Recently, I discussed my General Theory of Rehabilitation with Peter Halligan, friend and co-author of The biopsychosocial model of illness; a model whose time has come. We considered the idea of no rehabilitation, and he pointed out that it was equally difficult to define no education. We went on to discuss how analysing life through the lens of the holistic biopsychosocial model of health placed rehabilitation, education, healthcare and many other matters in a broader context, highlighting their conceptual similarity. This post is an initial outline of ideas I hope to explore more fully in future.
The core concept is that as we grow, develop, and participate in society, our experiences lead to learning and change. At all times, we learn and are guided by the people around us: parents, family, friends, or strangers. In addition, we receive or seek help with learning and adapting, such as through formal education, advice from others, and, if unwell, from healthcare services. In almost every situation, we learn from many aspects; for example, in education, we learn our most important lessons from other pupils, inspirational teachers, and cultural activities, and formal teaching is only a minor part of being at school or university.
Table of Contents
Introduction
“What is your goal in life?” This question, often posed in appraisals or other management settings, presupposes that people have fixed goals, whereas much of one’s life is serendipitous. In retrospect, my medical training was ideal for my role as a consultant in rehabilitation medicine. In fact, I knew nothing about rehabilitation for the first ten years after qualifying, and I only began applying for rehabilitation posts in the last year before securing my post at the Rivermead Rehabilitation Centre in 1986.
Nonetheless, people’s lives appear to follow a consistent direction. I did not discover ‘science’ until 1960, but once I had tasted lessons in physics, chemistry, and biology, I became interested in science. I never had a specific goal and might have gone into any science. In about 1962, I read two books. One, Rachel Carson’s Silent Spring could have led me to biology and a concern about the environment. I also read W Grey Walter’s The Living Brain, which fascinated me and, in retrospect, probably accounts for my present work. Many other chance events and opportunities led to my long-term interest in healthcare, and then neurology and psychiatry, and eventually rehabilitation.
The metaphor of life as a journey reflects the idea that one is always moving forward. Initially, the direction is pretty vague and variable, but over time it narrows due to external constraints and internal motivations, values, etc. The specific outcome is rarely articulated. However, a person’s values and interests, as well as their motivational goals, will strongly influence their choices.
The journey may be disrupted by events that you must react to. Sometimes they may alter the direction positively by generating new opportunities of interest. Sometimes events may severely threaten progress or make some potential outcomes unattainable; the journey’s direction must be altered, but still within the envelope of values and interests.
This post explores how rehabilitation fits into someone’s life, concluding that it is a response to events, just as consulting an advisor about an alternative career after losing a job is; it helps someone re-establish their journey.
Metaphors for life.
There are many metaphors for life: a journey, a river, a book, a battle, and a blank canvas, to name but a few. Each emphasises a particular aspect of life.
Shakespeare’s monologue by Jaques in As You Like It presents another metaphor, that happens to focus on aspects relevant to rehabilitation:
“All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts,
His acts being seven ages. …”
This can be equated with the idea I explored in Relational Quantum Mechanics and Rehabilitation: that life’s reality is a series of interactions between a person and others. Each interaction is an event, and my post highlights how a person may change according to circumstances, ‘playing many parts.’
Another one is that “life is a book written by time, and every action adds a line”, which also introduces the idea of a succession of events.
This is not an actual quotation; it was constructed by Google AI from several similar metaphors. The AI summary of the ‘life is a book’ metaphor suggests the following:
- Time is the Author:
Time dictates the progression of our lives. We cannot stop the clock, just as we cannot pause the writing of the story. Every day is a new page, every month a new chapter, and every year a new series in this narrative. - Actions are the Ink:
Every action, decision, and moment—good or bad—is a line added to the book. It highlights that our behaviour defines our life’s record. - You are the Protagonist and Author:
While time passes automatically, you have the agency to determine what is written in those lines. It is a call to take control and consciously shape your life, rather than letting others or circumstances write it for you. - Legacy and Impact:
The entries in this book are not just fleeting moments; they have a lasting, even eternal, impact. The “book” represents the totality of our experiences, choices, and character.
