Discipline, Desire, and Transgression in Physiotherapy Practice

PERSPECTIVE Discipline, desire, and transgression in physiotherapy practice

David A. Nicholls, PhD, MA, GradDipPhys, MNZSP1 and Dave Holmes, RN, PhD, MSc, BSc2

1Head of Department, School of Rehabilitation and Occupation Studies, AUT University, North Shore Campus, A-11, 90 Akoranga Road, Northcote, Auckland, New Zealand 2Vice-Dean (Academic)/Full Professor, Faculty of Health Sciences, School of Nursing, University of Ottawa, 75, Laurier Ave East Ottawa, ON, Canada

ABSTRACT

Therapeutic touch has played an important part in human civilization and continues to contribute to our social relations and individual identities. Therapeutic touch has been a vital component in the development and definition of physiotherapy practice and continues to be one of the profession's principal distinguishing competencies. It is surprising then that while so much has been written about how to perform therapeutic touch techniques, little has been written about the role that these techniques have played in defining physiotherapy's professional identity. Drawing on the work of three postmodern philosophers, we offer a critique of physio-therapeutic approaches to therapeutic touch, examining why certain modes of touch were adopted by the profession in the past and not others; how the innate sensuality of touch had to be managed; and how the disciplinary technologies that surrounded the practice of massage came to define physiotherapy's professional identity. Our thesis is that the disciplinary technologies adopted by the profession in the 1890s endure today and that the profession's heavily disciplined approach to touch is now constraining new therapeutic possibilities that may be necessary if the profession is to respond to the demands of twenty-first century health care. For personal use only.

INTRODUCTION manipulate, mobilize, and move their body, there exists an unspoken “problem” that must be managed. The therapeutic application of touch has played an The problem is how to maximize the therapeutic possi- important part in our civilization as a species and con- bilities of the encounter while retaining a dignified sep- tinues to contribute to our social relations and individ- aration between therapist and patient. As McKintosh ual identities (Beck, 2010; Fritz, 2009; Schenkman, (2005) argues; “We cannot ignore sexual issues when 2010). It has been a vital component in the develop- learning to work with our clients … The manual ment and definition of physiotherapy practice therapies are intimate and can bring up issues about throughout the last two centuries and continues to sexuality, both for us and for our clients”. 1 be one of the profession's principal distinguishing It is axiomatic that touch is innately sensual, both

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 competencies (Holey and Cook, 2003; Nicholls and as a broadly sensory experience, and an experience Cheek, 2006; Valentine, 1988). Central to this devel- linked to sexuality. It is also axiomatic that all prac- opment and definition have been the problems posed titioners of therapeutic touch must demonstrate that by the innate sensuality of touch. they can manage this sensuality if they are to When a patient exposes their body to a therapist and allows the therapist to touch them: to massage, 1 In this article, we refer to sensuality in both its “sexual” sense (i.e., in association with sexual arousal) and also, importantly, more broadly in “ ” Accepted for publication 20 February 2012 relation to sensation and being in the world (Van Manen, 1990). An important feature of this article is our attempt to broaden the meaning Address correspondence to David A. Nicholls, PhD, MA, GradDipPhys, and significance of words like desire, sensuality, massage, and touch MNZSP, Head of Department, School of Rehabilitation and Occupation for physiotherapists, to create space in which it might then be possible Studies, AUT University, North Shore Campus, A-11, 90 Akoranga to think differently about our practice. Inherent in this process is a “trou- Road, Northcote, Auckland, Private Bag 92006, New Zealand. E-mail: bling” of taken-for-granted language and an attempt to liberate words [email protected] from their prior meaning and significance.

