Rehabilitation: a Norwegian expert asks if it's still a useful concept?
By Johans Sandvin, Chair of the Norwegian State Council on Disability
Introduction
Not many normative concepts have survived the ideological shifts in health- and social services we have witnessed over the last decades. One of them, however, is rehabilitation. Indeed, many would argue that rehabilitation is an antiquated concept that should have been swept out of the vocabulary decades ago. Some would say that it is not only the concept that is out-of date, but also the content and values that it imparts. Still, rehabilitation conferences seem to gather more people than ever before and not only health professionals. At a rehabilitation conference today you are also likely to meet social workers, teachers, cultural workers, technicians, and quite a few researchers, like ourselves. Even users of rehabilitation services and representatives for various disability organizations are likely to show up at such conferences, even though the enthusiasm seems to be more tangible among professionals. What is it about rehabilitation that exerts such a strong attraction on professionals, even to day?
One obvious answer is the strong and rapid increase we have seen in the number of people participating in long-term sick leave, rehabilitation and disability pension programs. The exclusion of people from the labor market place heavy burdens on government budgets, and it is a central goal in welfare policy in all western countries that workfare should be preferred to welfare. Thus, there is a growing need for rehabilitation in order to ease the financial burdens of the state and to secure the future need of labor. Although, rehabilitation with work as the desired outcome is the main focus for these policies, the scope of rehabilitation is much wider and calls for a new and revitalized concept and practice.
The question, however, is whether the concept "rehabilitation" is beyond rescue, or whether it is possible to revitalize it by updating its content and connotations in a way that makes it more in line with the requirements and challenges we are facing at the dawn of the 21st century. The next question is how such an "update" will affect the current professional enthusiasm about rehabilitation.
Body fixing and repair
Both as a concept and as practice, rehabilitation is fundamentally modern in nature. With regard to individuals (and not buildings or institutions), rehabilitation is commonly defined as the restoring of previous functions, abilities or dignity. As a professional practice, rehabilitation seemingly rests upon the assumption that there is a causal link between bodily (and mental) functionality or ability on the one hand, and dignity on the other, which has from its very beginning placed medicine in the leading position. Even to day, being a low-prestige area of medicine, rehabilitation medicine practitioners in many countries try to distance themselves from semi-professional practices, in order to cultivate a more purely medical, academic and "evidence based" rehabilitation discipline.
Thus, as a social practice, rehabilitation is traditionally a repairing, correcting and body fixing practice, based on clear distinctions between sick and healthy, normal and abnormal, functional and dysfunctional, abled and disabled. The legitimization of rehabilitation practices was based on such distinctions being collectively shared representations of reality, and on the modernistic vision of doing away with all sorts of disorder. The very essence of modernity, the British sociologist Zygmunt Bauman argues, is the practice of ordering.
The dawn of a new era?
Over the last couple of decades the goal or purpose of rehabilitation has gradually shifted, from bodily functioning and correction in itself - or the restoring of people's capacity for work - to a stronger emphasizes on participation, self-determination and equal opportunity. One of the recommendations from a global conference on "Rethinking Care", which Norway hosted in 2001 on behalf of the World Health Organization (WHO), was that the primary goal of all rehabilitation programs must be the equalization of opportunities for all disadvantaged people.
The problem, however, is that rehabilitation - the concept as well as the practice - in most countries is still heavily rooted in a medical model, were bodily (and mental) functioning is seen as the presupposition for participation and self determination. It is still medical diagnoses that serve as eligibility criteria for rehabilitation services, which keeps the medical professions at the top of the rehabilitation hierarchy.
But what we should have learned by now is that it is not the impairment that first and foremost limits people's participation in society, but the way in which the society is organized. When a child goes to a special school, it is not because the child has an intellectual impairment, but because the community school does not welcome children with intellectual impairment. When a man in a wheelchair cannot enter the bus, it is not because he uses a wheelchair, but because the bus is inaccessible. That is not to say that medical services or other forms of therapy and treatment are of no importance to people with impairments. What we say is that it is not always important, and it is seldom sufficient to secure people equal opportunity to participation. Some times it is not even relevant at all.
Rehabilitation for the 21st Century?
The scope of services and measures that people with impairments need to obtain the same opportunities as others regarding participation in society, will differ from person to person. And if the aim of rehabilitation is equal opportunities to participation, it must contain whatever necessary to assist people to obtain just that. This means that rehabilitation cannot have a definite content. Rehabilitation can neither be a professional nor an institutional practice. It is not some specific services that are rehabilitation, because services cannot in themselves comprise rehabilitation. Instead services and measures become rehabilitation when they form a necessary part of a purposeful strategy to assist a person's effort to achieve his or her own defined goals. Thus, rehabilitation in this meaning could never be a standardized activity and will have to be constituted or defined again and again in accordance with the individual person's own goals and needs. Rehabilitation is whatever it takes to support and fulfill these goals.
This is, as we see it, the necessary consequence of shifting the aim of rehabilitation from the improvement of bodily functions, to participation and the equalization of opportunities. The question is how this will affect the professional enthusiasm that rehabilitation currently enjoys. Some of the health and medical professions might feel their exceptional position somewhat threatened. However, this conception of rehabilitation does not imply a power shift between professions, but between the service system and the user. It is the needs and preferences of the user that define the content of rehabilitation. And that should, according to the health and medical professions own stated values, make it easier to accept?
Nevertheless, if rehabilitation does have a future, the question should no longer be which profession that is most important, or represent the best or most relevant perspective. The question should now be how to organize services and practices in accordance with this understanding - a practice that respond to person's individual needs and preferences, and facilitate a true interdisciplinary assistance to peoples own endeavor. The final question is whether rehabilitation as a concept will survive such a shift in perspective. But if not, we must save the perspective, not the concept.
|
