Content uploaded by Jenny Setchell
Author content
All content in this area was uploaded by Jenny Setchell on Mar 15, 2018
Content may be subject to copyright.
Content uploaded by Ukachukwu Okoroafor Abaraogu
Author content
All content in this area was uploaded by Ukachukwu Okoroafor Abaraogu on Jan 08, 2018
Content may be subject to copyright.
CHAPTER 6
A critical perspective on
stigma in physiotherapy:
The example of weight
stigma
Jenny Setchell | Bloorview Research Institute, Holland Bloorview
Kids Rehabilitation Hospital / School of Health and Rehabilitation
Sciences, The University of Queensland
Ukachukwu Abaraogu | University of Nigeria, Department of
Medical Rehabilitation / School of Health and Life Sciences,
Glasgow Caledonian University
Abstract
is chapter explores what might be learnt about physiotherapy
by considering its intersection with stigma. Stigma was described
by Goman as a phenomenon whereby an individual has an attri-
bute that is deeply discredited by society, and is rejected as a result
as a result of the attribute; where “normal identity” is “spoilt” by
the process of stigmatisation. From a post-structuralist critical
perspective, stigma is not static or nite but is (re)constructed
in various social, historical, cultural and political environments.
A characteristic that is stigmatised in one context may not be in
another. Considering this, the context of physiotherapy has the
possibility to (re)create or (re)inforce stigmatisation of certain
a critical perspective on stigma in physiotherapy
attributes not only in ways that may reect general societal stigma,
but also in ways that may be specic to the profession. In this
chapter, we discuss stigma in physiotherapy broadly, considering
what it is about physiotherapy that may contribute to the discre-
diting of certain attributes. We use the example of weight stigma,
a topical and little explored form of stigma that is becoming more
evident in healthcare in the current climate of “the obesity epide-
mic”. We draw from empirical research, denitions and narratives
of physiotherapy in dierent countries (particularly our home
countries of Nigeria and Australia) to help examine weight stigma
in physiotherapy. We explore how weight stigma is enacted in a
physiotherapy context – a profession in which there is an inherent
focus on bodies. We conclude with a discussion of possibilities for
the physiotherapy profession to learn from a greater considera-
tion of stigma.
Introduction
He [the physiotherapist] was very sporty and t. Even though I’d been
doing step aerobics I didn’t feel very t …. I think I have a stereotype
that physios are very healthy and very t and very slim and …. I feel
like I’m not really like that… I guess that makes me feel sort of inade-
quate in a way…. It’s almost like I started making lots of excuses.
Hetti (pseudonym), from Setchell, .
is chapter explores physiotherapy using a stigma lens. We argue
that thinking critically about stigma can illuminate much about
physiotherapy – in particular some of the psychological, social,
political and power aspects of the profession. We highlight that tra-
ditional understandings of stigma tend to focus primarily on the
psychological and interpersonal aspects of stigma (e.g., the essen-
tialist understandings of Allport, and Adorno, and the symbolic
jenny setchell and ukachukwu abaraogu
interactionism of Goman) and do not suciently attend to broa-
der contextual aspects. To further understandings of stigma in
physiotherapy beyond the psychological/interpersonal, and to
consider broader contextual issues, we draw on post structuralism
(in particular Foucault) to engage a critical perspective. e epi-
graph above provides hints of some of these contextual factors: for
example, it reveals that physiotherapy is constructed as health- and
tness-focussed. Oen returning to the exemplar of weight stigma,
we discuss how such constructions can have some (usually uninte-
ntional) negative eects, which we believe are little explored in the
profession.
e epigraph, and other ndings from the same study which
involved interviews with patients about their experiences of atten-
ding physiotherapy, provide an opportunity to imagine what it
might feel like for someone with a stigmatised characteristic (in
this case being labelled “overweight”) to enter a physiotherapy
clinic (Setchell, Watson, Jones & Gard, ). People in this
study described their experiences of discomfort when attending a
physiotherapy clinic including: sitting on a chair that is too small
for them; seeing health promotion posters of thin people on the
walls; observing sporty-looking people exercising in the Pilates
area; meeting the physiotherapist who (like in the epigraph) was
thin and sporty-looking; feeling like their body was exposed to
judgement when they undress or are observed; and being told that
their condition was due to their weight (ibid). ese types of expe-
riences, where the person feels judged (stigmatised) for a particular
characteristic, are known to negatively aect people, including cau-
sing them to have poorer physical and psychological health outco-
mes; exercising less; having more disordered eating; and avoiding
health care appointments – eectively being denied healthcare
(Drury & Louis, ; Phelan et al., ). is chapter explores
why patients might have these types of stigmatising experiences
a critical perspective on stigma in physiotherapy
in physiotherapy, and considers what physiotherapists might do
to help create a more supportive environment for their clients. We
have divided the chapter into two distinct sections. e rst section
is a theoretical introduction to stigma – and a critical exploration
into why it might occur. e second section discusses the physio-
therapy profession, highlighting how thinking critically about the
nexus between stigma and physiotherapy can help develop new
thinking and practices.