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distinguish themselves as therapeutic professionals endures, barring lost consciousness or neurological and not to be associated with unregulated or morally injury, until we die. reprehensible practices. It could be reasonable to The language of touch provides us with powerful argue then, that physiotherapists have been particu- metaphors that link our thoughts with our feelings. larly successful in this endeavor, since they are the We speak of feel-ings, grasp-ing ideas, hold-ing on largest organized and legitimized professional body to life and catch-ing our breath. Modern forms of that has therapeutic touch techniques at the core of interpersonal communication and social networking their professional identity. have become increasingly reliant on haptic technology Most physiotherapists will have, at times, experi- through touch-screen smart phones, texting, and ence the effects of their skilled handling on their email. As Fritz (2009) argues; touch is “the most per- patients. Sometimes this may be through a patient's sonalized form of communication that we know”, and sexual arousal that is often unexpected and embarras- one of our most powerful modes of communication sing, or through emotional outbursts that can disrupt with others. the therapy session. Consequently, most clinicians Touch is also one of the defining characteristics of learn how to handle these experiences with dignity, the care offered by skilled health care workers, and a but this does not belie the fact that sensuality is significant variable in defining the technical compe- present in varying degrees in every therapeutic tence of health care professions (Lauterstein, 2004). encounter and therefore relies on constant vigilance Here, the combination of skilled, purposeful, and and ongoing management. non-intentional touch contributes significantly to the Given the critical tension that exists around the client/patient's experience of health care (McCarthy, practice of therapeutic touch, it is surprising that 1998). there has been little critical analysis of the importance For physiotherapists, the most commonly applied of the sensuality of touch to the physiotherapy pro- forms of purposeful touch are the various forms of fession. In this article, we cannot address the full massage, assisted movement, mobilization, and breadth of this question, we can, however: manipulation that we categorize here as modes of therapeutic touch. These approaches, alongside 1. Examine the relationship between sensuality and hydrotherapy, remedial exercise, and later electrother- physiotherapy practice and explore how sensuality apy, are the oldest forms of practice known to phy- continues to contribute to physiotherapy's pro- siotherapy (Creighton-Hale, 1893; Dowse, 1906; For personal use only. fessional identity Ellison, 1898; Palmer, 1901; Symons Eccles, 1895). 2. Explore ways in which physiotherapy might now Focusing specifically on massage, it has been argued rethink its approach to the sensuality of touch, that the physiotherapy profession owes much of its drawing on the work of three postmodern philoso- past and present professional identities to its approach phers, and in so doing, open a space for thinking to the sensuality of touch, and that physiotherapy was differently about the relationship between therapist effectively founded as an attempt to legitimize and client. massage practice (Dixon, 2003; Linker, 2011; Nicholls and Cheek, 2006). While it is not our inten- To begin to address these questions, we examine tion here to revisit this history (for a comprehensive the cultural significance of touch and its historical account of the events surrounding the birth of the pro- role in defining physiotherapy practice. fession, see Wicksteed, 1948; Barclay, 1994), we do, however, need to spend a moment considering how the nascent physiotherapy profession was able to THE CULTURE OF TOUCH

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 prove its legitimacy in the late-nineteenth century, because this is pivotal to our argument that phy- Forms of therapeutic touch may be some of the oldest siotherapy has, knowingly or otherwise, retained therapies known to human-kind. They range from many of the approaches to massage common in the simple primitive efforts to rub away pain to the Victorian era, and that these approaches now require sophisticated manipulation of tools and instruments. review and reform. Touch itself plays a vital role in our growth and maturation; our gestures, our habits and social conventions; our music and art; our communication and PHYSIOTHERAPY'S HISTORY OF interaction with others; and our means of healing, DISCIPLINING TOUCH giving pleasure and relief, punishing and hurting (Classen, 2005). Our haptic vocabulary develops Physiotherapy practices have long been defined by the from our first sense of being in the world, and need to regulate touch (Mason, 1985; Nicholls and

Physiotherapy Theory and Practice 456 Nicholls et al.

