Perspectives On ‘Person-Centeredness’ From Neurological Rehabilitation and Critical Theory: Toward a Critical Constellation

JHR C R I T I C A L R E S E A R C H A N D P E R S P E C T I V E S Published online 01 May 2020 at jhrehab.org 1 © Emory University; authors retain copyright for their original articles Perspectives On ‘Person-Centeredness’ From Neurological Rehabiliation and Critical Theory: Toward a Critical Constellation By Jenni Aittokallio, PT, MH and Anna Ilona Rajala, PT, MA Abstract This interdisciplinary article addresses the putative gap between person-centeredness and the biomedical model of physiotherapy. We draw both from a primary qualitative study and philosophical praxis to critically evaluate person-centeredness. We suggest that because person-centeredness is difficult to define, conceptual clarification can hardly optimize person-centered practice. Rather, drawing on the Frankfurt school critical theorist, Theodor W. Adorno, we argue it is more helpful to accept its elusiveness as an antipositivist ‘constellation’ of multiple ideas that critically guide practice. The original purpose of the qualitative investigation was to explore with informants a key question: What matters to them the most in their physiotherapy? The data was generated in 13 semistructured focused interviews and analyzed using Interpretative Phenomenological Analysis. The findings demonstrate that both evidence-based and person-centered perspectives matter, but according to research they do not always fit together without difficulties. To address this, we suggest that the experiencing and meaning-making embodied person needs to be brought on par with the biomedical objectbody of positivist physiotherapy. Person-centeredness recast as a critical constellation (as described in Adorno’s magnum opus Negative Dialectics) works toward this goal because it addresses the narrowness of the biomedical model by drawing widely on human sciences—not excluding biomedicine—as a source of meaningful knowledge. It also draws attention to critical issues that are difficult to research using only biomedical methods. Recasting person-centeredness as a constellation therefore helps to create an awareness among practitioners and students about a variety of issues that might affect person-centeredness in clinical practice. CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 2 © Emory University; authors retain copyright for their original articles Introduction “Philosophy will not dispense with truth…but will illuminate the narrowness of scientific truth.” —Theodor W. Adorno1 Physiotherapy research has seen an increase in thinking outside the dominant biomedical model. Despite the development of critical thinking about physiotherapy, the assumptions of the still-dominant positivistic biomedical paradigm that values objective science above any other approach and sees the body-asmachine as a problem to be fixed, go unchallenged in the mainstream.2-9 The dominance of what according to Max Horkheimer10 might be called a traditional paradigm—one that draws on Cartesian science and positivism—is evident, for example, in how critical physiotherapy research is still grossly underrepresented in rehabilitation publications.11 Physiotherapy research has largely concentrated on the effectiveness of interventions.9 Effectiveness of interventions—the research aims of direct utility, generalizability and applicability—fit the ideal of positivism whereas critical transformative ideas that challenge physiotherapy’s taken-for-granted conceptions and practices do not, not at least without resistance. In this article, we assume for the sake of argument that there indeed is a gap, although not a necessary one, between the traditional physiotherapy paradigm and critical physiotherapy. We frame the gap in terms of the difficulty of fitting person-centeredness comfortably with evidence-based practice—keeping in mind that biomedical physiotherapy and evidencebased practice are not the same, but simply fall under the same positivistic paradigm. In our view, the uncomfortable relationship between personcenteredness and evidence-based practice is evident in the policy statement and glossary definition of evidence-based practice by the World Confederation for Physical Therapy (WCPT): Evidence-based practice (EBP)—is an approach to practice wherein health professionals use the best available evidence from systematic research, integrating it with clinical expertise to make clinical decisions for service users, [emphasis added] who may be individual patients/clients, carers and communities/populations. ...It involves complex and conscientious decision-making based not only on the available evidence but also [emphasis added] on patient characteristics, situations, and preferences. It recognises that health services are individualised and ever changing and involves uncertainties and probabilities.12 The policy statement, unwittingly perhaps, confirms that patient characteristics, situations, and preferences—arguably these pertain to personcenteredness—are something additional rather than integral to ‘evidence’ from systemic research that, according to the same statement, “includes, but is not limited to, meta-analyses, systematic reviews of randomised controlled trials (RCTs), individual RCTs, systematic reviews of cohort studies, individual