Holistic rehabilitation thinking – 2
Last edited: May 5, 2025
My first post on rehabilitation thinking discussed the crucial role of expertise when considering three aspects of rehabilitation: the process, the professional, and the person. I finished by introducing a fourth viewpoint, holistic rehabilitation thinking. This post expands on holistic thinking. I start by exploring the implications of the General Theory of Rehabilitation, which reframes rehabilitation as facilitating the patient’s adaptation to their malady; I suggest how thinking should change to recognise the implications of the General Theory. Next, I consider using the holistic biopsychosocial model as a framework for organising information and an analytic model. This leads to a discussion about enablement theories, which provide a rationale for specific interventions. These ideas are then reconceived from the perspective of person-centred rehabilitation. What is a person? Drawing on ideas from theoretical physics, I suggest a person is a part of a vast network of relationships, manifest as the effect of interactions between items within a complex system. General Systems theory might consider a person as part of a system. This independent approach leads to the same conclusions as my earlier approach: rehabilitation must think holistically to be effective. The post suggests ways to achieve this.
Table of Contents
Introduction
In the Western world, the biomedical approach dominates our concepts of health and personhood. We diagnose and treat diseases or conditions the patient has. Patients expect to receive treatments for their problems. People, politicians, policy-makers, etc, all consider illness something a person has that others will cure. Everyone realises some issues are not curable, but the assumptions remain intact. This approach divorces the ill person from his world. The patient is seen as a separate entity needing help.
The influence of external factors on illness is widely accepted. For example, in 1854, John Snow demonstrated that a single water pump caused a typhoid outbreak in London. The social and environmental determinants of disease are also widely accepted, but little is done to address them. Alcohol, poor housing, and the effects of poverty on children are all readily reversible causes of lifelong ill health, yet they persist in the UK, the US, and elsewhere.
Nevertheless, the general approach to illness continues to see the patient as a passive victim of circumstances with little agency.
A holistic approach offers a radically different approach. It conceives a person as part of a complex system or, more accurately, the person is located in a hierarchy of systems both above and below the person’s level. While parts of the system influence the person and their illness, they also affect and can use parts of the system. A person’s illness can be considered a malfunction of their system. It may be related to many other systems, affect many systems, and its return to health may draw on various systems.
In this systems approach, a person’s systems may malfunction for many reasons, ranging from an accident resulting in the loss of a leg to the death of a much-loved pet, causing distress and an inability to work. We need a generic term to represent alterations in the person’s functioning in the overall systems without implying or requiring any specific cause. As I discussed in a post on Disease, Illness, Sickness, and Disability, malady is the best generic term.
Rehabilitation frequently proclaims that it is holistic. This post explores how to undertake genuinely holistic thinking in rehabilitation.
Rehabilitation's role.
What is rehabilitation’s role within the complex network of systems mentioned above? We must understand how a person responds to a malady. (Read more about malady here.)
When a person considers they have a health-related problem justifying input from the healthcare system, they will do so. From the moment the malady starts, they will adapt to any changes associated with its onset. The decision to seek healthcare advice is one part of that adaptation, but they may also notify their employers that they cannot work and ask a friend to collect shopping for them.
People react to events and changes throughout their lives, including adapting to significant developments during adolescence and, usually later, to leaving home, meeting a partner, buying a car, etc. Moreover, with the most important events or changes, they discuss issues with others, seek help, and learn new skills.
The General Theory and holistic rehabilitation thinking
Thus, rehabilitation cannot be considered an external, independent process. It is only a part of the person’s adaptation to their malady or losses, albeit sometimes a crucial part. This is the first key insight underlying the General Theory of Rehabilitation, which leads to insights into rehabilitation’s role and goals. (A table shows relevant secondary pages.)
I published the General Theory of Rehabilitation in 2024 and have also published pages on this site that explore its different aspects and implications. The theory is based on
- Maslow’s motivational needs, discussed in an earlier post
- A general theory of behaviour, discussed below
- The holistic biopsychosocial model of illness, discussed later
The second key insight of the theory is that the adaptation process must be considered a homeostatic mechanism to maintain an acceptable biopsychosocial equilibrium that modulates goals within the five domains of motivational need developed by Maslow in 1943. Doubtless, another similar systematic classification could be used; I chose to use Maslow’s because persistence, widespread use, and an evidential base support its validity.
In the more recent General Theory of Behaviour (2018), Marks suggested that the idea of homeostasis, first developed in 1929 by Cannon to explain physiological stability, could be applied to cognitive motivational processes. There is evidence for this hypothesis.
The homeostatic mechanism must balance prioritisation between the different need domains, particularly between the lower two physiological needs and the three higher-level needs. Generally, when someone’s basic needs are not being met satisfactorily, they are given priority because they impact survival.
The mechanism must also adjust the specific goals in each class to maintain a discrepancy between the goal and the current situation sufficient to motivate but not so significant as to cause hopelessness. The person’s ‘central homeostatic network’ maintains the balance and the discrepancy.
When a goal becomes unattainable, causing depression or distress instead of motivating the person, they need to identify other, less challenging goals that still meet their needs. This is a conscious cognitive activity, outside the central homeostatic network’s capability.
