The relationship between theory and practice seems to be something I always return to. This blog post is based on my very first attempt to make sense of the topic; an essay I co-authored with my dear friend two years ago in Finnish. I have translated it into English for the purpose of sharing it but also as a way to go back, as it were, to where it started. This essay was written as a popular piece so the intention is not to offer a philosophically robust text but rather an accessible polemics about how to think about thinking and doing in physiotherapy. I also feel that what we wrote was an “inspirational piece” to some extent: the intention was to encourage critical thinking and thinking that is perhaps unconventional for the majority of practicing physiotherapists; one that challenges the prevailing scientific world view, established “truths” and formality of thinking.
The original Finnish version is published as: Rajala, Anna Ilona and Jenni Aittokallio. “Dikotomiat ajattelun kahleina. Mitä teorian ja käytännön erottelu merkitsee fysioterapeutin työssä.” Fysioterapia 61, no. 4 (2014): 27–31. Translation into English is mine.
Last updated 13 June 2017 (referencing corrected and some poor translations amended).
Dichotomies shackle thinking
What does the division between theory and practice signify in physiotherapy?
If practical knowledge is considered primary in physiotherapy, should theoretical knowledge be separated from practice once and for all? The purpose of this philosophical essay is to demonstrate that the idea of a division between theory and practice is false. It arises from a tendency to think in dualities; a tendency that has dominated Western thought and its attempts to explain the world around us. Our claim is that understanding the relationship between theory and practice can only emanate from the complex idea that they already contain one another. The reality is more complicated than dichotomies lead us to believe. So settling for dichotomies and other divided totalities, which structure our understanding in a restricted manner, is to undermine our very capacity to think. Instead of trying to model or depict the world through divided totalities, we ought to strive towards the very boundaries of our understanding; towards what lies beyond what we might consider as knowledge-certainty. It is the only way to open up possibilities to realise something new.
Physiotherapy is strongly based on empirical things: on practice and on concrete physical action. This approach is also inseparably included in the origins of the word physiotherapy. The ancient Greek fysis (φύσις) refers both to nature’s transformative processes and to the concrete matter that constitutes nature. Therapeia (θεραπεία) refers to caring, serving and healing.
Practicality is no doubt an important part of professionalism and a source of pride in physiotherapy. The evidence base in physiotherapy is also based upon practice and systematic practical research. Its aim is to produce indisputable knowledge and practical tools for professional use. The need for this type of knowledge is undeniable: it makes physiotherapy more accurate, safe and effective. By doing so, it contributes to the appreciation and recognition of the profession.
What about theoretical knowledge that is based on, for example, ethics or philosophy? Do physiotherapists need such knowledge? If practicality is considered as the primary value for knowledge in physiotherapy, should theoretical knowledge be separated from physiotherapy practice once and for all?
The aim of this essay is to show that theory and practice are not as dissimilar as perhaps is often thought. The contraposition of the two arises from the duality that has characterised Western thinking for centuries. This worldview, we argue, restricts understanding and needs to be set under scrutiny.
Our claim is that understanding the nature of theory and practice can only arise from the idea that they always already contain something of one another.
Dichotomies are deeply rooted
People tend to think in dichotomies (image 1). Dichotomies are based on the idea that the two sides of a whole are fundamentally different, which means they are also separate. Thus neither one of the opposites can contain something of the other.
According to a dualistic worldview, upon which dichotomies are based, everything is strictly separated in two basic elements: immaterial and material. The relationship between theory and practice is also seen as such a dichotomy where theory represents the immaterial and practice the material side of things.
Dichotomies do not always, however, mean that the opposites cannot interact with one another (image 2). For example, René Descartes (1596—1650) famously argues that the mind and body are different and separate elements. The mind is the I or the self who confirms its existence through its own ability to think and who moves the machine-like body. (1) Similarly to Descartes’ mind-body interaction, the interaction between the parts of a dichotomy is usually hierarchical: one of the parts dominates and guides the other but neither can contain something of the other.
It is often difficult to notice the way dichotomies emerge in our everyday life because they are very deep-rooted. For example Lauri Rauhala [translator’s note: a Finnish psychologist whose theory of the unity between body, consciousness and situation is often used as an opposite to Descartes’ mind-body dualism in the Finnish health care context] also expresses quite explicitly that his theory is based on Descartes’ dualism. (2) Descartes’ mind-body dualism is not, however, entirely satisfactory for Rauhala. Instead, he argues, what constitutes a human being is the inseparable unity of body, consciousness and situation (3). This latter element, situation, transforms dualism into pluralism, but it does not change the fact that even pluralism separates the parts of a whole as fundamentally different elements.
