The practice of physical therapy is continuously chan-ging. However, our perspective of practice continuesto be primarily biomedical with less focus on socio-cultural and existential dimensions. The practice ofphysical therapy is very complex and the interactionof therapist and patient has not been well investigated.
This special issue discusses the role that philosophymight play in evolving physical therapy practice. Thenotion of a philosophically informed practice is new,exciting and different. Drs Nicholls and Gibson,both outstanding writers and internationally knownspeakers, head this issue as our special issue editors,and I thank them for their tremendous dedication
leading this philosophical evolution globally for phys-ical therapists and more specifically for their tremen-dous effort on this important and practice changingvolume. Enjoy this incredibly interesting specialissue and please embrace these philosophical conceptsinto your daily practice.
Scott Hasson, EdD, PT, FACSM, FAPTAEditor, Physiotherapy Theory and PracticeProfessor – Department of Physical Therapy
Philosophy is not something that features strongly inphysiotherapy literature. There is no lack of theoreticalwork available, especially in the practice and mid-range theories that have come to dominate debatesaround how approach ‘X’ is better than approach‘Y’, but philosophically informed practice is some-thing quite different. Until the 1980s, few universityfaculties had physiotherapy departments. Most ofour training was vocational, and opportunities forresearch and higher degrees were few. Scholarlyoutput was limited and the theoretical underpinningsof physiotherapy adhered to a model that had beenstable for much of the twentieth century.
Over the last three decades, however, academicsand clinicians have begun to ask: what is physiother-apy? Is it art, science, craft, or all of these things?What should it be or do to enable and support ourclients within the changing world of health care(Belanger, 1997; De Souza, 1998; Riddoch, 1982;Roberts, 1994; Sim, 1985; Tyni-Lenne, 1989;Wilson, 1984)? In response, a number of modelshave been formed that have sought to capture the‘essence’ of what it is to be a physiotherapist and dophysiotherapy, and writers have begun to providegreater definition of key concepts like the body, move-ment, independence, participation, and function(Broberg et al, 2003; Cott et al, 1995; Hislop,1975). Physiotherapists have become more aware oftheir role in society, not only as rehabilitationprofessionals with an interest in assessing and treatingindividuals, but as practitioners with a larger roleto play in the physical and social wellbeing ofpopulations.
Nevertheless, this emerging work has largely beenundertaken in the absence of strong philosophicalfoundations. Papers that question or advance theunderpinnings of physiotherapy through a philoso-phical focus are largely absent from physiotherapyjournals. Furthermore, it is only in recent years thatour students have been introduced alternatives waysof understanding health and illness.
So how might physiotherapists individually andcollectively benefit from a greater engagement withphilosophy? Philosophy attempts to provide conceptualclarity in a complex world. Thus, at a minimum, phil-osophy serves as a tool to gain greater understanding ofphysiotherapy's assumptions, goals, and commitments,and what these might be in the future. In simple terms,
we are asking what is it we are doing, and why does ithave to be so? What assumptions are built into ourassessment tools, the way we construct clinical pro-blems and how we conceive of patient wellbeing?How might the practice of physiotherapy change ifthese assumptions were questioned? The value of phil-osophy is that it provides the tools to think differentlyabout ingrained assumptions. By challenging long-held beliefs about how things should be done, and byexposing the ways that power, knowledge, and truthhave become entrenched, we can access new opportu-nities for professional growth.
The papers in this collection all explore the inter-section between philosophy and physiotherapy anddemonstrate how applied philosophy can inform anarray of practice areas and issues. Central issues inthe practice of physiotherapy including: movement;walking; rehabilitation; disability; normality; andtouch are discussed in new ways that destabilize anddisrupt common understandings. These disruptionsserve to enhance our perceptions of what physiother-apy is and might be, allowing us to consider multipleinnovative and creative ways of approaching the com-plexity of physiotherapy care.
Epistemology (ways of knowing) and ontology (thenature of phenomena) are keys areas for the philoso-phical exploration of physical therapy and featurestrongly in this collection. Shaw and Ryan explorewhat counts as physiotherapy knowledge and intro-duce the notion of physiotherapist as bricoleur. Theysuggest the bricoleur is open to and utilizes multipleepistemologies, learning not only through observationand assessment, but through investigation of patients'emotional, social, and political experiences of injuryor illness to provide a more holistic approach to prac-tice. Wikström-Grotell draws from Gadamer's herme-neutics to explore the ontology of human movement,suggesting that in physiotherapy, movement ismostly understood through a biomedical perspectivebut has socio-cultural and existential dimensions thathave been underexplored.
Three papers draw on post-modern approaches tore-imagine and re-interpret physiotherapy and itsobjects of interest. Situating physiotherapy withinthe broader history of Western medicine, Eisenbergexamines how relations of power perpetuate hierar-chal divisions between patients and physiotherapists.She suggests that questioning these relationships
opens the possibility for alternative ways of engagingin fruitful therapeutic relationships. Nicholls alsodraws on the work of Foucault to explore a seeminglybenign device; the physiotherapy treatment bed, toexamine how technologies convey meanings thatmediate relationships. He presents the example of aphysiotherapy clinic space deliberately designed tocounter the sterile, clinical atmosphere of thetypical treatment spaces and how this has helped toreorient practices. In another paper, Nicholls andHolmes radically re-consider the notion of thera-peutic touch, and how current ‘heavily disciplined’approaches to touch constrain physiotherapeuticpossibilities.
The papers by Trede and Gibson and Teachmandemonstrate how critical philosophical approachesopen up new areas of physiotherapy research. Trededraws on Habermas' theory of communicativeaction to deepen conceptualizations of person-centered care and the implications for shareddecision-making. Gibson and Teachman outlinehow Bourdieu's sociology of practice informed astudy exploring how socially ingrained notions of‘normal’ and ‘disabled’ are reflected in rehabilitationpractices and taken up by disabled children and theirparents.
What these papers collectively show is thatphysiotherapy is a complex assemblage of concepts,ideas and practices that demands much more philoso-phically informed examination. More than anything,these papers promote the idea that there is a placefor philosophy in physiotherapy, and we commendthe journal and its editorial team for supporting thisventure. We believe that this is the first edited collec-tion that has brought together writers from aroundthe world to engage explicitly in writing about philos-ophy and physiotherapy. We hope that this volumeserves to encourage other writers, researchers, thin-kers, and practitioners to use these papers as theimpetus to open a space in their professional lives tothink differently about their practice.
REFERENCES
Belanger AY 1997 Dialogue: The culture of professional title in phy-siotherapy:Why should we care? Physiotherapy Canada 49: 14–15
Broberg C, Aars M, Beckmann K, Emaus N, Lehto P, LahteenmakiM, Thys W, Vandenberghe R 2003 A conceptual framework forcurriculum design in physiotherapy education: An internationalperspective. Advances in Physiotherapy 5: 161–168
Cott CA, Finch E, Gasner D, Yoshida K, Thomas SG, Verrier MC1995 The movement continuum theory of Physical Therapy.Physiotherapy Canada 47: 87–95
De Souza L 1998 Editorial – Theories about therapies are underde-veloped. Physiotherapy Research International 3: v–vi
Hislop HJ 1975 The not-so-impossible dream. Physical Therapy 55:1069–1080
Riddoch J 1982 The future of research in physiotherapy. Physiother-apy 68: 358–360
Roberts P 1994 Theoretical models of physiotherapy. Physiotherapy80: 361–366
Sim J 1985 Physiotherapy: A professional profile. PhysiotherapyTheory and Practice 1: 14–22
Tyni-Lenne R 1989 To identify the physiotherapy paradigm: A chal-lenge for the future. Physiotherapy Theory and Practice 5:169–170
Wilson J 1984What is it that is Physiotherapy? New Zealand Journalof Physiotherapy 12: 23
David A. Nicholls, PhD, MA, GradDipPhys, MNZSPPostgraduate Head
School of Rehabilitation and Occupation StudiesAuckland University of Technology
Barbara E. Gibson, Physiotherapist, PhD, MSc,BMR(PT)
Assistant ProfessorDepartment of Physical Therapy
University of TorontoToronto, Ontario, Canada
Scientist, Bloorview Research InstituteHolland Bloorview Kids Rehabilitation Hospital
Toronto, Ontario, Canada
Editorial 419
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PERSPECTIVE
Physiotherapy as bricolage: Theorizing expert practiceJames A. Shaw, MPT, PhD Candidate and Ryan T. DeForge, MSc, PhD Candidate
Department ofHealth&Rehabilitation Sciences, ElbornCollege,University ofWesternOntario, London,Ontario, Canada
ABSTRACT
Theories about how knowledge is sought and applied in clinical practice are often referred to as practice epistem-ologies, and have not been extensively explored in the physiotherapy profession. Tacit assumptions about whatcounts as physiotherapy knowledge thus form the basis for many approaches to gaining and using informationin practice. The purpose of this paper is to propose a physiotherapy practice epistemology, through the notion ofthebricoleur,which takesanalternativeapproach tounderstanding howknowledgemight best be viewed in relationto physiotherapy. The term bricoleur refers to a handyman or handywoman who uses all tools and types of knowl-edgeavailable. Thenotionof physiotherapistsas bricoleurs recognizes that all practice knowledge is situatedwithinsocial, cultural, and historical contexts that shape our beliefs about what counts as physiotherapy knowledge. Thisrecognition leads physiotherapists who act as bricoleurs to embrace multiple epistemologies, discovering newways of knowing and clinical reasoning strategies to provide a more holistic approach to physiotherapy practice.The relationships between expertise in clinical reasoning and the epistemology of the bricoleur are then addressed,explicating the utility of multiple epistemologies in achieving excellent physiotherapy care. A bricoleur’s epistem-ology is then applied to the concept of expertise in physiotherapy, de-stabilizing the notion that a single authoritativeapproach to the practice of physiotherapy ought to be idealized.
An epistemology of physiotherapy practice thatcan justify and legitimise the sources of knowl-edge that underpin the inter-subjectivity of inter-personal relationships as well as the proven use ofphysical interventions in effective practice has notbeen fully explored or defined. (Edwards andRichardson, 2008, p. 185)
INTRODUCTION
Distinctions between physiotherapists and other healthservice providers have been a part of the professionaldiscourse of physiotherapy throughout its history(Cleather, 1995; Nicholls and Cheek, 2006; Nichollsand Gibson, 2010), forming the basis for the continualeffort to defend and demarcate the territory of phy-siotherapy as a valued profession in contemporaryhealth care. Initiatives to identify and describe, orperhaps to inscribe, physiotherapy knowledge (Ameri-can Physical Therapy Association, 2003) may be seenas movements to claim function and the body as the
exclusive territory of physiotherapists. What counts as‘physiotherapy knowledge’ has not been as consistentlyor critically explored, leading to unexamined assump-tions in practice that physiotherapists already havephysical rehabilitation ‘figured out’, that we alreadyenact the best possible approach to rehabilitative care.Examining what counts as physiotherapy knowledge,and as physiotherapy epistemology, may help toposition the practice of physiotherapy within its socio-political context; this will allow physiotherapists torecognize ‘that knowledge is always in process,developing, culturally specific, and power-inscribed’(Kincheloe, 2005). Recognizing that physiotherapyknowledge and practice are embedded in a complexand ever-changing socio-historical context will help toclarify the discrepancy between the predominance ofa biomechanical approach to physiotherapy care(Nicholls and Gibson, 2010) and the more complex,nuanced processes of clinical reasoning that exemplifyphysiotherapy expertise (Edwards et al, 2004).
Edwards and Richardson (2008) define practiceepistemology as ‘the focus on how knowledge is gener-ated and used in clinical practice’. Citing the widevariety of influences on the experience of pain, theseauthors suggest that the complexity of issues thatcompose physiotherapy practice areas necessitates a
Address correspondence to JamesA.Shaw,Department ofHealth&Reha-bilitation Sciences, Elborn College, University of Western Ontario,London, Ontario, Canada. E-mail: [email protected]
broadened understanding of the types and sources ofknowledge that inform physiotherapy approaches tocare. The complexity discussed by Edwards andRichardson (2008) raises another important conceptin understanding the knowledge base for physiother-apy: the notion of ontology. Ontology refers to beliefsabout the nature of reality, addressing the question ofwhat really exists in the world (Denzin and Lincoln,2001). Issues of ontology and epistemology are then,closely related in their influence on physiotherapy prac-tice, as beliefs about what really exists (e.g. in relation tothe body) will have a clear impact on ‘clinical knowl-edge’ and decision-making. Taking ontology and epis-temology together to reflect a person’s fundamentalbeliefs about the world and how the world can beknown is often referred to as paradigm or worldview(Guba and Lincoln, 2004). Just as these issues impactthe way physiotherapists approach clinical practice,they also impact the way researchers approach inquiry.
Previous literature has debated issues around knowl-edge and practice epistemology to guide and representthe physiotherapy profession, largely advocating for adiversity of approaches to knowledge generation andapplication that reflect the multi-faceted nature of phy-siotherapy practice (Edwards and Richardson, 2008;Higgs and Titchen, 1995; Noronen and Wikstrom-Grotell, 1999; Parry, 1997; Plack, 2005). This paperextends these discussions by examining the argumentthat in a field as (ontologically) complex as physiother-apy, a single, consensus-based practice epistemology isinsufficient. We contend that this is so by illustratingthe parallels between ‘expert physiotherapy practice’and ‘bricolage’, an approach to practice epistemologythat embraces multiple ways of knowing and applyingknowledge in physiotherapy care. Drawing on empiri-cal evidence describing expertise in physiotherapy, weargue that embracing bricolage and its many ways ofknowing in practice forms a foundation for the theoryand practice of expert physiotherapy, that is, both inno-vative in conceptualization as well as beingmore reflec-tive of the true depth of complex expert practice. Themulti-faceted approach to physiotherapy knowledgeand practice found in bricolage is not only importantfor its relationship to expertise, but because knowledgeitself evolves with every change in the socio-culturalpolitical life of physiotherapists, clients, and societies.
In this paper, we suggest that an understanding ofepistemology through pluralism, found in the notionof bricolage, is a theoretically rigorous and empiricallygrounded fit for conceptualizing the knowledge thatcomposes, enacts, and arises from expert physiother-apy practice. We then extend this more complexconceptualization of ‘epistemological bricolage’ toquestion the authoritative status of expertise in phy-siotherapy, challenging the epistemological basis for
claims that those who are designated experts inrelation to current approaches to physiotherapy prac-tice ought to be considered ‘right’, ‘true’, or ‘ideal’.We will build on the critique that contemporary phy-siotherapy practice is derived, to a large extent, froma biomechanical view of the body that is theoreticallyand practically limited in its scope (Nicholls andGibson, 2010), and, in a similar vein, argue that inter-preting and enacting expert physiotherapy as bricolagewill help to move physiotherapists in more critical andself-conscious directions. As opposed to portraying anartificial and polemical opposition between the biome-chanical approach to physiotherapy practice and theapproach of a bricoleur, we emphasize that physiother-apy as bricolage integrates biomechanical concernsinto a broader, contextually aware orientation to phy-siotherapy care.
Implicit in our argument is the assumption that allphysiotherapists who are interested in and dedicated toimproving the quality of care they provide in their prac-tice are themselves already endeavoring to move toward‘expertise’ in physiotherapy. In this way, bricolage pro-vides a theoretical understanding of the goal that issought by physiotherapists in general, to the extent thatphysiotherapists may be understood as seeking toachieve expertise in their practice. We will conclude byproviding a resolution to the apparent paradox of advo-cating for one encompassing approach to understandingexpertise in physiotherapy, through bricolage,while sim-ultaneously claiming to de-stabilize the authoritativestatus of any single approach. To set the context forthis discussion, we outline documented differencesbetween physiotherapists in terms of epistemologies, ap-proaches, and professional identities with respect to thepractice of physiotherapy. First though, we introducethe concept of the bricoleur and bricolage.
BRICOLAGE: DOING EPISTEMOLOGYDIFFERENTLY
Bricoleur is a French word that connotes a handymanor handywoman who makes use of any or all of thetools at hand to complete a task (Denzin and Lincoln,2005; Kincheloe, 2005). Initially introduced to thesocial sciences by Levi-Strauss (1966), bricolage (i.e.the product of a bricoleur) was premised on the under-standing that the cultural domain is immenselycomplex and unpredictable (Kincheloe, 2005), thusinsinuating that a bricoleur ought to make use of asmany tools as possible to understand and respond tothis complexity. As an anthropologist teasing apartscience and magic, Levi-Strauss ‘engaged in debatesabout the modes of thinking exhibited by the then
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modernWestern societies and the tribes andnatives en-countered by the early anthropologists and ethnogra-phers of the nineteenth and twentieth century’(Gobbi, 2005). Reluctant to privilege one mode ofknowing over another, Levi-Strauss instead arguedthat it is better to compare science andmyth ‘as twopar-allel modes of acquiring knowledge that have equal val-idity’ and represent ‘two strategic levels at which natureis accessible to scientific enquiry: one roughly adaptedto that of perception and the imagination; the other at aremove from it’ (Gobbi, 2005). This notion of embra-cing multiplicity rather than privileging receivedmodes of knowing/ways of doing forms the conceptualbasis for being a bricoleur.
While the notion of bricoleur as one who embracesmany ways of knowing and doing has been applied to avariety of domains, we focus here on a bricoleur’sapproach to understanding knowledge in general(Denzin and Lincoln, 2005; Kincheloe, 2005); thisis particularly relevant to an inquiry of beliefs aboutknowledge in physiotherapy. Denzin and Lincoln(2005) conceive of a bricoleur as one who is intellec-tually informed, widely read, and able to draw ondiverse conceptions of reality and knowledge – orparadigms – of interpretation. Such emphasis on onto-logical and epistemological diversity has become thehallmark of contemporary bricolage:
Because all observers viewanobject of inquiry fromtheir own vantage points in the web of reality, noportrait of a social phenomenon is ever exactly thesame as another. Because all physical, social, cul-tural, psychological, and educational dynamicsare connected in a larger fabric, researchers willproduce different descriptions of an object ofinquiry depending on what part of the fabric theyhave focused. (Kincheloe, 2005)
This excerpt reflects what Kincheloe calls an ontologyof complexity, wherein social, historical, cultural, andpsychological influences on reality are considered sim-ultaneously. Assumptions of such a complex nature ofreality lead to the embracing of ‘diverse epistemologiesfor their unique insights and sophisticated modes ofmaking meaning’, providing alternative frames ofreference for better understanding the world.
Inherent in a position that seeks out various epis-temologies in the process of making knowledgeclaims is the recognition that contextual nuances pre-clude an ability to generalize findings or practices, andthat context affects what meaning different people findin different words and phrases (Lincoln, 2001;McLaren, 2001). A contemporary bricoleur recog-nizes the processual nature of the world, wherein pro-cesses may be more fundamental than isolate entities,or individual objects, to understanding the socio-
cultural world. In this sense, rather than seeking to un-derstand the world in terms of individual (isolate)phenomena severed from their context, a bricoleurseeks to understand the world in terms of contextualrelatedness (e.g. treating a person and their functionalactivities as opposed to a specific joint). Thus, theterm bricoleur embraces an ontology of relationshipsand connections; a bricoleur understands thatculture and ‘self’ are inseparable. This understandingleads to consideration of the bricoleur’s conceptionsof knowledge in general, recognizing that we asresearchers, clinicians, or people in general can onlyobtain knowledge that is ‘shaped tacitly or consciouslyby discursive rules and practices’ (McLaren, 2001),infusing culture into our knowledge base.
This view of knowledge and its generation differsfrom how epistemologies tend to be understood inmuch contemporary research; as a fixed componentof a paradigm or worldview that is deterministic of aresearchers’ approach to inquiry (Guba and Lincoln,2004). Herein lies one of the greatest challenges forthe bricoleur, who is required to develop the imagin-ation necessary to understand and value different per-spectives and the types of knowledge that accompanythem. Building on this, Kincheloe’s (2005) bricoleurappreciates the intersecting nature of contexts: ‘con-textualization is always a complex act, as it exposesconnections between what were assumed to be separ-ate entities’, calling for the bricoleur to see synergiesemerge from the interaction between types of knowl-edge that were previously assumed to be mutuallyexclusive. As Lincoln (2001) surmises,
Kincheloe’s bricoleur is far more skilled thanmerely a handyman/handywoman. This bricoleurlooks for not yet imagined tools, fashioning themwith not yet imagined connections. This handy-man is searching for the nodes, the nexuses, thelinkages, the interconnections, the fragile bondsbetween disciplines, between bodies of knowl-edge, between knowing and understanding them-selves. … It is ‘boundary-work’ taken to theextreme, boundary-work beyond race, ethnicity,sexual orientation, class. It works the marginsand liminal spaces between both formal knowl-edge, and what has been proposed as boundaryknowledge, knitting them together, forming anew consciousness.
‘Extreme boundary work’, however, is no easy task,particularly along the divisions between and amongdisparate paradigms or worldviews. Reflecting on theresearcher as bricoleur, Denzin and Lincoln (2005)acknowledge that paradigms might not be easilymingled or synthesized. That is, one ‘cannot easilymove between paradigms as overarching philosophical
systems denoting particular ontologies, epistemologies,and methodologies. They represent belief systems thatattach users to particular worldviews’. That prac-titioners and, indeed, many researchers alike taketheir worldviews for granted (insofar that their beliefsystems remain unarticulated) serves to strengthen theattachment they might have to their (perhaps unarticu-lated) worldview. These observations highlight theimportance of examining the ways that culture hascreated people’s beliefs about knowledge and theworld and to look for ways to embrace new perspectivesand insights, reiterating the task at hand for thebricoleur.
We now turn to a discussion outlining the centralbeliefs that have been proposed as the source(s) of phy-siotherapy knowledge and practice, exploring the epis-temologies, paradigms, and professional identities thathave characterized approaches to physiotherapy care.Thereafter, we encourage practitioners to engage inthe kind of boundary-work outlined above so as tode-stabilize the dominant and largely unquestionedconfidence in the definitiveness and authoritativestatus of expertise in physiotherapy practice vis-à-vis amore skeptical approach to knowledge claims thatnecessitates self-critique in all (methodological or clini-cal) decision-making.
CENTRAL BELIEFS INPHYSIOTHERAPY: GUIDES TOPRACTICE
Research on physiotherapy socialization and the devel-opment of expertise in clinical practice has sought toidentify what characterizes excellent physiotherapycare and how novices can pursue excellence in prac-tice. Efforts addressing what it means to provide thebest possible care have focused on a variety ofconcepts, including the exploration of broad ideaspotentially composing the ‘core’ or ‘essence’ of phy-siotherapy. Scholars have variably described the coreof physiotherapy as being inherent in practice epistem-ologies (Edwards and Richardson, 2008), practiceparadigms (Noronen and Wikstrom-Grotell, 1999;Plack, 2005; Thornquist, 2001), and professionalidentities (Lindquist et al, 2006), and in doing sopropose that all other components of practice are insome way influenced by these central beliefs. In thisway, these core or essential elements of approachesto the practice of physiotherapy reflect the notion ofparadigms or worldviews in research, as outlined inthe introduction to this paper. Recall that beliefsabout ontology (the nature of reality) and epistem-ology (the nature of knowledge) are seen as the
foundation on which decisions about specific researchquestions, methods, and analysis strategies areselected. In a very similar way, processes of clinicalreasoning and hypothesis formation, foci and type oftreatments, and assumptions about diagnosis in aclinical context will come from ontological and epis-temological beliefs of physiotherapists. As we prepareto discuss the notion of physiotherapists as bricoleurs,we will focus here on issues related to knowledge andreasoning in clinical practice.
Edwards and Richardson (2008) provided adetailed exploration of the concept of practice epis-temology, suggesting that it is the general orientationof physiotherapists toward knowledge that in essencedetermines their approach to decision-making andcare. They outlined three distinct epistemologies asparadigms of knowledge generation that lead to twodifferent types of clinical reasoning in physiotherapy.The first is the ‘scientific/experimental/positivist’ para-digm that leads to hypothetico-deductive clinicalreasoning, focusing on objective and predictabletypes of knowledge in practice. An example of thistype of knowledge and reasoning would be the sys-tematic identification of which tissue (ligament,tendon, muscle, etc.) is the source of joint painthrough selective tissue tension testing. The remainingtwo epistemologies are ‘interpretive’ and ‘critical’,both leading to narrative clinical reasoning. Narrativereasoning from an interpretive epistemology focuseson contextual influences, socially constructed knowl-edge, and different lived experiences of patients andtherapists. An example of this type of knowledge andreasoning would be the integration of the patients’wishes, lifestyle, and broader life context into (co-)constructing patient-centered goals for physiotherapy.Narrative reasoning from a critical epistemologyfocuses on historically situated knowledge, how indi-viduals have been empowered or disempowered, andhow knowledge might be used for emancipatoryaims. An example of this type of knowledge andreasoning would be the recognition of the need andprocess to advocate for frail elderly clients whorequire further resources to remain independent athome. This work by Edwards and Richardson(2008) provides a clear depiction of how epistemologi-cal beliefs impact on the knowledge sources that arethe foci of the approaches to clinical practice and thetypes of clinical reasoning different practitionersemploy, serving as evidence that methods in phy-siotherapy care are guided by epistemology in similarways as methods in research projects.
Previous research has identified a central ‘model’ ofthe approach taken by physiotherapists as the primarydriver of physiotherapy practice, differing fromEdwards and Richardson’s (2008) suggestion that
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epistemological beliefs compose the essence of the ap-proach to physiotherapy. Noronen and Wikstrom-Grotell (1999) state that ‘human actions, in practice,are guided by the model a person has adopted’,supporting the assertion that the specific practiceapproach taken by physiotherapists will be a functionof central beliefs or practice models. Thornquist(2001) reported on findings from a doctoral disser-tation on the diagnostic and clinical decision-makingapproaches of physiotherapists practicing in differentspecialties of physiotherapy, specifically manual thera-pists, psychomotor therapists (where psychodynamicphysiotherapy focuses on psychological and physicalbalance), and visiting (home-care) therapists. Shefound fundamental differences in practice betweenthese speciality areas of physiotherapy, specifically interms of guiding concerns, aims, and focus of treat-ments. These differences reflect the central beliefs ormodels taken up by physiotherapists in these differentspecialty areas, leading to different types of knowledgethat are used in clinical practice (Thornquist, 2001).The set of beliefs discussed by Thornquist (2001)might best be referred to as practice paradigms,reflecting a persistent, clinically oriented worldviewthat influences which knowledge is predominantlyused in practice and how it will be used (Plack,2005; Shaw, Connelly, and Zecevic, 2010).
A third perspective from which to articulate theessential core of physiotherapy explores notions ofprofessional identity. In their longitudinal qualitativestudy of the first year of practice in novice physiothera-pists, Black et al (2010) found that the emergence ofan individual professional identity was the centraltheme for their participants. Recognizing the impor-tant role that professional identity plays in determiningapproaches to physiotherapy care, these authorssuggest that ‘who you are becoming shapes what youknow or come to know’. Lindquist et al (2006)studied the professional identities of novice phy-siotherapists, finding three distinct identities inphysiotherapy students about to begin working life.The first identity was the ‘empowerer’, focusing on abroad ‘world’ context and the informal knowledge ofthe life of the patient. The second identity was the‘educator’, focusing on an open fluid context andthe practice knowledge that emerges by interactingwith the patient. The final identity was the ‘treater’,focusing on the specific treatment context and theformal knowledge gained in professional education.Each identity was seen as essentially guiding the phy-siotherapist to attend to certain elements of the thera-pist–patient encounter, composing the foundation fortheir entire approach to physiotherapy care.