None of the many metaphors for life sheds much light on the determinants of the direct and eventual outcome; they explain how you get there, but not why you arrive at the actual destination rather than one of the myriad other destinations.
Maslow’s hierarchy of needs, which considers what motivates people, may offer an answer. The first two motivational needs, physiological and safety needs, are likely to be prioritised during war and other emergencies and may remain the dominant motivating factors when resources are limited, for example, among the 20% of the UK population living below the poverty line.
People with greater discretion are likely to prioritise one of the three more elective motivations: affiliation, esteem (including self-esteem), or self-actualisation. Their actual goals will be open-ended, undefined, and usually unachievable. They will reflect a person’s values and interests and influence how they respond to events and opportunities.
Thus, the journey aims toward a particular direction in the surrounding fog, knowing that within that fog lie goals that will align with your wishes, but not knowing their exact nature. If your path is obstructed by something, you will find an alternative path toward the same compass point.
Childhood and education.
A person’s values, beliefs, and interests are influenced by experience and by intrinsic, presumably genetic factors; the proportional influence is unknowable.
As a baby matures, it adapts to its increasing abilities guided by family, other children, friends etc. Most of the guidance is informal, but society has developed additional formal guidance from specialist educators (i.e., teachers!). In principle, education should develop a child’s knowledge and skills to optimise their ability to be a socially and physically independent, engaged, and contributing member of society. We have, unfortunately, constrained our educational efforts with an inappropriate, excessive focus on a person’s cognitive abilities.
Education extends to university, where many people learn vital, broader life skills, though again the government mistakenly focuses on academic outcomes.
Looking at this process another way, the infant has few intrinsic skills and little knowledge, but it is excellent at learning from experience and exploring its capacity and its environment. The term, experience, refers to each event that occurs; we all learn something from the myriad of daily events, even if we only learn that our reaction is correct. Society’s role is to facilitate and optimise learning so that the infant becomes, eventually, an autonomous adult who can contribute to society and be socially active.
Life in adulthood.
Further increase and development of intrinsic neurophysiological processes in the brain eventually stops. Socially, people may enter adulthood at 16, 18, or 21 years, and some people suggest that brain maturation continues to 25 years. In practical terms, few major changes occur in cognitive skills after the mid-teens; but, of course, we continue learning and changing using the abilities we have, usually building on our better skills.
After leaving formal education, people continue to learn both formally, for example, as apprentices, through specific training courses, and most importantly, through encountering and reacting to normal day-to-day events at work and elsewhere.
Some situations, such as the arrival of a new child or the death of a close family member, are best managed with additional advice and support from friends and colleagues. Some events or situations are best resolved with more professional advice and support. For example, a divorce, a job loss, moving house, car theft, or moving to a new city far away. One unique feature of humans is the huge reservoir of knowledge accumulated over centuries, and we can use that to guide our response to new events.
Thus, over an adult’s lifetime, most people pick up new skills and learn how to respond to challenging events; they adapt to change and new challenges more easily and can share this acquired information with others. Towards the end of life, some aspects of bodily function decline, and we adapt to that also.
Ill-health (malady)
No one has perfect health all day, every day. Our abilities fluctuate naturally. For example, we all sleep; most people become more tired at the end of the day; minor infections such as the common cold; symptoms such as a headache; small injuries such as twisting an ankle; etc.
Moreover, most people have more significant health-related events. For example, a spell of diarrhoea and vomiting due to norovirus, a limb fracture from an accident, appendicitis, community-acquired pneumonia etc. Most of these are not life-threatening, recover relatively quickly, do not leave lasting difficulties, and are managed with short-term help with diagnosis, treatment, and straightforward advice from friends or the initial healthcare professional.
Some illnesses are associated with longer-lasting, often more severe losses and may leave persisting effects. In many, if not most of these illnesses, the patient needs unambiguous guidance explaining the problem, discussing causes and management, and giving advice on timescales and important issues such as work or driving. However, few will need any more.
A few patients will have more complex, usually more severe losses and difficulties. They will benefit from a rehabilitation service to help them respond and adapt appropriately through giving high-quality, dependable information, providing support, and helping with behavioural changes if needed.
