How `we' are different from `them': occupational ... - Wiley Online Library

Sociology of Health & Illness Vol. 23 No. 1 2001 ISSN 0141±9889, pp. 24±43

How `we' are different from `them': occupational boundary maintenance in the treatment of musculo-skeletal problems Pauline Norris Health Services Research Centre, Victoria University, Wellington

Abstract

Strategies of occupational control at the macro-level have been described by many sociologists. This paper draws on a study of the division of labour in the treatment of musculo-skeletal problems in New Zealand to look at micro-level strategies of occupational control. These are rhetorical strategies used by individual practitioners to establish and maintain occupational boundaries. Practitioners used these strategies to distinguish their occupation from others, creating a sense of professional identity and enabling claims to jurisdiction over an area of work. Many of these strategies involved notions of limitation (i.e. other occupations are limited because they do not possess something we do), holism (we are holistic in our approach while others are not), and prevention (we prevent problems by treating the causes, while others treat the symptoms).

Keywords: boundary maintenance, occupational control, alternative medicine, musculo-skeletal Introduction Many sociologists have described strategies of occupational control pursued by professional associations, such as seeking autonomy over work, licensing, disciplinary powers over members and authority over other related occupations (e.g. Berlant 1975, Johnson 1972, Larson 1977, Starr 1982, Willis 1983). However, Cant and Calnan (1991) note that professionalisation strategies can be followed at a number of levels, including the micro-level of individual practitioners. The alternative practitioners interviewed by Cant and Calnan placed great emphasis on the importance of their training in distinguishing themselves from others. Cant and Calnan found that therapists often condemned some other kinds of therapists as quacks. Sharma (1992) also suggests that the notion of the untrained `cowboy' # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.

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performs a moral function in defining and legitimating professional boundaries for alternative practitioners. Sociologists have looked at how boundaries are maintained in a variety of areas (e.g. Britton (1990), Whyte (1986)). Gaziano (1996) and Gieryn (1983) look at boundary maintenance in the context of professions. They suggest that constructing boundaries is used by professionals for the pursuit of professional goals. Gieryn sees the demarcation of boundaries between science and non-science as a practical and ongoing problem for scientists. Scientists, he argues use `boundary-work' as a technique to accomplish this. This is: an ideological style found in scientists' attempt to create a public image for science by contrasting it favorably to non-scientific intellectual or technical activities (1983: 781) [and] a rhetorical style. . . in which scientists describe science for the public and its political authorities, sometimes hoping to enlarge the material and symbolic resources of scientists or to defend professional autonomy (1983: 782). In a later paper Gieryn (1995) draws on the sociology of professions, in particular Abbott's (1988) work, to provide further theoretical insights on the problem of how people in society construct boundaries between science and non-science. This paper explores `boundary work' performed by practitioners treating musculo-skeletal problems. I argue that there are relatively few differences, and a considerable amount of overlap between treatments provided by these practitioners. This makes successful jurisdictional claims over an area of work difficult. To deal with this, treatment providers do boundary work, that is, they adopt professional ideologies which attempt to distinguish themselves from others. This paper is not about real differences between occupations, but about how individual practitioners, within their talk, express and produce differences between occupations. Thus, boundaries between occupations are seen as being constructed by practitioners, whose descriptions of their own and others' occupations are seen as rhetorical devices (Potter and Wetherell, 1994), the goal of which is occupational control. Such devices may be different from macro-level strategies pursued by professional associations to achieve the same objective. Methods This paper draws on a study of the treatment of musculo-skeletal problems. It starts from Abbott's (1988) argument that professions form an interlocking system in which they compete for work. He argued that the # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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relationships between professions, rather than the stories of individual professions, were the most fruitful area for study and that the history of individual professions is shaped by their relationships with others. The treatment of musculo-skeletal problems is a particularly fertile area in which to use insights from Abbott's work. The study involved semi-structured interviews with 83 treatment providers, and 13 professional associations in New Zealand, including both orthodox and alternative occupations. These included seven medical specialists, 17 general practitioners, 17 physiotherapists, eight chiropractors, eight osteopaths, six massage therapists (including aromatherapy massage), four acupuncturists, two Alexander Technique practitioners, two podiatrists, two psychologists, two beauty therapists who practised massage, and practitioners of a range of other therapies. Practitioners were chosen to represent the range of different practice within each occupation. They were drawn from four geographical areas: two cities of 3±400,000 people (Wellington and Christchurch); and two predominantly rural areas (the Wairarapa and the West Coast of the South Island). The interviews covered a range of topics about clientele, funding and methods of diagnosis and treatment, but in this paper I concentrate on responses to questions about how each respondent's practice was different from that of practitioners in another closely related occupation. I also use appropriate material from other questions, such as descriptions of diagnostic and treatment techniques, which sometimes involved comparisons with other occupations. Some