Approaches to Rehabilitation
Psychiatric rehabilitation ensures persons who suffer from a psychiatric disability
can perform those physical, emotional, social, and intellectual skills needed to live, learn,
and work in their community, with the least amount of professional help necessary
(Anthony, 1979). In rehabilitation psychology, psycho-social models are necessary for
facilitating treatment planning, explaining impairments and treatments to patients and
caregivers, and allowing clinicians and interdisciplinary team members to conceptualize
outcomes (Rath & Elliott, 2012). There are several conceptual rehabilitation-related
approaches which have been identified in literature. The most prominent ones have been
discussed below.
The Biomedical Model
Biomedical model emphasizes on the working and functioning of the physical body
and how diseases or disorders can be cured or treated with the help of medical therapeutics
(Jahan & Ellibidy, 2017). This means that the human body is considered somewhat similar
to a machine that can be broken down into its parts and analysed. The disease or disorder is
considered to be a kind of biological or chemical defect that can be corrected by a clinician
physically or chemically in order to restore its function.
In this approach, the disability is said to be the result of trauma, disease or some other
kind of medical condition, and individuals with disabilities are considered to be ‘abnormal’
or those that deviate from the normal health conditions. As a result, these individuals are
identified and described with regard to their pathology, such as “an amputee” instead of being
recognized as an individual with a medical condition such as “an individual with an
amputation” (Jahan & Ellibidy, 2017). The biomedical model is not the best suited for
rehabilitation practice as it presents disability as a result of pathological, physiological and
chemical changes, while disregarding the influence of personal, social and environmental
factors (Jahan & Ellibidy, 2017).
The Social Model
In contrast to the biomedical model, the social model states that a disability is the
result of a ‘socially created problem’ rather than a defect in the body’s function. Although the
biological disease or disorder causes limitations for the individual, it is believed that the
social or physical environment enhances these limitations and plays a significant role in
creating barriers for the individual (Durell, 2014). For example, an elderly person may have
weakness in their arms which leads to difficulty in opening doors in public spaces. The
solution according to the social model would be modifying the environment by providing
automatic doors across all public spaces.
According to the social model, each individual is equal in terms of functional ability
and participation. If the environment is appropriate for those with and without a disability,
then everyone will be able to participate successfully (Durell, 2014).
Essentially, while the social model focuses a great deal on the environment of the
individual, it ignores and fails to acknowledge the individual characteristics that may
contribute to the disability process.
The International Classification of Impairments, Disabilities and Handicaps (ICIDH)
The International Classification of Impairments, Disabilities and Handicaps model
(ICIDH) was published in 1980 - as the first model of rehabilitation by the World Health
Organization (WHO, 1980). In ICIDH, three main concepts are highlighted, i.e. impairments,
disabilities and handicaps. These three concepts are considered the consequences of a disease
in unidirectional manner; impairment, disability and handicap being the first, second and
third consequence respectively (WHO, 1980).
This model is not without its limitations. First, it has been widely criticized due to less
importance given to the social as well as environmental factors that are associated with the
concepts mentioned, especially the contribution of these factors to the concept of handicap
(WHO, 1980). Second, the model fails to understand the relationships between three concepts
as the unidirectional manner indicates more of a causal relationship and does not allow the
freedom to move from handicap or disability back to impairment (WHO, 1980).
Biopsychosocial Model
The biopsychosocial model of disability considers the interactive effects of disease,
psychosocial stressors and personal and environmental factors that account for varying
degrees of adaptation (Peterson & Elliot, 2008). This model has been typically used to study
adjustment associated with specific diagnostic conditions, e.g. traumatic brain injury, spinal
cord injury etc. It attempts to integrate medical aspects of a given disability diagnosis with
important psychological (e.g. coping abilities, personality traits) and social (e.g. social
support, stressors) variables and their various interactions in the prediction of optimal
adjustment.
