Miks Brasli

mb09143
Antr5042
Rhetorics of Phsyical Therapy
Rhetoric is defined in a variety ways, but fundamentally it can be viewed as the art of
effective communication and persuasion. It is usually associated with politics and the
Classical world, however, social scientists propose that rhetoric has a much wider
scope and possibility for analytical application, as it encompasses every aspect of
culture and permeates human interactions. Namely, rhetoric is employed whenever
someone tries to achieve a desirable outcome through communication. Persuasion
plays a crucial role in medical interactions. Doctors need to convince their patients for
a variety of reasons, for instance, to make them follow instructions or adhere to a
regimen of medication. Different rhetorical strategies are used to accomplish these
goals. I am particularly interested in investigating the rhetorics in doctor-patient
interviews and treatment sessions. Who persuades who to do what and how? This is
the main query of my study. For the purposes of this essay I will use fieldwork data
from my previous ethnography on the work of physical therapists. I intend to analyze
the data from a linguistic point of view, focusing on rhetorical strategies used by
doctors and patients. The paper consists of three sections. First of all, I will discuss
relevent theoretical material on rhetoric and its application in anthropology and
specifically in the medical setting. Furthermore, I will also outline the framework for
analysis. The following section includes a brief description of the methodology used
for the fieldwork I am refering to. Lastly, I will analyse the gathered data from
physical therapy session interactions and draw conclusions about the ways rhetoric is
employed in this context.
Anthropological Perspective on Rhetoric
It is important to elaborate the social function of rhetoric how it relates to culture.
Micheal Carrithers provides an explanation of how rhetoric can be viewed and applied
from an anthropological perspective,
Rhetoric adds to that previous depiction of human sociality a more vivid sense
of (1) the moving force in interaction, (2) the cultural and distinctly human

character of that force, and (3) the creation of new cultural forms in social life.
(Carrithers, 2005:576)
I will briefly explain the main points of Carrithersideas. The author argues that in
social life rhetoric is used, to draw people and effects toward us or push them away
and whenever we wish to convince and persuade or discourage and dissuade.
(2005:578) It is a form of negotiation, which follows distinct pattern, namely, some
act to persuade, others are targets. (ibid.) Carrithers actually claims that the events in
a persons life are driven by what he terms the rhetorical will, something Fernandez
explains the idea that the rhetorical effort makes a movement[of mind] and leads to a
performance. (ibid.) Thus, rhetoric can be seen as an intrinsic and inseparable
component of how humans think, reason and derive motivation to act. Furthermore, it
should be noted that persuasion and rhetoric are not something used only on others,
but also on oneself and ones own thoughts. (ibid.) Making a decision to do something
can be viewed as engaging a rhetorical debate with ones own thoughts. Overall,
Carrithers conceptualization of rhetoric makes it a pervasive phenomenon, thus,
expanding its meaning and theoretical application.
Moving on, Carrithers second point is paramount, as it demonstrates how
rhetoric encompasses culture. Basically, rhetoric draws its resources from culture and
at the same time expresses culture. Carrithers gives an example of a Sri Lankan
mother scolding her child and telling him to stop playing in the mud. Through this
scolding the mother conveys a number of things simultaneously,
In fact this is quite an extraordinary and highly concentrated slice of rhetoric
cum-culture, for it conveys to the child, in one short hot virtuoso burst, at once
a desired aesthetic of comportment (cleanliness), a classification of the social
world (us vs outcastes), and a negative evaluation of the others (dirty in
nature, even if not in actual appearance). (Carrithers, 2005:579)
Persuasion and rhetoric contain within themselves cultural matter such as norms,
particular understandings of things, ideological content, etc. The resources and the
ways they get configured to deliver a convincing persuasion are deeply rooted in
culture and are context-specific.
Rhetoric in Medical Settings
Having established the approach to rhetoric from anthropological point of
view, I now turn to the problematization of rhetoric in medical settings. First and
foremost, as I narrow my investigation to the consultation room, as the medical world

