Sleep as Homework and Engagement in 
Rehabilitation 
 

Trine Schifter Larsen    Mari Holen 

Copenhagen University Hospital Hvidovre  Roskilde University, Denmark 
Trine.schifter.larsen.01@regionh.dk   holen@ruc.dk 
 
     
 

Abstract 
 

In today’s push for shorter and quicker hospitalizations, everyday life often becomes a place of 

rehabilitation for people after they undergo surgical procedures. In order for hospitals to manage 

shortened periods of admission and to facilitate post-operative rehabilitation, a patient‘s active 

engagement has become a central element to clinical treatment and care in Denmark. For example, 

in the recovery from orthopedic surgery, sleep becomes a type of "homework" assignment that is a 

vital element of the patient‘s rehabilitation trajectory. Building on the theoretical concept of 

‘engagement’ developed by Gilles Deleuze and Félix Guattari (2005), we examine the patient‘s 

relation to sleep as part of recovery; we refer to this as 'sleep engagement.' In particular, we analyze 

sleep as part of an institutional pedagogy in rehabilitation, and we ask how this pedagogy mobilizes 

rehabilitation for older patients after they have been admitted to the hospital for an orthopedic 

surgical procedure. Using ethnographic material, our analysis leads to a discussion of institutional 

expectations for what it means to be engaged in one's own patient trajectory. The article presents 

three results: 1) Expectations of sleep as an institutionally defined homework assignment are fulfilled 

through the establishment of the ‘rehabilitable and non-rehabilitable body’; 2) As an active attempt 

to mobilize resources in rehabilitation, patient sleep engagement becomes part of a historical and 

contextual nexus; and 3) Institutional sleep potential creates new points of ambivalence—on the one 

hand, sleep is an optimization-promoting requirement in order to exercise while, on the other hand, 

the midday nap reflects an outdated view of old age that opposes an active lifestyle perspective. 

 

Keywords: sleep; patient-engagement; rehabilitation and everyday life; aging; relational ontology 
 

Anthropology & Aging, Vol 42, No 2 (2021), pp. 105-125 

ISSN 2374-2267 (online) DOI 10.5195/aa.2021.284 

 

 

 
 

 
This work is licensed under a Creative Commons Attribution 4.0 International License. 

 
This journal is published by the University Library System of the University of Pittsburgh as 

part of its 

D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. 



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Sleep as Homework and Engagement in 
Rehabilitation 

 

Trine Schifter Larsen    Mari Holen 

Copenhagen University Hospital Hvidovre  Roskilde University, Denmark 
Trine.schifter.larsen.01@regionh.dk   holen@ruc.dk  
 
 

 
 

Introduction 

With the introduction of ‘fast track’ programs in Danish hospitals and generally reduced admission 

periods, patients’ own efforts in post-operative rehabilitation have gained importance. Fast track is the 

name of a trajectory that allows patients operated with total hip alloplasty (THA) and total knee 

alloplasty (TKA) for faster discharge. The purpose is to reduce the length of hospital stay and prevent 

readmissions, minimize surgical complications, decrease morbidity, and improve cost-effectiveness. 

These goals are founded on standardized regimes that are based on a large amount of research-based 

evidence from randomized controlled trials (RCTs). Previously patients used to lie in bed for weeks 

after an operation (Søndergaard 2007), whereas now bed rest is considered problematic. Instead, 

patients are encouraged to engage in physical ‘activity’ that e.g., involves getting out of bed and 

engaging in their own recovery trajectory through activity and taking responsibility and initiative for 

activity to happen (Holen and Ahrenkiel 2011; Larsen 2019). This new patient position becomes the new 

mantra after surgery and particularly orthopedic surgery. Being active thus becomes a way for patients 

to express their motivation to participate in the institutionally defined activities (Holen and Ahrenkiel 

2011; Meldgaard Hansen 2016) during hospitalization and after discharge. In a joint seminar prior to 

the scheduled surgery, the surgeons, physical therapists, and nurses involved typically emphasize the 

need for activity, personal responsibility in management of the rehabilitation process. It is also during 

this seminar that the term 'patient' is replaced with the term ‘partner,’ indicating the desired clinical 

relationship in the trajectory to come.  

 

These changes in patient- and rehabilitation regimes invite for a conceptualization of rehabilitation. 

Illness and trauma limit or alter bodily capacity and thus change the relations we have with our 

surroundings (Fox and Alldred 2016). Rehabilitation is the process of making new and effective 

relations in a changed reality. What is conceived as effective does not refer to a biological issue but rather 

to the possibility of (re)integrating the injured body into one’s environment and daily life. 

Anthropologist Cheryl Mattingly explains why integration is more than a biological issue: “the patient 

had not just injured a hand or suffered a brain lesion, but in the process disrupted an entire life” 

(Mattingly 1991, 983). Mattingly emphasizes how historicity is built into bodies and into the way bodies 

engage with the surroundings in everyday life, or what can be stated as ‘functionality.’ Mattingly focus 

on the phenomenological experiences of rehabilitation and describes the body as phenomenological 

with own sense of identity and lived experiences why body changings imposes a process of making 

sense of these changes in functionality and reclaiming the body, and thereby articulate a new sense of 

self (1991). Another way to conceptualize ‘functionality’ is proposed through Science and Technology 

Studies in which the focus is on how a network of relations that enable one to act is created. This means 

that people are enabled to act in and by the practices and relations in which they are located (Moser 

2006). Functionality or capability is here understood as a relational matter enacted through the social 

and physical surroundings. Changed bodily capacities are, in this sense, a disruption of everyday 

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relational arrangements. Moser (2006) further argues how the concept of ability, and thereby disability, 

is shaped through technology and medicine as a capacity of active agency and independence. This 

concept of ability, she argues, directs relational engagements through a normalizing mode of ordering 

that centers agency in the body.  

 

Eli Clare—an author and activist who writes and lectures about disability, queer and transgender 

identities, and social justice—discusses how the concept of ‘cure’ via biomedicine becomes a matter of 

getting as close as possible to the normative universal middle-class body (2017). This pursuit is seen as 

essential to achieve what anthropologist Matthew Wolf-Meyer calls “full personhood” (2020, 233). The 

link between the body and personhood causes disability and illness to be associated with not full 

personhood, which is equated with limited social participation (Rapp and Ginsburg 2001). As a result, 

biomedicine promises both the restoration of the ‘normal’ body and full social participation (Wolf‐

Meyer 2020).  

 

After orthopedic-surgical procedures, the focus of rehabilitation is on creating physical functionality; 

e.g., how much the knee can bend after an operation is measured and used to evaluate the rehabilitation 

outcome. However, this concept of functionality is linked to the notion of a universal (Lock and Nguyen 

2010) and middle-class body (Lupton 2013; Skeggs 1997, 2005) as the norm against which other bodies 

are measured and which is used to determine adequacy (Buch 2018; Wolf‐Meyer 2020). Anthropologist 

Elana Buch states that the idea of the body as a universal and pre-social object form special expectations, 

as modes of ordering, affecting the body’s relation to its surroundings, as she defines as ‘embodiment’ 

(Buch 2018). In a similar conceptualization and body norm critique, embodiment is described as 

“interactions that are obscured through ideological practices that support neoliberal notions of the 

individual” (Wolf‐Meyer 2020, 232).  

 

From these theoretical perspectives, we understand that what can be termed as functionality and how 

to become a functional subject is also directed by modes of ordering such as through medical and 

institutional concepts such as fast track programs and associated patient positions and pedagogies 

foregrounding a particular conceptualization and significance of engagement. 

