53 Social action and physiotherapy

In Chapter 3 I used Karl Marx’s historical analysis of the birth of capitalism to argue that physiotherapy had come to play a key role in maintaining a population of fit workers able to fuel the engine of capitalism. In Chapter 4 I argued that the profession’s affinity with Western biomedicine added a gendered, racial, heteronormative and ableist tinge to this work. From this chapter, we can add Weber’s concept of the Protestant work ethic. Weber’s analysis explains how the entrepreneurial spirit changed Western culture in the 18th and 19th centuries. But for physiotherapists, it helps to explain the profession’s longstanding interest in bodily function, work and productivity, independence and autonomy, resilience, rehabilitation, and reablement ^[1].

Work on the working body is the physiotherapy profession’s mechanism for influencing human performance, and influencing human performance is the profession’s way of showing that physiotherapy matters. As Chris Shilling argued, we are ‘bodies-working-on-bodies’ ^[2]. The Protestant work ethic shows us, however, that it is not any human performance that matters socially, but purposeful, task-focused, productive movement. Rest, indulgent luxury, and idleness have no place in ‘normal’ function, and so they have no place in physiotherapy.

But the nature of work is changing, and few people now expect to be labouring in the future in the way that was the norm when physiotherapy was becoming established. From agriculture and banking, to education, transportation, and manufacturing, the working lives of people will be vastly different in the future. Bodies are also changing, and have become ‘the product we both manufacture and consume’ ^[3]. And so, if two of the main physiotherapy ‘fields’ change, the profession must change too, which raises a number of issues at the heart of social action. The first is around the professions boundaries.

As neo-Weberian theorists have shown, social closure has been an important way for professions to manage boundary tensions since orthodox healthcare began to incorporate more professions in the 1930s. The incorporation of physiotherapy into the welfare state in the 1940s brought security of income, training subsidies, and legislative protection, but physiotherapists had ‘won recognition but only to a degree which met with medical and state approval’ ^[4]. Attempting to extricate itself from the perception that it was merely a ‘medical auxiliary’ ^[5], whilst not wanting to lose the valued patronage of medicine, meant many professional bodies pursuing professional autonomy, which led to a flush of social theory work by physiotherapists ^{[6][7][8][9][10]}. In the 1990s attention turned to new managerial practices, audit, and financial accountability for professional decisions ^{[11][12][13][14]}. This pre-empted today’s focus on legitimate boundary-breaching practices like extended scopes and interprofessional practice^{[15][16][17][18][19][20]}. From a social action perspective, the challenge for physiotherapists here is how to transgress its traditional profession enclosure ^[21][22]. Having spent decades establishing mechanisms to police the professions vulnerable margins, physiotherapists, and every other health discipline, are being asked to change. Narelle Patton and Joy Higgs have suggested that because professional practice is ‘rich, complex, embodied, and inherently human’ ^[23], embracing a more person-centred approach to practice demands more than just the bland acknowledgement that physiotherapists care about people. Being person-centred means giving the patient the power to decide that they might not want your input. Would a profession risk such a transfer of power if it might result in it becoming obsolete? Adopting person-centred practice also involves ‘hearing’ clients/patients in ways that physiotherapists have never emphasised. Physiotherapy has pursued the kinds of objectivity, quantitative detachment, and value-neutral ethical judgement that have earned the respect of medicine. To relinquish this to give priority to the patient’s subjective lived experience, or to a reality based on shared meaning, qualitative, humanistic practice, might create a rift with medicine and inducing a rapid decline in the profession’s social prestige.

Perhaps physiotherapists already sense this. We have known for a long time that the female dominated professions that emphasise caring and partnership (especially nursing, midwifery, social work), command high levels of social prestige, but much lower levels of economic reward, than those that subscribe to biomedical discourses. But physiotherapy’s affinity with biomedicine presents other barriers too, not the least of these being that the profession has no history of significant creativity and innovation. Indeed, it works hard to ensure people do not ‘fail fast and often’. Creative professionals are trained from day one to anticipate people’s future needs and wants, to break things, to be playful, to de-emphasise conformity and concentrate on innovation. Not so physiotherapists. Physiotherapy education and practice is about learning trustworthy and repeatable techniques, using proven methods in predictable situations, conformity, rule-following, accountability. Anyone found practicing outside of their scope is liable to be sanctioned by the regulatory authority. In such a climate, it is hard to imagine how boundary breaches will occur that will allow for the kinds of transformations in healthcare now being called for.