offers a vastly rich source of opportunities for studying rhetoric. The medical
interviews are an interactive genre,
They are dynamic and dialogic; they unfold in real time and depend on the
exchange between or among speakers with their own attitudes, beliefs, ideals,
priorities, knowledge, and motives. (Derkatch & Segal 2005:140)
As previously discussed, rhetoric draws upon certain cultural content/discourse, the
medical interview is special in the sense that doctor and patient draw their resources
for persuasion from different discoursive universes. This is a distinction that has been
made by various anthropologists. Kleinman calls the different discourses the universe
of illness and the universe of disease, Eliot G. Mishler distinguishes between the
voice of the life world and the voice of medicine. (ibid.) The difference between
the two is that the first one draws persuasive resources from the patients own
experience of bodily illness and distress, as well as the patients biographical and
social context. The other draws from the doctors interpretation of the pathologies of
the body. (ibid.) It is a view that is shaped by a specific kind of education and training,
which evaluates disease and functioning of the body according to a strict biological
framework, which is based on empiric data and hard science. (Mishler, 1984:104)
This sort of relationship puts the doctor and patient in unequal positions of power, as
the doctor can operate in both types of discourses, while the patient is more often than
not unable to follow the specific terminology or complex medical science. Moreover,
the doctor is in a position of power because he or she bases his/her arguments on
scientifically proven facts and theories. Science is widely treated as a cultural
authority; hence it gives a doctors arguments credibility. Lastly, the doctor is trained
to filter out certain information given by the patient while focusing on the parts that
facilitate making a diagnosis. Evidently, the doctor has more of a rhetorical edge in
the interaction, which more often than not makes the doctor the one who persuades
and the patient the one who is being persuaded, and not the other way around.
Narrative as Rhetoric
Analysing narrative structure is an effective approach to identify rhetorical strategies.
Narratives are commonplace in the clinical setting for both doctors and patients. They
provide the foundation for understanding and dealing with illness/disease. When a
patient visits the doctor,

[..]she presents a narrative account of her symptoms; then the doctor, whose
own work is made up of interconnected narratives (e.g. patient histories, case
presentations, patient charts) compares that narrative against a sort of mental
index of illness narratives to find a match a diagnosis. (Derkatch & Segal,
2005:140)
A doctor makes sense of diseases and formulates treatment approaches by working in
a narrative mode. Narratives are equally important, if not more so, for patients
themselves. This is a topic that has researched to a great extent in anthropology.
Arthur Frank proposes the concept of narrative wreckage to describe the way illness
can disrupt the course of everyday life, thus, causing a person lose coherence and
sense of continuity. (Frank, 1995:53) Arthur Frank sees narration as a therapeutic
solution, as framing ones experience of illness in a narrative redefines ones
orientation and expectations. He claims that by constructing self-story a person fixes
their narrative and reaffirm to themselves and others that their life has purpose.
(1995:55) The key word here is affirm, going back to what Carrithers proposed,
namely, the idea of rhetorical will and that a person can engage in persuading him or
herself, I propose that creating a self-story entails persuading oneself to a certain
degree, using rhetorical strategies to challenge certain doubts, negative thoughts and
perceptions that the illness brings to the fore.
Another author who looks at the role of narratives in treatment is Cheryl
Mattingly. She argues that narratives in general are driven by a sense of lack which
creates desire to find a resolution. (Mattingly, 1998:92) Stories are not just an account
of what happens, they offer structure through which it is possible to organise
experience in meaningful way, namely, as parts of a larger whole, which purposefully
unite the perception of past/present/future. (1998:40) However, most importantly,
narratives hold the rhetorical potential to persuade and motivate. (1998:8) This is a
very important point she makes. The narrative in and of itself is based on rhetorical
strategies. Another important point is that Mattingly, unlike other authors who write
about the narrative approach, is sceptical about the idea that narratives serve to give a
sense of cohesion of ones life. Mattinglys main counter-argument to the cohesion
theory is that a persons life story cannot be whole or cohesive in the first place. The
illusion of cohesiveness is achieved through discursive strategies. The sense of
continuity and cohesiveness derives not so much from experience, but rather
culturally informed representational capacities. (1998:106) The narrative approach

to illness tries to fix is the narratives which do not fit the culturally established
narratives of how a cohesive life ought to be. What Cheryl Mattingly emphasizes
through her research that the purpose of narratives in the treatment process is not so
much to return a sense of coherence but to persuade. (1998:107) Therefore narratives
can be considered rhetorical tools.
Methodology
The fieldwork took place in a rehabilitation centre in Limbai, where I
travelled occasionally to study the work of physical therapists. I managed to arrange
with the centres administration that I am allowed to sit in with therapists during their
patient consultations and physical therapy sessions. The primary modes of data
gathering were observation, taking field notes and recording. I worked with three
different therapists in order to observe different styles of interaction with patients.
Furthermore, I took part in two types of therapy sessions, namely, both individual and
group, to see how the communication between therapist and patient changes in
different settings. Getting consent was crucial and also the hardest part during
fieldwork. In-depth analysis of narrative and rhetoric requires access to the whole text
of an interaction, as the details can yield important information. Recording is the only
possible way of capturing the exchanges made by the doctor and patient during a
session because it is impossible to keep up by just taking field notes. Recording was
the biggest hurdle also due to ethical reasons. I had to take into consideration that both
patients and doctors might not feel comfortable during their session if someone was
present and recording every word they say. Furthermore, the patient may be unwilling
to have intimate information of their condition being used for study purposes.
Nonetheless, I managed to arrange with some patients and doctors to allow to record
their whole session from beginning until the end. These recorded sessions served as
the foundation of my study. The fieldwork itself proceeded quite smoothly, doctors
and patients generally did not feel bothered by my presence and, as soon as I
identified myself as a student conducting research, they felt willing to cooperate when
I briefly explained some of the goal of my study. Altogether I observed about a dozen
sessions, the usual procedure included sitting in an inconspicuous spot in the cabinet,
watching the patient and doctor work through their thirty-minute session while
recording and taking notes of key events and specific moments during the recording.