 

With the term institutional, we draw on James G. March and Johan P. Olsen (1989), who see institutions 

such as the hospital as producing norms for appropriate behavior specifying the role of the actor. These 

norms and rules of appropriate behavior they define as “the routines, procedures, conventions, roles, 

strategies, organizational forms, and technologies around which  activity is constructed. We also mean 

the beliefs, paradigms, codes, cultures, and knowledge that surround, support, elaborate, and contradict 

those rules and norms” (March & Olsen 1989, 22). Biomedicine is often foregrounded as a dominating 

force directing modes of ordering. However, we understand biomedicine as one force among others 

forming institutional norms such as engagement. 

 

In this article, we examine engagement as a question of how older patients engage in making new and 

relational arrangements after orthopedic trauma and/or surgery and thereby (re)integrate the body into 

their environment. To examine engagement we draw on Gilles Deleuze and Félix Guattari’s concept of 

‘engagement’; i.e., as the effort and desire to build capacity to create effective relations (2005). With this 

concept of engagement, we discuss what can be termed as effective in the sense of building capacity 

and how normalizing modes of ordering produced through medical and institutional concepts form in- 

and exclusions of bodies and forms of agencies. The article builds on ethnographic fieldwork carried 

out by one of the two authors. 

 

 

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Sleep as a Rehabilitative Potential 

Sleep is being incorporated into the system of rehabilitation management institutionally constituted as 

what we propose as ‘rehabilitative homework.’ In the pedagogy for the recovery of ‘partners,’ to 

practice sleep1 becomes a means of engaging in one’s recovery trajectory. Along with activity as a 

dominant requirement, sleeping shifts from being a biological and mundane habit to something 

individuals can actively manage. With reference to sociologist Deborah Lupton (1997), this practice may 

be and is likely to be associated with knowledge and motivation shaping a pedagogy of sleep, why 

sleep managing approaches such as sleep-hygiene-rules have been developed and implemented in 

clinical practice (Ghavami, Safarzadeh, and Asl 2018; Ghorbani et al. 2019; Greve and Pedersen 2015; 

Machado et al. 2017). Sleep hygiene includes guidelines developed by, among others, the American 

Academy of Sleep Medicine. Sleep hygiene is a central part of the national clinical guidelines in 

Denmark for nursing interventions concerning sleep. The latter defines sleep hygiene as related “to the 

habits, relations, and rituals that promote unbroken, strengthening and effective sleep”(Fog et al. 2016). 

Good habits involve following prescripts about tobacco and alcohol intake in the evening, napping, 

physical activity, eating, bedroom environment. 

In the context of rehabilitation in orthopedic trajectories and ‘fast track’ regimes, sleep is seen as both a 

barrier to training and as a facilitator for the opportunity to train. In both instances, sleep requires a 

balancing of time. Balancing time here means that you need sleep to build physical and mental capacity 

to optimize training possibilities, but time spent on sleeping may not subsume the time that should be 

allocated to training. Sleep, thereby becomes a means for rehabilitation as well as rehabilitative work in 

itself (Aasvang, Luna, and Kehlet 2015; Gong, Wang, and Fan 2015; Greve and Pedersen 2015; Krenk, 

Jennum, and Kehlet 2013; Sveinsdóttir and Skúladóttir 2012).  

Within this notion of rehabilitative sleep-practice and as something to be managed, patients’ sleep-

practices are assessed as being either an active or passive form of patient engagement. Active sleep 

engagement is viewed as developmental and motivated sleep behavior, as a will-driven intention to 

portion sleep in time and place according to institutional time (Larsen 2019). Passive sleep is stagnating 

and non-motivated sleep behavior. What may be interpreted as passive sleep behavior in practice is 

often pathologized and, as such, regulated.  

Sleep as a rehabilitative practice makes an interesting case for studying how institutional 

understandings of patient engagement correspond with how patients build capacity to make new 

arrangements during rehabilitation, and how institutional understandings of engagement allow or 

prevent the possibility of creating effective relations. Through what we refer to as patients’ ‘sleep 

engagement,’ we ask how such engagements can be understood as either active or passive in one’s own 

care trajectory, and how sleep practices may create certain subject positions for some older people. This 

paper is based on an ethnographic study in which data was collected via participant observation and 

interviews with eight patients aged 67-86. Data were gathered during the patients’ hospitalizations for 

orthopedic surgical procedures and over the course of six to eight months post-discharge during 2017. 

The research is part of the Ph.D. project, “The role of sleep in rehabilitation of older patients during 

hopitalisation and rehabilitation at home.” The project is co-funded by Roskilde University and the 

Department of Clinical Research and the Department of Orthopedic Surgery at Amager and Hvidovre 

University Hospital. 

 

Rehabilitative Homework – How the Analytical Focus Differs and Builds on the 

Field and Methodology Within Rehabilitation Studies 

Many patients can expect an extended period of rehabilitation after they undergo an orthopedic surgical 

procedure and hospitalization. Patients are typically discharged to their own homes but some may first 

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be sent to specialized centers for respite care. Hospitalization varies depending on the diagnosis and 

can last from one or a few days and sometimes weeks. Such shorter periods of hospitalization can be 

seen as part of larger neoliberal transformations of the health care sector with centering competencies 

and resources in fewer but highly specialized hospitals with specialized care guided through quality 

standards (Christiansen and Vrangbæk 2018) and fast-track programs based on ideals of cost-efficiency, 

productivity, and individual responsibility. As part of this movement, and in response to a growing 

aging population and the need to control increasing costs political and economical interests are deeply 

attached to home-based rehabilitation (Mikkelsen, Schwennesen, and Lassen 2019), and in producing 

knowledge about how people engage with this rehabilitative homework and the tasks associated with 

it (Clotworthy 2018; Mattingly, Grøn, and Meinert 2011). From a clinical perspective, research is largely 

focused on examining patient compliance and the management of self-care with respect to patients’ 

completion of homework assignments related to rehabilitation and as part of overall care trajectories 

and treatment outcomes (e.g., Hørdam and Boolsen 2017; Kuo et al. 2019; Szöts et al. 2015). Rehabilitation 

research related to ‘homework’ also focuses on the increasing number of people who are living with 

chronic disease—many of whom are expected to undertake a greater range of tasks. These tasks may 

include more technological and instrumental tasks related to their own care and treatment, such as 

through tele-rehabilitation. Here, telecommunications technology is used in rehabilitation (Bugajski et 

al. 2020; Crotty et al. 2014; Edbrooke et al. 2020) and patients are digitally given tasks previously 

performed by medical staff. Also, studies addressing municipal rehabilitation programs related to tasks 

of everyday life may focus on ‘homework.’ Here rehabilitation also focuses on increasing the level of 

functionality through training in activities of daily living (ADLs), such as bathing, dressing, cooking, 

and other household chores, known as reablement (Clotworthy 2017; Cochrane et al. 2016; Glendinning 

et al. 2010; Hjelle et al. 2017; Lewin and Vandermeulen 2010; Meldgaard Hansen 2015; Thuesen 2013; 

Vedsegaard 2019; Wilde and Glendinning 2012). 

 

Utilizing a social determinant of health perspective, Helle Vedsegaard (2019) divides home 

rehabilitation research into two categories: research focusing on the effect of rehabilitation in relation to 

the citizen’s ability to account for care needs and practical tasks in the home; and research focusing on 

the subjective construction of meaning between institutional rehabilitation initiatives and everyday 

practice at home and in neighborhoods. This latter field of research highlights the consequences for 

meaning-making when there is a discrepancy between categories of institutional practice and everyday 

practice (Andersen, Pedersen, and Steffen 2016; Bødker 2018; Hjelle et al. 2017; Mattingly, Grøn, and 

Meinert 2011; Meldgaard Hansen 2015; Thuesen 2013; Vedsegaard and Dybroe 2020). 

