Understanding rehabilitation
Saying that someone understands rehabilitation implies that a person appreciates and accepts the goals and processes of rehabilitation and their role in the endeavour. This page discusses rehabilitation from the perspective of people outside the rehabilitation team. Two obstacles make this a challenging task. Members of the rehabilitation team may not have a shared understanding, and some members of the worldwide rehabilitation community certainly disagree. Little research investigates the knowledge of rehabilitation among patients, other specialities, or the public. Julie Pryor and Beverly O’Connell found significant incongruence in understanding between nurses and patients in an inpatient service. I will speculate on some likely misunderstandings and explain rehabilitation from my perspective, drawing on work I have published, especially the General Theory of Rehabilitation, an empirical investigation into rehabilitation, and the biopsychosocial model of illness. [All are openly accessible, and I will also link to pages on this site later.]
Table of Contents
Introduction: why understanding rehabilitation matters
A profession is defined by its members’ knowledge and skills. However, its clients lack this expertise, which immediately disadvantages users because they need help understanding what is being done or why. Professionals working in groups, teams, or services rapidly forget that outsiders do not know what they do because most people they interact with share the same language and culture.
Several adverse consequences arise. There is an obvious imbalance in power, which risks, for example, a paternalistic approach. Professionals usually develop a jargon where unusual words are used, or words acquire additional specific meanings. For example, therapists often refer to an upper limb (the arm or, sometimes, the hand) or dual-tasking, meaning doing two things simultaneously. This leads to poor communication and misunderstanding.
Third, the client may not recognise how crucial a specific piece of information is. For example, a patient may not tell a professional about a skin rash developing after starting a drug, or a taxpayer may not mention the sale of a good which has increased in value and is subject to capital gains tax. They may not generally appreciate their role in rehabilitation, considering they are passive recipients rather than active participants.
These problems affect all interactions between professionals and their clients. Patients need to understand their role in rehabilitation because it requires engagement and action. A good understanding requires knowledge of its goals and how these are achieved.
Common misunderstandings.
People have internal models of health that guide their response to illness and what they expect of healthcare. I discuss models of healthcare in detail elsewhere. The dominant healthcare model in developed countries, and increasingly so in all countries, is the biomedical model, also known as the medical model. It is part of the culture, not considered or discussed.
When someone considers rehabilitation, they will naturally continue to use the biomedical model to frame their expectations. This leads to a series of serious misunderstandings, which I will discuss.
Rehabilitation is therapy.
Most people consider rehabilitation to be therapy, such as physiotherapy. They believe that therapy is rehabilitation and that there is nothing more. In addition, most people interpret therapy as having face-to-face interaction with a therapist and, usually, the therapist doing something to the patient.
This understanding needs to be corrected. A few minutes of thought show why. A therapist knows many treatments he can offer and will need to discover which ones are appropriate for his patient. Thus, he must first assess the person to find her problems, factors influencing the treatment, and her wishes and expectations. He should also evaluate how effective the chosen therapy is.
If, as is likely, other people are involved with the patient, he will need to liaise with them to agree on a common approach. She might also require adaptations at home, more care, or special equipment. The therapist will undertake many other activities on behalf of his patient, such as referring to Social Services, identifying a patient support group, and explaining how she can help herself.
This makes it evident that rehabilitation is not just therapy and that therapy is only a part of rehabilitation.
Rehabilitation is a treatment.
A closely related misunderstanding is that rehabilitation is equivalent to other healthcare interventions, such as giving a drug or doing an operation.
Patients and their families often view rehabilitation as they would view admission to a hospital for a course of chemotherapy or treatment after trauma. Rehabilitation is something that will be given to them to improve them. Frequently, they may expect it to be curative, returning them to their previous state. They will usually consider it a dose, with more being better.
Unfortunately, commissioners (people who purchase rehabilitation in the UK National Health Service) also consider rehabilitation treatment with a fixed ‘dose’. For example, they may buy 12 weeks for a patient without any thought about what might be included, whether 12 weeks is more than needed, etc. Similarly, contracts for early supported discharge frequently limit it to eight or twelve weeks.
No one would consider or purchase surgery or intensive care or chemotherapy and radiotherapy in that way. Imagine only paying for ten weeks of chemotherapy when the person needed 14 weeks or suggesting that someone should leave intensive care after six days, whatever the situation.
Rehabilitation is not a treatment but undoubtedly includes many treatments (activities that lead to sustained patient benefit). Measuring it in terms of the length of a spell, the frequency of contact, or the time spent in ‘hands-on face-to-face’ contact is simply invalid.
Rehabilitation is only for ….
When I started working in rehabilitation, the generally accepted wisdom was that rehabilitation only applied to people aged 16-65 years with conditions where improvement was expected. People aged 66 years were excluded, patients with almost all progressive disorders were excluded, and anyone with a congenital condition such as cerebral palsy was excluded. The only notable exceptions to these rules were people with traumatic spinal cord injury or amputation.
