The range of potential effective interventions within rehabilitation is large. Specific actions will be discussed elsewhere on this site. This page gives an overview of the different types of action (see graphic). It introduces the idea that most actions can be classified in one of three groups: treatment, care, collecting information. The reality is, as with all classifications, that most actions include something from all three categories. The conceptual separation is, however, useful when considering services design and resource allocation.
Most people think that rehabilitation is synonymous with the giving and receiving of therapy, a term that implies treatment. [Therapy is “treatment intended to relieve or heal a disorder” (OED) and comes from the Greek therapeutic, to treat medically.] Rehabilitation is not the same as therapy, a matter to be discussed elsewhere.
Treatment refers to an action or activity that is intended to improve upon the expected natural history of a patient’s situation, that improvement being sustained after the course of treatment is ended. The important features are that:
- it is intended to improve matters; if it does not, it is unsuccessful treatment.
- it is expected to have an end, with the improvement being maintained; continuous ‘treatment’ is care.
Treatments can be directed at any of the eight domains within the biopsychosocial model of illness, as illustrated in this figure. In most cases the ‘action’ is in fact a complex activity or set of actions. It is often difficult to know what the effective ingredients are, though attempts at classification are being published; they need studies both of their validity, and of their utility.
Care refers to an action or activity that is primarily intended to maintain the patient’s physiological stability (life), well-being, and safety (and, sometimes, the safety of others). It covers everything from providing nutrition using a gastrostomy feeding tube and giving ventilatory support through assistance with daily activities, both basic and more complex, up to providing a secure environment or providing a structured, predictable routine.
Thus, though most care is dependent upon people working as carers, the concept extends further to include, at times, constraining or structuring their environment so that it helps maintain safety and well-being.
Collection of information is the third category of planned action. This refers to specific assessments or investigations that require specific activities. Thus noting how someone changes is part of normal care, but keeping a chart of episodes of challenging behaviour is a specific activity.
The information may be a more-or-less formal assessment (if of impairment or activities, or of something contextual like identifying neighbours who can help) or investigation such as cerebral imaging, or ruling out some alternative of addition pathology. It includes investigating whether possible treatments have an effect.
Reflection on treatment v care classification.
This classification is, I believe, helpful when thinking about or discussing rehabilitation. It helps when considering such questions as “is he still receiving rehabilitation?“, a question frequently asked by funders. Making the distinction allows one to highlight that the care/rehabilitation divide is not possible, as everyone has a combination of both at all times.
On the other hand it must also be remembered that the care process can also be therapeutic. Supervising someone and ensuring the avoid a fall when transferring is, at first glance, caring but encouraging carers to do this rather than hoisting the person or always giving hands-on care makes it a therapeutic caring activity, because eventually the person may no longer need supervision.