cohort studies, outcomes research, systematic reviews of casecontrol studies, individual case-control studies, caseseries and expert opinion.”12 We argue that the statement is problematic: evaluating which characteristics, situations, and preferences are relevant is still in the hands of the practitioner, keeping decision-making practitioner-led rather than personcentered or shared. Our assumption of a gap is based on the simple CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 3 © Emory University; authors retain copyright for their original articles possibility that evidence-based practice is not always person-centered despite the ideal of the WCPT. We acknowledge that integrating evidence-based practice with person-centeredness can also be successful. However, we are interested in the possibilities of unsuccessful integration, because it offers a starting point for a critical ethical investigation. Our approach is a collaboration between qualitative research and philosophy. We draw both from a primary qualitative investigation and critical philosophical inquiry. The aim is to find ways to address both practical and conceptual difficulties of person-centeredness. I N V E S T I G A T I O N A N D I N Q U I R Y The empirical investigation was guided by a personcentered question: What might people who receive neurological rehabilitation find particularly meaningful in their physiotherapy? The philosophical inquiry draws on the work of Theodor W. Adorno and takes a critical look at personcenteredness by asking: What does it mean, from a philosophical perspective, to put the person at the ‘center’ of physiotherapy practice? For the empirical section, the first author (JA) conducted 13 semi-structured focused interviews and analyzed the material using Interpretative Phenomenological Analysis (IPA).13-14 Four themes regarding the particularly meaningful aspects of physiotherapy were identified: 1. Being heard and listened to 2. Having positive physical experiences 3. Having out-of-the-ordinary physiotherapy sessions 4. Trusting the physiotherapists and their skills After the empirical analysis, both authors engaged in a critical philosophical dialogue concerning the findings and their implications. We argue that the four themes do not only reflect aspects of person-centeredness but also traditional evidence-based physiotherapy. This finding worked as the basis of our philosophical praxis. We acknowledge that many physiotherapy practices rely on numerical information about the human body and, therefore, physiotherapy needs quantitative science and knowledge; but there should also be room for critical interrogations. Our critique does not aim at dispensing with quantitative science. We argue, however, that because physiotherapy involves complex social and bodily interactions,2-6,8,15 which demonstrate its intrinsic moral nature,16 quantitative science does not suffice to encompass the practice of contemporary physiotherapy in its entirety.3 In our view, acknowledging that physiotherapy is dependent on both empirical knowledge and theoretical understanding does not help to move beyond the putative gap between the two but throws the gap into an even sharper relief. Therefore, instead of person-centeredness being an add-on to evidencebased practice, as the WCPT’s policy statement seems to suggest, it should be recast in a critical and disruptive manner that draws attention to the dominance of positivism. To do so, we argue, person-centeredness should get rid of all its own traces of positivism. Positivism only recognizes knowledge that can be verified with quantitative scientific methods as valid.17 Therefore, to scientifically affirm precise knowledge of what person-centeredness is falls under positivism. In contrast, to recast person-centeredness as critical of positivism means that physiotherapists should embrace the intrinsic ambiguity and complexity of CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 4 © Emory University; authors retain copyright for their original articles person-centeredness, both as a concept and a practice, and accept the possibility that unanimity about what person-centeredness is might be impossible to reach. Adorno’s thought is notoriously complex; it is impossible to be exhaustive of his work here. For our purposes, it is sufficient to understand roughly what Adorno means by ‘negative dialectics’ and ‘constellations.’ Adorno states that negative dialectics is not a method or a dogmatic world-view.1 It is rather a critique of what he calls ‘identity thinking.’ Identity thinking, according to Adorno, seeks to know objects according to all the possible and correct classifications and concepts under which objects fall. Although we cannot think without identifying, Adorno argues, identity thinking is nevertheless problematic because it necessarily falls short of capturing the particularity of objects. Negative dialectics seeks to demonstrate the insufficiency of any given identification.1 ‘Constellations’ relate closely to negative dialectics. Adorno suggests that instead of identifying an object with an overarching classificatory concept, concepts “enter into a constellation…[that] illuminates what is specific in the object, that which is burdensome or a matter of indifference to a classificatory procedure.”1(p162) Constellations of concepts around objects, therefore, reveal more particular knowledge about the object. S T R U C T U R E We begin by explaining our starting point in two interrelated problems of person-centeredness: practical difficulties and conceptual difficulties. We suggest that because person-centeredness is difficult to define, clarification of person-centeredness as a standardized concept can hardly help to optimize person-centered practice. Rather, drawing on Adorno’s magnum opus Negative Dialectics,1 it is more helpful to think of personcenteredness as a ‘constellation’ that critically guides practice. We then explain our methodology and present the findings of the empirical work. Finally, we discuss the findings to further analyze personcenteredness. We conclude that a critical constellation around person-centeredness aims at creating an awareness of the ever-present possibility of non-person-centered practice in physiotherapy by drawing attention to critical areas of physiotherapy scholarship. We invite readers to remain open to the possibility that conceptual clarifications and definitions are not, as Adorno argues, the be-all and end-all of knowledge.1 Should We Define PersonCenteredness? Moving From a Concept Toward a Constellation Person-centeredness, patient-centeredness, clientcenteredness: the way practitioners, researchers, and other stakeholders refer to the concept and practice vary. For the sake of clarity, we use ‘person-centered’ throughout this article to refer to all the related concepts. We return to the different meanings attached to person-centeredness below. Person-centeredness has been approached in physiotherapy research from different points of view: goal-setting in rehabilitation,18-20 developing assessment tools for evaluating person-centered practice,21 considering disabled persons’ and their families’ perspectives,22-23 communicating in a personcentered manner,24 examining practitioner and student perspectives,25-27 identifying the outcomes of implementing a person-centered framework,28 and CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 5 © Emory University; authors retain copyright for their original articles developing person-centered skills through research-led drama.29 Person-centeredness has also been applied to telerehabilitation and passive assistive technology,30-32 which represents a deviation from the more usual use of the term that describes different qualitative and psychosocial aspects of person-to-person care—as opposed to care standardized by technology—such as respecting and empowering patients as persons.33-34 Although there is less research on person-centeredness in physiotherapy compared to other areas of healthcare such as nursing, medicine, and mental health,35 its varied implementation, as demonstrated above, shows that it has made its way into physiotherapy as a valued goal. There is also some physiotherapy research on person-centeredness that might be termed critical (we discuss some of this research below) but considerably less so compared to more conventional approaches. To understand what criticality might entail, Barbara E. Gibson provides a helpful list of central tenets: questioning the taken-for-granted, attending to power relations, and critiquing the dominance of positivism.36 We return to these tenets in the discussion. No Agreed-Upon Meaning In this section, we address the tension between conceptual complexity on the one hand, and the resulting lack of normative content (ie, lack of an evaluative standard for behavior and action) on the other. Currently, both physiotherapy and healthcare in general lack unanimity on the meaning of personcenteredness.35 Leplege et al have identified four possible meanings: addressing the person’s specific and holistic properties; addressing the person’s difficulties in everyday life; considering the person an expert on their own condition, emphasizing participation and empowerment; and respecting the person ‘behind’ the impairment or the disease. They argue that the vagueness of the concept and the possible clashes between different definitions are problematic—so much so that they suggest we ought to keep the values but stop using the term.33 Another conceptual problem arises with new technologies, such as telerehabilitation.30-31This raises the question whether person-centeredness ought to be redefined in the new context. In addition to the different understandings among physiotherapists, there are also varying understandings among different stakeholders such as patients and decisionmakers, which brings further conceptual ambiguity.35,37 Dukhu, Purcell, and Bulley argue that the lack of a standardized definition reflects the complexity of the concept of person-centeredness and makes meeting expectations of person-centeredness in physiotherapy problematic.38 The problem they point out can be formulated in philosophical terms as an impassable aporia: the concept of person-centeredness lacks normative content, but its very own conceptual complexity restricts clarifying its normative content. How indeed do physiotherapists meet expectations of person-centeredness, if they do not know what the expectations are? However, it is equally problematic to standardize a definition because it would standardize the practice—one size fits all—which is exactly contrary to the person-centered ideal of encountering each person