding sci-
ence and its relationship to culture, alternative ways of philosophically
ordering scientific knowledge, and newly influential social movements—
from ecology to animal rights—have all combined in recent years to impel
or facilitate new ways of thinking about biology and the human sciences.
The choices, he suggests:

. . . no longer have to be seen (in reality they never did) as limited to an

intellectual imperialist, politically conservative biological reductionism,
on the one hand and an idealist or dualist anthropocentricism, on the
other. The state of biological science is fluid, there are numerous compet-
ing conceptualisations within biology, and there are several well-
articulated alternatives to reductionist materialism available for use as
philosophical means in the attempt to re-think the biology/society relation-
ships (Benton 1991: 18, my emphasis).

We may indeed, therefore, as this quote rightly suggests, need to give the
biological an, albeit cautious, ‘welcome back in’: a re-alignment which in no
way implies ‘reductionism’ or a defence of ‘genetic determinism’ (Benton
1991). Such a programme meshes closely with critical realist views of the
natural and social world; one which strikes at the very heart of postmod-
ernist claims regarding the discursive body/self as an inter-textual effect or
modernist; fabrication’, and at disability theorists’ attempts to write the
reality of impairment out of the picture so to speak, through a ‘social model
of oppression’.
This, then, is the first premise upon which a critical realist contribution to
the disability debate is based, building as it does on an ontological defence
of the body, impaired or otherwise, as a pre-discursive entity.

Structure/agency: disability as an ‘emergent’ property

The next step in piecing together this case for critical realism concerns how
precisely we are to relate this ontologically premised, biological body, to
society and what we are to make of disability in the process: a property of
bodies, a social product, or both? Certainly, these problems are not intrinsic
to the disability debate, rather, micro-macro, structure-agency, individual-
society questions have dogged sociology since its inception. This, in turn,
suggests a further, preliminary question, concerning what exactly we mean
by the ‘social’ in the first place: a linguistic contrivance or a real entity, like
bodies themselves, with deep underlying structures and generative mecha-
nisms? In answering this question, and resolving the dilemmas it raises, we
© Blackwell Publishers Ltd/Editorial Board 1999
808 Simon J Williams

should, hopefully, be in a far better position to relate one to the other, so to

speak (i.e. real bodies to real social structures).
In responding to these key questions, critical realism begins from three
basic ontological premises about the nature of social reality, namely: intran-
sitivity, transfactuality and stratification. Together, as we shall see, they not
only preclude the (postmodernist/post-structuralist) collapse of the ontolog-
ical into the epistemological, but also provide us with a resolution of the
structure/agency problem in a manner which accords equal weight to each
without falling into the other ‘conflationary traps’ of structuration theory
(Archer 1995), or the ‘one-sided social determinism’ of disability theory.
Taking each of these issues in turn, first, critical realism, in keeping with
its commitment to the three domains of the empirical, actual and real,
involves the substitution of an ontology of structures for one of observable
events (i.e. positivist empiricism based on experience) (Archer 1998: 195).
The existence of intransitive entities, which are independent of their identifi-
cation, is, Bhaskar (1989a) claims, a precondition of the possibility of social
science, without which there could be no explanatory programme.
Knowledge has intransitive objects, in other words, which exist and act
independently of it (1989a: 68). Not only does this preclude the pitfalls of
the ‘epistemic fallacy’ (discussed above), it also insists that what is the case
places limits upon how we can construe it (Archer 1998: 195).
The second core premise upon which critical realism is founded is that of
the transfactuality of mechanisms (i.e. that their activities are continuous and
invariant, stemming from their relatively enduring properties and powers,
despite their outcome displaying variability in ‘open’ as opposed to ‘closed’
systems). Only on the metaphysical assumption that some things are neces-
sary and at least relatively enduring can we reasonably set out to practise
science or study society (Archer 1998: 196). The key word here is relatively
enduring, for the transitive is essentially mutable, therefore freeing critical
realism from the charge of over-determinism in which structures can never
be changed and social agents are stripped of social agency. Indeed, as we
shall see, one of the defining features of society, for the critical social realist,
is its morphogenetic nature (i.e. its capacity to change its shape and form)
(Archer 1995).
Finally, the realist insistence that reality is stratified underpins the general
rejection of a social or any other science reliant upon surface sense data
alone (i.e. experience)—one in which the three domains of the real, the
actual and the empirical, identified earlier, are collapsed into one. This lack
of ontological depth precludes crucial transcendental questions about the
necessary conditions under which experience is possible at all. This, in turn,
as Archer (1995) points out, introduces elements of temporality into the
explanatory programme, for instead of horizontal explanations relating one
experience, observation or event to another—cf. Humean notions of causal-
ity as the ‘constant conjunction of events’—the fact that these themselves
are conditional upon antecedents requires vertical explanations in terms of
© Blackwell Publishers Ltd/Editorial Board 1999
 Is anybody there? 809

