41 Critical theory and physiotherapy

As has been mentioned already, there has been little critical theory applied to the physiotherapy profession over the past half century, be it by physiotherapists themselves, or by sociologists interested in the health professions. Medicine and nursing have provided such rich material for anyone interested in the asymmetrical exercise of power that sociologists may have felt they can glean all that can be said critically about healthcare from these professions? And because the physiotherapy profession itself has never expressed any real interest in critical theory as a tool for self-analysis, it may have been simply ignored. But as I hope I have shown in this chapter, there is no shortage of material that physiotherapists and sociologists might sink their teeth into, if they are so inclined.

To take just a few examples: How could we better understand the reasons for the ‘whiteness’ of the Western physiotherapy profession? From a short perspective, piece on Life as a black physiotherapist for the Chartered Society of Physiotherapy’s Frontline magazine recently, Warren Caffrey wrote that ‘as I mature within my career I realise I’ve had to work incredibly hard to fit into a predominantly white middle-class profession’ ^[1]. This is not the first time that the profession has been described this way. Gillian Yeowell said something similar in 2013 ^[2], while commenting on the lack of diversity and pace of change within the profession. Although 32.4% of the American population self-identify as African American, Hispanic, or Latino, only 1.2% of American Physical Therapy Association members are African American, and 2.4% Hispanic or Latino. 91.7% of APTA members, however, are white ^[3]. Proportions of racialised people in other professional bodies in the Global North are not that dissimilar.

We might also ask why it is that a female dominated profession has always employed supposedly ‘male’ virtues of detachment, individuality, objectivity, reductionism, technical mastery, autonomy, domination, and value neutrality, and eschewed historically ‘female’ approaches to care like empathy, relationships, mutuality, community, and subjectivity? Celia Davies has argued that masculine approaches to healthcare would be simply incompatible with nursing ^[4]. So, what role does the gender of the physiotherapy profession play in shaping its philosophy of practice? Is it, as Arlie Hochschild suggested in 1983, simply that the supposedly masculine virtues of cognition, intellect and reason were consistently valued above feelings and emotions; perhaps because they appear an impediment to ‘getting things done’ ^[5]? Or is it that the profession’s founding mothers wanted to offer women a different image of healthcare than their ‘angelic’ caring sisters? Julius Sim, writing in 1985, saw physiotherapists as sitting ‘between the archetypal elite male role of the doctor and the female role of the nurse’, being both ‘curative and caring’. For Sim, this ‘sex-role duality’ may ‘give rise to a feeling of conflict among female physiotherapists’ (but not, it seems, the male physiotherapists)^[6]. If physiotherapists are now looking to move away from their historical affinity with the body-as-machine, will the decision to embrace greater care also mean embracing lower social capital, or does the profession see virtue in fighting the stigmatising social structures that constantly undervalue ‘women’s’ work? And, does it follow that holding supposedly ‘feminine’ virtues automatically sacrifices ‘masculine’ values and beliefs?

One of the casualties of physiotherapy’s historically reductive approach to the body has been its relationship with those we are supposed to serve. Historically, physiotherapists have objectified bodies by focusing not on the person but on the faulty body part, and they have deliberately analysed movement and function dispassionately so as to detach the person from their context ^[7]. But in doing this, they replicate the kinds of objectifying gaze that women have fought so hard against for years. As White suggests, ‘By locating illness within the woman’s biological body, medicine helps perpetuate a sleight of hand which effectively ignores the social reasons for women’s ongoing oppression’ ^[8]. We might ask whether physiotherapists are happy being on the side of the oppressor? This is a question that has been raised within the disability community before ^[9], and in more recent times in the context of the social determinants, that physiotherapists are so dependent upon for work, but apparently have no interest in engaging with critically.