respondents, particularly those from small and less well-known therapies, seemed to view the interview as an opportunity to gain favourable public attention for their therapy. Some also used it as an opportunity to criticise other individuals either within their own occupation, or from another. However, the interviews seemed to be less overtly politicised and competitive than those described by Cant and Sharma (1998) in their study of professionalisation and alternative practitioners in the United Kingdom. I think this was due to my focus on the micro-level of daily practice. I asked practitioners to describe the patients and conditions they treated, and their methods of treatment, and this meant that there was less focus on occupational disputes at the macro-level. Almost all the interviews were carried out in the practitioners' place of work, although for a number of people this was a room in their home. Practitioners' were all assured of confidentiality, both verbally and in writing. The study had been approved by the Wellington Ethics Committee, which provided practitioners with assurance and an avenue of complaint if they felt I had not respected this requirement. However, many waived aside these assurances and said that they were not concerned about confidentiality because they were not saying anything they would not want people to know. Again, this suggests a less politicised interview situation than Cant and Sharma (1998) describe, in which respondents made controversial and indiscreet comments about each other. # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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Only very infrequently did practitioners appear to distrust my motives in doing the research. Both orthodox and alternative practitioners who treated musculo-skeletal problems were included in the same way in the study, and I think this conveyed the message that I took alternative therapies seriously, and was not antagonistic to them. This was reinforced in the interview situation when I asked about methods of diagnosis and treatment and asked questions which implied some understanding of `new age' and alternative ways of viewing health and illness. I was interested in what practitioners had to say, and genuinely puzzled about the differences between the occupations, and I tried to communicate this to respondents.

Differences between occupations treating musculo-skeletal problems In New Zealand the primary care treatment of musculo-skeletal problems is the site for a complex division of labour. A very large number of occupations offer treatment for these problems. There are considerable differences between occupations (and in the case of osteopaths and acupuncturists, within occupations) in access to state funding. At the macro-level many of the larger occupations were engaging in considerable professionalisation activities at the time of the study. In 1994 chiropractors opened the first New Zealand-based chiropractic school. Training involves a BSc course at the University of Auckland, with additional chiropractic courses provided at the School. Osteopaths were undergoing a period of intense activity, based on an attempt to gain legislative protection. This involved considerable negotiation between the two professional associations who had previously had an antagonistic relationship. State activity, especially increasing attempts to control public expenditure on accident-related conditions, and also the introduction of evidence-based guidelines for acute back pain (mentioned below), was making many professional groups uncomfortable and being seen as an opportunity by some groups, and a threat to others. At both the macro, and the micro levels, practitioners who treat musculoskeletal problems face particular difficulties in distinguishing themselves from other treatment providers. In some areas, such as the treatment of dental problems, or the dispensing of medication, there is one occupation (dentistry or pharmacy), which has a comparatively undisputed claim to the bulk of routine work. For musculo-skeletal problems, however, there are many competing providers of treatment. Two other factors make defining and drawing boundaries between occupations treating musculo-skeletal problems extremely difficult. First, there are considerable differences within each occupation. To take one example, many New Zealand physiotherapists stress the need to educate patients and provide exercises and advice so that they can treat their own # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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musculo-skeletal problems. They provide little `hands-on' treatment. Others do a great deal of `hands-on' treatment, and provide comparatively little advice on exercises. Similar differences in approach are found within other occupations in the area. Secondly, many of the techniques used by the occupations are similar. Acupuncture is practised by acupuncturists, physiotherapists and general practitioners; manipulation is practised by chiropractors, osteopaths, physiotherapists and some general practitioners; mobilisation techniques are practised by physiotherapists, osteopaths and some chiropractors; massage is practised by massage therapists, physiotherapists, some osteopaths and chiropractors, and some acupuncturists. This is partly a result of both large-scale and small-scale `copying' of other occupations' techniques. On the large scale, a very large proportion of physiotherapists in New Zealand now practise manipulation, a technique traditionally associated with chiropractors and osteopaths. On a smaller scale, some practitioners interviewed in each occupation reported using techniques picked up from a variety of sources. Physiotherapists, for example, use osteopathic techniques, chiropractors use physiotherapy and osteopathic techniques. The high degree of variation within occupations, and the tendency for providers to borrow techniques from other occupations, mean that boundaries between occupations in this area are difficult to draw. But practitioners do strive to distinguish themselves and their work from their competitors, not necessarily by describing real observed differences in practice, but by recounting stereotypes: stories they tell about themselves and others. The practitioners I interviewed generally knew very little about each other. Many mentioned that they had never been to, or seen other types of practitioner in action.

