Rehabilitation and education; a useful analogy?
About 15 years ago, at a meeting in Bath of the Society for Research in Rehabilitation, I proposed in a lecture that rehabilitation was analogous to education. I have used the analogy for years and wrote a brief page about it on this site, which has now been removed. This page is a more detailed explanation aimed at everyone: the public, patients, healthcare professionals, and rehabilitation specialists. The analogy is helpful for several reasons. Education of patients, families, carers and others is a significant part of rehabilitation work. It is immediately understood by anyone, especially managers and commissioners, and the analogy may persuade people to appreciate that rehabilitation is a flexible and adaptive process, not a fixed programme. It may also give rehabilitation professionals a different insight into their work; that was the feedback I received after my talk.
Table of Contents
Introduction
Is suggesting rehabilitation is like education a valid analogy? Analogies are powerful ways to explain something. They use something people are familiar with, and showing similarities can rapidly increase understanding, provided the two are alike. This page explores the parallels between education and rehabilitation, reviews similarities and what is not similar, and discusses what we can learn from the comparison. Other people have made the comparison, albeit not specifically about healthcare rehabilitation.
Lorraine Higgins explored the relationship between education and rehabilitation in a prison context. She wrote: “This article suggests … it could be said that: the way prison
rehabilitation is conceived and how the person in prison is perceived are two sides of the same coin. Consequently, education and rehabilitation efforts may be seen as compatible endeavours when they adopt an approach that prioritises the person and not the ‘offender’”
Interestingly, she characterises medical rehabilitation as top-down and directive, saying, “While authoritative forms of rehabilitation often focus on fixing the person and/or making them ‘fit back in’, liberty-centred models of adult education and rehabilitation provides the person in prison with the opportunity to express themselves, to question and to disagree.”
Cormac Behan (University of Sheffield, UK), in an article entitled Learning to Escape: Prison Education, Rehabilitation and the Potential for Transformation compares the Irish approach to prison rehabilitation to the English approach. The article “considers whether the potential for personal change and transformation in penal environments is possible through an adult educational approach that distinguishes itself from the disciplinary goals of the institution and the correctional objectives of authoritarian rehabilitation.”
He describes prison education using words and concepts that would apply well to healthcare rehabilitation and concludes (about the English system) that education may replace authoritarian rehabilitation.
In other words, for political reasons, prison rehabilitation has moved to a punitive and dictatorial approach that does not try to reintegrate the person back into society. The reaction has been to replace rehabilitation with an educational approach that mirrors healthcare rehabilitation.
The similarity is worth exploring.
Rehabilitation and education compared
I will first consider aspects of the two processes to see what similarities may exist, as shown in the table below. Each row considers an aspect of the services, identified with a central heading, and the educational and rehabilitation components on the left and right, respectively. The word subject is used for the people receiving education or rehabilitation.
Education
Rehabilitation
The subjects (recipients)
In educational settings, the subjects are called pupils in the early stages but later may be called students or trainees. At university, they may be called undergraduates.
In healthcare, we generally refer to patients and occasionally to clients. In care homes, the term residents is typically used. Sometimes, we refer to “people with ….”.
Location/setting.
Teaching typically occurs in classrooms in schools and lecture theatres in colleges and universities. However, some learning happens in other settings, such as trips to museums or to see geographical or other places. Rarely will a professional teach at home; sometimes, education (training) in a vocational skill takes place on the job. Schools or colleges usually have public meeting places like playgrounds or canteens that pupils use. They may also have specific shared educational spaces, especially libraries.
For hospital inpatients and care home residents, rehabilitation typically occurs on the ward or in therapy settings such as gyms or treatment kitchens. For patients at home, it usually occurs in an outpatient department but may also occur at home; visits to a workplace are rare. Patients may be taken out into the community as part of their assessment or treatment. Hospitals may have extensive shared spaces like corridors, stairs, shops and lifts, all open to patients and sometimes specifically used for planned rehabilitation activities.
Specialisation
There is a steady change in specialisation in the educational sector from primary schools to university postgraduate departments; the change is primarily in the scope of topics a teacher, school, or department will cover. It is crucial to note that the level of professional expertise associated with each level is high. I doubt that a university lecturer in the history of the early Middle Ages could teach in a primary school any more than a primary school teacher could teach the history of the Middle Ages.