In their discussion, Lindquist et al (2006) encour-aged educators to find ways to foster the ability of
students who adopted these different types of identi-ties to learn from one another, indicating that the‘best’ physiotherapists will be those who approachcare while drawing on elements of each identity.This theme has recurred in physiotherapy socializationand expertise literature (Edwards et al, 2004; Jensen,Gwyer, Shepard, and Hack, 2000; Lindquist,Engardt, and Richardson, 2010; Resnik and Jensen,2003), suggesting a pluralistic epistemological per-spective might be most appropriate in the physiother-apy profession.
EVIDENCE ON EXPERTISE INPHYSIOTHERAPY
Edwards et al (2004) conducted research on the clini-cal reasoning of expert physiotherapists. Theseauthors found that experts employed each of the nar-rative and hypothetico-deductive reasoning strategiesas outlined in the discussion of practice epistem-ologies above, as opposed to only one single reasoningstrategy in their clinical practice. They found dialecti-cal reasoning among the different approaches, that is‘an interplay between the different paradigms ofknowledge and reasoning processes that are expressedin each of the various clinical reasoning strategies’.This finding provides an explicit commentary that itis through the interaction between epistemologies,types of knowledge, and types of clinical reasoningthat expert physiotherapy practice can be achieved.
Similarly, Jensen, Gwyer, Shepard, and Hack(2000) and Resnik and Jensen (2003) conductedresearch on experts in different practice fields of phy-siotherapy and found that the practice of ‘experts’ wasexemplified by: multi-dimensional knowledge, clinicalreasoning in a collaborative context, a focus on andunderstanding of movement, and communicatingvirtues of caring and commitment. This collection ofdescriptors suggests that approaching practice fromany single practice epistemology might preclude thepossibility of achieving expert practice. The character-istics found in these studies cannot all be locatedin any one epistemology, paradigm, or identity,but are instead achieved by employing different epis-temologies at different moments in the clinicalencounter. These findings provide further credenceto the assertion that expertise in practice results fromthe integration of and interaction between central epis-temological or paradigmatic beliefs.
In 1997, Parry made the astute assertion that ‘phy-siotherapy is multi-paradigmatic and there is little tobe gained by physiotherapists turning their faces ortheir minds against anything’. This statement echoes
the sentiments of bricolage outlined above and illus-trates the areas of potential overlap and connectionbetween the notions and practices of physiotherapistsand bricoleurs. As has been explored in the discussionof practice epistemologies, paradigms, and pro-fessional identities, there seem to be different funda-mental beliefs that characterize various approaches toclinical reasoning and decision-making in physiother-apy care. These fundamental beliefs reflect the notionof worldview, including important assumptions aboutepistemology in practice. However, research suggeststhat expertise is only to be achieved through the inte-gration of these various fundamental beliefs, mirroringthe multiple epistemological perspective of the brico-leur. As such, the concept of bricolage introduced inthis paper may provide a useful theoretical tool forconceptualizing and operationalizing the notions ofexpertise found in the literature presented here.
DISCUSSION: PHYSIOTHERAPISTS ASBRICOLEURS
Having summarized the literature on epistemologies,paradigms, and professional identities in terms oftheir relationships to expertise in physiotherapy, wenow turn to consider expert physiotherapists ‘as brico-leurs’. As a starting point, expert physiotherapists asbricoleurs engage with issues of ontology and epistem-ology in order to explore and understand their own as-sumptions about the nature of the world and theirknowledge of it. This self-examination of the relation-ships between self and culture, reality and knowledge,and assumptions and actions forms the foundation forbecoming/embodying a bricoleur. Such a startingpoint extends the current emphasis on reflective prac-tice during the education and training of studentphysiotherapists, and thus invites physiotherapy curri-culum to pay attention to the depth of reflexivityespoused by bricolage. By de-constructing ourassumptions about ontology, epistemology, and howthese ought to inform our clinical practice, weprepare ourselves to engage with types of knowledgewe may not have previously recognized or valued; sim-ultaneously, we are able to view dominant and author-itative knowledge with renewed skepticism andawareness of the socio-cultural, historical powerwithin which that knowledge is situated.
While theoretical models enjoying wide acceptancein physiotherapy education and practice, such as theInternational Classification of Functioning, Disability,and Health (ICF), encourage reflection on a widerange of contextual factors, the notion of physiother-apy as bricolage encourages a level of self-reflection
and awareness that extends the ICF into greaterdepth. The ICF encourages a physiotherapist to con-sider body functions/structures, activities, and socialparticipation, and as such invites critical reflectionon the goals of rehabilitation provided by physiothera-pists. Building upon this critical reflection, the notionof bricolage encourages physiotherapists and traineesto embrace multiple ways of reflecting upon howsocio-cultural norms influence their approach theitems identified within models such as the ICF.
An important effect of embracing multiple epistem-ologies is the recognition of the tentative and hesitantnature of knowledge claims about the world, the body,and clinical practice. In valuing a variety of ways ofknowing about the world, a bricoleur understandsthat each of these ways of knowing deserves to be pri-vileged throughout inquiry into the nature of healthand illness. This leads to a perspective on knowledgethat holds assertions in constant critique, understand-ing that knowledge on which clinical decisions arebased is always changing through the influence ofsocio-cultural power. While physiotherapists in train-ing often seek foundational rules or guidelines toinform their approach to clinical care, understandinghow the patterns they learn are influenced by thesepower dynamics will help students to recognize thateven the most obvious and common practices oughtto be re-visited and held in question. Such a perspec-tive ‘provides bricoleurs with the dangerous knowl-edge of the multi-vocal results of humans’ desire tounderstand, to know themselves and the world’(Kincheloe, 2005). It is through this critique ofone’s own assumptions that a bricoleur can begin to(de)construct knowledge and develop the tentativebelief system that permits an embracing of multipleepistemologies.
Applying this lens to the knowledge base for phy-siotherapy helps us to recognize that biomedical andbiomechanical research and knowledge largely domi-nate the evidence base for physiotherapy (Higgs andTitchen, 1995; Parry, 1997; Williams, 2007). In sub-scribing to the authoritative nature of this biomedicaland biomechanical knowledge base, derived from asingular positivist epistemology, ‘we may have inad-vertently reduced the subtle complexities of healthand illness to a narrow set of biological principles’(Nicholls and Gibson, 2010). Indeed, the view ofthe person as (a) body and the body as machine-likehas historically dominated physiotherapy researchand practice prevents physiotherapists from embracingthe holistic approach to practice that characterizesexpertise in physiotherapy (Ekdahl and Nilstrun,1998; Nicholls and Gibson, 2010). Focusing on a bio-mechanical impairment present within one specificdomain of functioning, for example, range of motion
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or muscle strength at a single joint, prevents phy-siotherapists from considering the constellation offactors that influence both the care that is providedand the outcomes achieved: factors including, forexample, work/labor-related stress, psycho-socialelements of pain, and client confidence in the prac-titioner. Becoming entrenched in this biomechanicalapproach to care that acts to defend and demarcatephysiotherapists’ territory leads to the de-valuing ofalternative understandings and perspectives of phy-siotherapy practice, precluding the multiple ways ofknowing and applying knowledge that are found inphysiotherapy expertise. Thus, physiotherapists whostrive to achieve expertise in their practice are encour-aged to de-construct their habitual practices – what-ever they may be – and instead focus on embracingalternative understandings. As Nicholls and Gibson(2010) have said, this might typically entail a lesseningof one’s grip on all things biomechanical so as toembrace more socially derived insights, but to the phy-siotherapist whose practice is typically of an educatingor empowering orientation (Lindquist et al, 2006),s/he would be equally encouraged to broaden his/herperspective to include (more) biomechanical con-siderations. The role of a bricoleur is to weave togethera myriad of evidence and insights, suggesting thatmultiple types of knowledge and clinical reasoningstrategies, not just those of the dominant biomedicalperspective, might contribute to improving the prac-tice of a physiotherapist seeking expertise.
Kincheloe (2005) considers the knowledge of brico-lage ‘dangerous’ because of its potential to underminedominant bodies of knowledge and ways of knowing ingeneral. This is true insofar as constituents of dominantperspectives necessarily have a vested interest in main-taining their positions of power, and therefore maymarginalize those individuals (the bricoleurs) whoadvocate for a collage of claims and insights thatemphasize the complexity and partiality of culturallymediated professional and practice knowledge. Phy-siotherapist practitioners who enjoy recognition andesteem for their specific technologies or techniques ofcare for the body tend to have less interest in consider-ing approaches to evidence, knowledge, and practicethat might de-stabilize their own approach, leading tothe often unintentional or unnoticed de-valuation ofalternative approaches. By embracing partiality, a bri-coleur’s criticality calls into question the authorityand privilege of singular approaches to contemporarysocial science, including those seen in health care; indoing so, a bricoleur de- then re-constructs theconcept of expertise as a more holistic, less entrenchedway of knowing for physiotherapists.
By embracing multiple epistemologies in practice,physiotherapists acting as bricoleurs consider not only
knowledge that is readily obtained through observationand assessment, but the emotional, social, and politicalexperience of the injury, disease, or condition.Anortho-pedic physiotherapist as bricoleur recognizes that yearsof physical labor under psychologically stressful con-ditions, the politics of income replacement for employ-ees who are unable to work, and altered roles in homeand family life due to pain might further complicaterecovery from chronic over-use injuries. A neurologic-focused physiotherapist as bricoleur understands that itmight not just be function and lifestyle that are soughtduring recovery from a stroke, but re-establishing thevery social identity from which a person derivesmeaning and quality in his or her life. An acute care phy-siotherapist as bricoleur might understand the impor-tance of individual characteristics of the patients theyare treating in determining the applicability of resultsof randomized trials, while educating their patientsfrom an empathetic perspective that recognizes andvalues input from the family as well as other membersof the health-care team. Physiotherapists acting as brico-leurs consider the multiple contextual and dynamicfactors that impact not only the care they choose toprovide, but the perspectives, needs, and preferencesof their clients; this in turn describes the approach toreasoning that characterizes expertise in physiotherapy.
CONCLUSION
The view of physiotherapists being seen as – or becom-ing bricoleurs intends to embrace multiple ways ofknowing and reasoning, and in doing so it puts fortha perspective that de-constructs the authority ofclaims to expertise. In relation to expert physiothera-pists, we propose that the idea of a bricoleur we havepresented is a desirable interpretation of what itmeans to be an expert. Inherent in this position isthe apparent paradox of making a claim to a betterapproach to knowledge and practice (through brico-lage) while claiming that no approach can be betterthan another. In the interest of avoiding being paral-yzed by such an apparently relativist position, the useof the term bricoleur recognizes: (1) that we are privi-leging a combination of knowledges and knowledgeapproaches; and (2) that clinical decisions must bemade with the knowledge that has been sought andacquired by the practitioner. Even if a bricoleur ischarged with having one central belief, the belief isin multiplicity; the charge of replacing one dominantview with another dissipates in the light of bricolagethat seeks knowledge from multiple perspectives andthat recognizes the value in each type of knowledge.
We are troubled by definitions of expertise that elicitnotions of the ideal, the goal, the true way of doing
things. We believe that it is important to emphasize thatclaims to expertise always consist of partial knowledgeclaims that emphasize different elements of physiother-apy practice. We wish to avoid claims to expertise thatemphasize the authoritative status of experts within theprofession of physiotherapy, instead advocating for aview of expertise that embraces multiple types of knowl-edge inpractice andemphasizes the tentative, contextual,and dynamic nature of physiotherapy epistemologies.
Through our exposition of bricolage, we haveemphasized that embracing knowledge from a varietyof partial perspectives characterizes ‘physiotherapistsas bricoleurs’. Physiotherapists who are bricoleurs donot make claims to authoritarian expertise, butinstead forefront the tentative nature of their knowl-edge claims, recognizing the roles of history, society,and power in creating and changing what they know.Building on this critical and hesitant knowledgebase, they draw from those bodies of knowledge thatare undervalued and marginalized, using philosophi-cal and theoretical insights to explore new and variedways to approach physiotherapy practice. Perhapsthis perspective of multiple epistemologies, drawingon more types of knowledge instead of less, will helpto move the physiotherapy profession toward a moreholistic understanding of health and illness.
Declaration of interest: The authors report nodeclaration of interest.
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PERSPECTIVE
Movement as a basic concept in physiotherapy – Ahuman science approachCamilla Wikström-Grotell, PT,1,2 Licentiate in Health Sciences andKatie Eriksson, PhD, RN3,4
1Head of Department of Health and Welfare, Arcada University of Applied Sciences, Helsinki, Finland2PhD Student, Åbo Akademi University, Vasa, Finland3Professor, Åbo Akademi University, Vasa, Finland4Director of Nursing, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
ABSTRACT
The development of scientific knowledge of physiotherapy (PT) has advanced significantly. Research is mostlyconducted within a biomedical paradigm and theory-building is underpinned by a positivist paradigm. The basicphilosophical questions and concepts are not much reflected on, and PT lacks an established theoretical frame.The first step in theory development is to define the basic concepts. The aim of this professional theoretical paperwas to reflect on and describe the concept of movement in PT based on earlier research as a standpoint for abroader and deeper understanding of the complex nature of PT reality inspired by a model for concept analysisdeveloped in caring science [Eriksson K 2010 Concept determination as part of the development of knowledge incaring science. Scandinavian Journal of Caring Sciences 24: 2–11]. The concept of movement in PT is concep-tualized as complex and multidimensional. The understanding of human movement in PT is based on five cat-egories described in the paper. The conceptualization of movement includes acting in relation to the socio-cultural environment, inter-dynamic aspects, as well as personal, intradynamic aspects. This paper argues forthe need to further develop the concept of movement in PT within a human science approach. A deeper under-standing is needed as a basis for understanding complex clinical practice as well as in shaping the PT discipline.
INTRODUCTION
Over recent decades, the development of scientificknowledge of physiotherapy (PT) has advanced sig-nificantly, with research focusing on the effects ofPT interventions (Maher et al, 2008). Despite thisadvance, research results have not been implementedin practice to the same extent (Grimmer-Somers,2007). There is also criticism against both the gapbetween research and PT practice as well as againstthe biomedical paradigm as an almost exclusive per-spective for knowledge development (GrönblomLundström, 2008; Öhman, 2001; Shaw, Connelly,
and Zezevik, 2010; Shepard et al, 1993). Theorybuilding in PT is discussed within a positivist para-digm underpinned by an objectivist epistemologyand the PT discipline lacks an established theoreticalframework (Bithell, 2005). There is increased useof qualitative research approaches in PT besidesthe quantitative. Additionally, the evidence-basedapproach in PT practice has put the need to includepatients' values and beliefs and the complex natureof PT reality in the scientific arena (Hammond,2007; Shaw, Connelly, and Zezevik, 2010).However, the conceptualization of theory develop-ment still largely ignores the relevance of knowledgeof interactional and interpersonal experiences of PTin social contexts (Richardson and Lindqvist, 2010).
The need to describe the unique core of knowledgein PT has been on the international agenda since the1970s (Hislop, 1975), but has never become estab-lished as an ongoing cumulative development of
Address correspondence to Camilla Wikström-Grotell, PT, Licentiate inHealth Sciences, Head of Department of Health and Welfare, ArcadaUniversity of Applied Sciences, Helsinki, Finland. E-mail: [email protected]
scientific knowledge. It has also been argued that PTneeds a philosophical and theoretical base for the de-velopment of relevant PT practice and research, andthat the paradigm should be formulated based onthe profession's own terms (Jensen, 2004; Jette,1995; Pratt, 1989; Robertson, 1996; Tyni-Lenné,1989). Shaw, Connelly, and Zezevik (2010) statedthat no single paradigm is enough to describe thecomplex nature of PT practice. They pointed outthat pragmatism is a philosophy well suited for prac-tice as well as for research in PT, as it can link con-cerns raised in practice directly to research and thusbridge the gap between research and the complexnature of PT reality. Today there is an academic dis-cussion concerning the importance of relating philo-sophical theory to PT practice in order to achieve abroader understanding of PT reality (Kerry, Mad-docks, and Mumford, 2008; Nicholls and Gibson,2010). PT needs knowledge development that isbased on an explicit ontology (what really exists)1 toincrease understanding of the complex nature of PTreality and bridge the gap between theory and practice.There is a need to include the epistemological andontological questions in the academic arena in PT(Higgs and Thitchen, 1998; Noronen and Wikström-Grotell, 1999; Shaw, Connelly, and Zezevik, 2010).
The World Confederation for Physical Therapy(WCPT) declares that physical therapists, as auton-omous professionals, have their own physical thera-pist's knowledge, competence, and scope of practice(WCPT, 2011). The WCPT description of physicaltherapy is based on movement and function as keyconcepts:
Physical therapy provides services to individualsand populations to develop maintain and restoremaximum movement and functional abilitythroughout the lifespan. This includes providingservices in circumstances where movement andfunction are threatened by ageing, injury, dis-eases, disorders, conditions or environmentalfactors. Functional movement is central to whatit means to be healthy.
In this description, movement is related to the qualityof life, functional capacity, and health, includingrelations between movement and physical, psychologi-cal, social, and environmental factors. Despite thebroad view of PT in practice, based on a holisticview of man, health, and wellbeing, PT research hasmainly been conducted according to the traditional
natural perspective leaving the humanistic scienceapproach aside. PT lacks conceptual models, whichare needed to link research, education, and practiceclosely (Broberg et al, 2003; Jensen, 2004; Richard-son, 1993). The International Classification of Func-tioning, Disability, and Health (ICF) (WHO, 2001)has, since it was introduced, been broadly used toguide clinical thinking, practice, education, andresearch in PT. The ICF model is a useful tool inPT practice for reflecting current views of the interac-tive relationship between health conditions and con-textual factors. It also provides a common languagefor health professionals (Jette, 2006) but is not suitablefor PT-specific theory development and conceptualiz-ation (Cott et al, 1995). The first step in theory devel-opment is to define the basic concepts. There isagreement about movement as a key or basicconcept in PT (Cott et al, 1995; Hislop, 1975; Ling,1834; WCPT, 2011), which can describe the uniquecore knowledge in PT and thus be developed as apractical as well as theoretical concept. Eriksson(2010) pointed out the difference between practicalconcepts that are used to describe the reality, andideal concepts that can be developed by research astheoretical and scientific concepts. However, only afew theories and models that provide a broader ordeeper conceptualization of movement are articulatedin PT.
The concept of movement in PT has been in focusin theory development and has been studied fromdifferent perspectives. It is well understood from a bio-medical perspective. It has been analyzed contextuallyin different fields of PT practice and education mainlyfrom a professional perspective. The models and the-ories introduced and used in PT have especially con-tributed to broadening the pragmatic features of theconcept of movement in PT. The ontological dimen-sions are, however, not covered as much. Therefore,exploring concepts in different contexts, as well asempirically from the patients' point of view, is impor-tant in deepening the understanding of the meaning ofthe basic concepts in PT, and thus in shaping move-ment not only as a practical but also as a scientificconcept. The need to deepen the understanding of acumulatively developed theoretical concept of move-ment in PT remains (Abrandt, 1997; Broberg, 1995;Kukkonen, 1987; Öberg, 1998; Skjearven, Kristoffer-sen, and Gard, 2008; Stenmar and Broberg, 1993).
The aim of this professional theoretical paper is todescribe and reflect on movement as a basic conceptin PT as the basis for a broader and deeper under-standing of the complex PT reality and as a standpointfor further theory development and ontological reflec-tions. The paper also argues for the need of conceptdetermination as part of the basic research in PT.
1 Ontology is the study of the nature of being. Epistemology is the studyof the nature of knowledge. A certain ontology is followed by a certainepistemology (Alvesson and Sköldberg 2009; The Stanford Encyclope-dia of Philosophy http://plato.stanford.edu).
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This is accomplished by first mapping the concept ofmovement in conceptual models and theories in PT.Secondly, the concept of movement in PT is depictedbased on earlier research concerning the conceptualiz-ation of movement in PT inspired by a model forconcept determination developed by Eriksson2
(2010) and Gadamer‘s (1989) hermeneutics3.Finally, the idea of developing movement as a basicconcept in PT is reflected in relation to theory develop-ment as well as understanding of human movement inthe complex PT practice.
THE CONCEPT OF MOVEMENT IN PTMODELS AND THEORIES
Per H. Ling (1776–1839), the father of Swedishmedical gymnastics, was one of the first to describemovement in PT. He developed a theory of medicalor mechanical gymnastics called the “health or move-ment cure” as long ago as the middle of the nineteenthcentury. His concept for medical gymnastics is theorigin of modern PT. Ling (1866; p. 481) definedmedical gymnastics as:
Medical gymnastics whereby man either useshimself in a suitable position or uses assistanceof others and influencing movements in seekingto overcome or alleviate the sufferings, whichoccur in the body, through its abnormalconditions.
The writings of Ling were scarce, but the idea ofmovement as a health cure was different from thecure of medical drugs. According to Ling (1834),movement as a health-promoting tool was natural, incontrast to chemical drugs, and closely connected toa holistic view of man and the individual's inherentvitality. The idea was to overcome or alleviate suffer-ings in the body. Ling's theory, which originallyincluded basic assumptions about man, health, andlife, was developed in a more naturalistic directiondue to influence from the discipline of medicine andespecially anatomy and physiology during the begin-ning of the twentieth century.
One of the most notable and cited grand theories isthe model of physical therapy presented by HelenHislop in 1975. Hislop conceptualized human move-ment using the term human motion, on six differentlevels of the human being, all interrelated with eachother. Each level of the hierarchy is a subsystem ofthe level above as well as a system of itself thatexpresses its function in movement. Hislop (1975)stated that humanism is an intrinsic element of phys-ical therapy, which she defines as a health professionthat emphasizes the sciences of pathokinesiology asthe distinguishing clinical science of PT and the appli-cation of therapeutic exercise for the prevention,evaluation, and treatment of disorders of humanmotion.
Physical therapy can claim the unique privilege ofplacing the role of exercise in health and diseasein its proper scientific focus and perspective.(Hislop, 1975; p. 1071)
Motion is the basic concept in the model which refersto both intra- and interpersonal levels.
Without motion there is no communication, nointerpersonal reaction and no development ofsociety. (Hislop 1975; p. 1071)
Hislop's model has been criticized for focusing toomuch on pathokinesiology. This may at least partlybe due to misunderstandings, because she did notexplicitly articulate a PT paradigm or deeper describeher view of PT from a human science perspective.
Cott et al (1995) proposed the movement conti-nuum theory of physical therapy (MCT of PT) 20years later in 1995, which like the model of Hislop isa systems model based on the idea of movementoccurring at every level of the system interactively.They criticized Hislop's model for failing to reflectthe interaction between individuals and the environ-ment. Cott et al (1995) stated, however, that themodel provides a useful theory base to build on inPT. Their ecological model “MCT” (Cott et al,1995), which brings the social and physical environ-ment into the framework of PT, can be seen as afurther development of Hislop's model. According toCott et al (1995), movement is conceptualized on acontinuum that incorporates physical and pathologicalaspects with social and psychological considerations.The focus of PT is to minimize the potential and/orexisting difference between preferred and currentmovement potential for the patient. According toHislop (1975) and Cott et al (1995), a basic principleof PT is that movement is essential to human life and itis movement which comprises the primary focus onPT. Neither Hislop (1975) nor Cott et al (1995),however, articulate or explain in detail these existential
2 Eriksson has since the 1970s developed a methodology for conceptdetermination as part of caring science basic research. The model wasoriginally developed by Koort in pedagogies (Sivonen, Kasen, and Eriks-son, 2010) and further developed in caring science at the Department ofCaring Science at Åbo Akademi University (Eriksson, 2010).3 Hans-Georg Gadamer (1900–2002) was a German philosopher of thecontinental tradition, best known for the opus Truth and Method(Wahrheit und Methode 1960). Gadamer built his philosophy on theidea of a “historically effected consciousness” (wirkungsgeschichtlichesBewußtsein), which means that people are embedded in and shapedby a particular history and culture, which is articulated in their under-standing of the world or being (Gadamer, 1989).
aspects about the relations between human movementand life.
During the 1980s and 1990s, several theories basedon dynamic motor control theory, with influencesfrom neuroscience and pedagogics were adapted inPT. These theories directed the development of exer-cise and use of movement in PT practice by emphasiz-ing the role of information in the environment (Carrand Shephard, 1987; Mulder, 1991; Shumway-Cookand Woollacott, 1995). The approach in PT practicewas refined to include intentional and functionalactivities in the individual's natural environmentwithin the context of the individual's preferences andneeds.
The models and theories presented in PT arelargely influenced by the biomedical view and thedynamic motor control theory. Besides this, a holistichuman science approach is partially articulated orunderpinned in the texts.
THE CONCEPT OF MOVEMENT IN PTBASED ON EARLIER RESEARCH
The concept of movement in PT is described in thefollowing based on a systematic literature search.Studies aiming to describe or deepening the under-standing of the concept or phenomenon of movementin PT theory, practice, or education, which are basedon empirical data, were included in the study. Anoverview of the included studies is presented inTable 1.
The depiction of the concept of movement in PT isinspired by the model for concept determinationdeveloped by Eriksson (2010) in caring science. Themodel is useful also in PT because it includes explor-ing the pragmatic as well as the scientific aspects of aconcept, which aims to bridge the gap betweentheory and practice. The focus is on the essence of abeing in the world and the nature of reality. Thisapproach enables exploring PT in a human scienceapproach and opens up a broader and deeper view ofthe PT reality and nature of PT in different contexts.The model (Figure 1) includes: 1) determination ofthe being; 2) the etymology (origin and history ofwords) and semantics (meaning of expressions) of aconcept; 3) the pragmatic features of a concept; and4) the meaning of the concept in various contexts.The ontological concept determination aims toachieve an understanding of the substance andclarity of the true nature of reality, while the contextualanalysis focuses on determining the pragmatic featuresand the meaning of a concept in various contexts(Eriksson, 2010). The model is based on Gadamer'shermeneutic ontology, which closely links
experiences, concepts, and language as well as think-ing and conceptualization (Gadamer, 1989).Figure 1 describes the positioning of the studiesused to describe a comprehensive understanding ofthe concept of movement in PT based on the modelfor concept determination by Eriksson (2010).
The concept of movement from PTstudents’ and PT experts' point of view
Abrandt (1997) studied the concept of movement withcontextual analysis and a qualitative phenomeno-graphic approach carried out among two groups of stu-dents (n = 14, n= 16). She came up with fourcategories to describe the conceptualization of move-ment in PT. In the categorymovement as a prerequisiteof functional activity and independence, movement isconceptualized as the ability to move the body and ex-tremities and is conceived of as a condition fulfillingthe goals of the individual as well as independence.Movement as an emotional expression is connectedwith body image, quality of life, joy, and beauty aswell as with a person's self-confidence and positive feel-ings about his body.Movement as a shift in position de-scribes the concept of movement in mechanical termsas locomotion or shift of the body position in theroom with the physical body as the frame of reference.Movement as a sign of life is related to biological pro-cesses on different levels. In this category, movementis also conceptualized as a fundamental condition oflife. The meaning of movement was thus characterizedby two frames of references: 1) the individual person;and 2) his capacities and intentions on the humanbody. Abrandt (1997) concluded that the relationshipbetweenmovement, health, and function is understoodwithin two different perspectives: a holistic as well as abiomedical context of meaning.