 

In this article, we draw on a third field of research in which home rehabilitation is understood from a 

socio-material perspective, and which is particularly concerned with technologically mediated 

homework (Mort, Roberts, and Callén 2013; Oxlund and Whyte 2014; Pols 2012; Pols and Moser 2009; 

Pols, Willems, and Aanestad 2019; Schwennesen 2017). Within this field technology such as e.g., tele-

care which is technical devices and professional practices applied in ‘care at a distance,’ that supports 

chronically ill people living at home (Pols 2012) is seen as without an inherent essence and the focus is 

on studying the effects of the complex assemblage of relations technology is part of. These studies show 

how homework technology is applied in practice and what this practice is helping to create. They 

illustrate how technology is creating not only new concepts of care and relations of caregiving, for 

example, but is also inviting new subject-positions. New modes of caring and notions of rehabilitation 

both offer new possibilities for agency and becoming-citizen, and simultaneously impose new and 

changing requirements to live up to in order to be a ‘good’ citizen or a ‘good’ patient.  

 

Utilizing a socio-material perspective shifts attention away from rehabilitation as the subjective 

construction of meaning to a focus on rehabilitation as a process of making new relational arrangements. 

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We work with a concept of rehabilitation that concerns how people with bodily changes that occur 

suddenly may create or restore their way of being in the world. Inspired by Deleuze and Guattari, we 

understand “being in the world” as a way of forming relations with one’s environment (‘environment’ 

is understood as both social and material) (2005). These relations are created continuously and 

situationally; in this context, “being” or existence is understood to mean “becoming” (Deleuze 1994; 

Deleuze and Guattari 2005). Working with becomings means to understand processes as unfinished 

and delimited events since events are connected to other events, which in themselves are an assemblage 

of different elements. Examining the rehabilitation process, we explore how ways of becoming-subject 

emerge. Becoming-subject through rehabilitation and as a temporary knotting of relations is perhaps 

what anthropologists João Biehl and Peter Locke describe as “the power of specifically growing out of 

one’s self, of making the past and the strange one body with the near and present” (2017, 4). 

Ethnographically following and analyzing this process of subjectification as materialization, we 

undertake an anthropology of becoming (Biehl and Locke 2017). 

 

The focus on becoming instead of being is also employed by Sarah Nettleton, Robert Meadows, and 

Joanne Neale in a sociological sleep-rehabilitation project (2017). Their aim is to study the ontology of 

sleep as complex socio-material interactions. They investigate sleep in rehabilitation within an 

institutional setting; specifically, in relation to residential services for drug and alcohol rehabilitation. 

In this article, we study sleep as an orthopedic homework assignment in order to analyze the enactment 

and transformation of ‘engagement’ as an institutional category in mundane practices of becoming-

subject through rehabilitation. An anthropology of becoming acknowledges how power and knowledge 

form bodies, identities, and meanings, and how inequalities disfigure living – while, at the same time, 

the anthropology of becoming refuses to reduce people to the workings of such forces (Biehl and Locke 

2017, 5). Instead, plasticity is emphasized, which also applies power (Biehl and Locke 2017), as the 

directions that process becoming (Skrubbeltrang, Olesen, and Nielsen 2016). The notion of ‘plasticity’ 

give us the opportunity to study both stability and instability of the enacting forces and allow us to 

comprehend how patients live up to, co-create, rework, and ultimately depart from the possible 

positions that exist for doing rehabilitation (Skrubbeltrang, Olesen, and Nielsen 2016). 

 

Through our examination of older patients’ sleep-practices this article contributes to research on 

rehabilitative homework with the focus on the transition established between the hospital and everyday 

life at home. This is an investigation of how institutional norms flow through mundane practices and 

affect the capacity to make new and relational arrangements after orthopedic trauma and/or surgery 

and how new ways of becoming subject is directed.  

 

Methodology 

The article is based on an ethnographic study of the role of sleep in hospitalization and rehabilitation 

for older patients who have undergone orthopedic surgery. The empirical material that provides the 

basis for this analysis was generated during one year of fieldwork, with three months of participant 

observation in two different units of an orthopedic-surgery department in Denmark: an inpatient unit 

for scheduled surgeries and a unit for acute orthopedic surgeries. As a follow-up to the participant 

observations, 24 exploratory interviews with eight patients were conducted after discharge. These 

patients were aged 67–86, five women and three men. Other than one of the women, who was still 

working as a teacher (yet who retired six months after her operation), all of my interlocutors were 

retired. The participants were all part of the Danish ethnic-majority group and had different 

occupational histories and retired at different ages. Three of the women and one of the men lived alone. 

Three of them lived alone because their spouses passed away. Of the eight interlocutors, four had 

planned hip or knee surgery, and the other four were hospitalized due to trauma resulting in knee, 

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pelvic, neck, and/or hand injuries. Some of those injuries resulted in surgery, and others in pain 

treatment and relief for the joint. One interlocutor was hospitalized after years of complications from 

an earlier hip surgery in order to undergo re-surgery.  

 

In this article, we focus primarily on the interviews conducted after discharge, while the fieldwork 

conducted in the hospital is used as a backdrop to illustrate the medical pedagogies that underpins 

sleep, and to discuss how this relates to rehabilitation.  

 

The interviews were divided over three visits with each patient and were conducted at intervals of 

approximately one week after discharge, one month after discharge, and eight months after discharge. 

The interviews focused on questions about how the patients were doing, how their days would unfold, 

and their everyday practices, which also presented the patients with the opportunity to reflect on 

changes over time. At the end of each final interview, concrete sleep-hygiene rules were presented in 

order to discuss the medical pedagogy of sleep. These were read aloud in the interview and followed 

by an open discussion about how they related to such rules/guidelines in their everyday lives.  

 

Exploring the Concept of Engagement 

‘Engagement’ is an empirically based concept but one that we also approach theoretically in order to 

examine how sleep can be understood as a way of making one’s own patient trajectory. 

Based on Deleuze and Guattari’s definition, we understand engagement relationally; this means that 

engagement is a capacity to create effective relations (2005) in new realities with different bodies. 

Effective relations are socio-material relationships that for the individual can mobilize resources in 

everyday-life encounters with other people, things, and places (Vitus 2018). People are made up by 

relations  – as the lived entanglement with their surroundings formed in particular ways due to both 

historical and present circumstances (Lock and Nguyen 2010). In other words, throughout their lives, 

people practice how to enter and participate in both physical and social contexts. This process is 

ritualized through everyday practices—practices that also help direct them into new contexts or 

relations in which they are included (Deleuze and Guattari 2005, 204; Wolf-Meyer 2012). Relations are 

materialized through the body, which is why these relations affect the body, while the body, in turn, 

affects the relations. These relational practices are not deterministic; they can be changed but in a 

directive sense. The way these relations can be created is influenced by power structures and 

discourses—e.g., in the field of health, which Deleuze and Guattari argue can serve as a territorialization 

of the body (2005, 72-73). Territorialization can affect or block the capacity to create effective relations. 