The division of labour and boundary maintenance in the treatment of musculo-skeletal problems In the following section some of the major occupations concerned with the treatment of musculo-skeletal problems will be discussed. The practitioners' legislative and funding arrangements, and position in the division of labour will be described very briefly, along with some of the boundary issues, and how they characterise themselves and were characterised by others. Although some medical specialists (occupational health specialists, orthopaedic surgeons, rheumatologists) were included in the study, the main focus was on those who provided primary care (i.e. those whom patients could approach directly). The final section will discuss some common themes: the lack of reference to science, and the use of the concepts of limitation, holism and prevention. # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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General practitioners In New Zealand general practitioners are the first treatment provider consulted by many people with musculo-skeletal problems. They act as gatekeepers to Accident Compensation (ACC) funding. This means that if the musculo-skeletal problems are caused by an accident, patients are eligible for subsidised treatment by GPs themselves, or by other approved practitioners, such as physiotherapists, osteopaths, chiropractors or registered acupuncturists, if they have this certified by a GP. However, if patients are not eligible for, or do not want, ACC funding, they may also approach any treatment provider without having seen a GP. When discussing GPs, other providers noted the connection between GPs and medication. If each occupation has a `signature' treatment, prescribed medication was seen as that of the GP. Along with providing medication, referral to physiotherapy seems to have been the most common response of GPs to musculo-skeletal problems. Others sometimes pointed out, in the process of trying to distinguish physiotherapy, chiropractice and osteopathy, that the medical profession was lucky to have such a clear jurisdiction. The very òbviousness' of what GPs do, and the distinctiveness of their role meant that GPs were not discussed in the same way as other occupations. Other practitioners did not compare themselves to GPs. Physiotherapy Most physiotherapists providing treatment for musculo-skeletal problems are in private practices. Physiotherapists utilise a wide range of techniques, and so their territory overlaps with many occupations. Their major competitors for the role of first line referral options from GPs are chiropractors and osteopaths. Another boundary physiotherapists protect is that with massage therapists. Physiotherapy grew out of massage therapy, and the boundary between them is, compared to others in the area, well policed. The 1949 Physiotherapy Act makes the practice of therapeutic massage illegal for non-physiotherapists, with some minor exceptions. Practitioners of therapeutic massage currently act illegally in advertising and providing their services. Although this has been policed in the recent past, this seems to have ceased, and massage therapists are now accepted and very visible. Few people seem to be aware that the current law forbids therapeutic massage by massage therapists. Physiotherapists use a wide variety of electrical equipment and this distinguishes them from other practitioners. Their signature treatments are `machinery and exercises' (chiropractor interviewed). Other practitioners sometimes made similar disparaging comments. An osteopath said: They just, they rely on those machines too much and they're not doing enough hands on stuff. . . you don't just go to a physio there [in the US] # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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and just get stuck with an ultrasound machine and a bunch of exercises (respondent 107, osteopath). Physiotherapists themselves pointed out that, although they might use similar techniques to chiropractors and osteopaths, they were distinguishable by their use of a wide range of modalities. As an occupation, they had chosen to include a wide range of techniques. They regarded this as an advantage: A manipulative physiotherapist will still do the manipulation, but we will also do all these other things, like your soft tissue and your electro therapy . . . ultrasound and all those things, your acupuncture and your exercise and your rehabilitation (respondent 130, physiotherapist). Physiotherapists' position as a first-line treatment option for many people had implications for how they were seen by other occupations. Providers of second-line options spent a considerable amount of time treating people who had seen physiotherapists but still wanted treatment. Thus, their patients were often those who regarded physiotherapy as `failing' for them. Many other providers were critical of physiotherapists. They often argued that physiotherapy techniques were not very effective, yet physiotherapists enjoyed close relationships with GPs and ACC. The release of guidelines on acute low back pain (ACC and Core Services Committee (NACCHDSS) 1995), which suggested a lack of evidence supporting physiotherapy techniques, was used by some practitioners to shore up this criticism. Chiropractice Chiropractice is the alternative therapy accorded most legislative recognition in New Zealand. The Chiropractors' Act 1960 prohibits unregistered people from practising as chiropractors, and, along with osteopaths and acupuncturists, chiropractors are eligible for funding from ACC to provide treatment for accident-related problems. Unlike physiotherapists, chiropractors have largely stuck to one method of treatment. Spinal manipulation is chiropractors' signature treatment. Many other practitioners also perform manipulation, but they use a variety of rhetorical techniques to distinguish their practice from that of chiropractors. These practitioners were obviously not critical of manipulation per se, but some were critical of chiropractors' emphasis on manipulation, of its interpretation, and the style of manipulation. They raised concerns about the long-term effects of manipulation, which was related to their perception that chiropractors encourage their clients to return for repeated maintenance visits. This was criticised by practitioners who emphasised patient self-management and independence. No physiotherapists identified differences between the kind of manipulation they provided and that provided by chiropractors. They did suggest, though, that