What is the biomedical model #6

Thus far, we’ve covered five of the main features of the biomedical model - the model that underpins so much of the theory behind the way physiotherapy functions. These have been:

Specific aetiology, or the search for the specific cause of the patient’s signs and symptoms

Germ theory and the belief that illness is caused by disease within the body

Cartesian dualism and the mind-body split

Objectivity and experimentation

And reductionism, or the anti-holistic belief that the person can be understood as a collection of systems and structures

In this penultimate post, we’ll look at normalisation.

Normalisation is the belief that certain people, certain bodily functions, behaviours, and characteristics, can be considered normal, and those that do not conform to this normalised idea can be labelled as abnormal, deviant, or diseased.

Normalisation is first and foremost, therefore, a process undertaken by experts whose role it is to distinguish those that are considered normal from those who are thought to be abnormal, and, in the case of medicine, to return the sick and the ill to health.

Normalisation doesn’t only occur in medicine but in any social field where people are identified as occupying spaces outside of the norm (think of the criminal justice system, for example).

It can’t be understated how powerful normalisation has been in the history of medicine. Indeed, medicines ability to claim the power to define who and what would be considered normal was, perhaps, one of the most important elements in establishing medicine as the way to think about health and illness in the West from the 18th century onwards.

Medicine linked two related functions to normalisation, and in doing so, established a stranglehold over how health and illness could be thought of for centuries to come. The first was the emphasis that doctors placed on the normal workings of the body: its anatomy and physiology, and the creation of the field of pathology to account for how body systems and structures failed. The 2nd was the development and use of public health epidemiological data across whole sections of the population to establish the normal distribution of bodily functions throughout the population.

The need for this data gave birth to new surveys and censuses, new language of incidence and prevalence, and many of the statistical tests we still use today, including things like correlation coefficients, which were invented by Francis Galton, Darwin’s cousin, and one of the founders of the eugenics movement.

Taken together, these approaches allowed doctors to say that the majority of the population’s bodies functioned in a particular way, and that this would henceforth be considered normal. Conversely, any body that fell outside of this theoretical and abstract ‘norm’ would be labelled as abnormal and thereby amenable to medical therapy.

Rather than being an objective statement of fact, therefore, normalisation was, and remains, a practice of labelling based on the most commonly presented bodily functions. There is therefore nothing essentially wrong or bad about the kinds of abnormality uncovered by normalisation; they only represent deviations from the mean, existing over a threshold that has been decided arbitrarily by someone in a position of power.

Practices of normalisation have resulted in medicine labelling any number of personality traits, human characteristics, bodily forms and functions as abnormal, and what is considered abnormal today may well have shifted dramatically over the years.

It should also be borne in mind that that the benchmark human form against which most parameters of normalisation were historically established was that of the heterosexual, cis gendered, caucasian, Anglo-American, able-bodied male, since these represented the vast majority of doctors who developed the idea of normalisation in the 18th and 19th centuries. Normalisation cannot, therefore, be seen as an objective, apolitical clinical principle, but as a way of reinforcing certain cultural norms in society.

Normalisation plays a pivotal role in physiotherapy practice. Consider, for example, the images of the body physiotherapy students learn from anatomy textbooks. Every body presented is the same, and the students are taught to believe from the outset that one hamstring muscle is exactly like another. Physiotherapy curricula often begin with an extensive study of the normal body’s anatomy and physiology, and students slowly progress onto pathology, before introducing some of the main complicating subjective human ‘variables’.

Physiotherapists have also achieved first contact status in many countries on the basis that they also have the ability to distinguish normal from abnormal as well as a doctor.

Normalisation, therefore, plays a pivotal role in the construction of physiotherapy, and provides another tangible link between the profession and medicine.

In the last of these blog posts on the biomedical model, we will look at perhaps the most powerful discourse linking physiotherapy with medicine – the body-as-machine.