Personal factors in rehabilitation
Personal factors (WHO ICF) are an invalid construct. They cannot exist separate from the person as independent influential factors. The person has characteristics, which vary according to the person’s role at the time.
The World Health Organisation’s International Classification of Impairment, Disability and Handicap, published in 1980, was an early interpretation of the biopsychosocial model of illness. It was soon criticised for overlooking the person and their environment. In the International Classification of Functioning, Disability and Health, published in 2000, the WHO introduced environmental and personal factors, which, in 2004, Peter Halligan and I translated into Physical, Social, and Personal contexts. The concept of personal factors and what they include has been researched without a clear answer. Given the central role of the person in all discussions of rehabilitation, I wish to explore the concept of personal context further. Given that the biopsychosocial model leads to a person-centred approach to rehabilitation assessment, I will use that framework. This post works through my analysis, and I conclude that personal context and personal factors complicate matters and are best replaced by talking about the person and their characteristics. This is introduced in the figure here; it shows how the person should be integrated into the biopsychosocial model of illness, the six main constructs that characterise a person, and how the person interacts with every part of the model, including over time.
Table of Contents
Introduction
“What is man, that thou art mindful of him?” This quotation from the King James version of David’s eighth Psalm asks the question of God, but it applies equally to each of us: who is that person when we think of them, and who are we when we think of ourselves? The psalm implies that, though man is an animal like others, there is an added extra that God sees. It asks what that extra is; David asks, how do you, God, describe a person?
When you ask a colleague to describe another person, you would be surprised if they quantified their physical characteristics such as height, weight, hair colour, chest circumference, etc. You expect a description of the person, such as their friendliness, interests, emotional characteristics, way of talking and walking, etc.
You are interested in their personality, but not in a psychometric sense. Some readers will have taken the Myers-Briggs personality test for management or leadership training. However, you would not expect your colleague to give you the person’s scores on that or any other test.
Understanding what we mean by a person is highly relevant to rehabilitation. We must agree on what characterises a person before judging whether we are person-centred or what aspects of the person we should consider. It also might help us understand a person’s response to their illness, for example, if their house or car is associated with how they see themselves.
In a document suggesting a common language for healthcare to use when classifying functioning, the World Health Organisation introduced ‘personal factors’. The intention was to develop a set of headings or domains covering aspects of a person that increased our understanding of a person’s functioning.
What are personal factors?
In its 2002 document, Towards a Common Language for Functioning, Disability and Health, the World Health Organisation (WHO) introduced environmental and personal factors into the biopsychosocial model of illness to help interpret and analyse recorded functioning.
Environmental factors were defined thus on page 10, “for example, social attitudes, architectural characteristics, legal and social structures, as well as climate, terrain and so forth.” The WHO have provided further details in their online International Classification of Functioning. Their idea of environmental factors is over-inclusive, mixing concepts, and Peter Halligan and I have separated social and physical contexts.
Personal factors included “gender, age, coping styles, social background, education, profession, past and current experience, overall behaviour pattern, character and other factors that influence how disability is experienced by the individual.” The WHO has not provided a comparable system for classifying personal factors. Some people have attempted a classification.
In 2012, Sabine Grotkamp and colleagues reviewed previous studies into the classification of personal factors. Most studies were centred on specific populations, for example, people with hearing impairment. Sabine Grotkamp et al. recruited many people with interests covering a range of situations and conditions and identified 72 potential factors. These were then developed into six chapters, groups that covered similar issues. A follow-up study in 2020 confirmed the basic structure, with a few minor changes in single items.
Group 1
The first group covered biological and demographic factors such as age, gender, and genetic factors, a more inclusive term in place of ethnicity.
Group 2
The second group covered physical and structural matters relating to the person’s physique. They also included measures of impairment or activity performance, but as these are already covered in the data collected in the International Classification of Functioning, this seems inappropriate.
Group 3
The third group was entitled mental factors. It encompassed personality and cognitive factors.
The range of personality characteristics included extraversion, emotionality and stability, reliability (dependability), openness and curiosity, friendliness and altruism, self-confidence, optimism, and “other specified or unspecified personality factors.”
The cognitive factors specified intelligence and memory but had a third category covering most other cognitive abilities. These are all measurable aspects of a person and are all described already in the classification of impairments.
Group 4
The fourth group considered attitudes, basic skills, and behaviour patterns. Each of these was further sub-classified.
The attitudes mentioned included a person’s worldview (philosophy, religion, etc.) and attitudes towards work, health, treatments, and the social environment. Within attitudes, they included life satisfaction. This is misplaced; life satisfaction is an outcome, not a factor influencing functioning.
The basic skills mentioned included social skills, the ability to use digital media, and the ability to plan and carry through actions. These are all measurable activities that are or should be in the International Classification of Functioning. Skills such as problem-solving and self-evaluation are on the borderline between measurable impairment and personal characteristics.
