Body work, physiotherapy and ‘chiasmic’ ethics

In this post I’m revisiting, and reproducing, some of the thoughts I presented in the Critical Physiotherapy Network colloquium in Cardiff June 5th 2017.

The idea for the work-in-progress paper began with the astonishing find that body work – the concept used in sociology to describe work that revolves around bodies – has not been used in physiotherapy research much at all. Perhaps this is because physiotherapy so obviously is what has been called body work. However, body work is a concept that sociology of care takes very seriously and care is no less obviously body work than physiotherapy. Why is it, then, that physiotherapy research shows little interest in the concept of body work?

Body work

If we look at some of these descriptions of the concept, it becomes clear that body work fits physiotherapy well:

Carol Wolkowitz (2002) defines body work as work that takes the body as its immediate site of labour. It is work that textualises and controls the social body; body that is often supine and/or naked. Body work involves often intimate and messy contact or proximity with the body and its products.

Linda McDowell (2009) has conceptualised body work in reference to service economy. According to her, body work is interactive work that requires co-presence, involves emotions and personal interaction, but need not always involve direct physical touch. Body work in service economy, she argues, is gendered, racialised and classed – just like the service sector.

Julia Twigg et al. (2011) have looked at body work in health and social care. Twigg (2006) defines body work as direct work on the bodies of others. It typically involves touching, assessing, diagnosing, handling, treating, manipulating, and/or monitoring bodies. These kinds of activities make the bodies of others the objects of the healthcare practitioner’s labour. The aim of such work can be medical, therapeutic, pleasurable, aesthetic, hygienic, and/or symbolic. Through the range of aims it encompasses an equally wast range of practitioners. According to Twigg, body work is central for health and social care but obviously the contexts and specificities of different professions vary.

There are some characteristics of body work, Twigg (2006) argues, that all body work in the healthcare sector shares:

First, there is a hierarchy in which the distance from the body defines the status of the worker. For example, doctors may delegate the immediate proximity to the body – the treatment or therapy itself – to nurses or physiotherapists. Doctors also typically distance themselves from bodily contact or frame the body to bracket off the ambivalent, both symbolically and concretely: white coats, bodily stance, surgical cloaking, mediating instruments and machinery, the way they arrive, position themselves in the room and depart (or to borrow Bourdieu’s vocabulary, their habitus), all mark how high-status workers deal with the bodily.

There are similar hierarchies in work also within professions: high-status nurses deal with clean high-tech work, so to say, sometimes with no need to deal with the body at all, for example in managerial or teaching level. This leaves the direct high-touch work, or the so-called “dirty” work – sponge baths, toilet activities, etc. – for those with “lower skills” and thus lower status, who are also typically in gendered, racialised and classed positions.

Second, body work in health and social care is also asymmetrical between the professional bodies and the bodies as the objects of labour. The professionals are usually stronger, healthier, younger, clothed, and also often situated higher in the physical space compared to the patient/client. As Twigg (2006) argues, this exemplifies the exercise of Foucauldian biopower.

Third, body work involves activities that are necessary but also transgress the boundaries of social norms: ambivalent touch and proximity, leakiness and bodily fluids, smells, nakedness, old age, non-normative bodies, decay, death, dealing with intimate areas, as well as ambivalent emotions. This side of body work tends to be hidden, Twigg (2000) argues, but body work is also there to keep it hidden in institutions and people’s homes.

Physiotherapy as body work

Physiotherapy is body work. It is work with, through, for, and on bodies that move and are being moved in the same space and time. I think body work is a helpful framework for researching physiotherapy as a profession and practice, which is why it is surprising to me why it hasn’t been utilised more. This is not, however, what is interesting to me here. Stating the obvious rarely is.

Body work in physiotherapy has its own context and specificities, of course, but it also shares something important with care work: the necessity that creates the need for both professions. In other words, the personal medical or functional need and the professional answering to that need – this is what Silva Tedre (2004) calls “body of necessities”. In both care and physiotherapy, the body and the labour time of the practitioner is given to the one who needs it for the duration of the care or therapy session. The body in need, however, is often hidden and silenced – even more so in physiotherapy than in care – especially if the body does not fit the social norms and ideals of youth, body shape, beauty and cleanliness. This is partly because such bodies are stigmatised and they often fit poorly the liberal image of the autonomous client exercising their freedom of wants.

I have deliberately kept repeating the words ‘need’ and ‘necessary’. I see a dialectics of need and necessity here, both of which reside in the body of the other and in the body work that becomes a necessity because of the need. Making visible what is hidden and giving voice to what is silenced is, as Tedre (2004) argues, a political act. Whether answering to needs is recognised as a necessity, i.e. whether physiotherapy is recognised as an integral part of health care, of course depends on whether needs, and the people who have them, are politically recognised.