Stigma
Research on the nature of stigma has spanned a number of discipli-
nes, and many stigmatised characteristics, which may explain why
there are many denitions of stigma. Crocker, Major, and Steele
() produced a widely-used denition: “stigmatized individu-
als possess (or are believed to possess) some attribute, or characte-
ristic, that conveys a social identity that is devalued in a particular
social context” (p. ). eir denition, derived from Goman’s
symbolic interactionist stigma theories, outlines some of
the major micro-social components of stigma: it is linked to an
attribute, it involves negative judgement, it is social rather than
individual, it does not reside within a person or the stigmatised
characteristic but is produced in interactions with others, and it
is not a static phenomenon but is created only in some contexts.
Applied to this chapter’s examplar of weight stigma, this deni-
tion highlights that people are judged negatively based on their
perceived status as overweight, and that this conveys a devalued
social identity in many contexts (at times including, as we will
argue, physiotherapy). However, while useful, we believe there
are a number of limitations to such denitions. To explore this
issue, we will discuss and critique three mainstream approaches
to understanding why stigma happens – and illustrate what they
jenny setchell and ukachukwu abaraogu
might mean in the context of physiotherapy research on weight
stigma. We have chosen these approaches because, while they are
largely discredited as comprehensive theories, they continue to
underpin most research into stigma, and are also part of what cur-
rently constitutes lay understandings of (and rationale for) stigma-
tisation (Dixon & Levine, ).
Social cognition approaches explain stigma as the result of the
brain’s oversimplication when processing the large amounts of
information it receives about other people (Allport, ). By sug-
gesting that all minds function similarly, these approaches present
stigma as an inherent, essential part of being human. However, this
theory cannot explain why only some people stigmatise. It cannot
explain why some physiotherapists score highly on weight stigma
tests, while others do not (Abaraogu, Duru & Setchell forthcoming;
Setchell, Watson, Jones, Gard & Bria, ). Further attempts to
explain stigma include the personality trait approaches associated
primarily with Adorno, Frenkel-Brunswick, Levinson, and Sanford
(). As the name suggests, these theories posit that only people
with certain personality types stigmatise; that is, the physiotherapists
who stigmatise do so because they have a particular personality type.
One critique of these approaches, however, is again their essentia-
lism: they constitute personalities as static and do not allow for ana-
lysis of stigma that is incited in particular social or political contexts.
Both the personality and the social cognition approaches are indivi-
dualistic and cannot consider, for example, the societal or institutio-
nal production or perpetuation of stigma that has repeatedly been
shown to be possible in experimental and real life conditions.
e nal proposed way of understanding stigma we discuss
is grounded in Goman’s symbolic interactionism. e group
membership approaches focus on the eects on individuals of
being part of a group (Tajfel & Turner, ). ose using these
approaches argue that when people behave as members of a group
a critical perspective on stigma in physiotherapy
(e.g. physiotherapists) they react to other people according to their
group’s social beliefs in order to consolidate their own sense of
identity, or as a result of cognitive simplications (like the social
cognition approaches). As a result, proponents argue that people
give preferential treatment to those they identify as being part of
the same social group to which they themselves belong and may
stigmatise other people on the basis of perceived other group mem-
bership. Using this theory, physiotherapists (and other groups)
are seen as inherently stigmatising – they might be expected to
stigmatise people who are overweight (for example) if they are
not seen to be similar to physiotherapists – thus constituting an
outside “group”. While this group membership understanding of
stigma is more complex, and takes social context into account more
than other approaches we have outlined, stigma is still considered
to be a by-product of cognitive simplications (Tun, ). As a
result, the same criticisms are relevant as for the social cognition
approaches regarding the nature of stigma as inherent to human
thinking (ibid). Some have also contested that this theory presents
an oversimplied, static understanding of how groups operate,
arguing that they are largely considered in isolation from wider
contexts (Jenkins, ). For example, some cultures tend to favour
people from other groups rather than stigmatise them (Gough &
McFadden, ). In relation to physiotherapists and people who
are considered overweight – this is a valuable approach to under-
stand some of the stigma that might pass between the two groups,
but the approach lacks the nuance to consider how broader insti-
tutional issues of power might be involved, or where these issues
might vary (for example, what happens if a physiotherapist herself/
himself is labelled overweight?).
In summary, while the three approaches (social cognition, perso-
nality trait, and group membership) we have discussed above may
account for certain occasions of stigma they all lack mechanisms to
jenny setchell and ukachukwu abaraogu
understand the eects of political, cultural or historical variations
on stigma, and do not directly consider the relevance of power
(Gough & McFadden, ). As a result, they are not able to acco-
unt for possible contextual aspects of stigma in physiotherapy. To
address these issues, we draw from post-structuralist thinking, in
particular work based on theories of the French post-structuralist
philosopher Michel Foucault.
Foucault considered behaviour, interactions and feelings to be
produced through discourses (ways of constituting knowledge
through particular patterns of thinking and doing), which he saw as
created by (and creating) not only social, but also political, cultural
and historical contexts (Foucault, , ). Applied to stigma,
Hannem () argued that this means stigma is not only socially,
historically, culturally and politically situated, but also created or
recreated. Stigma is not nite or static but may be (re)constructed
in varying environments and linked to power inequalities.