The International Classification of Functioning, Disability and Health (WHO, 2001)
emerged from the biopsychosocial model of rehabilitation, which is an integration of earlier
medical and social models of disability and addresses biological, individual and societal
perspectives on health (Peterson, 2005). ICF’s interactive conceptual framework illustrates
how facilitators and barriers in the environment are key factors in understanding disability
and how advocacy occurs through social change (Hurst, 2003). Most important to
rehabilitation psychology, individuals appraisals’ of environmental assets and liabilities,
personal body functions, and their ability to participate in desired personal and social
activities are important considerations in classifying functioning, disability and health with
the ICF (Peterson & Elliot, 2008).
The main limitation of the biopsychosocial model is that it is not a psychological
model of adjustment; it does not provide explicit and testable hypothesis to advance
understanding of behavioural processes among people living with chronic health problems
and disabilities (Elliot & Warren, 2007)
Learning Theory and Behaviour Modification Model
Learning principles have been applied to identify environmental contingencies that
reinforce and shape “disabled” behaviours and produce impairment that is beyond what can
be attributed directly to a physical condition. These models supply rehabilitation
psychologists with many potential intervention strategies, such as shaping, modelling,
desensitization, chaining, extinction, and reinforcement, any of which can be adapted or
modified to suit particular individuals, purposes and problems.
One example of the application of learning principles was seen in Wilbert E.
Fordyce’s application of operant conditioning theory to pain behaviours. In this model, pain
behaviours are conditioned by a patient’s interpersonal and social environment, and these
environment reactions serve to maintain or increase pain behaviours. Fordyce advocated the
use of time-contingent schedules to prevent acquisition of maladaptive behavioural patterns,
with the additional benefit of maintaining steady medication levels in the patient.
The learning model has clear relevance for rehabilitation of motor impairments in
humans following CNS damage and other injuries (Taub, 1980). In rehabilitation settings,
one of the most important applications of these models is to help patients optimize therapy
participation by increasing the frequency of therapeutically on-task behaviours, while
decreasing the frequency of therapy-competing behaviours. The focus is on the use of
differential reinforcement, in which reinforcement is provided when the individual refrains
form performing a problematic behaviour during specific time interval. The Premack
principle is also applicable, wherein naturally occurring high-frequency responses (e.g.
resting on exercise mat) reinforce lower frequency target responses (e.g. participating in
uncomfortable range of motion exercises). Learning theory has also been used to improve
language skills in individuals with brain injury and other cognitive impairments (Goodkin,
1966).
Community Based Rehabilitation Model (CBR)
According to the WHO Expert Committee on Disability Prevention and
Rehabilitation, CBR can be defined as “the measures taken at the community level to use and
build on the resources of the community, including the impaired, disabled and handicapped
persons themselves, their families and their community as a whole” (WHO, 1981). The CBR
model was first proposed by the WHO in 1978, in order to decrease the difficulties associated
with disabilities and to improve self-efficacy and independence of individuals with
disabilities from developing countries (WHO, 1981). The World Health Organization and the
World Bank reported that individuals with disabilities represent about 15% of the total
population of the world and are concentrated in poor communities in the poorest areas in the
world (WHO, 1981).
The objective of the CBR strategy is to improve the quality of life for individuals with
disabilities and their families, by doing their daily tasks independently, and by participating
effectively in their community. It also aims to empower individuals with disabilities to
benefit from education, working positions, health, community, and social services (Jahan &
Ellibidy, 2017). The implementation of the model hugely relies on the individuals with
disabilities to cooperate as well as their families, local communities, governmental
administrations, non-governmental organizations, associations and other relevant services to
take part in the implementation process (Chatterjee et al., 2009).
However, the CBR model comes with a few limitations. First, there is a lack of
consistency in outcome measurement scales for CBR evaluation (Wirz & Thomas, 2002).