chiropractors performed manipulation more frequently: # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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I think that they only do manipulation, whereas we tend to do a lot of other things as well as manipulation. And so if someone comes in to my practice I'd actually assess them to see if they required manipulation, whereas I think a chiropractor would be assessing them to see what manipulation to do (respondent 408, physiotherapist). Physiotherapists often talked about the `click' that manipulation produces. They claimed some patients liked this click and regarded it as integral to their recovery. They argued that the public misinterpreted the nature of their problems, and the significance of the `click'. Joints don't go in and out. But the public think, people think joints go in and out. And they think by that click, that means it's in again (respondent 201, physiotherapist). It was sometimes implied that chiropractors encouraged, or at least colluded in, this public misinterpretation. Chiropractors tend to use firmer manipulation techniques than osteopaths or physiotherapists. They are more likely to use high velocity thrusts. Sometimes other practitioners seem to be critical of the `heroic' nature of at least some chiropractice: Some people like that click, some of them also like that crunch, you know, a really full on, hard `he had to jump off the floor to get me in', type thing (respondent 305, physiotherapist). Other practitioners were critical of the effect of ongoing manipulation on joints: I know that that noise creates a sloppy joint if you keep on and on doing it (respondent 201, physiotherapist). You get people who have been to chiropractors on a long-term basis . . . [and] there's scar tissue formed around the joint (respondent 410, acupuncturist). The issue of ongoing manipulation and maintenance visits, and whether these can be seen as encouraging patient dependence, or as prevention, is discussed below. Osteopathy Osteopaths in New Zealand are a diverse range of practitioners represented by two professional bodies. The New Zealand Register of Osteopaths, mostly representing osteopaths trained outside New Zealand, has some legislative recognition, and its members are entitled to ACC funding. The International Society of Osteopathic Practice consists mainly of New # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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Zealand-trained osteopaths, and currently has no legislative recognition or entitlement to ACC. Moves to reorganise the profession into one legislatively-recognised group are currently underway. Osteopaths' signature treatments are manipulation and a range of methods of working on soft tissue (that is, tissue such as muscles and tendons rather than joints, bones or cartilage). These treatments clearly overlap with some of both chiropractors' and physiotherapists' jurisdictions. This was acknowledged by the respondents in my interviews. Rather than differences, the other occupations often stressed similarities to osteopathy. Several physiotherapists suggested that osteopathy and physiotherapy had strongly influenced each other: Our text books are often osteopathic text books and the osteopaths will use physio text books. There are a lot of interchangeable type things and the ideas are not dissimilar. Okay, so although there is different education, the philosophies are not that dissimilar (respondent 205, physiotherapist). A lot of our techniques that we do as manipulative physiotherapy, . . . are in fact osteopathic techniques (respondent 130, physiotherapist): This was echoed by osteopaths: We use quite a few physiotherapy texts in our training. And I'm sure physiotherapists use a lot of osteopathic texts in their manipulative work (respondent 501, osteopath). Chiropractors also felt that they had a lot in common with osteopaths. Both occupations do manipulation, but chiropractors suggested: Their objectives are similar in the sense that we want to enhance health and well-being. But they will do it perhaps from a raft of different procedures, as opposed to our relatively unified treatment modality, which is manipulation of the spine (respondent 502, chiropractor). In this quote the chiropractor is portraying chiropractors' concentration on spinal manipulation as a ùnified treatment modality' which seems to have an advantage over the osteopaths' `raft of different procedures'. This distinction was commonly alluded to by both groups of practitioners. Each regarded it as an indication of the superiority of their own occupation. Massage therapy As noted above, massage therapists contravene the Physiotherapy Act 1949 in advertising and providing therapeutic massage. This act forms a legally enforceable (but currently not enforced) boundary between the work of # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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massage therapists and physiotherapists. Thus, therapeutic massage is technically illegal, and not eligible for any state funding. The signature treatment of massage therapists is massage of a variety of types, usually involving large areas of, or the whole, body. Massage therapists increasingly combine this with other treatments such as Bowen therapy, Reiki, and use of essential oils. Thus their territory directly overlaps with that of other practitioners who practise these other therapies without massage. In addition to distinguishing themselves from other health professionals, massage therapists must distinguish themselves from workers in massage parlours (commonly used as a euphemism for brothels in New Zealand). Several massage therapists reported some public confusion between massage and the sex industry. Problems ranged from just `the odd strange phone call on a Saturday' to demands for èxtras' during massages. Massage therapists had several strategies for dealing with the need to distinguish themselves from parlours. These included àlways looking professional', and advertising which specifically countered the sex industry image, such as gift vouchers for Valentine's Day. One woman had encountered particular difficulties and described clearly the difficulty of clarifying the nature of the service provided: We had something like À Professional Therapeutic Massage', and the people that rung in ± in the end I had to put `no extras'. Because even though they were told verbally over the phone, they'd still get to me and get on the table, and at the end of the massage they'd still ask . . . So, yeah, it's a real hard industry to keep