Cheek, 2006; Quinter, 1993). This century-long Exercise,3 for example, disciplinary measures that problem can be traced to the English Massage Scan- later came to be seen as custom-and-practice, dals of 1894 and the resulting actions of the founders became established. There were strategies directed at of the Society of Trained Masseuses (STM) (British the practice “environment”; with the use of treatment Medical Journal, 1894a, 1894b; Society of Trained beds that were visibly similar to theater tables and Masseuses, 1895). In essence, the profession that looked nothing like a domestic bed, situated in would later become physiotherapy was born of a sterile-looking, hospital-like clinical spaces; there desire to legitimize therapeutic touch and differentiate were dedicated uniforms, biomedical language and legitimate masseuses from unregulated and morally curricula of study that situated the profession in repugnant practitioners (Nicholls and Cheek, 2006). close proximity to medicine; and there were practice Legitimacy depended on the Society's2 ability to choices made that actively denied the inherent sen- demonstrate that its registrants could offer a plainly suality of physical contact between practitioners and de-sensualized form of touch to its clients. It achieved patients through rigid taxonomies and regimentation. this by implementing a series of disciplinary measures Swedish Remedial Exercise, for example, a mainstay directed at regulating the conduct of its members of physiotherapy's approach to exercise for much of (Table 1) (Palmer, 1901). the twentieth-century, was based on the ability to con- By the outbreak of World War I, the Society had strain movement through a comprehensive series of done enough to demonstrate its legitimacy for the fundamental and derived positions (Angove, 1936; Society's masseuses to be formally included in the Despard, 1916; Guthrie Smith, 1952; Tidy, 1952), war effort. With subsequent outbreaks of influenza, and this approach can be seen as one measure tuberculosis, and polio in the 1920s and 1930s, among many chosen to reinforce the perception and the formation of the Welfare State in the within the profession and without, that physiothera- 1930s and 1940s, the profession further established pists could practice without fear of licentiousness. its orthodoxy, leading ultimately to profession- Among the disciplinary techniques and strategies specific legislation in most Commonwealth countries deployed in physiotherapy, possibly the most potent (Anderson, 1977; Bentley and Dunstan, 2006; was the adoption of the notion of the body-as-machine, Cleather, 1995; Nicholls, 2008). None of these suc- which underpinned many of the other approaches cesses would have been achieved, however, had it (Nicholls and Gibson, 2010). This approach empha- not been for the early efforts to establish a disciplin- sized the primacy of an anatomic, biomechanical, and For personal use only. ary approach to touch. And at no time could the kinesiological view of the body at the exclusion of profession resile from its commitment to its highly “other” ways of understanding the reasons for illness restrictive approach to massage and movement for or injury (subjective, personal, social, or spiritual, for fear that it would bring the profession into disre- example). By adopting this approach, physiotherapists pute. Thus, the disciplines established by the could align themselves with the medical profession profession's founders endured and can be seen still without encroaching on their biomedical territory; dis- in the curricula, examinations, codes of ethics and tinguish themselves from other allied health professions systems of regulation systems around the world (by emphasizing cure as opposed to the care of nursing, (Chartered Society of Massage and Medical Gym- for example), and, most importantly, elevate them- nastics, 1930). selves above unregistered and licentious practitioners who had not received such a rigorous biomedical, and therefore deemed respectable training. ENDURING LEGACY OF DISCIPLINE IN

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 PHYSIOTHERAPY PRACTICE PROBLEMS RESULTING FROM PHYSIOTHERAPY'S DISCIPLINED In some of the earliest published physiotherapy litera- APPROACH TO TOUCH ture, we can see a clear image of a disciplinary approach to touch in the biomedically orientated prac- While this approach certainly contributed to phy- tices that define physiotherapy's orthodoxy (Butler, siotherapy's success in defining a role within the 1997). In Tidy's (1932) Massage and Remedial

3 Noel M. Tidy's Massage and Remedial Exercise text, first published in 1932 and now in its 14th edition, is the longest continuous text 2 We have used the capitalized form of the word “Society” throughout published in the field of physiotherapy. It offers a generic overview of the text to refer to the STM. This should be distinguished from the physiotherapy in a range of contemporary practice areas, and so provides lower case form of society which refers more generically to the social a useful ongoing barometer of the profession's interests and involve- world around us. ments (Tidy, 1932).

TABLE 1. Disciplinary strategies adopted by the STM.

Disciplinary strategy Rationale

No men allowed to train as masseuses The Society's founders believed that contact between men and women involved an ungovernable sensuality and that it would be easier to simply prevent men from gaining registration with the Society. Men would not gain registration as therapeutic masseurs with the STM until 1914. Indeed, the Society successfully lobbied to have rival organizations like the Harley Institute closed down on the basis that they trained men and women together (Barclay, 1994). The STM remained the Society for “masseuses” rather than “masseurs” until well into the twentieth- century. No men to be offered “general” massage unless in General massage was a euphemism for whole body massage. Although nursing cases and under the direction of a doctor mobilizations and manipulations of specific bodily regions were not uncommon, massage was thought of as a tonic for weak nerves, debilitation or generally poor health, and was a major part of the masseuse's work. Such massage for men, however, could only be offered under specific conditions that drew on many of the masseuse's primary roles as nurses. The tensions between massage as health work and massage as an indulgence of the wealthy may have been significant here. Examinations and registration In its early years, the STM did not have the resources to administer a massage curriculum. They could, however, govern who registered with the Society through an examination that effectively defined the curriculum that registrants needed to follow. Thus, the STM could define how massage should be thought and practiced. Massage examinations continued to be a mix of anatomy, physiology, treatment techniques, and moral questions associated with touch well into the 1920s. Patronage of doctors The STM actively and aggressively pursued the patronage of medical professionals prior to WWI. Many of the founders were independent women, well placed in society (Rosalind, later Dame, Paget's uncle, for example, was the famous Liverpool surgeon William Rathbone). The For personal use only. STM sought to adopt a biomedical curriculum and a strongly anatomical – or more accurately “biomechanical”–view of health and illness that proved very favorable with the medical profession The body-as-machine Possibly, the most significant measure taken by the Society to legitimize masseuses' philosophy of touch lay in the approach to the body that had to be learnt, or at least plainly demonstrated by registrants. The masseuses needed to be able to focus on the body-as-machine: they needed to be able to touch the inner thigh of a patient, for example, and think of the origins and insertions of adductor longus and not perceive it in any way as sensual. The ability to demonstrate this ability to the medical profession and the public at large was a defining feature of the Society's quest for legitimacy.