the generative mechanisms and relationships indispensable for their realisa-

tion (Archer 1995). Ontological depth, in short, necessarily introduces verti-
cality into causal explanation which simultaneously entails temporality:
‘when we ask what needs to be the case for “x” to be possible, we predicate
its realisation on the prior materialisation of the conditions of its possibility’
(Archer 1998: 197).
Underpinning this is the analytical decoupling of structure and agency,
not in order to abandon their articulation, but, on the contrary, so as to
examine their mutual interplay across time; something which can result both
in stable reproduction or change through the emergence of new properties
and powers. As Archer (1995) rightly argues, contra Giddens (1984) and
other conflationists, separability is the indispensable predicate for examining
the interface between structure and agency upon which practical social theo-
rising, in health as elsewhere, depends. Only on this basis, Archer claims, is
it possible to talk about the stringency of structural constraints versus degrees
of agential freedom. Social structure and human agency, in other words,
according to Bhaskar’s transformational model of social action (TMSA),
are:

. . . existentially interdependent but essentially distinct. Society is both

ever-present condition and continually reproduced outcome of human
agency: this is the duality of structure. And human agency is both work
(generically conceived), that is, (normally conscious) production, and
(normally unconscious) reproduction of the conditions of production,
including society: this is the duality of praxis (Bhaskar 1989a: 92).

In this respect, the social ontology of realism—based as it is on notions of

‘pre-existence’, ‘relative autonomy’, ‘causal influence’ and ‘emergent’ proper-
ties and powers—not only serves as an important counter-weight to the lin-
guistic indeterminacies of postmodernism and post-structuralism, it also
enables us to analyse critically the social processes by which structure and
agency shape and re-shape one another over time. In doing so, one is able to
counter the ‘over-socialised’ conception of the agent—a fallacy of both sociol-
ogists and disability theorists alike—and critically to explain variable outcomes
at different points in time. For the realist, the essential factor which guarantees
that social systems remain forever ‘open’ is that they are ‘peopled’ by agents
and actors who possess a critical reflexivity and creativity toward the world in
which they live (Archer 1995). It is this set of assumptions which form the core
of Bhaskar’s (activity-dependent) TMSA discussed above.
Schematically, this temporal model, in Archer’s (1995) morphogenetic
terms, becomes one of structural conditioning—which necessarily pre-dates
the actions which transform it, and about which we may or may not be con-
sciously aware—socio-cultural interaction, and either structural elaboration
(morphogenesis) or structural reproduction (morphostatis). Postmodernist
representations of ‘structures’ as mere constructs, subject only to ‘discursive
© Blackwell Publishers Ltd/Editorial Board 1999
810 Simon J Williams

negotiation’, thereby fall by the wayside in favour of a critical realist com-

mitment to deep, underlying, non-observable structures and generative
mechanisms, with real outcomes in the real world. So too, disability theo-
rists’ overly-drawn picture of the social as a one-way determinative struc-
ture is abandoned in favour of a more critically ‘open’, ‘variable’ outcome
or state of affairs.
The fact that not all is revealed to consciousness because it is shaped out-
side our conscious awareness is something the postmodernists have consid-
erable difficulty with. This is turn makes for the ‘critical’ and ‘emancipatory’
potential of critical realism: a project which, in the context of postmod-
ernism calls for resistance, promises something far more concrete and tangi-
ble than the shift to alternative discursive registers and economies of desire.
Revealing these factors not only points to the contextual causes of epistemic
fallibility, it also opens up the possibility of structural change, through con-
scious awareness and critical social praxis.
That such a realist explanatory programme and morphogenetic approach
to structure/agency meshes closely with current debates on chronic illness
and disability, body and society, should, I hope, be clear. Disability, from
this perspective, is an emergent property, located, temporally speaking, in
terms of the interplay between the biological reality of physiological impair-
ment, structural conditioning (i.e. enablements/constraints), and socio-cultural
interaction/elaboration. Within this model, structures may be faithfully
reproduced or transformed through the conscious awareness and critical
praxis of social agents, both individually and collectively: a factor of consid-
erable importance to the disability movement as a whole. The social, in
short, is more satisfactorily addressed (i.e. no mere linguistic contrivance),
and the body/society relationship, in turn, more adequately worked through
(i.e. both structural conditioning and degrees of agential freedom) from this
critical realist position. In doing so, as I have already argued, it exposes and
overcomes the limits of postmodernism and disability theory alike: both of
whom’s notions of the ‘social’ are found wanting in important respects.