the sleaze out of. Even getting a uniform was hard. You know, because if you wore something like a white nurse's uniform, it was sort of more than a turn on than it was. . . . (respondent 407, massage therapist). Related to this boundary problem, massage therapists sometimes suggested that what they did was not considered `real' therapy by members of other occupations, and by the public. Some people just think that it's something New Agey, airy fairy, or it's for the girls, and nothing to do with real therapy . . . real problems (respondent 106, massage therapist). Thus, massage therapists face two sets of boundary-maintenance problems. Like other therapists they must distinguish themselves from their competitors, but unlike the others, they also must struggle to be seen as providers of treatment. Nevertheless their ambiguous position as providers of pleasure and treatment does provide them with additional work (few people would give gift vouchers for physiotherapy or chiropractice, for example). # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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Alexander Technique and Feldenkrais Two similar approaches which look at the way people use their bodies are the Alexander Technique and Feldenkrais. Neither treatment receives public funding in New Zealand, unless provided by a practitioner such as a GP or physiotherapist. There is no compulsory registration of practitioners. Both treatments concentrate on teaching people how to hold and move their bodies differently. Feldenkrais was a student of the founder of the Alexander Technique who went on to develop his own approach. Alexander and Feldenkrais teachers I interviewed pointed to some similarities and some differences between the two approaches: Alexander Technique is working with changing things while you're doing them and working with the way that you can change your movement by working with different balance, different co-ordination. And my understanding of Feldenkrais is that it works more through an exploratory thing, or working with exploring different ranges of movement, finding your own limitations and possibilities through that (respondent 111, Alexander Teacher). This sense of Feldenkrais being more exploratory, whereas Alexander Technique provides more direction, was supported by comments from practitioners of both kinds. To Alexander teachers this direction was a good thing, but a Feldenkrais teacher said that while: It might not be meant this way, one of the tendencies of the Alexander Technique is, that it is interpreted as a corrective sort of thing. Rather than as a system that educates the person themselves (respondent 211, Feldenkrais practitioner). Thus, both practitioners pointed to the same difference between their occupations, but each evaluated their own completely differently. Practitioners' use of the concepts of limitation, holism and prevention illustrate further this flexible use of concepts. Discussion: strategies of boundary maintenance In the last section boundary-maintenance issues for occupations treating musculo-skeletal problems have been introduced. The following section looks more generally at the types of rhetorical strategies practitioners used. Orthodox and alternative occupations, and appeals to science Health professionals in other areas commonly make distinctions by appealing to the scientific basis of their work. In public pronouncements, # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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orthodox practitioners often distinguish themselves from alternative practitioners by saying that their practice is based on science, and their treatments are backed by scientific evidence (Dew 1998, Wolpe 1985). In reply, alternative practitioners sometimes criticise the scientific base of medical practice. It was striking that few practitioners in this study mentioned science to distinguish their practice and occupations from others. With the exception of the orthopaedic surgeons they seldom made reference to science at all. Orthodox practitioners seldom criticised alternative ones for their lack of scientific base, and alternative ones rarely either defended themselves from such claims, or criticised orthodox practitioners' claims to scientificity. For example, general practitioners did not use science to distinguish what they did from other occupations such as chiropractice and osteopathy. Some did mention the `fringe' nature of things like acupuncture, but only a few did this. Practitioners' accounts of relationships between occupations suggested these were based more on clinical experience of what worked, on beliefs about the appropriate relationship between provider and patient (largely concerns about patient dependence), and on social and political alliances between occupations. For example, a physiotherapist said her occupation benefited from a close relationship with doctors, established by physiotherapists training in hospitals. By contrast, chiropractors talked about the historically adversarial relationship between their occupation and medicine, and attributed GPs' reluctance to refer patients to chiropractors to this adversarial relationship. These accounts are closer to those provided by social scientists, than to public accounts made by spokespersons for orthodox and alternative occupations. Few practitioners explicitly distinguished between orthodox and alternative occupations at all. For example, the only claim physiotherapists made which relied on a distinction between orthodox and alternative occupations was: I think probably the difference in the public's eyes and probably in doctors' eyes too is that we are, we come under the umbrella of the medical profession, trained at medical school alongside the, so people understand the content of our training. . . . Whereas osteopaths, they're still not quite sure whether it is completely kosher. And again, with chiropractors they're not sure whether they're just not quacks, because they don't know what the training is (respondent 201, physiotherapist). Again, this is more of a claim to a relationship with the medical profession than a claim to superior scientificity. The lack of emphasis on scientificity as a basis for distinguishing orthodox from alternative treatments is likely to be one of the consequences of the overlap in treatments provided by different occupations. The high # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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level of overlap of techniques between occupations, and the `borrowing' of others' techniques