Rehabilitation thinking – 1
Last edited: May 5, 2025
In 2002, I wrote that “… rehabilitation is a way of thinking and not a way of doing.” The editorial did not develop the rehabilitation thinking hypothesis much. I have been asked to give a talk on “What is really important in rehabilitation?”. This is a challenging title. My initial idea was to structure my reply around the process, highlighting specific aspects of diagnosis, formulation, planning, intervention, and evaluation that I considered most essential. This seemed boring. I then considered the high-level capabilities used in the rehabilitation curriculum. These are undoubtedly crucial. I have discussed how they can be generalised to all professions and, more recently, how they can be used to define and evaluate rehabilitation services. However, they are tangential to providing an excellent rehabilitation service to a patient. I next considered the General Theory of Rehabilitation and how to structure a talk around that. At about the same time, I revised my post on personal factors, stimulated by an essay which won the British Society of Physical and Rehabilitation Medicine’s medical student prize. I have now settled on holistic thinking as the most crucial skill in rehabilitation. This post introduces the topic; a second post gives details.
Table of Contents
Introduction
Between 1935 and 1955, a few rehabilitation specialists transformed the lives of people with spinal cord injuries. They did not make any scientific discoveries or invent radical new treatments. Instead, they considered the problems and developed protocols and approaches that overcame them, allowing patients to lead fulfilling lives of near-normal length.
Between about 1970 and 1990, another small band of rehabilitation specialists, mostly geriatricians, developed specialist acute stroke rehabilitation services, which significantly reduced morbidity and mortality; pharmacological intervention had singularly failed at the time. Again, they did not create or invent radical new treatments, though there were general advances in healthcare that they used.
Despite these dramatic achievements, many people consider rehabilitation to be a non-specialist activity that anyone can provide. They had not appreciated the specific approach of expert rehabilitation thinking. This may be because most interventions seem mundane, with little high-tech equipment or procedures. In systems that pay for procedures, rehabilitation uses specific tests or treatments more frequently. Their value is debatable—an approach focusing on procedures risks being less holistic, mimicking a biomedical approach.
If one views professional expertise primarily in terms of specific procedures (tests or treatments), one risks entrapment by the Law of the Instrument, illustrated in 1868 thus: “Give a boy a hammer and chisel; show him how to use them; at once he begins to hack the doorposts, to take off the corners of shutter and window frames, until you teach him a better use for them, and how to keep his activity within bounds.” One may give undue priority to the activities you consider special, overlooking crucial other matters. (See also The law of the instrument. Would you rather be a theory or a nail?)
Thinking is a crucial skill in rehabilitation. I will consider four areas where rehabilitation thinking may have a significant impact.
Rehabilitation thinking: what?
The Oxford English Dictionary [OED] describes ‘to think’ as to “direct one’s mind towards someone or something; use one’s mind actively to form connected ideas” and ‘thinking’ as “the process of considering or reasoning about something.”
The American Psychological Association dictionary gives a more detailed description:
“cognitive behavior in which ideas, images, mental representations, or other hypothetical elements of thought are experienced or manipulated. In this sense, thinking includes imagining, remembering, problem solving, daydreaming, free association, concept formation, and many other processes. Thinking may be said to have two defining characteristics: (a) It is covert—that is, it is not directly observable but must be inferred from actions or self-reports; and (b) it is symbolic—that is, it seems to involve operations on mental symbols or representations, the nature of which remains obscure and controversial (see symbolic process).”
This post will refer to thinking as a covert, active cognitive process focused on a specific topic. In this process, people use and manipulate symbols or concepts to better understand a situation and make more dependable decisions and predictions.
The process will be more efficient and effective if the thinker uses a sound analytic conceptual framework, theories or models that identify significant relationships between the concepts used, and a model of the activity being considered, rehabilitation in this instance.
For rehabilitation, these three requirements translate into:
- The holistic biopsychosocial model of illness
- An enablement theory or theories
- The General Theory of Rehabilitation
Rehabilitation thinking: why?
Imagine (think) you survive an airline accident, finding yourself in a strange, uninhabited land. You would probably assess yourself and your resources, but what’s next? Looking around, you see distant hills, clumps of trees, but no signs of humans. You know that, once you have found a stream or river, you only need to follow it downstream, and you will reach a hamlet or larger settlement. No streams are in sight. You need a map and to know where you are on it.
As the professional rehabilitation advisor to a new patient with a significant problem, you are in a similar position. You need to establish your resources, usually in terms of the person’s limitations and prognosis, and their immediate physical and social context. Then you will identify your likely long-term goal and plan how to reach it.
Just as it would be unwise to walk away from the crashed airplane without considering how far you can walk, how much you can carry, and which direction is likely to be best, it is unwise to treat immediate problems without considering other aspects of the person and their goals. When asked to give a second opinion, I rarely know some facts that influence the situation or my advice. Typically, I collect more information and identify issues that have been missed or ignored; it is my thinking, not my knowledge, that counts.
