The individual model of disability

STAGE 2 DENIAL. A refusal to accept that complete recovery will not take place.
STAGE 3 ANGER. Often projected towards those physically active around them who serve as constant reminders of what has been lost.
STAGE 4 DEPRESSION. A realistic and most appropriate response to a condition of severe and permanent disability and a necessary stage if adjustment, rehabilitation and integration are to be achieved.
Thus the social work task is to help disabled individuals through these adjustment stages.
Albrecht characterises this and various other schemes as developmental models and argues that they all, at least partially, assume that:
1. an individual must move sequentially through all of these stages to become fully socialised;
2. there is but one path through the stages;
3. an individual can be placed clearly in one stage by operational criteria;
4. there is an acceptable time-frame for each stage and the entire process;
5. movement through the system is one way, that is, the system is recursive.
It is not just in the case of spinal-cord injury that such models are considered appropriate, for there are certainly similar ideas in the area, for example, of blindness. According to Carrol, 'loss of sight is dying. When in the full current of sighted life blindness comes on a man, it is the end, the death, of that sighted life'.
In order to come to terms with this death, Fitzgerald identified four distinct phases in the typical reaction to the onset of blindness: disbelief, protest, depression and recovery. And indeed these become models for professional practice. For example, a young newly-blinded woman was told by a social worker in hospital that she could not have adjusted properly to her blindness as she was not depressed enough. Subsequent social work intervention was thus based on the need to work through this (non-existent) depression despite the fact that the woman involved was more concerned with problems about whether she would be able to continue in her job as a teacher, whether she would be able to continue to live alone and what aids she might need.
There are a number of general criticisms that can be levelled at individualistic theories or explanations. First, these theories implicitly picture the individual as determined by the things that happen to him or her - the adjustment to disability can only be achieved by experiencing a number of these psychological mechanisms or by working through a number of fixed stages. Second, adjustment is seen as largely an individual phenomenon, a problem for the disabled person, and as a consequence the family context and the wider social situation are neglected. Finally, such explanations fail to accord with the personal experiences of many disabled people who may not grieve or mourn or pass through a series of adjustment stages.
Further, it is not just those with spinal-cord injury who question such models. Clark, who lost his sight as a result of a war injury, states:
The loss of sight need not and usually does not touch the core of a man's intellect and emotional being. What has changed is his relationship with the external world, a relationship with which he had grown so familiar that he scarcely thought of it.
At this stage the very words we use about blindness become a little dubious. It is of course right to describe a war casualty as having been 'blinded', because the word conveys an idea of the violence of the event. There-after, however, he simply thinks of himself as lacking the visual sense images to which he had formerly been accustomed. It is something negative that has to be allowed for. He may at times refer to himself as being 'blind' so as to conform with verbal habits of the rest of the public. But privately he does not think of it in that way. Only when he falls into the pattern of ideas that others have of him, does he feel of himself as being 'in darkness'.
Despite these criticisms, it would be true to say that these theories have made up the dominant, individual model of disability and this in itself needs to be explained. A major factor in this is that these theories are in accord with 'the psychological imagination' in that theorists who have imagined what it would be like to become disabled have assumed that it would be a tragedy and hence decided that such an occurrence would require difficult psychological mechanisms of adjustment. However, the psychological imagination may not be an appropriate starting-point for such theorising or research - it is surely a value judgement to assume that disability is a tragedy rather than that it is a phenomenon which may be explained in a number of ways. In the following chapter different meanings associated with disability will be discussed in more detail.
Another factor is that these explanations, being individualistic, are thereby politically convenient. When a disabled person fails to internalise the rehabilitation goals set by the professionals or persistently pesters his local social services department, he can be characterised as having problems in adjusting to his disability. This conveniently leaves the existing social world unchallenged; the goals of the rehabilitator remain unquestioned and the failure of the welfare department to provide the right assistance can be ignored.
While these and other factors may explain the adherence to these psychological theories, they do not explain why these theories have been empirically validated by a number of studies. In fact these theories may become self-fulfilling in at least two ways. At a methodological level, having conditioned research in the sense that they posit adjustment to disability as a problem, researchers then ask questions relevant to that problem and get answers which are then presented as findings, valid social facts. Prior to the criticisms of this model by disabled people there had been few, if any, studies which started out with the assumption that disability was not a problem. The following quote nicely illustrates the point:
Reflection on the many problems to which the cord injured person must make an adjustment impresses one with the gravity of the psychological processes which occur following cord injury.
Such an individual is confronted with grieving over his loss, coping with pain and phantom sensations, alterations in sexual functioning, loss of bladder and bowel control, the frustrations of immobilisation, loss of vocational goals and earning capacity, feelings of uselessness, role reversals in the family and the attendant loss of self-esteem and the social stigma of being 'different' in the public eye. It is an amazing tribute to the flexibility and magnificence of the human spirit that so many people whose lives are thus devastated survive and function at the level of physical and social independence which most cord injured people achieve.