as a unique individual. Might a clear definition be of any help? Jesus et al argue that “it is unlikely that person-centredness can be optimally attained without improved conceptual clarification.”35(p2) Gzil et al argue similarly that what rehabilitation needs is not “more person-centredness,” because “person-centredness is less a way forward for rehabilitation than it is a considerable challenge CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 6 © Emory University; authors retain copyright for their original articles requiring not only greater conceptual clarity but also methodological advance.”39(p1623) Both of these conclusions are, however, equally unhelpful because physiotherapy practice does not pause to wait for clearer conceptual definitions for optimizing personcenteredness. Moreover, conceptual clarification does not in itself guarantee person-centered practice because a standardized definition might not work in all possible situations. We are not saying that we ought to abandon concepts and definitions. Rather, we need another way of thinking about defining person-centeredness that is more pragmatic, contextual, and open-ended. In our view, a complex concept that refers to a complex practice is best defined in multiple different ways—as a constellation of concepts transforming ad infinitum— and used in variable ways in various contexts. We will return to the idea of constellations shortly. A C C E P T I N G E L U S I V E N E S S : L O O K I N G B E Y O N D R E D U C T I O N I S M … We argue that accepting the conceptual elusiveness of person-centeredness is a critical device to draw attention to the dominance of positivism and its problematic criteria for knowledge. Positivism rejects metaphysics as meaningless, and elevates empiricallyobserved verification and quantitative science to the criteria of truth.17 Seeking a clear definition of personcenteredness, and refusing to tolerate conceptual ambiguity, resonates with positivism and Wittgenstein’s famous statement that “[w]hat we cannot speak about we must pass over in silence.”40(p89) Instead, to disrupt positivism’s conceptual reductionism (since reductionism is problematic when it comes to complex concepts and practices), we suggest that person-centeredness ought to look beyond reductionist definitions and conceptualizations. As we indicated above, current research has not reached unanimity on what person-centeredness is. Perhaps unanimity is unreachable because personcenteredness is a whole complex of ideas, concepts, definitions, understandings, and practices that interact in different situations, with various people, and in different cultures in many ways. Attempting a standardized definition necessarily simplifies personcenteredness and whitewashes difference by silencing discourses that deviate from the standard. … T O W A R D A C O N S T E L L A T I O N O F C O N C E P T S We do think that it is helpful to have some kind of idea of how to approach person-centeredness. We suggest that person-centeredness can be thought of metaphorically as a ‘constellation’ of concepts (definitions, ideas, understandings, meanings, connotations) that surround an object (personcenteredness). Adorno uses Walter Benjamin’s41 metaphor of constellations (that ideas are to objects what constellations are to stars) to critique ‘identity thinking’ that claims to have grasped particulars by categorizing them under universals: to putatively know the object is to attach all possible correct classifications to it.1 However, Adorno argues, categorization does not reveal truth but instead loses sight of particularity because the concept of the object and the object are not the same (not identical). Adorno suggests that constellations stay true to particularity by approaching objects as a process necessarily bound to history (time and place). Therefore, constellations are not universally fixed and they tell us more about objects than standardized definitions. As Adorno writes: CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 7 © Emory University; authors retain copyright for their original articles Cognition of the object in its constellation is cognition of the process stored in the object. As a constellation, theoretical thought circles the concept it would like to unseal, hoping that it may fly open like the lock of a well-guarded safe-deposit box: in response, not to a single key or a single number, but to a combination of numbers.1(p163) Gillian Rose provides a helpful explanation of how Adorno intends to use constellations: “To examine something by a ‘constellation’ means to juxtapose a cluster of related words or connotations which characterise the object of investigation without implying that the concepts used are identical with their objects.”42(pp116-117) Adorno uses constellations, Rose explains, because the object cannot be captured by simply attaching a concept to it. Rather, she further elaborates, “a set of presentations may best approximate it [original emphasis].”42(p17) In the next section, we explore the possible ‘presentations’ that might enter into a constellation around person-centeredness in physiotherapy. A Constellation Around Person-Centeredness In Physiotherapy Leplege et al’s work briefly summarized above provides a helpful shorthand about the meanings that have been attached to person-centeredness