However, “de-territorializing” and “re-territorializing” relations can be made, as the movement out of 

territorialization that restore the capacity to create effective relations (Deleuze and Guattari 2005, 72-

73). De-territorialization, or lines of flight, can also be made through re-territorialized manifestations by 

which the relations can be legitimized (Deleuze and Guattari 2005, 5-34). Engagement and the desire 

that direct the making of new arrangements with the environment are thus steered by what opens or 

closes for the individual in terms of the body’s capacity to create effective relations and a new way of 

becoming subject. An analysis of patients’ sleep engagements also addresses how sleep—as an 

institutionally enacted rehabilitative potential—can have either a conducive or obstructive impact on a 

patient’s efforts to create effective relations.  

 

Analyzing Sleep as Engagements 

The various socio-material conditions of which patients are part of are, together with patients’ bodies, 

included in their engagement in their current situations. In this article, we refer to them as ‘sleep 

engagements.’ The focus on sleep engagements is a strategy that, in keeping with Nettleton, Meadows, 

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and Neale (2017), allows us to examine how a patient’s sleep during rehabilitation comes into being in 

concrete settings and circumstances. We analyze three sleep engagements here to show how they 

correspond with the hegemonic medical definition of sleep engagement in rehabilitation and how the 

pedagogy connected to this definition may open or close the possibility of creating effective relations. 

 

The three analytical sections, constructed as narratives, begin with a presentation of the participant and 

their sleep in everyday life. For our interlocutors, the body has a particularly prominent status in their 

everyday life and the cases describe how the body is made significant for the way sleep is practiced and 

positioned during rehabilitation. Each sleep engagement we introduce concludes with an analysis of 

how sleep as an institutionalized homework assignment may or may not create effective relations in 

rehabilitation. All interviews have been anonymized, and all of the interlocutors’ names are 

pseudonyms.  

 

Eva’s Narrative: “Oh, there’s nothing wrong with my sleep”  

Eva, age 85, was admitted to the acute orthopedic surgery department because she fell at home and 

broke her kneecap. Eva had also been diagnosed with a lower-intestinal condition in 1986, and she has 

chronic obstructive pulmonary disease (COPD), which restricts her breathing. Because of this, she must 

often sleep sitting up with the aid of a support on the mattress. But she does not consider her sleep to 

be problematic. During the first visit to her home, she explained, “I sleep wonderfully (emphasizing 

wonderfully), whether I’m in or out.” With this, she meant in the hospital or out at home. She remarked, 

“Oh, there’s nothing wrong with my sleep.” She told me how she sleeps without interruption from 

midnight until 5:30 AM when, as she said, “then I just lay there for a while.” If she is occasionally unable 

to fall asleep, she just reads a little. She also does this if she wakes up in the middle of the night.  

 

The dynamic and everyday body and sleep management during rehabilitation 

For Eva, sleep is not the only practice rearranged around bodily changes. For example, she does not 

leave her apartment before the afternoon because of problems related to her intestinal condition. The 

biological conditions that regulate her everyday life – such as COPD and the intestinal condition she 

has lived with for many years – are something that she has integrated into her everyday life and around 

which she has coordinated her everyday practices. This also applies to her sleep, which is a routine 

practice that she rarely even thinks about—not even now when additional elements, such as an injured 

knee and a wheelchair, must be incorporated into her daily sleep practice. Eva, therefore, has 

established and keeps re-establishing her own rhythm based on her body.  

 

Eva has a routine of turning off the television every night at exactly 10:00 PM, putting on her robe, and 

sitting in the kitchen where she plays solitaire and listens to the radio while drinking a beer and smoking 

a cigarette. She finds this routine relaxing and, in her view, this is precisely what helps her sleep well. 

Thus, she does not view it as something the hospital needs to interfere with or that necessitates any type 

of intervention in relation to rehabilitation. She feels provoked when, for example, the hospital asks 

about her alcohol consumption: “Yes, and when it’s 10:00 PM, I drink a beer. And they stand there 

looking at me like it’s so cheeky of me to say that.”  

 

In Eva’s case, sleep is rather unproblematic and something that does not require any type of 

intervention. Not being able to sleep once in a while is not a cause for any concern or irritation, nor is it 

necessarily indicative of missing out on something valuable. She sees sleep as something that has a life 

of its own and is not something to be controlled. The same applies to her approach to the body as a 

condition that is as it is. As such, agency does not center in the body as a potential that can be fulfilled 

through the ‘proper’ strategy in Eva’s own sleep engagement. 

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Effective relations across medical and everyday categories  

Arranging her everyday life based on the health conditions she has—and thereby not articulating them 

as limitations or complaining about them—is a form of self-preservation that is part of Eva’s explanation 

of why she manages well. Not only has she always wanted to take care of everything on her own, but 

she also believed that she could. She thinks this stems from her childhood, growing up as the eldest 

daughter with three younger brothers. Because her mother was ill and often hospitalized, she was 

almost like a mother to the others. Additionally, she helped her father with finances.  

 

When she had hip replacement surgery a few years prior to our interviews, Eva explained that she was 

not offered rehabilitation. She enjoyed a good post-surgical outcome and her ability to handle things on 

her own and in her own way becomes her explanation of the good outcome. She compared her own 

patient trajectory with that of a friend who had received rehabilitation offered through her municipality 

after the same type of hip operation. Eva concluded that her own outcome was better than if she had 

participated in municipal rehabilitation: “When she [Eva’s friend] was still walking very badly, I was 

walking really well.”   

 

Eva did not adhere to the hospital approach to managing rehabilitation, which is illustrated by the 

following excerpt from the field notes after a conversation with Eva during her hospitalization. At that 

time, Eva was close to being discharged, and she drew upon the positive experience of doing things her 

own way: “Now it’s about me,” she says. I wonder what she thinks it has been about so far. I ask her. 

She has difficulty explaining it, she says, but makes a movement with her arms as if she is pushing 

something away. Now she just wants to get out, she says, and do her own thing.” 

 

Eva’s practice is a matter of what she thinks will improve her life as it is now, but the fieldnote indicates 

that this is not what she finds the institutional instructions addressed to her to necessarily be about. Eva 

does not try to change her body, but with actions and everyday rhythms and routines, she adapts her 

environment to her body. In this way, she builds the capacity to create effective relations or new 

arrangements in her everyday life. She creates rehabilitation through effective relations motivated by 

self-confidence—this is a subjectivity that is strengthening engagement in a de-territorialization 

(Deleuze and Guattari 2005) of a medical discourse on sleep management. Prescribed sleep 

management of not drinking and smoking in the evening becomes, on the contrary, a constraint for the 

capacity to create effective relations; this is why Eva sticks to her own ways of organizing sleep. One 

may say that Eva enacts the concepts of independency and responsibility for her own situation, 

representing the socially affirmative relations and norms concerning patient engagement as presented 

initially. The enactment of independency and responsibility provides Eva with an opportunity to re-

territorialize (Deleuze and Guattari 2005) her body in the medical discourse on rehabilitation. However, 

this re-territorialization is also a process through which she simultaneously confirms her sleep through 

medical-related ideals of sleep. Even if she defies health recommendations by maintaining her practice 

of smoking and drinking alcohol in the evening, Eva as well argues for these habits as relaxation, which 

medical discourses recognize as being conducive to sleep quality and uninterrupted sleep.  