orthodox health system that developed in the first half Gibson, 2010). While this approach may have shielded Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 of the twentieth-century, it also, somewhat perversely, the profession from some of the ideological vacil- may have had a secondary effect that is only now being lations experienced by some other health professions realized. Some authors have begun to argue that phy- (nursing, occupational therapy, and psychotherapy siotherapy's biomechanical and biomedical approach being only three examples), there is now a growing to care effectively “blinkered” physiotherapists; dis- consensus that physiotherapy's historically biomecha- couraging them from engaging with other ways in nical and biomedical approach to the body is prevent- which people experienced health and illness. Phy- ing the profession from engaging humanistically with siotherapists have historically been discouraged from the diverse health needs of the population, with the exploring behavioral, cultural, economic, environ- inherent risk that the profession is increasingly being mental, political, spiritual, or social determinants of seen as out of touch (Nicholls and Larmer, 2005; health, believing that these approaches were the Nicholls, Reid, and Larmer 2009). It is as Juhan concern of other health professionals (Nicholls and (1987) argues:

Physiotherapy Theory and Practice 458 Nicholls et al.

The term “physical therapy” avoids these associ- FOUCAULT AND DISCIPLINE ations, but it is too narrow in the scope of its normal use. It refers to an official medical disci- Michel Foucault (1926–1984) is considered by many to pline, one which is licensed only after protracted have revolutionized how we have come to think about and highly specific studies, prescribed only by notions of truth, knowledge, power, subjectivity, and dis- physicians, and applied through fixed procedures. cipline in contemporary society (Ransom, 1997; Turner, Such academic rigor certainly does not count 2006). His writings on discipline alone have been the against it as a responsible therapeutic practice, focus of work in areas like: accountancy (Maclullich, but it does effectively partition “physical therapy” 2003); community development (Schofield, 2002); off from many other useful kinds of touching and economics (Miller and Rose, 1990); government manipulation. In particular, it typically eliminates (Higgins, 2004; Merlingen, 2003); law (Smith, 2000); a good deal of the intuitive element which seems education (Carpenterand Tait,2001; Race, 2000); man- to be such an important part of other approaches agement (McKinlay and Starkey, 1998; Yakhlef, 2002); and which is fact many physical therapists have sexuality (Maines, 1999; Pryce, 2000); sport (Johns and confessed to me that they wish they could use Johns, 2000; Markula and Pringle, 2006); and technol- more freely in the clinical practice. ogy (Mehta and Darier, 1998). In health care, Foucault's work on discipline has In recent years, a number of authors have questioned been applied extensively in areas like: aged care physiotherapy's affinity with the notion of the body-as- (Katz and Marshall, 2004; Pincombe, O'Brien, machine (Broberg et al, 2003; Cott et al, 1995; Cheek, and Ballantyne, 1996); dentistry (Nettleton, Darnell, 2007; Hislop, 1975; Nicholls, 2008; Nicholls 2001); disability (Reeve, 2002); nursing (Holmes and Gibson, 2010), and there is growing evidence of and Gastaldo, 2002; Perron, Fluet, and Holmes, an emerging crisis in physiotherapy that centers on the 2005; Riley and Manias, 2002); mental health, psy- care needs of an increasingly aging, chronically ill, and chology, and psychotherapy (Hazelton, 1995; Hook, complex population while the profession's attention 2003; Rose, 1997); health care management and remains strongly focused on curing acute illness and reform (Hau, 2004; Sheaff et al, 2004; Vicinus, injury (Gibson, Nixon, and Nicholls, 2010; Nicholls 1985a); professionalization (Wear and Kuczewski, and Larmer, 2005; Nicholls, Reid, and Larmer, 2004); techno-science (Rudge, 1999); and medical 2009). This also comes at a time when the volume of history (Armstrong, 1995; Wainwright, 2003). How For personal use only. scholarship roundly criticize those professions who then can Foucault's ideas and writings help us to cling to an exclusively biomedical philosophy of practice critically analyze the role of therapeutic touch in grows almost daily (Lupton, 2003; Nettleton, 2005; physiotherapy practice? Shilling, 2003; Turner, 2008; Williams, 2006). Part of the appeal of Foucault's work lies in the fact It is our belief that physiotherapy is transitioning to that he saw discipline not as an isolated practice more embodied or holistic modes of practice and away applied by one person over another, per se, but rather from purely biomechanically orientated views of the as a productive technology of power that extended body and illness. At the heart, this transformation is throughout society and helped to define who we were a questioning of the principles that underpin what it as individuals and actively constructed our society. means to practice physiotherapy, and at the very Foucault was interested, for instance, in how we had center of this debate is the profession's approach to learned as a society to distinguish between the mad therapeutic touch. Thus, part of our professional chal- and the sane, the healthy and the sick, and the good lenge involves finding new ways to liberate our practice and the bad sexual citizen. He was interested in how

