ChapterPDF Available
A critical perspective on
stigma in physiotherapy:
The example of weight
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
is chapter explores what might be learnt about physiotherapy
by considering its intersection with stigma. Stigma was described
by Goman 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 reect general societal stigma,
but also in ways that may be specic 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, denitions and narratives
of physiotherapy in dierent 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.
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 Goman) and do not suciently 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. Oen returning to the exemplar of weight stigma,
we discuss how such constructions can have some (usually uninte-
ntional) negative eects, which we believe are little explored in the
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 aect 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 – eectively 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.
Research on the nature of stigma has spanned a number of discipli-
nes, and many stigmatised characteristics, which may explain why
there are many denitions of stigma. Crocker, Major, and Steele
() produced a widely-used denition: “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 denition, derived from Goman’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 deni-
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 denitions. 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 oversimplication 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 & Bria, ). 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 Goman’s symbolic interactionism. e group
membership approaches focus on the eects 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 simplications (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 simplications (Tun, ). 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 oversimplied, 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 eects 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.
Foucaults 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
Foucaults 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 oen intends overtly to help “when the need for assistance
is justied by the inherently ‘dierent’, ‘risky’ or ‘tainted’ characte-
ristics of the population, stigma is created in the veryagencies that
are supposed to be providing help” (Hannem, , p. ). With
characteristics identied 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
ofstigma 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” oen 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 diers 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
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 reexively 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-denitions of professional bodies on their ocial
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
denes 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, denition of physiotherapy as a
profession that helps “people aected 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 denitions 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, ), reexivity (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 reexivity”.
a critical perspective on stigma in physiotherapy
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 scientic approaches
to health research. Although physiotherapy practice is arguably
grounded in both humanistic and scientic paradigms, the pro-
fession generally focuses on the biomedical scientic 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 reected in the physical
focus of the professional denitions 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 scientic 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 oen
primarily practitioner-centred, where the therapist oen controls
the direction, content and denition 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 dened, 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 oen established as a sci-
entic 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 diculty 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 oen 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 eects
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 denitions 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 persons 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 eort into establishing what a
“normal” body is. is eort 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 reexive 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, reexivity is not an established part of the practice and
education of clinical physiotherapists. In some cases, clinical
jenny setchell and ukachukwu abaraogu
self-reection 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-reection, Clouder
() highlighted that while participants oen demonstrated the
ability to reect on the technicalities of practice (such as the suc-
cess of treatment techniques), they found it dicult to consider
their own subjectivity: “the clinician her/himself did not appear
to be part of the reective frame of reference. Even though self-
awareness was clearly identied 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 reexivity, 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 reexivity 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.
inking critically about stigma in physiotherapy opens up
opportunities to think and practice otherwise in the profession.
Investigating stigma in physiotherapy has an unsettling eect 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 reexivity 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.
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-
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... There are critical studies exploring shame and stigma and their role in the marginalization of: otherness (Jóhannsdóttir, Egilson, and Gibson, 2021;Setchell, 2017Setchell, , 2018; aging and aged care (Hay, Connelly, and Kinsella, 2016;Nicholls, 2020); rehabilitation and barriers to patients' activity participation (Ahlsen, Mengshoel, and Engebretsen, 2023;Gibson, 2016;Gibson et al., 2017;Jachyra, and Gibson, 2016); politics of normalization (Gibson, 2014(Gibson, , 2019; critical disability studies (Gibson and Teachman, 2012;Yoshida, 2018); and cultural humility and equity (Cleaver, Carvajal, and Sheppard, 2016;Cleaver, Deslauriers, and Hudon, 2019;Nixon et al., 2016). There are also studies looking at: social and environmental determinants of health (Maric and Nicholls, 2020); micropolitics of care ; belonging for students of color (Hammond, Williams, Walker, and Norris, 2019); and the link between poverty and disability (Pinilla-Roncancio, 2018). ...
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Critical physiotherapy has been a rapidly expanding field over the last decade and could now justifiably be called a professional sub-discipline. In this paper we define three different but somewhat interconnected critical positions that have emerged over the last decade that share a critique of physiotherapy's historical approach to health and illness, while also diverging in the possibilities for new forms of practice and thinking. These three positions broadly align with three distinctive philosophies: approaches that emphasize lived experience, social theory, and a range of philosophies increasingly referred to as the "posts". In this paper we discuss the origins of these approaches, exploring the ways they critique contemporary physiotherapy thinking and practice. We offer an overview of the key principles of each approach and, for each in turn, suggest readings from key authors. We conclude each section by discussing the limits of these various approaches, but also indicate ways in which they might inform future thinking and practice. We end the paper by arguing that the various approaches that now fall under the rubric of critical physiotherapy represent some of the most exciting and opportune ways we might (re)think the future for the physiotherapy profession and the physical therapies more generally.