 

Sleeping through the night is also a standard to which Eva adheres. Although sleep is something that 

Eva just does and does not immediately experience as a matter of concern or special interventions, she 

also finds that she is sometimes overpowered by sleep during the day, as she told me during the third 

visit. She characterized this as involuntary sleep and problematized it. For her, sleep and everyday life 

are structured according to certain set times. With calm and contemplation, Eva’s evening ritual in the 

kitchen lasts for approximately two hours, which is why she goes to bed at 12:00 AM and perhaps reads 

a little. Even if she goes to bed at 12:00 or 1:00 AM, she gets up early at 6:00 AM. She again sits and 

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enjoys the quiet; she has a cup of coffee in the kitchen and eats some breakfast. She sits there until 

around 9:00 AM, after which she gets dressed if she needs to go into town; otherwise, she sits in the 

kitchen until 12:00 PM. She does not only sit there because she thinks it is nice—she specifically sits in 

her kitchen chair to avoid falling asleep. She waits until 12:00 PM before she goes into the living room, 

where she eats lunch and later dinner in her recliner in front of the television. However, she often falls 

asleep here after eating, which makes her extremely unhappy. She does not think it can be good for her 

to sleep so much over the course of the day. Thus, the qualitative time-space she practices early in the 

morning and late in the evening does not give her many hours during which to sleep she nonetheless 

thinks there must be something wrong since she just falls asleep throughout the day, against her will. 

Therefore, she wants to speak to her doctor about it.  

 

For Eva, sleep is concomitantly unproblematic and problematic. It is something that is as it is and not 

subject to control but, nonetheless, it becomes problematic when it occurs during the day. Eva’s sleep 

engagement can be seen as a de-territorialization of the body from medical discourses that promote 

sleep as a health practice and through which the body can be optimized. However, sleep during the day 

is pathologized by Eva, as also represented through the sleep-hygiene rules in which napping is 

something to be restricted. The midday nap is represented through her perspective as an outdated 

category connected to ‘elderly people’. As such, medical concepts of sleep might reject a concept of 

aging associated with daytime napping affecting Evas identification and concerns.  

 

The following sleep engagement is an example of explicitly disassociating oneself from the image of 

aging linked to being more tired.  

 

Sten’s Narrative: “No, no, I don’t use it at all. I don’t use it at all”  

Sten, age 78, underwent two hip replacement surgeries a few months apart. He has also lived for many 

years with back pain due to a sports injury and later hip pain as a result of osteoarthritis. Because of this 

pain, he has had to reconfigure his life in several ways. For example, he had to stop participating in 

sports, which had been a very important part of his life, he had to move from a house with a garden to 

an apartment in town, he had to take pain-relieving medication for many years, and he had to reduce 

his travel activity. Unlike Eva, who acts with her body as an everyday barometer against which she 

coordinates her activity, Sten has more difficulty accepting that his life is changing because of his body. 

 

Sten’s rehabilitable and potential body  

Sten is used to being able to achieve the goals he sets for himself by adopting the right approach and 

mindset. He nearly lives by the motto of ‘control and discipline.’ For example, he told me during the 

third visit: “I’m probably one of those people who, if you make a decision, then it tends to apply to 

every other thing in life as well. Everything else is just nonsense,” and “There are two types of people, 

those who get moved around and those who move others around. And you can decide which type you 

want to be.” Unlike Eva, the bodily changes for Sten are not merely an accepted development that 

determines what shape life can take, even if he says, “And then you try to get the most possible out of 

it (life with bodily changes) in some other way, but it’s still difficult, isn’t it?”  

 

Two hip-replacement procedures have strengthened Sten’s approach to control and discipline. He talks 

about an active life filled with sports, travel, and professional responsibilities, but that is now changing 

because of bodily changes, which are significant consequences not only to him but also to his family. 

One experience in particular “broke” him, as he told me in an interview. He recounted the time when 

he had to interrupt a vacation because he could not walk around. The experience he described is full of 

guilt and shame towards his family, who had arranged the trip. This guilt can be related to a sense of 

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not having done what was planned, doing too much, or doing it the wrong way. He said, “I’ve played 

handball, football, and table tennis, and I have been on Zealand’s [a region in Denmark] premier teams 

in both handball and football. But, on the other hand, this is perhaps also the type of thing that 

contributed to the deterioration [of my joints].” As a result, he indicated that he is personally responsible 

for the way his body is today and that he had failed to maintain his health competence (Fristrup and 

Munksgaard 2009). By doing so, he deprived himself and his family of some opportunities. In this sense, 

Sten positions physical decline as something shameful.  

 

However, in relation to his two hip-replacement procedures, Sten realized that doing exercises at home, 

with which he is highly disciplined, in combination with participating on the municipal 

physiotherapeutic rehabilitation team for patients who have undergone hip surgery, have given him a 

new opportunity for control—particularly control over his body through muscle-building. He 

remarked, “The thing I think is important is to keep your muscles fit, so you don’t just fall apart and 

think, ‘Well, I don’t give a damn about this anymore.’” He suggested that his efforts were useful, which 

is why he wants to continue with daily strength-training for the rest of his life: “I would like to go as far 

as I can with this, and there’s no doubt that exercise is something I will do for the rest of my life. . . . 

there’s no reason to believe that when you get old, or very old, that you can just say 'That's fine enough.’. 

. . No! It’s exercise once a day at a minimum.” With this, Sten also indicated that becoming older and 

weaker is not an excuse to ‘take it easy’ and to withdraw from engaging in optimizing one’s possibilities 

as a potential for agency he locates in the body —for Sten, this engagement with exercising is forever. 

Sten identifies with the responsibility that has been institutionally assigned to him through the patient 

trajectory—a responsibility that involves taking the initiative for activity as an institutional category of 

practice that is related to optimization of the body. At a pre-surgery joint seminar, the surgeon Jens 

explained to those to be operated: “The bed is a dangerous place—get out of it. The studies show the 

sooner, the better.” Like this surgeon, Sten identified the bed as a threat: “It can’t do any good to just lie 

there and just say, ‘Now, I’ll just stay in bed’ and so on. That’s not how it is. It’s a question of getting 

up—it’s about getting up and getting started with these things.” However, Sten underlined a 

contradiction—it is not only about getting up, as also stated by Marianne the physical therapist at the 

seminar. She said, “You may become tired, lie down and rest your legs several times a day.” Hence, 

sleep and rest are conveyed as a central element in hospital discourse on rehabilitation, but it is not 

merely addressed as a matter of sleeping as well and as much as possible. Rather, it is a matter of 

coordinating sleep and rest in the correct way so as to fully tap sleep’s potential as a tool to improve the 

patient’s mental and physical capacity in rehabilitation. Although he engages in this rehabilitative 

concept of sleep potentiality, Sten illustrates how hard it is to succeed. 

 

Sten’s sleep management  

It is difficult for Sten to accept that the body determines how life can take shape. He also struggles with 

accepting that his own body cannot comply with the health-promoting recommendations that he 

witnesses in his everyday life e.g. through friends and media and through interactions with healthcare 

that he wants to follow, such as with sleep. He said, “My only problem is that—and this happens to 

everyone—I have to get up several times at night to use the toilet. It’s a moment of irritation because I 

never get eight hours of sleep. I get sleep in two-hour increments, you see, and it’s a problem.” 

According to Sten, eight hours of uninterrupted sleep is the ideal against which he measures his own 

sleep. Even though Sten experiences the consequences of not getting consecutive hours of sleep (being 

tired during the day) which irritates him, he does not take a midday nap: 

 

Sten: No, I don’t sleep at 12:00 PM. I’ve actually wondered whether I should sleep a 

little at 12:00 PM, but I never really get to it. 

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TL: Why do you think that might be? 

Sten: Yes, I could just go in there, but . . . it’s not like, I could just go in and take a nap 

and say, “Now, I’ll just lie down for an hour and a half” and then be done with it. It 

would be easy . . . but then you also want to be able to fall asleep in the evening and 

sleep through the night, right? 