The politics and ethics of care, identity and difference

The last key issue I should like to raise in this critical realist reconstruction
of the disability debate returns us full circle, to a reassertion of real bodies
and real selves as an ‘antidote’ to the playful deconstructions of postmod-
ernism, including a ‘realist defence’ of biomedicine itself in the face of its
critics, both inside and outside the disability movement.
In by-passing the body, disability theorists have tended to assume, implic-
itly if not explicitly, a homogeneity of interest between themselves and those
whose interests they claim to represent. This, of course, is far from the case.
Much of the disability, as has been suggested, is the product of chronic ill-
ness conditions with a diverse array of symptoms and their own disease-
specific trajectories. Moreover, much of this is contained in the middle to
latter part of the lifecourse, making age, alongside gender, class and ethnic-
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 Is anybody there? 811

ity important factors in the social patterning of chronic illness and disabil-
ity. The needs and wishes, desires and interests of a middle-aged woman
with chronic rheumatoid arthritis are, therefore, likely to be very different
from those of an elderly man with senile dementia, or a young person in a
wheelchair following a severe, life-threatening, motor vehicle accident.
Diversity and difference, in other words, are rooted in real impaired bodies:
bodies problematically ‘written’ both in and out of the picture by postmod-
ernists and disability theorists alike. To the extent that heterogeneity is
acknowledged, it tends to be confined, by and large, to the ‘linguistic regis-
ter’ and the subtle play of signs and symbols through a politics of identity
reconstruction and the telling of ‘stories’ (see, for example, Shakespeare
1996). The selves figure in these stories, in this sense appear to be lodged in
them rather than the author of them.
Here we return to the problems of postmodernism and post-structuralism
discussed above. Clearly identity reconstruction, given the variety of nega-
tive imagery surrounding disability, both past and present (Hevey 1992), is
important. As Hughes and Paterson note:

The extent to which impairment can be re-represented (displaced from its

association with the grotesque and its role as the other relative to the
aesthetic ideals about the body) and reconstructed (in terms of pride and
positivity as opposed to a site for the existential fears of the non-disabled
community) could be a matter of considerable importance for the devel-
opment of a cultural politics of identity (1997: 332).

Yet we must not lose sight here, as argued above, of the fact that our identi-
ties are lodged in our bodies, for better or worse, and that this in turn places
certain fleshy ‘limits’ on the extent to which such ‘identity reconstruction’ is
possible. As Oliver Sacks’s (1985) weird and wonderful case-histories show,
identities are indeed organically moored, and individuals, sometimes against
all odds, struggle hard and heroically to maintain a sense of personal coher-
ence and continuity with the past in the face of their adversity (Williams
1993, 1996a). Even major impairment, such as bodily paralysis, cannot it
seems, as Seymour (1998) movingly shows, annihilate these people’s embod-
ied sense of fun.
Returning to our earlier arguments, a crucial distinction can be drawn
here, Archer (1995) claims, between our evolving concept of self (which is
indeed social) and the universal sense of self (which is not). Unless such a
distinction is maintained, she argues, the ‘persistent danger’ lurks of trying
to ‘absorb the sense of self into the concept and thus to credit what is
universal to the cultural balance sheet’ (1995: 283). Personal and social
identities are not therefore synonymous, yet an enduring sense of the former
is essential for the latter. Social identity, in short, is emergent from personal
identity: one grounded in our humanity which, in turn, is prior and
© Blackwell Publishers Ltd/Editorial Board 1999
812 Simon J Williams

primitive to our sociality. It is only if due weight and allowance is given to

this ‘extra-social space’, Archer maintains:

. . . that there can be a self who is sufficiently strong to resist collapsing

into the social . . . one . . . who actively contributes to the social identity
which s/he adopts (1995: 292).