Foucault’s theories (particularly those on governmentality) con-
tribute an understanding that power and governance are exerci-
sed not only by the state and its institutions, such as the army and
police, but also by other institutions that are not traditionally seen as
exercising power (Foucault, ). While never directly discussed
by Foucault, other theorists such as Stacey Hannem have applied
Foucault’s thinking to stigma in ways that help to consider osten-
sibly power-neutral “institutions” such as physiotherapy (Setchell,
Gard, Jones & Watson, ). For example, Hannem () noted
that stigma can come from the institutionalisation of ways of mana-
ging the perceived risk of a stigmatised attribute. While the insti-
tution oen intends overtly to help “when the need for assistance
is justied by the inherently ‘dierent’, ‘risky’ or ‘tainted’ characte-
ristics of the population, stigma is created in the veryagencies that
are supposed to be providing help” (Hannem, , p. ). With
characteristics identied as risky, certain “truths” are produced
a critical perspective on stigma in physiotherapy
that they (or the people that possess these characteristics) require
management, or what Foucault would call “discipline”. Particular
behaviours and bodies are thus valorised, allowing for other beha-
viours (e.g., exercising, dieting) and bodies (e.g., thin, muscular)
to become considered “less-than”: in this way, power is interwoven
into some forms of stigma. It is important to note, however, that
this power moves in both directions; people who are stigmatised
can resist individuals or institutions (Foucault, ). ese theo-
ries on power provide an opportunity to explore this production of
truth in the profession of physiotherapy that may result in stigma.
Post-structuralist perspectives provide insight into the socio-
political reasons behind weight stigma in a contemporary context.
Foucault argued that the ingenuity of the systems of power (or what
he referred to as “regimes of truth”) that create the conditions for
disciplining people who have particular characteristics is that any
people, even those who possess the “risky” characteristic themsel-
ves, can take up a disciplining action. People are thus disciplined
(or discipline themselves) to manage this socially produced risk-
truth so that they are maintained as “productive citizens’ to support
the ‘greater good’ of society” (Farrugia, ). erefore, a person
can be seen as “unproductive” or “expensive” and can be held indi-
vidually accountable for this lack of productivity (Foucault, ).
is thinking can be applied to this chapter’s example of weight
stigma, but it can also help understand aspects of other types
ofstigma found in physiotherapy such as chronic pain or disability
stigma. Foucault () argued that this way of viewing people is
in line with neoliberal economic rationalist systems of governance,
where there is a focus on individual (rather than state) responsibi-
lity for productivity.
Furthermore, Foucault highlighted an increase in medicali-
sation, where attributes that had not previously been considered
“an illness” were subsequently deemed “abnormal” and the subject
jenny setchell and ukachukwu abaraogu
of medical attention – and stigma (Gard & Wright, ; Lupton,
a). For example, Murray () discusses medical construc-
tions of fatness as “deviance”, and Tischner and Malson ()
argue that health approaches to “obesity” oen present fatness as a
“failing”. Again, similar thinking has been applied to other forms of
stigma such as disability stigma (Shildrick, ).
Based on these post-structural, critical perspectives on stigma,
we argue for an emphasis on power, and the historical, political,
cultural constructions or enactments of stigma. A post-structu-
ral perspective helps illuminate why weight stigma, for example,
appears common in the west (Puhl et al., ) and has been less
common, but is increasing, in the global south (Brewis, Wutich,
Falletta-Cowden, & Rodriguez-Soto, ), and that weight stigma
also diers with various other contexts such as gender or sexuality
(van Amsterdam, ). A nuanced understanding of context is
thus important to an exploration of stigma. In the next section, we
highlight how the context of physiotherapy might intersect with
stigma.
Physiotherapy
Overall there has been little discussion about stigma in the phy-
siotherapy literature. A small amount of research has been done
on the stigmatisation of disability, mental illness and chronic pain
(e.g., French, ; Probst & Peuskens, ; Synnott et al., ).
To summarise, this research highlights two main points: stigma
occurs in a number of situations in physiotherapy, and physio-
therapists lack an understanding of the stigma that their patients
might experience. ere is an even smaller amount of research
highlighting the claim that physiotherapists also are stigmatised
(or self-stigmatise) for possessing various “othered” attributes. For
example, physiotherapists hold self-stigmatising fears of gaining
a critical perspective on stigma in physiotherapy
weight (Setchell et al., ), discipline their own bodies to “main-
tain a healthy weight” (Black, Marcoux, Stiller, Qu & Gellish,
, p. ), and negotiate disability stigma (Atkinson, & Owen
Hutchinson, ). is second body of research, although not the
focus of this chapter, highlights that it is important to acknowledge
that physiotherapists too can have bodies, behaviours or attributes
that may be stigmatised. As we hope readers are already starting
to see, a deeper consideration of stigma might illuminate much
about physiotherapy – providing opportunities to enact social,
psychological and political aspects of care towards rethinking
aspects of practice that might produce stigma. We now examine
physiotherapy reexively to consider some relevant assumptions
underpinning the profession thinking and practices.
e physiotherapy profession demonstrates many similarities
across the world, despite some local variations. Similarities are evi-
dent in the self-denitions of professional bodies on their ocial
websites. e Australian Physiotherapy Association () de-
nes physiotherapy as “a healthcare profession that assesses, diag-
noses, treats and works to prevent disease and disability through
physical means”. e physical focus of the Australian association
is echoed by the Nigeria Society of Physiotherapy (), which
denes physiotherapy as involving the “evaluation of patients
through the administration of physical tests to determine the pre-
sence and/or extent of an injury prior to the use of physical moda-
lities for preventive and therapeutic purposes”. However, this focus
applies not only to our home countries. For example, the Chartered
Society of Physiotherapy in the United Kingdom () provides
a similar, but somewhat broader, denition of physiotherapy as a
profession that helps “people aected by injury, illness or disabi-
lity through movement and exercise, manual therapy, education
and advice”.While seemingly an obvious point, it is interesting to
note the repetition in these denitions of words such as “physical”,
jenny setchell and ukachukwu abaraogu
“exercise”, “manual” and “injury”. While these words cannot reveal
what happens in clinical practice, we argue that they do highlight
an underlying institutionalised assumption in physiotherapy that
physical issues are primary, and necessarily demand physical tests
and physical treatments. We unpack and problematise this assump-
tion in the remainder of this chapter and argue that it is a key issue
that exploring stigma exposes in the profession.
