What is Social Rehabilitation? Latvia, with a population of 1.86 million, has 333 professionals in social rehabilitation, employed in social rehabilitation services managed as part of its social services. Is it appropriate to separate social rehabilitation? If not, are professionals specialising in social rehabilitation a helpful innovation? Iluta Bērziņa from Latvia asked me these questions. This post explores the questions and gives my answer. I thank her for raising the question and for providing a key reference, the “only one worth reading”, a qualitative meta-synthesis by Kati Kataja et al. (2022) on the dimension of social rehabilitation. The authors work in Finland, one of the very few countries with identified separate social rehabilitation services.
Table of Contents
Introduction
Optimising social function and participation is a goal, if not the primary goal, of rehabilitation in most definitions or descriptions of rehabilitation across healthcare and criminal justice systems. Therefore, the phrase “social rehabilitation” is confusing. Does it refer to a subspeciality, equivalent to spinal cord injury rehabilitation? Is it focused on one outcome among a basket of possible outcomes, such as mobility, communication, and work? Or does it identify people with behaviours outside the societal norms of a population?
My initial Google search identified the use of the term in several contexts and countries:
- “Social rehabilitation is defined as a social service that helps people through various supportive services, work towards the goal of reaching their full potential and live fulfilling lives.”
Community Support Network, California. - “We understand social rehabilitation as a non-paternalistic type of rehabilitation that seeks to restore positive relationships between crime perpetrators and the rest of society, and aims at enabling actual processes of social reintegration.”
In: Social Rehabilitation and Criminal Justice. Introduction. - “Social rehabilitation is a social service designed to support a person with a disability or reduced work capacity in coping with their everyday life.”
Republic of Estonia. Social Insurance Board. - “Social rehabilitation was identified as a dynamic process in which the environment, activities, social interaction, self-recognition and awareness of social problems, coping and satisfaction played an essential role.”
Mari Portillo & Sarah Cowley, Social rehabilitation in long-term conditions.
Evidently, the term has many meanings, most of which appear to be unique to a single setting or service, with little overlap or critical evaluation.
Social rehabilitation: the evidence.
Rehabilitation was first used (CE 1533) to describe the reinstatement of a person to their social status, typically lost due to a misdemeanour.
One common use now concerns the rehabilitation of criminals, which is apt and reflects its original meaning. The original misdemeanours in 1533 were social, not criminal. Further, the actions taken to reinstate the person may have been indirect rather than directly aimed at the person’s behaviour.
In the 21st century, the intention is to alter the person’s behaviour and thereby reduce the risk of criminal behaviour by increasing the likelihood that they will enter other socially approved roles, typically employment.
“Social rehabilitation is a process of integrated recovery activities, both physical, mental and social, so that former drug addicts can return to carry out social functions in community life.” Susi Delmiati and Irsal, Ekasaki Journal of Law and Justice.
This focus on drug addiction is particularly interesting because it straddles the boundaries between criminal activity, a medical condition, and a chosen behaviour. Sometimes society criminalises the behaviour, imprisons the person, and offers or enforces ‘rehabilitation’; at other times, a medical diagnosis leads to treatment being offered or imposed under the Mental Health Act (in the UK, but similar laws exist in most countries); and occasionally the person will seek out help and rehabilitation.
Most of the descriptions above apply to any rehabilitation. They do stress one feature, such as being non-paternalistic or a social service, but none explain how ‘social rehabilitation’ differs from other forms of rehabilitation.
Possible distinguishing features.
Although no one has provided a coherent explanation of how social rehabilitation differs from other forms of rehabilitation, I will discuss several possible distinctions.
Funding organisation.
The term may identify the organisation responsible for the service, thereby distinguishing between healthcare rehabilitation and social care rehabilitation. In the UK, this would imply that social services are responsible.
This is not a sensible distinction and risks further disintegration of an already disintegrated service. The challenge of separating out financial responsibility for services needed because of a health condition is destroying the UK National Health Service. Arguments about the right to free care occur daily, and a huge bureaucracy surrounds the process. The problems associated with funding long-term care would extend to all healthcare, as some rehabilitation will be needed and may be provided in most acute wards.
Goal of rehabilitation.