Holistic rehabilitation thinking & the General Theory.
A professional or team that approaches rehabilitation using the general theory will have a different and hopefully more effective way of thinking, leading to better decisions and actions. I will give some examples.
It highlights the crucial role of the patient who will adapt regardless of any rehabilitation input, and whose goals will motivate further learning and adaptation. Most patients will conceive rehabilitation as ‘just another medical treatment’. If you explain that:
- They have and will continue to adapt, so they are already actively involved, and
- Rehabilitation’s role is to facilitate and catalyse their adaptation,
you may alter their perception of rehabilitation and engage them fully.
Giving the family a similar explanation will strengthen the message. It will also enable the team to discuss how they (the family) are adapting and how they play a vital role in the patient’s adaptation.
Reframing rehabilitation in this way often leads the family and patient to reveal their expectations about the process and the outcomes; the altered perspective is so surprising that they will usually reveal what they expected.
It will also alter the team’s approach and usually reduce the emphasis on ‘therapy’. While teaching people how to achieve a goal, enabling safe practice, and providing feedback undoubtedly benefit some patients, one may consider transferring practice to the patient, with feedback coming from others or generated by the patient.
Next, it enables a broader discussion about goals and needs. You can give the patient a framework by informing them that most people’s needs and goals fall into one of five groups. Just asking, “What are your goals?” is daunting for anyone, whereas saying, “Finding goals must be difficult, but research suggests five areas most people are concerned about, and we can discuss them to help you work out your hopes” may lead to a more productive discussion. Another approach is to frame goals as hope, an approach I have written about.
Third, you can discuss with the patient how they have adapted so far and then encourage them to suggest changes to help them continue. This can lead to a discussion about learning self-management, a vital part of all effective rehabilitation. One particular change that may become evident is an alteration in some previously held goals, such as working full-time with much travel.
The essential features of all these changes are they broaden the perspective from the here and now (next few days, interacting with the rehabilitation service) to the reasonably distant future (one or more years, at home) and they transfer the centre of attention from the therapy team to the patient and their friends and family. It increases the extent of being holistic and patient-centred.
Holistic rehabilitation thinking & biopsychosocial model.
The general theory must be placed in a holistic analytic framework so that you can structure and analyse your information. Engel’s original biopsychosocial model, which was built on ideas put forward by Nagi and others, was a significant advance. The rehabilitation community, especially the World Health Organisation, rapidly adopted it and developed it considerably between 1980 and 2000.
Further development by Peter Halligan and I added (a) time as an important contextual factor, (b) personal factors or context, (c) choice, and (d) quality of life or subjective well-being as a global assessment only the person can make. I now refer to this as the holistic biopsychosocial model, to distinguish it from the original basic model.
Rehabilitation professionals are brought up in a world where the biomedical model of illness is the only model; it is ingrained and rarely articulated or discussed. Consequently, they must consciously consider clinical issues within the holistic biopsychosocial model (BPS). This is a cognitively demanding task, as it is not the default mode of thinking about illness.
I have discussed this model extensively on this site and elsewhere. For anyone unfamiliar with it, I will summarise it. The structural framework:
- Uses four hierarchical systems centred on the person: their disease, symptoms and signs, disabilities, and impacted social role functions.
- Sets the person in four contexts: physical, social, time, and personal. The temporal context is subdivided into time within the person’s life and the illness.
- Proposes two orthogonal person-centred concepts: choices and evaluation of global well-being
Biopsychosocial holistic thinking
The model fulfils two functions when considering individual patients; it is additionally helpful in other clinical spheres such as planning and undertaking research or quality improvement, designing services, and writing guidelines.
The model provides a comprehensive framework for classifying the information collected. Information should be collected in a natural conversational flow. As this progresses, one can review whether you have heard anything about, for example, support from friends or the patient’s beliefs and ask if needed.
It can also be the theoretical model used when formulating the case; for example, one may discover a person has few social contacts each week and then discuss whether this is a change and something the person would like help overcoming. It will usually underlie the enablement theory used when considering treatment.
Robert Smith and colleagues gave a specific example of the model informing practice, who published “An evidence-based patient-centered method makes the biopsychosocial model scientific” in 2013. The paper outlines a structured assessment for patients attending rehabilitation. They researched the approach in two trials involving people with ‘medically unexplained symptoms’ (see here and here). The original paper gives details, which I have transferred into a MindMap, as shown below.
I have also devised a measure of case complexity based on this model, the Oxford Case Complexity Measure (OCCAM). This was designed to be filled in after an initial clinical assessment, not to be completed while with the person. It covers each domain. The 26 items can act as an aide memoire and may highlight areas for further exploration. The MindMap below illustrates the items.
The crucial role of the biopsychosocial model in rehabilitation is highlighted in the only professional rehabilitation curriculum, the Rehabilitation Medicine training curriculum. The first speciality Capability in Practice is “Able to formulate a full rehabilitation analysis of any clinical problem presented, to include both disease-related and disability-related factors,” and the first descriptor is “Uses the holistic biopsychosocial model of illness for all areas of professional practice.” This requires all doctors to think about clinical problems using that framework.