makes a science-based distinction untenable. It is difficult to argue that acupuncture is unscientific if doctors also do it, or that manipulation is unscientific if physiotherapists do it. Thus, although the overlap in treatment methods between occupations makes it necessary for providers to distinguish themselves from others, it also makes certain kinds of differentiations problematic. Another explanation is that, while there is increasing emphasis on evidence-based medicine, there is a lack of evidence for the efficacy of any particular treatments for musculo-skeletal problems. In New Zealand the National Health Committee released clinical practice guidelines on the assessment and treatment of acute low back problems in adults (ACC and Core Services Committee (NACCHDSS) 1995). This put manipulation, which has traditionally been a chiropractic or osteopathic technique, in the `Recommended' category while physical agents and modalities (traditional physiotherapy techniques) were in the Òptions' category, and were described as having `no proven efficacy in the treatment of acute low back symptoms' (emphasis in original). Many practitioners were aware of these guidelines, which may have made the equating of òrthodox' with `scientific' and àlternative' with ùnscientific' problematic. The two orthopaedic surgeons interviewed were an exception to the pattern of not using science as a way to distinguish occupations. They seemed to be more conscious of the distinction between orthodox and alternative providers, and more critical of alternative practitioners. This kind of distinction may be tenable for orthopaedic surgeons because what they do (surgery) is clearly science-based. They are isolated from the `borrowing' which other occupations engage in. In addition, like some alternative practitioners, surgeons were often treating people for whom other treatment had not worked. Thus, they were unlikely to see people who considered that alternative treatments had been successful for them. This was not the case for GPs who saw patients who felt they had previously been helped by an alternative practitioner, and wanted a further referral to that practitioner. Tovey's (1997) study of alternative therapists in the UK also found much greater resistance to alternative medicine amongst consultants and hospital doctors than among other orthodox health professionals. Limitation, holism and prevention The concepts of limitation (i.e. others are limited because they do not possess something we do), holism (we're holistic in our approach while others are not), and prevention (we prevent problems by treating the causes, while others treat the symptoms) were the basis of claims commonly used by practitioners to distinguish, and to stress the advantages of, their approach. However, the extent to which the content of these concepts varied from # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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practitioner to practitioner was striking. The same style of argument was often used by one practitioner against others, and by others against that kind of practitioner. The concept of limitation was a consistent theme in the way practitioners portrayed other occupations. Orthopaedic surgeons portrayed all others as limited by their lack of ability to operate. They portrayed other non-medical occupations, such as nurses, as limited by their inability to diagnose. Alternative practitioners such as osteopaths and chiropractors were portrayed by surgeons as limited by a lack of scientific evidence for their treatment. Meanwhile, other practitioners down-played surgeons' ability to operate. Sometimes it was even presented as a limitation for surgeons: it made them focus on surgery, to the detriment of their understanding of other treatment modalities. Others sometimes portrayed surgeons as limited by their lack of consideration or knowledge of other treatments. A GP suggested that surgeons: either operate or they don't operate. If they don't operate, they haven't got any answers, other than what we can provide (respondent 313, general practitioner). GPs themselves were sometimes portrayed by others as limited by their lack of time with their patients. This was thought to prevent them adequately treating musculo-skeletal problems. Other practitioners suggested that GPs were limited by a lack of knowledge and training in musculo-skeletal problems and in the mechanics of the spine. Chiropractors were portrayed as limited by having only one major treatment modality, and because they spent only a short time with each patient. For chiropractors, the former criticism made it easy for others to argue that they were inferior, by highlighting the treatments which they did not provide. However, occupations which included a wide variety of techniques were portrayed by others as limited in other ways. For example, massage therapists, who usually had long appointment times themselves, were critical of physiotherapists' shorter times, which limited their treatment options. They, and other practitioners, sometimes suggested that physiotherapists treated large numbers of patients in order to maximise their incomes. The concept of limitation was closely linked to the idea of holism. Practitioners sometimes argued that their approach, unlike that of others, encompassed the `whole person' or the whole range of influence on a person. What constituted the `whole person' varied between practitioners. For example, massage therapists stressed the importance of whole body massage, and were very critical of physiotherapists focusing on a small area of the body: # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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The way that I see it is that the whole body is linked together and you need to work on the whole body. So even if you have a sore muscle in one area there's usually a problem in other parts of the body as well, that you're not even aware of until you start working on it (respondent 312, massage therapist). Thus, for massage therapists the whole person was taken to mean the whole physical body. But aromatherapists argued their practice was more holistic than that of massage therapists because the oils they used worked on both the mind and the body. For example, one aromatherapist I interviewed worked at a hospice and used oils to work on grief and trauma. Another was concerned about beauty therapists advertising aromatherapy: We tend to think that aromatherapy as we see it is not a beauty therapy. It's a holistic therapy. It treats the whole person (respondent 