Unfortunately, there are still some people who do not consider rehabilitation services should be involved with, for example, people:
- who have problems with substance abuse, including alcohol
- diagnosed as having a learning disability
- with functional disorders, though this is changing rapidly
- who have hearing or visual disorders
- who are considered frail (despite the uncertainty about that diagnosis)
Last, some people suggest one can assess who will benefit and thus select who should receive input from a rehabilitation service, much as one might select someone with multiple sclerosis for treatment using a disease-modifying drug. As I have explained, this is impossible, and the concept of a person’s rehabilitation potential is flawed.
The evidence shows that anyone with a significant persisting disability may benefit from rehabilitation and that there are no valid, evidence-based ways of selecting people who will benefit more or less than others.
Rehabilitation is non-specialist.
Many healthcare professionals, managers, policy-makers, and commissioners also misunderstand because they believe that anyone can ‘do rehabilitation’ and does not require specialised training. This is a convenient belief because it enables politicians to restrict funding.
Several incorrect ideas lead to this belief. Equating rehabilitation with therapy leads to the conclusion that one only requires many rehabilitation assistants who can encourage patients in activities. This overlooks the substantial number of activities therapists undertake leading to a particular therapeutic activity and the need to evaluate and adjust therapy.
Another false belief is that analysing the problem is simple. Rehabilitation analysis leading to a formulation and a plan is just as complex as any other medical situation; it is probably more complicated given the number of interacting variables involved.
Third, many people, even among rehabilitation professionals, believe that doctors, psychologists, engineers, or other professions are not needed. Again, this belief is false. Every patient has a medical condition, and a doctor who knows about the disease and can relate it to rehabilitation will always be essential. Other professions will be crucial, depending on the caseload. Engineers, for example, will be needed in any service providing specialist equipment.
These misunderstandings follow from using the wrong framework and the wrong conceptual model. A rough analogy is to consider a car that is not working, for example, failing to start or run smoothly.
If the person had only ever driven a petrol-engine car, they would approach the problem on that basis. They would thus consider spark plugs, distributors, carburettors, etc. If the car were a diesel car, they would fail because their conceptual framework for analysis was wrong. Moreover, if they concluded that the vehicle was out of fuel, they might put petrol into a diesel tank, causing significant additional problems. And if the car were electric, they would have even more difficulty.
I will now consider what rehabilitation is, explaining its different perspectives.
Rehabilitation is person-centred.
All healthcare claims to be patient-centred; undoubtedly, most services are or try to be. Rehabilitation differs in two ways. Its activities are centred on a patient’s disabilities, not their diseases. Its goals are related to the person as a social being, not the patient as a body with a disease.
Being person-centred means the patient judges success according to their goals, priorities, wishes, etc. I will expand on the difference and how it arises.
Biomedical health care.
The biomedical approach (the medical model) used by most healthcare services considers the patient to have a diseased body or mind with some abnormality of structure or function within the whole. Its goal is to identify the abnormal part, understand the nature and cause of the abnormality, and remove, reverse, or at least control the abnormality. This abnormality is the disease diagnosis, and treatments are focused on the disease.
One crucial aspect of this approach is that the abnormality is placed within the body. The approach acknowledges that external factors may be the cause. For example, radiation exposure may cause cells to become cancerous, or a pneumococcus bacterium may enter the body to cause meningitis. However, once started, the patient’s illness is entirely attributable to bodily abnormalities, and external factors are irrelevant.
This approach explains the frequent statements that a person ‘no longer needs hospital care’ when they are patently unable to return to living as they used to because they have ongoing problems such as marked pain, confusion, breathlessness, an inability to walk, or any other disability.
Thus, biomedical healthcare is entirely disease-oriented. All efforts aim to diagnose and treat the disease, and success is judged by how well it is achieved. Naturally, staff treat the patient respectfully and consider their wishes, but only insofar as they affect the diagnosis and treatment.
Biopsychosocial health care.
As its name implies, the biopsychosocial approach (the biopsychosocial model) considers a person’s illness holistically, considering biological, social, and psychological factors equally; in contrast, the biomedical approach only considers the biological aspects. This approach is central to rehabilitation. It is also used, to a variable extent, in other specialities such as psychiatry (where it originated), learning disability, palliative care, and geriatrics. This approach underlies two significant features of rehabilitation: uncertainty and multiprofessional teamwork.
The analytic framework is complex in a mathematical sense, but complexity is more than being complicated. Complexity arises from multiple bidirectional interactions between factors, which leads to non-linear effects and unpredictable consequences when altering a factor. Thus, the effects of treatment are often unpredictable, and uncertainty affects all aspects of rehabilitation.
Second, a multiprofessional team (the multidisciplinary team) is vital because one may need to undertake a broad assessment and offer a range of interventions. A complete analysis and formulation are essential to ensure that an important factor is not overlooked and to deliver the required wide range of tailored actions.