Many physiotherapists would argue that this physical focus
of the profession is changing. Certainly, in recent times there
have been signs of a shi away from a purely physical approach
in some sub-specialities. For example, there is growing aware-
ness that conditions such as pain may also have psychological or
social origins. However, relevant to considerations of stigma, there
remains a notable absence of any discussion of the cultural, politi-
cal or temporal factors involved in physical health. eoretical and
philosophical investigations of physiotherapy are scarce, and some
authors argue that the profession lacks self-analysis (Wikström-
Grotell & Eriksson, ), reexivity (Trede, ) and acknowled-
gement of its historical and sociopolitical context (Shaw & DeForge,
). A small but growing number of authors (many of whom are
included in this book) have begun to investigate the philosophical
underpinnings of physiotherapy. We draw mainly upon the work
of these critical physiotherapy scholars (and at times critical health
literature from related elds) to discuss elements of the profession
relevant to stigma. Here we apply the Foucauldian concept introdu-
ced earlier: that power and governance play out in physiotherapy,
an institution that has not been traditionally thought of as a site of
political power. We make visible the elements of the profession that
can render stigma (with a particular focus on weight stigma) pos-
sible, salient and consequential. We introduce these topics under
three sub-headings: “positivism”; “bodies, visibility and norma-
lity”; and “professional reexivity”.
a critical perspective on stigma in physiotherapy
Positivism
Positivism is underpinned by the idea that there is a stable, know-
able reality that can be described through observation and is the
underlying philosophy behind traditional scientic approaches
to health research. Although physiotherapy practice is arguably
grounded in both humanistic and scientic paradigms, the pro-
fession generally focuses on the biomedical scientic perspec-
tive grounded in positivism (Praestegaard & Gard, ; Setchell,
Nicholls & Gibson, ). Parry () argued that the adoption
of this orthodox “medical model” dates back to gender-related his-
torical constraints on the women who founded the profession and
who were willing to “trade autonomy for orthodoxy, to carry out
ancillary and subordinate tasks … in exchange for recognition and
patronage” (p. ). Today, this positivist way of thinking is evident
(for example) in the way that randomised controlled trials and sys-
tematic reviews are upheld as “gold standards” in the profession,
to the marginalisation of other methodologies (Crosbie, ).
Orthodox biomedical approaches are also reected in the physical
focus of the professional denitions we discussed earlier, and many
aspects of physiotherapy-patient interactions.
Before continuing, we want to highlight that we do not intend
to suggest that positivistic scientic endeavours are unimportant,
or necessarily bad. Rather, like others, we propose that this type of
science can only address some of the phenomena physiotherapists
deal with, while also having some underexplored negative con-
sequences. For example, Bolam and Chamberlain () argued
that positivism positions the health professional as the powerful
“expert”. Recent literature discusses this “expert positioning” in
physiotherapy, highlighting that physiotherapy practice is oen
primarily practitioner-centred, where the therapist oen controls
the direction, content and denition of “truths” in their interac-
tions with patients (Hiller, Guillemin, &Delany, ). is expert
jenny setchell and ukachukwu abaraogu
positioning can have ethical implications (Trede, ; Wikström-
Grotell & Eriksson, ). For example, Bjorbækmo and Engelsrud
() argued that an “expert” perspective can be noted in extensive
“testing” of children with disabilities. Using a phenomenological
approach, the authors suggested that such testing transmitted the
physiotherapists’ views of what was “important, correct or admi-
rable” (p. ), which could result in insecurity and lack of con-
dence of the patient in themselves. In a Foucauldian analysis of
Danish physiotherapy practice, Praestegaard, Gard, and Glasdam
(, p. ) argued that when patients resisted physiotherapists’
“regimes of truth”, including those about body size, they were met
with stigma and judgement from physiotherapists:
ese patients resisted the physiotherapists’ understandings and
descriptions of body image, self-care and medicalization of the body.
is means that the patients do not accept the premise for physiothe-
rapeutic treatment, and even worse, they defy by not obeying. Accor-
dingly, the physiotherapists meet these patients with judgmental and
stigmatizing attitudes. Patients, who are not able to live in the politi-
cally dened, normative “healthy” way, are disapproved as they are
regarded as not taking active responsibility for their own life. (p. )
Another possible negative consequence of having a positivist per-
spective is that the health professional is oen established as a sci-
entic or “objective” observer, assumed to be free from subjective
observations or moral judgements (Lupton, b). Assumed objec-
tivity or neutrality is likely to obscure the need for critical examina-
tion of the beliefs underlying healthcare practice. In particular, the
social, cultural, power and political elements of practice may not be
attended to (Eisenberg, ; Jorgensen, ). Patton and Nicholls
() posited that lack of attention to these elements might result
in health professionals having diculty observing judgement or
stigma in their own attitudes or behaviour. is explains the ndings
a critical perspective on stigma in physiotherapy
in the stigma studies that physiotherapists oen overlook that stig-
matised attributes such as fatness can potentially be assigned social,
cultural and economic/political value (e.g., Setchell, Watson, Gard
& Jones, ). As Nicholls and Gibson () argued, these aspects
may well be overlooked as “confounding factors” when employing a
predominantly positivist perspective.