A second reason might be to identify the goal of rehabilitation, for example, by distinguishing social goals from functional rehabilitation, which is mainly aimed at achieving adequate independence in personal care and mobility to enable safe discharge from the hospital.
This is counter to the aim of all rehabilitation. Rehabilitation focuses on functional activities because they are crucial to most social activities; they are a means to an end: the person’s reintegration into an active social life. If that purpose is removed, the person’s motivation will be reduced.
An inpatient service may not achieve social goals before discharge, but it remains vital in planning. Furthermore, the many domiciliary rehabilitation services funded by health have, or should have, relevant social goals.
Location of rehabilitation.
A third distinction concerns the setting of rehabilitation, typically distinguishing inpatient from at-home or other community-based care.
This is closely allied to who is funding, though not necessarily. It is true that rehabilitation incorporated into natural settings and activities is likely to be more effective. However, if it is identified as a separate service, it will result in poorer service, as the distinction will inevitably affect collaboration and funding.
Social rehabilitation: the meta-synthesis.
Kati Kataja and colleagues (2022) published a paper titled Dimensions of social rehabilitation: A qualitative interpretive meta-synthesis. In their summary, the conclusion is that “social rehabilitation should be understood as an entity consisting of interrelated and interdependent components forming a constantly shifting assemblage.” As I cannot interpret this, I will outline its main content. However, I will explain it later.
The introduction discusses the nature and purpose of rehabilitation and notes that social aspects are central to most public services. Interestingly, and rather disappointingly, the word biopsychosocial does not appear once in the whole paper. This is despite asking, “On what kinds of quintessential premises are the needs for, foci and aims of social rehabilitation based?”. The holistic biopsychosocial model of illness must be one of the ‘quintessential premises’.
They undertook an extensive search and identified 25 published articles covering a wide range of conditions, including older people, children, neurological conditions, mental health, homelessness, sex workers, and people who had broken the law.
Services could be classified into three organisational types:
- Residential social rehabilitation
- Community-based programmes
- Based in other institutions, such as prisons, hospitals, or care homes..
They also noted that social rehabilitation services could be characterised on three dimensions: needs, foci, and aims.
Needs.
One dimension was the needs generated by the person. For example, the person may have had disabilities, with activities that were limited or impossible. Alternatively, the person’s behaviours may have been deviant or socially unacceptable. Although the person’s characteristics determined the need, in most instances, the physical and social environments were significant contributors and required attention.
Focus
A second dimension concerned whether the service focused on the individual or on the social and physical environment, such as family members or the built environment. Services differed in the effort invested in changing social attitudes and the physical structure more broadly.
Aims.
The third dimension was the expressed aims. Some services were aimed at achieving conformity with social or cultural norms. Others were primarily person-centred, aiming to achieve a satisfying life by concentrating on the person’s wishes and values.
Assemblage.
This is a term I had not encountered before. As far as I can understand it, it is a different way of referring to systems and networks. The paper appears to suggest that the conglomeration of social rehabilitation services addresses all needs, yet each individual service has distinct features.
The paper uses the term “assemblage” but is actually describing a network of rehabilitation services; I have already discussed the need for a rehabilitation network, as have many others. The situation they describe is identical to that observed across the entire healthcare sector, which comprises numerous biomedical and rehabilitation specialities and services. Networks are also common, such as for cancer.
The conclusion that individual social rehabilitation services meet only a few social rehabilitation needs means that they should be fully integrated with all other rehabilitation services, because almost all patients (clients?) will have healthcare needs. The young, the old, the disabled, drug addicts, the mentally ill, etc., will all need support from healthcare rehabilitation and biomedical services.
Conclusion
The readily available literature and documents provide no coherent or rational basis for distinguishing social rehabilitation from other forms of rehabilitation. Consideration of potential distinctions does not suggest that any method exists. Indeed, given that rehabilitation acts on function to enable the person to have or develop a more satisfying social life and network, establishing a separate social rehabilitation service will inevitably lead to further fragmentation of services, with a loss of efficiency and effectiveness. The ideal would be to develop a healthcare system that delivers biopsychosocial care, encompassing more acute biomedical care while paying greater attention to social and contextual factors and to patient functioning.