Thanks to my supervisors’ amazing guidance and influence, I used sociological thinking and concepts to help me reimagine how clinical practices could move beyond the biopsychosocial model. Although I wrote a couple papers during my PhD that touched on multiple aspects that the biopsychosocial model does not fully attend to (Mescouto, Olson, Costa, et al., 2022; Mescouto, Olson, Hodges, Costa, et al., 2022), it was in my final paper (Mescouto et al., 2023) that I proposed a theoretical tool that could be helpful to think about the multidimensionality of a condition differently. I proposed that practices could engage with an ethical multiplicity.

As a physiotherapist, this is not different. The biopsychosocial model has been one of the most advocated models in the profession (World Physiotherapy, 2021). Personally, the model helped guide my clinical practice, lectures to students, and my way of thinking. That is until I did my PhD and ultimately challenged this assumption. In my PhD, I researched and realised the model’s vast limitations regarding its applicability, theoretical clarity and claimed multidimensionality (Mescouto, 2023). One important limitation drove my entire thesis and the interest/desire to move practices beyond it: the model’s lack of attention to sociocultural and political dimensions of health.

Ethical multiplicity acknowledges that social and material forces shape our daily life and healthcare practices. That is, our reality is constructed and produced through a network of relations between human social-cultural factors and non-humans’ bodies, objects, places, and things. Combining philosophers Annemarie Mol’s concept of multiplicity (Mol, 2002) and Rosi Braidotti’s nomadic ethics (Braidotti, 2006), the term ethical multiplicity draws our attention to an ethical engagement with multiple others – humans and non-humans. These concepts bring our attention to how the boundaries between social/material, body/mind/world, huma/things are artificial (Barad & Alice, 2007; Braidotti, 2013; Latour, 2005). For example, let us think about a typical day in the clinic: the physiotherapist usually focuses on what they will ask the patient and how the information will guide them in the decision-making process. Here there is an engagement with human others: the physiotherapist and the patient. This engagement could also encompass other humans, such as the clinic’s receptionist, the patient’s family or significant others, the other physiotherapists and healthcare professionals, etc. In this interaction, power, culture, norms, values, and beliefs intertwine in how we speak, move, think, and act. These human elements already move practices beyond the biopsychosocial model.

In addition to these human elements and the multiplicity of human others implied in them, a typical day in the clinic also encompasses an engagement with non-human others: things, objects, and places. This engagement is easily missed because we usually focus on human-centred approaches to guide our clinical practices. Non-human others also shape our clinical decisions and how conditions are felt, lived and contextualised. For example, posters and information on the clinic’s wall can (implicitly) signal what aspects of the treatment will likely be emphasised. If the clinic only has many pictures of anatomical structures, it might signal that only biological aspects of conditions are important to focus on. Other examples are having only the same-sized chairs in the waiting room, images of thin, white, heteronormative-looking people in the clinic’s brochures, and pictures and information depicted only in one language (usually English). In such a setting, the non-human objects and physical space signal implicit power relations and do not accommodate people from different body shapes, cultures, or languages. Making the clinics’ physical environment more inclusive may make more people feel welcomed and represented through the physical space. Thus, an ethical multiplicity helps us be attentive to those and other multiple elements that are part of our healthcare practices but are not usually given that much attention.

Photo by Ricardo Viana on Unsplash

An ethical multiplicity might provide a better understanding of how places, objects, emotions, power, bodies and professions are interconnected. Although the example I presented in this blogpost is a simplification of deeper philosophical and sociological underpinnings, such conceptualisation move healthcare practices beyond the biopsychosocial model of health. However, within my paper and my PhD, I acknowledge the limitations of this concept. For example, I did not explore in detail how an ethical multiplicity would directly attend to the entanglement between humans and environments beyond the clinic to encompass nature and environmental health issues – a fantastic endeavour by the collective Environmental Physiotherapy Association I highly admire.

In addition, by being placed in a Western context, an ethical multiplicity may (unintentionally) sideline non-Western views and traditional and Indigenous possibilities of human and non-human entanglements (Rosiek et al., 2019; Tiffany Lethabo, 2017). I also acknowledge how confronting it is to question and challenge ourselves, our assumptions and practices. Thus, an ethical multiplicity is not – and should not be – a universal model to replace the biopsychosocial model or a tool that should be universally used on all occasions. Ethical multiplicity is an invitation – perhaps a provocation – to think differently about how we practice as healthcare professionals, to challenge ways of doing and thinking about our roles in society. It is an invitation to open up possibilities and to be creative in moving our practices beyond a biopsychosocial approach. Finally, ethical multiplicity is a hope to contribute to a more relational shift in clinical and research practices. This relation encompasses more ethical and socially just healthcare practices for all human and non-human others. 

References

Header image by Alice Dietrich on Unsplash 

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