Thanks to everyone who sent me comments and thoughts on the Connectivity writing project. Over the next few days I’ll post up some of the feedback and thoughts that these pieces. Remember to send comments on these things too and I’ll pull them all together.
This post came from Barbara Gibson – Associate Professor, in the Department of Physical Therapy at University of Toronto, and Senior Scientist at Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto.
I am hoping that as a critical group we can use this as a point of departure to delve a little more into the philosophical approach(es) that underpin these ideas. In particular, drawing out the relational nature of connectivity and extending the elements beyond people and things to include emotions, places etc. and to explore how “people” are also connectivities in themselves (and constantly changing). Here is how I described it in a recent paper that might help. (I use the term assemblages but I think they are parallel concepts) – see reference at the bottom of this post. The notion of ‘assemblages’ that I further explore below, comes from the work of Deleuze and Guattari who describe collections of heterogenous elements that in coming together produce particular effects. For my purposes here, the primary elements of interest are bodies, identities, technologies, and places, but assemblages can include an endless variety of elements from physical objects to events to utterances. Importantly, assemblages are not stable or closed systems, but rather temporary connections that continually come together and then break apart, forming different assemblages with other elements that produce different effects. For example, assemblages formed between bodies, wheelchairs, and places are not permanent states, but temporary connections that enable certain actions and activities and constrain others. To refer to a person as ‘wheelchair-dependent’ carries with it stable notions of ability and disability that belie the myriad possibilities of a body-wheelchair-place assemblage. A wheelchair can provide significant advantages in one time/place, i.e. making movement easier or faster, and disadvantages in others, if movement is limited by stairs, for example. Thus talk of dependence and disability becomes reconfigured as moments of possibility realized through multiple temporary assemblages . As you note the social versus medical model discussion has created its own classificatory binary. The connectivity premise is a radical departure in that it challenges the parameters of the debate. Instead of focusing on where disability is located ie body vs society, it rejects disability as a (stable) category. Different connectivities can then be analyzed for their effects. Some will be ‘disabling’ some ‘enabling’; often they will be both depending on context and how disability and ability are ordered within that context. Another way of thinking of this is not to focus on what a person is (disabled vs non-disabled) but what the connections (assemblages) do in the world (eg through an ANT analysis) . A potential direction for the paper is to critically examine the success of the ICF in putatively addressing the divide between the social and personal models of disability. The ICF was created in part in response to critiques of the ICIDH and its presupposition that impairment led to disability in a linear cause and effect relationship. A close reading of the ICF reveals that this relationship still lurks in the details of the model. Moreover the ICF still positions disability in opposition to typical or “normal” body structures , functions, activities and roles. The ICF then, while perhaps useful in many ways, functions to categorize persons as disabled or non-disabled in relation to their biological impairments and to normative assumptions of good or poor function. Reference Gibson BE. Parallels and problems of normalization in rehabilitation and universal design: enabling connectivities. Disability and Rehabilitation. 2014 Mar;36(16):1328-33. http://informahealthcare.com/doi/pdf/10.3109/09638288.2014.891661
kaatkinson says
These ideas of connectivity are really helpful in starting to ‘re-imagine’ physiotherapy and how we could change the ways in which we interact and collaborate with patients (or how we might influence our students to do this). The model used almost exclusively to teach students about ‘dysfunction’ (not a ‘good’ word), however, is the ICF and as Barbara alludes to, it falls into the pattern to which physios tend to default: that of the focus on measurement and classification. I find the concept that a person can be categorised and essentially, put into a pigeonhole in a five to twenty minute assessment, worrying. This reductive approach positions the therapist as the powerful expert and the patient as the passive recipient of ‘management’; a passive body. (We do perhaps need to put the ICF in its context as a global resource that consider many issues relevant to a wide range of countries where disability is seen very differently).
I am not suggesting that physiotherapists, either individually or collectively, approach their daily activities filled with ‘predispositions’ of power which they simply execute. They, along with their patients, are social actors subject to social relations which “constitute structures of choices within which people perceive, evaluate and act” (Lukes 2005 p 9). Most physiotherapists work in institutions (generally NHS outlets in the UK) and within those are also subject to power relationships to which they largely consent.
Whilst physiotherapists may be able to appreciate and understand a critique of the biomechanical/biomedical approach to the body, because of the entrenched power relations within medicine, they are possibly held in a position of not being able to change that by the instrumentality of the institution. There is a sense in which therapists could be seen as being (or could perceive themselves as) entrenched or entrapped; not necessarily self entrapped but almost put into that position by the organisational behaviour and power structures of the NHS. People are where they are because of context rather than as a result of active intent. This is a challenging situation to address.
I think that anything we can do to enable physiotherapists (and other allied health professionals) to think outside these boxes is crucial. There is a lot of work to do and starting to get physiotherapists to recognise that philosophical ideas do actually apply to their practice is a good starting point!
I love the idea of “moments of possibility” related to ‘assemblages’ or connections in the world. Maybe that’s a starting place for us.
Lukes S (2005) Power: a radical view (2nd ed) Palgrave, Basingstoke
Dave Nicholls says
Hi Karen
Thanks for the comments on power relations in health care and for the Lukes book reference.
Another aspect of the ICF that’s often overlooked is that it’s designed primarily as an assessment tool, i.e. as a way for me (biomedically-skilled practitioner) to assess you (disabled person). This idea of external objective assessment is a cornerstone of Western biomedicine. We need to acknowledge the strengths of this approach, but also its limitations. It reinforces the power asymetry between clinician and patient; does little to give voice to people who are ‘othered’ by biomedicine; and restates the value of quantitative evaluation of what are actually highly complex, nuanced, personal and social phenomena.