This blog is in response to a twitter thread where it dawned on me that very few of us physiotherapists understand the political water that we are swimming in. So I thought of writing a blog that highlights the possible dangers of self-efficacy, person-centered care, or the biopsychosocial model and how it might intersect with a “pull yourself up by the bootstraps” approach to health. Specifically, I am exploring the questions “how much are we paying attention to the individual?”, “how much does it contribute to health?”, and “how much might attention to the individual be perpetuating ill health?” I do want to highlight that I am not “anti self-efficacy” but against its current dominance as an approach and I am skeptical of what it might obscure.

A Terribly Brief History of Individualism

Physiotherapy has a long and boring history that helps explain how the profession came to construct a hierarchy with the clinician holding authority over the patient’s body. This has led to paternalistic practices where clinicians exercise power over people, dictating what is deemed healthy, what an ideal body is, what a patient’s rehabilitation plan will be, and ultimately which interventions the patient ought to endure - all with little regard for the individual person subjected to the treatment. Any deviation from said plan by the patient, of course, is met with labels such as non-compliant patient or malingering patient.

Realizing the harms of paternalism and authoritative forms of healthcare practice, physiotherapy has taken up models and frameworks of health that center the patient such as the biopsychosocial model of health, person-centered care, and a newfound emphasis on self-efficacy. The biopsychosocial model suggests that an individual is a complex combination of biological, psychological, and social factors and therefore the individual is infinitely unique and individual. The clinician, then, cannot know the complexity of what the individual person requires and by logical necessity, must hand control over to the patient. This, then, leads to person-centered care where the person is the “expert of their own health,” and health related goals are determined by the individual in collaboration with the clinician.

The trouble clinicians run into is when their newfound altruistic desire to empower patients to be the authors of their own lives, runs up against a patient’s belief that they do not have the capability to take that responsibility, or perform an activity or behavior. This is what psychologist Albert Bandura has called self-efficacy ¹, publishing literature with titles such as Self-efficacy in changing societies ² and Self-efficacy: The exercise of control³. Physiotherapists are particularly fond of assessing pain self-efficacy which is the confidence a patient has in performing activities while in pain. At first glance we might think “Well hell, let’s improve self-efficacy then, right? The more capable and in control of their own health, the better.” The trouble with this view is that it understands that the problem of poor health lies within the individual; therefore, its solution must be found within the individual too. While people may feel in control, their episode of low back pain (for example) may improve, and they may even feel more resilient and able to overcome future episodes of back pain, this perceived positive health outcome shrouds a much larger impending problem - slow death.

Slow Death

Slow death is a term coined by cultural theorist Lauren Berlant and described by philosopher Jasbir Puar in her book The Right to Maim as “the debilitating ongoingness of structural inequality and suffering” (p. 1)⁴. Berlant, in her article Slow Death (Sovereignty, Obesity, Lateral Agency) emphasizes that it is the “wearing out” and “deterioration” of the people in a population that defines slow death (p. 754)⁵. I think of slow death as a complex yet precise modulation of how life is regulated in society. The example Berlant uses is the obesity crisis. Person-centered care might address obesity by constructing goals with the client and empower them to achieve these goals by improving someone’s self-efficacy and belief in their own capabilities to diet, exercise, or participate in “adaptive behaviors”. However, no matter how much self-efficacy they possess, they may face a plethora of structural obstacles that an individual has no power to change. For instance, obesity may be due to having limited food options and access to affordable highly palatable food with high caloric value ⁶⁷⁸. Or, overeating might be an appropriate kind of “self-medication” to a stressful environment ⁵⁹¹⁰. A stressful environment, of course, may be a result of other systemic inequities such as poorer and more vulnerable populations (although the least to blame for man-made climate change) typically bear the worst of the impact. ¹¹. Or having to work multiple low paying jobs to pay the bills ¹². Only having opportunities to perform low paying jobs may be due to someone’s level of education ¹². Having a lower level of education may be due to coming from a low income household. I think you get the point. What should be gradually becoming clear is that any amount of emphasis on the individual erases the very real structural inequities present in many people’s lives. As we will soon see, it isn’t that inequities and injustices are accidental and merely unfortunate, but highly political - particular bodies are made available to be debilitated or injured and then made to endure their debilitation or injury. This very act of debilitation and modulation of slow death is what keeps the lights on for late stage capitalism. To be able to tackle the politics of inequity, I first need to say something about capitalism’s part in all of this.