... Clinicians tend to be very interested in defining, understanding, and restoring 'normal' function (Harradine & Bevan, 2009;Murley et al., 2009;Setchell & Abaraogu, 2018). For example, the 1000 Norms Project (McKay et al., 2016) is an initiative intended to define 'normal' human movement and function. ...
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The words spoken by clinicians can profoundly impact a person's perception of their body. Words may influence pain, as pain is a measure of perceived threat. Words such as tear, rupture, degeneration, instability, and damage may increase perceived threat. Similarly, pathologising 'abnormal' anatomical variation may leave people feeling vulnerable and fragile. This article aimed to explore the potential consequences of particular words and narratives commonly used to describe plantar heel pain and justify interventions used to treat plantar heel pain. Drawing on the existing body of pain-science research, the authors argue that some of the language and narratives used in the literature and practice may potentially be threat invoking/nocebic. In addition, we argue that justifying interventions such as orthoses by stating that they normalise foot function may leave patients feeling broken, deficient, and abnormal. In response, we provide several recommendations for clinicians to help them avoid invoking threat when describing plantar heel pain and justifying interventions for it. McGrath, R. L., Murray, A. W., Maw, R. A., & Searle, D. J. (2022). 'Collapsed arches', 'ripped plantar fasciae', and 'heel spurs': The painful language of plantar heel pain. New Zealand Journal of Physiotherapy, 50(2), 58–63.
Care is central to many health professions, including physiotherapy. Different forms of care are enacted as part of being a caring professional. For example, a practitioner who provides good service to others and upholds standards while doing so is in-grained in education for professional formation. However, there are other topics and aspects of care that are not as well attended to, and that is care for the future of the profession. This too is an aspect of care, and it is an urgent objective in an era where societies and healthcare are changing at rapid rates. In this paper, I argue that Golde and Walker’s (2006) idea of stewardship can help health professionals think about this often overlooked aspect of care. Stewardship adds a perspective that is centered on a deep authentic care for and responsibility towards the ongoing relevance of the profession. Stewardship keeps the question of what the profession is, and what a professional does, alive as part of its present and future practice.
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In this paper, we propose a theory-driven approach to developing interventions for reducing weight stigma in physiotherapy and discuss the design and exploratory trial of such an intervention. Weight stigma has been identified in physiotherapists in empirical investigations. However, there has been little consideration of how this stigma might be addressed. We highlight Goffman’s work on stigma that provides social and embodied understandings of stigma. Goffman’s approach, however, is notably apolitical, ahistorical and lacks mechanisms for understanding power. We suggest that post-structuralist perspectives can provide insight into these areas. Drawing on these theories, we critically examine the literature on weight stigma reduction, finding that trials have largely been unsuccessful. We argue that this may be due to overly passive and simplistic intervention designs. As context-specific understandings are desirable, we examine the nature of physiotherapy to determine what might be relevant to (re)thinking weight in this profession. We then discuss the development of a multifactorial, active weight stigma intervention we trialed with eight physiotherapists. Supported by theory, the outcomes of the exploratory study suggest that physiotherapy-specific factors such as fostering professional reflexivity and improving understandings of stigma need to be incorporated into an active intervention that considers the complex determinants of weight stigma.
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Drawing from Annemarie Mol's conceptulisation of multiplicity, we explore how health care practices enact their object(s), using physiotherapy as our example. Our concern is particularly to mobilise ways of practicing or doing physiotherapy that are largely under-theorised, unexamined or marginalised. This approach explores those actions that reside in the interstitial spaces around, beneath and beyond the limits of established practices. Using Mol's understanding of multiplicity as a theoretical and methodological driver, we argue that physiotherapy in practice often subverts the ubiquitous reductive discourses of biomedicine. Physiotherapy thus enacts multiple objects that it then works to suppress. We argue that highlighting multiplicities opens up physiotherapy as a space which can broaden the objects of practice and resist the kinds of closure that have become emblematic of contemporary physiotherapy practice. Using an exemplar from a rehabilitation setting, we explore how physiotherapists construct their object(s) and consider how multiplicity informs an otherwise physiotherapy that has broader implications for health care and rehabilitation.
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Having spent their first century anchored to a biomedical model of practice, physiotherapists have been increasingly interested in exploring new models and concepts that will better equip them for serving the health-care needs of 21st century clients/patients. Connectivity offers one such model. With an extensive philosophical background in phenomenology, symbolic interactionism, structuralism, and postmodern research, connectivity resists the prevailing western biomedical view that health professionals should aim to increase people’s independence and autonomy, preferring instead to identify and amplify opportunities for collaboration and co-dependence. Connectivity critiques the normalization that underpins modern health care, arguing that our constant search for deviance is building stigma and discrimination into our everyday practice. It offers provocative opportunities for physiotherapists to rethink some of the fundamental tenets of their profession and better align physiotherapy with 21st ce...