Lindqvist (2006) explored the ways undergraduatestudents identified with their profession beforeleaving university. The students who perceived iden-tity as a treater put evidence-based learning in focusand viewed movement as prerequisites. The educatoris patient-focused and concentrates on movementability, while the empowerer is patient-centered witha focus on movement behavior. Using a qualitativephenomenographic design, Lindqvist, Engardt, andRichardson (2010) studied the “learning to be a phy-siotherapist” in a cohort of 18 PT students, which alsoincluded views of the concept of movement. Theyfound three qualitatively different patterns with theaim of learning to influence health through and withmobility. The patterns were named: 1) learning tocure body structure; 2) learning to educate aboutmovement problems; and 3) learning to manage
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people's health. The patterns reflect different views oflearning and knowledge and implicate various concep-tualizations of human movement and PT reality. Thetwo first-mentioned patterns are underpinned by thebiomedical traditional paradigm, while the third
relates to a human science approach that focuses onhow to get into somebody else's world.
Öberg (1998) studied the concept of movementbased on movement science and psychiatric PT litera-ture as well as on qualitative interviews with seven
TABLE 1 Studies describing the concept of movement in PT.
Type of informationAim or focus of the study Method and material
Conceptualization ofmovement (M) in PT
Perspective onmovement or PT
StudentsAbrandt (1997)PT students' way of experiencing health,movement, function, and interaction in PT
M as a prerequisite offunctional activity andindependency
BiomedicalHolistic
Two groups of students (n= 14and n = 16) were interviewed twotimes
M as emotional expressionM as a shift in positionM as a sign of life
Lindqvist (2006)The experience of learning to be aphysiotherapist from a students' perspectiveLindqvist, Engardt, and Richardson (2010)
Qualitative phenomenographicdesignInterviews with students (n= 18)Metasynthesis
Prerequisites for M, M abilityand M behaviorTo cure body structuresTo educate about M problemsTo manage people's health
Biomedical paradigmHuman science approach
Learning to influence health through andwith mobility
Expert physiotherapistsÖberg (1998)To define the concept of movement in PTwithin the perspective of PT science
Qualitative contextual analysisPT literature (movement scienceand psychiatric PT)Interviews with expertphysiotherapists (n= 7)
M as an aim, intervention ortreatment, and indicator in PTM in PT included consciousreflection on body, movement,and life
NaturalisticHolistic
Skjearven, Kristoffersen, and Gard (2008)To investigate the lived experiencessearching for essential features andcharacteristics of the phenomenonmovement quality
Phenomenological approachIn-depth interviews with expertphysiotherapists (n= 15)
M quality asbiomechanical,physiological,psycho-socio-cultural, andexistential
All perspectives areintegrated in the core ofM qualityMultidimensional andholistic
Healthy informants/patientsWikström-Grotell, Lindholm, andEriksson (2002)To explore the meaning of the concept ofmovement in PT in a non-professionalcontext
Contextual and ontologicalanalysisHermeneutic approachInterviews with healthyinformants (n = 11)
M as an absolute valueM as a personal value calledindependencyM as a meansM as emotions and sensationsin body and mind
Human science approachInter- and intra-dynamic
Johnsen and Råheim (2010)To deepen the understanding of patients'perspective on movement practice inpsychiatric health care
Focus group interviewsInterviews with patients withpsychiatric disorders (n= 18)
Increased awareness of one'sown bodyBetter knowledge of selfThe relationships betweenoneself and others
BodySocial interaction
LiteratureWikström-Grotell (2000)To analyze the concept of movement as abase for further theory development in PT
Etymological and semanticanalysisDictionaries with scientificrelevance (n= 12)
To put in movement physicallyand mentallyM as complex andmultidimensional with 60different meanings
clinically active expert physiotherapists from differentfields of PT. The concept of movement in PT litera-ture was described from a narrow naturalistic perspec-tive with a strong influence from biomechanics.Within the psychiatric PT literature, a more holisticperspective was found. The expert physiotherapistsdescribed three different perspectives on movement:movement as an aim, intervention or treatment, andindicator in PT. This view on movement includesspatial, temporal, and force elements as well askinematic and kinetic aspects. Movement was alsodescribed as active, voluntary, intentional, concentric,as part and whole, and emotional. Furthermore, thedepiction of movement in PT included consciousreflection on body, movement, and life.
Skjearven, Kristoffersen, and Gard (2008) investi-gated the real-life experiences of a group of expert phy-siotherapists, five from each field of neurology,psychosomatic/psychiatry, and primary health care,by searching for essential features and characteristicsof movement quality (MQ) phenomenon. Four mainthemes were identified, seeing MQ as: 1) biomechani-cal; 2) physiological; 3) psycho-socio-cultural; and 4)existential, all of which are interacting processes.MQ as biomechanical is connected to how a personrelates to space and postural stability as crucial topromote functional form and path in movement.This aspect is viewed as a fundamental factor to beintegrated into movement training. MQ as physiologi-cal is connected to how the person relates to time withreference to physiological processes. Increasedfreedom in breathing was viewed as crucial to be inte-grated into movement training for a more flowing,elastic, and rhythmical MQ. MQ as psycho-socio-cultural is connected to how a person relates tointernal mental processes as well as to external
socio-cultural processes. Seeing MQ existentially isconnected to self-awareness and the ability of beingpresent. They also investigated how the PT expertspromoted MQ in their clinical settings and foundthat movement awareness and a bodily felt sense, aform of personal knowing called embodied presence,evoke an understanding and foster meaning in clinicalpractice (Skjearven, Kristoffersen, and Gard, 2010).
The concept of movement in PT from thepatients' point of view
Johnsen and Råheim (2010) interviewed 18 patientswith psychiatric disorders in Basic Body AwarenessTreatment groups in order to deepen the understand-ing of patients' perspective on movement practice.They extracted three core meanings: 1) increasedawareness of one's own body; 2) better knowledge ofself; and 3) the relationships between oneself andothers. In this field of practice, movement is stronglyconnected to the body and social interaction.
Movement was explored ontologically in a studyconducted in the context of everyday life based on in-terviews with 11 healthy informants, all with variousexperiences of movement and movement dysfunction(Wikström-Grotell, Lindholm, and Eriksson, 2002).The statements and expressions of the informantsabout the importance, meaning, and experiences ofmovement and movement ability were interpretedand reflected upon in relation to a holistic view ofman and a broad pre-understanding of the conceptof movement. The ontological approach aimed todeepen the understanding of the meaning of the exis-tential dimensions intertwined with other dimensionsof movement. The understanding of movement(Table 2) was described by the informants accordingto four categories: 1) movement as an absolutevalue; 2) movement as a personal value; 3) movementas a means; and 4) movement as emotions and asensation in the body or mind, also related tohealth. These categories were interpreted as inter- orintradynamic and closely related to each other.
According to the informants, movement was said tohave an absolute value, which was difficult to describein words, and a personal value that was named inde-pendency and expressed in relation to self and others.To be independent of and not dependent on otherswas also described as an important personal valuerelated to being able to take care of oneself as well asrelated to feelings of freedom. The informants alsodescribed existential feelings related to empowermentof the self, self–confidence, and trust. Another impor-tant meaning in daily life was movement as a means
FIGURE 1 Positioning of the studies described in Table 1according to Eriksson's model of conceptual determination(Eriksson 2010).
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for satisfying bodily needs, enabling human relation-ships, and participating in meaningful activities. Move-ment as a means was described as related to basicneeds, but also to human relations and the possibilityto participate in meaningful activities, which wasrelated to work and work ability or leisure time orfamily life. To have a functional capacity made thelived world bigger and was related to self-confidencein a broad meaning as well as to trust in oneself butalso to have empathy for others. In addition, the possi-bility of self-realization and creativity as well as workability and productivity were pointed out. The infor-mants also mentioned the importance of experiencesrelated to spontaneity and excitement. The informantspointed out a strong relation between movement andsensations in body andmind. The experiences of move-ment were related to nature, joy of movement andhealth, feeling well and healthy, and physical as wellas mental wellbeing.
The etymology and semantics of theconcept of movement
An etymological and semantic analysis of the conceptof movement interpreted from a physiotherapeuticpoint of view depicts more than 60 different meaningsof the concept of movement in PT (Wikström-Grotell2000). Those of most significance to PT are: transfer;change; flow; gymnastics; physical training; exercise;
action activity; emotion; life; idea; and anxiety. Theoriginal meaning of movement (in the Swedishlanguage) is to put in movement both mentally andphysically. The study points out a semantic relationbetween movement and emotions. Movement in PTis interpreted as a complex and multidimensionalconcept and categorized as inter- and intradynamic.
DISCUSSION
The scientific concept of movement in PT is wellunderstood from a biomedical perspective (GrönblomLundström, 2008; Shaw, Connelly, and Zezevik,2010) and conceptualized as intentional specifichuman movements or part of PT interventions.However, movement in PT is also used in a holistichuman science approach in practice, education, andresearch. This broader concept of movement in PTis complex and multidimensional, including not onlyphysical, emotional, mental, and socio-cultural butalso existential dimensions, as shown in earlierresearch (Abrandt, 1997; Öberg, 1998; Skjearven,Kristoffersen, and Gard, 2008; Wikström-Grotell,Lindholm, and Eriksson, 2002). The conceptualiz-ation of movement in these empirical studies includesmore nuances in comparison to the more technicallanguage used in professional and scientific PT litera-ture (Öberg, 1998). The broad concept of movementin PT is underpinned by a holistic approach, which
TABLE 2 Categories and meaningful elements describing movement from the patients' point of viewin everyday life (Wikström-Grotell, Lindholm, and Eriksson, 2002). Translation from Swedish.
Interdynamic movement in PT Intradynamic movement in PT
Movement as a means Movement as sensation in body or mindMovement as functional ability or capacity Joy from movement and harmonyMeans for satisfying bodily needs Enforcement of emotionsEnabling of human relationships Nature
Sense of community A feeling of closeness and connectionBeing together HealthSympathy, empathy To feel fit and well, physical and mental wellbeing
Participation inmeaningful activities
To feel well in the body
Self-realization and creativity A personal value, independencyWork and productivity Self-confidenceExcitement andspontaneity
TrustFreedom
Absolute valueOf high importanceEmpowerment of the selfHope for the futureTo believe in life
can broaden the view of PT reality and ontologicalreflections about man, health, and life.
Synthesis of the conceptualization ofhuman movement in PT
Concepts are naturally shaped within a language andtherefore necessary and valuable for the appliedresearch of scientific conception. To search for theessential meaning and the substance is therefore partof the ontological shaping. Gadamer‘s (1989) herme-neutic ontology is practically oriented and based onlanguage as a tool for thoughts and understandingthe meaning of reality and substance, the being inthe world. The depth of meaning and understandingof concepts enables the intellectual as well as emotion-al understanding of a being. Interpreting a textinvolves a fusion of horizons, where the text's historyis in a dialogue with the pre-understanding and theunderstanding of the researcher. Understanding isan ongoing hermeneutic movement, a spiral towardsa deeper understanding of the true essence of aconcept (Alvesson and Sköldberg, 2009).
The understanding of the concept of movement inPT based on the cited studies (Table 1) in this papercan be synthesized into five categories that describethe concept of movement in PT. The categories are:1) movement in PT as intentional and a means; 2)movement in PT as emotional or psychological; 3)movement in PT as a personal value and indepen-dency; 4) movement in PT as an absolute value anda sign of life; and 5) movement as treatment. The con-ceptualization of movement includes acting in relationto the environment, inter-dynamic aspects, as well asindividual, intradynamic, or intrapersonal aspects.Movement in PT as a health cure or interventionwas originally described by Ling (1834) based on aholistic view of man and health. This fifth category,movement in PT as treatment, exercise, or interven-tion, is not discussed in this paper, since the outcomesof PT are in the focus of research, and already providePT with a solid knowledge base for evidence-basedpractice.
1) Movement in PT as intentional and ameans
Intentional movement in PT is both comprehen-sively scientifically described and practically orientedwith a physical and social perspective of movement.Movement as a means or intentional movement isthe most used conceptualization of movement in PT,which is understood in a biomedical perspective asspecific human movements related to function andfunctional ability in relation to the environment.
Hislop (1975) used the expression biological motionwhile the PT students in the study of Abrandt(1997) described movement in PT as a shift in pos-ition and as prerequisites for functional capacity andindependency. This view of movement in PT isbased on dynamic motor control theories as well ascognitive aspects of movement. Cott et al (1995)declared that the idea with PT is to reduce the differ-ence between preferred and actual movementcapacity, while the informants in the study conductedby Wikström-Grotell, Lindholm, and Eriksson (2002)used meaning and meaningful activities in a corre-sponding way. One of the most significant meaningsis human movement as a means for satisfying bodilyneeds, enabling human relationships, and participat-ing in meaningful activities. This conceptualizationis broader and includes both socio-cultural and exis-tential dimensions. There is a risk for PT to losearenas to other professionals or to be considered the“ultimate placebo” (Stack, 2006) if the movementand its effects on health and function are seen asonly physical and not related to other dimensions ofmovement.
2) Movement in PT as emotionalMovement and emotions are related according to
PT students and experts as well as the healthy infor-mants in earlier research (Abrandt, 1997; Skjearven,Kristoffersen, and Gard 2008; Wikström-Grotell,Lindholm, and Eriksson 2002). Human movementin PT is expressed as feelings of health and wellbeing,quality of life, and joy. Movement is related to thebody image, a person's self-confidence, the relation-ship between self and others, and how a personrelates to time. This relation in PT is articulatedmainly in the area of psychiatric PT, putting thebody as a whole, the lived body, and feelings con-nected to the body in focus. In the area of psychiatricPT, human movement is described as body move-ments and concepts like body awareness and bodyexperience rather than specific human movements(Roxendal, 1987). Nicholls and Gibson (2010) likeEngelsrud (1990) favor a dialectic view of the body,influenced by phenomenology and a social under-standing of the body in contrast to the dualistic viewin biomedicine. Nicholls and Gibson (2010) foundthe body under-theorized in existing PT literature,and claim that the body as a philosophical or theoreti-cal concept needs more attention. They pointed out,as did Rosberg (2000) as well as Lundvik Gyllensten,Skär, Miller, and Gard (2010), the importance of adeeper theoretical understanding of conceptualizationof the body; the being as understood as embodied andbody awareness as the embodied identity, which isdescribed as living in the body and living in society.There is also agreement about a relation between
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health and the conceptualization of movement in PTin earlier research (Abrandt, 1997; Broberg, 1995;Lindqvist, Engardt, and Richardson, 2010; Wik-ström-Grotell, Lindholm, and Eriksson 2002). Move-ment is related to a multidimensional view of healthand is experienced as and related to mental and phys-ical wellness and wellbeing. Despite this, the emotion-al aspects are not covered much or intentionally usedon a general level in PT. Gard and Gyllensten (2000)studied the interaction between physiotherapists andpatients. They stated that the physiotherapists areaware of emotional aspects and their importance,but they are acting on an intellectual level. Theypoint out the importance of expressing emotions intreatment situations. To act more emphatically mayincrease positive treatment outcomes, thanks to trans-ference processes.
3) Movement in PT as a personal value orindependency
The aim of intentional movement in PT isexpressed as maximum movement and functionalability (WCPT, 2011), functional activity, and inde-pendence (Abrandt, 1997), and as preferred andcurrent movement capacity (Cott et al, 1995). Thisconceptualization focuses on the ability to moveand a physical perspective of movement. However,independency in PT has a personal deepermeaning as well. The healthy informants expressedas a personal value the feeling of being independentas feelings of freedom (Wikström-Grotell, Lindholm,and Eriksson 2002). Movement in PT is thus con-ceptualized as a personal value expressed as indepen-dency in relation to self and others, to beindependent of and not dependent on others, andbeing able to take care of oneself with focus onsocial dimensions and intra- as well as interpersonalaspects. There is a need to include not only patients’values and beliefs but also the intrapersonal existen-tial dimensions related to movement to deepen theunderstanding of the patient as well as the healtheffects of PT. There is a lot of evidence of theeffects of physical activity and exercise in PT. PThas an important role in health promotion and pre-vention in the future to promote lifelong healthwithin the context of life-style-related conditions(Dean, 2009). However, research in PT has notfocused much on how to influence people's move-ment behavior taking interactional and intrapersonalaspects into consideration.
4) Movement in PT as an absolute value anda sign of life
Movement as an absolute value, related to humandignity and life, is described in statements aboutmovement as being connected to the meaning of lifeor as a sign of life, a sense of being present and
alive, empowerment of one self, and feelings of trustin and hope for the future (Abrandt, 1997; Öberg,1998; Skjearven, Kristoffersen, and Gard 2008; Wik-ström-Grotell, Lindholm, and Eriksson, 2002). Earlyon, Ling (1834) as well as Hislop (1975) and Cottet al (1995) established that movement is essential tohuman life, even if they did not more closely describeeither existential or ontological assumptions. Move-ment as a personal and absolute value is a valuablepart of the substance and the being in PT. Theseexistential dimensions form the essence and shouldconsequently be integrated into the innermost coreof PT. PT practice that is based on a broader viewof the relation between the intraindividual aspects ofhuman movement and health raises the awareness ofhealth effects in PT among clinicians as well asresearchers.
The different perspectives of movement, includingalso the existential dimensions of human movement,are all integrated in the innermost core or substanceof PT and the multidimensional nature of PT reality.Movement as a basic concept in PT can be developedas a scientific, ideal concept, which also articulatesontological assumptions in PT.
Concept determination as part of the basic researchin PT is needed as a first step towards a cumulativetheory development and in shaping the ontology ofPT. Several authors over the years have agreed aboutthe need for development of a general theory in PT(Bithell, 2005; Edwards and Richardson, 2008;Richardson and Lindqvist, 2010). PT needs an epis-temology that is based on an explicit ontology tobridge the gap between research and practice(Helders, 2004; Jensen, 2004). The first step in theorydevelopment and outlining a theory of science for a dis-cipline is concept determination. In nursing, asmethods for analyzing concepts have proliferated,there has also been criticism and methodological con-fusion (Hupcey and Penrod, 2005). The need to usetheoretical as well as patient-centered approaches issupported. The advantage of concept analysis is tomake existing concepts explicit objects of reflection.However, concept analysis needs to be integrated inconcept as well as theory development. Further-more, a researcher's competence to understandlanguage and culture is limited. According toSivonen, Kasen, and Eriksson (2010), a conceptualunderstanding is an understanding within onelanguage at a time. It is challenging to find wordsthat express a similar meaning content in anotherlanguage. There is, therefore, a need to explore theconceptualization of the core concepts in PT onto-logically in different meaningful contexts – variousfields of PT practice, languages, and cultures, toenable a common understanding of the core and
nature of PT globally. In addition, historical devel-opment, which is part of the concept determinationaccording to Eriksson (2010), could bring value tofuture theory development in PT (Terlouw, 2006).
The knowledge base in PT has grown exponentially,and constitutes a solid base for scientific knowledge de-velopment and evidence-based PT practice (Maheret al, 2008). What PT lacks is cumulative theory devel-opment, including concept determination aimed at de-scribing the nature of PT based on explicitly articulatedontological assumptions. The human being cannot becomprehensively understood or described in biomedi-cal terms. InPTresearch, the viewof the basic conceptsseems to be characterized by ontological reduction,which means describing or explaining a phenomenonin terms of another, within a narrow biomedical per-spective (Noronen and Wikström-Grotell, 1999). Theorigin of the core knowledge of the profession in twodifferent knowledge traditions has influenced the aca-demic development of PT, the use of concepts, andhow physiotherapists understand and interpret thecomplex, multidimensional PT practice. Researchresults based on a biomedical paradigm should be con-sidered in relation to a holistic view of humans, usingreduction on a methodological, not an ontologicallevel.
CONCLUSIONS
The concept of human movement in PT is multi-dimensional, including physical, emotional, socio-cultural, and existential dimensions. Movement is acore concept in PT that can be developed further asa practical as well as scientific concept to obtain abroader and deeper understanding of the complexreality of PT. A need to develop a more specific anddeeper conceptualization of the meaning of movementin relation to other central PT concepts as well as fromthe patients' point of view in different contexts andvarious fields of PT practice remains. PT practicetakes advantage of a comprehensive understanding ofthewhole complex PT reality and has use for an under-standing of human movement that includes interactiveand intrapersonal aspects within a human scienceapproach. In PT education, curriculum design couldbenefit from a knowledge base which includes adescription of core concepts broad enough to apply toall aspects of current as well as forthcoming PT prac-tice. To include concept determination in basic aswell as applied research of PT is necessary for develop-ing the unique knowledge and substance of PT.Human movement as a basic value for being in theworld is not much explored. PT could benefit fromknowledge in philosophical and psychological theories
as well as sport sciences concerning human movementand individual inner recourses in relation to changes inlife style and motor behavior. A deeper understandingof the significance of humanmovement inPT, intraper-sonal aswell as existential dimensions can contribute toa better understanding of patients and health on a uni-versal level in the health-care system as well.
ACKNOWLEDGMENTS
Camilla Wikström-Grotell was responsible for all partsof this article. Katie Eriksson contributed with scienti-fic and critical comments to refine the article andacted as an overall supervisor.
Declaration of Interest: The authors report noconflict of interest.
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Post-structural conceptualizations of powerrelationships in physiotherapyNaomi R. Eisenberg, BPHE, BHSc(PT), MEd
Department of Vascular Surgery, University Health Network, Toronto, Ontario, Canada
ABSTRACT
This paper uses a post-structuralist lens to explore the nature of power relationships within the patient–physicaltherapist relationship. To ground the discussion, I begin with an overview of the salient aspects of the traditionalevolution of Western medicine. I then draw from the philosophy/history of Foucault to challenge traditional think-ing and consider the applications to physiotherapy. The analysis reveals that the application of a Foucauldianframe of reference has the potential of modifying the therapeutic relationship to one that is more equitable asopposed to the hierarchical one. I conclude with a discussion of the implications for the development and edu-cation of physiotherapists.
INTRODUCTION
Physiotherapists, like other health care practitioners,are taught how to treat patients’ bodies, but notnecessarily how to delve beneath the material surfaceof a therapeutic interaction. As physiotherapy (PT)students, we were taught to see patients through abiopsychosocial framework (Alonso, 2004; Engel,1977), which “regards social and psychologicalaspects as giving a better understanding of the illnessprocess” (Alonso, 2004; p. 239). Despite the putativeemphasis of the framework on the relationshipbetween biology and the psychosocial aspects ofillness and disease, it does not account for the powerrelationships and inequities that form and inform thebodies and minds of both patients and clinicians. PTnecessarily involves a clinical relationship betweenthe therapist, patient, and often others, and thisrelationship can be complex.
The primary focus of the biomedical frameworkremains that of a body with a diagnosis/dysfunction,with clinical treatment delivered in a particular way.More recently, and especially with the introduction
of the International Classification of Functioning,Disability, and Health (ICF), physiotherapists havebegun to think about their practice in different waysthat include a consideration of participation in “lifesituations” (Stucki, Cieza, and Melvin, 2007). Never-theless, the focus on fixing the body remains central toPT practice (Nicholls and Gibson, 2010). Moreover,how power relationships shape interactions is largelyabsent from any of the dominant models that under-pin current practice including the ICF or the biopsy-chosocial model. Evidence-based practice, which isincreasingly dominant in health care discourse,de-emphasizes the importance of relationships inshaping clinical encounters and decision-making. Ashealth professionals, our views of the world and ofthe ill or impaired body are formed and dominatedby how we are taught to view and thus treat ourpatients. The biopsychosocial framework suggests acompartmentalization of the patient and clinicianwho each have specific roles within the health careencounter (Nicholls and Gibson, 2010). It provideslittle space for the negotiation of power relationshipsand fails to acknowledge that power struggles existwithin the patient–clinician relationship.
There has been little discussion in the PT literatureabout the multiple ways of understanding bodiesbeyond the physical or about the effects of powerwithin the patient–practitioner relationship. Becauseof this, individual physiotherapists may not fully
Address correspondence to Naomi R. Eisenberg, BPHE, BHSc(PT),MEd, Departments of Allied Health and Vascular Surgery, UniversityHealth Network, Toronto, Ontario, Canada; Ontario Institute forStudies in Education, University of Toronto, Toronto, Ontario,Canada. E-mail: [email protected]
appreciate how biomedical knowledge of the bodyputs them in a position of power in relation to theirpatients. By the aspects of the power that they hold,and how, by viewing their patients in a particularway, they may further contribute to their marginaliza-tion within the therapeutic relationship and, on alarger scale, the health care system.
This paper seeks to explore some of the origins ofthe power held by health practitioners by drawing onthe work of French historian and philosopher MichelFoucault. Foucault’s writings explore the invisiblenature of power relationships and, consequently,their existence plays a role in shaping the outcomeswithin the therapeutic relationship. I explore howpower relationships play out in patient–practitionerrelationships and discuss how PT educational pro-cesses might influence and improve these relation-ships. I begin with a review of the development ofcontemporary medical and health care practices tosituate the discussion of post-structuralism and thecritique inherent in some of Foucault’s work. Indoing so, I outline some of the dominant understand-ings of health, health care, and the body that have per-vaded modern health care discourses and howFoucault’s ideas can be used to challenge these in-grained perspectives.
Humanism and the development of“modern Western medicine”
It is helpful to understand that modern Western medi-cine has been in a relatively continuous evolutionduring the past 300–400 years (Alonso, 2004; Engel,1977).
In his foundational work, Engel (1977) describedthe traditional biomedical model of disease as beingbased in molecular biology. Engel suggested thatduring the Enlightenment period (!1650–1800),biomedicine “assume(d) disease to be fully accountedfor by deviations from the norm of measurable biologi-cal (somatic) variables…. [T]he biomedical modelembrace(d) both reductionism…and mind-bodydualism” (Engel, 1977; p. 130). By “mind–bodydualism”, Engel referred to the separation of the phys-ical body from the person. This idea was first intro-duced by Enlightenment philosophers such as ReneDescartes and was a key philosophical shift thathelped form modern ideas of the body as akin to a bio-logical machine. Engel’s critique of a biomedicine thatwas designed to study organic disease was anchored inthe idea that it only allowed for behavioral illness asbeing rooted in somatic processes. “Science” as thebasis of biomedicine implied observation where theobject of observation is the patient as object.
Engel (1977) stated that “…[C]lassical science readilyfostered the notion of the bodyas amachine, of disease astheconsequenceofbreakdownof themachine, andof thedoctor’s task as repairof themachine” (p. 131).Once thiskind of duality was established and accepted, biologicalprocesses became the focus of early Western medicine,and behavioral or psychological processes were ignoredor excluded from study.
These ideals were reinforced by Enlightenmentphilosophers such as Descartes, Hegel, and Comte,whose ideas have evolved and influenced contempor-ary health care and the way we think and behave asclinicians today. Each of these three philosophers,along with others, has contributed to the way wehave generally come to accept the division of themind and body in the twenty-first century. A full dis-cussion of their work is beyond the scope of this paper,but the reader may refer to St Pierre (2000).
The ideas sometimes referred to as “mind overmatter” or “the power of the mind” can be thought ofas colloquial references to the work of Descartes, whowas a key proponent of mind–body duality, and thischallenged the temporal teachings of the Church,since Cogito ergo sum (I think therefore I am) separatedand placed the mind in a superior position to the body.
Descartes’ ideas of rationalism were echoed in thework of Hegel, who was a key proponent of the dialec-tic, which linked binaries and their evolution together(St Pierre, 2000). Like an upward-reaching spiral, hedescribed how each idea (thesis) evolved with aresponse (antithesis) that led to the formation of anew idea (synthesis). Furthermore, Hegel believed inthe concept of knowledge as a stable construct. Thelater work of Auguste Comte held that “true knowl-edge of the world could only be gained by obser-vation” (cited in St Pierre, 2000; p. 495). Comte’swork thus emphasized the importance of the neutralobserver who gathered facts about the world throughrigorous empirical methods. This required carefulattention to the observation of the task at hand.
