2 Why do we need more social theory in physiotherapy?

Perhaps the first thing to establish is that the kinds of sociology this book deals with bears little resemblance to the kinds of ‘social’ questions physiotherapists ask in their patient assessments. We are not talking here about whether the patient is currently working, whether they live alone, or whether they have stairs at home. Nor are we talking about the kinds of social factors that are frequently confused for behaviours, cognitions, learning, or personal experiences. This is very common in the recent physiotherapy literature on the biopsychosocial model, for example, where personal attitudes, beliefs, and emotions are called ‘social’ because they place abstract psychological concepts into the real world. But they are still fundamentally psychological constructs.

The kind of sociology we are dealing with here concerns a very different set of principles. Its interest is in social groups, and individuals within groups. It sees reality as constructed by groups. Health and illness are seen as social constructs, not as a biological reality or the expression of an individual mind. Sociologists are interested in the way language constructs reality, and the social structures and forces that shape who we are, what we can say and do. And, in the context of this book, they are interested in what makes institutions like the professions socially possible. Their focus is on professional power and boundaries; the role of professions in enhancing social order or acting as governmental arms of the state; concepts like work, encroachment, and wage slavery; and debates around the future of all professions in the new industrial revolution.

From a sociological perspective, then, the first reason why physiotherapists should have at least some understanding of social theory, is because physiotherapy is an entirely social construct. It is not a physical object like a pen or a cup. You cannot pick it up and put it in your pocket. It is an idea, created by people and ‘performed’ every day based on a set of loosely agreed social conventions. Physiotherapy is what Jason Turner called a ‘folk institution’ ^[1]; a part of the apparatus of society, and one that is no more fixed and immutable than football or the weather. As with all professional practices, physiotherapy ‘is a social phenomenon’, and ’is inherently situated and temporally located in local settings, lifeworlds and systems’ ^[2].

Because it is a social construct, it takes a lot of artifice, cunning, and hard work to corral a diffuse collection of concepts, strategies, practices, customs, beliefs, and objects about health and the body, medicine, disease and disability, movement and function, never mind people, and mould them into a coherent whole and call it a profession. Physiotherapy is a social construct in the same way that medicine, work, health, and gender are. And far from being a stable constant, the profession’s identity is in perpetual motion, with the changing ways its supporting concepts deform and reform. It is different today to the way it was yesterday, and it is different here than it is over there.

The fluidity of the profession is only one dimension to be considered, though because there are also many different ways to understand the professions sociologically. There are schools of thought that see the professions as institutions bringing order to society (functionalism); as the product of industrial capitalism (Marxism), or entrenched gender relations (feminism); as the product of territorial disputes (neo-Weberianism), or as the positive result of circulating power relations (postmodernism). Symbolic interactionists see the professions as formed in the relationships between people in society, and critical realists aim to strike a balance between social structures and professional ‘agency’. Each of these has something interesting to say about physiotherapy, and we will look at them all shortly. (Agency in sociology refers to the ability of individuals or groups to act independently and make their own decisions. It is often contrasted with the idea of ‘structure’, which refers to conditions that shape what people can think and do. These ideas will be unpacked in much more detail later in the book.)

Social theories are particularly useful ways to understand the professions because they challenge some of the mythologies that the professions themselves have constructed. For instance, most professions promote the idea that their history has been one of gradual progress from struggle and strategic alliance, to maturity and autonomy. Over the last century, sociologists have shown that this is a fiction created by the professions themselves, as a necessary part of demonstrating that they are ‘true’ professions (more on this in Chapter 2). But few sociologists subscribe to this view any more. Rather than the authors of their own professional destinies, sociologists see the professions as the outcome of social forces. Societies make the professions, not the other way around. This conceptual shift is important because it helps us think differently about the pressures now being faced by professions like physiotherapy. If professions are the ‘effect’ of social change, then their future will depend on their ability to understand the social forces that shape them. And it will be hard to do this without a reasonable understanding of social theory.

