56 Technologies of discipline

Technologies of Discipline (ToD) are the methods developed to organise society so that people did what was considered right or necessary, and maximised their productive value without the need for force ^[1][2]. ToD begin with thoroughgoing knowledge of people’s bodies and behaviours. Through the systematic study of people’s movements, attitudes and beliefs, conduct, connections, habits and routines, Terry Johnson argued we have divided the normal from the pathological, and maximised every facet of life for the presumed betterment of the individual and society at large ^[3].

In The Birth of the Clinic ^[4], Foucault showed how medicine had been particularly effective as a ToD, through what he called the medical gaze. Foucault showed that the kinds of medical practices we take for granted today (systematic examination of the body, the emphasis on pathological anatomy, and judgements about what is normal and abnormal, for example), were techniques developed by physicians to acquire enormous social power on the basis of the profession’s extensive knowledge of the inner workings of the body ^[5][6].

Before the 1850s, medical practice worked from general statements of the patient’s wellbeing, and the belief that illness affected the person as a whole ^[7]. ‘Surveillance medicine’ — as David Armstrong calls it ^[8] — shifted this focus to a specific medical examination, designed to classify and categorise different disease presentations, and reveal ‘discrete bodily structures and tissues; the specific ‘grammar’ of signs and symptoms; the trajectory that diseases took; the body tissues that became disrupted; and the specific locations where the patient experienced pain or abnormality’ ^[9].

Unlike the spiritual practices that saw the priest as a conduit for the word of God, doctors now argued that they interpreted only what they saw, without bias or subjectivity. This connected medicine squarely with Enlightenment science, and justified the accumulation of massive amounts of patient data, not least because the new ‘objective’ medicine could claim to be able to predict more accurately the likely course of illness and injury without any claim to abstract faith.

The ability to connect the patient’s reported symptoms, and then later specialised test results, to the detailed knowledge of pathological anatomy, unavailable to the lay person, afforded medicine enormous social prestige. With this prestige came the ability to define what forms of knowledge about health were to be deemed valid, and, perhaps more importantly, how validity itself would be defined.

Critically, the medical gaze always served broader political ends. From the 18th century onwards, attention increasingly turned to any aspect of society that threatened the prosperity of the Western economic powers. Criminality, madness, sexual ‘deviance’, political dissent, and illness, all became ‘particular field[s] of special enquiry’ ^[10], requiring new disciplines, codes, procedures, and ways of thinking and practicing that would inscribe the patient ‘into a medical code, thus turning the individual body into a valid object of scientific knowledge’ (ibid). So while the idea of the ‘sick poor’ had existed for centuries, it was peoples’ ‘economic relevance rather than their need for assistance’ (ibid, p.70-1) that gave the medical profession the impetus to invent the body as the site of legitimate scientific inquiry. In other words, it was ‘the concern for the preservation and reproduction of the labour force’ (ibid), that created the conditions within which medicine could construct a professional enclosure.

Perhaps one of the best examples of this comes from work on the role that normalisation plays in disability. Foucault argued that ‘The judges of normality are everywhere… and each individual, wherever he may find himself, subjects to it his body, his gestures, his behaviors, his attitudes, his achievements’ ^[11]. This resulted in beliefs about normalisation that are so pervasive today, that any form of deviance or difference becomes ‘everyone’s fiefdom of oversight’ ^[12]. Crucially, though, such beliefs only work because they conceal their immense power to shape our conduct without force. Physiotherapists are no less folded into this network than disabled people themselves, as normalisation becomes the default way to think and shape everyone’s practices. The same logic can be seen in the way ToD have come to define our attitudes to work.

In Madness and Civilization ^[13], Foucault explored how the need to maximise human productivity in industrial capitalism had shifted attitudes towards idleness and rest. But Foucault showed that the new approaches to work developed in the 18th and 19th centuries also applied to education, the military, and medicine. At the heart of these institutions were efforts to ‘capture’ individuals, opened them to constant surveillance, and engender compliance and docility. From pre-school to school; school to college, factory, or barracks; and from the hospital, asylum, prison, and rest home, the goal was to bring everyone under the unremitting ‘calculating control of discipline’ ^[14].