Most of the work was done away from the field, transcribing and analysing rhetorical
strategies in the texts.
In order to avoid ethical transgressions, I kept the names of the doctors and
patients I worked with anonymous, furthermore, I do not use the actual name of the
rehabilitation centre so that the data I gathered would not affect the reputation of the
staff or the establishment itself. As mentioned previously, I acquired consent to
perform my study from the centres administration and each therapist and patient
individually as well. I explained that the data and analysis would only be used for
academic purposes, and if any of the staff or patients wished to see the end result they
would have access to it.
Data Analysis
I selected the most prominent rhetorical strategies that observed physical therapists
using in order to persuade their patients. Each of them is looked at in further detail.
The following sections focus on the particular way rhetoric is employed and the
situational context where it is used. Special attention is dedicated analysing why the
particular use of was effective and how it links up to wider sociocultural aspects.
The Authority of the Voice of Medicine
Switching to biomedical discourse has great persuasive power. The style-switch is
something that can be easily identified during an interaction. It usually occurred
during times when a patient was reluctant to perform a certain exercise or has
deviated from the prescribed treatment plan, the switch to biomedical discourse is
used as a means by the doctor to influence and modify the behaviour of the patient,
namely, an appeal is made to the patient explaining the rationality of obeying the
doctors instructions. The following is an excerpt from a therapy session with an
elderly lady who had blood pressure related issues. It should be noted that during the
physical therapy sessions I observed the therapist and patient would usually interact in
an informal manner. They would go through a set of exercises the patient had learned
during the previous session and they would engage in small talk. If the flow of
exercises is disrupted, the therapist would intervene.
Patient: I got dizzy.
Therapist: Alright, lets stop a bit for now. Have youve been doing your
evening walks? Did you do one yesterday?

Patient: No, I didnt.

Therapist: Why didnt you?
Patient: I wasnt feeling well that day.
Therapist: You see, when you exercise your legs it helps blood circulation for
the heart, and that could also help you with your light-headedness. Thats why
you need to do walks.
The therapist tries to persuade the patient to engage in the treatment plan which she
had not done. The rhetorical strategy is to convince the patient to see the scientific
logic behind the argument and also the authority of the therapist as being a
knowledgeable expert on the cause of the patients problem. When I asked the
therapist about this approach, he attested that is something that has an effect on
patients. He claimed that an explanation of the inner-workings and mechanism behind
a certain exercise and why it is beneficial generally helps make it clearer for patient
why it ought to be done. This sort of persuasion is effective due to the status of
science and biomedicine, their modes of knowledge creation in Western society and
culture across the globe. The view of biomedicine is widely embedded as being
trustworthy and effective. This is something not only patients, but doctors themselves
believe to a great extent. Furthermore, if looked at from the perspective of discursive
universes, the patient does not really have a counter-argument for a persuasion that is
based on biomedical findings. It would make no sense to go against something that an
expert presents as being proven as fact, moreover, the patient does not possess the
expertise to adequately analyse and challenge the doctors argument. This makes the
doctors rhetorical strategy all the more effective.
Emotional Appeal and Gender Identity
Using discourse of biomedicine to persuade is the most often used approach,
however, there are other equally persuasive strategies possible. Appealing to a
patients emotions can be just as effective. The following example is taken from a
session with an ex-soldier who was suffering from a knee injury and breathing
problems. The therapist was trying to motivate the patient to try and perform better
with each successive session.
Therapist: Are you tired?
Patient: No, not yet.
Therapist: Good, think you can still keep going?

Patient: I already did the number of repetitions you gave me.