Sociology can be useful, for instance, in explaining why it was that the professions emerged in the first place. Because not only the health professions, but all of the professions are all quite recent social inventions. The health professions, as we know them today, have really only existed for just over a century. So, for the vast span of human history, societies have tended to people’s health and illness, injury and rehabilitation, without any recourse to an expert, specialist, or regulated practitioner. Linda Jones puts it this way;

‘In most of the Western world the healthcare system as we know it today — with its biomedical focus, its hierarchy of training health professionals and complex primary, secondary and tertiary facilities for cure and care — came fully into being only in the 20th century. In Britain some health occupations, such as health visiting, only came into existence after 1900, and the idea of a national, coordinated service to treat illness was a product of the 1940s. The notion of a single medical ‘profession’, with a virtual monopoly of medical practice, dates from the later 19th century in Britain; the USA monopoly status for doctors came much later. It was only in the 1880s that ‘germ theory’ began to be accepted, and it took another 30 years for it to become the orthodox way of thinking about disease among professional health workers in Europe. Finally, it was about 200 years ago in the West that people began to think about bodies as collections of discrete cells and membranes rather than mainly undifferentiated ‘flesh’ and organs. In other words, the ways of thinking about and organising healthcare that we take for granted are actually quite ‘new’ and distinctive ^[3].

It follows then that if the professions are a relatively recent social construct, we should ask: why they came into existence at all, and why now? As Albert Schütz argued in 1946, ‘Knowledge is socially distributed and the mechanism of this distribution can be made the subject matter of a sociological discipline’ ^[4]. What is more, the professions are only one of a number of ways of organising society and getting things done. People have organised things like healthcare, education, law and order, food production, labour, leisure, building, faith, finances, and government, in all sorts of ways around the world over the last 12,000 years, and only the smallest fraction of this work has involved professionals. So, we should ask how, of the thousands of different ways the physical therapies could have manifested over the last century or so, did we arrive at a point where a profession like physiotherapy has an effective monopoly over the orthodox provision of physical rehabilitation services in many high-income countries around the world? How is it possible that a group of practitioners, with relatively modest claims to therapeutic efficacy, can become the world’s third-largest profession allied to medicine; have 650,000 registered practitioners; have its status entrenched in law, and receive substantial subsidies for training and practice; and have secured enormous social prestige?

The answers to questions like these have proven elusive not only to physiotherapists, but to most professionals in the past. Part of the problem is that our professions are often so familiar to us that we struggle to be objective. Katherine Shepard and her co-researchers found this in their 1999 paper Describing expert practice in physical therapy ^[5]. The team undertook an enormous eight-year study into the theoretical frameworks underpinning physiotherapy, but it took three non-physiotherapy ‘consultants’ to show them that they were taking some of the most obvious things for granted;

‘… Because it was so obvious to us as physical therapists what the experts were actually doing with the patients, such as performing mobilisation techniques teaching functional activities, we simply forgot to record and speak to movement and task data. Because our consultants are from outside the field of physical therapy, what we saw the physical therapists doing with the patients on videotape was new and quite fascinating to them, and they immediately pointed out what we have missed’ (ibid).

Canadian physiotherapist and educator Dave Walton found something similar in his 2018 Canada-wide study of therapists’ perceptions of the profession. Walton’s data indicated that physiotherapists had been learning, practicing, and thinking in much the same way for decades, but had almost no understanding why ^[6]. The physiotherapists in the study did not really know what physiotherapy was, which is strange because in EoP I argued that the profession is actually based upon some very straightforward principles. And quite obviously the principles that underpin physiotherapy must — at least on a tacit level — be understood by members of the profession because physiotherapy practice around the world shows remarkable internal consistency. So, there must be at least some understanding of what defines our physiotherapy-ness. What Dave Walton’s work shows, then, echoes one of the key findings of EoP: that the true nature of the profession eludes physiotherapists because most practitioners are never given the tools to know how to make sense of it.

The absence of a firm appreciation for the way physiotherapy is socially constructed has led many to overstate the profession’s distinctiveness, and has underpinned the drive for greater professional autonomy. In a recent article asking What Is Physiotherapy, and Where Are We Heading?, Tori Smedal and Bente Elisabeth Bassøe Gjelsvik suggest that; ‘A person seeks the expertise of a physiotherapist because he/she has experienced a negative change in body function and thereby the ability to use his/her body as before, leading to functional challenges for movement control and activity’ ^[7]. Whilst this seems a reasonable explanation of contemporary physiotherapy, it does overstate the power of physiotherapists in determining how people act in society. It seems to suggest that “people come to me because I’m skilled and knowledgeable in certain things”, which may be true on one level, but it also ignores the many other reasons why people engage a physiotherapist. Perhaps they were referred by a doctor or insurer, or because it was a physiotherapist that appeared at their bedside in hospital, or because they had the nicest website, were the nearest person to the patient’s home, or were the only practitioner available this week? Thinking about healthcare from a profession-first perspective undermines our claims to be person-centred. It encourages physiotherapists to think that professional progress entails greater autonomy and separation, rather than collaboration and social activism. And it perpetuates a myth that the profession is in control of its own destiny. My contention is that a good understanding of social theory would make this kind of solipsistic thinking less likely.