We want to be careful to clarify that we are not suggesting that
positivism necessarily leads to behaviours such as practitioner-
centred practice or positioning the therapist as an “expert”, nor that
these ways of working always lead to less ethical practices. Rather,
we wish to argue that in relation to the stigma, it is important to
consider potential issues of power involved in positivism, which
can be evident in some of the clinical expressions of this particular
way of viewing the world.
Bodies, visibility and normality
e body is clearly central to practice in physiotherapy. “Doing”
physiotherapy involves closely observing bodies, touching bodies,
and partial undress of the body. In clinical settings physiothera-
pists commonly comment on, assess, move bodies or body parts.
Furthermore, they ask patients to be aware of their own bodies, so
that, for example, patients can learn about and potentially change
their postural or movement habits. is can involve physiothera-
pists encouraging patients to give visual attention to their bodies
by observing themselves in mirrors or video recordings. Clinical
interactions are frequently about two (or more) bodies interacting
in close and intimate ways. We argue that these interactions are
about the eshy reality of bodies at least as much as about think-
ing about the vector a muscle exerts on a bone or the number of
degrees a joint moves. e corporeal presence of bodies (and thus
corporeal stigmatised attributes such as fatness) are thus routine
and integral parts of physiotherapy.
jenny setchell and ukachukwu abaraogu
While a physiotherapist might ostensibly focus on observing
the movement of a joint, other elements of what they are doing
have implications for the visibility of stigmatised characteristics.
Returning to this chapter’s example of weight stigma, the fatness of
a body is likely to be more obvious because the physiotherapist may
have removed clothing from the body, might be touching the body
and looking closely at the body (Setchell et al., ). Increased
visibility of this stigmatised attribute could have a number of eects
on the consultation. Rolls of fat can become exposed, touched, and
under the therapist’s gaze (ibid) in ways that are rare in many other
healthcare environments (e.g., dentistry or psychology) or most
day-to-day interactions. Regardless of what the therapist is actually
thinking, the way the body looks – including visible stigmatised
characteristics - may become a particularly salient issue for people
in physiotherapy contexts.
Despite the integral involvement of the body in physiotherapy,
little theoretical or philosophical attention has been given to how
the body is constructed, viewed and managed by the profession
(Nicholls & Gibson, ). is is not unexpected when consid-
ering the predominantly physical focus of the denitions of the
profession presented earlier in this chapter and the positivist theo-
retical perspective that underpins much of the thinking in the pro-
fession. Congruent with these theoretical underpinnings, Nicholls
and Gibson () argued that physiotherapists generally attend to
the body in a biomechanical (or “machine-like”) way. For example,
physiotherapy research and clinical work has placed much focus
on the length of muscles, joint range of movement, the type of
exercises to prescribe for a particular condition and physical func-
tion (Jorgensen, ; ornquist, ). However, there are many
other possible understandings of bodies that physiotherapy mar-
ginalises, such as the person’s lived experiences of their body in
health and illness, and the social, cultural or political meanings of
a critical perspective on stigma in physiotherapy
bodies, including stigma. e priority physiotherapists ascribe to
various understandings of the body has important implications for
clinical practice.
Using a Bourdieusian approach, Gibson and Teachman ()
examined the biomechanical focus of the profession, arguing that
physiotherapists put considerable eort into establishing what a
“normal” body is. is eort can be seen in studies such as the
Norms Project, which aims to establish for physiotherapists what
a “normal” range is in “healthy” humans in the areas of dexterity,
balance, ambulation, joint range of motion, strength, endurance
and motor planning (McKay et al., ). Looking at power from
a Foucauldian perspective, considering who constructs what con-
stitutes “normal” is very important, as these people have the power
to decide who/what needs intervention (disciplining) to become
more “normal”. As discussed by Nicholls and Gibson (), hav-
ing a construction of a “ normal” body in physiotherapy necessarily
means an “abnormal” or “deviant” body is also established. When
physiotherapy seeks a normatively functioning body it “disciplines”
bodies that are “abnormal”. Notions of normality can contribute to
negative self-identities, and potential stigmatisation, of those who
are constructed as “not normal”.
Professional reflexivity
Considering the potential issues that we have outlined associ-
ated with positivism and the understandings of bodies, we sug-
gest it is a matter of concern that authors have highlighted a lack
of reexive practice within the profession (Shaw & DeForge,
). Clouder () has argued that this lack can be seen at
an individual level where, unlike some other healthcare profes-
sions, reexivity is not an established part of the practice and
education of clinical physiotherapists. In some cases, clinical
jenny setchell and ukachukwu abaraogu
self-reection is encouraged (Patton, Higgs, & Smith, ) and
has been taken up institutionally (Frith, Cowan, & Delany, ;
Rowe, ). However, in discussing interviews and workshops
with physiotherapists on the topic of self-reection, Clouder
() highlighted that while participants oen demonstrated the
ability to reect on the technicalities of practice (such as the suc-
cess of treatment techniques), they found it dicult to consider
their own subjectivity: “the clinician her/himself did not appear
to be part of the reective frame of reference. Even though self-
awareness was clearly identied as important, there was – without
exception – a transfer of attention to the client/patient” (p.).