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 from its historical disciplines; celebrating the fully we had established layers of examination throughout embodied possibilities of touch, without, at the same society (from school tests, to regular medical check- time, losing our professional identity, destroying the ups, and accounting measures), and used these as dis- public's trust in the profession or exposing ourselves ciplinary strategies to distinguish between what was and our client's/patient's to abuse. In this article, we normal conduct (and by extension what defined a offer only a preliminary and tentative response to normal person) and what was abnormal. Foucault this challenge, drawing on the work of three philoso- (1977) wrote extensively about what he called “tech- phers whose work we believe might be particularly nologies of surveillance” as measures developed by instructive as physiotherapy seeks a new approach to governments and institutions to better know and practice; one that re-defines its relationship with the thereby govern the population. innate sensuality of touch. To begin with, we look at Foucault showed that all these measures had the work of Michel Foucault. their own history and that they were tactics or

“technologies” as Foucault called them, of power. continental philosophy as Michel Foucault's. And like Foucault did not see power as something negative; Foucault, Deleuze wrote in a style designed to chal- as a force that controlled people; or as something lenge convention. Deleuze's writing, often written one person possessed over others. While he did not with psychoanalyst Félix Guattari, is dense, often con- deny that these forms of oppression existed, he had, fusing, and idiosyncratic, and yet, beyond this, it has after all, experienced fascism and Stalinism at first brought forth some startlingly influential thought hand, he was more interested in the power that over the last few decades (Deleuze and Guattari, obtained its results without force and oppression. 1987). These forms of power were multiple, various, and Deleuze and Guattari's writings have been best- widely distributed throughout society and operated selling books in France, and have had a profound at every level. They constituted a “micro-politics” effect on contemporary philosophy, the arts and the and through their actions, how we came to see our- humanities, leading Michel Foucault to claim that selves and others. “one day, perhaps, this century will be called Deleu- In the history of physiotherapy, efforts to discipline zian” (Foucault, 1970). In recent years, books such the conduct of massage practitioners illustrate one as Anti-Oedipus and A Thousand Plateaus have begun micro-politics among many. In the measures taken to influence health philosophers and theorists by the founders of the STM detailed above, the (Brown, 2004; Fox, 2002; Malins, 2004; Roberts, Society illustrated some of the most familiar technol- 2005). For example, Fox (2002) whose work has ogies of discipline unpacked by Foucault. To repeat, been a significant influence in the medical humanities, Foucault's reading was not that these were necessarily wrote Beyond Health which draws heavily on Deleuzian negative technologies, far from it. They were pro- notions to advocate for a new focus on embodiment ductive in not only clearly defining the limits of phy- (Nicholls and Gibson, 2010). Holmes and Gastaldo siotherapy practice, but also lending its legitimacy (2004) have written about the need to move away and orthodoxy. In this way, they helped to from the limits of linear logic in nursing and the “produce” a particular kind of practitioner that met need to embrace Deleuze's ideas of rhizomatic think- with the approval of the medical profession and the ing. Indeed, Deleuze's work has begun to feature in public alike. Accordingly, rather than seeing pro- areas as diverse as: mental health (Roberts, 2004, fessions like physiotherapy as the initiator of dis- 2005); visual arts (Olkowski, 1999); literature (Le courses and ideas of practice, Foucault saw them as Clézio, 2004)4; dance and movement (Manning, For personal use only. representing the effects of discourse; as the outwork- 2009); politics (Patton, 2000); and social philosophy ing of disciplinary technologies, governmental strat- (DeLanda, 2006). egies, competitions between different knowledges Deleuze and Guattari (1987) argue that the con- and relations of power. temporary thinking has become “arborescent” or In all Foucauldian thinking, power can only operate tree-like, with ever-refined branches of knowledge where there is the possibility of resistance; where a that follow increasingly linear pathways. By contrast, person could choose to do otherwise, but chooses they believe that our social world is more “rhizo- the preferred path anyway because of societal matic”. Drawing on botanical metaphors, they con- norms. In physiotherapy, we have seen a remarkable trast the traditional Western belief in ongoing exercise of Foucauldian-like power in the way that a progression towards enlightenment with what they century of practitioners have adhered consistently to believe is a more realistic view of our social world; a a model of practice handed down by previous prac- world in which we constantly find ourselves in the titioners. But, the possibility of licentiousness and middle of multiple, competing discourses and lines