Physiotherapists traditionally emphasised their social distance from patients as a way to demonstrate their legitimacy, expertise, and authority, but growing interest in the biopsychosocial model, person-centred care, patients’ perspectives in evidence-based practice, and the emerging field of the humanities in rehabilitation, have seen many clinicians question the profession’s longstanding affinity with paternalistic, detached, and reductive healthcare ^[24]. Some of the challenges of narrowing the social distance to clients/patients (whilst also not overly extending the distance between physiotherapist and Western biomedical healthcare), are currently being played out in the management of chronic pain, lung disease, and neurological disability, for which the client’s subjective worldview is significantly more important than their pathology. But this has created some problems for physiotherapists because although patient values are considered important in high-value care, and are explicitly a part of concepts as EBP (evidence-based practice), VBP (value-based practice) and PCC (patient- or person-centred care), they are largely unclear and unknown how to be ‘integrated’ in clinical decision-making ^[25].

Key to this transformation, then, will be the way physiotherapists are socialised to become practitioners. Recent studies are showing that physiotherapists are uncomfortable and unprepared for person-centred practice. They prioritise their authority and expertise, and ‘overrule patients’ ^[26]. Physiotherapists respected patients’ concerns more when they gave up some of their own priorities, techniques, and goals ^[27], but often found it uncomfortable dealing with a patient narrative that did not resonate with their professional learning ^[28]. The therapists had been socialised to treat patients paternalistically, and felt ill-equipped to manage even some of the most basic communication skills like rapport-building (ibid). Some of the reasons for this become clearer when the subtle depth of the profession’s reductive, paternalistic approach to practice is explored ^[29].

The extent to which the practitioner should assert their authority had been problematic for all Western health professions since the rise of consumer-led healthcare in the 1970s. If the practitioner believes ‘they have greater knowledge about what is ‘best’ for the patient’ Sarah Nettleton asks, ‘should they insist that the patient complies with their instructions, or should they defer to the patient’s wishes’ ^[30]? If they risk being accused of paternalism, or ‘medical imperialism’ ^[31][32], then the answer may be no. But if they demur from a therapy for these reasons, they may well cause more problems for the patient and abdicate their professional duty.

In the past, functionalists argued that society had given elite professionals like doctors the power to make difficult health decisions for people; a responsibility for which they received special status and reward. But functionalism largely ignores the immense social power that this gave to doctors and their allies. Seeking a new more democratic and egalitarian approach to healthcare, some authors after the 1990s began to explore the idea of ‘partnership’ as a radical alternative to biomedicine ^[33][34]. These approaches propose ‘a shift away from the biomedical model of care, in which medical intervention is the solution to health problems, to a holistic approach in which the patient is an active participant in care’ ^[35]. But, as these new approaches show, the fundamental question is never one of policy or legislation, the value of evidence, or the importance of diagnosis and treatment, it is about power; whether healthcare workers are prepared to relinquish their authority to ‘empower’ consumers; whether it can even be ‘transferred’, or whether it is ‘performed’ in social encounters, as social action advocates argue.

The question of how one ‘becomes’ a physiotherapist, therefore, cannot be answered without considering the social context in which physiotherapy practice operates. Social action argues that all good practice is fundamentally context-specific, making it very hard to standardise, regurgitate, and repeat. It is radically relational ^[36], and challenges the longstanding axiom that ‘the doctor knows best’. It is, in many ways, the opposite of our historical approach to physiotherapy. Of course, social action perspectives are not without their critics, and so we close this chapter with a brief review of where some people believe social action falls short.