 

Sten considered a midday nap to be a possibility in his everyday life, but he did not do it because he 

was afraid of how it might impact his sleep at night. The midday nap, which he actually thought could 

be necessary, thus became one of several elements that might theoretically disrupt his ability to fall 

asleep or sleep through the night. As such, the thought of a midday nap had a controlling effect over 

his actions. Preventing something that might be disruptive is an approach that was also mentioned in 

the interview:  

 

Sten: We drink a lot of coffee at home. And we probably drink too much of it, but we’ve 

started to drink less at night, I have to admit—much less than we used to. 

TL: Why do you think that is?  

Sten: It’s just because I heard someone say that we won’t be able to sleep at night, so 

we don’t drink coffee—we don’t drink coffee after such and such a time.  

 

These preventive actions are not based on personal experience but rather on Sten “hearing someone 

say” something. Sten changes his actions according to something that may give him sleep-possibilities 

rather than based on actual experiences of sleeping better if drinking less coffee. In his statement, “We 

probably drink too much of it,” he also refers to the fact that there might be an additional health 

promotional and rehabilitative potential in drinking less coffee. As such, it becomes something he 

‘should’ do. Similarly, based on the idea of a defined amount of sleep that he should have, Sten thinks 

that he should prioritize the time at which he goes to bed a little differently. 

 

We actually go to bed rather late; I have to admit. We go to bed between 10:00 PM and 

12:00 AM. And 10:00 PM is very early right now, but . . . or it’s very early in general, I 

should say. It’s probably between 11:00 PM and 12:00 AM, at some point, when we go 

to bed. And when it comes down to it, that’s probably a little late. It should probably 

be 11:00 PM, in any case, instead of 12:00 AM. 

 

Paradoxically, Sten was irritated by the fact that his body does not allow itself to be controlled, such as 

in the case of night-time urination, which interfered with his ‘you can get what you want if you work 

for it’ philosophy. He was frustrated by his inability to control his will during the night. Thus, it was a 

dilemma for him that, following his hospital discharge, his legs needed rest throughout the day when 

activity was the very thing that he considered important to do. He illustrated this dilemma in the 

following quote, in which he sarcastically emphasized the first part of the sentence and—with a sense 

of acknowledgment—inflected the last part, saying, “Even if I fully know they (healthcare professionals) 

say, ‘Just get moving, just get moving’ (sarcasm), it’s all about just getting moving (recognition).” With 

this, Sten both disassociated from and acknowledged the expectation of activity in his patient trajectory. 

 

Effective relations: Across normative and medical categories 

At the joint pre-surgery patient seminar, the physical therapist Marianne emphasized an increased need 

for sleep and rest in rehabilitation, while simultaneously suggesting that they must be carefully 

balanced by standardizing the increased need for sleep that an operation produces: “You will get 

exhausted and have an off-day where you might not be able to exercise three times a day, but only 

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twice. Then it gets better the following day.” In her view, an increased need for sleep is not an obstacle 

to a training opportunity—in any case, there might just be a single day when the training can only be 

done twice instead of three times. Yet, she stressed that after this little break one will bounce back and 

be able to perform optimal training again. There appears to be an implicit concern that orthopedic-

surgery patients see themselves as sick and associated with having to stay in bed and get a lot of rest, 

which is why an increased need for sleep is recognized but at the same time emphasized by healthcare 

professionals as something to be minimized. 

 

Sten’s narrative illustrates the dual nature that is embedded in sleep as a potential homework 

assignment in post-operative rehabilitation. 

  

Sleep is an individual bodily event and biological force. When placed into a rehabilitative management 

context connected to medical concerns of recovery, sleep is expected to be practiced and controlled in 

‘the right way,’ with the promise to achieve health-promoting potential of the body. This concept of 

potentiality can be examined through a health-policy lens. Here, the patient’s rehabilitative change 

process should lead to an improved level of bodily functioning that allows for active agency and 

independence. Independence is precisely the objective Sten hopes to achieve; he would like to postpone 

or avoid having other people “take over,” as he told me. The body becomes the means for this 

independence, which is why the body needs to be controlled. Resting during the day can take time from 

the most important thing—activity—which can be seen as a lack of will or control, and perhaps even be 

associated with laziness. In the following interview excerpt, Sten rejected the midday nap and he 

emphasized the idea that a midday nap is something he can choose to forego.  

 

Sten: No, no, I don’t need the nap at all. I don’t need it at all. It’s true that right when I 

came home [after hospital discharge], then it was really nice to lay down to sleep for an 

hour or so. That’s over with now. That was a long, long time ago. 

TL: It’s not something you used to do in your normal everyday life before the surgery, 

either? 

Sten: No, no—I could have done it if it were necessary, but it wasn’t like that. Not 

anymore. That’s over with. 

 

While Eva associates daytime sleep with the notion that something is medically wrong, for Sten, 

daytime sleep is perhaps associated with laziness and is thus something that one can choose. According 

to Sten, daytime sleep is almost something that can only be legitimized through illness and daytime 

sleep is something Sten chooses to distance himself from when it is no longer a question of having 

recently undergone an operation or being affected by complications such as diarrhea due to analgesic 

treatment, which left him very exhausted for a week after the operation. In this example, another dual 

nature regarding sleep is mobilized—one in which sleep that does not take place at night is for sick 

people and, if one is not sick, then sleep is for lazy people. 

 

For Sten, sleep is something that can be optimized—not because ‘a good night’s sleep’ is a goal in its 

own right, but because it can become a means to something else, such as preventing disease. Sleep can 

also support his ability to exercise and therefore prevent decline, which can lead to being able to 

maintain or improve his independence. Routines and arrangements are therefore established in another 

way—in order to make the best possible conditions for sleep. For example, Sten avoided watching 

nighttime television shows that might have an emotional impact on him. If he needed to get up during 

the night, he used a flashlight so that a more intense light would not wake him up too much. The key 

point is that Sten’s sleep was planned in advance—unlike Eva, for whom sleep was something that 

simply is and was unproblematic. In Sten’s case, however, sleep was something to be protected and 

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promoted through control and discipline. With his sleep engagement, Sten enacts a notion of 

potentiality also represented in medical discourses of rehabilitation in which control and discipline 

enable a person to shape their body and strengthen independency. Engaging in a bodily optimization 

with the promise of independency Sten builds relational capacity. But, at the same time, these 

engagements frustrated him because his body disrupted his plans for what he wants, and he 

consequently felt guilty when it was not possible for him to engage in certain activities. He also felt 

frustrated when he had to adhere to conflicting rehabilitative logics about both training and sleep and 

rest. In this way, sleep as a medical defined homework assignment and potential may both close and 

open Sten’s capacity to form effective relations that mobilize resources in his everyday life.  

 

In the following case, we illustrate how the physical changes generated by disease and/or trauma 

neither can be included as a part of an obvious and everyday engagement or as an engagement in which 

sleep takes place as a rehabilitative potential that can be managed. Here, the non-rehabilitable body is 

created, but sleep is also included in an effective relation that is a matter of preserving authority in 

repudiation of institutional requirements performed by both hospital and the municipal services and 

standards for health behavior.  

 

Henning’s  Narrative: “This is not for us”  

Henning, age 72, was hospitalized in the acute orthopedic unit for a week after breaking his pelvis. 

