Abstract
This paper applies a hybrid Heideggerian-ethnomethodological approach to physiotherapy practice. Unlike previous studies written by and for practitioners, this paper uses my personal experience receiving physical therapy as its point of departure. By combining Heidegger’s [Being and time (trans: Stambaugh J). State University of New York Press, New York 1996] notion of the ‘ontological difference’ with Garfinkel’s (Studies in ethnomethodology, Prentice-Hall, Englewood Cliffs 1967) concept of ‘accountability,’ I argue that in physical therapy practice, both client and practitioner actively shape the body into a coherent object for medical intervention. I begin by introducing three key phenomenological concepts, the life-world, the ontological difference, and Heidegger’s critique of subjectivity. I then empirically substantiate these concepts by reviewing classic and recent studies in ethnomethodology. I conclude with my own experience of physical therapy, and demonstrate how both client and practitioner actively constitute the body as a medical and therapeutic object. This is cause for both disability studies and physiotherapy to reconsider some of their core concepts, ‘medicalization’ and ‘client-specific measurement,’ respectively.
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Notes
Eisenberg (2012) is a notable exception.
Titchkosky and Michalko argue that in our societies, the ‘natural attitude’ towards disability is ‘a problem in need of a solution’—most frequently ‘solved’ normalization. “Through the social act of normalization, disability becomes merely a problem that some people have. Ironically, being ‘merely a problem’ requires that disability never come to consciousness as anything but a problem” (2012: 133).
The interaction between the ‘scientific attitude’ and the ‘natural attitude’ is the key question addressed in Husserl’s Crisis (1970). The scientific attitude is an historical attitude; the modern sciences forget that their self-evidence is based in the ontologically more primary life-world. The modern sciences treat nature mathematically, but forget the historical process of ‘mathematization,’ broken down into two steps: “Galileo’s geometrization of nature, and the arithmatization of geometry accomplished by Descartes and Leibniz. Nature becomes a mathematical manifold and mathematical techniques provide the key to its innerworkings” (Carr 1970: 333).
Of course, not all human beings ‘grasp’ books uniformly, due to the varying somatic equipment available to them. Heidegger’s philosophy accounts for this: though a heavy book may be physically closer to a person with little muscular strength, it can be the farthest thing away from them in terms of ease of use. In this case, Heidegger (1996: 67-70) contrasts between the ‘present-at-hand’ and the ‘ready-to-hand’: whereas the ungraspable book is a mere thing farthest from us, simply present in space, the ready-to-hand book is disclosed within an entire scheme of reference. It is a useful thing for care, ready-to-hand. Here again, we find the ontological difference. For a theoretically robust application of the difference between handiness and objective presence to the case of blindness, see Schillmeier (2010).
This view of subjectivity also accounts for Heidegger’s break with Husserl over the primacy of the thinking subject, which I cannot address here due to limited space. See Dreyfus (1993).
In “The Question Concerning Technology” (1993b), Heidegger uses the example of the Rhine River, which in the age of technology is seen as a source of hydroelectric power or tourist revenue, rather than as an object of beauty, as in Hölderlin’s poetry. “The Origin of the Work of Art” (1993a) contains Heidegger’s most succinct expression of the beauty-truth relationship.
Both Greek-English translations are taken from the Stambaugh translation of Being and Time (1996). Guignon uses ‘un-hiddenness,’ but does so instrumentally, placing importance in the concept, rather than the term’s translation: “Whether or not this etymological association is accepted, the point that Heidegger is making is important. […] The paradigmatic case of truth in logic, that of elementary predication, is possible only in a world in which things have already been taken out of their hiddenness through Dasein’s disclosing of the intelligible world” (1983: 199f.).
‘Indexical’ derives from the work of American Pragmatist philosopher C.S. Peirce: “of, relating to, or denoting a word or expression whose meaning is dependent on the context in which it is used” (OED). Garfinkel, of course, extends this to anything heavily context-dependent.
I write ‘aligns’ as Merleau-Ponty is the only phenomenologist Garfinkel explicitly names in chapter 5. However, as the volume’s introduction attests, ethnomethodology is very much influenced by various phenomenologists, particularly Alfred Schütz and Edmund Husserl. Further, McHoul (1998) discusses Garfinkel’s similarities with Heidegger.
Heidegger uses ‘authenticity’ not in reference to a ‘genuine, opposed to fake’ state of being, but rather to ways of being where human Dasein is made most apparent—in accepting one’s own being-toward-death, for instance. In Guignon’s words: “authenticity is not so much a matter of the ‘content’ of a life as it is of the ‘style’ with which one lives. The distinction between authenticity and inauthenticity seems to hinge not on what one is in the sense of specific possibilities one takes up, but rather the how one lives” (1984: 334).
See Raby (2000) for a critical examination of social science’s use of the transsexual-as-Other, both in terms of Garfinkel’s interview with Agnes, and the paper’s interdisciplinary legacy, in the decades since its initial publication.
