55 Foucault, the professions, and the state

Over a roughly 20-year writing period between 1961 and his death in 1984, Michel Foucault revolutionised the study of Western society, and especially the role that experts and professionals played in its machinery. The first decade of Foucault’s writing showed that what we had come to believe as the truth had shifted over time, and so different kinds of knowledge were better understood as ‘discourses’ that worked to bring about certain ends, rather than bald ‘facts’ that could be discovered through scientific investigation. Foucault was interested in what truths did, not how they could be captured and categorised. The concept of ‘reason’ that emerged from the Enlightenment, for instance, made it possible for some authority figures in society to define some people as sane, healthy, and fit, and others as insane, sick, and ‘handicapped’. This, in turn, helped explain why the health professions were invented, and why we created a Western healthcare system in the image of medicine.

Foucault’s second period of writing in the early 1970s concentrated on power and how society had become ‘disciplinary’. Mapping the shift from religious and sovereign rule before the 18th century, Foucault showed how we created the idea of modern government through acts of discipline and control that achieved their ends without the use of force. Institutions like the family, school, the hospital, the factory, and the professions, all became vital to the exercise of this new governmental power. And then in Foucault’s third and final period, his attention shifted to the ways in which we each take up the responsibility to fashion ourselves, creating our own subjectivities as ethical beings.

Tellingly, there are echoes of many different social theories in Foucault’s writing on expertise and the professions. He agrees with the functionalist claim that the professions are a specific response to a social need. And there are definite strands of Marxian and critical theory in his belief that deeper structures favour some kinds of subjectivity over others. But in both cases Foucault argued that there was something missing from these accounts, something that Foucault believed revolved around the idea of power.

Unlike the functionalists, Foucault did not believe that the professions had acquired prestige and social capital as a reward for their noble service. He believed that it was wrong to talk about some people ‘having’ power, whilst other people were denied it. Consequently, he rejected the critical and Marxian idea that we had to overturn power asymmetries in society and speak up against oppression. He was disinterested in revolutionary change or providing the ‘theoretical foundations for furthering social enlightenment and democracy’ ^[1]. This obviously put him at odds with many traditional social theorists, who celebrated the ways that his methods shed new light on class and gendered power, colonisation, and ableism, but were less enamoured with his argument that oppressive power had been overstated.

Foucault’s radical idea about how power circulated in society changed the way many people thought about the professions. Earlier theories had concentrated on power as a ‘fixed capacity’ ^[2], that some, like white men and doctors, held, and most everyone else wanted. But Foucault was more interested in how power worked as a more positive force for making things happen. Power was not something that a person or group wielded, but rather an ‘arena of struggle’ ^[3]. And power only operated when people are free to resist. So, where oppression is about brute force, the real power operating in society works best when people do things without force. The ability to resist power is key here then because for real power to work, people have to have the ability to do otherwise and yet choose to do what you want, seemingly exercising their free will.

Foucault used these ideas to study how societies had learnt to govern the population. Foucault showed that the mass migration of people from the countryside to the towns during the 17th and 18th centuries created enormous problems of civic rule. Foucault identified a gradual shift from early forms of ’sovereign’ power to approaches that were less punitive. The emerging nation states of Western Europe, needed people to work in the factories and serve in standing armies. They needed obedient, loyal subjects to fuel the machinery of growth and expansion around the globe. But this could not be achieved through violence and oppression alone. And so, the idea of citizenship, and civic rights and responsibilities were developed (the right to safe working conditions and the responsibility to pay taxes, for instance); new ways to measure and monitor the population were implemented (censuses, bureaucracy, surveys, the police, etc.); and new institutions of governance were designed (the family, schooling, professional education, and so on).

Foucault showed that the state, and its experts and professionals, were not born from their own initiatives and interests, but from a desire to administer society to ensure the health, wealth and happiness of the population. So, Foucault argued it is mistaken to think of ‘the state’ as a distinctive body separate, and often at odds, with the professions. The professions are not isolated entities working for the state (functionalism), or competing interests vying for control of the market (neo-Weberian). Neither are they powerful organisations that oppress minorities (critical theory, Marxism). Instead, both the state and the professions are ‘inextricably fused’ together as ‘progenitors’ and ‘beneficiaries’ of a complex network of interrelated social realities which both constitute the world they operate within, and render it governable’ ^[4]. For Foucault, there is a ‘warm friendship’ between the professions and the state ^[5], and both are ‘integral to the process of governmentality’ ^[6]. (Governmentality is a phrase Foucault used to describe the inclination to govern that developed in the West after the 17th century. Foucault saw that the various ‘technologies’ of government (making laws, securing borders, managing people’s time and labour, facilitating enterprise, supporting alliances with experts, etc.), were specific to a particular set of problems created by society after the Industrial Revolution. The creation of a professional class, physiotherapy included, was a part of that governmental process.) Following a Foucauldian reading, then, we might say that physiotherapy does not have or lack power, but that it is the result of power, and is one of its effects, residues, or ‘achievements’.

The ‘shape’ that modern forms of government take insinuates physiotherapists, patients and families, case managers, other professionals, government ministers, and myriad others, in a network of power relations that produce what we call healthcare. There is no healthcare pre-existing these relations, waiting to be discovered and competed over by professionals. There is no biological basis to illness that is not, in turn, mediated through language and meaning. And so, the exact specifications of healthcare that we see in different places depends upon the myriad discourses that compete to define what it is reasonable to believe, what is right and wrong, and whose authority offers the most seductive truth narrative. Not surprisingly, Foucault spent a great deal of time exploring how contests over the truth, power, and knowledge, had shaped the structure of Western society over the last four centuries, and much of his most powerful work centres on what he called the Technologies of Discipline.