Against medical advice, Henning discharged himself from the hospital early, and he did not want to go 

to a specialized centers for respite care because he could not afford to go there and because his wife 

could not join him. Henning’s general weakness and pain after hospitalization and recovery for his 

pelvic fracture made him extremely tired, and he slept frequently following his discharge. Municipal 

services supporting him in the home after discharge installed a hospital bed in his home, so he could 

get into bed on his own and avoided disturbing his wife Connie, when getting up at night to urinate. 

However, at the time of our interview, the municipality had removed the hospital bed from his home 

why he was sleeping on the sofa in the living room. According to Henning, the reasons why the 

municipal service retrieved the bed and other kinds of equipment were because the municipal 

authorities did not believe that he still demonstrated a need for these assistive devices since he was not 

complying with the hospital’s recommendations. He gave the example, that he was walking around 

even though the hospital staff told him to try not to support his own weight until six weeks after 

surgery. However, he was walking because he experienced he was capable of doing so why he also 

suspected the healthcare professionals of imposing on him unnecessary restrictions as an act of power.  

 

Henning’s non-rehabilitable and non-potential body  

Even though Henning and Connie took midday naps together every day at fixed times, sleep was not a 

delimited event in Henning's life after hospital discharge—instead, it was rather fluid. He spent most 

of the time on the sofa in the living room, drifting in and out of sleep. Eight months after discharge, 

sleep was still something that filled much of his everyday life, especially because he was bothered by 

abdominal pain and chronic lower-intestinal disease, the symptoms of which worsened after his 

orthopedic hospitalization.  

 

Regarding the sleep-hygiene rules, Connie told me: “This is not for us.” With this, she meant that their 

various chronic disorders—such as diabetes, COPD, osteoporosis, lower-intestinal disease, and 

complications after hip and pelvic fractures—would prevent them both from practicing the health-

promoting sleep hygiene rules regarding exercise, fresh air, no napping (or only very briefly), no eating 

before bedtime, etc. With these sleep rules, sleep becomes a potential for health—but, as Henning and 

Connie saw it, they are only for people who are already healthy. She problematized what psychologist 

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Niels Christian Nickelsen has also problematized; i.e., standards are attached to concepts of normality 

that create order for those with standardized—or here, potential—bodies, yet they create problems and 

exclude others with non-standardized or non-potential bodies (Nickelsen 2008).  

 

Henning’s sleep management  

For Henning, sleep was neither something that is just figured in as a balanced part of everyday life like 

it was for Eva, nor was it something that he problematized as such. Sleep was also not something he 

could organize into a rehabilitative-potential perspective, defined by medical and institutional 

rationale—rather, it was something to which he must surrender in a bodily sense, day and night. Sleep 

also proved to be an accessible strategy Henning used to ‘check out’ whenever something became 

unpleasant or difficult. Whether it was pain, arguments with Connie, or when the demands of the 

municipal services or hospital were difficult to fulfill, Henning explained: 

 

Henning: I’m more tired now. I’m more tired. I don’t do much, and if I were to lie down 

now, I could easily sleep until 3:00 PM, and it wouldn’t bother me a damn bit.  

TL: But you don’t do it, or . . .? 

H: Yes, I might definitely do it. Once you’ve left, that is. 

Connie: Or, let me put it a bit differently. If there is anything bothering him, then I have 

to deal with it, and he just lies there, and then drifts off . . . 

H: Yes, I just lie down. I don’t like to argue, so I just lie down and sleep, and then you 

all can just disappear. 

 

For Henning, there is also a social potential in sleep as the possibility to escape both private and 

institutional demands. 

 

Effective relations: A de-territorialization of medical and institutional categories 

Several times during our interviews, Henning circled back to the importance of making his own 

decisions. He kept on top of patient law, about which he also advised his neighbors and referred to 

terms such as “self-functional,” he said:  

 

As long as we do not present a risk to others or ourselves. And we aren’t – we get the 

food and care that we need. We’re not a danger to ourselves or others when we can 

manage ourselves, so we are self-functional. We can handle it ourselves. So, people are 

actually allowed to say, “No, thank you.” . . . It’s what the law says today, and that’s 

what we choose. They cannot make decisions for me—not when I’m self-functional.  

 

Although it is Henning’s legal right to opt-out of hospital- and municipal recommendations and offers, 

he found it strange that opting out can have consequences. For example, he was convinced that the 

hospital did not want him to come in for a follow-up X-ray of his pelvic fracture because he had 

discharged himself against their recommendation. 

 

For Henning, sleep is something that just happens and to which he has to surrender, but it also becomes 

a conscious way of distancing himself from institutional requirements and other difficulties he 

experiences in his life. Therefore, it can perhaps be seen as though he is not engaged in forming relations 

with the world. But, on the other hand, this sleep practice can also be seen as a re-territorialization 

through an engagement that can realize self-determination and where power over the body is reclaimed 

from state and municipal institutions. The modes of ordering creating a medical pedagogy of sleep that 

requires a special form of engagement deprives Henning of the opportunity to legitimate his actions, 

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and the hospital and municipal requirements thereby obstruct his ability to create effective relations. 

Sleep as something one can tighten down through control or change through one’s evening routines is 

not an option. Hennings sleep practice cannot be formed to the medical notion of active engagement 

with the potential to optimize the body and hereby give him independency. But, at the same time, sleep 

becomes an effective relation that, like a body-based resistance and position allowing for self-authority. 

The desire that guides Henning to build relational capacity thus becomes authority or integrity (Bakken 

2020), and an option of de-territorialization of the medical logic; for him, it is a connection that does 

mobilize agency. Henning cannot optimize his body, it is non-potential from a medical perspective. 

With the notion of ability proposed by among other Ingunn Moser, this non-potential body gives him 

fewer possibilities of action and of participation, however, Henning creates a body of resistance 

destabilizing an institutionally sanctioned subjectivity of the ‘good patient.’     

 

Effective Relations and Becoming Subject 

The three sleep engagements we have described in this article point to the different ways in which 

effective relations are created, and how they are mobilized (or not) by the institutional expectations of 

sleep as an ideological practice and homework assignment in post-operative rehabilitation.  

 

Referring to sociologist Pierre Bourdieu’s concept of habitus, Buch argues that humans have different 

embodied dispositions created through different backgrounds and generational histories (Buch 2018). 

The consequence of embodiment connected to ideological practices formed through modes of ordering 

is that, when those from non-dominant groups fail to embody the habitus of more powerful groups, 

embodiment is used to justify their disadvantage and exclude them from opportunity (Buch 2018). Our 

analysis here suggests that rehabilitation is formed as a biomedical neoliberal practice as the ideological 

practice that creates different bodies and thus different opportunities for inclusion in the subject 

position of ‘engaged patient and responsible citizen,’ which is linked to full social participation. Our 

analysis also indicates that some patients, through their engagement, must free themselves from these 

subjectifying forces and power structures in order to create effective relations. Through this process of 

de-territorialization, patients create new bodies, as the everyday body and the body of resistance, and 

new forms of social participation. In doing so, they destabilize the medical/institutional category of 

engagement (Deleuze 1994; Deleuze and Guattari 2005).  

 

The first sleep engagement (Eva’s case) illustrates how sleep and the body are included in an everyday 

relation with built-in distance to medical and institutional categories. But, at the same time, it is an 

engagement that simultaneously draws upon medical concepts—not only in conjunction with its 

legitimization but also its problematization. The other two sleep engagements (Sten and Henning’s 

cases) characterize engagements that, each in their own way, differ from Eva’s sleep engagement. In 

Sten’s sleep engagement, sleep and the body are directly connected to medical categories of sleep as 

rehabilitative potential, while in Henning’s sleep engagement, sleep becomes a means of de-

territorializing the body from the medical rehabilitative potential.  