I find Tedre’s (2004) description of care fitting for physiotherapy. I just wanted to add this to further highlight that body work in care and physiotherapy is not that different, especially in the interactive entwinement of bodies, spaces, movement, emotions, and people. Terde (2004, my trans.) writes:

“Care is embodied encounters and more; it is the necessary embracing of bodies, almost like in a wrestling hold. Care is bodies sidestepping each other, it is bodies directing their gaze, it is doing hands, it is bodies that lift, it is embodied people who are in and are set in physical places, who turn, arise and walk with the help of embodied people, who use physical spaces and move between them.”

In this complex entwinement, there is also a dialectical forming of subjectivities through acts of recognition and misrecognition.

Excursus: physiotherapy in those white rooms

Now for something anecdotal. I did a quick google image search for “physiotherapy” and these are the first images on the first page. Although this is just a bit of unscientific fun, I think using the framework of body work to analyse the representation of physiotherapy in images such as these is quite interesting. It is also interesting, as a side note, that if you search for physical therapy, the American English term, the search gives you far more diversity than what we see here.

 

physio
Google image search for “physiotherapy” (June 28th 2017). Are all physios aspiring to be knee specialists?

The image of a physiotherapist in these advertising images reflects the self-perception, and aspiration, of how physiotherapists see themselves and want to be seen. The object-body of labour is central in these images, but it is compartmentalised and framed, supine, managed by the therapist, and also able-bodied, white, young or at least fit. The therapist in these images works in a bright white room, rarely looking at the person, but compartmentalising the object-body by gazing, to use the Foucauldian term, at body parts – the knee or shoulder or hip. This analytic gaze disintegrates the body and reduces it to what is being gazed at. The stance of both bodies signifies the use of technical skills, such as specific tests or manual techniques, signifying a high-tech rather than high-touch aspiration despite the direct physical touch.

Some of the other images here indicate that the goal of physiotherapy is normality: from wheelchair to walking or even running. They also indicate cleanliness. The white room, the light colours of the clothing, the general clean and able appearance of the patient/clients. If analysed through the body work lens, these images indicate privileged bodies and professional status and therefore, paradoxically, a greater distance from the body despite the central role it first appears to have.

Chiasmus: “flippin ethics”

Chiasmus means the rhetorical reversal of the order of words in two parallel phrases. My idea is to think how it works as a dialectical model for ethical thinking, in reference to bodies and body work in physiotherapy.

In the opening scene for Shakespeare’s Macbeth the three witches’ spell, “Fair is foul, fouls fair / hover through fog and filthy air” establishes a critical moral imperative, a moral confusion, for the play: the chiasmic pairing, fair is foul / foul is fair, reveals that not everything is as it immediately appears.

As an ethical model, chiasmus does not represent dichotomous opposites; rather, the opposites exist in a relationship of contradiction that challenges us to think with contractions, not to force a resolution or a synthesis between them. In other words, not to affirm fair as fairness and foul as foulness – to affirm the tautology, the self-sameness of fairness or foulness – but to reflect the contradiction and that the opposites determine each other mutually. In this manner, chiasmus breaks through the façade of affirmation, of positive – positive and negative refer here to the philosophical sense (cf. Hegel, Adorno), not the emotions of everyday language – and it draws attention to whatever is behind the positive: the façade, the identity, the ideology, what is merely given or posited. Such critique and indeed resistance to the given is, as I argue elsewhere, a political stance that is ethical, and an ethical stance that is political.

What would such chiasmic model mean for physiotherapy as body work? The chiasmic model points towards critical areas of research for physiotherapy, ones that are hidden from the positivistic mainstream: non-normative bodies, ambivalence in touch, body waste and fluids, stigmas and taboos, the affective and abjective, as well as challenging the image of the physiotherapist as the privileged body that tends to de-materialise the object-body of its labour which constructs and maintains an identity that is exclusive of non-normative bodies both as patient/clients and as therapists.

In sum, the concern of the chiasmic is in the negative; the hidden and invisible, the silent and silenced, the unknown and unknowable, the non-conceptual, the nonidentical, that which we do not fully grasp – this concern with the negative is the heart of critique and resistance. It is this difficult area that body work unveils and since physiotherapy research has only recently shown increasing interest in the critical, it is perhaps no surprise after all that there has been little interest in body work.

 

References

McDowell, Linda. Working Bodies: Interactive Service Employment and Workplace Identities. London: Routledge, 2009.

Tedre, Silva. “Tukisukkahousut sosiaalipolitiikkaan.” In Eeva Jokinen, Marja Kaskisaari and Marita Husso (eds.) Ruumis töihin! Käsite ja käytäntö. Tampere: Vastapaino, 2004.

Twigg, Julia. Bathing – The Body and Community Care. London: Routledge, 2000.

Twigg, Julia. The body in health and social care. Houndmills: Palgrave, 2006.

Twigg, Julia, Carol Wolkowitz, Rachel Lara Cohen, and Sarah Nettleton. “Conceptualising body work in health and social care.” Sociolofy of Health and Illness 33 (2011): 171-88.

Wolkowitz, Carol. Bodies at Work. London: Sage, 2006.

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