The imperative of ‘disclosure’

Participants’ accounts repeatedly returned to disclosure: students should ‘disclose’ their disability, preferably in advance of the placement. This was expressed in terms which, arguably, illustrated the doxa permeating the NHS field and the development of their physiotherapy identity whilst immersed within it. For example, the contention that students should ‘come to terms’ with their impairments and be responsible for disclosure which should, in any case, be required or compulsory.

As noted, unspoken assumptions exist that able-bodied identities and perspectives are preferable and should be aspired to (McRuer 2013) which poses a dilemma when

considering disabled bodies and could be implicated in the maintenance and reproduction of inequality (Adams et al 2013). If we concur that the NHS is founded upon a largely bioreductive framework aligned with an ableist approach, where medical sense making is unquestioningly accepted, then perhaps it is only ‘common sense’ to believe that disability can and should be cured; an “unexamined belief in the perfectibility of the living

organism...and abolition of abnormalities” (Titchkosky 2007;92). This then contributes to what might be termed ‘perfectible practice’; physiotherapists view disabled clients, and indeed disabled people in general, as bodies that need fixing to bring them toward the perfectible ideal.

Similarly to my reading of the literature, most participants’ accounts of disabled students are characterised by assumption of deficit, possibly as a consequence of habitual

interactions with disabled clients. These therapeutic practices may be unconsciously influencing their educational practice with disabled students because of their immersion in biomedical cultural practices in healthcare. If so, this indicates unquestioned assumptions that disability can necessarily be articulated or made visible as an object on which to act. Some participants considered concepts and approaches to disability more critically in practice, although they indicated that it was difficult for these ideas to be heard over dominant discourses existing in healthcare and socio-political arenas. They expressed

140 concerns that the NHS was not sensitive enough to individual requirements to be a good place in which disabled people should work.

These issues provide a context within which to examine participants’ accounts of communication of sensitive information about students’ impairments.

8.7.1 Why don’t students ‘disclose’?

While participants recognised that some students would not identify as disabled they were puzzled as to why they did not ‘disclose’. In work with VI physiotherapists (Atkinson 2010) I highlighted factors influencing disabled people’s decisions about sharing information. For example, not considering themselves to be disabled, disability identity is not perceived as a key focus, possibly explaining why all participants had experiences involving ‘non-

disclosure’.

Stigmatisation can be a strong influence: invisible or ‘discreditable’ stigmas (Goffman 1963) are difficult to manage. Some participants reported that disabled students did not ‘disclose’ because they perceived they would encounter stereotypical attitudes and did not want to be ‘labelled’ or treated differently perhaps implying a degree of internalised ableism (Campbell 2009). Bourdieu (2001,38) describes this as “symbolic violence” which “triggers dispositions that the work of inculcation and embodiment had deposited in those already primed for it” but it is also noted that this symbolic type of power cannot be experienced without the contribution of those who undergo it. Among those disabled students who may be attuned to the “rules of the game” (Gibson and Teachman 2012,479) disability is perhaps understood as a source of negative capital that needs to be minimised.

This being the case, it is crucial for practice educators and academic staff to be aware of these issues to support students effectively in deciding to explore and communicate the possible impact of their impairment in the clinical setting. Participants expected

‘disclosure’, linking this to preparation and provision of a good clinical experience, citing work pressures as reasons for ‘needing to know’. However, not all participants appeared to appreciate how difficult this might be for disabled students given the power relations involved; educators being in the dominant position with greater access to, and possession of, cultural and social capital (Edwards and Imrie 2003).

Participants’ narratives included experiences with students who attempted to pass whilst on placement. Some reported that disabled students recounted experiences of being

141 treated negatively on previous placements. Arguably, because of these issues, students may assume an identity other than their own, almost fabricating ‘who they are’ to conform to what they believe is expected of them in the field. This indicates a fit with Bourdieu’s concept of doxa in the sense that disabled students then reinforce understandings of ‘normal’ as ‘positive capital’ and provide no counter-narrative of disability which might help to reduce reliance on an “arbitrary construction of normal” (Gibson and Teachman

2012,481).

8.7.2 Disclosure and honesty

Participants’ accounts indicated ‘doxa’ within which they expected students to perform. When a disabled student arrived, however, this potentially had a disruptive effect on the recognised, familiar clinical pedagogic dynamic. When considering disclosure, differences between disabled students, denoted as ‘good’ and ‘problematic’, indicated a ranking not necessarily applied to their non-disabled peers.