There is also a steady change in specialisation in rehabilitation, from services with expertise in specific conditions or interventions, often in hospital wards or outpatient departments, to services providing longer-term rehabilitation in the community, focusing on better integration into the person’s culture and locality. Again, the professionals all have different types of expertise. The degree of expertise is comparable, and people working in one setting can rarely transfer to another area with some retraining.
Independent learning
From an early age, pupils are given work to do at home, with support from parents in the early stages. As they grow older, the proportion of self-directed learning increases, including through university, if attended.
One of the central features of effective rehabilitation is teaching the patient self-management, often including goal-setting techniques. Second, and equally important, patients must practice the activities they are learning or relearning from the outset. The total time with team members is small, and success is closely linked to the amount of self-directed practice undertaken.
Life-long learning.
In the educational sphere, self-directed learning continues indefinitely in many jobs. For professions, this is typically called Continuous Professional Development. People are expected to need refresher teaching or teaching of new techniques throughout their careers. Resources are routinely set aside to meet this requirement.
The contrast with rehabilitation is stark. Specialist rehabilitation input – reassessment, refreshing plans, teaching new activities, etc.- is notable by its absence because funders will not fund it. Given that life expectancy is often only minimally shortened, the person’s clinical situation may change, and new interventions are developed, it is depressing that lifelong learning is not supported.
Annual review
People who continue to learn and receive educational support often have an annual appraisal that reviews their performance and areas requiring further academic attention. Objectives are set and monitored annually. This system ensures continuing performance improvement and that someone maintains acquired expertise.
People who have had an episode of rehabilitation typically do not have a formal review of their progress or change (in progressive disorders); at most, they may be checked medically and their care needs reviewed, but they never have a review of their rehabilitation needs, nor are they offered further rehabilitation input.
System goals
Education aims to prepare subjects for living independently in society, earning a living, contributing socially, and developing social networks. The education gives them generic knowledge and skills that are adjusted to a small degree to suit their culture and interests. Educational organisations may advise their pupils or students on the available careers. This should be based on understanding the student’s interests, strengths, and weaknesses and what is available regarding jobs and further education.
Educational goals are rarely negotiated with the pupil, mainly concerning their ability to manage when leaving education.
The rehabilitation team or service may have some goals related to the service, but their practical goals are specific to the person. In principle, rehabilitation should establish a person’s interests, values, aspirations, expectations, etc, at an early stage. All lower-level goals and all learning should enable the person to continue striving towards their primary goals. This contrasts significantly with education. The practice differs because (a) the commissioning imperative is towards reducing care needs, not increasing quality of life, and (b) many actions needed to achieve the goals are outside rehabilitation’s influence.
Rehabilitation and education: similarities
Teaching and learning are crucial in education and rehabilitation. Both have the person’s learning new knowledge and skills as their central activity. Research into any aspect of learning will be relevant and applicable to both enterprises.
Thus, both take a similar approach to transferring responsibility from the teacher to the learner. Learning independently is essential in education and rehabilitation, although this goal is rarely articulated explicitly in either service. Practice through repetition is also vital in both services.
The relationship and role of professionals change with time. Initially, the professional is the person with expert knowledge and is the primary source of learning for the subject (patient, pupil). The professional assesses the subject’s strengths and weaknesses and tailors their input to the person’s situation. Over time – years for teachers and days or weeks in rehabilitation – the professional moves from direct teaching or training to an indirect role of reassessing, giving advice with some direct teaching, and being available for the subject when needed.
The interventions in both services must be tailored initially to the subject’s identified needs and, later, to the person’s values and goals.
Rehabilitation and education: differences.
The differences fall into two categories. One set is primarily related to resources, and the other arises from different starting points.
Starting points
Everyone needs education. Children must learn as they grow and mature. Much of this learning is adaptation to changes in body and social status. Much learning occurs naturally from family, friends, and others as part of life. Formal educational resources should be unnecessary for many basic social and personal skills. Still, preschool and primary schools now must teach essential matters such as toileting, talking, and social interaction.