The philosophies of these three men together weretremendously influential in the development of themodern-day scientific method where the idea ofwhat is true and what is contingent was constructedas stable, permanent, and objective. This positiondominates contemporary medicine and health careand pervades the way patients are, by and large,reduced to malfunctioning machines that can berepaired through interventions. Biomechanical dis-courses are prominent in PT’s preference for objectiveresearch paradigms, and they lie at the heart of PT’stheoretical and practical approaches. Nicholls andGibson (2010) provided an excellent discussion ofhow the body has come to be seen by PT andsuggested that non-traditional views of the body have
been rejected, reinforcing the prominence of the bio-medical model.
As discussed in more detail below, these assump-tions about mind–body dualism and truth exerteffects on the clinical encounter. A clinical focus onpathology and movement dysfunction, for example,may come at the expense of engagement with thepatients’ or therapist’s experiential knowledge.
A Foucauldian frame of reference
Foucault’s work radically challenged the persistenceof the enlightenment model of medicine and hiswork underpins an emerging body of post-structuralscholarship that examines how power mediates thehealth care enterprise. His work carefully traced theevolution of modern medicine to illuminate howcurrent ideas became dominant. Foucault (1980d)discussed how during the eighteenth and nineteenthcenturies, a newly emerging recognition of healthbecame a political and economic challenge in lightof the Industrial Revolution. The political sources ofpower extended beyond the monarchy and the ideasof “war and peace” to include “peace and justice”,and this expanded the role of the police, who wereassigned the responsibility of enforcing rules ofhygiene (Foucault, 1980d). Hygiene became anapparatus of medicine to establish some element ofsocial control, and the hospitals and prisons becamethe physicians’ early laboratories for observation.
According to Foucault (1975, 1980a), the modernmedical clinic arose during the eighteenth and nine-teenth centuries in post-revolutionary France andEurope. In France, hospitals had previously func-tioned as vessels for the sick poor, sponsored by foun-dations and religious organizations affiliated with thehospital. With the advent of the Industrial Revolution,poverty became equated with idleness, and the politi-cal power structures of the day were determined toutilize the poor as human capital in the factories;thus, the health and well-being of the populationbecame central to industrial progress.
Foucault identified that it was during this time thatthe era of what he termed “bio-power” emerged. Heoutlined the “explosion of numerous and diverse tech-niques for achieving the subjugation of bodies and thecontrol of bodies…embodied in institutions such asthe army and the schools” (Foucault, 1978; p. 140).These techniques gave the state and its agencies con-siderable control over individuals’ bodies. The appar-atus of medicine gave the physician considerablefreedom to examine and “medicalize” social phenom-ena. It allowed the physician to emerge from a gentle-man to an authority figure who studied the biology
and pathology of disease in an environment that con-centrated these elements. Foucault identified how therelationships between doctors and patients were beingconsiderably changed.
The development of a claim to scientific authorityand legitimacy was paralleled in PT. Nicholls andCheek (2006) discussed the evolution of PT inBritain, in the latter part of the nineteenth century,where prostitution was sometimes masked as thera-peutic massage. This necessitated the development oflegitimate ties of the masseuses to physicians, whicheventually led to the formation of the CharteredSociety of Physiotherapy in the early twentieth century.
Engel (1977) similarly outlined how biomedicineacquired “the status of dogma” (p. 130):
Thus taxonomy progresses from symptoms, toclusters of symptoms, to syndromes, and finallyto diseases with specific pathogenesis and pathol-ogy. This sequence accurately describes thesuccessful application of the scientific methodto the elucidation and classification into discreteentities of disease in its generic sense.
Engel was not a Foucauldian, but his critique of bio-medical dogma resonates with some of Foucault’s keyideas. He argued that the physiological findings ofdisease may be incongruent with the experience ofillness. “Patients”, he suggested, may be feeling fineand so do not apply the label of disease to themselves.Bodily experience is unchanged prior to the blood test,until the physician intervenes. He believed thatpsychological and social conditions helped to framethe patient’s experience of the disease, and this hasbeen widely embraced in nursing and psychology(Alonso, 2004) and to some extent in the practice ofmusculoskeletal PT (Main et al, 2011).
Modern Western medicine evolved into what wetoday might refer to as the practice of the scientificmethod.1 This movement was historically importantin bringing humankind from the medieval to themodern era. But like all systems of thought, it facili-tated one way of knowing and acting in the worldwhile limiting others. Enlightenment thinkersacknowledged only one kind of truth that was contem-poraneously relevant. An example of this may befound in Rembrandt’s painting “The AnatomyLesson of Dr Nicolaeus Tulp” (Figure 1). Theimage of the physician and his students dissecting acorpse can be seen as an illustration of
1 Scientific method refers to techniques of investigation of phenomena.It requires the gathering of observable, empirical, and measurable datathat can be evaluated through a reasoning process. It starts with anidea “a causes b”, and then “a” is tested through an experiment to seeif it in fact causes “b”.
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Enlightenment’s European origins, where truth wasconstructed from the position of being white, male,gentrified, and Christian and other points of viewwere more or less viewed as illegitimate.
Enlightenment thought has contributed to contem-porary Western belief systems and, as alluded to, thesethoughts have been challenged by other thinkers.Foucault helped identify some of the challenges oftraditional thought in order to bring about socialchange. Central to his thesis was the concept of thepower relationship between a patient and a prac-titioner and its impact on health care delivery.
Foucault and power relationships within PT
Post-structuralism, as espoused by Foucault, chal-lenged commonly held definitions of what was know-able and posited that truth takes many forms. Hechallenged the Enlightenment ideals of the stabilityof truth and that what we know needs to be decon-structed to explore what is not being said or thoughtand how power circulates to produce particulareffects. This approach was utilized to uncover pro-cesses of power and marginalization in the healthcare system. Post-structuralism incorporates whatFoucault referred to as “archaeology” and “geneal-ogy”. The former looks to understand “the historicalconditions, assumptions and power relations thatallow certain statements…to appear” (St Pierre;p. 496). The latter examines what is not being said,thus challenging deeply embedded assumptions thatunderpin how we think about a concept such ashealth care (Foucault, 1998; St Pierre, 2000). Thesemethods begin to move away from what is expectedand instead allow an examination of phenomena
from those perspectives that might otherwise havebeen repressed.
As stated in the introduction, relationships betweena patient and a practitioner are complex. Health pro-fessionals, including physiotherapists, have knowledgeof the disease/dysfunction and how to treat it versusthe patient who has the knowledge and experience ofillness, pain, or dysfunction. The clinician holds theknowledge and experience of how to help the patientmake decisions regarding the treatment; hence thepower relationship is inherently unequal. A Foucaul-dian framework provides an excellent basis for addres-sing the issues that may arise within this relationship.Foucault’s method of archeology provides a historicalperspective for understanding the development ofcurrent medical practice, and his method of genealogyof the power relationships helps to explain the discon-nects that may be perceived to exist between patientsand practitioners (Foucault, 1975, 1977, 1980a,1980b, 1980c).
From the archeological perspective, PT in Britain,Canada, and the USA evolved during the lastcentury as a profession closely aligned to medicine,and curricula were directed by faculties of medicineuntil the latter half of the twentieth century, whenvarious PT faculties gained autonomy as the pro-fession evolved. Physiotherapeutic relationships wereformed initially based largely on the medical modelof thinking (Cleather, 1995; Linker, 2005; Murphy,1995; Nicholls and Cheek, 2006). It was during thisevolution that the assumptions of dominant discourseof biomedical thinking became applied to PT.
From the genealogical perspective, physiotherapistseducated in the Anglo-American tradition have beentaught that there are necessary boundaries in thepatient–therapist relationship (i.e., College of Phy-siotherapists of Ontario [CPO], 2005). Rules regard-ing maintaining boundaries are in place to maintaintherapeutic efficacy and efficiency and preserve the“objective” role of the therapist. They also protectpatients from real or perceived abuse by the acknowl-edged power holder. In Ontario, for example, someprofessionals are forbidden to have personal relation-ships with patients (psychiatrists), and for someothers (physiotherapists), a suitable time periodmust elapse before a personal relationship is allowed.Professional power was thus legitimated by pro-fessional bodies, which in turn were internalized byclinicians.
As alluded to earlier, the notions of “power” andthat of the “power relationship” are not interchange-able. Power is a broadly interpreted construct withmany implications. At its most basic, power can bedefined as a force that produces a change (Griffin,2001). It may be a trait of a profession or an
FIGURE 1 Rembrandt, The Anatomy Lesson of Dr Nico-laeus Tulp, 1632, Mauritshuis Museum, The Hague,Netherlands.
organizational (political) structure. These formsof power may be easily visible to the observer.Foucault, on the other hand, discussed power relation-ships as those involving more subtle and invisiblecharacteristics.
Foucault (1980a, 1980b, 1980c, 1980d) exploredpower relationships in great detail as they related tothe medical complex. By extension, these could beapplied to the practice of PT. He identified thatpower is a relational cluster that is coordinated butnot hierarchical, and the perspective is mutable (a“grid of analysis”) (Foucault, 1980c; p. 199). In theclinic, for example, a physiotherapist holds thebalance of power toward his or her patient duringtreatment, but the patient may have more equalpower with the physiotherapist in a different sharedcontext, such as playing together on a sports team.In the first part of the example, the physiotherapistcan determine a course of treatment for his or herpatient, whereas on the playing field, the therapistand the patient, if they are on the same team, shareequally in achieving their common goal: winning thegame.
Foucault suggested that a power-based relationshipis fluid, that is, the balance of power can shift back andforth over time and in different contexts. An examplefrom my own experience as a patient helps to demon-strate this point. I initially felt like I was floatingoutside myself during the period of diagnosisand early treatment. I referred to this period as“dual-ling bedrails” whereby I existed simultaneouslyas a patient (inside the bedrail) and as a clinician(outside the bedrail) and I experienced internal con-flict, both dual and duell-ling. As I progressedthrough the medical complex, however, my powerrelationships with the staff shifted. I became moreinformed about my disease and treatment optionsopen to me. I became better able to advocate formyself and was less vulnerable. The balance ofpower had shifted, even if slightly, and I felt more incontrol of my body and my fate. The question,though, is how was that possible? To understandthis, it is helpful to understand Foucault’s perspectiveson health care relationships.
Foucault demonstrated how health care and healthcare relationships developed through the evolution ofhealth and hygiene controls by the state. As discussedearlier, health became a locus of primary importancefor the government during the early days of the Indus-trial Revolution, and this apparatus acted as a lynch-pin facilitating medical participation within the newlyemerging economy. As Foucault (1980d) stated,“The doctor becomes the great adviser and expert, ifnot in the art of governing at least in that of observing,and correcting, and improving the social ‘body’ and
in maintaining it in a permanent state of health”(p. 100). However, as the able-bodied poor wereejected from the hospitals, the physical structure wasno longer used for its initial purpose. The hospitalwas transformed into a place of observation and inter-vention rather than into that of charitable assistance.As the hospital evolved, so too evolved the “hierarch-ical prerogatives of doctors” (Foucault, 1980d;p. 104) and, with it, the articulation of knowledgewith therapeutic efficiency also evolved. It allowedfor the observation of the subject/patient, which wascritical for the development of the profession and theprofessional relationship:
Doctor and patient are caught up in an evergreater proximity, bound together, the doctor byan ever more attentive, more insistent, morepenetrating gaze, the patient by all the silent irre-placeable qualities that, in him, betray – that is,reveal and conceal – the clearly ordered formsof the disease. (Foucault, 1975; pp. 15–16)
Foucault (1975) explained that the rise of medicalschools in France during the eighteenth and nine-teenth centuries gave the old hospital structures newpurpose. He wrote that by observing large groups ofpatients and submitting them to the “medical gaze”(Foucault, 1975; p. xii), certain conclusions couldbe drawn about diseases and their progression. Analy-sis of disease would enable the physician to define it.Observing patients was akin to a painter capturingdetails in a portrait (Foucault, 1975). Ironically, thecloser a physician observed the disease, the fartheraway the patient became: “(P)aradoxically, in relationto that which he is suffering from, the patient is only anexternal fact, the medical reading must take him intoaccount only to place him in parentheses” (Foucault,1975; p. 8). Today, we may continue to unintention-ally objectify the patient (e.g., “the pneumonia inroom 541”). The patient has been intellectually separ-ated from his or her illness by the very people whom heor she turned to for assistance. Foucault (1975) ident-ified the genesis of this kind of loss of identity:
…if one wishes to know the illness from which heis suffering, one must subtract the individual,with his particular qualities…if the course of thedisease is not interrupted or disturbed by thepatient, at this level the individual was merely anegative element, the accident of the disease,which, for it and in it, is most alien to itsessence. (p. 14)
Relating this back to my own experience, there were,thankfully, only a few times when I felt that my subjec-tive experience was ignored and my diagnosis andsymptoms were the object of care. However, it was
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interesting to note that at times when I reported anincrease in symptoms, the response was “Well yourscans have improved”, as if the objective evidencesuperseded my experience. In these instances, Iexperienced Foucault’s notion of the subtraction ofthe individual in the health care encounter.
For Foucault, forms of power existed in a relationalfashion, a further example of which might be found inhis description of the Panopticon (Foucault, 1977).The Panopticon was described as being an ideal typeof prison: a tower in the middle with the prisoners intheir cells all around in a circle. There was onewindow outside and one inside each cell, the formerlighting the cell, so the prisoner was always visible tothe tower inside. The prisoners knew that they werebeing watched, but the watcher was invisible, and itwas the invisibility of this surveillance that succeededin enforcing order within the prison (Foucault,1977). The Panopticon has been used as a metaphorfor medical practice wherein the clinician knows andobserves the patient, but the reverse does not happen(Filc, 2006; Foucault, 1975, 1980a). Filc (2006)described this as being a literal form: a body was putunder surveillance, which in turn produced a new body:
In the medical encounter bodies are not only putunder surveillance, they are produced. They areproduced not only as an effect of discourse, butin a more concrete sense: they are acted uponand transformed. Bodies are produced and trans-formed by the medical gaze, by touch,medication, changes in habits, or – the mostinvasive way – through surgical procedures; evenup to the point that scholars working within theFoucauldian tradition claim that the very notionof individuality is linked to the medical practice.(p. 222)
This is crucial: by entering the medical complex,patients may experience a shift in their pre-existingidentities in unexpected and potentially unwelcomeways. Once a patient is under the scrutiny of themedical gaze, he or she becomes the subject of thehealth care practitioner. This changes who thepatient is, and a new body is produced through inter-vention – both metaphorically and literally. I relatedwell to this feeling. At each doctor’s appointment, Iworried about what my doctors said about me, myblood test results, and my scans, and when I left, Iwas always just a little different, and I know that Iwill never be quite who I was before. My (Panopticon)experience certainly coincided with feelings of beingpowerless and disembodied and of being completelyat the mercy of the medical complex and questioningmy own identity.
This may be readily extrapolated to PT, where, forexample, through the taking of the patient’s history,the therapist may gain awareness of the patient’s per-sonal issues, without revealing himself or herselfback to the patient. Patients’ knowledge of a physicalreassessment of their symptoms becomes the invisibleenforcer of compliance with the therapeutic regimenprescribed by the therapist. Patients come to interna-lize the authority of the physiotherapist, adhering totreatment regimens, often with little questioning.The “non-compliant” patient who questions theexpertise of the PT is thus an exception rather thanthe norm. Hence, Foucault’s point about self-surveillance in relation to the Panopticon is as promi-nent in PT as in other health disciplines.
The decision to seek out PT care results in enga-ging in a power relationship and may result in aninternal struggle with the medical complex (“I’m inpain; I need help, but I’m afraid of physio, becauseit might hurt…” or “I know I have to get up and gofor a walk, but I just don’t feel like it right now; Idon’t care if I get pneumonia…”). It is here that Iwould suggest that the models that underpin contem-porary PT/health care practice and training have adirect bearing on patients. The clinical encounter isthe site where power relations get played out andwhere patients’ bodies are constructed according todifferent kinds of subjectivities.
DISCUSSION
Application to PT
What is the relevance of these theoretical explorationsto PT practice? An example of a clinical scenario of apatient with a chronic neurological illness, multiplesclerosis, helps to illuminate the primary issues. Thepatient is having difficulty mobilizing and has beenreferred to the physiotherapist for “gait training”. Ofnote, even before beginning the physiotherapist–patient relationship, other power relationships maybe coming into play. Depending on the locale, a phys-ician may be required to initiate the referral, creating athree-way relationship among the physician, patient,and therapist, and this may be a further complicatingfactor during the clinical encounter.
Using a traditional approach, the physiotherapistwould take a history, perform an assessment, and pre-scribe a treatment regimen based on the availablescientific literature and best practice guidelines.The physiotherapist would be well aware of the physio-pathology of this condition. Initial therapeutic plansmay include short-term and long-term goals measured
using reliable and valid outcome measures, estab-lished through standard scientific methods. What arethe consequences to the patient if these goals are notachieved? Where does that leave the patient and thephysiotherapist and who is supposed to have “theanswers”? Where does that leave their relationship atthe time of discharge?
In an alternative approach that takes seriouslyFoucault’s ideas and the need to attend to powerrelationships, the therapist would listen to the patientand consider the patient’s needs in a different way.He or she would consider looking beyond the role oftherapist and its accompanying professional obligationsor adherence to concepts of evidence-based practice(American Physical Therapy Association, 2011;Canadian Physiotherapy Association, 2011) and letgo of assumptions about what is “best”. In conjunctionwith the patient, he or she would explore meaningfuloptions for the patient even if he or she deviates signifi-cantly from typical rehabilitation goals and assumptionsof “good” outcomes. This could shift the balancetoward being more equitable and, furthermore, addthe patient even more deeply into the equation. Themaintenance of walking, for example, might not bethe “best” option for this particular person, even if itis assumed to be a usual goal for this cluster of symp-toms and abilities and even if it is what the patientinitially expressed as a goal. Peeling back the layers ofexpectation and thinking beyond the traditional (i.e.,a genealogical approach), the two might agree that,for example, a wheelchair might be a more feasibleoption for mobility and is not necessarily a “failure”.Larger questions would be asked about identity, experi-ence, hopes, and disappointments. How does thepatient feel about this change? What kind of freedomor constraints might it grant?
An approach such as this acknowledges the mul-tiple ways power operates in the relationship. It doesnot try to eliminate power, but works from thestrengths of different sources of knowledge andpower to creatively seek solutions. Foucault’s notionof governmentality helps to illuminate, question, orchallenge the traditional norms of professional sociali-zation for physiotherapists and their relationshipswithin the health care system. Professional socializa-tion involves the integration of both formal and tacitlearning, which results in a sense of professional iden-tity (Arndt et al, 2009; Öhman and Hagg, 1998). Stu-dents and practicing professionals alike are “inductedinto the culture of their respective disciplines” (Arndtet al, 2009; p. 18). We are taught to emulate thosetraits that are deemed desirable. This is governed bythe academic champions who “perpetuate andreinforce existing culture” (Arndt et al, 2009; p. 18).Role-taking activities, as well as interacting with
significant others, allow a novice to imitate thatperson from the reference group who is desired(Arndt et al, 2009; Öhman and Hagg, 1998). We aretaught that normative behavior is the desired outcome:
Health care students form an identity through theinteraction with others by acquiring…the adop-tion of social norms (i.e., the standard patternsof behaviour), attitudes and values that governhow to conduct oneself in a variety of settings.(Arndt et al, 2009; p. 19)
In adopting a Foucauldian approach that attends topower relations, physiotherapists need to be willing tobe open, vulnerable, and transparent. They need tofeel confident to say that “I don’t know; I don’t haveall the answers”, mitigating some of their traditionalsources of power and building on others. From myown experience, I was frustrated by health care provi-ders always having to feel that they had to have ananswer even if it meant twisting my question to suit aready answer. Being quoted numbers and percentagesreduced the experience of my illness to somethingabstract rather than as a concrete, lived experience.
Paying attention to patients in this way could beconsidered as a brave and risky path to follow. I amnot suggesting that scientific evidence is unimportant;rather, science is only part of the therapeutic equation.I think it is important to acknowledge that eachindividual experiences his or her body differently aswell as the patient who will have an individual experi-ence of PT. As therapists, I think we also need toacknowledge that there are both visible and invisibleforms of power within the therapeutic relationship,and attending to this has the potential of helping thephysiotherapist become more compassionate andaccessible to the patient. There is still an art to beinga successful physiotherapist; perhaps sometimes thekey to the art is acknowledging one’s frailty.
CONCLUSION
In this paper, I have reviewed some of the historicalorigins of medical power from traditional and post-structural perspectives. I have discussed aspects ofthe power relationships within Western medicine andhow they might be manifested in patient–therapistrelationships. Finally, I provided an example of howre-thinking power relationships in the patient–physiotherapist relationship might work.
Physiotherapists learn about the legal limits of powerwithin a therapeutic relationship, but not necessarilyabout the nature of power relationships, and how theymanifest themselves in health care environments. Mypersonal experience with PT students and colleagues
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has demonstrated this to me frequently. This is notoften covered during the educational experience.Exposing students and professionals to both traditionaland post-modern histories of their respective pro-fessions can help them understand the multiple fruitfulways of engaging with patients. Physiotherapists wouldbe enriched by an understanding of how they have beenconstructed as health professionals and become criticalof this process. Most of us have little exposure to ideasabout how we are taught: to reproduce some tenets andreject others; the construction of our professionalpower; how our patients as subjects of the health careapparatus are made vulnerable; and regarding theirown professional power. This could lead to betterunderstanding and re-imagination of their place in thehealth care complex and, in the end, can contributeto better patient care.
Acknowledgments
I thank Barbara Gibson, PhD, PT, for the time shespent with me in preparing this paper. Parts of thiswork were written in preparation for the author’sMaster’s degree.
Declaration of Interest: The author reports nodeclaration of interest.
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Foucault and physiotherapyDr David Nicholls, Phd, MA, GradDipPhys, MNZSP
Postgraduate Head, School of Rehabilitation and Occupation Studies, North Shore Campus, Northcote, Auckland,New Zealand
ABSTRACT
For nearly 40 years, researchers have been coming to terms with the impact of Michel Foucault’s philosophicalwork. In fields as diverse as medical sociology, health policy, architecture, urban geography, history, and sport,scholars have made use of Foucault’s notions of discourse, knowledge, truth, and power. With a few exceptions,however, Foucault’s writings have yet to permeate physiotherapy. Foucault’s ideas represent powerful, andhighly useful analytical strategies for analyzing our past, present, and future, and his writings provide us with aset of conceptual, methodological, and philosophical approaches to help us unpack the cultural, historical, andsocial context in which we operate as a profession. In this paper, I attempt to introduce the reader to some ofFoucault’s radical ideas and show how these might be applied to physiotherapy practice. Drawing onFoucault’s writings on the functions of discourse to illustrate how something as benign as a physiotherapist’streatment bed can be understood as something more than a piece of necessary medical technology, I showthat by approaching seemingly obvious, everyday objects, practices, systems, and structures, we can learnmuch about physiotherapy’s past, present, and future and apply this knowledge to think in new ways aboutthe profession.
INTRODUCTION
French postmodern philosopher, historian, and socialtheorist Michel Foucault (1926–1984) is one of themost influential philosophers of the twentiethcentury. His works, which continue to be publishedposthumously, have become the focal point for a vastamount of debate and discussion in areas as diverseas architecture, disability studies, drama, feminism,health care, history, management, politics, socialpolicy, and sport (Benjamin, 1990; Corker andFrench, 1999; Danaher, Shirato, and Webb, 2000).In health care, Foucault’s writings have influenced avariety of theorists, particularly in medicine, nursing,and what Nicolas Rose called the ‘psy’ disciplines –psychology and psychiatry (Armstrong, 1995; Cheek,2000; Lupton, 2003; Nettleton, 1989; Petersen andBunton, 1997; Rose, 1999). His ideas have profoundlychallenged our assumptions about what we know and
believe in, how we have come to believe in particulartruths, relations of power in society, the nature of our‘selves’, and how we live our lives (Mills, 2003, 2004).
Foucault was one of the leaders of an artistic, philo-sophical, and political movement that took place inFrance around the time of the 1968 student riots. Heand his contemporaries, Jean-Paul Sartre, JacquesDerrida, Gilles Deleuze, and others, led moves awayfrom Anglo-American analytic philosophy and pio-neered postmodern and post-structural ways of think-ing. At the heart of their philosophy lay a belief in thesocial construction of meaning (Arribas-Ayllon andWalkerdine, 2008; Willig, 2001), in which the pro-duction of truth was seen as a social process ratherthan as a simple natural fact. This view ran counter tothe beliefs about the nature of truth and the power ofscience and, understandably, made these philosophershighly controversial. Their impact on the sociology ofhealth and illness, where medical ‘facts’ so often failto explain the whole story, cannot be underestimatedhowever, and postmodern philosophy continues to bea potent voice in the debates around the meaning weascribe to health and health care.
Foucault’s work deals with the nature of truth, theway knowledge is constructed, the way forms of
Address correspondence to Dr David Nicholls, Postgraduate Head,School of Rehabilitation and Occupation Studies, North ShoreCampus, A-11, 90 Akoranga Road, Northcote, Auckland, Private Bag92006, New Zealand. E-mail: [email protected]
knowledge are interwoven with the machinery ofpower, the function of government, and the natureof the ‘self’. He was concerned less with what wethought to be true, as how we had come to think thisway in the first place. His writings can be verycrudely divided into three overlapping ‘periods’, withhis early works exploring the functions of discourses(or historically specific ways of thinking, practicing,or speaking about things), and their effect on theideas that we had come to accept as true (Foucault,1965, 1970, 1972, 1973). During the later 1970s,Foucault moved from a focus on the functions of dis-course to concentrate more on knowledge, power, andthe construction of truth (Foucault, 1977, 1979,1980). Finally, leading up to his untimely death atthe age of 58, Foucault began to explore the ways inwhich we ‘governed’ our selves and the moral dimen-sions of our conduct (Foucault, 1985, 1986, 1991).Much more detailed representations of Foucault’swork than can be offered here can be found elsewhere(Danaher, Shirato, and Webb 2000; Gutting, 1994;Hall, 2003; McHoul and Grace, 1993; Mills, 2003;Paras, 2006). My purpose here, however, is tointroduce one of Foucault’s philosophical ideas andillustrate how it might have relevance for our under-standing of physiotherapy practice.
In this paper, I will draw on Foucault’s writings onthe functions of discourse, and illustrate how some-thing as benign as a physiotherapist’s treatment bedcan be analyzed for the way it constructs knowledgein physiotherapy practice1. From here, I will moveon to examine Foucault’s radical views on knowledge,power, and the construction of truth, focusing on howa Foucauldian understanding of the nature of powercan be used to analyze why treatment beds areanything but the obvious object familiar to mostphysiotherapy practitioners.
The paper begins with an examination of some ofthe discourses that give meaning to the treatmentbeds that are so often taken for granted by the pro-fession, before I examine how significant the treatmentbeds have been for physiotherapy, and show that thedesign of the bed has been pivotal in the profession’squest for legitimacy. Although I attempt to showhow important the design of treatment beds hasbeen for the profession, they represent only one of amyriad other examples of cultural objects, practices,systems, or beliefs that give physiotherapy its unique
character. The paper, therefore, functions as a way ofintroducing readers unfamiliar with Foucault’s workto an applied example of some of his ideas, in thehope that other systems of thought common to theprofession also undergo critical examination.
BEDS, COUCHES, PLINTHS, ANDTABLES
Erin: That’s the other thing. I never know what tocall it.
David: What, a bed?
Erin: A bed? I call it a bed but I feel…hmmm.
David: What’s wrong with ‘a bed?’
Erin: Too personal: ‘lying on a bed’. ‘Lying on aplinth?’…too clinical.