Capitalism

The structure of late stage capitalism causes much of the inequity and poor health we see today ¹³¹⁴. Here is a basic breakdown of what we see in capitalism today: The capitalist class (those who own the majority of the wealth), driven by profit, desire to decrease their input to maximize their outputs. Cheaper labor, materials, and operating costs, allowing corporations to make a larger profit on their commodities. This means, for example, paying lower wages to workers while accumulating more wealth for themselves, making it challenging for the labor class to make ends meet ¹⁵. In addition, the working class (who is also the consumer class) is burdened with debt due to powerful corporations manipulating prices, limiting competition, and encouraging excessive consumer spending. And of course, corporations lobby political parties, strongly influencing the policies and bills that pass to favor the capitalist class, exacerbating inequality ¹⁶¹⁷. Crucially, capitalism is not an economic structure that one can simply opt out of. Part of its oppressive structure is that we are involuntarily coerced into participating - you either work for the capitalist or starve. Capitalism has led to outrageously inequitable concentrations of wealth and has led to equally outrageous statistics such as the combined wealth of the richest eight billionaires is greater than the combined wealth of the poorest bottom half of the entire population. To be clear, eight people own more wealth than 3.6 billion of the poorest people in the world.

Late-stage capitalism and its principle of unlimited growth has infiltrated every part of society and the world, causing irreparable necrosis of our ecology, the production and sale of cheaper and more harmful foods, the exposure and ingestion of carcinogenic chemicals, the accumulation of plastics in our tissues, a loneliness epidemic despite being more ‘connected’ than ever, a mental health epidemic, a persistent pain crisis, just to name a few. This is called debilitation. Through our involuntary coercive participation in capitalism (laboring for wages and buying commodities to live) we are slowly being killed - capitalists profit from debilitating people. Debilitation, however, does not work in isolation but in a careful balance with capacitation. For example, once a body is debilitated, that debilitation may be re-capacitated by the medical industrial complex to return to a consumer or laboring body. The balance of debilitation and capacitation constitutes the mechanism of slow death, the “the maintenance of living” or as Puar writes “a condition of being worn out by the activity of reproducing life” ⁴. Capitalism modulates the speed of death through a meticulous balance between the destruction of health and the conditions for living. As Puar cogently writes:

finance capital enforces repeated mandatory investments in our own slow deaths, continually reproducing the conditions of possibility that enable the sustained emergence and proliferation of debility, capacity, and disability. ⁴

Healthcare is both a commodity to be consumed by the patient and also a manner of re-capacitating bodies to return to labor. This is where we begin to see healthcare professions as appearing altruistic through their provision of “health” while participating in the very capitalist machine that debilitates people and capacitates people.

Inequity

There is the obvious argument that those who are in marginalized social locations are disproportionately more negatively affected by the destruction of health and by lack of access to conditions for living than those who are more privileged. This can be understood as the complex interaction of vocation, access to health services, access to affordable healthy food, financial security, community safety and so forth. However, scholars such as Puar insist that these inequalities are not a mere glitch in the system but part of its mechanism. Debilitation is “no accident but [is] part of the biopolitical scripting of populations available for injury,” the state predisposes those who are to be debilitated ⁴. The politics of debilitation, according to Puar, render some populations as definitively unworthy of health and targeted for injury. The labor class, for example, are disposable populations consigned to having accidents. This is especially true for populations and bodies that are slated for high risk work. They are made to pay for progress by being targeted for premature slow death through debilitation, risking a body’s health by doing risky labor and once injured, furthers the economy by becoming a consumer of the medical industrial complex. Other bodies are made to pay for progress through capacitation, the maintenance of certain bodies to continue being productive bodies of labor. Or capacitation could be the process by which debilitated bodies are available or deemed valuable enough for rehabilitation back into the labor market. The balance between being a productive laboring body, and being a productive patient that participates in the medical industrial complex is a fine balance that is very lucrative to the capitalist class. Thus, the modulation of slow death in certain populations is an exercise of power over people, to force their living not just to happen but to endure.