This quote accurately reflects the process of 'sanctification' of disabled people which is deeply embedded in the social consciousness and reinforced through stereotyped media presentations. There is a polar opposite of this image which presents disability as a tragedy and personal disaster. As Shearer suggests:
The 'norm' demands that people whose disabilities are obvious and severe must be at least 'sad' and even 'tragic'. And if that defence breaks down in the face of individual reality, it is ready with its own flip-side. The reaction of people who break out of the mould becomes: 'Aren't they wonderful?'
In view of these images it is understandable that social workers are reluctant to get involved, for the scope of professional intervention with super-heroes or tragic victims must appear somewhat limited. However, the basic point remains: instead of questioning social reality with regard to disability; researchers simply proceed on the basis of taken-for-granted everyday meanings. But as so many paraplegics and blind people are able to function at a reasonable level, it is surely more logical to assume that this is a normal everyday reaction. To put the matter simply, adjustment may be normal and not a problem at all. And yet there had been few studies which started from the assumption of disability as normality prior to Shearer and Finkelstein.
There is a second way in which these theories may become self-fulfilling in that they may actually create the reality they purport to explain. In the case of mental illness it has been shown that psychiatrists impose their own definitions of the reality of particular problems upon their patients. Similarly in the study of criminal behaviour it has been shown that criminals will often verbalise theoretical explanations picked up in sessions with psychiatrists, psychologists and welfare workers as excuses for their behaviour even in compulsive crimes like pyromania, kleptomania and child molesting. With regard to disability, many disabled people will have contact with the theories described above, not through meeting academic psychologists or participating in research projects, but through the everyday contact with professional workers who are also internalising these theories.
Professional journals have tended to disseminate these theories widely. An article in Occupational Therapy argued not only that individuals must experience the phases of shock, denial, turbulent aggression and working through, but also that there are a number of adaptations that patients must make, including adaptations in body-image, adaptation in roleimage, loss of security and loss of self-esteem. A practising social worker expressed the following sentiments:
Patients must be allowed to come to terms, they must grieve and mourn for their lost limbs, lost abilities or lost looks and be helped to adjust to their lost body-image. Personally, I doubt if anyone who has not experienced the onset of irreversible disability can fully understand the horror of the situation.
Finkelstein, himself disabled, has argued that the use of such concepts is nothing less than the imposition of standards of able-bodied normalcy upon the meaning of disability for disabled individuals, partly engendered by the 'helper/helped' relationship:
The attitude that a disabled person has 'suffered' a personal loss is a value judgment based upon an unspoken acceptance of the standard being able-bodied normalcy. But attributing loss to disabled people is not just the whim of certain helpers. The existence of helpers/helped builds into this relationship normative assumptions. 'If they had not lost something they would not need help' goes the logic' and since it is us, the representatives of society doing the help, it is this society which sets the norms for the problem solutions'.
What is being suggested is that the psychological mechanisms and processes that research has identified and described are themselves the product of that research activity both as a result of its methodological predispositions and the spread of this knowledge to professionals who are then able to impose this definition of reality upon their clients. This is beautifully captured by Trieschmann, who asks:
Is it possible that some of the publications that professionals have written reflect the requirement of mourning? Have professionals seen more stress and psychological difficulty than actually is present? Have professionals uncritically applied terms and theoretical concepts from the field of 'mental illness' to describe the 'normal reaction to an abnormal situation' which onset of spinal injury represents? Have professionals been describing phenomena that do not exist? Have professionals in clinical interactions placed disabled persons in a 'Catch 22' position? If you have a disability, you must have psychological problems: if you state you have no psychological problems, then this is denial and that is a psychological problem. And because this is so, have psychologists, psychiatrists, social workers and rehabilitation counsellors lost credibility with other rehabilitation personnel and with persons who have spinal cord injury, and rightly so?
And it is not just a matter of losing faith but, as she points out, disabled people 'have felt victimised by professionals who write articles about the reactions to spinal cord injury that are based more on theory than fact.
The unquestioning use by social work of psychological and physiological explanations of disability has been reinforced during the 1990s, a period in which welfare has been technologised. The process of compartmentalising and coding 'abnormality' that is derived from the individual model and that drives the World Health Organisation's (1980) International Classification of Impairment, Disability and Handicap (ICIDH), becomes attractive and administratively convenient to welfare managers who are keen to account for what has always been the difficult to define practice of social work. The introduction of new technology with an algorithmic basis of analysis naturally leads to the selection of explanations that permit some quantifiable form of linking behaviour and need. Rather than seeking to understand the nature of the relationship between impairment and disability, the instrumentally-driven bureaucratic processes that prevail seek an analysis that is compatible with the technology, and therefore it is of little surprise that the use of such classification systems are promoted as the way forward for social welfare.
Despite the long-standing criticisms, it is clear that the individual model remains the dominant one with regard to disability and it has perhaps taken on the attributes of what Kuhn has called a 'paradigm'- that is, a body of knowledge to which all those working in the field adhere. However, the same writer has shown that paradigms are sometimes replaced or overthrown by 'revolution', and this revolutionary process is often sparked by one or two criticisms of the existing paradigm. Only then can a new paradigm develop to replace the old. Having provided one such criticism, it is now worth considering what a new paradigm - a 'social model' of disability - might look like.