David: Treatment couch?
Erin: Sounds too ‘psych’.
David: Hmmm.
Erin: It’s very hard, especially something like this;to keep it appropriately clinical, but not tooclinical.
David: What do you mean by appropriatelyclinical?
Erin: Erm, the patient has to feel safe. They havecome to see a health professional, I think I can saythat, they expect to see a health professional, sothey have expectations, and if you move beyondthat…
David: To what?
Erin: Well they have to be comfortable with that.
The above conversation occurred between myself anda physiotherapist I was interviewing as part of a studythat looked into ‘bleeding edge’ physiotherapy practice(Nicholls, Walton, and Price, 2009)2. What it illus-trates is a well-established feature of discourse
1 I have used the phrase ‘treatment bed’ throughout the paper for thepurposes of consistency only. There is no attempt here to privilege thisvariation over the bed/couch/plinth/table preferred by other authorsand more familiar to other readers. Indeed, the question of the preferredterm for the treatment bed becomes a significant feature of analysis laterin the paper.
2 ‘Bleedingedge’ practice is a term that derives from the business litera-ture (see, for example, Kleinke 1998). A bleeding edge enterprise is onethat breaks new ground. It challenges taken-for-granted assumptionsand demonstrates a high degree of innovation. Bleeding edge practicesare often highly speculative and have a high failure rates, but theycreate opportunities that subsequent enterprises can take advantage ofby challenging conventional ways of doing things. In health care, inno-vative practices are commonplace, either as a result of invention,policy change, prioritization, or market transformation. Often thechanges are led by practitioners exploring new territory, challenging pro-fessional boundaries, customs, and practice.
analysis; namely the attempt to unpack taken forgranted assumptions, and to search for the historical,political, and social basis of how we think today.Why is it important, for example, that we settle onthe right word for the bed/plinth/couch/table? Whydoes it matter? And in choosing one word overanother, what is said and what is not said about thepractices that are associated with each word? Whilethis search for meaning is inherent in many critical,historical, linguistic, and social modes of research, itreaches a particularly refined form of expression inthe work of Michel Foucault.
Foucault has been called a historian, a philosopher,a sociologist, a linguist, a structuralist, and a postmo-dernist/poststructuralist (Mills, 2003). While his workbears many of the hallmarks of historiography, linguis-tics, and the social and political sciences, he also offerssome significant challenges to these disciplines and isconsidered iconoclastic by many specifically becauseof his departure from these fields (Halperin, 1995).Firstly, Foucault argued that words were not merelystable signifiers of objects, but rather that languagewas something dynamic and violent; shaping notonly what we spoke of, but ourselves at the sametime; making it possible for us to adopt certainsubject positions while rejecting others. He alsoargued against the historical view that present ideaswere the result of a long progression toward enlighten-ment, and also that some modes of research (primarilyphenomenological) put too much emphasis on theoriginality of the words of the speaker/author.Instead, Foucault argued that the knowledges andtruths we espoused were the expression or outworkingof numerous competing discourses, and that the adop-tion of a particular word for the treatment bed heldsignificance for Erin, not only for the naming of theobject itself, but for the kind of therapist Erinaspired to be.
The importance of language, or more accurately‘statements’ and discourses in defining our subjectiv-ity cannot be understated, and it was something thatknowingly or otherwise has been a feature of moderncivilization throughout its history. In our ownmodest way, physiotherapists have molded their sub-jectivity by defining what is central to their practiceand what is marginal. And treatment beds lie at theepicenter of this sense of self.
Since the inception of the profession in late-Victor-ian England, treatment beds have been as synonymouswith physiotherapy practice as stethoscopes are withmedicine3, and our treatment beds are distinctive.
They are not the low-lying chaise-type bed of thepsychiatrist, nor are they the sterile metal tables ofthe operating theatre. They are neither the mattress-covered metal hospital beds, nor the comfortable,well-padded domestic beds from home. Physiotherapytreatment beds are rudimentary in their design: func-tional; minimally padded; adjustable; and mobile(Figure 1). Indeed, they are so familiar to us that wevery rarely ever question or mention why they arethis way. Very few physiotherapy textbooks discusstheir design, and no one writes about them in theliterature.
The same jarring juxtaposition happens if we remainin our familiar present surroundings, but insteadreplace the objects within them with a comparator.Imagine walking into a physiotherapy clinic andfinding that the traditional treatment bed had beenreplaced by a domestic double bed from home, orwalking into your familiar clinic to find that the wallshad been replaced to make it look like a boudoir.What perception would you have of the physiotherapyencounter you were about to experience?
If, however, we mentally remove the treatment bedfrom its present situation and relocate it to an unfami-liar time and place (like a medieval hospital or a sub-Saharan African village, for example), its every-dayobviousness disappears. It immediately looks out ofplace and anachronistic. Its reliance on electricity topower the bed’s motors would make it dysfunctional,its vinyl covering would probably look gaudy andout-of-place, and the design of the bed itself totallyout of context with its surroundings. The point ofthese fanciful exercises is to encourage us to realizehow much the everyday, familiar objects we surroundourselves with are neither benign, obvious, or stable.By contrast, they are powerful markers of ourculture, they are particular to a time and place, andthey are ever changing as we seek to say new thingsabout our practice.
FIGURE 1 Image of a modern treatment bed.
3 For a Foucauldian analysis of the role of stethoscopes in medicine, seeFoucault’s ‘The Birth of the Clinic’.
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At the clinic where I did some of the research intoinnovative forms of physiotherapy practice, a consciousdecision had been made to move away from conven-tional respiratory physiotherapy. Tradition held that res-piratory physiotherapists saw people in hospital wardsor, less often, in the community, but that to see a respir-atory physiotherapist one had to have been diagnosedwith a respiratory disease. Assessment and treatmentoften occurred in sterile-looking hospital rooms thatemphasized Nightingale-esque cleanliness and order.But the practitioners I researched were looking fornew modes of practice, in which the client (no longera patient) worked to optimize their breathing. Nolonger did people need to have an organic lungdisease to see a physiotherapist, and the work couldbe undertaken away from the confines of the hospital.
To ‘market’ themselves as different, and to makesense of their change of direction, the founders ofthe above clinic went to great lengths to change theenvironment in which the clients were seen. Gonewere the sterile white clinic walls, and gone was theoften-visible medical equipment. In their place camepotted palms, luxurious fixtures and furnishings,subtle paint effects, and framed landscape photo-graphs. But the most notable change had taken placewith the treatment bed, which was now fully drapedto disguise it’s machinery and structure; a nod,perhaps to the founders’ desire to offer a more ‘holis-tic’ approach to treatment than had previously beenavailable (Figure 2). What was this device now? Was
it a bed, a plinth, a table, or a couch? And what didit mean for the new practices of the clinic?
We should be clear here, that people are rarely con-scious of the discursive significance of the everydayobjects that they place around themselves. The foun-ders of the above clinic knew nothing particular aboutthe historical significance of treatment beds when theychose to redesign their clinic space. As with all of us,it is often either an instinctive decision or one thatjust feels right at the time. And this is as true forevery object, subject, or practice that defines our sub-jectivity. For those who analyze the historical, political,and social conditions that govern the conduct of peoplelike health professionals, however, there is no suchthing as instinct or actions without significance. Everyaction is the outworking of powerful discourses thatare constantly competing to influence the way wethink and act. Indeed, as Foucault argued, the most sig-nificant and powerful actions are those that we think arethe most benign. Thus, to understand which discoursesinfluence us and which do not, we need to turn now toFoucault’s iconoclastic interpretation of power and itsoperation in modern culture.
POWER AND GOVERNMENTALITY
A few years ago, there was an article on a Thai massagetherapist on the front of our local community newspa-per. In the article, the therapist complained that nomatter how she advertised and conducted herself,she was repeatedly being asked by male clients toperform sexual services as part of her therapy. Whilethe story is familiar, what struck me was the accompa-nying picture, which showed the young woman sittingon the corner of her treatment bed, in a room in whichshe had made every effort to be ‘clinical’. There was noindication in the design of her treatment space that shewas offering anything other than a legitimate thera-peutic encounter, and yet the appeals of some of hermale clients persisted (Figure 3).
In the previous section, I argued that the treatmentbeds spoke loudly of the kind of practice offered by thetherapist, so surely this story contradicts my point,since if I were right, the mere presence of a treatmentbed in a sterile clinical room would be enough to dis-suade men from inappropriate advances. But, inreality, no single discourse can ever be this powerful.Which brings us to two important aspects of Fou-cault’s thinking that were revolutionary at the time.Firstly, discourses are never absolute or totalizing,and secondly, discourses are intimately connectedwith knowledge, truth, and power.
The story at the beginning of this section illustratesthat while the Thai masseuse deployed a range of
FIGURE 2 Image of a non-traditional ‘bed’ and itssurroundings.
‘strategies’ to exert her legitimacy, other discourses ofsexuality, for example prevailed. Not all the time, cer-tainly, but enough to make the masseuse questionwhether she would ever be fully respected as a legiti-mate therapist. From a Foucauldian perspective, thisreinforces the belief that multiple discourses exist insociety; that they are in a constant state of flux oftencompeting, overlapping, or reinforcing each other;and that the effect of these competing discoursescreates what we understand to be knowledge and truth.
Thus, for Foucault, truth is not something based inabsolute laws of physics or inalienable facts, but rathersomething that is created by competing discourses.Physiotherapy, for example, is not a ‘fact’ per se, butan abstract concept, recreated every day by its prac-titioners, and sedimented in numerous ways of thinkingand practicing. The same can be said of biomedicine,which is a composite of some very powerful discourses.
Foucault has been associated with a movementknown as social constructionism, which argues thatthe world we have often thought of as made up of‘real’ objects and solid natural laws is in fact con-structed, or to use Judith Butler’s term, ‘performed’on a daily basis (Butler, 1994; Powell and Gilbert,2007). One extension of this idea is postmodernism,in which all forms of knowledge are considered arbitraryand challengeable. For social constructionists like Fou-cault, a treatment bed is not the physical object fromwhich we derive meaning, but rather the ‘effect’ orend result of our thought. In other words, a treatmentbed is the way it is because we need it to ‘say’ certainthings about the conduct of the person using it. Thebed as an object comes after the thought, not before.And the thought is a product of competing discourses.
To recap, Foucault argued that discourses werenever absolute, and that at any one time, we werebeing assailed by numerous discourses in a constantstate of tension. Thus, today I may be challenged tothink about the power of biomedicine, democracy,or religion in society, the benefits of information tech-nology, or the role of sport. Of course, I do not actu-ally think of these things in such grand terms; it ismore likely that I feel their subtle influence while Iread the paper or talk with a colleague about lastnight’s football results. But this is a critical point forFoucault; namely that the power that these discourseshave over us is largely hidden, and that this act ofhiding, or suppressing their power is a vital feature oftheir facility. In fact, the more a discourse can getunder our skin unseen, the more powerful it will be.
Foucault arrived at this point at a time when France,like many other developed countries, was experiencingmassive civil unrest. Domestic politics was dominatedby the political ‘left’, and intellectual debate centeredaround social and civil rights. Some of the loudestvoices were those of structuralists, most often feministor Marxist scholars who argued that society had beenstructured to give power to some (particularly able-bodied, bourgeois, white men), while actively denyingit from others (e.g., disabled, working class, non-white women). Their argument was predicated on theidea that some in society possessed power, whileothers did not. While Foucault was not unsympatheticto their arguments, his own explanation for the func-tions of power was far more radical.
Foucault argued instead that power was not some-thing that some people had and other people did not.He argued that power was never this one-sided, nor
FIGURE 3 Thai massage therapist seated on her treatment bed.
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was it necessarily this negative. Instead he argued thatpower in society pervaded every thought and everyaction; that it was ever-present and defined ourconduct. Indeed, it defined us; it constructed our‘subjectivity’.
Foucault’s belief was that no one, neither a king, aGod, or boss or partner, could ever exert total powerover us. This was not power per se, but oppression,and that real power lay in the ability to get people todo what you wanted without coercion, oppression,or force. Foucault developed his ideas about powerin three highly influential books written in the late1970s (Foucault, 1973, 1977, 1980), and these textswere based very closely on the work he had done pre-viously exploring the history of madness, medicine,and what came to be known as the history of ideas(Foucault, 1965, 1970, 1972, 1973).
Foucault’s ideas about the relationship betweendiscourse and power came together in work that wasonly partially completed by the time of his death.This work into what Foucault called ‘governmentality’has been highly influential for researchers in healthand social welfare (Barry, Rose, and Osborne, 1996;Dean, 1999; Rose, 1994; Turner, 1997). Governmen-tality was an attempt to understand how modernforms of government had developed (the mentalityor government, or govern-mentality), such thatpeople’s conduct could be refined for the benefit ofthe state. Connecting closely with his views on dis-course, knowledge, truth, and power, Foucaultargued that if we traced the history of modern govern-ment, we would see that there had been an ongoingproject to refine the way in which the state operated.Beginning with the brutal power of kings and queensin the sixteenth and seventeenth centuries, Foucaulttraced a long, slow, deliberate project to bettergovern the ‘conduct of conduct’ of state citizens,with the goal not of maximizing the state’s power (asmight be argued by structuralists), but rather itsefficiency. Thus, the most successful states werethose that maximized the health, wealth, and happi-ness of its citizens, affording them freedom, rights,and responsibilities while concealing the necessarymechanisms of power from plain sight. In its mostrefined form of expression, people both act in waysthat are desirable, and feel as if they are free tochoose to do so.
Thus, in a developed system of government, peoplewill feel free to choose to visit any masseuse they wish,but by preference they visit a masseuse that demon-strates their legitimacy through professional title,codes of conduct, legislative protection, etc. Since thequestion of who is legitimate and who is not is notalways clear, a number of strategies have become fea-tures of modern government to ensure people make
agreeable choices: state sponsorship through legis-lation; the creation of preferred status professionalsilos; and the funding of preferred services throughthe welfare state, for example, have all been effectivestrategies in promoting what most developed statessee as ‘legitimate’ approaches to health care. Fortu-nately, the physiotherapy profession was one significantbeneficiary of this strategy in the first half of the twenti-eth century, and today’s practitioners benefit greatlyfrom the legitimacy ‘performed’ by the profession’s pio-neers. Naturally, when one group of professionalsobtain preferred status, it is at the expense of otherswho do not (Dew, 2003; Fournier, 1999). In NewZealand, for example, the 1949 Physiotherapy Actdefined that anyone practicing as a registered masseurmust have qualified as a physiotherapist and be regis-tered with its Board. Since there was only one trainingschool at the time, only those that went through thegovernment-scrutinized training program achieved thestatus of legitimate massage practitioner4.
Returning to our Thai masseuse, we can read heractions not only in the context of the objects sheuses to demonstrate her legitimacy (i.e., treatmentbeds and sterile-looking clinical spaces), but also interms of a social, cultural, and historical context.The legitimacy she craves is not a ‘thing’ but anabstract concept that is constantly in a state of flux.The ability to define what is and is not consideredlegitimate is specific to particular communities, andit acts to privilege some while marginalizing others.And while physiotherapy finds itself, for themoment, on the desirable side of the equation, itrelies on its ability to continually ‘perform’ its legiti-macy to remain so. For the profession at large then,disciplinary mechanisms abound to ensure that theprofession does not slip from favored status, butthese cannot be oppressive, because as Foucault hasshown us, these represent highly inefficient andlargely ineffective forms of power.
CONCLUSIONS
Foucault’s iconoclastic interpretation of discourse,knowledge, truth, and power represents a powerful,
4 In an interesting footnote to this, those practitioners who wished tohave their massage practices recognized by the state, but who did notwant to train as a physiotherapist, were forced to register their practicesunder the Massage Parlours Act which was legislation covering brothelsand prostitutes. Not surprisingly, not many practices took up this offerand, instead, operated in resistance to the legislation. As a consequence,the New Zealand Physiotherapy Board was drawn into policing theboundaries that the government had set up to give physiotherapy elitestatus. And although it rarely took action against the illegitimatemassage practices, it handled repeated complaints about ‘illegal’massage practices from professional members (Scrymgeour 2000).
and highly useful set of analytical strategies that areincreasingly being put to use by researchers in healthcare. For nearly 40 years, researchers have beenunpacking Foucault’s ideas and undertaking second-ary analysis to apply his principles to other fields.With a few exceptions, Foucault’s ideas have yet topermeate physiotherapy. As with many of the othercritical thinkers and philosophers, physiotherapy hasbeen slow to take up the challenge to think beyondthe confines of biomedical reasoning, to the possibili-ties for thinking ‘otherwise’. And for many, this isFoucault’s greatest legacy.
1. In this paper, I have drawn on some of Foucault’sradical notions of discourse, knowledge, power,and truth to illustrate how objects common to theeveryday practice of physiotherapy can revealmuch about the discursive construction of the pro-fession. I would argue that Foucault’s concepts,theoretical notions, methodological strategies,and philosophical innovations offer physiothera-pists meaningful ways of understanding the cultur-al, historical, and social context in which theprofession operates. I suggest that we shouldexplore some of these ideas more deeply andutilize them in our thinking and practice as wecome to terms with rapidly changing world of pro-fessional practice.
Declaration of interest: The authors report nodeclaration of interest.
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PERSPECTIVE
Discipline, desire, and transgression in physiotherapypracticeDavid Nicholls, PhD,MA, GradDipPhys, MNZSP1 and Dave Holmes, RN, PhD, MSc, BSc2
1Postgraduate Head, School of Rehabilitation and Occupation Studies, AUT University, North Shore Campus, A-11,90 Akoranga Road, Northcote, Auckland, New Zealand2Vice-Dean (Academic)/Full Professor, Faculty of Health Sciences, School of Nursing, University of Ottawa, 75, LaurierAve East Ottawa, ON, Canada
ABSTRACT
Therapeutic touch has played an important part in human civilization and continues to contribute to our socialrelations and individual identities. Therapeutic touch has been a vital component in the development and defi-nition of physiotherapy practice and continues to be one of the profession's principal distinguishing competen-cies. It is surprising then that while so much has been written about how to perform therapeutic touchtechniques, little has been written about the role that these techniques have played in defining physiotherapy'sprofessional identity. Drawing on the work of three postmodern philosophers, we offer a critique of physio-thera-peutic approaches to therapeutic touch, examining why certain modes of touch were adopted by the profession inthe past and not others; how the innate sensuality of touch had to be managed; and how the disciplinary tech-nologies that surrounded the practice of massage came to define physiotherapy's professional identity. Our thesisis that the disciplinary technologies adopted by the profession in the 1890s endure today and that the profession'sheavily disciplined approach to touch is now constraining new therapeutic possibilities that may be necessary ifthe profession is to respond to the demands of twenty-first century health care.
INTRODUCTION
The therapeutic application of touch has played animportant part in our civilization as a species and con-tinues to contribute to our social relations and individ-ual identities (Beck, 2010; Fritz, 2009; Schenkman,2010). It has been a vital component in the develop-ment and definition of physiotherapy practicethroughout the last two centuries and continues tobe one of the profession's principal distinguishingcompetencies (Holey and Cook, 2003; Nicholls andCheek, 2006; Valentine, 1988). Central to this devel-opment and definition have been the problems posedby the innate sensuality of touch.
When a patient exposes their body to a therapist andallows the therapist to touch them: to massage,
manipulate, mobilize, and move their body, thereexists an unspoken “problem” that must be managed.The problem is how to maximize the therapeutic possi-bilities of the encounter while retaining a dignified sep-aration between therapist and patient. As McKintosh(2005) argues; “We cannot ignore sexual issues whenlearning to work with our clients … The manualtherapies are intimate and can bring up issues aboutsexuality, both for us and for our clients”.
It is axiomatic that touch is innately sensual,1 bothas a broadly sensory experience, and an experiencelinked to sexuality. It is also axiomatic that all prac-titioners of therapeutic touch must demonstrate thatthey can manage this sensuality if they are to
Address correspondence to David Nicholls, PhD, MA, GradDipPhys,MNZSP, Postgraduate Head, School of Rehabilitation and OccupationStudies, AUT University, North Shore Campus, A-11, 90 AkorangaRoad, Northcote, Auckland, Private Bag 92006, New Zealand. E-mail:[email protected]
Accepted for publication 20 February 2012
1 In this article, we refer to sensuality in both its “sexual” sense (i.e., inassociation with sexual arousal) and also, importantly, more broadly inrelation to sensation and “being in the world” (Van Manen, 1990). Animportant feature of this article is our attempt to broaden the meaningand significance of words like desire, sensuality, massage, and touchfor physiotherapists, to create space in which it might then be possibleto think differently about our practice. Inherent in this process is a “trou-bling” of taken-for-granted language and an attempt to liberate wordsfrom their prior meaning and significance.
distinguish themselves as therapeutic professionalsand not to be associated with unregulated or morallyreprehensible practices. It could be reasonable toargue then, that physiotherapists have been particu-larly successful in this endeavor, since they are thelargest organized and legitimized professional bodythat has therapeutic touch techniques at the core oftheir professional identity.
Most physiotherapists will have, at times, experi-ence the effects of their skilled handling on theirpatients. Sometimes this may be through a patient'ssexual arousal that is often unexpected and embarras-sing, or through emotional outbursts that can disruptthe therapy session. Consequently, most clinicianslearn how to handle these experiences with dignity,but this does not belie the fact that sensuality ispresent in varying degrees in every therapeuticencounter and therefore relies on constant vigilanceand ongoing management.
Given the critical tension that exists around thepractice of therapeutic touch, it is surprising thatthere has been little critical analysis of the importanceof the sensuality of touch to the physiotherapy pro-fession. In this article, we cannot address the fullbreadth of this question, we can, however:
1. Examine the relationship between sensuality andphysiotherapy practice and explore how sensualitycontinues to contribute to physiotherapy's pro-fessional identity
2. Explore ways in which physiotherapy might nowrethink its approach to the sensuality of touch,drawing on the work of three postmodern philoso-phers, and in so doing, open a space for thinkingdifferently about the relationship between therapistand client.
To begin to address these questions, we examinethe cultural significance of touch and its historicalrole in defining physiotherapy practice.
THE CULTURE OF TOUCH
Forms of therapeutic touch may be some of the oldesttherapies known to human-kind. They range fromsimple primitive efforts to rub away pain to thesophisticated manipulation of tools and instruments.Touch itself plays a vital role in our growth andmaturation; our gestures, our habits and social con-ventions; our music and art; our communication andinteraction with others; and our means of healing,giving pleasure and relief, punishing and hurting(Classen, 2005). Our haptic vocabulary developsfrom our first sense of being in the world, and
endures, barring lost consciousness or neurologicalinjury, until we die.
The language of touch provides us with powerfulmetaphors that link our thoughts with our feelings.We speak of feel-ings, grasp-ing ideas, hold-ing onto life and catch-ing our breath. Modern forms ofinterpersonal communication and social networkinghave become increasingly reliant on haptic technologythrough touch-screen smart phones, texting, andemail. As Fritz (2009) argues; touch is “the most per-sonalized form of communication that we know”, andone of our most powerful modes of communicationwith others.
Touch is also one of the defining characteristics ofthe care offered by skilled health care workers, and asignificant variable in defining the technical compe-tence of health care professions (Lauterstein, 2004).Here, the combination of skilled, purposeful, andnon-intentional touch contributes significantly to theclient/patient's experience of health care (McCarthy,1998).
For physiotherapists, the most commonly appliedforms of purposeful touch are the various forms ofmassage, assisted movement, mobilization, andmanipulation that we categorize here as modes oftherapeutic touch. These approaches, alongsidehydrotherapy, remedial exercise, and later electrother-apy, are the oldest forms of practice known to phy-siotherapy (Creighton-Hale, 1893; Dowse, 1906;Ellison, 1898; Palmer, 1901; Symons Eccles, 1895).Focusing specifically on massage, it has been arguedthat the physiotherapy profession owes much of itspast and present professional identities to its approachto the sensuality of touch, and that physiotherapy waseffectively founded as an attempt to legitimizemassage practice (Dixon, 2003; Linker, 2011;Nicholls and Cheek, 2006). While it is not our inten-tion here to revisit this history (for a comprehensiveaccount of the events surrounding the birth of the pro-fession, see Wicksteed, 1948; Barclay, 1994), we do,however, need to spend a moment considering howthe nascent physiotherapy profession was able toprove its legitimacy in the late-nineteenth century,because this is pivotal to our argument that phy-siotherapy has, knowingly or otherwise, retainedmany of the approaches to massage common in theVictorian era, and that these approaches now requirereview and reform.
PHYSIOTHERAPY'S HISTORY OFDISCIPLINING TOUCH
Physiotherapy practices have long been defined by theneed to regulate touch (Mason, 1985; Nicholls and
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Cheek, 2006; Quinter, 1993). This century-longproblem can be traced to the English Massage Scan-dals of 1894 and the resulting actions of the foundersof the Society of Trained Masseuses (STM) (BritishMedical Journal, 1894a, 1894b; Society of TrainedMasseuses, 1895). In essence, the profession thatwould later become physiotherapy was born of adesire to legitimize therapeutic touch and differentiatelegitimate masseuses from unregulated and morallyrepugnant practitioners (Nicholls and Cheek, 2006).Legitimacy depended on the Society's2 ability todemonstrate that its registrants could offer a plainlyde-sensualized form of touch to its clients. It achievedthis by implementing a series of disciplinary measuresdirected at regulating the conduct of its members(Table 1) (Palmer, 1901).
By the outbreak of World War I, the Society haddone enough to demonstrate its legitimacy for theSociety's masseuses to be formally included in thewar effort. With subsequent outbreaks of influenza,tuberculosis, and polio in the 1920s and 1930s,and the formation of the Welfare State in the1930s and 1940s, the profession further establishedits orthodoxy, leading ultimately to profession-specific legislation in most Commonwealth countries(Anderson, 1977; Bentley and Dunstan, 2006;Cleather, 1995; Nicholls, 2008). None of these suc-cesses would have been achieved, however, had itnot been for the early efforts to establish a disciplin-ary approach to touch. And at no time could theprofession resile from its commitment to its highlyrestrictive approach to massage and movement forfear that it would bring the profession into disre-pute. Thus, the disciplines established by theprofession's founders endured and can be seen stillin the curricula, examinations, codes of ethics andsystems of regulation systems around the world(Chartered Society of Massage and Medical Gym-nastics, 1930).
ENDURING LEGACY OF DISCIPLINE INPHYSIOTHERAPY PRACTICE
In some of the earliest published physiotherapy litera-ture, we can see a clear image of a disciplinaryapproach to touch in the biomedically orientated prac-tices that define physiotherapy's orthodoxy (Butler,1997). In Tidy's (1932) Massage and Remedial
Exercise,3 for example, disciplinary measures thatlater came to be seen as custom-and-practice,became established. There were strategies directed atthe practice “environment”; with the use of treatmentbeds that were visibly similar to theater tables andlooked nothing like a domestic bed, situated insterile-looking, hospital-like clinical spaces; therewere dedicated uniforms, biomedical language andcurricula of study that situated the profession inclose proximity to medicine; and there were practicechoices made that actively denied the inherent sen-suality of physical contact between practitioners andpatients through rigid taxonomies and regimentation.Swedish Remedial Exercise, for example, a mainstayof physiotherapy's approach to exercise for much ofthe twentieth-century, was based on the ability to con-strain movement through a comprehensive series offundamental and derived positions (Angove, 1936;Despard, 1916; Guthrie Smith, 1952; Tidy, 1952),and this approach can be seen as one measureamong many chosen to reinforce the perceptionwithin the profession and without, that physiothera-pists could practice without fear of licentiousness.
