74 A critical sociology of physiotherapy

This question of how would we know was really the inspiration for this book. In an effort to unpack the discourses shaping physiotherapy, I was looking to add sociological depth to our understanding of the profession, and build on the critical historical analysis in EoP. My belief is that by understanding physiotherapy sociologically, we will be better able to make sense of the profession’s past, present, and future. In very broad terms, I think this book explains why so many physiotherapists feel that healthcare is getting away from them, and why orthodox healthcare feels as if it has lost connection with 21st century society.

The sociology of the professions tells us that part of the reason for this is the gradual unbundling of all professions’ claims to goodness and expertise. And that this is de-centring even the most elite and established disciplines. Orthodox health professions, like physiotherapy, are increasingly becoming only one among many ways in which people now engage in health and wellbeing.

Added to this, neoliberal economic reforms have also been building on late capitalist atomisation, globalisation, and new forms of technological disruption, to turn healthcare into virgin territory for innovators, speculators, and investors. Having said that, the biggest initial disruptions for physiotherapists may not come from digital technologies like AI, robotics, and natural language processing, because healthcare speculators currently have their eye only on the money to be made from healthcare’s low-hanging fruit: technologies like image processing, routine surgery, genetic screening, drug development, and prescribing ^[1][2]. But physiotherapists are certainly open to widespread late capitalist professional work reconfiguration, routinisation, role delegation, and decomposition ^[3], and so cannot assume that they will be immune from disruption.

Physiotherapists have been guilty in the past of ignoring societal shifts, and many of the profession’s present dilemmas have, in many ways, been brought about by physiotherapists’ intransigence ^[4]. Sarah Barradell has suggested that physiotherapists have ‘lacked the careful systematic criticality that can be observed in some other health professions, such as nursing’ ^[5][6][7][8]. Arthur Frank has suggested that this is a common problem because ‘our times condition people to lack… a reflective sense of how engagements in their own practices weave the nets that impair their freedom… We ourselves weave the nets that hold us’ ^[9].

Physiotherapists have long grounded their practice in the idea of the body-as-machine, believing that thorough knowledge of the pure sciences, the application of objective tests and measures, and a dispassionate approach to the patient, they would engender trust in the therapist’s touch and gaze ^[10][11]. What was never acknowledged, though, was that these approaches were underpinned by androcentric bias, the othering of colonisation, and the normalising practices that perpetuate disability ^[12]. They have been strategies utilised and promoted because they helped physiotherapists enclose certain physical therapies and advance the profession’s pursuit of prestige and social capital (Chapters 3 and 5). They were used to project the notion of physiotherapy expertise, and deliberately created an asymmetrical power relationship with patients (Chapter 5). And they allowed physiotherapists to ignore the cultural, economic, political, spiritual, and social conditions shaping people’s health so that the therapist could appear politically neutral and retain its favoured status with the state (Chapters 6 and 7).

But perhaps the most pernicious effect of physiotherapy’s adoption of the body-as-machine, has been its ability to hide the professogenic effects of physiotherapy from the therapists themselves. Because physiotherapists are not given the vocabulary or the analytical tools to ‘perceive’ the wider world of healthcare, they do not see how their acts of choosing carry an implicit rejection of ‘other’ ways of understanding health and illness. And because physiotherapy is a performative act ^[13], it requires the same biomechanical bias to be invented anew each day by people perpetuating the very ways of thinking and practicing that have created the problems they are now experiencing. This is the physiotherapy paradox discussed in EoP. The genius and the most serious latent danger of physiotherapy’s historical approach to health, then, may be its ability to convince therapists that their work is inherently good, and their expertise remains valid, whilst almost completely shielding the deleterious effects of their approach from view. So, what physiotherapists may be experiencing now, may be the social effects of Western healthcare bubbling to the surface in a way that cannot be ignored, nor easily explained. As Chijioke Nze, Elorm Avakame, Olusola Ayankola, and Jamaji Nwanaji-Enwerem argue, these issues are now in ‘our lane too’ ^[14].

I believe this book shows that sociology can bring a much-needed critical perspective to bear here because sociologists are much more objective when it comes to the professions’ claims to goodness and expertise. Sociologists assume that the professions, on their own, are unlikely to consider the unintended and problematic issues arising from their practice because to do so might harm their power and prestige. Jenni Aittokallio and Anna Ilona Rajala recently argued for ‘a greater understanding of the complex sociology of rehabilitation’ ^[15], including an ’Understanding of how power relationships, inequality, inequity, injustice, ableism, racism, ageism, sexism, heteronormativity, geography, and demography operate in a constellation around person-centeredness’ (ibid). So, if critical thinking, as it is applied here, implies ‘a sense of self-appraisal; re-assessing where we have come from, where we are at and where we might be going’ ^[16], then there is surely a place for more sociologically-informed criticality in the professions now. But, as well as using sociology to understand the problems now facing the profession, we can also use sociology to analyse how physiotherapists are responding. This becomes vitally important if we want to know if we are on the right track.

Given the depth of critique directed at biomedicine over the last seven decades, one of the important issues now facing contemporary physiotherapy is how the profession shapes its professional identity into the future. Should it attempt to secure its cultural capital through slavish adherence to the dominant, but increasingly de-centred, biomedical discourse? Or strike out on its own, in the hope of defining new cultural processes and artefacts that justify its distinctive work and interests? Sociology shows that this is not simply a question of what is best for the profession. Should women, queer, disabled and racialised people simply absorb the cultural artefacts that are associated with biomedicine (normalisation, othering, objective detachment, marginalisation, etc.), so that physiotherapy can secure social privilege for itself? And what are the costs for the profession if they choose not to do so? Analysing the ways that physiotherapists are attempting to shape the profession can, therefore, provide some useful insights into the discourses that are having the greatest bearing on their thoughts about the future.