If this first point fires a warning shot across the bows of those disability the-
orists currently contemplating the merits of a postmodern politics of iden-
tity reconstruction, then the next point, equally, should force them to
reconsider the merits of modern medicine itself as a response to the misery
and suffering of chronic disabling illness.
Any adequate discussion of ethics, I venture, must ultimately return us to
our embodiment (i.e. our fleshy all-too-human selves), the contingencies this
involves, and the carnal link it provides with other similarly mortal beings
and enmattered selves, rich or poor, healthy or sick. That modern medicine
responds to these dilemmas, however problematically, puts it on a firm
moral footing: a candle of hope flickering precariously in the wind of our
malaise. Anything else, to put it bluntly, is an abrogation of our responsibil-
ities in the real world. Postmodernism, in truth, as Charlton (1993) rightly
comments, is really only an option for the healthy, not the sick. Similarly,
endorsement of disability solely as social oppression is really only an option,
and an erroneous one at that, for those spared the ravages of chronic illness.
This is an option, it should be noted, which negates the reality of their own
impairment, the needs to which it gives rise, and the biological basis for
legitimate social change. When we are ill, when the taken-for-granted rela-
tionship we have to our bodies is rendered problematic, we need the ‘cer-
tainties’, however precarious, which modern medicine can afford (Bury
1982). Seen in these terms, modernism is eminently preferable to postmod-
ernism when the ‘chips are down’, so to speak, and in chronic disabling ill-
ness they certainly are (Charlton 1993).

Discussion and concluding remarks

Let me take the opportunity to recap here on the central arguments of this
paper as a whole. Taking as its point of departure the contested nature of
the body, both in mainstream theory and the sociology of health and illness
alike, I have sought, albeit tentatively, to chart what a critical realist alter-
native to these debates entails using the controversial terrain of chronic ill-
ness and disability as a case-study or litmus paper test. A critical realist
approach, as I hope to have shown, enables us to: (i) bring the biological
body, impaired or otherwise, ‘back in’; (ii) relate the individual to society in
a challenging, non-conflationary or non ‘uni-directional’ way, and; (iii)
rethink questions of identity, difference and the ethics of care through a
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 Is anybody there? 813

commitment to real bodies and real selves, real lives and real worlds. Within
all this, as we have seen, modern medicine does indeed, contra disability
theory and postmodern calls for the pursuit of so-called ‘arche-health’ (Fox
1993), have a continuing role to play in the mitigation of human pain and
suffering, including the realities of chronic disabling illness conditions and
the associated ‘greying’ of Western populations. Biology too, far from pro-
viding a legitimation of existing divisions and inequalities, itself becomes a
crucial point of reference (i.e. real bodies, real needs), if not a radical cri-
tique, of existing social arrangements.
Underpinning these arguments lies a defence of the WHO’s International
Classification of Impairment, Disability and Handicap (ICIDH), one which
places it on both a firmer philosophical (i.e. ontological) and sociological
(i.e. morphogenetic) footing, so to speak. Disability, from this viewpoint, is
neither the sole product of the impaired body or a socially oppressive soci-
ety. Rather, it is, as we have seen, an emergent property, one involving the
interplay of physiological impairment, structural enablements/constraints
and socio-cultural elaboration over time. Moreover, within such a model,
the conflationary traps of structuration theory are avoided, yet a critical
view of agency is still retained, including the transformatory potential of
embodied social praxis. ‘Personal tragedy’ and ‘social oppression’ therefore,
on this reading, become extreme models and overly drawn contrasts
between what is, in fact, best seen as a dynamic, dialectically unfolding
process between body and society, located within a temporal frame of refer-
ence (both historical and biographical).
Whilst I have sought to confine my comments largely to chronic illness
and disability, the relevance of critical realism, as I have indicated, extends
far beyond this particular domain to other important areas of new and on-
going research within medical sociology. These include current debates sur-
rounding inequalities in health, particularly developments in materialist
explanations (Macintyre 1997), the role of social support and stress in the
aetiology of disease (Taylor and Ashworth 1987, Wilkinson 1996, Williams
1998), as well as emerging realist critiques of the sociology of scientific
knowledge (SSK) (Abrahams 1995, 1997). That realism itself has been an
abiding theme in sociology since its inception, and is gaining ground in
social theory today, adds further weight to these arguments, particularly
given the declining fortunes of postmodernist and post-structuralist thought
(Layder 1996). Who, it is tempting to ask, amidst claims of a new ‘Past-
modern Sociology’ (Stones 1996), is a postmodernist these days anyway
(Williams and Bendelow 1998b)?
None of this, it should be pointed out, is antithetical to a consideration of
the lived body, or to previous questions concerning the meaning and experi-
ence of chronic illness and disability. Rather, a return to ontological ques-
tions concerning the very nature of bodies themselves, provides the
foundational basis upon which any such discussion must necessarily pro-
ceed. Mind, on this reading, may indeed emerge from matter, but its
© Blackwell Publishers Ltd/Editorial Board 1999
814 Simon J Williams