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 abuse of power continues to surround the profession of thought; occupying many roles and juggling many and requires a constant vigilance to ensure that it different ways of being, thinking, and practicing retains its hard-won status. To understand the object (Cormier, 2008; Holmes and Gastaldo, 2004; Lawr- of these organizations' disciplinary interest, we will ence, 2007). Thus, a rhizome works as a better meta- turn to the work of one of Foucault's colleagues and phor for our lives as people and as practitioners collaborators, Gilles Deleuze and his writings on because it “has no beginning or end; it is always in desire.

4 Nobel Prize winning author Jean-Marie Gustave Le Clézio's writings DELEUZE AND DESIRE draw heavily on Deleuzian ideas. Wandering Star, the story of a chance meeting between an Israeli and Palestinian girl, emphasize the – importance of indigenous marginal cultures, the virtues of nomadic The work of Gilles Deleuze (1925 1995) that we draw freedom, and our ethical responsibility to open space for new modes on here comes from the same tradition of postmodern of expression and thought.

Physiotherapy Theory and Practice 460 Nicholls et al.

the middle, between things, interbeing, intermezzo” touch. Physiotherapists are by no means the first (Deleuze and Guattari, 1987). people to draw on disciplinary technologies to Despite parallels between Deleuze and Guattari's govern the conduct of their practitioners and patients. writings and ways of thinking that exist within and There are many other examples of disciplines directed about health care, one area of interest is particularly at people's bodies that have been highly significant fea- relevant to this article, that of desire. For Deleuze tures of western civilization over the last few centuries and Guattari, desire carries a double meaning. including: posture and “attitude” of school children There is the desire associated with sensuality, and a (Armstrong, 2002; Foucault, 1979); the moral gui- more complex desire that is inherent in all things: a dance of mothers and the moral conduct of women desire to actualize; to achieve a particular end; or in general (Bland, 2001; Jackson-Houlston, 1999; serve a particular purpose. This desire is akin to the Vicinus, 1985b); the role of confessional and psy- desire of the therapist to reduce a person's pain, or chotherapy in governing people's thoughts (Rose, the desire to move. Importantly, Deleuze and Guattari 1997, 1999); and the maximization of work capacity extend this notion of desire to include the connection following injury (Linker, 2011; Seymour, 1998). between inanimate objects and their environments. Indeed, every profession has its own history of disci- Thus, water desires to flow and chairs to be sat pline directed at some expression of the body's desir- upon. This is obviously not implying that these ing (Armstrong, 1995; Gastaldo and Holmes, 1999; objects “think”, only that in their existence they com- Nettleton, 1992), and while a large part of physiother- municate to us their desired purposes. apy's particular disciplinary focus falls upon the sen- When the desiring object connects with its target, an suality of touch, each profession essentially grapples assemblage is formed, and these assemblages are many with the seemingly unlimited potential our bodies and varied (DeLanda, 2006). As I write this article, for have for transgression. As Williams (1998) argues: example, my hand has formed an assemblage with my [A]s the history of western civilization shows, computer keyboard. The computer desires my touch bodies are amenable to discipline and control – as much as I desire it. In the same way, the therapist's from the prison to the factory, the school to the hand forms an assemblage with the body of their asylum – but this nonetheless fails to detract patient with the client/patient “desiring” the skilled from the fact that they are always threatening, touch of the therapist as much as the therapist desires through their libidinal ﬂows and corporeal to deploy their skills. This notion of a desiring assem- For personal use only. desires, their pleasures and their pains, their blage formed around therapeutic touch seems alien to agonies and their ecstasies, to “overspill” the cul- physiotherapy practice more familiar with evidence- turally constituted boundaries which currently based justifications for massage (Holey and Cook, seek to “contain/constrain” them. Indeed, it is 2003), but as Williams (1998) argues; from these “unruly” desires that the need for cor- These issues…are clearly, if somewhat problema- poreal “discipline” arises. tically, expressed in the new holistic health move- Transgression, therefore, provides the conditions that ment: a movement which illustrates very clearly make discipline necessary, and so must be understood the dilemmatic features of health as control and if we are to make sense of our actions as physiothera- release, and the possibility, however distant it pists. For help, with this we turn to the work of may be, of new more sensual, emotionally Georges Bataille. informed, ways of “seeing” and “keeping in touch” with the world around us. BATAILLE AND TRANSGRESSION