The primary role of education is to transfer a large volume of factual knowledge and skills that will facilitate the person’s functioning in society when they mature and enter society away from their family. A significant secondary aim concerns culture, which is vital to social functioning but quite fluid and forever changing – which underlies some of the political arguments about education.
Given the vast numbers of children and young adults passing through education, it is inevitable and appropriate that education is delivered to groups with only small amounts of personal teaching. It is also suitable to have relatively uniform teaching programmes, increasingly selecting people appropriate to the programme as pupils start following their interests.
Rehabilitation, in contrast, receives patients one at a time, each quite different in terms of their pattern of losses and circumstances. Therefore, much more attention is needed initially on assessment, formulation, and planning interventions. Furthermore, in the early stages, group treatments are inappropriate.
However, over time, patients join many others with similar residual problems, and occasionally, it may be possible to arrange groups, although their size will be small, and the variation may still be too great to allow groups to succeed.
Goals.
A second difference concerns goals. Most education aims to prepare people to live independently in society. The preparation is adjusted by factors such as a child’s natural abilities and wishes and social circumstances, but the goals are reasonably generic.
In contrast, excepting some paediatric rehabilitation where educational goals will also appertain, rehabilitation goals are centred on the person’s expectations, wishes, values, and goals. Limitations imposed by the conditions may necessarily modify them, but they are still person-centred.
Range of interventions.
Education is solely focused on learning so that the child can become independent within society. It is affected by external factors, especially poverty and other social deprivation. However, it is not responsible for identifying and managing any factors affecting education. For example, if a child has a health condition affecting education, the rehabilitation services will be involved.
In contrast, rehabilitation takes a holistic, person-centred approach based on the biopsychosocial model of illness. It will not only identify external factors affecting the situation; it will expect to alter them directly or by appropriate referral. This is not to say that education is not holistic and aware of external factors affecting a child’s education. It usually is. However, it is not expected to influence these factors, whereas rehabilitation is.
Rehabilitation plays a significant role in altering a person’s environment, including equipment and other aids. This requires assessment to decide on their need, acquisition, provision and teaching of their use. It also involves referrals to and liaison with many other organisations, usually outside healthcare.
Other roles include symptom management, disease diagnosis and management, psychosocial interventions, etc.
Resources
The other significant difference is in resources. Although educational resources have been cut significantly over in the UK, they still exist. In contrast, rehabilitation resources are minimal and are not increasing despite widely acknowledged needs and evidence of cost-effectiveness.
The lack of resources, coupled with a widespread misunderstanding of rehabilitation, leads to differences in delivery. Rehabilitation is considered in short timeframes; it is a one-off episode, and ongoing support and the ability to have further episodes are notable by their absence.
Conclusion
Education is a helpful analogy. The involvement of education in many people’s lives, used to help them adapt to, for example, losing a job or being asked to take on a new role, mirrors the role rehabilitation has in facilitating adaptation to changes arising from an illness. Moreover, the regular appraisals leading to education through continuing professional development is a model that should be accepted for people with a persisting disability; whenever circumstances change, a formal rehabilitation review (appraisal) should occur with further input if needed.
The analogy might benefit people outside healthcare, such as commissioners and policymakers. As professionals, they will acknowledge the essential nature of appraisal and further learning or training when needed. They should understand that a single episode of rehabilitation should not be considered the end of rehabilitation, just as leaving university is not the end of education. They should also understand that the length of rehabilitation should be adjusted according to a person’s needs and that the nature of rehabilitation will change over time.
The analogy might also help patients and families understand that rehabilitation requires their involvement and that they must learn actively through practice. Although some people undoubtedly consider education a passive activity of little value, more will appreciate its value and see the parallels.
However, the limitations discussed above must also be recognised. The analogy may be helpful, but it is imperfect and sufficient to learn from but not a substitute for understanding rehabilitation. In particular, education does not have a holistic approach in that it may recognise external factors as relevant, but it does not address the issues. Second, rehabilitation is uniquely person-centred, whereas education acknowledges individual differences but does not tailor its actions for most people.
