Review (Dorothee Holscher) – The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice

Thank you for the opportunity to review this paper, which I enjoyed greatly. I have used Levinas’ work in some of my thinking about social work ethics and have no doubt of its relevance for contemporary human, social and health services. You also articulated your paper’s purpose clearly and provided a convincing rationale: to say that there is an implicit violence within contemporary, professional helping relationships – here, physiotherapy – indeed calls for critical engagement and exploration of possible openings for change. Based on the argument that Levinas enables such a critique, then, your paper aims to introduce him to a wider audience, with a view to making a novel and timely contribution to the theory and practice of physiotherapy. Doubtlessly, this will be relevant wherever physiotherapy is studied, taught and practiced. Your endeavour to introduce Levinas’ work to a new audience informed my feedback below.

I found your paper to be carefully researched with a wide range or literature used, as well as being clearly and logically structured, so I would not want to see any changes in this respect. As a theoretical paper, research methods were not of concern. In terms of language, I also found this to be well-written paper with only few editing oversights. However, to the extent that my suggestions translate into adding further, or expanding on existing content, a thorough proof-read with a view to tightening the argument further might bring down the word count sufficiently to accommodate these recommendations.

Below are some comments on individual sections.

  1. Levinas – a brief introduction

This is an immensely interesting section, and I agree with the importance of contextualising a philosopher’s work in order to render it accessible, and to tease out its relevance in new, different, or changed contexts. So here, you explain the extent to, and ways in which, Levinas’ writing was influenced by the rise and terror of Nazism and the pull it had on important intellectuals of this time, particularly Heidegger. However, in the remainder of the paper you do not then proceed to interrogate to what extent and in what ways the violence that characterises physiotherapeutic relationships relates to the kind of violence that informed Levinas’s philosophy. Conversely, should you feel that these different types and scale of violence have little or nothing in common, you might want to justify why Levinas’ work is relevant regardless. In other words, in what ways might a violation of the Other by rendering them knowable be linked to the Holocaust? What, if any, is the nature of the relationship between the Holocaust on the one hand and the forms of violence perpetrated by well-intentioned physiotherapists on the other?

  1. Thematisation – the violence of ontology

This section is crucial for all the arguments that follow and as such, I would find it important to ensure that it is as easily accessible as possible to an audience that might well be unfamiliar with Levinas’ work. To this end, I would recommend that you revise this section with a view to reducing somewhat the number of direct quotes and further translating your summaries, paraphrases and interpretations of the original work into everyday language.

More specifically, as not all readers may be entirely familiar with the concept and practices of phenomenology, you might want to provide at least some explication. Moreover, while Levinas critiqued phenomenology, your critique appears focused on physiotherapy as a predominantly positivist science and practice. Given that phenomenology developed, at least in part, as a response to positivist sciences, it would make sense to make more explicit the logic by which you apply Levinas work to contemporary physiotherapy.

  1. The aims of physiotherapy

I found this section to be succinct and convincingly argued, however, the last paragraph (from “More specifically, physiotherapy’s aim …” to the end of the section) is quite compact and abstract. Could you unpack this a bit more?

  1. The theory and practice of diagnosis

Here I have some more specific comments:

At the end of paragraph 2 (starting with “The issue with these diagnostic labels …”), you state that “… the act of diagnosis itself may be seen, paradoxically as…” –

  • “…diametrically opposed to ‘the ethical foundation of medicine’…” My question is: which ethical foundations of medicine is the act of diagnosis diametrically opposed to? In what ways? Further, if brief, explication of this claim would be needed.
  • “… the supposed aim of physiotherapy to maximise movement…” This claim is confusing. Why is this only a supposed aim? I thought maximising movement is in fact physiotherapy’s explicit aim?

Similarly, in the last paragraph of this section it remains unclear exactly how labels and categories serve to immobilise and incapacitate patients. Given the importance of this claim in your overall argument, I recommend that you carefully explicate this point.

  1. Professional identity

I found that compared to your discussion of aims and diagnosis, this section was the least well developed. For example, in paragraph 1, you critique the ways in which undergraduate education focuses on students attaining “knowledge, skills and attributes” of physiotherapists, which they are then expected to maintain, develop and enhance. While I share your criticism of the idea of professional identity as a whole, I found myself perplexed nonetheless: the question of attributes to me seems debatable, for sure, but if not knowledge and skills, what would be their substitutes? Surely, competent practice is ethical practice? What would be the alternatives? Linked to this is the question of the professional context within which physiotherapists are staking their claims, in that the health sector is made up of competing professions. I think it would be important that a critique of the notions of professional identity – including physiotherapists’ particular claims to knowledge, skills and attributes – considers the very real dynamics that are at play in this field. After all jobs, relative authority and pay are at stake. Is it possible, that the ability of Levinas’ work to inform a critique of contemporary physiotherapy reaches its limits here? In other words, might this be a good place to critically engage with Levinas as well?

Finally, I am not sure how the concluding sentence (from “… what remains as the broad, underpinning professional identity …” to “… we find the irreconcilable tension at the heart of the profession’s aim to ‘develop, maintain and restore people’s maximum movement’”) follows from the arguments presented in this section. Could you please re-look at this?

  1. Towards an otherwise physiotherapy

Some of the issues raised above resurface here. Thus, in paragraph 1, you say that “… Levinas’ critique … underscores the extent to which physiotherapy may … immobilise otherness, rather than liberating it.” Up to this point, it remains unclear to me exactly how, against the goal of maximum movement, otherness can be liberated. So given its importance to the possible solutions and recommendations you want to present here, I think this point needs better development in the preceding sections. Similarly, at the end of paragraph 1, you say that physiotherapeutic practices “… achieve colonisation and containment of the other, rather than mobilisation”. This claim, too, would require some building-up to.

Importantly, you are proposing a person-centred approach as a solution to the violence perpetrated within mainstream physiotherapy, which would fit well with a Levinasian critique. This culminates, in your third-last paragraph, in your suggestion that an “otherwise physiotherapy” would “… not just be abut providing a ‘provisional diagnosis’ but in possibly not applying a diagnostic label at all …”  On some level, I find these to be intriguing and convincing arguments. On another level, however, I wonder how this could possibly work in a neoliberal practice context where professions are consistently pressured to ‘produce more for less’, to be able to have themselves evaluated against measurable outcomes, and, on that basis, to be able to stake their claims for professional legitimacy. Of course, this, too is a form of structural violence affecting both therapists and patients. So, I wonder if you shouldn’t at least acknowledge some of the forms of violence in contemporary health systems that would make difficult the application of your propositions in practice. You may not need to resolve these concerns entirely but could at least acknowledge them. And of course, the question arises again: does the applicability of Levinas reach its limits here? Considering such possible limitations and translating them into recommendations for further research, debate and practice might indeed strengthen your work.

  1. Conclusions

Attending to my suggestions above would lead to some necessary revisions of the conclusions reached.

One final point on your use of terminology might be useful here: In your article, you refer to physiotherapy’s “others” as “patients”, but at times also as “clients”, but never as, for example, “service users”. These terms, of course, are also labels that categorise, limit and to the extent that they do, also violate. Against this background, I want to suggest that you include some explication (possibly also some rethinking) of the terminology used.

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