The failure to think is common; how often have you said, “If only I had thought of that earlier”? Once you recognise the missed opportunity, it seems obvious. On a grand scale, a lack of critical thinking initially underlies many of the projects undertaken by the government in the UK. The planners give priority to politics, not thinking. We should avoid starting significant rehabilitation interventions without ensuring they are appropriate.
Failure to think usually risks wasting resources and may harm. The formulation process, discussed here and here, should encourage team thinking.
Rehabilitation thinking: what about?
There are many ways to approach rehabilitation, so choosing a framework for this post was difficult. I will briefly outline four, as shown in the MindMap below. I will enlarge on holistic rehabilitation thinking separately.
The person
Rehabilitation is person-centred, so framing thinking around the person seems appropriate. I have chosen four contexts that are often not thought about adequately:
- Healthcare:
Rehabilitation is a part of healthcare, and the patient will likely consider it to be another treatment, like other biomedical treatments—something done to them that will improve, if not abolish, their problems. The patient will not easily distinguish rehabilitation from other healthcare, which may lead to confusion or mixed messages about their condition. One must consider this and usually explain that rehabilitation interventions differ. - Time:
The rehabilitation episode is brief compared to their life expectancy, even if one adds earlier episodes. They spend little time on rehabilitation activities, even during an episode. Consequently, we must always realise we are a bit player in their lives, although we will make a significant difference. Secondly, we must always consider their situation in five years. Often, rehabilitation services focus exclusively on their episode, overlooking the long term, “because we can do nothing about it.” This is untrue; we can give them skills and help them reach a vision with hope. One must consider their whole life and how we can help them throughout their life. - Social:
Two of Maslow’s five motivating human needs depend totally on interpersonal relationships and social networks: the need to have emotionally and physically close relationships and the need for esteem, both self-esteem and the esteem of others. Although we cannot make social relationships for someone, we can discuss whether the need is met and, if not, explore how the person might meet these needs. We must always think about their social networks and roles. - Personal:
I have discussed personal factors in another post. We must also consider them because they probably have more influence than any other factor. We must appreciate the person as an individual, not someone with a diagnosis or problem.
The process
Every patient will undergo the same rehabilitation process, and every stage needs conscious attention and thinking. One significant challenge arises from contextual misunderstandings. Many people outside the clinical team do not appreciate the need to think and tailor the process to the patient, and, unfortunately, some clinicians prefer a less challenging approach by completing forms and using standardised methods.
Four of the five stages require thought and should not be dictated externally. If external agents need data, they must make the reasons explicit and the data proportionate. The stages are:
- Assessment
This should not be considered a routine process, collecting information that others say you must. It primarily systematically tests hypotheses about the patient’s situation, as experts do in biomedical and rehabilitation practice. The expert generates hypotheses and tests them. - Formulation
This depends exclusively on determining which factors are relevant and what their relationships are. It requires thought, primarily through debate within the team and critical reflection if there is no team. - Planning
This is also exclusively dependent on cognitive thinking processes, as one identifies far and near goals, organises people to undertake actions, etc. - Intervention
These are the practical outcomes of the preceding three cognitive stages. Most actions depend on some knowledge and much skill. - Evaluation
This stage is a reassessment, and it involves considering what should be measured, how, and when, as well as collecting and interpreting data.
The professional
Rehabilitation teams are all professionals who should think, and I suggest the following are relevant to every patient:
- Recognising strangeness.
All clinicians must be curious about unusual or unexpected features and investigate until they are explained, or the clinician is satisfied that the features are not symptomatic of some significant unknown factor. This requires critical consideration of known information and curiosity, both cognitive phenomena. - Tailoring the process.
The rehabilitation process must be adapted to suit the patient’s needs and characteristics; successful rehabilitation depends on this. One cannot just apply a ‘fatigue programme’ or any other fixed protocol. One must explore how the likely effective actions need to be modified for the particular patient. - Relating to others.
Most patients are involved with other professionals, teams, services, and agencies, and not uncommonly with other members of the same profession. The professional should consider how they will relate to them, and when they should be asked to give specific input. One should also consider and discuss with the patient how one will relate to family and friends, what they can be told and what they can be asked to do.
Holistic rehabilitation thinking.
Holistic rehabilitation thinking encompasses all viewpoints when exploring human relationships and activities. It is a higher-level set of concepts than the previous three, but still subordinate to socio-economic theories about social structures and functions, such as healthcare.
This level of thinking has three main components, each having two major components.
The General Theory of Rehabilitation.
The General Theory of Rehabilitation is explored in detail elsewhere on this site. It has two components. First, it recognises that people afflicted by a disease will adapt as best they can, given their losses, limitations, strengths, and resources. This is natural and inevitable and occurs in all illnesses. The immediate consequence is understanding that rehabilitation’s role is to facilitate and optimise these natural changes and catalyse some that might otherwise not happen.