These responses to events due to illness are like the responses to all other events. The people needing specialist, professional help adapting to a change approach or are referred to a rehabilitation service just as someone whose job has gone because their skills are no longer needed will need advice on what is most suitable and, often, a period of further education or retraining.
Rehabilitation is part of a typical life.
I have suggested that people react and adapt to:
- Natural changes in body structure and function as they grow and mature
- External events and circumstances, both minor routine events and larger one-off events
And that, as people adapt and change, they will:
- Be helped by or seek help from an informal network of family, friends, colleagues etc.
- Be helped by or seek help from more formal professional organisations and services
- Change and adapt is ways that reflect their underlying values, beliefs, and motivational goals.
One type of event or challenge is a change in bodily structure or function, typically as part of a malady or illness. In the immediate or short term, people manage minor changes, as they do with other events, by drawing on experience, family, friends, and other resources, such as the internet.
If the symptoms are more severe or do not resolve as expected, the person will usually see a doctor or other healthcare professional to determine the cause and/or receive treatment. The healthcare professional will generally provide information about the illness and advise on how to manage it, including guidance on how and when to return to usual activities.
If the problem is more severe and/or more prolonged, the healthcare professional may seek further diagnostic or treatment advice, focused on the presumed disease, and may also seek more specialised help from professions that assist with the non-disease aspects of healthcare: nurses for skin ulcers or incontinence, palliative medicine if the illness involves the end-of-life, and occupational therapy for equipment, etc. These professions, and many others, focus more on the social and functional sequelae.
Rehabilitation services are even more specialised, involving a multiprofessional team dedicated to facilitating adaptation to more complex long-term social and functional losses.
However, at all stages and in all conditions, with any level of severity from trivial to catastrophic, the healthcare service is concerned not only with disease but also with alleviating symptoms and assisting the person in responding to the limitations that arise.
In other words, a health-related change or event should be treated the same as any other change or event; people must react, usually adapting to a greater or lesser extent for a shorter or longer period.
Rehabilitation in healthcare.
The synthesis above presents rehabilitation in a new light, because every healthcare professional will (or should) provide advice and information to a patient, and that advice should cover the diagnosis, how to manage it, and any other matters that arise. For example, for many conditions, advice on diet, exercise, smoking, alcohol and other lifestyle alterations is an integral part of disease management. In some circumstances, one must also inform patients, for example, that they may not drive or that they should avoid contact with people vulnerable to infection.
Therefore, in addition to diagnosing the cause of a presenting healthcare problem, providing or arranging specific disease-modifying treatments, and alleviating pain and other distressing symptoms, all healthcare professionals must also consider the broader consequences for a patient. They should provide as much information and advice as is within their competence, discuss all other consequences, and explain how the patient can obtain more support if needed.
The management of these broader consequences of disease, in essence, facilitates the person’s adaptation to their malady. Often, the advice is simple and straightforward, well within the professional’s competence. Nevertheless, it is not aimed at the disease; it is aimed at the person’s behaviours and functional abilities, and thus it is rehabilitation.
Slightly more challenging issues beyond a professional’s competence may be helped by another more experienced professional, often in another profession that is more focused on helping with the consequences of disease: nurses, most allied health professionals, psychologists etc.
Some problems require even more expert help, at which point a multiprofessional rehabilitation team is likely needed. Their input may be short-term or long-term, but in most cases the patient should return to more general services that can provide a lower level of rehabilitation.
Finally, some patients with long-term significant disability may need further expert input, for example, if the disease progresses, or they develop a new disorder, or their circumstances change. This is the same as a person needing additional training in their job when a new technology arrives or the job changes.
Is adaptation to illness different?
Yes. Adaptation involves changing behaviours. Behaviours are enacted by the person, and if the person’s bodily structure or function is altered, their ability to develop new behaviours may be constrained. Because adaptation depends on cognitive function and learning, disruption of the nervous system is especially likely to affect adaptation adversely.
Thus, the patient may need to consult a professional or service with expertise in health conditions, their prognosis, and the likely strengths and weaknesses the person may have. The effectiveness of a professional or service specialising in helping a person with a health problem adjust to illness is crucial and depends on their analytical prowess (their rehabilitation thinking). Often, a clear explanation with useful advice enables the person to continue.