Many of the impairments and disabilities that provide work for physiotherapists, for instance, are created through dangerous working conditions, sporting injuries, and by the violence and wars that have been ‘constantly provoked by the North, either directly or indirectly, in the struggle over the control of minerals, oil and other economic resources’ ^[10]. The ability to ignore these determinants, and situate therapy within the body of the individual patient is an almost unique power available only to a very elite group of ‘Northern’ specialists ^[11][12][13]. Neville Chiavaroli, Julia Blitz, and Jennifer Cleland have recently suggested that it is only majority groups, like doctors, nurses, and physiotherapists, that have the ability to eliminate ‘difficult causes’ from their scope of interest ^[14]. They can do this because they exist, and uphold, a society that has sufficient power and economic resources to determine ‘[w]hat gets considered under diversity’ (ibid).

We might ask why it is that so few disabled students graduate from physiotherapy programmes. Alfiya Battalova’s research team recently argued that the orthodox, patriarchal professions encourage their practitioners to be fit and strong, non-disabled and free from significant disability, despite that fact that this is the population that it putatively serves ^[15]. Nurses, midwives, and social workers, purposefully look for caring attitudes in their students, and many of the mental health disciplines expect their practitioners to be actively engaging with their own psychic development. How might physiotherapy be different if the profession did not expect its students to represent non-disabled norms, but instead actively engaged in ‘dissecting their own power and privilege’ ^[16]? Or by expecting its students and practitioners to have some first-hand experience of significant injury, illness, or disability as a desirable attribute of training and practice?

In Hazel Horobin’s doctoral study of Indian physiotherapists studying a masters degree at an English university ^[17], Horobin suggested that physiotherapists have historically used their clinical reasoning and professional judgement to bring ‘authority and prowess’ to the profession (ibid). And the heavy reliance on biomedicine has worked well for practitioners because it has enabled physiotherapists ‘to wield power’ over clients (ibid). But her study showed that Western-trained physiotherapists all too easily see ‘other cultures as lesser’, and label ‘other practices as ‘deficient’’ (ibid). Tellingly, perhaps, the tutors ‘that most need to alter their perspectives appear[ed] the most resistant to do so’ (ibid). Crucially, ‘even whilst the programme [was] apparently benign, cultural oppression [was] present, unrecognised by participants and staff alike’ (ibid). Here, then, we have the crux of a critical theory perspective on contemporary physiotherapy: it is not that physiotherapy cannot see minorities, after all, it is entirely dependent on the construction of some people as ‘others’. Rather, the problem physiotherapy currently faces is that it cannot see itself. And its practices are deeply rooted in occidental privilege and prestige.

The American writer and art critic Rebecca Solnit, once joked that museums love artists the way that taxidermists love deer ^[18] because ‘something of that desire to secure, to stabilize, to render certain and definite the open-ended, nebulous, and adventurous work of artists is present in many who work in that confinement sometimes called the art world’ (ibid). We could perhaps draw a similar comparison with physiotherapy, which loves to stabilise and render certainty from clinical situations, in which there is often very little. Critical theory has been very dubious of functionalist claims by the health professionals themselves that they are altruistic and public-spirited. Instead, they see practices like hierarchical ordering, normalisation, and othering, as endlessly inventive ways for elite professionals, like physiotherapists, to benefit from identifying people as ‘other’, under the cloak of objectivist science ^[19][20]. As Merata Mita argued, ‘The ones doing the looking are [always] giving themselves the power to define’ ^[21]. But as Kylie Smith and Thomas Foth recently argued, to do this is ‘to get one’s epoch wrong’ ^[22].

Gender, colonisation, and disability are but three of the many axes through which professions like physiotherapy assert and maintain their social privilege. Critical theorists have argued for more than 50 years that the elite professions have been able to do this because they have grounded their work in hegemonic Western values. As Ludwig Fleck reflected in 1935; ‘science reduces the complexities of cultural influences… to produce scientific facts’ ^[23]. Whether professions like physiotherapy will be allowed to continue this practice into the 21st century, remains to be seen.