60 Postmodern thinking and physiotherapy

Although the approaches touched on in this chapter cover some quite diverse concepts and ideas, they share in common the belief that the old ways of analysing the professions, that emphasised different forms of structure and agency, are too linear and simplistic to really explain what the professions really are. From a postmodern perspective, physiotherapy cannot be defined by its functionalist traits, nor as a product of Marxian beliefs in economic capital. It is too diffuse to be seen as a solid entity in competition with others for market advantage, as neo-Weberians suggest. It has less agency than social action perspectives argue, but has more agency than critical theories allow. What is physiotherapy according to postmodernism, then?

Firstly, a postmodernist might suggest that physiotherapy — like all things in postmodernism — is an assemblage of ideas and practices, that have coalesced in a fluid and ever-changing field, in response to a temporary set of context-specific circumstances. Rather than having a solid, bounded identity, the myriad physiotherapies that exist represent an amorphous set of temporary and loosely coherent subjectivities. The fluid and amorphous nature of a profession like physiotherapy stems from it being the outcome, effect, or achievement of discourses circulating in society, and its perception of solidity reflects the endurance of some powerful discourses (governance, biomedicine, science, objectivity, etc.). And so, physiotherapy is no different, in this regard, to the state, the family, medicine, care, and chronic pain, and other discursive effects of governmentality.

Secondly, a postmodernist might suggest that physiotherapy is deeply woven into the fabric of contemporary healthcare and relies entirely on its interconnections and dependencies to convey the sense that it is a real ‘thing’ ^[1]. It is misleading, therefore, to think of physiotherapy as autonomous, hindered, controlled, or oppressed by ‘the state’. Rather, physiotherapy’s prestige derives from its ability to exercise its freedom in appropriate ways ^[2][3][4]. One of the most important of these is its tendency to be ‘constantly suspicious of its own authority’ ^[5], and change its shape and focus as its field morphs and mutates.

And finally, there is nothing inherently stable about physiotherapy knowledge. The subjects that we think are ‘core’ to the profession remain so only as long as they allow members to translate particular forms of knowledge into better forms of governing. Biomechanics will matter more than cognitive psychology as long as physiotherapists can use this to render ‘the complexities of modern social and economic life knowable, practicable and amenable to governing’ ^[6]. What is more, the concepts that reside at the heart of the profession’s subjectivity, will derive their stability from their ability to conceal their power to shape professional thinking and practice. Concepts like the body-as-machine, for example, have succeeded because they have naturalised, ‘embodied and habituated’ prejudices ^[7], and suppressed concerns over intersecting issues of social justice, especially patriarchy, prejudice, and paternalism, evident throughout healthcare in the Global North ^[8].

If physiotherapy is the outcome or effect of discourse, it begs the question whether it can ever change of its own accord. In functionalism, it is easy to see where change came from because physiotherapy enters a ‘contract’ with society to offer certain skills and abilities, in exchange for patronage and security of tenure. As it changes, ’society’ simply asks the profession for a different service, and the willing profession provides. A neo-Weberian alternative might be that physiotherapy is actually in competition with others in a market for services, and the ‘winner’ is the one that best matches up to society’s needs ^[9]. Postmodernism shares something of both of these, but is also quite close to a critical theory position. Critical theories argue that professional ‘success’ is about power: the power of the Global North to define what health and illness means; the power of elite social groups, especially white, anglophone, heteronormative, non-disabled, and affluent men, to establish a social norm in their own image.

In all three cases, though, resistance and change comes from within; from the solid sense of ‘identity’ that derives from ‘being’ a physiotherapist. In critical theory, for instance, activists argue passionately that it is the responsibility of the professional to reflect on their privilege and transfer power to those who are socially marginalised. This belief manifests in a number of ways:

1. It has surfaced in the editorial of the Journal for Humanities in Rehabilitation, calling for health professionals to become ‘moral agents of change’, to ‘reimagine a more equitable and just future’, and to ‘dismantle the systemic racism that has plagued Black bodies and communities for centuries’ ^[10];
2. It is evident in recent calls for health professionals to develop ‘critical consciousness’ ^{[11][12][13][14]}, as opposed to the cultural competence and cultural safety that are now thought to reinforce the sense that professionals can become experts in others’ culture, or tick off competence without engaging in longstanding change^{[15][16][17][18][19][20]}.
3. And we see it in work on social determinants of health. These conditions have far more significant long-term effects on the health and wellbeing of people and communities than the ‘soft targets’ ^[21], and ‘weak utility’ ^[22] of behaviour change. But they also require physiotherapy confronts its historical lack of focus on social justice. Anna Luise Kerkengen, writing recently about the causal complexity lying behind medical diagnoses, has suggested that the professions allied to medicine have become ‘complicit in obscuring abuses of power and all kinds of societal injustice’^[23]. Yet, at present, no population-based approach to practice exists in physiotherapy. Nor is there a recognised approach to social justice ^[24], or any concerted evidence in the literature, that physiotherapists take the social determinants seriously. In his Penny Cerasoli Lecture, Terrance Nordstrom asked ‘what parts of (society) are we (APTA members) committed to transforming. Writing recently about the causal complexity lying behind medical diagnoses, Kirkengen has suggested that the professions allied to medicine have become ‘complicit in obscuring abuses of power and all kinds of societal injustice’ ^[25]. ‘Must such consequences remain unexplored within medicine’, she asks, ‘because they are defined as lying outside the mandate of the profession?’[/footnote] (ibid). ‘Must such consequences remain unexplored within medicine’, she asks, ‘because they are defined as lying outside the mandate of the profession?’