A dualist might speak about the connection or severance between mind and body. A pluralist might speak about the interaction between mind, body and situation that constitute the human being as a whole. However, these expressions are based on the mind-body dichotomy. This dichotomy sees mind and body as different and separate. It is a dichotomy not even Rauhala was willing to deconstruct. (2)
The relationship between theory and practice is often described in this very same manner: theory and practice are fundamentally different and thus separate, sometimes even independent of each other. Theory is thought to guide practice and vice versa but they do not contain anything of one another (image 3).
There is no pure theory and practice
The relationship between theory and practice can be understood in at least two ways. In general, empirical research—the evidence base—can be understood as theory and clinical work with patients or clients as practice. On the other hand, empirical research can be seen as a part of physiotherapy practice. In this case, philosophy, ethics or untested scientific hypotheses—everything that is literally theoretical as opposed to empirical—can be understood as theory. (See image 3)
In both instances the idea of a strict separation between theory and practice is false. Rather, they are constantly intertwined, interacting and sometimes indistinguishable so that they form the complex web of our everyday practices. Theodor Adorno argues that all theory, or all thinking that constitutes theory, is in itself already a form of practice as long as it concerns the world that we live in (4). This argument can be explained further: the significance of thinking becomes relevant when it is shared with others, as it then becomes something very concrete. As Peter L. Berger and Thomas Luckmann argue, our ability to express is something that objectifies thought. (5)
If thinking is itself an active doing, a practice, it is by a closer inspection practical rather than theoretical. Communication is the relevant practice in objectifying a theory, making thinking concrete. Communication can include all culture and social interaction that contains meanings: writing, dancing, visual arts, music, sign language, expressiveness of the body, and speaking. Because communication is also an active practice, the theory or thought that is shared becomes a part of that practice. Such practice, when it affects people, has a potential to change something in the concrete world we live in. Similarly, when we read or hear something theoretical that we were not familiar with, it has the potential to change the way we think and, by doing so, it then changes the way we act. This intertwined chain of theory and practice highlights the fact that it is very difficult to actually make a clear separation between the two.
Even if there were something like a pure practice or pure theory, we can never reach an understanding about their pure forms. When we think we have reached something pure and immediate, it is already mediated though our own understanding, which is always coloured by everything we have learned and experienced previously. This means that behind every conscious action, there is always at least something theoretical upon which our understanding is formed.
Physiotherapy practice always contains theory
In order to further the understanding about theory and practice, it is necessary to understand objectivity and subjectivity. Objectivity refers here to the knowledge that is claimed to be true independent of the interpretation of human actors (subjects). Contrarily, subjectivity always refers to acting human beings.
Physiotherapy is guided, on the one hand, by methods that are based on objective research and, on the other, by subjective intuitions that arise from the interaction with the patient/client. Intuitions, although they are formed unconsciously, affect our actions. The objectivity of science and the subjectivity of intuition can be thought to represent two extremes. However, the one cannot be understood without the other.
It is not uncommon that in scientific research and methods pure objectivity is held in higher regard than subjectivity or everyday clinical practice. Scientific research, however, can never get rid of the human being as its interpreter and sharer. The action of human beings, as argued above, is always based on theoretical knowledge to some extent: understanding of language and meanings, current theories of human nature and consciousness, ethical principles, and so on. This subjective quality, as Adorno argues, is irreplaceable in sciences. It is the only way in which scientific abstractions, such as numbers, can be combined and interpreted as something understandable. (4) For example, the result 22 from Berg’s balance test becomes understandable only when the physiotherapist interprets the meaning of the number and its significance to the patient/client.
Subjectivity is thus an inseparable part of objective science: an object becomes something at all only when someone defines its meaning (6). This means that physiotherapy cannot be based solely on empirical research or mere everyday practice. It is also based on non-empirical theories with which both researchers and clinicians form, interpret and understand their perceptions.
Similarly, the subject cannot separate itself form the objective environment. Intuitions that are formed in interaction and that guide actions are not born in isolation within the subject. They arise from outside the subject; the subject interacting with the objective world.
Problems of dichotomies
Dichotomies restrict thinking
The idea of the hierarchical relationship between the parts of a dichotomy highlights oppositions that are already wholly unnecessary. For example, hierarchies always make the possibility of a reciprocal learning process between researchers and clinicians more difficult.
The hierarchical theory-practice dichotomy can also signify instrumental thinking, where theory is used merely as a tool. According to such mode of thinking, ethics or philosophical theories are used only when convenient to achieve a goal. They are not thought to have any active, more permanent role in practice.
Dichotomies also simplify our understanding of the world. They become closed systems, readily given sets of concepts, which exclude every possibility to think otherwise.
The problem of closed systems
Dichotomies are defined positively, that is, through what they are or what they contain. The problem in maintaining such positively defined dichotomies is that it does not further understanding. Positive definitions are static and they prescribe every dichotomy as a finite system of meanings.