In the ‘good’ disabled student framework, disability became a non-issue because participants did not need to focus on it or provide remediation. They praised students’ openness and honesty which, arguably, increased levels of positive cultural capital by apparently fitting into the field and assuming the required habitus. They took responsibility, shared information, used effective strategies and often worked extra hard to meet

expectations; the ‘appropriate’ behaviour (Hopkins 2011; Nash 2014). All participants noted ‘good’ disabled students exerted extra effort to reach required standards, their assumptions and criteria of what comprised a ‘good’ disabled student apparently being based on the student’s behaviour.

Conversely, experiences with ‘problematic’ disabled students appeared to disrupt the pedagogic relationship. If students did not ‘disclose’ and their practice failed to meet expectations, the impairment became visible and so, challenging. These disabled students were variously described as failing to assume responsibility, not being honest, failing to adjust to their situation or being in denial; mirroring accounts reported in the literature (Charmaz 1995, Nash 2014). This returns to expectations of compliance with the fundamental, taken for granted presuppositions of the field (Bourdieu 1990a). By not exhibiting the preferred behaviour of the ‘good’ disabled student they did not fit into the field as expected or increase their levels of capital and status.

142 Arguably these presuppositions may result in participants not appreciating the emotional processes involved in this situation so making disabled students appear dishonest in not ‘disclosing’. The ‘good’ disabled student behaviour was assumed to indicate that students had ‘come to terms’ with their disabled identity. This might not be true, but it was unlikely that educators would discover this, because the situation provided little incentive to investigate further. In a perverse way, it might have limited the likelihood of them increasing their awareness of disability and the challenges of ‘disclosure’.

8.7.3 Compulsory information exchange

If a compulsory approach to information sharing were to be enacted, as suggested by some participants, it could impact on students’ behaviour, subsequently affecting the ways in which educators interact with them. Hebl and Kleck (2003) describe the notion of the ‘self- fulfilling prophecy’ in which participants’ expectations of disabled students could result in them treating those students in ways that create the anticipated behaviour. Alternatively, students who acknowledge stigmatising characteristics, can contribute to dismantling stereotypes, enabling ‘the person’ rather than the stigma to be seen. People who

acknowledge impairment may be accorded more positive responses (Hebl and Kleck 2003), borne out by participants’ accounts when disabled students ‘disclosed’. In my professional experience of supporting significant numbers of disabled students, however, they

frequently did not recognise or understand the impact that their impairments would have in clinical settings. This is where academic colleagues play an important role in the

preparation of disabled students for their placements, however, legally, requiring a compulsory information exchange would be problematic.

Participants described expending considerable effort supporting disabled students. On further examination, these efforts often focussed on ‘normalising’ the situation/student to fit the habitus of the incumbents and the ‘doxa’ of the setting. They noted ways in which they facilitated disabled students to perform in the same way as their non-disabled peers. If educator and/or student strategies were not effective, however, this approach magnified both disabled students’ struggles and the difficult balance that educators tried to maintain juggling their various roles. The competing pressures with which educators must contend have been considered, sometimes resulting in personal stress particularly when demands of their different roles came into conflict (Mooney, Smythe and Jones 2008). This may cause educators to be confused, to fail to recognise what is happening in the situation and to respond inappropriately, possibly affecting their judgement and/or assessment

143 decisions. Participants expressed uncertainty about levels of support they should provide and what this indicated about the competency of disabled students.

If disabled students shared information about impairment in advance, they often failed to meet educators’ expectations of ‘disclosure’. Anxieties arose if they did not provide enough information or merely stated that they had an impairment so disrupting expected social relations and the usual assessment processes. These processes were disrupted further if students chose to share information when they arrived, part-way through a placement, or not at all. Arguably, this compromised dialogue because of pre-existing power relations, in which students feared prejudicial or stereotypical responses that could negatively affect their experience and marks.

Participants’ accounts indicated that these issues were problematic and yet they felt disempowered and unable to ascertain how best to ameliorate the situation. Without exception, however, in all phases of the placement, participants indicated that ‘disclosure’ was imperative and enabled them to manage the situation and support students

effectively.