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The goal of this book is to examine the social phenomenon of stigma as a substantive, everyday experience, and to contextualize the lived realities of stigmatized and marginalized persons theoretically. We need to appreciate that stigma is both symbolically realized in individual interactions and structurally embedded in the cultural values, practices, and institutions of society. To realize this objective we need a new theoretical perspective. While the work of Erving Goffman (1963a) has justifiably been the authority on stigma for several generations of academics, his focus on understanding stigma as a function of interaction at the individual level is not conducive to exploring the institutional and societal regulation of "discredited" individuals. Building on the work of others, such as Brian Castellani (1999) and Ian Hacking (2004),1 I would suggest that Michel Foucault's broader perspective on the production of truth, knowledge, and power provides a useful conceptual point of entry for thinking about the construction of stigma and its effects on individuals and groups. At the same time, however, Foucault's work is itself lacking in its consideration of the individual subject and agency. As Castellani (1999) states, While [Foucault] wonderfully illustrated over and over again how practice, as an interaction, structures the rules of formation involved in the construction of subjectivity and "truth," [he] refused to acknowledge the important role interacting individuals have on this process, and was therefore unable to fully appreciate the importance of agency. (260) In 2004, Ian Hacking identified the work of Foucault (1961) and Goffman (1961) as presenting complementary accounts of "making up people" and explored how the two theorists could contribute to his own efforts at understanding how "the actual and possible lives of individuals are constituted" (288). In his brilliant article, Hacking demonstrates how both Foucault and Goffman may be seen as grounded in the existentialist thought of Jean Paul Sartre. He argues that in his quest to comprehend how classifications of people interact with the people so classified he has come to realize that labels, like institutions, artefacts, and interaction, may both limit individuals' possible understandings of themselves and constitute possibility. As Sartre (1959) emphasized, the boundaries of one's knowledge and experience present limitations to how one might understand one's self and on the consequent choices that one may make. Hacking (2004) goes on to explain that "the choices that are open to use are made possible by the intersection of the immediate social settings, target of the sociologist, [Goffman] and the history of that present, target of the archaeologist [Foucault]" (288). Hacking uses Goffman's book, Asylums (1961), and Foucault's Folie et Déraison: Histoire de la folie à l'âge classique (1961) (published in English as Madness and Civilization in 1965) to demonstrate how their studies of mental illness and the mentally ill might be used in concert to produce a more holistic understanding of how the mentally ill are "made up" as people. Hacking insists from the outset that, as a philosopher "steeped in Foucault," he is "not concerned with completing Goffman, but rather with filling out Foucault" (278). He states, Foucault gave us ways in which to understand what is said, can be said, what is possible, what is meaningful-as well as how it lies apart from the unthinkable and indecipherable. He gave us no idea of how, in everyday life, one comes to incorporate those possibilities and impossibilities as part of oneself. We have to go to Goffman to begin to think about that. (300) My goal here is the opposite of Hacking's; as a sociologist, schooled in the traditions of the Chicago school and concerned with the everyday, lived realities of my subjects, I wish to explore what Foucault-and an understanding of the archaeology of divisive stereotypes and discriminatory institutions-might contribute to an understanding of how lived realities are constituted and shaped by the limits of social structure, and what insights that might have for a more activist political agenda. By incorporating Goffman's work (and symbolic interactionism, more generally) with Michel Foucault's post-structural perspective, I offer here a point of entry to articulate a more holistic picture of the phenomenon of stigma and the complex relationship between interaction, knowledge construction, and power. In short, this discussion is aimed at using Foucauldian insights to expand on Goffman's analysis of stigma. This creates a new space for sociological theory that integrates the individual experience into the larger macro-structures of power, government, and social institutions and opens up avenues for deconstructing previously takenfor- granted knowledges that are experienced as limiting and oppressive. In this chapter, I build on Hacking by examining the complementary offerings of these two traditions and demonstrating how each can inform our understanding of stigma; first laying out the key ideas of Goffman and Foucault, respectively, and then bringing these perspectives together to explore the symbolic and structural aspects of stigma. Specifically, what is added to Hacking's analysis concerns how modern notions of risk are used by institutions to constitute structurally stigmatized populations, thereby creating and/or reinforcing symbolic, interpersonal stigma and discrimination.
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Understanding Critical Social Psychology is an exciting new textbook providing a comprehensive and reader-friendly approach to the theories and methods surrounding Critical Social Psychology. This book combines a critical examination of the traditional philosophies, practices and topics with an emphasis on introducing innovative and contemporary developments in social psychological research. In this way, Tuffin integrates newer insights with established modes of thinking.
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