Moreover, much of the direct assistance needed may come from related non-health professionals and services such as fitness advisors and gyms, educationalists and services, engineers or builders, etc.
This is also no different from other services that help during other events. For example, a lawyer will guide someone through a divorce, but much of the work can be done by the person. Professional services have special knowledge and skills and are effective because they can analyse the situation and develop a plan. For example, many law firms now employ legal assistants, paralegals, and associates, and have relatively few highly qualified experts.
Synthesis: rehabilitation, education, life
This post has suggested that, from birth, each person:
- Responds to and learns from events. An event is an interaction between the person and their environment, another person or a physical object.
- Responds to bodily changes affecting their abilities (physical, social, cognitive) as they grow and mature.
- Develops a set of values and motivational needs that guide choices arising in their life
- Will be offered or may seek out help from family, friends, or colleagues as and when they need it, before approaching specific help
- Uses societal services or professionals to assist their learning and response to changes and events when informal help is insufficient
- Society especially requires children to have support from formal educational professionals or services
- The supporting services and professions used after childhood have areas of expertise to assist, usually in the short-term
- Their main function is to analyse the change or event, explain what is happening, and advise on what action to take
- When someone has a health problem, they will look to healthcare services for support
- Much helpful analysis and advice is given by all healthcare professions every day
- The specialist professions are healthcare professions
- The specialist service is the rehabilitation service
Thus, one can appreciate that:
- For most healthcare interactions, the healthcare person will have sufficient understanding and give an adequate explanation, prognosis, and advice. This is facilitating the patient’s adaptation to the event; it is rehabilitation.
- When someone’s problems are a little more challenging, support from a single profession with focused expertise in disease-related consequences is sufficient.
- If the changes are more complex or long-lasting, a multiprofessional team may be needed
- Specialist services should focus on analysis, formulation, planning, and return execution, and hand off to other services once the programme is within their expertise.
Rehabilitation journeys
The illustration below sketches out some rehabilitation journeys. Time flows from left to right.
Minor events, such as a headache, low back pain, or mild influenza, are discussed only with an informal network.
The informal network usually includes family and friends and may extend to acquaintances who are considered knowledgeable about the issues. Sometimes it can include people who experience similar problems. In the later stages after a severe loss, other people who have had a similar event may have considerable expertise in how best to respond to incidental changes. This includes patient-led organisations, which are available for many disabling conditions.
A significant event is something that the person considers warrants a visit to a doctor or other primary healthcare professional, such as a practice nurse. Informal support is almost always used as well. The healthcare professional will diagnose and, if appropriate, manage the cause; provide an explanation and advice. The dark black arrow indicates a discharge back to the patient.
A moderate event, such as a fractured tibia or forearm, will initially be managed by a primary healthcare professional, such as an orthopaedic surgeon, but the person will usually benefit from expert rehabilitation advice from a physiotherapist. Further professional help is rarely needed, but if it were, the single professional should refer to a multiprofessional team.
After a major event, for example, a stroke or severe traumatic brain injury, the primary healthcare team will usually refer directly to a multiprofessional team. This team will, sooner or later, refer the person to a more local single professional to continue management before final discharge.
If a person who has survived a major event experiences a subsequent minor or significant event, they may need additional input from the multiprofessional team.
I will discuss how services could be altered to enable this approach in future. At this point, I will simply point out that a rehabilitation network is essential for this to function smoothly.
Conclusion
This post demonstrates that rehabilitation is similar to many other specialised professions and services; it helps the person achieve the best long-term outcome as they respond to an event. The event in this case is a change in health status, but events requiring other services include losing a job, bereavement, and moving to a new geographic area to take up a new job and house. It also highlights that rehabilitation input is inevitably provided by all healthcare professionals during their encounters with patients, and that more specialised rehabilitation is only one part of their recovery process. Third, it emphasises that rehabilitation must be seen in the context of a person’s journey towards meeting their personal motivational needs; hopefully, rehabilitation will help, but it is only a brief episode and plays only a small part.