Among the disciplinary techniques and strategiesdeployed in physiotherapy, possibly the most potentwas the adoption of the notion of the body-as-machine,which underpinned many of the other approaches(Nicholls and Gibson, 2010). This approach empha-sized the primacy of an anatomic, biomechanical, andkinesiological view of the body at the exclusion of“other” ways of understanding the reasons for illnessor injury (subjective, personal, social, or spiritual, forexample). By adopting this approach, physiotherapistscould align themselves with the medical professionwithout encroaching on their biomedical territory; dis-tinguish themselves fromotherallied health professions(by emphasizing cure as opposed to the care of nursing,for example), and, most importantly, elevate them-selves above unregistered and licentious practitionerswho had not received such a rigorous biomedical, andtherefore deemed respectable training.
PROBLEMS RESULTING FROMPHYSIOTHERAPY'S DISCIPLINEDAPPROACH TO TOUCH
While this approach certainly contributed to phy-siotherapy's success in defining a role within the
2 We have used the capitalized form of the word “Society” throughoutthe text to refer to the STM. This should be distinguished from thelower case form of society which refers more generically to the socialworld around us.
3 Noel M. Tidy's Massage and Remedial Exercise text, first publishedin 1932 and now in its 14th edition, is the longest continuous textpublished in the field of physiotherapy. It offers a generic overview ofphysiotherapy in a range of contemporary practice areas, and so providesa useful ongoing barometer of the profession's interests and involve-ments (Tidy, 1932).
orthodox health system that developed in the first halfof the twentieth-century, it also, somewhat perversely,may have had a secondary effect that is only now beingrealized. Some authors have begun to argue that phy-siotherapy's biomechanical and biomedical approachto care effectively “blinkered” physiotherapists; dis-couraging them from engaging with other ways inwhich people experienced health and illness. Phy-siotherapists have historically been discouraged fromexploring behavioral, cultural, economic, environ-mental, political, spiritual, or social determinants ofhealth, believing that these approaches were theconcern of other health professionals (Nicholls and
Gibson, 2010). While this approach may have shieldedthe profession from some of the ideological vacil-lations experienced by some other health professions(nursing, occupational therapy, and psychotherapybeing only three examples), there is now a growingconsensus that physiotherapy's historically biomecha-nical and biomedical approach to the body is prevent-ing the profession from engaging humanistically withthe diverse health needs of the population, with theinherent risk that the profession is increasingly beingseen as out of touch (Nicholls and Larmer, 2005;Nicholls, Reid, and Larmer 2009). It is as Juhan(1987) argues:
TABLE 1. Disciplinary strategies adopted by the STM.
Disciplinary strategy Rationale
No men allowed to train as masseuses The Society's founders believed that contact between men and womeninvolved an ungovernable sensuality and that it would be easier to simplyprevent men from gaining registration with the Society. Men would notgain registration as therapeutic masseurs with the STM until 1914.Indeed, the Society successfully lobbied to have rival organizations likethe Harley Institute closed down on the basis that they trained men andwomen together (Barclay, 1994). The STM remained the Society for“masseuses” rather than “masseurs” until well into the twentieth-century.
No men to be offered “general” massage unless innursing cases and under the direction of a doctor
General massage was a euphemism for whole body massage. Althoughmobilizations and manipulations of specific bodily regions were notuncommon, massage was thought of as a tonic for weak nerves,debilitation or generally poor health, and was a major part of themasseuse's work. Such massage for men, however, could only be offeredunder specific conditions that drew on many of the masseuse's primaryroles as nurses. The tensions between massage as health work andmassage as an indulgence of the wealthy may have been significant here.
Examinations and registration In its early years, the STM did not have the resources to administer amassage curriculum. They could, however, govern who registered withthe Society through an examination that effectively defined thecurriculum that registrants needed to follow. Thus, the STM coulddefine how massage should be thought and practiced. Massageexaminations continued to be a mix of anatomy, physiology, treatmenttechniques, and moral questions associated with touch well into the1920s.
Patronage of doctors The STM actively and aggressively pursued the patronage of medicalprofessionals prior to WWI. Many of the founders were independentwomen, well placed in society (Rosalind, later Dame, Paget's uncle, forexample, was the famous Liverpool surgeon William Rathbone). TheSTM sought to adopt a biomedical curriculum and a strongly anatomical– or more accurately “biomechanical” – view of health and illness thatproved very favorable with the medical profession
The body-as-machine Possibly, the most significant measure taken by the Society to legitimizemasseuses' philosophy of touch lay in the approach to the body that had tobe learnt, or at least plainly demonstrated by registrants. The masseusesneeded to be able to focus on the body-as-machine: they needed to beable to touch the inner thigh of a patient, for example, and think of theorigins and insertions of adductor longus and not perceive it in any way assensual. The ability to demonstrate this ability to the medical professionand the public at large was a defining feature of the Society's quest forlegitimacy.
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The term “physical therapy” avoids these associ-ations, but it is too narrow in the scope of itsnormal use. It refers to an official medical disci-pline, one which is licensed only after protractedand highly specific studies, prescribed only byphysicians, and applied through fixed procedures.Such academic rigor certainly does not countagainst it as a responsible therapeutic practice,but it does effectively partition “physical therapy”off from many other useful kinds of touching andmanipulation. In particular, it typically eliminatesa good deal of the intuitive element which seemsto be such an important part of other approachesand which is fact many physical therapists haveconfessed to me that they wish they could usemore freely in the clinical practice.
In recent years, a number of authors have questionedphysiotherapy's affinity with the notion of the body-as-machine (Broberg et al, 2003; Cott et al, 1995;Darnell, 2007; Hislop, 1975; Nicholls, 2008; Nichollsand Gibson, 2010), and there is growing evidence ofan emerging crisis in physiotherapy that centers on thecare needs of an increasingly aging, chronically ill, andcomplex population while the profession's attentionremains strongly focused on curing acute illness andinjury (Gibson, Nixon, and Nicholls, 2010; Nichollsand Larmer, 2005; Nicholls, Reid, and Larmer,2009). This also comes at a time when the volume ofscholarship roundly criticize those professions whocling to an exclusively biomedical philosophyof practicegrows almost daily (Lupton, 2003; Nettleton, 2005;Shilling, 2003; Turner, 2008; Williams, 2006).
It is our belief that physiotherapy is transitioning tomore embodied or holistic modes of practice and awayfrom purely biomechanically orientated views of thebody and illness. At the heart, this transformation isa questioning of the principles that underpin what itmeans to practice physiotherapy, and at the verycenter of this debate is the profession's approach totherapeutic touch. Thus, part of our professional chal-lenge involves finding new ways to liberate our practicefrom its historical disciplines; celebrating the fullyembodied possibilities of touch, without, at the sametime, losing our professional identity, destroying thepublic's trust in the profession or exposing ourselvesand our client's/patient's to abuse. In this article, weoffer only a preliminary and tentative response tothis challenge, drawing on the work of three philoso-phers whose work we believe might be particularlyinstructive as physiotherapy seeks a new approach topractice; one that re-defines its relationship with theinnate sensuality of touch. To begin with, we look atthe work of Michel Foucault.
FOUCAULT AND DISCIPLINE
Michel Foucault (1926–1984) is considered by many tohave revolutionized how we have come to think aboutnotionsof truth, knowledge, power, subjectivity, anddis-cipline in contemporary society (Ransom,1997;Turner,2006). His writings on discipline alone have been thefocus of work in areas like: accountancy (Maclullich,2003); community development (Schofield, 2002);economics (Miller and Rose, 1990); government(Higgins, 2004; Merlingen, 2003); law (Smith, 2000);education (CarpenterandTait,2001;Race, 2000);man-agement (McKinlay and Starkey, 1998; Yakhlef, 2002);sexuality (Maines, 1999; Pryce, 2000); sport (Johns andJohns, 2000; Markula and Pringle, 2006); and technol-ogy (Mehta and Darier, 1998).
In health care, Foucault's work on discipline hasbeen applied extensively in areas like: aged care(Katz and Marshall, 2004; Pincombe, O'Brien,Cheek, and Ballantyne, 1996); dentistry (Nettleton,2001); disability (Reeve, 2002); nursing (Holmesand Gastaldo, 2002; Perron, Fluet, and Holmes,2005; Riley and Manias, 2002); mental health, psy-chology, and psychotherapy (Hazelton, 1995; Hook,2003; Rose, 1997); health care management andreform (Hau, 2004; Sheaff et al, 2004; Vicinus,1985a); professionalization (Wear and Kuczewski,2004); techno-science (Rudge, 1999); and medicalhistory (Armstrong, 1995; Wainwright, 2003). Howthen can Foucault's ideas and writings help us tocritically analyze the role of therapeutic touch inphysiotherapy practice?
Part of the appeal of Foucault's work lies in the factthat he saw discipline not as an isolated practiceapplied by one person over another, per se, but ratheras a productive technology of power that extendedthroughout society and helped to define who we wereas individuals and actively constructed our society.Foucault was interested, for instance, in how we hadlearned as a society to distinguish between the madand the sane, the healthy and the sick, and the goodand the bad sexual citizen. He was interested in howwe had established layers of examination throughoutsociety (from school tests, to regular medical check-ups, and accounting measures), and used these as dis-ciplinary strategies to distinguish between what wasnormal conduct (and by extension what defined anormal person) and what was abnormal. Foucault(1977) wrote extensively about what he called “tech-nologies of surveillance” as measures developed bygovernments and institutions to better know andthereby govern the population.
Foucault showed that all these measures hadtheir own history and that they were tactics or
“technologies” as Foucault called them, of power.Foucault did not see power as something negative;as a force that controlled people; or as somethingone person possessed over others. While he did notdeny that these forms of oppression existed, he had,after all, experienced fascism and Stalinism at firsthand, he was more interested in the power thatobtained its results without force and oppression.These forms of power were multiple, various, andwidely distributed throughout society and operatedat every level. They constituted a “micro-politics”and through their actions, how we came to see our-selves and others.
In the history of physiotherapy, efforts to disciplinethe conduct of massage practitioners illustrate onemicro-politics among many. In the measures takenby the founders of the STM detailed above, theSociety illustrated some of the most familiar technol-ogies of discipline unpacked by Foucault. To repeat,Foucault's reading was not that these were necessarilynegative technologies, far from it. They were pro-ductive in not only clearly defining the limits of phy-siotherapy practice, but also lending its legitimacyand orthodoxy. In this way, they helped to“produce” a particular kind of practitioner that metwith the approval of the medical profession and thepublic alike. Accordingly, rather than seeing pro-fessions like physiotherapy as the initiator of dis-courses and ideas of practice, Foucault saw them asrepresenting the effects of discourse; as the outwork-ing of disciplinary technologies, governmental strat-egies, competitions between different knowledgesand relations of power.
In all Foucauldian thinking, power can only operatewhere there is the possibility of resistance; where aperson could choose to do otherwise, but choosesthe preferred path anyway because of societalnorms. In physiotherapy, we have seen a remarkableexercise of Foucauldian-like power in the way that acentury of practitioners have adhered consistently toa model of practice handed down by previous prac-titioners. But, the possibility of licentiousness andabuse of power continues to surround the professionand requires a constant vigilance to ensure that itretains its hard-won status. To understand the objectof these organizations' disciplinary interest, we willturn to the work of one of Foucault's colleagues andcollaborators, Gilles Deleuze and his writings ondesire.
DELEUZE AND DESIRE
The work of Gilles Deleuze (1925–1995) that we drawon here comes from the same tradition of postmodern
continental philosophy as Michel Foucault's. And likeFoucault, Deleuze wrote in a style designed to chal-lenge convention. Deleuze's writing, often writtenwith psychoanalyst Félix Guattari, is dense, often con-fusing, and idiosyncratic, and yet, beyond this, it hasbrought forth some startlingly influential thoughtover the last few decades (Deleuze and Guattari,1987).
Deleuze and Guattari's writings have been best-selling books in France, and have had a profoundeffect on contemporary philosophy, the arts and thehumanities, leading Michel Foucault to claim that“one day, perhaps, this century will be called Deleu-zian” (Foucault, 1970). In recent years, books suchas Anti-Oedipus and A Thousand Plateaus have begunto influence health philosophers and theorists(Brown, 2004; Fox, 2002; Malins, 2004; Roberts,2005). For example, Fox (2002) whose work hasbeen a significant influence in the medical humanities,wrote Beyond Healthwhich draws heavily on Deleuziannotions to advocate for a new focus on embodiment(Nicholls and Gibson, 2010). Holmes and Gastaldo(2004) have written about the need to move awayfrom the limits of linear logic in nursing and theneed to embrace Deleuze's ideas of rhizomatic think-ing. Indeed, Deleuze's work has begun to feature inareas as diverse as: mental health (Roberts, 2004,2005); visual arts (Olkowski, 1999); literature (LeClézio, 2004)4; dance and movement (Manning,2009); politics (Patton, 2000); and social philosophy(DeLanda, 2006).
Deleuze and Guattari (1987) argue that the con-temporary thinking has become “arborescent” ortree-like, with ever-refined branches of knowledgethat follow increasingly linear pathways. By contrast,they believe that our social world is more “rhizo-matic”. Drawing on botanical metaphors, they con-trast the traditional Western belief in ongoingprogression towards enlightenment with what theybelieve is a more realistic view of our social world; aworld in which we constantly find ourselves in themiddle of multiple, competing discourses and linesof thought; occupying many roles and juggling manydifferent ways of being, thinking, and practicing(Cormier, 2008; Holmes and Gastaldo, 2004; Lawr-ence, 2007). Thus, a rhizome works as a better meta-phor for our lives as people and as practitionersbecause it “has no beginning or end; it is always in
4 Nobel Prize winning author Jean-Marie Gustave Le Clézio's writingsdraw heavily on Deleuzian ideas. Wandering Star, the story of achance meeting between an Israeli and Palestinian girl, emphasize theimportance of indigenous marginal cultures, the virtues of nomadicfreedom, and our ethical responsibility to open space for new modesof expression and thought.
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the middle, between things, interbeing, intermezzo”(Deleuze and Guattari, 1987).
Despite parallels between Deleuze and Guattari'swritings and ways of thinking that exist within andabout health care, one area of interest is particularlyrelevant to this article, that of desire. For Deleuzeand Guattari, desire carries a double meaning.There is the desire associated with sensuality, and amore complex desire that is inherent in all things: adesire to actualize; to achieve a particular end; orserve a particular purpose. This desire is akin to thedesire of the therapist to reduce a person's pain, orthe desire to move. Importantly, Deleuze and Guattariextend this notion of desire to include the connectionbetween inanimate objects and their environments.Thus, water desires to flow and chairs to be satupon. This is obviously not implying that theseobjects “think”, only that in their existence they com-municate to us their desired purposes.
When the desiring object connects with its target, anassemblage is formed, and these assemblages are manyand varied (DeLanda, 2006). As I write this article, forexample, my hand has formed an assemblage with mycomputer keyboard. The computer desires my touchas much as I desire it. In the same way, the therapist'shand forms an assemblage with the body of theirpatient with the client/patient “desiring” the skilledtouch of the therapist as much as the therapist desiresto deploy their skills. This notion of a desiring assem-blage formed around therapeutic touch seems alien tophysiotherapy practice more familiar with evidence-based justifications for massage (Holey and Cook,2003), but as Williams (1998) argues;
These issues…are clearly, if somewhat problema-tically, expressed in the new holistic health move-ment: a movement which illustrates very clearlythe dilemmatic features of health as control andrelease, and the possibility, however distant itmay be, of new more sensual, emotionallyinformed, ways of “seeing” and “keeping intouch” with the world around us.
Not surprisingly, it is in the complementary andalternative health literature that many of these issuesare debated (Lauterstein, 2004; McKintosh, 2005;Oerton, 2004; Schenkman, 2010), and it is here thatthe “re-sensualization” and “re-enchantment” withhealth care is at its greatest (Williams, 1998).
Connecting Deleuze's and Guattari's work back toFoucault's notions of discipline, we can say thatdespite the best efforts of the physiotherapy professionto remove all association between sensuality and touchfrom the profession's identity, sensual experiences, inthe broadest sense of the word, remain a natural, inevi-table and, indeed, necessary part of the experience of
touch. Physiotherapists are by no means the firstpeople to draw on disciplinary technologies togovern the conduct of their practitioners and patients.There are many other examples of disciplines directedat people's bodies that have been highly significant fea-tures of western civilization over the last few centuriesincluding: posture and “attitude” of school children(Armstrong, 2002; Foucault, 1979); the moral gui-dance of mothers and the moral conduct of womenin general (Bland, 2001; Jackson-Houlston, 1999;Vicinus, 1985b); the role of confessional and psy-chotherapy in governing people's thoughts (Rose,1997, 1999); and the maximization of work capacityfollowing injury (Linker, 2011; Seymour, 1998).Indeed, every profession has its own history of disci-pline directed at some expression of the body's desir-ing (Armstrong, 1995; Gastaldo and Holmes, 1999;Nettleton, 1992), and while a large part of physiother-apy's particular disciplinary focus falls upon the sen-suality of touch, each profession essentially grappleswith the seemingly unlimited potential our bodieshave for transgression. As Williams (1998) argues:
[A]s the history of western civilization shows,bodies are amenable to discipline and control –from the prison to the factory, the school to theasylum – but this nonetheless fails to detractfrom the fact that they are always threatening,through their libidinal flows and corporealdesires, their pleasures and their pains, theiragonies and their ecstasies, to “overspill” the cul-turally constituted boundaries which currentlyseek to “contain/constrain” them. Indeed, it isfrom these “unruly” desires that the need for cor-poreal “discipline” arises.
Transgression, therefore, provides the conditions thatmake discipline necessary, and so must be understoodif we are to make sense of our actions as physiothera-pists. For help, with this we turn to the work ofGeorges Bataille.
BATAILLE AND TRANSGRESSION
Georges Bataille (1897–1962) was a French writer andphilosopher whose influences extend to economics,literature, film, philosophy, and sociology. Althoughmuch less well known than Foucault and Deleuze,particularly in the broad field of health care, Bataille'swork has begun to be applied in areas where research-ers are exploring “…the continuing resilience of thehuman body to rational, in this case biomedicalcontrol” (Williams, 1998); modes of performancesports (Marcia, 2001); conditions of profound phys-ical disruption (Williams and Bendelow, 2000);
“marginal” health practices (Väänänen, Mäkelä, andArppe, 2011); and mental illness (Elden, 2006;Whitebook, 1999). Notwithstanding the fact thatBataille's writings, like those of Foucault andDeleuze, are challenging, confrontational, and oftendisturbing (Bataille, 1987, 1991), our focus here ison one of the pivotal ideas explored by Bataille in hiswork. Transgression, for Bataille, is an important phi-losophical concept that is an inherent part of our civi-lization. Transgression is seen throughout societywhere people exceed what is socially acceptable andchallenge orthodox behavior. Young people who testthe authority of older generations transgress. Margin-alized groups who fight for their right to be heardtransgress. Practitioners who challenge conventiontransgress (Noys, 2000). Transgressions are the“unauthorized crossings of boundaries or refusals toacquiesce to norms and mandates” (Crawford, 1999).
If transgression is an inevitable and necessaryfeature of social life, then so are the disciplines thatsurround it. Transgression is defined in many waysnot by the acts of defiance as much as the conventionsand boundaries it seeks to breach. As Falk (1994)argues, “The more articulated and multifarious therestrictions on corporeality, the more sophisticatedthe forms of transgression become”. Like the compu-ter hackers who breach security systems to expose theirlimitations, transgressions reveal previously unseenboundaries; the limits to our tolerance; and the con-tingent perimeters to conventional thoughts and prac-tices. Part of the inevitability of transgression derivesfrom the belief that we can never fully contain our-selves, either individually or collectively. Our bodies,for example, are inherently “leaky” (Falk, 1994); con-stantly threatening to over-spill, whether throughsweat or blood, through menstruation, coughing, orincontinence (Nettleton and Watson, 1998). Our“[b]odies, in short, from their leaky fluids to theiroverflowing desires and voracious appetites, are firstand foremost transgressive” (Williams, 1998). Whatis more, because we are social animals; always occupy-ing each other's spaces, exchanging ideas and buildingcommunities and social relations, we are constantlytransgressing the limits of our individuality.
Our potential for transgression, therefore, becomesa problem that must be managed, and this is no moreevident than in the area of eroticism, which Bataillesaw as the paradigm case of transgression and disci-pline. Sexual transgression strikes “at the very heartof rational modernity, involving as it does a ‘transgres-sive desire’ to go ‘beyond’ the order, to break prevail-ing boundaries in ‘regressive’ and ‘progressive’ turns”(Falk, 1994), reminding us of our age-old anxietiesover dirt, body fluids, and the unconstrained contactbetween bodies (Hall, 1999; Lupton, 1994; Wood,
2005). Transgression, therefore, relates to the sensual-ity of therapeutic touch in a number of ways:
1. From Deleuze, we can say that desire is an inevita-ble feature of therapeutic touch because touch is asensual experience.
2. We can also say that there is a desire inherent intouch that transcends mere sensuality. Our skilledhands “desire” to help and heal; our client's skin“desires” to be touched; their pain desires relief,etc.
3. From Bataille, we can say that transgression is anatural feature of our bodies and our culture, andthis is no more evident than where sensuality oreroticism is involved.
4. And from Foucault, we can say that discipline hasbeen a powerful tool used to govern our conductin the face of this inevitable transgression.
We will conclude this very brief overview of theseconcepts with a short discussion of how we thinkthat these ideas can be deployed in physiotherapy.
DISCUSSION
The honest pleasure of sensuality is part of theprofession, but the dark possibilities of seductionand exploitation are lurking in the background.(McKintosh, 2005)
The principal argument set out in this article is that theindividual, institutional, and professional constraintsput on physiotherapy practice by the need to disciplinetherapeutic touch are too restrictive for the needs ofcontemporary health care. Physiotherapy's disciplinedapproach to touch may well be credited with providingit with the legitimacy and orthodoxy that was necessaryin the first half-century of the profession's growth, butthese disciplines may now be acting to constrain poss-ible alternatives for professional approaches. Phy-siotherapists may be struggling to adapt to the needsof increasingly aging, chronically ill populations, inpart, because they only permit themselves to touchwhen there is a clear biomedical, evidence-basedrationale. Touch that is simply “pleasant”, withoutany other justification, is currently beyond the pro-fession's scope. Thus, it would still be hard for a thera-pist to offer “general” massage to a patient on apalliative care ward, for example, simply as a means ofgiving comfort or short-term relief. The fact that forthe duration of the session the patient is transportedaway from their suffering matters little if there is nophysiological evidence of therapeutic efficacy.
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The evidence of an increasing public desire for amore embodied health experience is now considerable(Csordas, 2000; Fox, 1999; Williams, 1996), but evenwithout this, many are now more aware of their needto feel relief from pain, or to experience comfort inthe hands of a skilled practitioner. Juhan (1987)expresses this idea clearly when he asks:
Why should such a few sessions of bodywork,often accompanied by a minimum of verbal dialo-gue, affect so dramatically these people's symp-toms, their relationships with themselves, andtheir relationships with others? Most of the body-work techniques I have observed and practicedare neither rigidly systematic nor forceful. Theusual impression is that the client is beinggentled and pleasured, not being “fixed” or“cured”. By what possible mechanisms, then,could something so simple as soothing touch alle-viate painful and long-standing physical con-ditions, quell anxieties, foster more productiveattitudes?
The fact that currently one is unlikely to see a refer-ence to “gentling” or “pleasuring” a patient expressedwithin the physiotherapy literature, may be indicativeof an association in the minds of physiotherapistswith un-regulated alternative therapists, or the formsof massage offered in brothels and bordellos. Earlyin their careers, physiotherapists are taught to feelmore comfortable trading in the biomechanicallanguage of assessment, diagnosis, and cure. Butthese approaches have their own constraints, notleast because they narrow how it is possible to thinkof notions of touch, desire, and sensuality.
Clearly, we are not advocating a laissez-faireapproach to touch, or a position of complete moralrelativity where physiotherapists are free to performin whatever way they choose. We are aware of thefact that there will always be the need to have pro-fessional ethics and policies within the profession, toprotect ourselves as much as our patients. Neitherdo we believe that the future of the profession lies ina wholesale rejection of past values that have servedphysiotherapists so well. We do, however, believethat physiotherapists should have a clearer under-standing of where their disciplinary boundaries havebeen set, and an appreciation for what these thenenable and constrain; what they presently make poss-ible and impossible; and, most importantly, if this iswhat physiotherapists want for themselves and theirpatients.
To undertake such an analysis will require a con-certed effort to challenge taken-for-granted assump-tions within the profession; to examine things thatseem, on the surface, to be obvious, and readily
accepted. What is more, it will require physiotherapiststo propose new ways of thinking that seem to trans-gress the disciplinary technologies of the profession;if only to follow Bataille's example of transgressionand use such approaches to identify where we haveset our present boundaries and ask if there is a possi-bility of going beyond those boundaries.
If physiotherapists are to be able to meet thecomplex, multifaceted demands of the population,then they must develop practice models that cater formuch greater inclusiveness and diversity. They mustbe able to use their skills for care, not just for cure.They must be able to offer a more embodied or holisticapproach and use their touch for a much wider set ofcapabilities than is presently allowed. Of course, to usetouch in these more diverse ways risks opening up todifferent questions about sensuality, which have beenconstrained throughout the profession's past, but ifphysiotherapists cannot deploy their skills in theseways, they may see themselves gradually replaced bythose who have grappled with these tensions andfound a solution that satisfies everyone's desires.
CONCLUSION
In this article, we have examined the technologiesused by physiotherapists to discipline therapeutictouch, drawing on the work of three postmodern phi-losophers whose work may be of particular value giventhat they deal with questions of desire (Deleuze), dis-cipline, (Foucault) and transgression (Bataille). Thesenotions strike at the heart of some very powerfulethical, historical, and philosophical questions in phy-siotherapy; questions that will have an importantbearing on the future viability of the profession. Inthe article, we conclude that rather than seeingdesire, discipline, and transgression as negativeaspects that need to be “managed out” of the pro-fession, or issues to be ignored, physiotherapistsshould look to bring these issues to the surface andexplore the possibilities they offer for the professionin the twenty-first century.
Declaration of interest: The authors report nodeclaration of interest.
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Deputy Director, Associate Professor, The Education for Practice Institute, Charles Sturt University, Sydney, Australia
ABSTRACT
Inphysiotherapy, aswithmanyother health-carepractices, therapeutic interventions, basedonscientific knowledge,may be at oddswith patient experiences. Patientsmay understand what they need to do to improve their health con-dition, but feel that these requirements may be emotionally, socially, or culturally incompatible with their lifestyles,social behavior, or personal choices. To work in the best interest of their patients, physiotherapists need to engagewith the tensions that exist between scientific reason and social reality to offer a meaningful and relevant service fortheir patients.Thechallenge for physiotherapists is toarriveat decisionsand interventions togetherwith their patientsthat enhance, for example,mobility, social function, andwell-being. To achieve this, physiotherapists need to rethinktheir professional role and translate their technical knowledgeandgoals into thepatient's ‘lifeworld’, andpatients– fortheir part – need to engagewith physiotherapy professional knowledge. Often, themost commonly used strategy forfacilitating this reciprocal engagement is open dialogue between patients and therapists. Habermas, a prominentcontemporary philosopher and critical theorist, has developed a communicative theory that may support phy-siotherapists in their efforts to arrive at more sustainable and shared decisions with their patients. In this paper,I examinewhat constitutes physiotherapists' practice knowledgeandhowHabermas's theoryof knowledge, interest,and communication strengthens shared decision-making and can be used as a vehicle toward emancipatorypractice. Drawing on data generated in an action research project, I examine howHabermas's ideas can be appliedin emancipatory physiotherapy practice. The paper concludes that emancipatory practice is meaningful becauseit creates opportunities for reflection, evaluation, and choice for future physiotherapy practice.