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 Not surprisingly, it is in the complementary and alternative health literature that many of these issues are debated (Lauterstein, 2004; McKintosh, 2005; Georges Bataille (1897–1962) was a French writer and Oerton, 2004; Schenkman, 2010), and it is here that philosopher whose influences extend to economics, the “re-sensualization” and “re-enchantment” with literature, film, philosophy, and sociology. Although health care is at its greatest (Williams, 1998). much less well known than Foucault and Deleuze, Connecting Deleuze's and Guattari's work back to particularly in the broad field of health care, Bataille's Foucault's notions of discipline, we can say that work has begun to be applied in areas where research- despite the best efforts of the physiotherapy profession ers are exploring “…the continuing resilience of the to remove all association between sensuality and touch human body to rational, in this case biomedical from the profession's identity, sensual experiences, in control” (Williams, 1998); modes of performance the broadest sense of the word, remain a natural, inevi- sports (Marcia, 2001); conditions of profound phys- table and, indeed, necessary part of the experience of ical disruption (Williams and Bendelow, 2000);

“marginal” health practices (Väänänen, Mäkelä, and 2005). Transgression, therefore, relates to the sensual- Arppe, 2011); and mental illness (Elden, 2006; ity of therapeutic touch in a number of ways: Whitebook, 1999). Notwithstanding the fact that Bataille's writings, like those of Foucault and 1. From Deleuze, we can say that desire is an inevita- Deleuze, are challenging, confrontational, and often ble feature of therapeutic touch because touch is a disturbing (Bataille, 1987, 1991), our focus here is sensual experience. on one of the pivotal ideas explored by Bataille in his 2. We can also say that there is a desire inherent in work. Transgression, for Bataille, is an important phi- touch that transcends mere sensuality. Our skilled losophical concept that is an inherent part of our civi- hands “desire” to help and heal; our client's skin lization. Transgression is seen throughout society “desires” to be touched; their pain desires relief, where people exceed what is socially acceptable and etc. challenge orthodox behavior. Young people who test 3. From Bataille, we can say that transgression is a the authority of older generations transgress. Margin- natural feature of our bodies and our culture, and alized groups who fight for their right to be heard this is no more evident than where sensuality or transgress. Practitioners who challenge convention eroticism is involved. transgress (Noys, 2000). Transgressions are the 4. And from Foucault, we can say that discipline has “unauthorized crossings of boundaries or refusals to been a powerful tool used to govern our conduct acquiesce to norms and mandates” (Crawford, 1999). in the face of this inevitable transgression. If transgression is an inevitable and necessary feature of social life, then so are the disciplines that We will conclude this very brief overview of these surround it. Transgression is defined in many ways concepts with a short discussion of how we think not by the acts of defiance as much as the conventions that these ideas can be deployed in physiotherapy. and boundaries it seeks to breach. As Falk (1994) argues, “The more articulated and multifarious the restrictions on corporeality, the more sophisticated the forms of transgression become”. Like the compu- DISCUSSION ter hackers who breach security systems to expose their limitations, transgressions reveal previously unseen The honest pleasure of sensuality is part of the boundaries; the limits to our tolerance; and the con- For personal use only. profession, but the dark possibilities of seduction tingent perimeters to conventional thoughts and prac- and exploitation are lurking in the background. tices. Part of the inevitability of transgression derives (McKintosh, 2005) from the belief that we can never fully contain ourselves, either individually or collectively. Our bodies, The principal argument set out in this article is that the for example, are inherently “leaky” (Falk, 1994); con- individual, institutional, and professional constraints stantly threatening to over-spill, whether through put on physiotherapy practice by the need to discipline sweat or blood, through menstruation, coughing, or therapeutic touch are too restrictive for the needs of incontinence (Nettleton and Watson, 1998). Our contemporary health care. Physiotherapy's disciplined “[b]odies, in short, from their leaky fluids to their approach to touch may well be credited with providing overflowing desires and voracious appetites, are first it with the legitimacy and orthodoxy that was necessary and foremost transgressive” (Williams, 1998). What in the first half-century of the profession's growth, but is more, because we are social animals; always occupy- these disciplines may now be acting to constrain poss- ing each other's spaces, exchanging ideas and building ible alternatives for professional approaches. Phy-

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 communities and social relations, we are constantly siotherapists may be struggling to adapt to the needs transgressing the limits of our individuality. of increasingly aging, chronically ill populations, in Our potential for transgression, therefore, becomes part, because they only permit themselves to touch a problem that must be managed, and this is no more when there is a clear biomedical, evidence-based evident than in the area of eroticism, which Bataille rationale. Touch that is simply “pleasant”, without saw as the paradigm case of transgression and disci- any other justification, is currently beyond the pro- pline. Sexual transgression strikes “at the very heart fession's scope. Thus, it would still be hard for a thera- of rational modernity, involving as it does a ‘transgres- pist to offer “general” massage to a patient on a sive desire’ to go ‘beyond’ the order, to break prevail- palliative care ward, for example, simply as a means of ing boundaries in ‘regressive’ and ‘progressive’ turns” giving comfort or short-term relief. The fact that for (Falk, 1994), reminding us of our age-old anxieties the duration of the session the patient is transported over dirt, body fluids, and the unconstrained contact away from their suffering matters little if there is no between bodies (Hall, 1999; Lupton, 1994; Wood, physiological evidence of therapeutic efficacy.

