38 Healthcare and disability

It would not be unreasonable to think, given physiotherapy’s long-held interest in disability, that Critical Disability Studies (CDS) would occupy a prominent place in professional literature, thinking, training, and practice. But CDS plays almost no part in the profession’s scholarship. There are many studies looking at the physical dimensions of disability from a biomedical perspective, and in recent years, attention has turned to the International Classification of Functioning, Disability and Health (ICF) as a way to assess, measure and categorise individual and population health and disability. But there is little critical research here. There is little here that looks at the relationships of power that shape physiotherapeutic practices around disability, or the asymmetrical relationships between therapists and service users ^[1]. CDS plays a significant role in rehabilitation studies, and a number of physiotherapists are prominent in this space ^{[2][3][4][5][6][7][8][9][10][11][12][13][14]}, but much of this work skirts around the question of physiotherapy’s role as a discipline. And so, as with critical gender and race studies, we are left wondering how structural power has shaped physiotherapy and disability.

Given how much disability is socially produced (through war, poor public infrastructure, dangerous workplaces, etc.), it is perhaps surprising that sociologists only began, in the 1980s, to give serious attention to the role health professionals have played in shaping the idea of disability as a social construct. Paul Abberley’s study of disability caused by industrial workplaces ^[15], paved the way for a radically different understanding of disability, that spoke directly to the unquestioned power of medicine.

The medical model of disability had monopolised how health professionals had been trained to think about disability for decades before Mike Oliver, and a range of Marxian-inspired critical disability activists and researchers, developed the social model ^{[16][17][18][19]}. The medical approach to disability — long promoted by Western medical professions like physiotherapy — ‘sited disability as a personal tragedy, biological deficiency, and psychical trauma ^[20]. Disability represented a ‘lack’. Orthodox health professionals used statistics and standards to argue disability was a break from the norm, using this as a justification for their therapeutic interventions. They labelled disabled people as pathological, deviant and aberrant, and as bioeconomic ‘loss’ ^[21], and in doing so, created a binary framework which made all disabled people ‘other’ ^[22][23]. The medical model saw health and disability as the responsibility of the individual, and bypassed serious consideration of the cultural, economic, political, and social worlds that people lived within ^[24][25]. Therapies were directed at individual behaviour change strategies, efforts to re-align people’s perceptions of disability, or strategies of ‘mainstreaming’ disability ^[26].

At the heart of the social model was a critique of the ‘medicalisation’ of disability by doctors and nurses, occupational therapists, and physiotherapists ^{[27][28][29][30]}. It argued that it was not the presence of an impairment that caused disability, but the existence of disabling environments, attitudes, and social structures that created disability. Disability was a function of people’s discrimination and the creation of social barriers. It was not a ‘lack’, but an expression of human diversity and something to be embraced; a form of resilience and resourcefulness to be celebrated.

The social model ‘unearthed the structural foundations of oppression faced by disabled people’ ^[31][32], and was a powerful response to a long history of stigmatising labelling, enforced institutionalisation, rehabilitation, medical and surgical procedures, and the enormous social pressure to fit in and be ‘normal’, experienced by ‘anomalously embodied’ people ^[33][34][35]. It ‘sever[ed] the causal link between the body and disability’ and ‘relocated disability to social, cultural, economic and political registers’ ^[36]. Advocates sought to address the myriad disabling social forces faced by disabled people, including the complicity of health professionals like physiotherapists, in working to meet the demands of industrial capitalism for ‘fit’ workers ^[37].

But what the social model also showed was that disability represented more than just a form of anomalous embodiment. Rather, it was a proxy for kinds of bodies and people that we had come to believe should not exist, were ‘unlike’ us, or needed assimilation back into the majoritarian norm ^[38]. Disability has been socially constructed as something that societies perceive to be frightening, monstrous, disturbing, out of control, disorderly, incomplete or disruptive ^[39][40]. Disability then cannot be seen as a fixed (in)capacity of the body or mind, but rather as a constantly moving screen onto which society projects its fears and anxieties ^[41]. And because of this, ‘[t]he dominant ableist self is ready and willing to bring disabled people back into the norm (re/habilitate, educate) or banish them (cure, segregate) from its ghostly centre’ ^[42].

Susannah Mintz suggested that these practices were not about identifying people’s needs so that therapy and rehabilitation could make disabled people’s lives better, ‘but rather about a need to guarantee the privileged status’ of the non-disabled, ‘that, in its turn, emerges from fears about the fragility and unpredictability of embodied identities’ ^[43]. The work of physiotherapists and other rehabilitation specialists is therefore akin to the struggle with abjection, explored by Julia Kristeva ^[44], and the emotional labour of ‘body work’ ^[45], in which a profession helps to resolve some of our social anxieties around that which is alien and strange. Physiotherapists and others help to mask the ‘huge problem’ we have in society with disabled people who disrupt our image of people who, we believe, should always be in control of their bodies ^[46]. Rehabilitating bodies is about integrating the disabled person into society without, at the same time, normalising the idea of disability itself ^[47].

This act of existential ‘othering’ feeds, and is fed by, Western attitudes to economics. Raewyn Connell, for example, ties rehabilitation closely to capitalism, arguing that there are two real categories of bodies operating in the West: ‘those whose labour generates profit, and those whose labour does not’ ^[48]. People’s ability to contribute to the labour market is the principle determinant of their ‘normality’, and enabling ‘labour market participation becomes a key form of treatment or rehabilitation’ (ibid). And Deborah Lupton has suggested that, ‘the institution of medicine exists to attempt to ensure that the population remains healthy enough to contribute to the economic system as workers and consumers’ ^[49].

What is critically absent from this approach, though, is the ‘meaningful integration of difference’ ^[50], that would see different bodies, ways of moving, functions and capabilities as the norm. So, for example, Mitchell and Snyder have highlighted how approaches to accessibility — seemingly so benign as a way to adopt empowering attitudes and practices towards disability — should be viewed more critically. Kerbs suitable for wheelchairs, audible signs at pedestrian crossings, and lighting-based signalling systems in homes, may be seen as enabling, but these do not fundamentally change society’s demeaning attitude towards anomalous embodiment. Rather, they allow us to integrate disability into our ‘normative frameworks’, without ‘significantly upset[ing] or disrupt[ing] environments already suited to a narrow range of abilities’ (ibid).

CDS scholars have worked to call our attitude towards disability ‘disablism’, to give it equivalence with heterosexism and racism. Carol Thomas defined disablism as a form ‘of social oppression involving the social imposition of restrictions of activity on people with impairments and the socially engendered undermining of their psycho-emotional well being’ ^[51]. Critical disability activists have shown that disablism can take many forms, some of which appear on the surface to promote positive messages about disability. Displays of disabled people using ‘lavish prosthetic enhancement[s]’ ^[52], or films like the X-Men series, showing ‘superpower overcompensation’ (ibid) point to a neoliberal, transhuman future, when people can supposedly make informed choices about their preferred level of (dis)ability; ‘Such systems enshrine bodies that are different yet enabled enough to ask nothing of their crumbling, obstruction-ridden infrastructure, continually naturalised as environments made for most but (unfortunately) not all bodies’ (ibid). And grand concepts like ‘movement’ become critically important here because they can all-too-easily flatten out the ‘affective, aesthetic and functional experiences’ of disabled people, losing any rights disabled people have to fight against the material conditions of their oppression (ibid).