1 What this book sets out to do

Although I had a classical physiotherapy training in the applied sciences, patient assessment and treatment, I’ve been teaching, researching, and using sociological ideas for more than 30 years. Over that time, I’ve often been struck by how useful sociological theories can be for thinking through all sorts of physio-related issues. But I’m also frequently reminded how few physiotherapists know about concepts like the sick role, wage slavery, social capital, and the division of labour. I suspect that many of my colleagues would know much more about Rob McKenzie than Judith Butler. This is no slight on Rob McKenzie, but Butler and countless other social theorists of the last century have important things to tell physiotherapists too.

I believe physiotherapy’s lack of interest in sociology derives both from the way our forebears set up the profession to focus on treating the body-as-machine, and from the social events that shaped physiotherapy in the last century. I unpacked these arguments at length in The End of Physiotherapy (forthwith, EoP). But to briefly summarise: the profession of physiotherapy was born from an attempt to legitimise touch, and most of the major events of the 20th century have helped it to bolster its claim to be an orthodox ally to the medical profession and the state. Nothing required physiotherapists to challenge their biomechanical principles until the economic crisis of the 1970s. But since then, the profession has been racing to keep up with the rapid pace of social change, widespread disruptions in our healthcare systems, changing public attitudes towards authority and control, changing lifestyles, globalisation, the information revolution, and free-market neoliberal competition. (For a more comprehensive discussion of these changes and how they are influencing physiotherapy, read Chapter 5 of EoP.)

And so, over the last half century, physiotherapists all over the world have been exploring ways to move beyond the body-as-machine, whilst not betraying the idea of what it means to be a physiotherapist. But we are trying to change our culture without cultural studies, and adapt to changing society without sociology. This book attempts to partially remedy this situation by bringing the sociology of the professions to our thinking about physiotherapy’s future.

Physiotherapy is certainly not the first health profession to do this, but neither is it the last, and we can now draw on decades of work, especially from the sociologies of medicine and nursing. The field has become diverse, but also reasonably clearly divided into distinctive schools of thought. Which means we now have the luxury of being able to examine the different perspectives and see what they can tell us about physiotherapy theory and practice.

I have three main goals in writing this book, then. Firstly, like EoP, I want to continue the project of ‘diagnosing’ physiotherapy; to understand the conditions that make it possible as a unique and specific professional entity. Karl Marx said that sociology was secondary only to history in its ability to diagnose how ideas emerge and change. So, if EoP was historical, this should be sociological. Given that the profession has no founding mythology around a hero like Florence Nightingale or Robert Koch; that it relied on no invention to bring it to life (unlike radiography, for instance); and is based on techniques that have been performed in thousands of different ways, across all civilisations, for millennia, the book attempts to understand how physiotherapy has maintained its dominance as a discrete professional entity.

Secondly, I have written the book as a way into the sociology of the professions for physiotherapists who have little or no experience of these ideas. Over the course of the next few chapters, I will discuss some of the main ways sociologists have understood the professions over the last 100 years. My hope is that this equips readers with some tools to undertake their own diagnostic work in the future.

And thirdly, I want to use the different theories in the book to suggest a way forward for the profession. So, even though social theories cannot tell us what to do, nor ‘be applied mechanistically to generate ‘an’ answer’ ^[1], they can still give us strong pointers to guide our thinking and practice. Because of my preference for postmodern thinking, I always prefer to hold on to what Diderot called an ‘attitude of incredulity’, and open space to alternative ideas, rather than suggest a way forward. The recommendations made throughout the book are responses to the different theories, and can be taken up according to the reader’s own context.

The fundamental conclusions I arrive at will, no doubt, challenge some people. Which is why I have tried to construct the recommendations throughout the book with the utmost care. Sarah Barradell, writing recently about the concept of professional stewardship, said that ‘being a caring professional is a different practice to that of caring for the profession’ ^[2]. Stewardship means having ‘a critical understanding of the historical foundations of the discipline’, acting ‘in unconventional ways to create new knowledge and ideas’, and having the will and the flexibility ‘to act in unconventional ways to translate new ideas into new fields’ (ibid). I have done my best to honour these principles here. Being a writer on one’s profession means always having what Thomas Jefferson called ‘vigilant and distrustful superintendence’ ^[3].

And finally, a brief word about the style and language in the book. We are often told that physiotherapists are pragmatic people who trade in practical advice and workable solutions. If this is true, then Sarah Barradell is right when she warns that physiotherapists will often ‘not appreciate the importance of thinking about their larger purpose and how they might participate in shaping the profession’s future in the ways that globalised societies require’ ^[4]. But physiotherapists are also highly educated, intelligent, and thoughtful people, who use theories and ideas every day in their practice. So, I am confident that although the book might require slow, deliberate reading at times, and its themes and ideas may be new to many and provocative to most, its utility will soon become clear. In fact, the practical application of the ideas in the book may well prove to be the most challenging aspect of all. Because although there are many complex and difficult sociological ideas in here, it will almost certainly be the way they lead to my conclusions that will cause readers the most consternation. More on this shortly, though. Firstly, we should establish why physiotherapists need social theory at all.