in general. In this section, we discuss research in rehabilitation that has emphasized critical ideas that might enter a constellation around person-centeredness, such as care and compassion;43 empowerment and shared decisionmaking;44 drawing attention to contextuality, justice, and how power operates;45 promoting relationality;46 and ‘tinkering’ with person-centered rehabilitation.47 The research we discuss below emphasizes collaboration from two intertwined perspectives: care and justice. A S S E M B L I N G C R I T I C A L I D E A S A R O U N D P E R S O N - C E N T E R E D N E S S MacLeod and McPherson suggest that more attention needs to be paid to care and compassion: if physiotherapy leans too heavily on advancing techniques as ends in themselves, physiotherapy may fail at person-centeredness. The authors argue that care and compassion facilitate psychological, spiritual, and social wellbeing, and that a compassionate perspective might guide practitioners toward care that is truly person-centered, empathetic, and collaborative.43 Ward et al also emphasize collaboration but from the point of view of empowerment. They found in their qualitative study on person-centeredness that physiotherapists emphasize the need to empower patients through education to enable shared decisionmaking.44 Durocher et al found that practitioners understand person-centeredness in different ways, recognizing that while respecting autonomy is important, not all patients have it. The authors argue that “autonomous action is mediated through relational, social, cultural, economic, contextual, situational, and political dimensions, and that power circulates in its enactment” drawing attention to how autonomy is constrained or enabled, and how circumstances promote or prohibit justice.45(p297) Bright et al’s autoethnographic study highlights relationality and collaboration as the basis for personcenteredness. They argue that person-centeredness CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 8 © Emory University; authors retain copyright for their original articles entails listening and ‘being with’ rather than ‘doing to’ patients.46 Finally, Gibson et al suggest that the idea of ‘tinkering’ is potentially a useful way to approach personcenteredness. Tinkering involves a continuous questioning of what to do, what might be the best, and what might person-centeredness mean in different situations and moments of care.47 The research above forms a constellation: care and compassion;43 empowerment and shared decisionmaking;44 drawing attention to contextuality, justice, and how power operates;45 promoting relationality;46 and ‘tinkering’ with person-centered rehabilitation.47 This sketch of a constellation gives an idea of what person-centeredness might include, but should remain open-ended so that countless other understandings might enter into it. C O N S I D E R I N G P O S S I B L E BAR R I E R S We suggest that a constellation around personcenteredness should also consider possible internal and external barriers that might have an adverse effect on implementing person-centeredness. As examples, we briefly introduce three studies that have addressed barriers to person-centeredness in the context of physiotherapy. In an autoethnographic reflection on personcenteredness in the biomedical paradigm, Mudge et al argue that person-centeredness not only causes potential clashes between patient perspectives and expert knowledge but also leaves physiotherapists unprepared for the emotional labor caused by a number of factors. These are: 1) having to practice in a person-centered manner in challenging situations, such as dealing with patients who have potentially unrealistic goals; 2) lacking tools to recognize patients as experts worth collaborating with; and 3) lacking flexibility to assign or assume responsibility with changing situations.48 Another barrier that practitioners might experience is lack of time and resources. Durocher et al’s study on discharge planning found that person-centeredness is considered too time-consuming when time, resources, and services imposed by health policies are already constrained.45 A study by Philips et al also exemplifies possible barriers. The authors found that the role of the patientas-professional has a potential to improve healthcare delivery and person-centered care, but not all patients want to be involved or have the capacity to be involved on the level that the patient-as-professional role requires. On the other hand, those who can and want to be involved demand more time from practitioners than often is available.37 These possible barriers are of course not exhaustive of the practical problems of person-centeredness. What they do demonstrate is that conceptual clarification is not sufficient to address all of the possible difficulties of implementing person-centeredness. Consider the three examples of barriers and how they might be overcome: • Mudge et al’s analysis suggests it might be helpful to clarify the relationship between biomedical knowledge and patient perspectives, and to consider how to negotiate between the two perspectives. In such negotiation, conceptual clarifications might prove useful; but so might challenging the taken-for-granted assumptions of both personcenteredness and the biomedical paradigm. CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 