Things can also be understood through negativity. Acknowledging the negative, what things are not or do not contain, or have not been defined as, is also significant. When thinking acknowledges something beyond positive definitions, the understanding of things remains more open-ended. This gives room for different points of view. Negative understanding has thus the tendency to avoid becoming a closed system (6).
Adorno argues that however dynamic a system might be conceived as, as long as it defines its contents positively, it becomes finite and static: closed systems are bound to be finished (6). When something is finished there is no more need to discover or progress. What is already discovered is found satisfactory and there is thus no need to question the foundations of whatever is considered as the truth at any time.
What could a closed system mean?
Let us further illuminate the problem of a closed system in physiotherapy by this following example.
Every divided totality—a whole that is constituted of parts—is formed in the same manner: the whole is first taken apart and then put back together. This is the case in both Descartes’ dualism and Rauhala’s pluralism. Interpreting these thinkers sets a challenge for physiotherapists who work with patients/clients whose experience of themselves is already shattered in pieces.
For example, Rauhala’s body-consciousness-situation division can be used to understand eating disorders: it can be said that the the condition of the physical body gets worse if the consciousness interprets its body image pathologically. This means that the connection between body and consciousness is disturbed. Eating disorders, its causes and effects, are also closely connected to the patient/client’s life or situation.
However valid this might sound, the truth is that no word composition (body-consciousness-situation, biopsychosocial, etc.) is ever enough to pick up the shatters and make the patient/client whole again (7). Instead, critical thinking that aims at developing our understanding is needed. Rauhala himself highlights this by writing that despite his popular tripartite representation, our understanding of what constitutes human beings is actually never complete (8).
Critical thinking – better understanding
What if there were other theories that could expand our understanding? According to Adorno, the conception of finite systems should be turned upside down and we should believe that there is always something else outside the system (6). Everyone benefits from such critical thinking: the least does is that it keeps every physiotherapist challenging their limits. A critical stance towards the foundation of our thinking, towards things and what we think we know about them, is healthy. For example, repeating some concept like a mantra (e.g. biopsychosociality) without considering its meaning, understanding and interpreting the world around us may become defined and restricted by this one concept in a narrow and blind manner.
Perhaps it is worthwhile to stop and think whether I, as a practical person, could benefit from theoretical thinking instead of rejecting it? Or, could I, as a theoretical person, benefit from practical things instead of rejecting them merely on the grounds that they are practical? Are there even people that are either purely theoretical or practical?
Leaning new by pushing boundaries
Settling for dichotomies or other divided totalities that define our understanding in a restricted manner is undermining our own potential and capacity to think. If we could ever define the nature of theory and practice once and for all, our drive for knowledge ends. There would be no more need for sciences, neither social nor natural sciences. We could repeat the same formulas without thinking or questioning our conduct, and never move forwards.
We can only move forwards by continuing to question our established ways of thinking and doing. What do my conceptions of things restrict or enable? Do I exclude something by defining my patient/client’s functioning in some particular way? Is some way of thinking a mere tool for me? Can I do more to maintain good physiotherapy practices by offering individualised therapy instead of the ossified patterns I might be repeating?
It is difficult, sometimes even impossible, to categorise knowledge without dichotomies. Human beings have always had the need to give things finite definitions. The finite nature of knowledge brings comfort.
While human beings seek something authentic they find models, examples, mathematical abstractions and simplifications instead (9). Admittedly, although such ways to represent things around us do not correspond to reality, the fact remains that models, examples, mathematical abstractions and simplifications are sometimes needed. Through them it is easier to begin to understand something and also learn or teach new. However, this is not something to settle for forever because the reality is more complicated than any dichotomy or model leads us to believe. The purpose is not to find the best model or depiction of the world but to strive toward the very boundaries of our understanding. By pushing boundaries we might realise something new.
Anna Ilona Rajala
MA, PT, PhD candidate
PT (specialisation in psychomotor physiotherapy)
(1) Descartes R: A Discourse on the Method. Oxford University Press. 2006.
(2) Rauhala L: Tajunnan itsepuolustus. Yliopistopaino kustannus. 2006.
(3) Rauhala L: Henkinen ihminen. Gaudeamus. 2009.
(4) Adorno TW: Stichworte. Kritische Modelle 2. Suhrkamp. 1998.
(5) Berger PL, Luckmann T: The Social Construction of Reality. Penguin. 1966.
(6) Adorno TW: Negative Dialectics. Routledge. 1990.
(7) Laing RD: The Divided Self: Penguin Books. 1969.
(8) Puhakainen J: Persoonan puolustaja. Like. 2001.
(9) Horkheimer M: Critique of Instrumental Reason. Verso. 2012.