Similarly, Trede () maintained that there is little prioritisa-
tion of a deeper individual reexivity, such as consideration of
social, philosophical, interpersonal, emotional, embodied or
power elements of practice. We suggest that this could mean
that physiotherapists are ill-equipped to recognise and respond
to potentially complex or sensitive interactions involving stigma.
ere is also a lack of theoretical and philosophical reexivity at
the discipline level. For example, little attention is given to these
factors in physiotherapy education curricula or research endeav-
ours (Nicholls & Gibson, ; Setchell et al., ). Without
these intellectual resources, the profession is likely to be unaware
of its theoretical underpinnings; psychological, social and politi-
cal issues such as stigma; and may struggle to nd other ways of
thinking about its practice.
Conclusion
inking critically about stigma in physiotherapy opens up
opportunities to think and practice otherwise in the profession.
Investigating stigma in physiotherapy has an unsettling eect on
some of the premises currently underpinning the profession: it
a critical perspective on stigma in physiotherapy
contributes to thinking and practice that questions the dominance
of the body-as-machine focus of the profession. Questioning this
focus supports calls for the profession to incorporate other ele-
ments such as the socio-political aspects of bodies and other
things. It contributes to calls for more person-centred approaches
to the individuals who seek our care. Encouragingly, this work has
begun to be taken up in a number of areas. For example, a number
of physiotherapists have argued for more reexivity in education
and practice. Both Patton et al. () and Rowe () argued
that it is important to critically examine physiotherapy pedagogy
to enhance clinical learning, and Nicholls and Gibson () dis-
cussed the importance of philosophy in physiotherapy. Further,
Grace and Trede () suggested the need to rethink pedagogi-
cal approaches to incorporate philosophical knowledge. ere are
also a growing number of physiotherapists who are developing
comprehensive theoretical insights into physiotherapy (Nicholls
et al., ; Nicholls & Gibson, ; Setchell et al., ). is
book also contains many examples of physiotherapists approach-
ing the socio-political and philosophical aspects of the profession
that can help physiotherapists build the theoretical resources to be
aware of aspects of stigma discussed in this chapter. Broadly, this
thinking matters politically. It is a challenge to an over-reliance on
reductionist thinking, including powerful systems that preference
individual blame for health conditions. is chapter supports other
critical thinking that advocates a paradigm shi to a physiotherapy
that incorporates broader considerations of the socio-political con-
ditions that create the possibilities for issues such as stigma.
Acknowledgments
Much of the material presented in this chapter is a reworked ver-
sion of an unpublished section of Dr Setchell’s PhD thesis, and a
jenny setchell and ukachukwu abaraogu
small section has already been published in Physiotherapy eory
& Practice (permission has been granted by the journal to repro-
duce the content here).
References
Abaraogu, U., Duru, D. & Setchell, J. (forthcoming). Weight stigma in
physiotherapy: A cross sectional survey of Nigerian physiotherapists.
Adorno, T. W., Frenkel-Brunswick, E., Levinson, D. J. & Sanford, N.
(1950). e authoritorian personality. New York, NY: Harper Row.
Allport, G. W. (1954). e nature of human prejudice. Oxford, England:
Addison-Wesley.
Atkinson, K. & Owen Hutchinson, J. (2005). Visually impaired
physiotherapists: Challenging professional attitudes. International
Congress Series, 1282, 908–912.
Australian Physiotherapy Association. (2015). What is physiotherapy?
Retrieved from http://www.physiotherapy.asn.au
Bjorbaekmo, W. S. & Engelsrud, G. H. (2011). Experiences of being
tested: A critical discussion of the knowledge involved and produced
in the practice of testing in children’s rehabilitation. Med Health Care
Philos, 14(2), 123–131. doi:10.1007/s11019-010-9254-3
Black, B., Marcoux, B. C., Stiller, C., Qu, X. G. & Gellish, R. (2012).
Personal health behaviors and role-modeling attitudes of physical
therapists and physical therapist students: A cross-sectional study.
Phys er, 92(11), 1419–1436.
Bolam, B. & Chamberlain, K. (2003). Professionalization and reexivity
in critical health psychology practice. Journal of Health Psychology,
8(2), 215–218. doi:10.1177/1359105303008002661
Brewis, A., Wutich, A., Falletta-Cowden, A. & Rodriguez-Soto, I.
(2011). Body norms and fat stigma in global perspective. Current
Anthropology, 52(269–276). doi:10.1086/
Chartered Society of Physiotherapy Website. (2015). What is
physiotherapy? Retrieved from http://www.csp.org.uk/your-health/
what-physiotherapy
Clouder, L. (2000). Reective practice in physiotherapy education: A
critical conversation. Studies in Higher Education, 25(2), 211–223.
a critical perspective on stigma in physiotherapy
Crocker, J., Major, B. & Steele, C. (1998). Social stigma. In D. Gilbert & S.
Fiske (eds.), e Handbook of Social Psychology (504–553). Boston,
MA: McGraw-Hill.