9 © Emory University; authors retain copyright for their original articles • In turn, the barrier Durocher et al perceive— time and budgetary constraints—is not reconciled simply on a conceptual level but rather requires drawing attention to the macrolevel of rehabilitation: social, economic, and political constraints. • Finally, the barrier Philips et al perceive—that patients are not necessarily willing or capable of making decisions—might again be reconciled with some conceptual clarification: sometimes person-centeredness might mean that the professional assumes decision-making responsibility. However, in our view, adding an opposite definition (practitioner-led practice) to person-centeredness only further highlights that person-centeredness is complex, and neither its definition nor the solutions to its practical problems are reconciled by reducing the complexity to a standardized definition. In some cases, it may even be more helpful to approach person-centeredness by thinking what it is not rather than affirming what it is. To argue that personcenteredness is not paternalistic practice that treats persons as mere means or standardized objects is less disputable than to argue that person-centeredness is necessarily one thing or another. This observation offers some shared ground for a diversity of discourses, even disagreement and criticism, that might enter into a constellation around person-centeredness. In the following two sections, we introduce the empirical work that we suggest demonstrates some of the complexity of person-centeredness discussed above. We then discuss the findings vis-à-vis constellations and person-centeredness. The Empirical Work The empirical data was originally generated for the first author’s master’s thesis.49 The question that guided the empirical work was: What do people receiving neurological physiotherapy find particularly meaningful in their rehabilitation? Research ethics approval was obtained from the first author’s institutional review board.49 The first author obtained consent from each participant for the interviews. She also obtained permission from each participant to re-use and re-analyze the data for the current article. The data provided useful material for the purposes of this article on what person-centered aspects might matter to people in neurological rehabilitation, which then guided our philosophical inquiry (explained below) that asks: What does it mean, from a philosophical perspective, to put the person at the ‘center’ of practice? The data was generated by the first author with 13 informants, each of whom participated in a semistructured focused interview. The interviews took place in a privately-owned rehabilitation center in Finland that provides publicly-funded outpatient rehabilitation for people with long-term neurological impairments. All of the informants received rehabilitation in the center. They were recruited by asking each physiotherapist employed in the rehabilitation center (n=12) to recruit one or two of their clients who were willing to share their experiences and had specialized knowledge of rehabilitation (=informant). The informants were between 24 to 67 years of age. Seven were men and six women, and all had a longterm neurological condition including cerebral palsy, stroke, spinal cord injury, multiple sclerosis, and CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 16 © Emory University; authors retain copyright for their original articles In contrast, thinking in constellations recognizes the need to pay attention to issues that require insight from multiple sources: social and political sciences, medicine, humanities, philosophy, ethics. In our empirical work, the experiencing and meaning-makingembodied persons provided a valuable source of knowledge. We suggest that such knowledge has as much practical value to physiotherapists as quantitative or biomedical knowledge about the human body. Therefore, we suggest bringing qualitative, philosophical, and embodied understanding on par with the biomedical to form constellations around both person-centeredness and evidence-based practice, and to drive physiotherapy toward a critically informed future. Conclusions We have argued that thinking person-centeredness through the idea of constellations is more helpful than fixing a definition or a procedure for personcenteredness. The latter would be exactly counter to individualized—or person-centered—care because, simply put, different issues affect different people. However, whether ‘person-centeredness’ describes what we have recast as a constellation remains an open question. If the practice that physiotherapists now refer to as ‘person-centeredness’ is in reality an extremely complex practice, is it possible to place the person (alone) at its center? Does ‘centeredness’ describe the complexity and dynamics of rehabilitation? Or does thinking through constellations actually ‘decentralize’ person-centeredness? Does the discourse placing the person at the ‘center’ make the person a target of rehabilitation rather than an active participant (person at the center versus person and practitioner side-by-side)? A S T A R T I N G P O I N T F O R D I S C U S S I O N We cannot hope to answer these questions here. Therefore, we suggest that person-centeredness can only work effectively as a starting point for critical discussion, but never be the conclusion. Physiotherapy still needs something to guide its ethics and morals, and ‘person-centeredness’ seems to have entered healthcare discourse to stay. It will do for now to mark the kinds of moral practices that seek to challenge paternalism. However, we suggest that physiotherapy needs more, not fewer, items to add to the constellation around ‘person-centeredness.’ T E A C H I N G T H E C O M P L E X S O C I O L O G Y O F R E H A B I L I T A T I O N To capture the complexity of person-centeredness, physiotherapy would benefit from a greater understanding of the complex sociology of rehabilitation, which we suggest should be integrated into preand post-qualification education and continuing professional development. By ‘complex sociology’ we refer to the countless intertwined issues that potentially affect persons in (or at the ‘center’ of) rehabilitation. The complex sociology includes, for example, the following: • Patient as the embodied expert of rehabilitation • Knowledge and experience of the practitioner • Continuing collaboration and negotiation between patient and practitioner expertise • Interaction between different practitioners, patients, and family members CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 17 © Emory University; authors retain copyright for their original articles • Interaction of emotions, affect, and bodies (bodies touching, moving, and being moved both emotionally and in space and time) • Physical and discursive spaces and places, and no-places and other-spaces • International political economy of rehabilitation and functioning • Understanding of how power relationships, inequality, inequity, injustice, ableism, racism, ageism, sexism, heteronormativity, geography, and demography operate in a constellation around person-centeredness. Acknowledgements The authors are grateful to Barbara Gibson, Timo Uotinen and the two anonymous reviewers for their helpful comments. We would like to express our deepest gratitude to Jukka Aittokallio for letting us use the writer’s retreat from the start to the finish line. D I S C L O S U R E S The first author was employed at the facility at which the interviews were conducted but none of the informants were her clients. She was on a non-paid leave to conduct the interviews. She received financial support from the facility to develop their rehabilitation pathway. The data concerning the development work, however, were not used in this article. She declares no conflict of interest. The second author declares no conflict of interest. C O R R E S P O N D I N G A U T H O R Anna Ilona Rajala, PhD Candidate, University of Brighton. [email protected] F U N D I N G S O U R C E The writing was supported with 500€ from the Finnish Association of Psychophysical Physiotherapists (PSYFY Ry). 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CRITICAL RESEARCH AND PERSPECTIVES PERSPECTIVES FROM ‘PERSON CENTEREDNESS’ Published online 01 May 2020 at jhrehab.org 20 © Emory University; authors retain copyright for their original articles About the Authors Jenni Aittokallio is a physiotherapist specializing in mental health and pediatrics. She has extensive clinical experience in adult neurology, both as a practical nurse and a physiotherapist. She received her Master of Health Care degree from Tampere University of Applied Science, Finland, focusing on healthcare management. She also holds a post-qualification certificate in mental health physiotherapy, and a comprehensive continuing education qualification in children’s physiotherapy. For the past six years she has been working with children and adolescents with neuropsychiatric disorders and mental health disorders. Her interest in the humanities is both academic and clinical. Her research interests include patient experience, embodiment, and embodied selfexpression. She uses methods that draw on the humanities in her clinical work, including painting and playing musical instruments, as well as body-based methods such as movement, play, and dance. She is a co-founder of a website that introduces physiotherapy research in mental health for Finnish audiences. Anna Ilona Rajala is a physiotherapist with clinical experience in neurology and gerontology. She received a Master of Arts degree in Philosophy, Politics and Economics of Health from University College London. She is currently finishing her PhD thesis, a philosophical critique of physiotherapy through the work of the Frankfurt School critical theorist Theodor W. Adorno, at CAPPE (Centre for Applied Philosophy, Politics and Ethics), School of Humanities, University of Brighton, UK. She also holds a research fellowship in political science at Tampere University, Finland. Her focus in a current project is on international political economy of dementia and rehabilitation. She is also co-founder of an independent research project on Shakespeare and philosophy, with an interest in themes of disablement, old age, and the body in Shakespeare’s plays. She is co-chair of the Critical Physiotherapy Network, co-editor-in-chief of the peer-reviewed journal Thanatos, and co-founder of a website on mental health physiotherapy in Finnish. Her research interests include humanities (the arts, literature, dance, and history), philosophy, and politics (including the politics of care).