Second, it works with a homeostatic model of human motivation and behaviour. In short, people work to satisfy needs, exemplified by Maslow’s hierarchy of five domains. Some people must adjust their higher-level goals to balance the motivating and demotivating discrepancy between the present and the aimed-for goal.
The holistic biopsychosocial model of illness.
This is the central framework for all rehabilitation thinking and conceptual development. It emphasises the influence of four systems associated with the person and four contextual domains. When faced with an unresolved clinical problem, one should consider whether a factor in each domain might explain it.
It helps to systematise thinking about almost all issues in rehabilitation, not just clinical presentation and patient management.
Enablement theory and knowledge.
Shanti Pinto, John Whyte and colleagues define enablement theory as “… the theoretical framework that describes the interrelationships among different areas of functioning, …” and they distinguish it from “… treatment theory, which describes how the active ingredient(s) of an intervention directly impact a measurable target.”
The distinction seems appropriate, but treatments will be derived from relationships within the analytic enablement theory, and treatment effects will validate or improve relationships in the enablement theory. Thus, there is no clear distinction, and enablement theory is the best overall descriptor of the analytic theories.
Enablement theory – there is no single theory – is a general systems theory. Therefore, it has two significant features: every factor or item has a direct or indirect relationship with every other factor, and the relationships can be bidirectional and influenced by third factors. In other words, a mathematically complex web of relationships exists between all parts of the biopsychosocial model.
Enablement theory, as used in this post, includes treatment theories, and many individual treatment theories exist. Only a few are strongly supported, and many treatments are empirical and have no specific theory. Thus, in rehabilitation, the treatment component is often based on experience, with some parts supported by scientific research.
Rehabilitation interventions are practical actions; after thinking, the professional acts. The action depends on an accurate formulation, and then considering how to alter the situation requires a combination of “knowing what works” and a theory justifying how and why the act will change matters. This combination is called clinical reasoning or evidence-based practice; rehabilitation actions are based on the professional’s experience, the experience of others, and published research data.
Holism in practice.
“The world we observe is continuously interacting. It is a dense web of interactions.”
“Individual objects are the way in which they interact. If there was an object that had no interactions, no effect upon anything, emitted no light, attracted nothing and repelled nothing, was not touched and had no smell . . . it would be as good as non-existent.”
“The world that we know, that relates to us, that interests us, what we call ‘reality’, is the vast web of interacting entities, of which we are a part, that manifest themselves by interaction with each other.”
These three sentences, written by Carlo Rovelli, a theoretical physicist, when discussing quantum mechanics and the mystery of ‘quantum entanglement’, apply to people, the biopsychosocial model of illness, and probably to all systems.
Most scientific research and management require isolating specific items. We always seek to categorise or classify phenomena. We distinguish health from social care, consciousness from unconsciousness, willed from unwilled actions, functional from non-functional illness, mental from physical illness, etc. The list is endless.
Carlo Rovelli tells us that everything is interconnected. He refers to the universe and the reality of atoms, electrons, etc. The same principle applies to rehabilitation. For example, one cannot separate symptoms into ‘physical’ and ‘mental’. People with a clinical stroke may have no evidence of brain damage, and about 5% of people with acute stroke are likely to have a functional illness. However, a much larger number have a definite pathology, but with limitations far above that expected (from Enablement Theory).
Rehabilitation is not immune to the wish to categorise. People with fatigue associated with multiple sclerosis may be offered a fatigue management programme, but if the person has, for example, fatigue after meningitis, they may be deemed ineligible. People with subarachnoid haemorrhage are referred to stroke services, even though their problems are closer to those seen after a traumatic brain injury. The desire for disease-specific services is another example.
A genuinely holistic rehabilitation would focus on the patient, and not on any one aspect of their situation. They would not have processes with access defined by single features such as a disease (a traumatic brain injury), an impairment (amnesia), a disability (arm function), an intervention (orthotics), or who pays (health, social service). They would identify what someone needs, then consider the most appropriate service or combination of services from those available.
Conclusion
Thinking is crucial to effective rehabilitation. This post has discussed rehabilitation from four perspectives, and each one requires individual team members and the team to consider and discuss the issues before acting. The drive to fragment rehabilitation into production-line parts, controlling patients by single or a few isolated fragments of their situation, has prevented it from being holistic and person-centred. Associated with this, clinical staff spend less time considering the person’s formulation and needs, and more time intervening. On the surface, this appears reasonable, but (a) the extra time is minimal and the dose-response relationship between input and outcome is weak or non-existent (the dose-response between time practising and outcome is significant) and (b) the Law of the Instrument will come into play, risking wasting resources on inappropriate treatment. Careful analysis, formulation, and person-centred planning and actions are vital; they depend upon active, critical thinking. The next post in this series will explore holistic thinking in more detail.