My paper, “What is rehabilitation? An empirical investigation leading to an evidence-based description,” found that using the biopsychosocial model to think about patient problems was associated with effective rehabilitation practice.
Enablement theory & rehabilitation
Rehabilitation facilitates adaptation by acting and doing things. I published a figure showing different ways rehabilitation acts, which can be seen here. The figure below, derived from the original drawing, shows the various types of action. Therapy teaches skills, but it is only one of many vital activities. These activities should have some theoretical underpinning, justifying how they will lead to the desired goal.
It is immediately apparent that there cannot be a single ‘enablement theory’ underpinning the different types of action. A theory or clinical reasoning explaining why strengthening leg muscles improves walking cannot also explain how to teach a carer to communicate with a patient with aphasia. The range of theories and scope of knowledge and skills a professional needs will depend on their case load.
Nonetheless, every professional should consider general principles when considering their intervention.
Rehabilitation is a complex system, and this is he central feature of rehabilitation that determines the principles of analysing and predicting cause and effect. The crucial aspects of a complex system are:
- Relationships are non-linear.
This means that relationships are rarely simple, straight-line equations; for example, doubling the time of therapy given to a patient will rarely double the change observed. It also means that halving the extent of a causative factor, such as the number of steps in a staircase, will rarely halve the effect (being unable to get up the stairs).Thus, a person with weak quadriceps muscles can make measurable increases in their strength, but until they are strong enough to allow them to stand from sitting, there will be little functional gain. Once that threshold is crossed, small increases will initially lead to increases in walking speed, but less so as they approach maximum possible speed.
- Inter-relationships are universal.
This means no single factor fully determines another; other factors will constantly modulate the relationship. For example, gait speed is influenced by muscle strength, but factors such as motivation, painful joints, and thinking about a complicated issue. Often, the influence of other factors is similar in power, and no single factor determines the performance of the factor.Thus, employment is influenced by interpersonal communication skills, knowledge required for the job, availability of transport to reach work, endurance, and a host of other factors. Having the required knowledge and abilities is usually a minor contributor to sustained success.
- Relationships may be bidirectional.
This means that two factors may reinforce or counter each other. For example, joint pain may reduce muscle use and cause weakness, which increases pain. However, if the person increases muscle strength and use, pain may be reduced. Depression is associated with reduced social interaction, which may further lower mood, but growing social interactions may lead to a reduction in depression.A significant proportion of challenges seen in rehabilitation fit into this pattern.
The overwhelming consequence of complexity is that nothing can be sure. Every statement must be framed in terms of probability. However, the more factors one considers, the more likely one is to be correct. One must look at patterns, not single relationships.
Most theories and most evidence concern a single relationship. They are invaluable as a starting point. They should never be considered sufficient reason to act or reach a decision.
The practical consequence is that all formulations and treatment plans must be subject to review and change. The empirical evidence from my review of successful rehabilitation interventions supports the need to tailor rehabilitation to the individual patient. Consequently, one must avoid dependence on inflexible programmes for individual impairments or disabilities.
Holistic rehabilitation thinking.
Rehabilitation is person-centred. What does this mean?
From the person’s perspective, it means that we must consider:
- The person’s experiences, successes, failures, and future hopes and expectations are all important. We must not concentrate only on their situation at the time of our contact
- Their social context (past and future); who they live with, and their social networks
- Their physical context, primarily now and in the future, while acknowledging the social and emotional significance of past housing, neighbourhoods, etc
- Their condition – the disease, prognosis, impairments, capabilities, etc
- Their characteristics
This holistic view is illustrated in the figure below.
Adolf Meyer, who worked at John Hopkins University from 1910 to 1918, first formalised holistic thinking about a patient. In his paper “What is formulation in psychiatry?” Gareth Owen shows an example of a ‘life chart’ made by Meyer for someone seen in 1918.
We cannot collect such detailed information in daily practice! Nevertheless, we can easily ask a few questions or ask the person to tell us a little about themselves. Similarly, we can explore in detail their life hopes, but we can also ask what they would like to be like in a few years. I have written about hope here and emphasised how it is key to person-centred rehabilitation.
Conclusion
Person-centred rehabilitation must consider the person in their total context, which includes their clinical, body-related changes and psychological state, physical and social contexts, and their narrative identity, including past experiences and hopes for their future. The person is part of a complex system, and the features and principles associated with general systems theory (see: Ludwig van Bertalanffy, 1950) apply. This requires a holistic approach because factors in each domain of the holistic biopsychosocial model of illness may have a significant influence. To facilitate thinking, I suggest using the General Theory of rehabilitation, which emphasises the facilitation of the person’s adaptation to their malady and the biopsychosocial model of illness as a framework for assessment and formulation. No single enablement theory exists to specify knowledge, skills, and mechanisms associated with interventions, but they are all embedded in a complex system. The empirical evidence on the characteristics of effective rehabilitation suggests a holistic, tailored approach is effective. It depends crucially on thinking carefully about each patient.