Crosbie, J. (2013). Does a stubborn commitment to ‘evidence’ stie
innovative thinking? Journal of Physiotherapy, 59, 69–71.
Dixon, J. & Levine, M. (2012). Beyond prejudice: Extending the social
psychology of conict, inequality and social change. Cambridge,
England: Cambridge University Press.
Drury, C. & Louis, M. (2002). Exploring the association between body
weight, stigma of obesity, and health care avoidance. Journal of
the American Academy of Nurse Practitioners, 14(12), 554–561.
doi:10.1111/j.1745-7599.2002.tb00089.x
Eisenberg, N. R. (2012). Post-structural conceptualizations of power
relationships in physiotherapy. Physiotherapy eory & Practice,
28(6), 439–446. doi:10.3109/09593985.2012.692585
Farrugia, D. (2009). Exploring stigma: Medical knowledge and
the stigmatisation of parents of children diagnosed with autism
spectrum disorder. Sociology of Health &Illness, 31(7), 1011–1027.
doi:10.1111/j.1467-9566.2009.01174.x
Foucault, M. (1977). Discipline and punish: e birth of the prison.
London, England: Allen Lane.
Foucault, M. (1978). Security, territory, population: Lectures at the
Collège de France 1977–1978 (G. Burchell, Trans.). Basingstoke,
England: Palgrave Macmillan.
Foucault, M. (1979). e birth of biopolitics: Lectures at the Collége de
France 1978–1979. New York, NY: Palgrave Macmillan.
French, S. (1994). Attitudes of health professionals towards disabled
people: A discussion and review of the literature. Physiotherapy,
80(10), 687–693.
Frith, C., Cowan, S. & Delany, C. (2015). Reection training as a form of
professional development for physiotherapy clinicial educators. Focus
on Health Professional Education: A Multidisciplinary Journal, 16(2),
88–91.
Gard, M. & Wright, J. (2005). e obesity epidemic: Science, morality
and ideology. London, UK: Routledge.
Gibson, B. E. & Teachman, G. (2012). Critical approaches in physical
therapy research: Investigating the symbolic value of walking.
jenny setchell and ukachukwu abaraogu
Physiotherapy eory & Practice, 28(6), 474–484. doi:10.3109/095939
85.2012.676936
Goman, E. (1963). Stigma: Notes on the management of spoiled
identity. London, England: Penguin.
Gough, B., & McFadden, M. (2013). Critical social psychology (2nd ed.).
New York, NY: Palgrave Macmillan.
Grace, S, & Trede, F. (2013). Developing professionalism in physiotherapy
and dietetics students in professional entry courses. Studies in Higher
Education, 38(6), 793–806. doi:10.1080/03075079.2011.603410
Hannem, S. (2012). eorizing stigma and the politics of resistance. In
S. Hannem & C. Bruckert (eds.), Stigma revisited. Ottawa, Canada:
University of Ottawa Press.
Hiller, A., Guillemin, M. & Delany, C. (2015). Exploring healthcare
communication models in private physiotherapy practice. Patient
Education and Counseling, 98(10), 1222–1228. doi:10.1016/j.
pec.2015.07.029
Jenkins, R. (2008). Social identity (3rd ed.). London, England: Routledge.
Jorgensen, P. (2009). Concepts of body and health in physiotherapy: e
meaning of the social/cultural aspects of life. Physiotherapy eory &
Practice, 16(2), 105–115. doi:10.1080/095939800407295
Lupton, D. (2012a). Fat. New York, NY: Routledge.
Lupton, D. (2012b). Medicine as culture: Illness, disease and the body
(3rd ed.). London, England: Sage.
McKay, M. J., Baldwin, J. N., Ferreira, P., Simic, M., Vanicek, N., Hiller,
C. E., . . . Norms project, C. (2016). 1000 norms project: Protocol of
a cross-sectional study cataloging human variation. Physiotherapy,
102(1), 50–56. doi:10.1016/j.physio.2014.12.002
Murray, S. (2007). Corporeal knowledges and deviant bodies:
Perceiving the fat body. Social Semiotics, 17(3), 361–373.
doi:10.1080/10350330701448694
Nicholls, D. A., Atkinson, K., Bjorbaekmo, W. S., Gibson, B. E., Latchem,
J., Oleson, J., . . . Setchell, J. (2016). Connectivity: An emerging
concept for physiotherapy practice. Physiotherapy eory & Practice,
32(3), 159–170. doi:10.3109/09593985.2015.1137665
Nicholls, D. A. & Gibson, B. E. (2010). e body and physiotherapy.
Physiotherapy eory & Practice, 26(8), 497–509.
doi:10.3109/09593981003710316
a critical perspective on stigma in physiotherapy
Nicholls, D. A. & Gibson, B. E. (2012). Editorial: Philosophy and
physiotherapy. Physiotherapy eory & Practice, 28(6), 418–419.
e Nigerian Society of Physiotherapy website. (2015). Welcome.
Retrieved from http://www.nigeriaphysio.org/welcome
Parry, R. (2004). Communication during goal-setting in physiotherapy
treatment sessions. Clinical Rehabilitation, 18(6), 668–682.
Patton, N., Higgs, J. & Smith, M. (2013). Using theories of learning
in workplaces to enhance physiotherapy clinical education.