Behaviour patterns are a fascinating inclusion. They refer to habits and how someone behaves rather than their behaviour on a particular occasion. The list given covers diet, use of legal drugs (coffee, alcohol), exercise, daily routines, and handling of money. Some of these are closely allied to attitudes.
Group 5
Group five covers social, economic, and cultural items. The first subgroup considers employment, accommodation, finances and who lives in the same accommodation; these are all objective matters included in other parts of the classification of functioning. The other subgroup refers to a person’s status in various settings or aspects, such as education or social class.
Group 6
This covers ‘other health issues’, already classified in the International Classifications of Diseases or Functioning.
Comment on this classification.
The study is helpful and is the only systematic attempt to cover all personal factors in the international classification of functioning (ICF). Its weakness is the lack of distinction between data that appertain to the individual, such as their strength, gender, or financial reserves and information that appertains to them as a person. An individual’s strength undoubtedly determines many functional abilities and is thus a relevant personal factor, but it is not an aspect of the person independent of bodily structure and function.
A hidden value of this study is that it forces one to consider what a personal factor means. To be valid, a personal factor must refer to a characteristic of the person not already covered by other parts of the ICF analytic framework. Most personal factors will refer to phenomena that extend across a continuum, vary from time to time in an individual, and have a pervasive general influence across many activities and over long periods.
Items in the first group, demographic material, are external descriptors and are not directly an aspect of the person. The person may ‘act their age’, but this is an attitude, not a demographic.
Although the objective measure of a person’s physique is not a relevant personal factor, the second group highlights the importance of how someone looks to others and how the person wants to be seen by others. Any discussion about a person should consider their appearance. For example, we can describe facial characteristics such as facial paralysis or birthmarks, but from the person’s perspective, we need to know how they perceive it; do they ignore it, forget it, or include it in how they present themselves?
The third group covers many central personal characteristics that one would use when describing other people. Identifying and distinguishing aspects of a personality is impossible; their list is as good as any other.
However, the group also covers measurable neuropsychological parameters. While we might legitimately describe someone as forgetful, bright, or easily distracted as a characteristic of their behaviour, we must avoid presenting them as measured neuropsychological phenomena.
The attitudes in the fourth group cover most of the remaining central personal characteristics used when describing someone else. The way someone undertakes activities is an aspect of them as a person. We are not commenting on the outcome so much as making a qualitative statement about how this person undertakes it.
The last two groups are repetitions of items that are or should be included in a more objective (i.e. externally verifiable) description.
What is personal identity?
John Drummond suggests there are two aspects to this question. Self-identity concerns the relationship between a person now and in their past; it concerns narrative identity and the persistence of a person.
Personal identity, he argues, concerns the question, who am I? He argues that this requires a description of the person now, describing the content of that person’s being. In a sentence, he considers “A person as a centre of conscious decision-making is an embodied, social and historical, practical, and reflection-capable minded entity.” Much of John Drummond’s complex argument highlights the influence of others on a person’s identity.
David Carr suggests that “Personal identity is social identity.” He argues that consciousness is equated to an experiential self and depends upon the unification of all experiences at the moment; I have explained this in a post on consciousness, cause and effect.
He then argues that, as a conscious being in a social setting with a social role, our behaviour is influenced by personal factors relating to the situation. The person in the situation has an identity that “… is inherently temporal, but not in the sense of temporal persistence but of temporal coherence of past, present and future.” One implication he explores is the challenges that might arise when one is in a situation where one has two roles associated with contrasting unique identities.
In a further development, David Carr argues that people can have a shared identity when two or more people share an activity in space and in time (i.e. face-to-face). This can lead to internal conflict. For example, I live and work in Oxford but spent some years at Cambridge University. When the Oxford – Cambridge boat race occurs, I could have split loyalties; do I support my University (Cambridge) or my home (Oxford)?
He ends his fascinating paper by saying, “What is clear in any case is that our personal identity is not something that exists independently of our social interactions and commitments. Our social world gives us our identity, or it is that world from which we choose our identity. Personal identity is social identity.”
Frederick White considers personhood “An essential characteristic of the human species.” He asks what makes a human being human and what defines a human being as a person.
His essay discusses the religious and biological aspects of personhood. Although he accepts competing philosophical and religious arguments, he says, “It is thus proper to assert that nature evidences human personhood as not only distinct within the natural order, but also intrinsic to human life.” He concludes, “… personhood is an essential characteristic of the human species, and is not a conditional state dependent upon circumstance, perception, cognition, or societal dictum.”.
You must judge whether personhood is something humans have uniquely, not associated with the biological structure (i.e. given by God) or whether it arises from our biological structures as an associated, emergent property.
A broader discussion of the concept of personhood separates various aspects:
- Moral, recognising that humans are moral agents and their behaviour can be considered as moral or immoral
- Metaphysical, concerned with the characteristics that confer personhood, such as use of language or consciousness
- Physical, which is a concern only if one believes in the separation of mind from body, that there is some soul independent of the body
- Legal, refers to legal entities such as a corporation, a group of individuals treated as a single individual in law.