This mythology encourages physiotherapists to believe their profession should have a singular, coherent, and uniform identity. But this can lead to frustration when we realise that, try as we might, we cannot put our finger on exactly what the profession is, and that it is much harder to capture than we first thought. We know physiotherapy is not fully evident in a lot of our research because much of that is devoted to testing discrete aspects of practice, rather than physiotherapy as a concept. And we know it is not in our textbooks because so often real practice defies simple explanation. It is not in the school curricula because we know that many people have to do a lot of work after they graduate to become deliberate and effective clinicians. And it is not in our scopes of practice or the definitions offered by our professional bodies because these only speak about physiotherapy in the most generic terms. We might say it is in the hands and the stories of the therapists themselves, but very few personal accounts of physiotherapy have ever been written, and translating the non-verbal work of therapy is often impossibly hard. So, where is this ‘physiotherapy’ to be found?

The reality is that physiotherapy resides in all of these places, and more besides; too many perhaps to comprehend with the tools that physiotherapists are currently equipped with. What we need are approaches that are designed to help us understand physiotherapy as it is in real life; occupying multiple social settings, and constructed by myriad forces and individuals across many different locations, all at the same time. But while the kind of scholarship needed to develop this level of understanding has been lavished on medicine in the past, much less attention has been paid to the professions allied to medicine. As Jonathan Gabe suggested about nursing; ‘there has been much less consensus among sociologists, and perhaps in society generally, about… the validity of nursing’s claim to be a profession’ ^[8]. But even the literature on the sociology of nursing looks like a vast treasure trove by comparison with the handful of studies exploring the sociology of physiotherapy.

This would be less concerning, perhaps, if physiotherapists didn’t at the same time claim a grand social mandate. But when organisations like the American Physical Therapy Association claims that their vision is for the profession to ‘transform society’ ^[9], and play ’an important role in supporting, maintaining and enhancing the physical activity level for better health on individual, group and societal levels’ ^[10], one would assume such claims were accompanied by a strong social theory. But this is not the case.

Historically, physiotherapists have been reluctant to think of their profession as a fundamentally social entity, anxious, perhaps, not to stray too far from a focus on the body of the person in front of them. Edgar Burns suggests this is common among other Anglo-American professionals, who have often sought ‘to bracket out the statutory space created for them and within which they enjoy significant privileges’ ^[11]. Physiotherapists certainly aren’t alone in being highly dependent on the patronage of powerful elites, like the medical profession and the state, whilst at the same time claiming to be autonomous. And physiotherapists are certainly not the only health professional claiming to be innately apolitical and asocial.

Given all the debates about the subordination of nursing knowledge and the gendering of caring, for instance, one could be forgiven for thinking that the nursing profession would be steeped in political rhetoric. But a number of authors have argued that the social dimensions of nursing rarely extend beyond the physical aspects of patient care and patient’s home surroundings ^[12]. In a study led by Iben Munksgaard Ravn into the visual representations of nursing in Norwegian and Danish journals, the authors showed that there was a ‘tendency in the nursing and research literature to represent nursing as an unchanging phenomenon untouched by developments in society and politically decontextualised’ ^[13]. This sentiment echoes the work of other nursing sociologists who have argued that the majority of nursing theories have paid little attention to the political dimensions of practice ^{[14][15][16][17]}. So, physiotherapy is by no means alone in bracketing out the political and the social dimensions of its work.

But physiotherapy certainly does appear to go to quite extraordinary lengths to maintain its indifference to sociology. In the course of writing this book, I spoke to dozens of physiotherapists from all over the world, and not one single person told me that they had had any exposure to social theory as part of their pre- or post-graduation training. Of course there are exceptions, but over the years I’ve come across physiotherapists who think that social theories have never really been part of physiotherapy, and it is not really a ‘political’ profession anyway. Some argued that while they had no problem with the sociology, per se, physiotherapy was already too full, too complex, and too diverse to accommodate other perspectives, (as if they weren’t already present anyway).