autonomous powers, though real, are nevertheless circumscribed (Bhaskar

1989a, PN: 97–114).5 Nor does it necessarily preclude inquiries into the
socially constructed aspects of bodies—representatives which themselves, in
keeping with Durkheimian realism, may assume the status of social ‘facts’—
only the erroneous claim that these representations are themselves constitu-
tive of the reality they portray. Critical realism, in this sense, in highlighting
the epistemic fallacy, attests to a reality beyond discourse, a reality which
postmodernists dismiss through a linguistic sleight of hand. It also therefore
attests to the possibility of non-social relations with non-social reality,
including an enduring non-linguistic sense of self based on personal identity.
The body in pain, as has been argued elsewhere (Bendelow and Williams
1995, Williams 1996a, b), provides a powerful reminder of this pre-
discursive realm and the limits of language and culture to ‘contain’ or
‘capture’ it. To this we may also add the existence of mind-independent,
non-observable structures and generative mechanisms, both social and nat-
ural in origin, which belong to the real rather than the actual or empirical.
Discussion of these issues, in turn, raises a broader set of questions. These
concern the ‘limits’ of our own explanatory frames of reference as a disci-
pline, including an over-hyping of the ‘social’ itself—an all too apparent trait,
as we have seen, of disability theorists and postmodernists alike. Here we
return to Strong’s (1979) important warnings, some 20 years ago, about the
dangers and risks associated with ‘sociological imperialism’: i.e. professional
expansionism. That this is now imperative is signalled by the resurgence of
genetic and biologically based explanations, from the Human Genome
Project to the emergence of evolutionary psychology (Higgs and Jones 1998)
and renewed interest in the mysteries of consciousness. According to Searle,
for instance, these latter ‘mysteries’—mysteries which have troubled philo-
sophers for centuries—are resolved through an unequivocal assertion that
consciousness is a natural, biological phenomenon; ‘as much a part of our
biological life as digestion, growth and photosynthesis’ (1997: xiii).
Undoubtedly sociology has a critical role to play in these debates (see, for
example, the recent critical exchange between Dickens 1998 and Shakespeare
1997, 1998 in the BSA Network newsletter). It cannot, however, rest content
with a view of biology as merely discursive or ‘additive’. Rather, new ways
are needed, as suggested above, of conceptualising the relationship between
the biological and the social, themselves real ontological strata, without
reducing one to the other. A socially ‘pliable’ view of biology as a relatively
‘open’ set of dispositions, completed by culture, is just one of many ways for-
ward in this respect—a position which critical realists might profitably take
forward and develop through their principles of stratification and
emergence.6 Indeed, looking to the future, what this might involve—though
not in the manner which E.O. Wilson predicted back in 1975—is a relaxation
rather than a merger of existing disciplinary boundaries between the social
and natural sciences: a development which medical sociology, given the
nature of its subject matter, is indeed well placed to exploit.
© Blackwell Publishers Ltd/Editorial Board 1999
 Is anybody there? 815

Whatever the outcome, a critical realist position is, I venture, an emi-

nently preferable basis, given the shifting sands of postmodernism and the
pitfalls of overly social models of illness and disability, upon which to fash-
ion both medical sociology and emerging forms of health care ‘fit’ for the
21st century. As for postmodern prayers and the endless process of becom-
ing ‘Other’, the only truly satisfactory answer and ethical response, I sug-
gest, in keeping with the general tone of the paper, is as follows: real bodies,
real selves; real lives, real worlds.
Address for correspondence: Simon J. Williams, Centre for Research in
Health, Medicine and Society, Department of Sociology, University of
Warwick, Coventry CV4 7AL
e-mail: syrbj@ice.csv.warwick.ac.uk

Acknowledgements

Thanks to Margaret Archer for some useful discussions on these and related themes.
Thanks also to the editors and anonymous referees for helpful comments on an ear-
lier draft of this paper.

Notes

1 See also Williams (1996b) on the relevance of body-image to these debates, and
Kelly and Field’s (1997) reply.
2 For studies concerning the importance of narrative and auto-biographical
themes in the experience of chronic illness see: Kleinman (1988), Frank (1992,
1995), Murphy (1987) and Zola (1982, 1991).
3 Scambler and Higgs’s (1998) recently co-edited volume Modernity, Medicine and
Health: Medical Sociology Towards 2000 also gives these postmodern matters the
proper airing they deserve in relation to health. See also Scambler (1996).
4 The main difference here, it can be ventured, is that disability theorists are less
concerned with the linguistic construction of the ‘social body’ than its structural
constitution through ‘disabling’ barriers and environments. Either way, the
impaired body receives scant attention.
5 What Bhaskar refers to, somewhat tortuously, as ‘synchronic emergent powers
materialism’ or SEPM for short (1989a, PN: 97–114).
6 See, for example, Shilling’s (1997) recent critique of the ‘undersocialised concep-
tion of the (embodied) agent in modern sociology’.

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