All of these social issues derive from the premise, common in critical theory, that power operates asynchronously in society, privileging some and marginalising others, and it is the profession’s responsibility to identify its privilege and emancipate the voice of the marginalised ‘other’. As I have tried to show in this chapter, postmodernists take a different view, and this alternative viewpoint has important implications for how one might rethink what physiotherapy is and might become. Firstly, postmodernism challenges the seeming obviousness of physiotherapy.

Postmodernism encourages us to see our professions as less natural or less available to us than we normally think. For example, in 1983, David Armstrong, a doctor and longstanding postmodern writer on medicine, puzzled over what he saw as the common-sense obviousness of the way medicine viewed health and illness;

‘At first it seemed strange to me how the apparent obviousness of disease and its manifestations inside the body had eluded scientific discovery for so long. How had pre-enlightenment generations failed to see clearly differentiated organs and tissues of the body? Or failed to link patient symptoms with the existence of localised pathological processes? Or failed to apply the most rudimentary diagnostic techniques of physical examination?’ ^[26].

But Armstrong realised that these questions began from the presumption that medicine was the natural starting point for thinking about health and the body. Turning the question around, Armstrong asked how it had been possible for biomedicine to assume such obviousness? What kinds of social mechanisms, forces, relationships, concepts, strategies, subjectivities, and technologies would you need to implement to convince millions of people that cure, experimental logic, colonial patronage, reductionism, androcentric bias, seeing the body-as-machine, and affective detachment, are the norms against which all other systems should be judged? In other words, Armstrong was attempting to do what many postmodern sociologists of the professions strive for, and make his profession strange to itself.

A slew of postmodern and intersectional thinkers have emerged in recent years, and their work centres on the complexities and ambiguities inherent in healthcare practice ^{[27][28][29][30][31][32][33][34][35][36][37][38]}. Key to this work is the desire to open up thinking and practicing to the complex material effects that discourses enable and constrain in people’s lives whilst, at the same time, not reducing them to a homogenous, undifferentiated whole. The idea of postmodernism celebrates ‘the multiple and entangled categories’ ^[39], that make up our subjectivities as people and professionals.

Just as David Armstrong’s work reframed how people understood medicine, Barbara Gibson’s work has been important in showing how physiotherapy and rehabilitation might be reimagined. Gibson’s work spans post-critical rehabilitation and disability studies, biomedical ethics, and post-structural philosophy ^[40]. In her book Rehabilitation: A post-critical approach, Gibson argued that concepts like movement might provide a useful vehicle to help physiotherapists and other rehabilitation practitioners challenge the obviousness of their practice. She writes;

’Movement is central to rehabilitation; it is an outcome, a practice, and an ideology. It can also be mobilized to foster connectivities, to re-form, re-consider, re-fuse, re-figure, re-collect, and re-assemble care, research, and education practices. Rehabilitation clinicians, researchers, and educators mostly discuss movement in terms of the physical movements of joints and limbs, and in relation to the anatomy, physiology, and biomechanics of the biological body. Collectively, we may speak of gross and fine motor function, or more recently in our history, how movement facilitates participation in activities and social roles. Despite this growing interest in the social and human aspects of persons’ lives, movement remains primarily focused on the mechanical: on mobilizing material bodies’ ^[41].

Gibson’s work, along with Tremain, Shildrick, and others ^{[42][43][44][45]} exemplifies the ‘tangled nature of bodies’ ^[46], and the idea of disability as possibility and potentiality (ibid, p.638). These challenge the ‘psychosocial imaginary that sustains modernist understandings of what it is to be properly human’ ^[47]. And they remind us that even the idea of what it is to be human today ’is increasingly contested in the era of postmodernity’ (ibid).

The kind of body that discursively shapes physiotherapy practice has changed dramatically over the last few decades, suggesting that new approaches to practice, education, research, and theorising are needed by the profession. Margrit Shildrick argues that, ‘all putative categories are slippery, unfixed, permeable, deeply intersectional, intrinsically hybrid and resistant to definition’ ^[48]. Accepting this slipperiness, and rejecting binary distinctions between normal and abnormal, straight and queer, non-disabled and disabled, male and female, collapses the distance between ‘us’ and ‘them’, professional and patient, the healthy one treating the sick one. We come to see the real resemblance between each other, not the ‘not-me-ness’ (ibid, p.42) of Western healthcare practice. We are forced to ‘reflect back aspects of ourselves that we do not usually acknowledge’ (ibid), and the idea of the self (person, patient, client, other etc.) takes on an ‘indeterminate status — as neither wholly self nor absolutely other’, and so ‘becomes deeply disturbing’ (ibid).

This is not to suggest that postmodernists are disinterested in professional traits, inter-disciplinary competition, class struggle, or the ‘roles of power and privilege in creating health disparities’ ^[49], only that they see these struggles as other material effects of societies that are constantly being constructed, deformed, and reformed by discourse. And so, the principle task of postmodern analysis is not to stabilise the profession around a fixed ‘identity’, fight for greater prestige, or locate injustice and argue for alternatives, but to see all of these as discursive effects, and to open doors to a thousand alternatives. The task is to locate the ‘multiplicity of possibilities’ ^[50], that are open to us when we move away from thinking about our professions as stable, codified, semi-permanent, and solid identities. For postmodernists, the professions are not the originators of ideas and forms of practice, but one effect, among many, of discourse and the urge to govern.