5 Sociology currently in physiotherapy

Any sociology of a profession like physiotherapy must try to understand the social forces and processes that shape how the profession operates, what this makes possible, and what it denies. It must ask why this, why now? But this is no simple task because in doing so, ‘physiotherapists can develop an increased sensitivity to the multiple hidden effects of practice and their unintended harms’^[1], and these might be things it is reluctant to do.

But a sociological analysis of a profession is also a ‘technically’ complex task, in part because a profession is shaped and made, not like a chair, but as a living entity, that is performed every day, and in every moment, by the people who embody it. So asking why an abstract, socially constructed entity, which has real material effects in the world, is here, and how it relates to the myriad ways people engage in health and healthcare today, is beset with complexities. Here, for instance, are some of the questions we might pose in a sociological analysis of physiotherapy:

• If the questions that prompted the formation of the profession in the 19th century have changed, are the answers also different?
• How and why did the profession rise to social prominence, and whose work did it supersede?
• What is the relationship between the profession and powerful institutions like ‘The State’, biomedicine, and capitalism?
• In what ways do social forces like power, discrimination, stigma, and privilege, manifest over time and in everyday work?
• Whose interests does the profession serve, whose voices does it privilege, and whose does it marginalise?
• What is the profession vocal around, and what is it silent on?
• How does the division of labour function in physiotherapy, and how does it favour particular social groupings over others?
• Where in the world is the profession prominent and strong, and where is it absent or only now emerging? What do these locations tell us about the discourses shaping the profession?
• What are the customs, habits, routines, and everyday rituals particular to physiotherapy?
• What beliefs and values around concepts like health, disability, movement, and independence, are physiotherapists socialised to favour?
• What kinds of relationships and interactions are customary, and how do these construct meaning?
• What are the technologies that are archetypical and commonplace to practice?
• If the profession is proclaiming new ways of working (person-centred care, evidence-based practice, telemedicine, for example), what function do these new social forces serve, and why are they only coming to prominence now?
• And what influence do the profession’s tools of social governance (laws, codes, guidelines, etc.), have in shaping social forces?
• Reading through this list of questions and prompts, it may become clear why I mentioned in the second paragraph of this chapter that, ‘you will find very few references to the material presented in this book in the physiotherapy literature’. This is not to say, of course, that sociological scholarship is entirely missing from physiotherapy. There are some really important examples cited throughout this book of physiotherapists addressing questions exactly like these. But the overwhelming sense, from reading around the sociology of healthcare and the professions, is that physiotherapy is largely absent. Some people may argue that sociology is very much a part of physiotherapy these days, perhaps citing the enormous growth of interest in the biopsychosocial model, person-centred care, or qualitative research, as examples. But while these are excellent case studies of a broadening in physiotherapy scholarship, and a subtle expansion on the profession’s historical biomechanism, there is very little about them that is really sociological.

The growth of interest in psycho-social aspects of physiotherapy practice, for instance, has been heavily underpinned by an increased interest in behavioural psychology. This is an approach that sits very comfortably within conventional biomedical notions of objective neuroscience, and measurable cause-effect responses to external stimuli, whilst also playing into neoliberal notions of personal responsibility for health and wellbeing. ^{[2][3][4][5][6][7][8]}. (This is discussed much more in Chapters 8, 9, and 10.) And although these studies often deploy the word ‘social’ as a way of shifting beyond the purely biomedical, the sociological dimensions of health are mostly portrayed as social ‘factors’ or polluting ‘variables’^[9].

This is particularly evident in the ‘soft’ behaviourism being promoted in the pain management literature; an approach which also works well to disrupt the profession’s historical affinity with so-called ‘passive’ therapies (manipulation, massage, mobilisation, etc.). Pain is no longer about ‘issues with the tissues’, and has become much more about behaviour change, personal agency and resilience, lifestyle choices, and healthy conversations ^[10]. But these are all psychological constructs, not sociological.

William Cockerham has suggested that social dimensions play only a ‘distant supporting role in studies of health and disease’, reflecting ‘the pervasiveness of the biomedical model in conceptualising sickness’ ^[11]. This situation has not been improved by the turn towards behaviourism in physiotherapy, leaving sociocultural influences on health poorly recognised, and ‘theoretically and empirically under-explored in comparison… to… biomedical aspects’ ^[12]. But;

‘If we are all different individuals acting according to the dictates of unique psychological influences, why do different people in the same social circumstances behave similarly and in ways others can understand? Clearly there is a social dimension to human existence, which requires sociological theorising to explain it’ ^[13].

Fortunately, we are seeing some awareness of this in the physiotherapy literature ^{[14][15][16][17][18][19]}, suggesting that sociological concepts are now being used to critique the taken-for-granted obviousness of approaches like the biopsychosocial, which claims to be a more holistic model of practice, but effectively hides its bio-behavioural bias. The biopsychosocial approach cannot be considered a viable ‘holistic’ model of practice for physiotherapists if it cannot effectively account for sociological paradigms ^[20][21]. But perhaps the vigour with which it has been taken up by some sections of the physiotherapy community, says something, at least, about our appetite for alternatives to the body-as-machine, which, in itself, creates an opening for social theory, if its principles can be explained in a reasonably coherent way. If Arthur Frank is right, that the social sciences help us to understand what Max Weber called ‘the fate of our times’ ^[22], then we owe it to ourselves, to physiotherapists to come, and to the people we serve, to learn something more about what they have to offer.