Second, CBR programs are expensive to implement (Jahan & Ellibidy, 2017). Third, to
evaluate the functional outcomes in a particular population, a larger sample size is required,
but because of the programs not being cost efficient, only smaller samples can be adapted
(Jahan & Ellibidy. 2017). Lastly, a time duration of 5-7 years on an average is required to
draw conclusions and to find out the effectiveness of the intervention, which is not always
possible in rehabilitation practice and research (Jahan & Ellibidy, 2017).
Health-Related Quality of Life Model (HRQoL)
The term “quality of life” has a variety of meanings, such as health status, physical
functioning, symptoms, psychosocial adjustment, well-being, life satisfaction and
happiness, which is why the term “health-related quality of life (HRQoL) was introduced to
make the definition more specific (Ferrans et al., 2005). This term was introduced to narrow
the focus to the effects of health, illness and treatment on quality of life.
HRQoL is a concept that includes measures of patient and social perspectives
regarding the impact of illness in order to improve treatment efficacy, safety and shared
decision-making (Ferrans et al., 2005). It focuses on the components of well-being, which are
affected by progressive changes in health status, health care and social support (Ferrans et al,
2005). There are three identified areas of consensus (Ojelabi, 2017). First, it is a
multidimensional construct encompassing symptoms of diseases, treatment side effects,
general perception of health status and life satisfaction; second, the assessment of it is
subjective based on self-report termed patient-reported outcomes; and third, research should
be based on conceptual models that would enhance the understandings of the relationships
and linkages among dimensions of HRQol, which in turn could facilitate the design of
protocols for optimal care. In the past 15 years, two conceptual models have been seen
frequently in literature, i.e., the Wilson and Cleary’s model and the revision of Wilson and
Cleary’s model by Ferrans and colleagues (Jahan & Ellibidy).
The Wilson and Clearly model is the most widely cited conceptual framework of
HRQoL (Bakas et al., 2012). The model focusses on relationships among different domains
of health by proposing a linear sequence of consequences of causal links along a pathway
which begins with the bio-physiological level, moving along the causal pathway outward to
the subjective level and the interaction of the individual as a social being (Ojelabi, 2017).
The model is categorised into five underlying health concepts and proposes specific causal
links between these health concepts. These five health concepts are biological and
physiological factors, symptoms status, functioning, general health perceptions and overall
quality of life.
The biological and physiological factors focus on the functioning of cells, organs and organ
systems, and the clinical factors include factors that generally affect health but are mediated
by changes in cells, organs or organ system functions. Next, in the continuum, is symptom
status which refers to a patient’s perception of an abnormal physical, emotional or cognitive
state. Next comes the ‘functional status’, which is reflected in the ability of the individual to
perform specific tasks such as climbing the stairs. Following this, is the ‘general health
perceptions’, which is a subjective rating that integrates all the previously mentioned health
concepts. And last comes the “overall or global health-related quality of life” at the end of the
continuum. Additionally, there are bidirectional arrows between the main domains that
indicate reciprocal relationships, and also point out that individual factors and environmental
factors could affect the overall HRQoL because they are related to the outcomes (Jahan &
Ellibidy, 2017).
The Wilson & Cleary model was further revised by Ferrans and colleagues (2005) in
which they added two well-defined domains: the individual and environmental
characteristics. They also deleted non-medical factors and the labels on the arrows.
Evidence-Based Approaches
Evidence-based practices are defined as a set of well-delineated interventions that
have demonstrated effectiveness in rigorous empirical research (Drake, et al., 2001).
According to Mueser, et al., (2003), six evidence-based practices have been highlighted by a
national consensus panel of leading mental health researchers, advocates and program
director. These are assertive community treatment, family psychoeducation, illness
management and recovery, integrated dual disorders treatment, medication management and
supported employment.