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The evidence of an increasing public desire for a accepted. What is more, it will require physiotherapists more embodied health experience is now considerable to propose new ways of thinking that seem to trans- (Csordas, 2000; Fox, 1999; Williams, 1996), but even gress the disciplinary technologies of the profession; without this, many are now more aware of their need if only to follow Bataille's example of transgression to feel relief from pain, or to experience comfort in and use such approaches to identify where we have the hands of a skilled practitioner. Juhan (1987) set our present boundaries and ask if there is a possi- expresses this idea clearly when he asks: bility of going beyond those boundaries. If physiotherapists are to be able to meet the Why should such a few sessions of bodywork, complex, multifaceted demands of the population, often accompanied by a minimum of verbal dialo- then they must develop practice models that cater for gue, affect so dramatically these people's symp- much greater inclusiveness and diversity. They must toms, their relationships with themselves, and be able to use their skills for care, not just for cure. their relationships with others? Most of the body- They must be able to offer a more embodied or holistic work techniques I have observed and practiced approach and use their touch for a much wider set of are neither rigidly systematic nor forceful. The capabilities than is presently allowed. Of course, to use usual impression is that the client is being touch in these more diverse ways risks opening up to gentled and pleasured, not being “fixed” or different questions about sensuality, which have been “cured”. By what possible mechanisms, then, constrained throughout the profession's past, but if could something so simple as soothing touch alle- physiotherapists cannot deploy their skills in these viate painful and long-standing physical con- ways, they may see themselves gradually replaced by ditions, quell anxieties, foster more productive those who have grappled with these tensions and attitudes? found a solution that satisfies everyone's desires. The fact that currently one is unlikely to see a reference to “gentling” or “pleasuring” a patient expressed within the physiotherapy literature, may be indicative CONCLUSION of an association in the minds of physiotherapists with un-regulated alternative therapists, or the forms In this article, we have examined the technologies of massage offered in brothels and bordellos. Early used by physiotherapists to discipline therapeutic in their careers, physiotherapists are taught to feel

For personal use only. touch, drawing on the work of three postmodern phi- more comfortable trading in the biomechanical losophers whose work may be of particular value given language of assessment, diagnosis, and cure. But that they deal with questions of desire (Deleuze), dis- these approaches have their own constraints, not cipline, (Foucault) and transgression (Bataille). These least because they narrow how it is possible to think notions strike at the heart of some very powerful of notions of touch, desire, and sensuality. ethical, historical, and philosophical questions in phy- Clearly, we are not advocating a laissez-faire siotherapy; questions that will have an important approach to touch, or a position of complete moral bearing on the future viability of the profession. In relativity where physiotherapists are free to perform the article, we conclude that rather than seeing in whatever way they choose. We are aware of the desire, discipline, and transgression as negative fact that there will always be the need to have pro- aspects that need to be “managed out” of the professional ethics and policies within the profession, to fession, or issues to be ignored, physiotherapists protect ourselves as much as our patients. Neither should look to bring these issues to the surface and do we believe that the future of the profession lies in explore the possibilities they offer for the profession

Physiother Theory Pract Downloaded from informahealthcare.com by AUT Auckland University of Technology on 01/21/14 a wholesale rejection of past values that have served in the twenty-first century. physiotherapists so well. We do, however, believe that physiotherapists should have a clearer under- Declaration of interest: The authors report no standing of where their disciplinary boundaries have declaration of interest. been set, and an appreciation for what these then enable and constrain; what they presently make possible and impossible; and, most importantly, if this is what physiotherapists want for themselves and their REFERENCES patients. To undertake such an analysis will require a con- Anderson EM 1977 New Zealand Society of Physiotherapists: Golden Jubilee 1923–1977. Wellington, New Zealand Society certed effort to challenge taken-for-granted assump- of Physiotherapists tions within the profession; to examine things that Angove HS 1936 Remedial Exercises for Certain Diseases of the seem, on the surface, to be obvious, and readily Heart and Lung. London, Faber & Faber

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