Many liberal activists mistakenly call the slow death and social murder of vulnerable populations a crisis, when in fact it is a life sentence - “a defining fact of life for a given population that lives it as a fact in ordinary time”⁵. Crises misdirects attention to make the environmental phenomenon that precipitate slow death appear as sudden, as an event. Slow death for certain populations, however, is not a state of exception. It is a state of living maintained by capital accumulation. Similarly, social determinants of health make “social” factors that cause the slow death of certain bodies appear natural, unfortunate, passive, and apolitical. As you might have guessed, I regard slow death anything but natural, apolitical, or accidental. Therefore, I prefer sociopolitical determinant of health, highlighting that inequality is attributable to a neocolonial and imperial system that is upheld by an elite class ¹⁸.

If health is political and structurally determined, we might imagine that the appropriate response would be to investigate and intervene on a collective and structural level. Here lies the problem with the biopsychosocial model of health, person centered care, and self-efficacy.

Neoliberalism

Since the biopsychosocial model of health boasts including the biological, psychological, and social domains into health, one would imagine that social (and therefore political) aspects of health would be addressed with the same or greater fervency as the biological and psychological domains. This is not the case. Why is that? It is the same reason that in 2004 British Petroleum (BP) hired the public relations professionals Ogilvy & Mather to promote the idea that climate change is not the fault of oil companies but of individuals by promoting and popularizing the concept of a “carbon footprint”. All wanting to do our part, we could now effortlessly determine how our normal daily lives are contributing to climate change. This was a genius tactic in diverting attention away from corporations that are largely responsible for climate disaster. Sorry to say, no amount of paper straw use will reverse the effects of unregulated dumping of millions of tons of waste into the ocean daily by corporations. Since just 100 companies are responsible for 71% of global emissions, no amount of cycling to work will make a dent in the 37 billion metric tons of carbon dioxide released into the atmosphere every year by corporations ¹⁹. Similarly in health, the responsibility is placed on the individual to make better dietary choices by ensuring calories are visible on packaging and high sugar soft drinks are more heavily taxed (in certain countries anyway). But there is less attention placed on corporations that are incentivised by profit to make “unhealthy”, highly palatable foods widely accessible (especially to poorer communities) at a fraction of the cost of healthier alternatives. This is the case with most, if not all, health related decisions.

The set of economic beliefs that makes this individualistic nonsense possible is called neoliberalism, a tactic first invented and deployed in both the US and UK in the early 1980s and is now a dominant set of beliefs that has become naturalized in the Global North, the majority of “Western” countries hold neoliberal beliefs with little cognizance of it. Neoliberalism presupposes that the individual is primary over the collective. As Margaret Thatcher famously said “there is no such thing as society” but only “individual men and women.” Neoliberalism posits that market forces of supply and demand create an optimal distribution of resources within society, thereby maximizing personal well-being of individuals and communities. The rapid uptake of this ideology led to widespread policy reforms where the majority of social needs (such as healthcare) were privatized and put on a market that one could buy into. These needs were, therefore, no longer provided by society or the government but were privatized so the individual could pay for their needs to be met by buying commodities from private corporations. In neoliberalism, one’s health is determined by one’s own ability and responsibility to “pull oneself up by the bootstraps”, labor for wages, then buying commodities one can afford. Issues, such as economic inequality, became apolitical, merely reduced to personal responsibility and choice.