Physiotherapy eory & Practice, 29(7), 493–503. doi:10.3109/0959
3985.2012.753651
Patton, N. & Nicholls, D. A. (2014). Access, agency and abilities. In Higgs
J, Croker A, Tasker D, Hummell J, & Patton N (eds.), Health practice
relationships: Practice, education, work and society (93–100.).
Rotterdam, e Netherlands: Sense Publishers.
Phelan, S., Burgess, D., Yeazel, M., Hellerstedt, W., Grin, J. & van Ryn,
M. (2015). Impact of weight bias and stigma on quality of care and
outcomes for patients with obesity. Obesity Review, 16(4), 319–326.
doi:10.1111/obr.12266
Praestegaard, J. & Gard, G. (2013). Ethical issues in physiotherapy:
Reected from the perspective of physiotherapists in private practice.
Physiotherapy eory & Practice, 29(2), 96–112. doi:10.3109/0959398
5.2012.700388
Praestegaard, J., Gard, G. & Glasdam, S. (2015). Physiotherapy as a
disciplinary institution in modern society - a Foucauldian perspective
on physiotherapy in Danish private practice. Physiotherapy eory &
Practice, 31(1), 17–28. doi:10.3109/09593985.2014.933917
Probst, M. & Peuskens, J. (2010). Attitudes of Flemish physiotherapy
students towards mental health and psychiatry. Physiotherapy, 96(1),
44–51. doi:10.1016/j.physio.2009.08.006
Puhl, R. M., Latner, J. D., O’Brien, K., Luedicke, J., Daníelsdóttir, S.
& Forhan, M. (2015). A multinational examination of weight bias:
Predictors of anti-fat attitudes across four countries. International
Journal of Obesity, 39, 1166–1173. doi:10.1038/ijo.2015.32
Rowe, M. (2012). e use of assisted performance within an online
social network to develop reective reasoning in undergraduate
physiotherapy students. Medical Teacher, 34(7), e469–475. doi:10.310
9/0142159X.2012.668634
jenny setchell and ukachukwu abaraogu
Rowe, M. (2015). Exploring the characteristics of capable healthcare
professionals. South African Journal of Physiotherapy, 71(1).
doi:10.4102/sajp.v71i1.247
Setchell, J., Gard, M., Jones, L. & Watson, B. M. (2017). Addressing
weight stigma in physiotherapy: Development of a theory driven
approach to (re)thinking weight related interactions. Physiotherapy
eory & Practice, 33(8), 597–610.
Setchell, J., Nicholls, D. A. & Gibson, B. E. (2017). Objecting: Multiplicity
and the practice of physiotherapy. Health, Available online.
Setchell, J., Watson, B. M., Jones, L., Gard, M. & Bria, K. (2014).
Physiotherapists demonstrate weight stigma: A cross-sectional survey of
Australian physiotherapists. Journal of Physiotherapy, 60(3), 157–162.
Setchell, J., Watson, B. M., Jones, L. & Gard, M. (2015). Weight stigma
in physiotherapy practice: Insights from patient perceptions of
interactions with physiotherapists. Manual erapy, 20, 835–841.
Setchell, J., Watson, B., Gard, M. & Jones, L. (2016). Physical therapists’
ways of talking about weight: Clinical implications. Physical erapy
Journal, 96(6), 865–875. doi:10.2522/ptj.20150286
Shaw, J. & DeForge, R. T. (2012). Physiotherapy as bricolage: eorizing
expert practice. Physiotherapy eory & Practice, 28(6), 420–427. doi:
10.3109/09593985.2012.676941
Shildrick, M. (1996). Posthumanism and the monstrous body. Body &
Society, 2(1), 1–15.
Synnott, A., O’Keee, M., Bunzli, S., Dankaerts, W., O’Sullivan,
P.&O’Sullivan, K. (2015). Physiotherapists may stigmatise
or feelunprepared to treat people with low back pain and
psychosocialfactors that inuence recovery: A systematic
review.Journal of Physiotherapy, 61(2), 68–76. doi:10.1016/j.
jphys.2015.02.016
Tajfel, H. & Turner, J. C. (1985). e social identity theory of intergroup
behaviour. Pacic Grove, California: Brooks-Cole.
ornquist, E. (2006). Face-to-face and hands-on: assumptions and
assessments in the physiotherapy clinic. Medical Anthropology, 25(1),
65–97. doi:10.1080/01459740500514489
Tischner, I. & Malson, H. (2012). Deconstructing health and the
un/healthy fat woman. Journal of Community & Applied Social
Psychology, 22(1), 50–62. doi:10.1002/casp.1096
a critical perspective on stigma in physiotherapy
Trede, F. (2006). A critical practice model for physiotherapy. (Doctoral
Dissertation), e University of Sydney. Retrieved from http://
eresearch.qmu.ac.uk/1722/1/eResearch_1722.pdf
Trede, F. (2012). Emancipatory physiotherapy practice.Physiotherapy
eory & Practice, 28(6), 466–473. doi:10.3109/09593985.2012.676942
Tun, K. (2004). Understanding critical social psychology. London,
England: Sage.
van Amsterdam, N. (2013). Big fat inequalities, thin privilege: An
intersectional perspective on ‘body size’. European Journal of Women’s
Studies, 20(2), 155–169. doi:10.1177/1350506812456461
Wikström-Grotell, C. & Eriksson, K. (2012). Movement as a basic
concept in physiotherapy: A human science approach. Physiotherapy
eory &Practice, 28(6), 428–438.