Assertive Community Treatment (ACT)
ACT is an intensive approach in which a group of professionals from various
disciplines such as psychiatry, nursing, vocational and substance use specialists work as a
team (Stein & Test, 1980). These professionals serve the clients on an individual basis, with
most contact occurring in consumers’ homes and neighbourhoods. Depending on the needs of
the clients, the teams help in activities such as budgeting money, shopping, finding housing,
and taking medication. ACT teams also attempt to anticipate crisis such as paying attention to
the warning signs of relapse. Clients are not discharged from ACT teams but continue to
receive services on a time-unlimited bases (Test, 1992).
Family Psychoeducation
The main goal of family psychoeducation is to provide information and support to
the families of persons with severe mental illnesses in order to optimize the outcomes
(Dixon, Adams & Lucksted, 2000). Family psychoeducation programs offer varying
combinations of information about mental illness, practical and emotional support, skill
developing in problem solving and crisis management (Dixon, Adams & Lucksted, 2000).
This may be conducted with individual families or multifamily group and may take place in
the home, in clinical settings or in other locations (Dixon, Adams & Lucksted, 2000). People
with schizophrenia living with family members who exhibit high levels of expressed
emotion (critical comment, hostility and overinvolvement) are more likely to relapse
(Scazufca & Kuipers, 1998), hence many family psychoeducation programs specifically
target only high expressed emotion families.
Illness Management and Recovery (IMR)
The Illness Management and Recovery (IMR) program was developed to teach people
how to cope with a severe psychiatric disorder such as schizophrenia more effectively, find
their own goals for recovery and make informed decisions about their treatment by teaching
them the necessary knowledge and skills (Gingerich & Mueser, 2010). Helping people with
schizophrenia and other serious mental illness learn how to manage their psychiatric
disorders more effectively, including reducing their susceptibility to relapses and improving
their ability to cope with symptoms, can improve their functioning and help them progress
towards recovery (Barber, 2012). The evidence-based components of IMR are
psychoeducation, behavioural tailoring for medication, relapse prevention training and coping
skills training (Mueser et al., 2002).
Integrated Dual Disorder Treatment (IDDT)
In the early 1980s, clinicians and researchers began to note that high rates of
substance abuse complicated the community adjustment of many people with severe mental
illness such as schizophrenia (Caton, 1981). Research has confirmed that comorbid substance
use disorder is associated with several medical or social complications such as relapse and
rehospitalisation (Haywood et al., 1995). In IDDT, the same clinicians or teams of clinicians
working in one setting provide psychiatric and substance abuse interventions in a coordinated
fashion. The critical factors of IDDT include assertive outreach, motivational interventions
and a comprehensive, long-term, stages and individualized approach to recovery (Drake, et
al., 2001). Contrary to traditional treatments for people with co-morbidities, the individual is
not pre-required to be abstinent for the assistance with consumer goals for stable housing or
meaningful activity such as employment.
Supported Employment
Supported employment emphasizes competitive employment rather than volunteer or
sheltered job settings, rapid search for a job, integration of mental health and vocational
services, attention to preferences of participants, and ongoing employment support (Becker &
Drake, 2003). As compared to traditional vocational rehabilitation services, many controlled
studies indicate that supported employment can increase the rate of competitive employment
with the help of supported employment (Bond, 2004; Mueser et al., 2004). The most
commonly implemented and studied model of supported employment is Individual
Placement and Support (IPS) in which participants are helped with a rapid job search by a
treatment team that unites mental health professionals with employment specialists (Becker
& Drake, 2003). This collaboration allows information about work problems, any unusual
stressors at work and symptoms in the workplace to be communicated by the employment
specialist to other treatment team members to allow psychiatric treatment to be tailored in
such a way that it optimizes work functioning (Nuechterlein et al., 2008). The level of
assistance in finding employment depends on the needs of the individual, and can range from
coaching a participant on how to apply for a job, to actually securing work on behalf of the
individual, and, with the participant’s permission, contacting the employer to provide
education about major mental illnesses and guidance in supervising such employees
(Nuechterlein et al., 2008).
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