AUTHOR PROLOGUE
As a philosophical practice paradigm, critical theory isrelatively new in physiotherapy. As a form of scholarlyinquiry, critical theory explores power relationships,knowledge formations, and claims to truth, and pro-vides tools to critically analyse ideological positions.In my own work, as a practicing physiotherapist I wasmotivated to explore critical theory after an incidentwith a physiotherapist student in an aged care facilityof a large teaching hospital. The student assessed apatient and reported to me there was nothing shecould do for him. The patient was bed-bound, unableto cope at home, and recovering from the effects of arecent hip replacement, superimposed on osteoar-thritis, and heart failure. It had not occurred to thisstudent to ask the patient about his functional goalsor how she might assist in his daily activities. This alltoo familiar incident prompted several questions:
Why had the student not talked with her patientabout his perceptions and goals? Why did she make aunilateral decision? What type of knowledge did sheexclude from her clinical reasoning that made herdecide that she could not treat this patient? WhenI posed these questions to academics and researchersthey told me that they match a critical theory perspec-tive and encouraged me to explore physiotherapists'self-reflections on their practice. In particular, I wasinterested in what constitutes physiotherapists' practiceknowledge; how they describe their role; and whatmotivates their clinical decisions. This paper summar-izes some of that work.
BACKGROUND
Research on patient-centered care has made importantcontributions to the way health professionals nowview communicative practices (Cott, 2004; Lund-strom, 2008; McPherson and Siegert, 2007). Existingresearch highlights the importance of the patient'svoice and the importance of representing patient expec-tations in clinical decisions. Critically, the engagementbetween the scientific and social worlds, the active
Address correspondence to Franziska Trede, Deputy Director,Associate Professor, The Education for Practice Institute, CharlesSturt University, Sydney, Australia. E-mail: [email protected]
participation of patients and the importance of focusingon achieving goals that are meaningful for patients arekey themes in the patient-centered literature (Best,Cant, and Ryan, 2001; Gruman et al, 2010; Gzil et al,2007). Little work has been undertaken that recognizesthe adjustments in professional roles that clinicians arefaced with when collaborating and sharing decision-making processes with patients. Such a democraticpatient-centered approach is referred to as a person-centered approach because it acknowledges that bothclinician and patient bring their agendas to the clinicalencounter, that there are power dynamics at play thatmust be taken into consideration, and that patientexperiences and ways of living with a health conditionneed to be an essential component of care plans(McCormack and McCane, 2006; Trede and Higgs,2003). Such a perspective is underpinned by intentionsto find agreement on treatment priorities that areappropriate for therapist and patient (Summer, 2001;Trede and Haynes, 2009). Such relational and dialogi-cal practices are underpinned by democratic principlesof reciprocity, mutual respect, and the right we have toquestion each other's motives and roles – regardless ofrank or social standing. These principles lie at theheart of what has come to be known as emancipatorypractice (Trede, Higgs, Jones, and Edwards, 2003).
Critical theory
The term critical theory originated with the FrankfurtSchool. This was a social science research centre inFrankfurt, Germany in the 1920s and 1930s that drewon direct experiences of German social life to questionsome of the dominant, superior, and ideologically trou-bling notions handed down from the Enlightenmentthat found their apotheosis in the fascism and Nazismof pre-war Germany (Newman, 1999).
The Frankfurt School's approach came to be knownas critical theory whose aim was to transform main-stream practices and dominant cultures and encouragemore humanistic and inclusive ideals (Rasmussen,1996). Critical theory remains an important philosophi-cal approach in research to this day because it questionsself-evident reality, challenges taken for grantedassumptions, and critiques unreflected policies, prac-tices and procedures. Critical theory is a theory that isnot only concerned with explaining and understandingthe realities of social life, but also builds on these toargue how things might be otherwise (Brookfield,2005). Logically, critical theory has responded to thesocial and political issues of the time (Agger, 1998;Rasmussen, 1996). The first generation critical theorists(1930s–1950s) questioned the rising dominance ofpositivism and mass popular culture. The second
generation (1960s–1970s) critiqued scientism (Haber-mas, 1972) and communication practices (Habermas,1984, 1987). And the third generation (1980s–1990s)challenged gender and multicultural issues (hooks,1994) as well as postmodernism and relativism(Honneth, 1993). The current generation of critical the-orists are actively engaged in (among other things) cri-tiques of economic rationalism and oppressive featuresof globalization that are having a profound impact onpeople's experiences of notions like health, well-being,freedom, identity, and society (Newman, 2009).
Critical theory and health care
Turning our attention specifically to health care and thework of the most well-known critical theorist, Haber-mas, there are many areas in health where Habermas'sinfluence can be seen: in the analysis of doctor–patientrelationships (Barry et al, 2001; Walseth and Schei,2011); collaborative practices between doctors andnurses (McClain, 1988); medical lifestyle interventions(Walseth and Schei, 2011); caring and ethical issues(Summer, 2001); nursing advocacy (Martin, 1998);health economics (Small and Mannion, 2005); andhealth promotion (Eakin et al, 1996). These studiesexplore levels of participation; integration of thepatient's lifeworld into clinical decision-making; anddemocratizing professional relationships. In all cases,the studies offer powerful critiques of the assumedsuperiority of the traditional scientistic objectivity ofhealth professions and the health-care system, andadvocate for the voices of those that had previouslybeen marginalized. Barry et al (2001), for example,found that while most patients did not suffer whendoctors ignored their particular ‘lifeworld’, chronicallyill patients needed to be able to speak about their per-sonal perspective, wants and needs if they were to beenabled to make lifestyle changes. Walseth and Schei(2011) found that open and freely negotiated treatmentdecisions instilled commitment in patients and allowedthem to follow throughwith clinical decisions, conclud-ing that decisions reached through such communicativerationality ‘represent[s] a way of giving everyday life alanguage, and a powerful access to non-oppressive pro-cesses of health related change’. The studiesmentionedin this section advocate for a critical theory approachfor clinical practice and have drawn on Habermas'stheory to develop notions of a person-centered practiceunderpinned by emancipatory interests.
Key features of critical theory
Two of the most important features of critical theoryare critique and emancipation (Agger, 1998).
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Criticality, critique and critical thinking are all termswith a specific meaning within a critical theoryframework. Newman (2006) described the meaningof critical thinking as:
[…] analysing human activity in terms of power,and refusing to take the words, ideas, injunctionsand orders of others at face value. It meant notletting others make up our minds for us. Itmeant abandoning the search for some fixed setof principles, and adopting a stance of informedand continual critique. Critical thinking was nota neutral activity. Like the critical theory fromwhich it sprang, critical thinking was associatedwith the pursuit of social justice.
The task of critiquing is to identify and unravel contra-diction, and reveal paradoxes in current practices. Itdoes this by scrutinizing the assumptions and motiv-ations that create current practices. A critical theoryperspective postulates that we can only know andunderstand our practice through interpretation andanalysis. It contends that perceptions of reality are dis-torted through values, ideology, and power and we canonly confirm knowledge through open communicationwith each other. A critical perspective asserts that thereis no view from nowhere and each truth claim is locatedin a particular philosophical framework. Within acritical perspective practice is seen to be shaped by aparticular history and context. Critical theorizing hasan acutely relational character and rejects notions ofa-historical, a-contextual, universal truth claims.
The second feature of critical theory which followscritique is emancipation; it means liberation fromunreflected, taken for granted practices, policies, andrules that restrict human flourishing (Harden, 1996).Based on the critical awareness of what createsinequalities and injustices, emancipation is the responseto this awareness. It means following up new under-standings with purposeful action.
Emancipatory interests and criticalrationality
Habermas acknowledged that there were ongoing ten-sions between the need to be objective and the need todemonstrate ethical reasoning in areas like health care.In his seminal book Knowledge and Human Interest(Habermas, 1972), Habermas argued that all formsof knowledge and practice were influenced by per-sonal/professional interests and that forms of knowl-edge could be categorized by considering threedistinct modes of interest: (1) technical, (2) practical,and (3) emancipatory. According to Habermas, eachinterest generates different types of knowledge, poses
different questions, creates different perceptions ofreality, and affects different actions. Technical interestis driven by a desire for control, prediction, and cer-tainty. Practical interest is driven by a desire to shareexperiences and come to consensual understanding.Emancipatory interest is driven by a desire for liber-ation from unnecessary constraints and limitations.Each of the three types of knowledge and interesthas their important place and Habermas (1972)objected to the notion that one was superior to theothers.
Emancipatory interest problematizes taken forgranted, unreflected practices that appear to belaw-like. It drives critical reasoning that is reflective,self-critical, and aware of interests of other dialoguepartners. Habermas contends that reasoning is morethan asking technical and practical questions. A preoc-cupation with technical, outcomes-driven interests aswell as practical consensus-reaching interests reducesour thinking capacity. He argues people need toimagine other possibilities and liberate thinking fromunnecessarily narrow perspectives if they were torealize an emancipatory practice (Habermas, 1979).
For Habermas, goals fixated on economic benefit,efficiency, unbiased knowledge, and technicaladvancement are too restrictive to the many otheraspects and influences that play into social life andtrouble the world today. Critical rationality is basedon open dialogue where everybody contributes,albeit differently, to generate shared consensus. Criti-cal rationality is a type of reason that serves humanity,advances democracy and is grounded in shared under-standing (Brookfield, 2005), and seeks to steer clear ofservicing sectional interests.
Habermas claims that every person (patient andclinician included), brings their own understandingsto practice situations. He calls people's upbringing,past experiences, education, and preconceived under-standings the lifeworld. He claims that the lifeworldshapes sense-making; that there is no worldviewwithout a viewpoint; and that there is no knowledgethat can be understood out of context and out ofhistory. He asserts that we reason from a particularviewpoint and that communication will becomedistorted if we are not aware of these viewpoints andthe interests that underpin them.
Theory of communicative action
Emancipatory interest generates critical knowledgethrough open democratic dialogues. It is importantto note here that dialogues remain in danger ofbeing distorted or dominated by professional authorityif they are allowed to proceed uncritiqued. To avoid
distorted dialogues, Habermas contends that com-munication needs to be underpinned by a willingnessbetween both parties to communicate openly, sin-cerely, and self-critically (Habermas, 1987). In histheory of communicative action, Habermas (1987)identifies three conditions that enable people to haveopen democratic dialogues, which he coined idealspeech situations (Habermas, 1984). First, reason pre-vails over power; second, speakers take a self-reflectivestance; and third, arguments need to be transparentand have intrinsic properties that help decidewhether to accept or reject validity claims. These con-ditions can assist clinicians and patients alike, to thinkfor one's self and identify any misuse of power.
A critical perspective toward dialogue promotesdisclosure of interests, bias and motivation, honorsgenuine transparent discussion, and rejects deridingrhetoric and unsubstantiated statements that lead todeception (Kögler, 1999). The notion of idealspeech situations allows dialogue partners to lookbelow the surface, as well as question motivationsand interests that lead to action. Habermas insiststhat communicative action needs to be grounded incritical reason where dialogue partners resist mono-logues and the use of power (Habermas, 1987). Inemancipatory dialogues, speakers feel encouraged toconfront each other respectfully and openly withquestions and answers. They are prepared to notagree or to change their mind as a result of opendemocratic dialogues rather than as a result ofpassively giving in.
Following on from the work of Habermas and thosethat have employed his ideas in health-care research, itmay be possible to critically analyse contemporaryphysiotherapy practice and, where necessary, disruptcurrent mainstream physiotherapy discourses thatmarginalize, de-personalize, or act against the interestsof person-centered care. To this end, I present here acase study that examined physiotherapy participants'capacity for reflexivity, their understanding of theirprofessional roles, and their perceived professionalauthority and approaches to shared decision-making.This case study draws on work published elsewherethat may provide useful supplementary reading(Trede, 2008; Trede, Higgs, Jones, and Edwards,2003).
A CASE STUDY
This case study revolves around research that was con-ducted with three groups as part of a larger studyexploring emancipatory practice in physiotherapy(Trede, 2008). The first group participated in a one-off in-depth interview as a preliminary study of
current practice perceptions. The second group par-ticipated in reflective interviews during a 9 monthtrial of emancipatory practice. The third group cri-tiqued the critical practice model that emerged fromthe research with the other groups in one-off inter-views. For reasons of brevity, I will only discuss thesecond participant group here. For more details ofthe methodological approach, please refer to Trede,Higgs, and Rothwell (2009).
The study participants consisted of nine phy-siotherapists, all from within a large teaching hospitalin Sydney, Australia. These physiotherapists workedin different fields of physiotherapy practice includingoutpatient, spinal unit, intensive care, and rehabilita-tion. Participants attended a pre-implementationworkshop where they were introduced to Habermas'stheory and encouraged to critically discuss its rel-evance and applicability to their practice. At the con-clusion of this workshop participants were asked towrite down the goals and strategies that they wereinterested in trialling as part of an emancipatory prac-tice framework. Participants were then supportedin their efforts to implement the framework. Theywere interviewed on up to three occasions over the9-month implementation period and in these inter-views they were asked to reflect on their experiencestrialling emancipatory practice.
Participants chose a variety of approaches to eman-cipatory practice, including focusing on patients andon self, on their professional relationships withpatients, and/or self compared with perceived practicenorm. The strategies they wanted to trial includedquestioning patients deeply about their concerns;asking questions that invite patients to state theirgoals; writing a reflective diary; empathizing and con-sidering patient perspectives; providing better expla-nations and using more experiential learningstrategies with patients; examining what was docu-mented about patient perspectives in medicalrecords; and noting what criteria were used fordecision-making.
Over the course of the 9 months, various percep-tions of physiotherapy practice emerged in the inter-views. For the purpose of simplicity, rather thangeneralizability, these perceptions of emancipatorypractice have been grouped here into three clusters:(1) ‘unconvinced’, (2) ‘contemplators’, and (3) ‘trans-formers’ (Trede, 2008).
The unconvinced
This first cluster comprised those participants whocompleted the trial without questioning their ownpractice assumptions and motivations. They remainedunconvinced of an emancipatory practice and felt that
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the engagement with emancipatory practice onlyreinforced their prior approach, as illustrated in thisquote:
I don't think anything has changed the way I prac-tise. No I don't think I have changed anything butI think it has been reassuring for me that myreflections show me consistency in my decisionmaking. It is not ad hoc, it is not at a whim butI had never thought about why I do it. It fitsand it feels comfortable. (Alan)
Alan realized that he valued consistency. He usedobjective reasoning to emphasize the importance oftechnical reasoning in practice to convince patients todowhat hewanted them to do.Democratizing relation-ships and critically reasoningwith patients was not feas-ible for him. Even though he acknowledged patientexperiences, his preference for a therapist-centeredpractice prevailed:
I think it is a decision that is made with my assess-ment. I am clinically trained…I think it lies in thebest interest to do what I say. I explain why theexercises need to be done and what they are tryingto achieve. (Alan)
From a critical theorist's perspective, such approachesare informed by rationality that ostensibly excludespatient experiences and notions of critical self-reflection. The unconvinced could not identify anytension, paradox or need for critique and so did notentertain or value the ideas espoused by emancipatorypractice.
The contemplators
This second cluster comprised participants who ident-ified some advantages of emancipatory practice, butfelt it was too hard to operationalize in physiotherapypractice, as illustrated in the following quote:
Doing-to patients saves lives and prevents compli-cations. Doing-to is simple and straightforward. Itmeans following my duty of care. In acute [set-tings] you focus on biomedical signs and youcannot always develop a relationship with thehuman being. In chronic settings you have timeto develop a professional/personal relationship.In long-term rehabilitation you need to considerthe human being more. It is more relaxing,working slower with patients. (Petra)
Participants in this cluster actively questioned theirpractice and were unsettled by the trial. They acknowl-edged their own and their patients' perspectives, andidentified potential tensions between them. They
understood patients' fears and concerns, but theyalso considered patients' potential lack of insight intotheir acute condition and the constraints of thehealth-care systems in which care is delivered:
I am ambivalent because I still really think that ifpatients did what they wanted to do really thenthey would only lie in bed all the time. It is amatter of explaining to them. It is a learningprocess. We are not really doing what patientswants. We do have to do what I want. Not what Iwant personally but what is necessary for aspeedy recovery. I will go as far as to say ‘lying inbed is very dangerous’. I explain what happenswhen people fly in the airplane, people get clotsin their legs, or even in the brain or lungs. Patientsthen say ‘you are frighteningme’. ‘I am sorry to tellyou this but you need to know, it is my responsibil-ity to tell you this’. I feel very anxious doing that[not treating due to patients' wishes] in case thepatient is developing a thrombosis or is going tostart getting a chest infection. (Petra)
Petra worked in acute care and felt it necessary toutilize objective reasoning. She did not want to riskbeing unprofessional and failing to fulfil her duty ofcare. She did not want to enter into a negotiated clini-cal reasoning process with patients because she feltthey were not necessarily well enough to make rationaldecisions:
It is nicer doing-with patients than doing-topatients. I feel less guilty towards patients if it isdoing-with but I also feel less guilty if it is doing-to if it is necessary for a speedy recovery. (Petra)
Although Petra argued for a therapist-centered prac-tice she remained open to the idea of emancipatoryconsiderations in their rightful place (i.e. in cases ofchronic illness). Participants in this ‘contemplator’cluster commonly stated that a more patient-centeredprocess made them feel better as therapists and prob-ably achieved more satisfaction for their patients aswell. On the other hand, they felt equally confidentin a therapist-centered practice, particularly in acutesituations where complications needed to be pre-vented and patients appeared particularly passive.The contemplators highlighted that emancipatorypractice may be a significant focus in specific practicecontexts.
The transformers
The third cluster comprised participants who usedtheir reflexive insights to transform their practice.With small steps, they started to develop and adopt a
model of emancipatory practice. They felt it importantto embrace patients' emotions and help them deal withtrauma. This group did not assume that patients ob-jectively understood what was happening to themnor did they expect patients to reason objectively.They questioned their practice assumptions andfound it increasingly challenging to account for objec-tive rationality within an evidence-based framework:
The problem is we cannot always prove that whatwe do works. We're human beings, we're notmachines, that's the problem. We are notmachines, we are emotional, psychological, phys-ical, physiological, spiritual beings and all of thataffects the way we function, and it's not possible,if we start treating people only like machines.(Corinne)
Corinne felt that aspects of trust, humanity, and asense of how to work with patients' fears and interestsneeded to be included in rethinking rationality andevidence in physiotherapy practice. On the otherhand. Corinne felt that physiotherapists need to leaddecisions and she concluded that being emancipatedmeans to take sides:
I think physiotherapists need to know that theyhave the power and that they have the right to in-troduce or not introduce whatever treatmenttechniques or treatments they choose, whetherto continue treatment, whether to stop treatment.I think they need to feel that they've got the rightto do that. But the patient also needs to have afeeling that they have some power in this situ-ation, and that they can say to physiotherapiststhat, ‘you know, this is not working, I wantsome more [of this other technique]’. (Corinne)
Corinne justified her position after careful self-criticalreflection. To her, a critical approach implies beingmindful of indecisiveness and chaos, while at thesame time trying to overcome it. Corinne concludedthat professional power rested with physiotherapistsover patients. However, when keeping patients' out-comes and interests in mind it was important forCorinne to have patient involvement. Corinne wasaware of her professional power, prejudices, andassumptions. Her practice interest was to makepatients feel part of the decision-making processeven though they did not have ultimate control. The‘transformers’ weaved in and out between a therapist-and person-centered practice. What defined theirpractice as emancipatory was their critical reasoningand open dialogues with patients.
Synthesizing the findings of the case study
Having completed the study with the practitioners,and having examined their perceptions of emancipa-tory practice, it was clear that emancipatory practicewas seen to:
. build capacity for reflexivity in physiotherapists toenable critical practice choices,
. encourage professional reflection to foster inclusive,appropriate, and ethical practice,
. raise awareness of interests and values that informclinical reasoning.
But emancipatory practice was also seen to:
. fit poorly with the current political health-care prac-tice climate,
. be alienating for some physiotherapists,
. assume that patients want to collaborate and partici-pate in treatment decisions,
. allow people to misuse critical self-reflection toconfirm therapist-dominated practices,
. lack evidence to measure outcomes of reflexivity.
At a theoretical level, emancipatory ideas about criticalrationality and communicative action have been criti-cized for being highly idealistic and utopian. And ata philosophical level, Gadamer (1967) asserted thatpeople focus more on what has been said than whysomething has been said. Foucault (1980) statedthat power relations cannot be reasoned away soeasily and remained skeptical of the prospect thatpeople can differentiate manipulative from emancipa-tory forces. Fay (1987) found that Habermas over-stated the power of reason. Habermas (1982)responded to such critiques thus:
To be sure, the concept of communicative ration-ality does contain a utopian perspective; in thestructure of undamaged intersubjectivity can befound a necessary condition for individuals reach-ing an understanding among themselves withoutcoercion, as well as for the identity of an individualcoming to an understanding with himself orherself without force.
Habermas concedes to his critics but has continuedto insist on the notion of coercion-free dialogue.Whether one agrees or disagrees, it appearsHabermas'stheoretical contributions have something useful to offerphysiotherapy practice in termsof rethinking communi-cation practices and the interests that underpindecision-making practice (Barry et al, 2001; Summer,2001; Walseth and Schei, 2011).
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CONCLUSION
Without perceived practice tensions there can be nostimulus for a critical dialogue that might enable usto rethink current ways of practicing. This case studyprovided an opportunity to engage with present prac-tice tensions and use the work of Habermas to move usbeyond the obvious or taken for granted practice sol-utions that lead, all too often in health care, to shortterm, superficial solutions. As such, a dialogicalapproach provides a stimulus to bring new questionsand solutions to the minds of physiotherapists. Impor-tantly, a number of participants struggled with theideas of emancipatory practice in a practice and organ-izational culture that did not openly support suchapproaches.
Gaining an understanding of emancipatory practiceopens opportunities for reflection, evaluation, andchoice for future physiotherapy practice. It highlightscommunication, self-insights, and professional relation-ships as important aspects of physiotherapy practice thatwarrant further exploration of the potential beyondtherapist- and patient-centered practice.
Declaration of interest: The author reports noconflict of interest.
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PERSPECTIVE
Critical approaches in physical therapy research:Investigating the symbolic value of walkingBarbara E. Gibson, PhD, MSc, BMR(PT)1,2 and Gail Teachman, PhD(c), MSc, BSc(OT)3
1Assistant Professor, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada2Scientist, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada3Lecturer, Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto,Ontario, Canada
ABSTRACT
Research using a critical social science perspective is uncommon in physiotherapy (PT) despite its potentialadvantages for investigating questions other approaches cannot address. Critical approaches can be used toexpose ideas and concepts that are dominant, given, or taken-for-granted in practice in order to reflect on how“things could be otherwise.” The purpose of this paper is to use an example of research examining the symbolicvalue of walking to outline the key features of critical research and its application to PT. The study drew fromPierre Bourdieu's sociology of practice to illuminate how socially ingrained notions of normality and disabilityare reflected in rehabilitation practices and affect parents and children with cerebral palsy. Dominant socialassumptions about the value of walking are shown to shape individual choices and contribute to parental feelingsof angst and doubt, and negative self-identities for children. The example reveals how critical approaches toresearch can be used to reveal the socio-political dimension of rehabilitation practice and address importantresearch questions that have been largely neglected.
INTRODUCTION
To date, scarce attention has been paid to the socio-political assumptions that underpin physiotherapy(PT) practices (Gibson, Nicholls, and Nixon,2010). PT, rehabilitation, and health care more gen-erally are rooted in some basic assumptions aboutthe goals of therapy and what constitutes successfuloutcomes or good quality of life. For example, theassumption that a reduction in impairment necess-arily equates to improved quality of life is pervasivelyreflected in clinical practice and the standardizedmeasures of health status. These beliefs organizepractices and, for the most part, go unrecognizedand unquestioned. Rather, they operate as tacitbackground understandings that determine a vastrange of practices and policies ranging from whatprograms get funded, to how goals are discussed
with patients, to the type and range of interventionsoffered.
Nicholls and colleagues suggest that the time isright to creatively reform the PT profession and con-sider the social forces that shape practice (Gibson,Nicholls, and Nixon, 2010; Nicholls and Cheek,2006; Nicholls and Larmer, 2005). An importantstep in re-imagining physical therapy is the creationof a body of research dedicated to the examinationof PT and rehabilitation as social processes embeddedin larger socio-political systems of relations. Such aproject is vital to understanding how these forces ulti-mately affect clients and can be addressed to improvecare. Nevertheless, there is scant applied PT researchavailable that shows how critical approaches actuallydo the work of answering these questions.
To address this gap, this paper uses a researchexample to outline the key features of critical researchand its application to PT. The example we draw fromis a critical qualitative study that used Bourdieu'stheory of practice (Bourdieu, 1980, 1990, 1997; Bour-dieu andWacquant, 1992) to explore beliefs about thevalue of walking with disabled children and theirparents. As a critical project, the study went beyond
Address correspondence to Barbara E. Gibson, Department of PhysicalTherapy, University of Toronto, Toronto, Ontario, Canada. E-mail:[email protected]
describing beliefs to investigating the mechanisms bywhich those beliefs mediate children and parents'goals, practices, and their perceptions of success orfailure. We first briefly outline some of the key tenetsof critical social science approaches. We then describethe Bourdieusian framework that guided the researchand our approach to conceptualizing disability. Wethen discuss the details of the study, demonstratinghow this critical approach guided the analyses. Thepaper concludes with some suggestions for futureareas of critical PT research to help inform andre-imagine PT practices.
CRITICAL SOCIAL SCIENCEAPPROACHES
Critical approaches examine every day practices andask why they persist, whose interests they serve, whatpower relations are at play, and what assumptionsunderpin their ongoing acceptance (Eakin et al,1996). Kincheloe and McLaren (2005) outline somebasic assumptions inherent in critical research including:
. All thought is fundamentally mediated by powerrelations that are socially and historically constituted
. Facts can never be isolated from the domain ofvalues or removed from some form of ideologicalinscription
. Language is central to the formation of subjectivity(conscious and unconscious awareness)
. Certain groups in any society … are privileged overothers, and although the reasons for this privilegingvary widely, the oppression that characterizes con-temporary societies is most forcefully reproducedwhen subordinates accept their social status asnatural, necessary, or inevitable
. Mainstream research practices are generally,although most often unwittingly, implicated in thereproduction of systems of …oppression
A critical lens thus suggests alternative areas ofinquiry, new ways of producing knowledge, and differ-ent ways of examining common issues compared tomainstream PT research. Explicitly political andaimed at emancipation, critical research asks questionsregarding social values and norms, institutional priori-ties, and socio-cultural power relations. For example,questioning the “body as machine” model that isprevalent in PT in order to offer new ways for phy-siotherapists to understand and to respond to theirpatients' experiences of illness (Nicholls and Gibson,2010; Papadimitriou, 2008) or unpacking notions of“autonomy” to facilitate power sharing and decision-making (Hunt and Ells, 2011).
A Bourdieusian approach
The study discussed in this paper drew on PierreBourdieu's “sociology of practice” which is a variantof critical social science. Bourdieu's central conceptsof habitus, capital, and field (Bourdieu, 1980)provide conceptual tools for examining interrelation-ships between individual practices (behaviors,beliefs, attitudes, and personal tastes) and thebroader social environment. Habitus can be describedas a set of dispositions that incline persons toward par-ticular behaviors and attitudes in given contexts(Bourdieu, 1990). Bourdieu (1990) describedhabitus as the mediating link through which repeatedexposure to a particular set of social conditionsbecomes integrated into a set of lasting perceptions,appreciations, and inclinations that animate practices.