Disability-focussed, not disease-focussed.
Although being person-centred prioritises their social and high-level goals, often related to Maslow’s five needs, these all require and depend on the person’s abilities in various activities. Activities are behaviours. When an activity is limited as part of an illness, it is usually called a disability.
Thus, rehabilitation focuses on activities to achieve the patient’s personal goals; it is disability-focused. The typical starting point of any assessment is to identify the patient’s disabilities, how they arise, and, more relevantly, how they may be lessened. Often, interventions will alter the environment.
From a patient’s perspective, this approach differs from biomedical services, and it initially seems positive.
However, the assessment primarily discovers what a patient cannot do, what skills they have lost, what aspects of their house are problematic, what expectations are unachievable in the medium term, and so on. Unsurprisingly, rehabilitation assessment and formulation are perceived as unfavourable and emphasise the patient’s negative aspects.
It would also be better to record formally what someone can do, how well, and what their strengths are for several reasons. The obvious one is that it is less depressing for the patient. It acts as a baseline against which change can be measured. The strengths may suggest ways to improve some activities or suggest alternative activities and goals.
Social goals, not sickness goals.
Last, rehabilitation explicitly aims at higher-level goals, whereas biomedical healthcare’s goals are related to sickness and the immediate consequences of disease.
High-level goals are challenging to define and classify. One characterisation suggested to me by Nils Richardson is that high-level goals can never be achieved. For example, some people wish to reduce social inequality; perfect social equality is unattainable.
Maslow’s hierarchy of needs is one helpful way to consider higher-level goals. Although now eighty years old, they have continued to be used and have evidence to support them. There are other ways. The essential features of these goals are that they are:
- long-term, usually set in the indefinite future
- personal to the individual, even if the general domain is typical of many people
- oriented around social roles, interactions, or outcomes
These features contrast greatly with biomedical healthcare, the model typically used by patients and the public. Indeed, most rehabilitation professionals constantly and inevitably rely on the biomedical model, which is deeply ingrained in our culture.
Rehabilitation is a process.
This is the last overarching feature to consider on the page. I have already stressed that rehabilitation is not a treatment. It is a problem-solving process. One can analogise this to biomedical healthcare. Biomedical healthcare starts with a person’s symptoms, identifies the disease, and treats it as far as possible. Biopsychosocial healthcare begins with a person’s disabilities, identifies the many factors that impact them, and, with multiple interventions, optimises the person’s well-being as far as possible.
Resources needed.
The central resource needed is a multiprofessional team, sometimes called a multidisciplinary team (MDT). However, multi-professional is more accurate because it emphasises the vital need for different professions.
The team’s features are that it:
- has expertise in rehabilitation and the clinical work it does (e.g. neurological disorders, provision of specialised equipment, etc.)
- undertakes ongoing, regular, multiprofessional education and training
- has regular meetings as a group to discuss:
- individual patients
- all cases
- procedures
- further developments and improvements
- the goals of the team
- has a team office or space to meet
- is financed and managed as a unit rather than being a collection of people who happen to work together
All other resources depend on the team’s caseload and setting. They need the equipment and space to carry out their work, administrative support, etc.
Process – theories used.
The process is a problem-solving process, which is common in all healthcare. It will be discussed on other pages.
However, the process must be undertaken within an appropriate intellectual (conceptual) framework. Three will be mentioned here, expanded on in other sections of this site, and covered in different pages in this section.
The first is the biopsychosocial model of illness, already discussed; a second page on this site considers its validity – is it correct, and what are the criticisms and weaknesses?
The second is the General Theory of Rehabilitation. This theory sets rehabilitation in the context of the person. It starts by considering what happens when someone develops an illness and then discusses how rehabilitation is the person’s natural response, adaptation. The central role of rehabilitation is to facilitate a person’s adaptation. This is discussed elsewhere and will be considered from the perspective of the person and society on other pages in this section.
The third will be unique to this section. I will compare rehabilitation to education, showing that they are essentially the same, with a different focus.
The rehabilitation process is complex and will not be considered further on this page. Aspects of it are discussed widely across the site and will be covered in later pages in this section.
Conclusion
This page has outlined the main features of rehabilitation, contrasting them to several widespread misconceptions which arise from the universal use of a biomedical model of illness and healthcare. I have stressed the differences, but they are not contradictory. Instead, the biomedical and biopsychosocial approaches are complementary. Rehabilitation must always consider a person’s diseases because they affect prognosis and indicate likely problems; also, they are often curable, avoiding the need for much rehabilitation. Biomedical healthcare needs rehabilitation because many patients have persistent losses secondary to the necessary disease treatment, from irreversible loss despite an eventual cure or secondary to persisting incurable disease. I have suggested that rehabilitation facilitates a patient’s adaptation to their losses or, at times, full recovery from them and that the process is analogous to education.