Key here were forms of surveillance that were actually built into all of the institutions people passed through, from gymnasiums to shopping malls, libraries and doctor’s surgeries. Surveillance was deemed necessary to quickly identify individual ‘irregularities’ in bodies, movements, thoughts, activities, histories, and achievements. These could then be used by a new cadre of experts, who would then claim the prestige associated with specifying ’empirical norms for all manner of physical and mental attributes and functions of human bodies’ ^[15].

The invention of the hospital is one of the best examples of this. The move away from bedside medicine to the ‘surveillance medicine’ of the hospital, fitted the industrial idea of more organised and efficient healthcare. Patients could be ‘managed’ in hospitals more easily, and the delivery of medical care made more efficient. But hospitals also gave doctors three significant advantages: it brought a mass of patients into one place, allowing medicine to accumulate enormous amounts of data about the subtle variations between clinical presentations; it created enormous amounts of new work, requiring new professional roles and hierarchical ordering of tasks under the guidance of doctors; and new centres of practice could become sites where ‘ancillary’ professions could become enculturated into ways of working that complemented medical practice and reinforced biomedical discourses ^[16]. Hospitals were places of healing, but they were also important sites for the concentration of medical discipline, surveillance, and science.

But because power can never be total or absolute, and real power only exists where people have the ability to think and do otherwise, institutional forms of authority can never afford to rest. They must always be attentive to exceptions, disputes, disagreements, and differences. So in Western healthcare, for instance, doctors and other orthodox professionals must constantly find new ways to overcome acts of resistance if they are to assert their knowledge as the most authentic, reasoned ‘truth’.

Because medicine has been so effective in doing this over the last century, there is no need here to force professions like physiotherapy to conform because the profession learned long ago that medicine’s ‘truth’ was a much more valuable conduit to professional legitimacy than any of the other circulating discourses. So, rather than seeing physiotherapy as autonomous, physiotherapists have learned to be part of the constantly negotiated social order. By keeping ‘themselves “in order” through internalised discipline’, they are now ‘qualified to participate in the maintenance of social order at a large-scale’ ^[17].

Because no profession has any pre-ordained right to assume a position of prestige and authority in society — on the basis of a set of ‘traits’, for example — professions constitute as much as reflect the realities they help to construct ^[18]. Professionals ‘exercise significant social power in shaping their professional context’ ^[19]. Their prestige is based on discourses that are mobile, fluid, and malleable, rather than fixed and predetermined. (Discourse’ is another Foucauldian term that refers to a set of practices, theories, and statements that drive a particular argument. Biomedicine is a powerful discourse in healthcare, promoted through thousands of ideas and actions that ensure its ideas supercede all others. How some discourses dominate others features heavily in Foucault’s writing. EoP was a book written to uncover what makes the discourse of physiotherapy historically and socially possible.) It is entirely possible ‘that at some future time we might come to hold a different view’ ^[20], and shift our reality entirely, and the professions will be both subject to, and architects of this shift. We should not forget, then, that, ‘The apparent objectivity of the body and the permanence of the medical model are open to question and change’ ^[21].

This has important implications for the way we think about bodies, impairments, disease, illness, and disability because Foucault is arguing that these things are social constructs, rather than ‘hard’ biological ‘facts’. This is not the same as saying that the body is not ‘real’, however, only that we cannot refer to the body without, at the same time, constructing it through language ^[22]. There is no objective reality to the body that is not, at the same time, an expression of someone’s desire to say certain things about what the body is and is not. Every description of the body, as Shelley Tremain argues, is also a ‘prescription for the formulation of the object (person, practice, or thing) to which it is claimed to innocently refer’ ^[23].