Have we ever treated patients yet? Actor- network theory and the changing patient in a changing world

Models in physiotherapy

Karime Moscouto stated in her blog for the EPA in September and in articles that the biopsychosocial model is the dominant model in today’s physiotherapy(Mescouto et al., 2022). As an evolution of the biomedical model, this model still represents mostly a dualistic cartesian view of humans. This means that body and mind are separated, and a lot is focused on reducing the patient's problems to either physical or mental problems. Jenny Slatman even states that: “within contemporary neuroscience and neuropsychology, the materialistic view of humans, which can be traced back to De La Mettrie, is flourishing.” In this, Slatman tells us that we are not evolving to a more systemic view of the patient,
but an even more mechanical view (Slatman, 2021). We also see this in physiotherapy, where our biomechanical knowledge is still at the root of physiotherapy (Nicholls, 2017). So, to change how we treat our patients, we must aim to redefine the patient's identity and propose a new way of seeing our patients influenced by Actor-Network Theory.

Redefining the patient's identity

The patient's identity has been shaped by modern society, with evidence-based medicine (EBM) in the early 1990’s as an upcoming modernist movement (Wieringe et al., 2017). In the movement of EBM it focussed on separating the objective and the subjective, as objective knowledge is considered more trustworthy than subjective knowledge (Wieringe et al., 2017). These approaches fail to capture the multidimensionality of patients. When focusing on the objective, we focus on the models, techniques and processes. We are not focussing on the patient, so to paraphrase a famous statement by Bruno Latour: Have we ever really treated patients yet (Latour, 1993)?

Embracing change in a changing world

A shift towards a broader concept of the human is also crucial as we face immense global social and ecological challenges that significantly affect health and healthcare (Romanello, 2022). As a result of the immense ecological changes caused by humanity, we are now in a period referred to as the Anthropocene (Steffen et al., 2011). In this period, human exceptionalism or anthropocentrism prevails, placing humans at the centre of the universe, prioritising human interests over those of other species and non-humans, and underestimating the environment's impact on our well-being.  Some might even say anthropocentrism is the main catalyst for the environmental crisis. Humans are
connected and symbiotic to their environment. if we acknowledge this more this can be meaningful in treating patients (Maric & Nicholls, 2021). As physiotherapists, we must consider how these global dynamics and anthropocentrism affect our patient care approach. To better understand the patient, we could try and move away from human-centred views and use Bruno Latour's Actor-Network
Theory to define our patients, which recognises them as complex interconnected networks encompassing humans and non-humans.

Actor-Network Theory: A New Perspective

Bruno Latour was a French sociologist and philosopher. He is best known for his work “We have never been modern” from 1993, and later as one of the greatest minds thinking about climate change and the Anthropocene. In all his work one of the most central points is that everything is connected and  constantly moving and he tried to capture this in the development of Actor-Network theory or ANT.

Actor

Latour’s definition of an actor invites us to see actors as dynamic elements within complex networks. He describes an actor as "not the source of an action but the moving target of a vast array of entities swarming towards it." This notion draws inspiration from the world of theatre, where actors are central but never act alone. They rely on the stage, props, the audience, and often other actors to bring a story to life (Latour, Reassembling the social; An introduction to actor network theory, 2007). Crucially, it can be both human and non-human, a table, a house, or an animal. Actors are not just passive participants; they have agency. They influence and transform other actors, often in unexpected ways. This perspective underscores the idea that everything in the network, whether it is a person, an object, or an idea, plays a role in shaping outcomes.

Network

The concept of a "network" does not refer to a simplistic image of spheres and dots connected by lines, or a vast array of speedways interconnected as a network. Latour describes a network as: ‘an expression to check how much energy, movement, and specificity our own reports are able to capture.’ (Latour, 2007) In other words, the network is about everything that happens between actors and within actors. It can be with two or countless actors. Even thoughts and emotions can be seen as actors; it is not about the dots and lines, but a network is about the transformations that actors effect on each other. ANT recognises that these interactions and influences are not static but dynamic,
always evolving. So networks, in ANT, are complex, ever-changing systems where actors continually shape and reshape the narrative.

Redefining the patient

Actor-network theory (ANT) stretches our imagination beyond the traditional perception of patients as central healthcare figures. It urges us to envision them as integral components intricately interwoven within an ecological web. Patients are no longer passive recipients but active participants, shaping and being shaped by their environment. Within this intricate web of actors, a patient emerges not as an isolated entity but as a phenomenon brought to life by the dynamic interplay of countless actors, human and non-human (Latour, 2007). For example, in a treatment room this is created by the patient's interaction with the computer on the desk, the therapist's expertise, the room's physical layout, the chairs, everything is an actor and can exert agency within the phenomenon of an actor-network. Through ANT, we can expand our

understanding of the ecology that is the patient. We recognise patients as part of intricate networks involving various factors, including emotions, social context, physical elements, etc.

Conclusion: Shaping a post-human future

Actor-network theory offers a new paradigm for physiotherapy, shifting our thoughts and ideas from static models to dynamic networks. By understanding patients as actor-networks, we can also gain an expanded, ecological view of the patient and the far more diverse entry points for intervention such an ecological perspective of patients might offer. Such a post-human approach would acknowledge the patient's complexity and emphasise the interconnectedness of all things, human and non-human, opening for more adaptive, meaningful, and less anthropocentric healthcare practices as we navigate our rapidly changing world.

References

• Dictionary, T. F. (2023). The Free Dictionary by Farlexx. Retrieved from medical dictionary: https://medical-dictionary.thefreedictionary.com/patient
• Latour, B. (2007). Reassembling the social; An introduction to actor network theory. Oup Oxford.
• Latour, B. (2012). We have never been modern. Harvard University Press.
• Latour, B. (2017). Facing Gaia; eight lectures on the new climate regime. John Wiley and Sons. Maric, F., & Nicholls, D. A. (2021, august 7). Environmental physiotherapy and the case for multispecies justice in planetary health. Physiotherapy Theory and Practice. Mescouto, K.,
• Olson, R. E., Hodges, P. W., & Setchel, J. (2020, December 7). A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation, 44(13), pp. 3270-3284.
• Mescouto, K., Olson, R. E., Hodges, P. W., & Setchel, J. (2022). A critical review of the biopsychosocial model of low back pain care; time for a new approach? Disability and Rehabilitation, 44, pp. 3270-3284.
• Nicholls, D. A. (2017). The End of physiotherapy. Routledge.
• Romanello, M. D. (2022). The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels. Lancet, pp. 1619-1654.
• Slatman, J. (2021). Plastic Mortals and 21st Century Healthcare. Second Thoughts. First Introductions to Philosophy. Tilburg.
  Stilwell, P. &. (2019). An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences, 4, pp. 637-665.
• Wieringe, Msc, DPhil student, S., Engebresten, PHD, E., Heggen PHD, K., & Greenhalg, PHD, T. (2017, Februari 23). Has evidence-based medicine ever been modern? A Latour inspired understanding of a changing EBM. Journal of evaluation in clinical practice, pp. 964-970.