503, aromatherapist). In another example, osteopaths saw their ability to do both soft tissue and spinal work as an advantage over chiropractors. Although they tended to be reluctant to use the term holistic, they did stress their consideration of a greater number of factors involved in musculo-skeletal problems, and their belief in the interrelatedness of structures, and suggested that this was superior to the chiropractic approach. They suggested that chiropractors tended to see the relationship between the spine and soft tissue as unidirectional: if the spine is corrected the soft tissue will naturally correct itself, whereas osteopaths tended to see the spine and soft tissue as more interrelated. An osteopath explained the difference between osteopathy and chiropractice: We believe that when the muscles are relaxed, and you've got good blood supply into that area, then that helps the whole process . . . that allows the joint to function better. And then you can also do work to release the joint. So the chiropractor would then say àh, fix the joint and everything else will sort itself out'. We tend to believe that you've got to sort of work on two sides of the circle. . . . The muscular system to relax the tension, which is putting the pressure onto the joint. Work on the joint as well, to stimulate the nerve supply to help the muscle. So you're working on a two-way process, rather than just only one-sided (respondent 214, osteopath). Osteopaths sometimes stressed their tendency to look at the whole physical body rather than just the spine, which was how they sometimes characterised chiropractors: An osteopath is more inclined to treat the whole body rather than just the spine, chiropractors are more inclined just to concentrate on the spine, # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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whereas an osteopath treats from the tip of the toe to the top of the head (respondent 501, osteopath). Prevention was another major theme in practitioners' descriptions of their own approaches. They tended to argue that they addressed the factors which caused musculo-skeletal problems, while others only addressed symptoms. Thus their own approach prevented people having to seek treatment in the future. This was interpreted differently by different practitioners. Most notably, chiropractors and physiotherapists disagreed dramatically. When comparing themselves to other occupations physiotherapists often noted their stress on creating independence and self-reliance in patients, rather than dependence: We try very much to make the patient independent. We want to explain to them what the problem is. What they can do about it, and how. The importance of returning to function and their then being in control is absolutely vital, rather than breeding dependency (respondent 130, physiotherapist). Physiotherapists often criticised other occupations, particularly chiropractors, for encouraging dependence. They believed that they prevented problems and reduced the amount of treatment needed by teaching patients how to manage their own problems. This was strongly contrasted with an approach of regular and ongoing treatment, which they attributed to chiropractors: The difference is that chiropractors have a philosophy that if something is out of place that they can manipulate it back into place, and then it needs to be routinely checked to make sure that it's not coming out. Whereas my philosophy as a physio is that `why is it going out of place in the first place?' And that could be a tight muscle, it could be a weak joint, it could be an overmobile joint or anything like that. So if you find the cause as to why something went out in the first place, then you can treat the cause and then it won't keep on going out (respondent 305, physiotherapist). Chiropractors were frequently criticised by other providers for encouraging patients to return regularly for maintenance visits. For example, an osteopath voiced similar views: Osteopaths believe that if the structure is working well, then the best thing for the structure is to leave it alone. Chiropractic tends to work in the opposite direction, where they seem to feel that the structure is best to be maintained with a maintenance treatment type of intervention. So osteopaths tend to try and move people away from treatment, rather than towards treatment (respondent 504, osteopath). # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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In contrast to this, chiropractors themselves argued that maintenance treatments were part of a preventive approach, which was common in other areas of health care such as dentistry. They suggested there was general and growing support for prevention in health care, which their approach was consistent with. Thus, physiotherapists and chiropractors used the concept of prevention in different ways. For physiotherapists and others, prevention meant not treating when there were no symptoms, and encouraging selfmanagement. For chiropractors, it meant providing ongoing treatment in order to maintain a healthy spine. The occupations which concentrated on re-educating people rather than directly treating musculo-skeletal problems, i.e. the Alexander Technique and Feldenkrais, also stressed the preventative and holistic nature of their work: Physiotherapists feel that they've become more and more expert at specific diagnosis and the treatment of localised conditions. But in general it still tends to be local treatment. . . . But the difference is that Feldenkrais is very much focused on the whole patterns involved and also on, in that regard, looking at how, how the person may have contributed to their own injury, even if it is an accident, there may be predisposing factors to having that accident in terms of the muscle tension, the way that person co-ordinates and organises their body (respondent 211, Feldenkrais practitioner). In this quote physiotherapy is seen as comparatively focused on treatment rather than prevention. This contrasts strongly with physiotherapists' view of themselves. Conclusion Many orthodox and alternative occupations compete to provide treatment for musculo-skeletal problems. Many provide similar kinds of treatment, albeit with different emphases. As occupations some pursue macro-level strategies of occupational control. At the micro-level practitioners attempt to distinguish their services from those provided by other occupations, in order to compete successfully with them. This paper has described some of the rhetorical strategies New Zealand