Michael Traynor has suggested that nurses have such a strong ‘orientation towards ‘usefulness’’ that this ‘limits the role of theory to dealing with the status quo and denies its radical possibilities” ^[18]. In physiotherapy, there appears to be a similar scepticism towards theory in general, underpinned by the profession’s long-standing belief that physiotherapists are “practical people”. This helps craft the image of the physiotherapist as a dynamic, go-getting practitioner, but it also hampers our ability to develop the profession in thoughtful, theoretically robust ways; to anticipate change; to prepare students for future practice; or to know how to adapt in any other way than by being simply reactive. Physiotherapy is awash with important social phenomena, but perhaps the way that physiotherapists construct their professional identity actively obstructs the ‘demonstrable and latent capacity of social and sociological theory to guide, shape and inform research, education and practice’ ^[19]?

Physiotherapy needs social theories more than ever now because the social world around the profession is changing so fast. The professions in general are such a familiar part of our everyday lives that we assume they have always been here and will endure. But as I argued earlier, the professions are a recent invention, and there is growing evidence from around the world that attitudes towards expertise and orthodox authority are changing. Edgar Burns wrote recently that, ‘The richer parts of the world have come to regard professions as indispensable to civic and general well-being and essential to how modern societies operate’, but a ‘rapidly globalising and connecting world society’, and ‘the digital technology revolution’, are marking the urgent need ‘to rethink the role and function of professions’ ^[20]. This echoes Daniel and Richard Susskind, who suggested that;

‘Professionals play such a central role in our lives that we can barely imagine different ways of tackling the problems that they sort out for us. But the professions are not immutable. They are an artefact that we have built to meet a particular set of needs in a print-based industrial society as we progress into a technology-based Internet society, however, we claim that the professions in their current form will no longer be the best answer to those needs. To pick out a few of their shortcomings—we cannot afford them, they are often antiquated, the expertise of the best is enjoyed only by a few, and their workings are not transparent. For these and other reasons, we believe today’s professions should and will be displaced by feasible alternatives’ ^[21].

The statement that ‘we cannot afford them, they are often antiquated, the expertise of the best is enjoyed only by a few, and their workings are not transparent’, bears repeating, because in various ways, over the course of this book, I will argue that this critique applies very much to contemporary physiotherapy. The seismic shifts now taking place in society are affecting ‘how knowledge is generated, accessed, distributed, resisted, authorised, applied and mis-applied, more and more in real time—for both individuals and at population levels’, and that these ‘will change decision-making dramatically in the coming decades with all sorts of unexpected consequences’ ^[22].

So, we need some help from social theories because, quite frankly, our professional leaders are struggling to know what to do. Gail Jensen’s writing team wrote recently that;

‘The lag in therapy education strategies that will prepare students for rapid change may be due in part to current leadership, including faculty and practitioners who are just catching up with the fact that apparently subtle societal changes have the power to dramatically affect physical therapy practice and are doing so at an accelerating rate’ ^[23].

We need social theories because it is becoming increasingly clear that the kinds of problems now facing the profession cannot be answered with more clinical trials and evidence-based practice. We have known for many decades that quantitative research has a poor track record of addressing the big, society-level health questions. This is because, ‘quantitative researchers have largely relied on a kind of empiricism whereby their data is presented as a set of statistical correlations without any attempt to provide a detailed theoretical engagement with their topic’ ^[24]. But it would also be wrong to place too much faith in the kinds of humanistic, behavioural, phenomenological, and relational scholarship that have emerged within healthcare (and latterly physiotherapy) in recent years. The kinds of social questions now being thrown up by today’s globalised, neoliberal, digitally mediated, precarious, and post-binary societies, cannot be addressed with the experiential, subjective, qualitative research, which all too often says little about the social conditions that shape what is possible for people to think and do. The questions now being asked of the profession are very different from the ones that once prompted the creation and organisation of the physiotherapy profession a century or more ago. It remains to be seen if physiotherapy still represents one of the answers.

If I were to summarise my argument thus far, it would be that an understanding of sociology will be vital in the coming years if we are going to better understanding the profession’s past, present, and future. Physiotherapy is awash with sociological concepts and principles, but these are mostly hiding in plain sight because physiotherapists have never equipped themselves with the tools and the vocabulary to interrogate them well. Edgar Burns suggests that ‘a ‘more of the same’ view of professions will not speak to present dilemmas and issues of performance. Even less will it prepare new thinking to face the future’ ^[25]), and I believe this is a message worth heeding. Mostly, I believe sociology can give us new and powerful tools to analyse who we are, what defines our work, who we serve, and why. But before we delve too deeply into these questions, we should know more about the tools we will be using. So, what is the sociology of the professions, where does it come from, and what does it have to say about the world of healthcare?