Bourdieu and Wacquant (1992) posited that socialprocesses place individuals and groups within com-petitive hierarchies where they struggle for relativestatus. Persons acquire a pre-reflective comprehensionof the social world, its hierarchies, and their “place” init by incorporating the structures of the social environ-ments they are exposed to since birth. This means thatindividuals tacitly understand, and more or lessaccept, which attributes of individuals and groupsconfer power and prestige, and which are discreditedor marginalized. Through their beliefs and practices,individuals unwittingly reproduce and reinforcethese understandings. Bourdieu (1997) referred tothis as “misrecognition.” Misrecognition occurswhen people accept the established order of “haves”and “have-nots” as natural and logical. Bourdieuused many examples, including deeply entrenchedaccepted differences between social classes (Bourdieu,1984), and women and men (Bourdieu, 2001), butthe concepts have also been employed to examinethe marginalization of disabled people (Edwards andImrie, 2003; Gibson, Young, Upshur, and McKeever,2007b; McKeever and Miller, 2004).
Two other key concepts ground Bourdieu's theoryof practice: 1) field and 2) capital. Fields are relativelyautonomous social microcosms such as the family, theeducation system, and rehabilitation that have theirown set of tacit rules and understandings (Bourdieu,1997). A person's (or group's) position in a field isdetermined by the amount and type of field-specificcapital at her or his disposal. Capital is any resource(economic, social, or cultural) that is acknowledgedas valuable within a field (Bourdieu, 1986). Fieldsare sites of struggle where possession of capital deter-mines one's position or status within a field.
For persons with physical differences, physicalcapital, that is, physical attributes and abilitiesjudged positively or negatively, can hold particular
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relevance. The body as a bearer of symbolic value isintegral to the production of social hierarchies andinequalities (Edwards and Imrie, 2003). The symbolicvalue connected to different forms becomes signifi-cant for individuals' sense of personal and groupidentification. For Bourdieu, symbolically inscribedbodily properties identify persons as belonging tosocial categories along lines of, for example, ethnicity,gender, or physical differences. These categorizations,far from being neutral markers, denote a hierarchywhereby some forms of physical capital are devaluedand group members are stigmatized. “Disability” is asocial categorization imposed on children with phys-ical differences, both formally and informally, inmyriad encounters across their social worlds.Through exposure to various fields including family,school, and rehabilitation, they internalize the unde-sirability of disability and the negative coding of theirbodies and ways of moving.
Conceptualizing disability in rehabilitationand disability studies
Before introducing the study, it is necessary to situatethe work within both rehabilitation science and dis-ability studies. Within rehabilitation, as in medicinemore broadly, disability is largely still viewed asarising from individual biological impairments(Hammell, 2007; Kielhofner, 2005). Thus, the clini-cal focus is most often either on repairing the biologi-cal body and/or helping the individual to adapt to theenvironment through maximizing their existing abil-ities (French and Swain, 2001; Gibson et al, 2009;Magasi, 2008a). Independence and “participation”are taken-for-granted goals that are reflected in theconceptual underpinnings of rehabilitation (Gignacand Cott, 1998), most notably through the widespreadinfluence of the International Classification of Func-tioning, Disability and Health (ICF) (World HealthOrganization, 2001). One of the principle aims ofthe ICF was to challenge the medical model andbring the effects of social exclusion onto the healthcareagenda (Bury, 2000). However, rehabilitation and theICF model (including its previous iterations) havebeen criticized for causally linking social exclusion tobodily impairment (Abberly, 1996; Oliver, 1990;Pfeiffer, 1998, 2000) and reinforcing pejorative viewsof disabled people by equating the inability toachieve performance norms with poor quality of life(Pfeiffer, 1998).
In juxtaposition to perspectives that causally linkdisability and impairment, the social model locatesdisability squarely in the environment (Oliver,1983). The basic premise of the social model is that
disability is the outcome of exclusionary social andmaterial arrangements. Its proponents rejectapproaches that focus on individual adaptation andinstead draw attention to dominant “ableist” ideol-ogies, practices, and policies (Hahn, 1988; Oliver,1983, 1996). In focusing on the material and socialproduction of disability, the social model has contrib-uted to shifting policy debates from the medical to thepolitical sphere (Hughes and Paterson, 1997; Silvers,Wasserman, and Mahowald, 1998). Critics argue,however, that the social model or at least workadvanced in its name focuses too heavily on socialand material barriers with little consideration of theexperiential aspects of disability and the significanceof physical impairment in people's lives (Corker,1999; Freund, 2001; Imrie, 2000; Kitchin, 1998;Thomas, 1999; pp 24–25, 2007).
In response to these and other critiques, criticalapproaches to disability studies have emerged thatintegrate the political with the personal by focusingon the dialogic relationships between impaired bodiesand socio-cultural contexts (Gabel and Peters, 2004;Hughes and Paterson, 1997; Williams, 1999); and at-tending to how disability intersects with other culturalidentities such as race, gender, sexuality, socioeco-nomic status, and age (Goodley, 2011; Grech, 2011;Meekosha and Shuttleworth, 2009). As with all criticalapproaches, critical disability studies examine powerand the patterns of domination built into the structureof societies. Research is focused on exposing actions,practices, and policies that perpetuate these patterns,including how oppressive social arrangements becomeinternalized by individuals and thus may be experi-enced as natural or given (Meekosha and Shuttleworth,2009). Bourdieu's conceptualization of the correspon-dence between embodied dispositions and sociallocation provides an example of a critical approachthat circumvents overly simplistic characterizations ofdisability as either a product of impairment or as theresult of socio-political disadvantage (Edwards andImrie, 2003).
STUDY AIMS AND BACKGROUND
The aim of the study was to illuminate how enduringsocial beliefs regarding walking, disability, and nor-mality mediate the ambulation goals, behaviors, andbeliefs of parents and children.
Using a critical Bourdieusian lens, we proposedthat while walking therapy has functional and physio-logical benefits, it also holds symbolic significancethat has been under-explored in the literature.
Intense ambulatory training is a major PT interven-tion for young children with cerebral palsy (CP)
(Bottos, 2003; Bottos et al, 2001; Rosenbaum et al,2002) that consumes significant public resources,and an enormous amount of children's and families'time and energy over many years. Despite theseefforts, however, a considerable number of childrendo not achieve functional walking, or will lose thisability and increasingly rely on wheelchairs as theyget older (Bottos et al, 2001; Wood and Rosenbaum,2000). Disability scholars have long argued that anuncritical “ideology of normality permeates mostrehabilitation practices” (Oliver, 1993, 1996).Walking and “standing on your own two feet” symbo-lize a whole set of moral virtues – rectitude, dignity,autonomy, not to “stoop to anything,” and to “standby” one's convictions (Straus, 1966). Health pro-fessionals, parents, and children are immersed inthese ideas which help shape the habitus, expressedthrough values, attitudes, and practices. Childrenwith physical disabilities thus risk developing a majorfocus on the body from a very young age at theexpense of engagement with their worlds (Priestley,1998; Thomas, 1998).
METHODS AND ANALYSIS
Critical approaches are methodologically “open” andmay utilize a variety of qualitative and quantitativemethods (Danemark, Ekstrom, Jakobsen, and Karls-son, 2002; Kincheloe and McLaren, 2005). In thestudy, a qualitative design was utilized, consisting ofindividual interviews and adapted child-centredmethods such as role-playing with puppets andcartoon captioning (Barker and Weller, 2003; Gibsonet al, 2011; Teachman and Gibson, in press). Inter-views focused on exploring participants' perspectiveson the value of walking and experiences with rehabilita-tion. Participants included six children with CP, ages9–18, and one of their parents (five mothers and onefather). All the participants lived in the same urbanregion in Canada and were recruited from a regionalchildren's rehabilitation centre, where research ethicsapproval was obtained. The children were in grossmotor functional classification levels of III or IV, indi-cating they had walking potential that required intensivetherapy to achieve or maintain (Palisano, Rosenbaum,Bartlett, and Livingston, 2008).
Critical qualitative interviewing does not differ sub-stantially from other qualitative approaches. Theanalysis, however, has some significant differences(Willis, 2007). Analysis can involve a number of differ-ent techniques, but the focus is on interrogating thedata to illuminate how social structures constrainand shape human practices (Kincheloe andMcLaren, 2005). Thus, conceptual tools and theories
are used to explain practices without solely relying onthe explanations provided by research participants.Williams (2003) suggests that expecting participantsto explain their behaviors without further analysis isproblematic because much of practice is accomplishedaccording to an implicit and largely unthinking practi-cal logic. Persons' accounts of their experiences informanalyses, but the analyst's work is to assist in uncover-ing the deep mechanisms that mediate practice. Thisinvolves combining what Edley and Wetherell (1997)term “top-down” analyses of how people are posi-tioned by social discourses with “bottom-up”approaches that examine persons' activities andperspectives.
In the study, our analysis focused on: 1) uncoveringthe underlying assumptions, values, and beliefsembedded in participants' accounts; 2) how theyaccommodated or resisted dominant ideologies of dis-ability, normality, and walking; and 3) how theseshaped their practices or choices about walking andtherapy. We began with deductive analyses related towalking beliefs and practices, rehabilitation interven-tions, and assessments of success. Inductive analysis,where concepts emerged from the data, was used toidentify emergent themes. Multiple coding cycles,extensive memoing (Birks, Chapman, and Francis,2008), and immersion in the data by the interdisci-plinary team helped ensure the rigor of the interpret-ations (Kvale, 1996) and the interpenetration ofconceptual reflection with empirical observations(Bourdieu and Wacquant, 1992). For further detailsof the study methods, see Gibson et al (2011) andTeachman and Gibson (in press).
RESULTS
The study's overarching themes have been detailed ina previously published paper (Gibson et al, 2011).Here, we focus on how parents and children repro-duced and resisted dominant notions of “normal”and “disabled” in order to illustrate how the criticalapproach guided analysis.
Reproducing and reformulating normal:parents
All parents discussed their children's mobilities anddisabilities in relation to future life chances and theachievement of “normal” lives and identities.Walking was seen as a powerful source of symboliccapital that conferred status across social fields.Parents' accounts revealed the range of strategiesused to minimize stigma (Goffman, 1963) and the
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negative capital assigned to their children's physicaldifferences. Strategies included long-term interven-tions aimed at correcting bodily deformities, normal-izing movement patterns, or achieving mobility goalssuch as independent ambulation. Parents reported“trying anything” including not only standard care,but also private therapy, home cures, and variousalternative therapies (Gibson et al, 2011). Commit-ment to treatment included sustained vigilance inthe form of daily exercises, walking practice, and rec-reational activities chosen for their potential thera-peutic benefit. As we discuss, through thesestrategies, parents positioned their children in relationto hegemonic ideals of normal bodies and identities.
Parents engaged in specific strategies to counterdisability identities and labeling. These included“passing” strategies (Goffman, 1963) designed toreduce the visibility of mobility differences such asthe prolonged use of a stroller instead of a wheelchair.All parents also emphasized creating opportunities fortheir children to engage in typical activities even if thismeant “doing it differently.” Ryan's mother, forexample, discussed how she worked to convey to herson that he is “no different” from other children andin so doing revealed how being “the same” is a formof capital that confers social status and belonging:
I don't treat Ryan [age 10] like he has a disability.“You're going to be treated as if you're normal …Just because you're in a chair doesn't make you nodifferent!” And that's how I tell him. “You're anormal child, you know, just because you can'twalk, that doesn't mean anything. You can playhockey, you can play basketball, you can do allthe other things that all the other people aregoing to do. It's just going to take you a bitlonger to do it.”
David's mother revealed a similar strategy:
To me, David's normal. He walks different thanothers, he might think a bit differently but he'snormal. There's nothing he can't do. When hetells me he can't do something, I look at himand say “Well, why can't you? You have a brain,you have arms, you can do it, we can figure outa way to do it.”… I've never been one to focuson the disability; we just have to do it differently.So he's normal, you know, to me. I'm not normal,I have sugar diabetes so that's my disability. Youknow what I mean? Everybody has a disability,no one's perfect you know.
These two passages reveal parents' tacit understand-ings of how bodily differences would marginalizeand exclude their children. Each participant resistsan imposed notion of normal and works within her
narrative to establish that her son is “different butnormal.” Their strategies are oriented toward refor-mulating these differences to minimize the intensityof negative symbolic capital associated with particularimpairments (Bourdieu, 1997). In both accounts,normality is constructed as a function of typical child-hood activities rather than related to bodily impair-ments. By claiming that their children are “normal”or “the same” because they do the same things asother children do, parents resist negative disability dis-courses and work to create a positive space for theirchildren. David's mother equates her son's impair-ments to her diabetes, and in so doing suggests thatthese differences are equal and irrelevant. By claimingthat “no one's perfect,” she rejects imposed socialhierarchies that would relegate her son to a lowersocial status.
Emily's (age 13) mother described the tremendousefforts required to provide her child with access tocommonplace activities:
If you want your kid to be normal, or experiencenormal activities, you have to be a leader andmodel … For instance I wanted her to be a girlguide, so what I did is I became a leader for a[girl guide] group, so I was able to facilitate herinto it.
In helping Emily “experience normal activities,” hermother resists the social order that would relegateher child to the margins. But doing so required some-what extraordinary acts to break down barriers andachieve what she recognized was a reconfiguredversion of a normal life. Emily's family thus mustengage in extraordinary acts in order to pursue ordin-ary lives.
These acts of resistance, however, are also acts ofreproduction that reinforce the pre-existing socialorder. None of the study parents rejected the domi-nant preferential status of non-disabled bodies andidentities. Absent from their accounts was any ques-tioning of the normal/abnormal distinction (Thomas,2007) that rewards conformity to arbitrary norms ofmobility. Rather they reconfigured their internalizedunderstandings to fit with their children's abilitiesand claim a reworked normality. Thus, their strategiesalso reproduce and sustain ingrained social values thatassign preferential status to non-disabled bodies.Bourdieu (2001) labels this “symbolic violence”which is the violence, “invisible even to its victimsthat is perpetuated by enduring ideas that sustainexisting power relations and the marginalization ofparticular groups through misrecognition that theseideas are natural and unalterable.” We will revisitthis notion later in discussion of the emancipatorypotential of critical research.
Using a Bourdieusian lens, parents' strategies areviewed as logical and productive given the prevailingsocial order. Their approaches emerge from ahabitus immersed in a particular set of social con-ditions, discourses, and ideologies (Bourdieu, 1980).Parents who strive to do the best for their childrenare closely attuned to the “rules of the game” thatsuggest what kinds of bodies and abilities are valuedand which are stigmatized. Given the social orderthat preceded them and is internalized over time,parents do “what works” with what they have. In sodoing, they both reinforce the social order and con-tribute to changing it through creative strategies thatcounter negative representations. Whether thesestruggles constitute acts of “resistance” or “sub-mission” is a matter of context and perception (Bour-dieu and Wacquant, 1992). For example, parentsresisted marginalizing forces that would deny theirchildren access to the same opportunities as theirpeers, but also reinforced common perceptions ofthe undesirability being identified as disabled. Thisis not surprising given that it is unlikely they havebeen exposed to alternative disability discourses oridentities. Thus, their strategies and modes ofresistance are consistent with their internalized under-standings of the stakes and capital across their socialfields.
Reproducing and reformulating normal:children
Variations of these ideas regarding disability, normal-ity, and walking also emerged in the children'saccounts, with some notable differences. Similar toparents, the children's accounts demonstrate waysthat they place a high value on doing “the samethings” as other children, “keeping up,” and beingincluded socially:
Emily [age 13]: I think normal means that what-ever disability I have, I'm still normal becauseeven though I just have a little problem walkingand writing and stuff … I write on the computer… but even though I just have a few problemswith writing on a piece of paper, people help medo whatever I want to do and need to do andstuff … I'm just the same as the other kidsbecause I try to do everything the other kids doin my class.
Children discussed their bodies and technologies assources of capital that both improved and worsenedtheir social positionings (Lupton and Seymour,2000; Pape, Kim, and Weiner, 2002). So, forexample, using a wheelchair might have marked their
bodies negatively in fields such as school, but providedindependence and access to other forms of culturalcapital such as keeping up with peers. Walking wasseen as a positive source of cultural capital, especiallyby the four children over the age of 11. Lina (age 12),for example, conveyed the importance of being ident-ified among peers as “someone who can walk.” In thefollowing, she first discusses an imaginary girl pre-sented in a picture, and then her own situation:
Lina: She knows that she can walk, it's just thatpeople see when she uses her wheelchair thatshe maybe can't walk. She keeps having to tellpeople that, like, she CAN walk, it's just that shedoesn't.
Interviewer: What about you using a walker?
Lina: No because they see that I just use it for,like, support. I like that I get exercise. ‘Causeeverybody else walks. I don't want to be, like, aperson that doesn't walk at all.
Interviewer: Is it important to try to be like every-body else when you can?
Lina: Yeah, it's pretty important to me.
The children in the study, however, also revealed howthey identified as “disabled” and resisted negativeinterpretations of their bodies and devices. David(age 12) discussed how he would redesign his walkerto address practical issues but also as a mode of self-expression. The walker is re-imagined as more mascu-line, rather than rejected outright as a negative symbolof disability:
David: I really feel that my walker is just a wholebunch of crap because it's just not doing its jobright and keeps on breaking on me.
Interviewer: Pretend we have a magic power thatyou could invent a better walker, what would itbe like?
David: Maybe I would add booster rockets to it.One thing it could use though is differentcolour, more style, maybe some hardcore pic-tures, like a car, or a motorbike, maybe fire.
In re-imagining his walker, David creatively trans-forms symbols of masculinity (cars, motorbikes) tohis own mode of mobility. The walker, a commonsymbol of disability, is transformed into an expressionof masculinities and reinforces membership withinparticular masculine fields. For further discussion ofmasculinities and disability see also Gerschick andMiller (1995), Gibson, Young, Upshur, and McKe-ever (2007b) and Robertson (2004).
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Similarly, Emily (age 13), who used a power wheel-chair as her primary mode of mobility, spoke positivelyabout the features of her new chair. Again, some ofthese were functional while others reflected her per-sonal tastes and markers of self-expression:
I like the elevating seat. If a table's high, I can goway high. It's sort of like my elevator, exceptsmaller. I love the way that they speciallyordered the seat, what pattern I wanted. And Ilove that I got to choose the colour of the chair.
Assistive devices thus could be seen as positivemarkers of identity and extensions of the self in waysthat differed from the parent accounts. This was exem-plified by Emily early in her interview when, as part ofa rapport building exercise, she was asked, “If youcould have any super power what would youchoose?” Emily replied, “make my wheelchair havewings and fly” powerfully expressing a notion ofbody and self that included her wheelchair. She con-sidered her “techno-body” (Gibson, Upshur, Young,and McKeever, 2007a) as a single entity that she ima-gined flying. In this context, her bodily configurationwas taken for granted as given, as her-self, neithertragic nor extraordinary.
Stephen, (age 18), the oldest youth in the study,conveyed a unique perspective that reflected both apositive understanding of his bodily realities and aconcurrent recognition of his oppression. In recount-ing comments made by peers when he was in fourthgrade regarding the possibility of a “cure” for CP, hestated, “And even then I thought ‘this is just abizarre attitude’, because I don't really look forwardto a cure. I'm used to not walking. I don't pitymyself for not being able to walk, you know.” Thesecomments suggested that Stephen, like Emily, experi-enced his differences and modes of mobility as givenand ordinary. In doing so, both individuals challengeand obscure cultural constructions of normal/dis-abled, walks/wheels binaries (Thomas, 2007). Theirconstructions of self, however, occur within a domi-nant culture that marginalizes and excludes disabledpeople in ways that children become increasinglyaware of over time. Repeated exposures to stigmatiza-tion and exclusion across diverse fields exert damagingeffects that are very difficult to counter. This is appar-ent in Stephen's follow-up comments:
I've come to the conclusion that my inability towalk makes me at various levels, a parasite onsociety … My parents are saying that often itlimits people's perception of me, and makesthem rather reluctant or unsure of how toapproach me. And if that's true, that's ratherdisheartening.
The children thus conveyed much more ambivalentbeliefs about the value of walking than their parents.Through repeated exposure to dominant ideas regard-ing walking and normality, they had incorporated intotheir habitus an understanding of normal as capital.Some children reproduced some of the same ideasrelated to normality/disability that were seen in theparent interviews. The differences were, however,also telling. Children were far more likely to be accept-ing or even excited about the alternate modes of mo-bility that socially marked them as “disabled.”
DISCUSSION
A critical examination of walking
The restoration and maintenance of movement is acentral purpose of PT interventions (Cott et al,1995), and yet larger questions about hierarchicalvaluing of some forms of mobility over others, andthe effects on clients, are largely absent in the pro-fession. A critical Bourdieusian approach begins tounpack such issues by illuminating the relationshipsbetween the dominant social order and individualpractices. The study reveals how the social construc-tion of disabled bodies as deficient can perpetrate anongoing symbolic violence against disabled childrenand their parents. Symbolic violence is “a gentle vio-lence, usually imperceptible and invisible even to itsvictims, exerted for the most part through the purelysymbolic channels of communication and cognition(more precisely, misrecognition), recognition, oreven feeling” (Bourdieu, 2001). The visibility ofbodily differences and alternate modes of mobilitynot only affects the way others perceive and acttoward children with CP, it also shapes the habitusso that children and their parents come to internalizethese differences. Persons come to “know theirplace” in the social world where the meaningsattached to biological variation can appear as legiti-mate justifications of socially constructed differences(Edwards and Imrie, 2003).
The internalization of these forces manifested in avariety of dispositions and practices in the accounts.Parents' and children's narratives reflected a tacitunderstanding of the social value attached to how abody looks, moves, and mobilizes according to an ar-bitrary construction of “normal.” Bodies, abilities,and assistive devices were recognized as sources ofboth positive and negative capital that had to be mini-mized or promoted. Thus, in applying their tacitknowledge of the social order, parents did what“needs to be done” according to an internalizedlogic to address their children's differences. This
includes all the strategies and interventions oriented topromoting walking and participation in typical child-hood activities. Children's practices differed from theparents' according to their unique experiences andemerging habitus. Not only had children beenexposed to fewer fields over fewer years, but hadlived life through their impairments by virtue of theembodied experience of having been labeled asdisabled from birth. Their narratives thus reflected atension in which they simultaneously experiencedtheir techno-bodies as unexceptional and as aproblem to be overcome.
Importantly, while dominant ideologies of disabil-ity shape and constrain parents' and children's prac-tices, they do not determine them. In the data, wesaw numerous instances of participants' agency inresisting disabling discourses even while they repro-duced them. Parents' vigilance and sacrifice in ensur-ing their children were able to participate in the typicalactivities of childhood powerfully resisted social forcesthat would relegate their children to the margins. Thiswas evident in, for example, Emily's mother creatingand leading an inclusive girl guide group or David'smother's refusal to “focus on the disability.” Childrenalso resisted negative disability discourses by creativelyembracing different modes of mobility and incorporat-ing their bodies and assistive devices into positiveidentities.
These creative acts contribute to ongoing changesto the way disabled persons are viewed and positionedwithin the social order. In transforming negativecapital into positive, disabled children and familiescontribute to changing the social landscape andimproving access to participation and power insociety (Björnsdóttir and Jóhannesson, 2009). Whenpractices coalesce at a group level in terms of collectivemovements or “consciousness raising,” they can beginto change the established order (Crossley, 2001).Persons may not always be fully conscious of themechanisms of symbolic violence, but they neverthe-less respond to it with some unique and creativestrategies.
Implications for physical therapy
Critical studies focus explicitly on identifying andaddressing power and the marginalization of particulargroups. In this study, we identified how dominant dis-courses related to walking and disability were taken upby participants and mediated their practices. In sodoing, the results suggest some possible waysforward for changes in rehabilitation and PT. To beclear, we are not suggesting that physiotherapistsstop providing ambulation therapies. Ambulation has
many positive physiological, functional, and socialbenefits. Furthermore, walking in CP is not a dichot-omous outcome – a child may walk in certain situ-ations and use wheeled mobility in others (Palisano,Hanna, Rosenbaum, and Tieman, 2010; Wood andRosenbaum, 2000). What this research supports,however, is critical reflection on walking interventions,and the need to make values and beliefs part of the PTconversation at several levels. Dominant societal viewsof disability and normality are reproduced andreflected in rehabilitation programs and practices butare not fixed. PT plays a pivotal role in either perpetu-ating or changing attitudes toward walking anddisability.
PT as a healthcare field has an inherent set of tacitassumptions, rules, and goals reflecting societal normsand structuring programs and practices. Along withother goals, physical rehabilitation acts to normalizemovement patterns and maximize function. Familiesclosely link walking with PT interventions and theexistence/availability of walking therapy in and ofitself can reinforce powerful messages about disabilityand mobility to parents and children (Daudji et al,2011). Walking therapies, many of which are pre-scribed and monitored by PTs, permeate all aspectsof family life including home, school, and recreationalprograms. Because PT is understood as geared towardnormalizing the body, it functions to reinforce a“normal/ disabled” binary, even when professionalsdo not discuss walking as a goal and may evenactively discourage it. Given the powerful symbolicappeal of walking, reinforced by the very existenceof government funded rehabilitation interventions,professionals are bound to be frustrated when theyask parents to give up their “unrealistic” walkinggoals or suggest other more functional forms ofmobility.
What to do? We see a number of possibilities forchanges in clinical practice and research. Parentsand children need exposure to counter-narratives ofdisability to help them write alternative life scriptsthat do not rely on pursuing an arbitrary constructionof normal. In clinical work, children and parentsshould be provided with ongoing opportunities toreflect on, understand, and cope with their choicesand values that may be shifting. An important task isto determine how best to assist children in maintaininga positive disability identity while pursuing achievabletherapeutic goals. To assist families with these efforts,clinicians also need to develop a reflexive stance ontheir own assumptions and how these are reflected intheir practices or the programs in which theyoperate. Bottos (2003), for example, has commentedthat the current emphasis on motor “recovery” needsto be avoided because it can set children and parents
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up for unachievable expectations and feelings offailure. Countering enduring ideologies and dis-courses does not happen quickly or easily but requiresa conscious and sustained effort at multiple levels ofpractice.
Critical research in children's rehabilitation, andphysical therapy more broadly, is extremely limitedand thus offers a host of opportunities for furtherareas of inquiry. We would suggest there is a particularneed to explore how disability, the body, and problemsof “quality of life” are conceptualized, researched, andaddressed in PT. There is a sustained, and to ourminds, largely justified critique of rehabilitation prac-tices of normalization from disability scholars thathas been largely overlooked by the PT community(Finkelstein, 1998; Oliver, 1996; Wendell, 1996).Further interdisciplinary critical scholarship betweenthese traditions has the potential to enrich PT scholar-ship and contribute to positive change in the lives ofdisabled people. Work that integrates disabilitystudies and critical approaches into PT and rehabilita-tion are beginning to emerge (French and Swain,2001; Hammell, 2006; Kielhofner, 2005; Magasi,2008a, 2008b; Papadimitriou, 2008; Rioux andBach, 1994; Swain and French, 2004; Yoshida, 1993).
ACKNOWLEDGMENTS
We would like to thank the parents and children whoparticipated in the study, and the following individualswho contributed to the research: Virginia Wright,Darcy Fehlings, Nancy Young, and Patricia McKe-ever. The study was funded by a grant from theSocial Sciences and Humanities Research Council ofCanada #820080009.
Declaration of interest: The authors report noconflict of interest.
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