providers used for this purpose. Practitioners cannot choose these rhetorical strategies at random: the repertoire available to them is shaped by the range of treatments they provide (itself partly a result of the macro-level strategies their occupation has pursued), and their position in the division of labour. The large number of competing occupations treating musculo-skeletal problems, the variation within occupations, and the overlap in treatment provided, make boundary maintenance a particularly important aspect of occupational control in this # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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area. However, the use of some treatment modalities by both orthodox and alternative practitioners makes it difficult for orthodox practitioners to appeal to science in supporting the superiority of their approach. Because orthopaedic surgeons had not `borrowed' any alternative techniques, they were the only group able successfully to do this. An occupation's position in referral networks also affected the rhetorical strategies they used. Some occupations spent a large proportion of their time treating other people's failures: that is, patients who had tried other treatments but felt these had not been helpful. These occupations were provided with a great deal of evidence on which to base criticisms of treatments which were usually tried first, like physiotherapy. Occupations used the concepts of limitation, holism and prevention to stress the advantages of their approaches. Limitation involved pointing out some quality or ability which other occupations were said to lack. Some occupations used a wide range of techniques to treat musculo-skeletal problems. Others concentrated on a narrow range. It was easy for the former to describe the latter as limited, by drawing attention to the techniques they did not use. However, this was not the only way that the concept of limitation was used. For example, other occupations were considered to be limited by lack of time spent with patients. Related to the idea of limitation, was the idea of holism. Occupations often claimed to have a wider concept of the causes and effects of musculo-skeletal problems, than others did. Thus, they claimed to treat the whole body or the whole person. What was regarded as the whole person varied from occupation to occupation, depending on their view of the causes and effects of musculo-skeletal problems. The best example of this was the contrast between physiotherapists, massage therapists and aromatherapists. Massage therapists felt that musculoskeletal problems were less localised than physiotherapists thought them to be. Thus, they felt they provided more holistic treatment because they treated larger sections of the body, or the whole body. However, aromatherapists believed that both body and mind were involved in musculoskeletal problems, and so felt that holistic treatment involved attending to both. So for them massage therapists' approach was less than holistic. Like holism, the concept of prevention was tied to the practitioners' views of the causes of musculo-skeletal problems, but in addition it reflected their views of the appropriate relationship between patients and treatment providers. Many physiotherapists placed high priority on discouraging dependency in their patients. Thus, they taught them self-help strategies so that they could attempt to prevent similar problems in the future, or treat themselves if problems recurred. They described this as a preventative approach. Chiropractors, on the other hand, sometimes encouraged regular visits, which they compared to dental check-ups. Physiotherapists were critical of these maintenance visits, seeing them as encouraging dependence on treatment. The concepts of limitation, holism and prevention seemed to be used very flexibly by practitioners to indicate the superiority of their approach. Again, # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001

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this shows that rhetorical strategies do not necessarily reflect real differences, but instead are a way in which practitioners in different occupations establish and maintain a collective identity for themselves and others. These are stories about how `we' know who `we' are, and know that `we' are not `them'. Focusing on the micro-level of individual practitioners adds an additional dimension to the study of professionalisation strategies. Macro-level professionalisation strategies can only work if practitioners, in their everyday lives and practices, can develop and sustain professional identity, and a sense of difference between themselves and other occupational groups. Berlant (1975) discusses the problem of the collective nature of professional mobility projects, and how these rely on practitioners identifying with collective goals: sacrificing some of their own autonomy for the autonomy of the profession as a whole. Many of the musculo-skeletal treatment providers in this study had little day-to-day contact with other members of their own occupation. In addition, for some, their period of training had been short or relied heavily on distance-teaching. Many had been in practice for a large number of years. These factors meant they had had comparatively little opportunity for developing and sustaining collective professional identities. Nevertheless, this paper shows that practitioners did use rhetorical strategies to sustain this sense of identity, and to differentiate themselves from others. Understanding this micro-level dimension of professionalisation strategies may shed further light on the success or otherwise of particular macro-level strategies. Address for correspondence: Pauline Norris, Health Services Research Centre, Victoria University, Box 600, Wellington, New Zealand e-mail: [email protected]

Acknowledgements I would like to thank the respondents for their time and the thoughtfulness with which they answered my questions about their work. I would also like to acknowledge helpful comments from the audience at the Social Science and Health Network meeting in September 1998, from colleagues at the Health Services Research Centre, and from anonymous reviewers. This research was funded by a grant from the Health Research Council of New Zealand. References Abbott, A. (1988) The System of Professions: an Essay on the Division of Expert Labour. Chicago: University of Chicago Press. # Blackwell Publishers Ltd and the Foundation for the Sociology of Health & Illness 2001


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