The rise of neoliberalism is one of the factors that made health promotion and behavior change interventions so popular among public health practitioners and even healthcare practitioners too. Neoliberal distractions misplace the responsibility of health on the individual and their knowledge, rather than on larger collective and systemic action. If there is only an individual subject, there can be only individual action. If there is a collective subject, there can be collective action. Cognitive behavioral therapy, explain pain, mindfulness, acceptance and commitment therapy, and resilience building interventions, all participate in “responsiblizing” individuals to manage their own health, rather than moving towards building environments, cities, neighborhoods, and communities that prevent major health decay in the first place.

Neoliberalism to Self-Efficacy

Corporations and the ruling class have spent years constructing a society that has produced in us a subtle inner voice that says “you have the power to make yourself whatever you want to be.”²⁰ As a result, ‘each individual member of the subordinate class is encouraged into feeling that their poverty, lack of opportunities, or unemployment, is their fault and their fault alone.’ ²⁰. We are all uniquely and individually responsible for our own misery, our failure to thrive, our failure to become our ‘authentic’ selves, or our failure to achieve success. Constantly working on our health while systems of oppression profit from our debilitation has led to widespread depression and anxiety, feeling “good for nothing” as the late Mark Fisher wrote ²⁰.

For some time now, we have increasingly accepted the idea that we are not the kind of people who can act. This isn’t a failure of will any more than an individual depressed person can ‘snap themselves out of it’ by ‘pulling their socks up’. ²⁰

Most people should feel incapable of taking responsibility for their health because it is a justified feeling, there is little we can do as individuals about our health. Low self-efficacy and feeling wholly out of control is an appropriate response to the Earth being trashed by billionaires and our health being risked for profit while we helplessly stand by as it happens. Or maybe someone has high self-efficacy for performing a task like “going for a walk” but the bigger question is “why?”.

It is of no measure of health to be well adjusted to a profoundly sick society - J. Krishnamurti

“Why go for a walk to improve my health by a small margin when most of my health has been hijacked and already decided for me? The speed of my slow death has been decided.” If there was a frog in a cauldron with high self-efficacy for swimming around in the cauldron while it was slowly heated, gradually boiling the frog, would high self-efficacy be a useful metric of health? If there was a frog living in a pristine pond teeming with life while believing that they are not very capable of swimming around in the pond, this might be a useful metric to promote well-being. In our current sociopolitical climate, self-efficacy has the danger of expending a lot of our energy paying attention to the frog while possibly overlooking the water. No amount of self-efficacy is going to stop the cauldron from boiling the frog.

So, what is self-efficacy telling us? And whatever it is telling us, how much of the “health pie” does it make up? No amount of feeling capable of going for a walk actually gives anyone control over what jobs they have access to, the foods they have access to, the neighborhoods they have access to live in, the ecological climate they are exposed to, and so forth. But by focusing all our attention on helping patient’s pursue self-efficacy and empowerment, we encourage them to participate in the cycle of debilitation, consumption, production, repeat. In fact, physiotherapy (and rehabilitation more broadly) is a key player in both erasing the mechanisms that debilitate and capacitate bodies and fine tuning the sweet spot between productive laborer and faithful consumer. Yes, physiotherapists are health professionals that largely work with individuals. But we cannot claim to be considering the bio, psycho, and social when very little is being done on the level of the social. What might be the harms of implicitly perpetuating a narrative that health is largely self-determined? In what ways might the profession divert energy away from individual action and collectively begin a nuanced conversation about interventions and healthcare approaches that benefit the individual, yes, but also resists the powerful social and political forces that are precipitating our necrosis.

I often hear physiotherapists who work with people experiencing persistent pain say that they occasionally struggle to simultaneously validate someone’s pain experience while also explaining that their pain is neurobiologically “in their brain.” Just wait until people find out that pain is largely in the political economy.

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