My use of 'standpoint’ does not presume any epistemological privilege to those with a standpoint over others without, only to note Robillard’s location in the social order. I borrow this usage from Frank (2000).
See especially chapter eight of Studies, “The Rational Properties of Scientific and Common Sense Activities” (1967: 284).
Here, temporally refers both to ‘elapsed clock time’ and the temporality closest to Dasein as in Robillard’s past ‘hows’ of communication used to determine present and future modes of conduct, albeit failed, using the letter-board.
Unlike Agnes, a ‘sole proprietor’ in passing, Michalko (1999) discusses passing as sighted with the aid of others in public situations, and the inability to do so with a guide dog or assistive devices that are ‘essential emblems’ of blindness. The quoted term stems from the study on Agnes, when she seeks to divide the possession of a particular sex organ from sexuality-in-passing.
‘Via biopsy’—doctors find this fact very important, and repeat it frequently.
See Abrams (2013) for a discussion of how the experience of disability is made objectively present as ‘marked’ or ‘significant restriction’ in the Disability Tax Credit Certificate criteria, at the expense of other task-based or environmentally sensitive enactments. Coincidentally, several of the categories permit a physical or occupational therapist to certify marked restriction, making its review pertinent to this case.
Erwin Straus’ classic paper “The Upright Body” (1952) provides a thorough etymological investigation of the relationship between uprightness and goodness in ‘standing’ and its root, ‘sta’. The moral order of falling, and the restoration of upright posture, is worthy of future phenomenological attention. Straus’ work would serve as an excellent point of departure.
I will return to this point below, considering that rehabilitation frequently refers to the return to normal function (Michalko 1998). While there are, of course, many persons who attend physical therapy with the aim of functional restoration, I believe they share many aspects with such palliative care.
The number increased from five exercises after the first meeting, to a final twelve.
Obviously, the two are not wholly distinct, but the regime of practices surrounding each object is different. For a similar account of medicine enacting disease in varying ways, and thus producing different objects, see Annemarie Mol’s The Body Multiple: Ontology in Medical Practice (2002).
Michalko similarly discusses how blindness is treated distinctly by ophthalmology and, once that subdiscipline can ‘say no more’, rehabilitation. See chapter 3 of his Mystery (op cit.).
Here I take inspiration from phenomenologist Drew Leder, whose The Absent Body uses phenomenology in a twofold manner, providing an experiential account of human embodiment, and as a philosophy of medicine: “If we seek out a healthcare provider, this is hardly an abandonment of self-exploration. Rather, the treater’s gaze provides an extension of our own. Through the mediation of another, we come to see our body in series of technologically and conceptually extended ways that otherwise would be unavailable” (1990: 78).
The word ‘terms’ is particularly apt, because it describes how patients, myself included, often mimic medical terminology in descriptions of their lived-experience of disease. Arthur Frank, describing his cancer treatment in his At the Will of the Body (2002), suggests that patients ‘lose themselves’ in this mimicking process. This may be so, but my interest here is not in what is lost, but rather how objective presence is achieved in the clinical encounter-as-social-order. Medical terminology is an important part of this process.
A common experience is having my peculiar gait ‘explained away’ as a symptom of intoxication, something similarly noted anecdotally in Michalko’s The Two-in-One: Walking with Smokie, Walking with Blindness (1999: 13). Here we find another expression of the ‘common-stock-of-knowledge’ endemic to the life-world, where uncommon embodiments are encountered first as deviation-from-normalcy, drunkenness-not-sobriety, rather than as a complete corporeal existence.
I was not given a copy of any rubrics applied to my case (despite a request). Only my post hoc research has led me to believe that this was, in fact, the ‘Patient-Specific Functional Scale’ against which my capacities were judged. This after-the-fact search for ‘what was really going on the whole time’ seems to be rather ethnomethodological itself, in retrospect.
Emerson’s Behaviour in Private Places (1970) examines how both client and practitioner sustain the ‘medical definition of reality’ during gynecological examinations, actively dividing the body-under-treatment from the lived body, in maintenance of the shared ‘clinical encounter going right’ definition. Ritual work is performed by both parties to fend off other possible definitions of ‘the real,’ as in the ‘encounter gone wrong’ or those of an erotic nature. I would include objectively present measurement in this repertoire of ontological negotiation.
I would like to thank an anonymous reviewer for raising this issue.
I borrow the term ‘career’ from Goffman’s “The Moral Career of the Mental Patient” essay, in Asylums (1961).
The seven categories: ‘client participation in decision-making and goal-setting,’ ‘client-centered education,’ ‘evaluation of Outcomes from client’s perspective,’ ‘family involvement,’ ‘emotional support,’ ‘co-ordination/continuity,’ and ‘physical comfort’ (Cott et al. 2006: 1389).
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Abrams, T. Flawed by Dasein? Phenomenology, Ethnomethodology, and the Personal Experience of Physiotherapy. Hum Stud 37, 431–446 (2014). https://doi.org/10.1007/s10746-014-9316-2
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DOI: https://doi.org/10.1007/s10746-014-9316-2