 

Throughout these three different sleep engagements, bodies come into being in the relation between 

everyday life and medical and institutional categories as well as through the individual’s embodied 

biographical practices. Therefore, the ways in which these changed bodies are incorporated in the 

formation of relations also differs. In Eva’s everyday life, the body becomes one of the structuring forces 

that she does not consider to be beholden to institutional norms of sleep while, in contrast, Sten’s body 

must comply with the requirements; he assumes the regimen of the body and sleep as potential. 

Henning’s body becomes a ‘non-rehabilitable and non-potential body’ that cannot be directed and 

thereby optimized by a choice to do something in another way with regard to rehabilitative notions of 

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controlling sleep. In contrast, Sten’s rehabilitable and potential body can make napping something he 

can choose, and allow him to regulate eating or drinking if he wants, in order to sleep better. Henning’s 

body cannot be adapted to the environment at all, as Eva’s everyday body can, and still preserve the 

temporality of everyday life as she knows it. The non-rehabilitable and non-potential body cannot be 

directed. Through his non-rehabilitable body, Henning’s self-determination is consolidated in his 

encounters with the healthcare and municipal systems and, for him, sleep becomes an opportunity to 

preserve authority as a biographical force that guides his ability to create relations with the surrounding 

world. Henning’s sleep engagement mobilizes resources in everyday life but in a very different way 

than in the other two sleep engagements. 

 

Elena Buch emphasizes, as we also suggest here, that “embodiment is ongoing across the life course, as 

people engage in intertwined biological, environmental, and social processes” (2018, 133). She calls 

embodiment, “bodily continuity” (Buch 2018), which refers to both the present and the past. Based on 

the concept of engagement that we have described here with reference to Deleuze and Guattari, 

rehabilitation is about creating effective relations, and that which is effective is tied to—but not 

determined by—the embodied dispositions and bodily continuity. We demonstrate that creating 

effective relations, therefore, does not become an issue that can be defined by the degree to which the 

knee can bend but rather by the degree of disrupted continuity and new acquisition. Acquisition is not 

dependent on the body ‘regaining’ its former physical form (Buch 2018), but it requires a body that, in 

its transformation, can create new relations with its surroundings, and in which the person can 

recognize him or herself and thus everyday life.   

 

What is essential to focus on in these three engagements is that sleep occurs as an effect of the various 

and embodied biographical ways that people are included in relations with their environments, which 

is why sleep and the potential embedded in it must first and foremost be seen as connected to a long 

life and then to a patient trajectory. This analysis suggests that what directs the formation of these 

relations has its own biography/historicity but a biography/historicity that is also created through 

institutional categories.  We see these institutional categories enacted through the patients’ affirmations, 

re- and deterritorializations. In different ways, Eva, Sten, and Henning incorporate the institutional 

dichotomies of active and passive engagement into the way they connect sleep, health, and aging. Both 

Eva and Sten associate daytime sleep to a notion of passivity, and the opposite, activity, becomes, for 

Eva and Sten, either a right or a duty. When Eva is unwillingly overpowered by sleep during the day, 

it prevents her from being the active person she identifies with. To her, daytime sleep becomes a medical 

concern and not a natural part of aging. For Sten, staying active and not giving in to daytime sleep is a 

choice. It is also a matter of moral engagement in his recovery trajectory because he can demonstrate 

that he is not being a “passive citizen” (Mikkelsen 2019); he does not give in to sleep but keeps on 

working to improve his musculoskeletal system which cannot be done while sleeping. Through their 

different discursive-material sleep practices, we argue that Sten and Eva subjectify to the discursive 

context of health as active aging. From a medical perspective, Henning enacts sleep as a passive form 

of engagement in relation to going to sleep when demands are put on him oposed to a notion of actively 

engaging with them. However, for Henning this enactment is a way to resist this normative and unequal 

understanding of engagement as either active or passive or potential or non-potential and of this being 

a choice or something he lacks motivation to do; as such, this sleep-practice can be characterized as a 

political act (Mikkelsen 2019) that demonstrate that he doesn´t subjectify to this concept. 

 

When Sten’s sleep engagement matches institutional expectations, it is because his approach to 

practicing sleep corresponds to the way he is historically directed through changes. The historical 

practice of disciplining himself and working hard to enable himself to remain in control of the situation 

he has confirmed to be effective throughout his patient trajectory. The same thing may also apply to 

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Henning. The institutional categories of sleep as a homework assignment and potential reinforces his 

lack of opportunity to legitimize his body and his practices. On the other hand, Henning’s sleep 

engagement acts as a retaliation to the institutional approach; here, as a desire that directs his 

engagement, his authority is preserved. Our analysis of ‘becoming subject’ thus demonstrates how we 

live “alongside, through, and despite the profoundly constraining effects of social, structural, and 

material forces, which are themselves plastic” (Biehl and Locke 2017, Foreword, X).  As these sleep-

engagements show is that how - and by what they are directed is an enactment of biographical forces, 

not understood as definitive, that themselves are effects of social, structural and material forces affecting 

the building of new arrangements. With this perspective on rehabilitation, we cannot make a linear 

cause-effect explanation, as represented through biomedicine, of how the building of new arrangements 

are mobilized or what they should be constituted of. 

 

Conclusion 

Sleep is increasingly addressed by media, consumer markets, and through healthcare interventions as 

a matter of concern regarding health and prevention of disease. In institutional rehabilitation practices, 

sleep becomes a homework assignment based on an idea of sleep as a particular type of potential. This 

movement makes sleep a rehabilitative task with an integral rehabilitative potential that patients are 

expected to achieve through the correct behavior, coupling sleep with patient engagement in post-

operative rehabilitation. In this article, we consider sleep as an activity that, through the recovery 

trajectory after orthopedic surgery, is instrumentalized and transformed into rehabilitative homework 

in which the conditions for optimal rehabilitation can be fulfilled. The institutional concept of sleep 

potential connects sleep to a concept of passive and active engagement. However, drawing upon 

Deleuze and Guattari’s (1994, 2005) concept of engagement, we find that the patients in this study 

cannot be viewed as passive and predetermined. Our analysis suggests how patients’ sleep practices 

are always an active and motivated socio-material engagement in creating effective relations that, in 

various ways, serve to mobilize resources in everyday life.  

 

However, these relations are also influenced by biomedical health categories co-creating institutional 

categories of engagement and potentiality. These categories create different types of bodies and 

agencies—for some patients, these categories have a conducive effect with respect to creating effective 

relations while, for others, it has the opposite effect. Although it is stated in this article that patients’ 

sleep practices are always an active engagement in creating effective relations the way arrangements 

are made possible and the way in which the elements are linked to one another do not always 

correspond with institutional expectations of mobilizing forces. However, living up to institutional 

expectations for what it means to be an engaged patient can be followed by shame and a guilty 

conscience, as seen in Sten’s case, or by retaliation with exclusion as a consequence, as seen in Henning’s 

case. However, another position emerges that can both present an opportunity for self-recognition 

through practices and the fulfillment of institutional categories, as was the case for Eva. With a relational 

perspective on post-operative rehabilitation and engagement, sleep as a homework assignment can be 

seen as a type of becoming that opens up possibilities for action—but perhaps not always the kind of 

action that fulfills institutional expectations. 

 

Notes 

1. With the concept of sleep as a practice, we include ‘resting.’ One can rest without sleeping, but these two 

practices often flow into each other and are difficult to separate. When patient engagement is considered to be 

‘not active enough,’ rest and sleep are often put together in one category. 

 

 

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