Therapist (teasing manner): A tough guy like you would probably have no
problem going for another twenty of those?
Patient: Sure. No problem.
The light-hearted teasing persuasion did its jobs. The therapist, fully aware of the
patients background, assumed that the man takes pride in his physical conditioning. It
was something both of them had negotiated in previous sessions and it seems that the
extra push on the therapists side was appreciated by the patient. This is a good
example of drawing rhetorical resources from cultural matter. In this case it draws
from the culturally embedded notion of masculinity and gender traits and values
typically associated with it, such as endurance and physical ability. In my opinion, the
teasing manner of the persuasion worked by challenging the mans pride and gender
identity. By giving in to the persuasion he actually reaffirms his prowess and
masculine identity.
Recovery Trajectory Narrative
Co-authoring a narrative which portrays the patients recovery progress was also
observed to be an effective strategy to persuade a patient to comply. Narratives help
put past experiences into a particular structure which help create an understanding of
where one is coming from and also shows a possible future and where one is going.
Therapists often have to deal with patients who are depressed and unmotivated
because their condition is not improving according to their expectations. A rhetoric
strategy employed by therapists is to tap in the patients inner motivations and help
them redefine their expectations, thus, persuading the patient to carry on with the
treatment regimen. The following example is a short fragment from the session with a
woman who had to gradually retrain her arm after a minor stroke in order to regain
muscle control and avoid spasticity. She was performing the exercises noncommittally and the therapist interjected.
Therapist: You need to put more effort into the movement, is everything
alright?
Patient: Yes Well, not exactly.
Therapist: Whats the matter?

Patient: Its just that I dont know. I dont see the point, Ive been doing this
for two months and it feels like it not getting better at all.
Therapist: Not true. Your range of motion has increased.
Patient: But its nowhere near the way I could move it before the stroke.
Therapist: Look, I understand. Stroke rehabilitation is tiring work, but at look
at the issue this way. There is a good prognosis that continuing the work weve
done until now will further help you regain your range of motion and control.
It might never be the same as before, but if you give up now you will there is
less likelihood of recovery in the future.
The therapist puts together a narrative which illustrates the past-present-future
trajectory of recovery which neatly shows what needs to be done to continue along the
path towards a more desirable outcome. Essentially, the persuasion is based on the
doctors expertise and knowledge about the way stroke related conditions are treated
and on the evidence of the patients progress. More importantly, the rhetoric strategy
is based on the narrative construction of two possible outcomes, the one that has a
desirable outcome (regaining the mobility of the arm) requires the patient to modify
her behaviour and follow the doctors instructions.
Conclusions
Rhetoric is the art of effective communication which largely entails persuasion.
Anthropologists such Micheal Carrithers propose that rhetoric is something that can
potentially expand the understanding of various social processes. Rhetoric is
conceptualized as a social moving force that draws its resources from culture and at
the same time expresses it as well. Rhetoric is central to a variety of practices in the
medical world. It is commonplace in doctor-patient interactions. One of the key
features of this particular clinical context is that patients and doctors draw their
rhetorical resources from different discursive universes (universe of disease/illness,
voice of the life-world/medicine) which puts the doctor in an unequal position of
power, as he/she has control over both discursive domains. Moving on, it should be
noted that narratives play a vital world in the medical world. Authors such as Cheryl
Mattingly argues that narratives inherently possess rhetorical potential to persuade
and motivate which is why it is such a powerful transformative instrument.

The analysis from the fieldwork data gathered in the Limbai rehabilitation
centre indicate that there are three prominent rhetorical strategies that physical
therapists employ during their treatment sessions. The first rhetorical strategy is using
the authority of biomedical discourse. It draws its persuasive power from the status of
science and biomedicine in Western culture as authority. The second strategy is
emotional appeal. These kind persuasions also draw from cultural matter, in the
particular example I observed the therapist drew upon the culturally embedded notion
of gender identity in order to challenge his patients sense of his masculinity and get
him to try and push his limits. Lastly, therapists use their expertise to construct
narratives to persuade patients by establishing possible outcomes and explaining how
they correlate to what they have been doing in therapy. Showing that what has been
done in the past has led to results in the present and that continuing will lead to further
improvements serves as a good motivation for patients.
Bibliography.
Derkatch, Colleen, Segal Z. Judy (2005). Realms of Rhetoric in Medicine and
Health in University of Toronto Medical Journal 82.2: 138-142.
Carrithers, Michael (2005). 'Why Anthropologists Should Study Rhetoric.' Journal of
the Royal Anthropological Institute 11 (3):577-583.
Elliot G. Mishler (1984). The discourse of medicine: The dialectics of medical
interviews. Norwood, N.J.: Ablex
Mattingly, Cheryl (1998). Healing Dramas and Clinical Plots: The Narrative
Structure of Experience. Cambridge University Press
Frank, Arthur (1995). The Wounded Storyteller: Body, Illness and Ethics. Univesity of
Chicago Press