- Human beings, where often the terms human, human being, and person are used interchangeably.
- Quantification: is personhood variable between people and over time, or is it intrinsic to being a human being?
Personal factors; a synthesis
In rehabilitation, we must consider how the person perceives or evaluates phenomena. For example, we may discount a slight limp if it does not alter safety, speed, or endurance. Still, the individual may not go outside, feeling that a limp identifies him as “a spastic”. We may suggest a cosmetic treatment for longstanding facial blemishes. Still, the person may feel the blemish is integral to him, and that loss would somehow reduce him.
We are interested in the person’s characteristics that describe, influence, or explain observed behaviours, where we look at general behaviour patterns. Can we identify something that will predict future behaviour? These characteristics will be constructs derived from behaviours. I will consider some.
Personality traits.
A trait is the likelihood of behaving in a certain way in a particular situation. They manifest as characteristic behavioural patterns in response to certain stimuli or, conversely, a train is deduced from observing the same behaviours in the same situations. There are five recognised traits: extraversion, agreeableness, openness, conscientiousness, and neuroticism. But this is not an exclusive list, and the work by Sabine Grotkamp et al. has identified others, such as emotional stability.
These are likely predictors of and explanations of behavioural responses, potentially useful to others but not a part of the patient’s perception.
Attitude.
An attitude is a general predisposition to consider something in a certain way. An attitude may be held on most matters. One may be bored by something, and if that thing comes up, you are unlikely to be interested, but there may be exceptions, when you will be interested.
These are likely predictors of and explanations of behavioural responses, potentially useful to others but not a part of the patient’s perception.
Behavioural characteristics.
As I have emphasised, there are behaviours which we may use to describe someone and that the person may feel is an integral part of who they are. Sometimes, if the behaviour is longstanding, the person may feel it is part of their identity; in contrast, they may feel a recently acquired behaviour identifies them as different and no longer the same person, and they dislike the behaviour.
These are descriptive, allowing others to distinguish the person from others. The person may attach significance to them as something that identifies them, whether positive or negative. Some behaviours are used to stigmatise people.
Bodily characteristics.
This is mentioned by Sabine Grotkamp et al., but they do not emphasise the vital aspect of this characteristic, which is the salience of the characteristic to the person. An external observer can never judge this; what may be small or barely discerned by another person may loom large for the person with it. The opposite can also be true.
If externally discernible, these can be descriptive; most people attach considerable significance to how they look. Others often use bodily characteristics to stigmatise a person.
Beliefs.
One influential personal factor is completely missing from Sabine Grotkamp’s paper: a person’s beliefs, which include expectations. This is a surprising omission. Two rehabilitation interventions focus on this personal factor. Cognitive Behavioural Therapy targets incorrect beliefs and is beneficial. Education targets wrong expectations and can also be helpful.
These are entirely internal to the person; we can only describe them if the person discloses the belief.
Narrative identity.
This personal factor was not within the factors Sabine Grotkamp and colleagues identified, yet it is a crucial part of everyone. One of the central features of most philosophical discussions about personal identity is a discussion about memory and its contribution to a person’s identity. We use our memory of events to construct an image of who we are. We also use that constructed image to help decide on actions now.
This factor is entirely within the person. Even if we know much about a person’s past, we can never see the salience of parts of the story; only the person can attribute (or not attribute) significance to an event.
Personal factors in rehabilitation.
We should replace ‘personal factors’ with ‘the person’.
By referring to personal factors as a specific item, we imply external personal factors influence a separate person. This is an example of a mereological fallacy where something is attributed to a part of the whole when it is integral to the whole. We will have described the person if we list all the relevant personal factors.
Next, we must recognise that the person is fully integrated into the biopsychosocial model. Without a social context, there can be no person because, to be a person, there has to be another person able to interact and experience the presence of the first.
The person is coterminous with the whole body and is not located anywhere. Loss or alteration of a body part may influence the person; for example, removal of ovaries, a breast, or a leg can hugely change a person. For some people, loss of hair causes a significant change.
The figure below represents one way to consider a person within the biopsychosocial model of illness. Although centred within the body, aspects of the person extend through the social and physical context, and those contexts influence the person. As in all other parts of a complex system, there are bidirectional relationships between items. The figure shows that the person must be considered in every part of our practice.
Conclusion
This discussion about the personal factors introduced by the World Health Organisation in 2002 and developed into the personal context in 2004 shows that personal factors are invalid. Personal factors are no more or less than the person, and referring to it by another name suggests that personal factors may influence the person, a logical inconsistency. Instead, one may describe or characterise a person. This will be based on a person’s behaviours, and all these descriptions arise from interactions between the person and others. Therefore, the person’s characteristics will likely vary according to the situation and the role or roles the person has at the time.
