MMD-081

Perspectives on
Disability
Indira Gandhi National Open University
National Centre for Disability Studies

Block

2
CONCEPT OF DISABILITY AND
REHABILITATION
UNIT 1
Definition of Disability and Concept of Impairment
Disability and Handicap 5
UNIT 2
Nature and Needs of Persons With Disability 15
UNIT 3
Concept and Evolution of Rehabilitation 30
UNIT 4
Paradigm Shift in Rehabilitation 50
Expert Committee
Dr. Latha Pillai Prof. Manmohan Singh Dr. Saroj Arya
Pro-Vice Chancellor Retd. Professor of Psychology Retd. Head, Dept. of Rehabilitation
IGNOU, New Delhi Usmania University, Hyderabad Psychology, Andhra Pradesh
Prof. S.P. K. Jena Prof. C.L. Kundu Prof. Yashvir Singh
Dept. of Applied Psychology Retd. Vice Chancellor Retd. Head of Department
South Campus Kurukshetra University Dept. of Psychology
Delhi University Agra
Prof. (Mrs). Amulya Khurana Dr. Seema Bhattacharya Dr. J.P. Singh
Dept. of Psychology Psychologist Member Secretary
IIT, Delhi Prayas, Jaipur Rehabilitation Council of India
New Delhi
Prof. J.P. Mittal Dr. S.K. Mishra Dr. Hemlata
Psychologist Dy. Director Dy. Director
Retd. Professor Rehabilitation Council of India NCDS,IGNOU
NCERT New Delhi New Delhi
Dr. S.K. Prasad Dr. Amiteshwar Ratra
Dy. Director Research Officer
NCDS,IGNOU NCDS,IGNOU
New Delhi New Delhi

Acknowledgement
We express our heartfelt gratitude to the Dr. Latha Pillai, Pro V.C., IGNOU for her
constant guidance and support in the initiation and development of this programme
of study.

Programme Coordinator Programme Consultant

Dr. S.K. Prasad Ms. Ngashangva Pamyaphy
Deputy Director Consultant
NCDS, IGNOU, New Delhi NCDS, IGNOU, New Delhi

Block Writer Block Editor Format Editor

Dr. Saroj Arya Dr. S.K. Prasad Dr. S.K. Prasad
Retd. Head, Dept. of Rehabilitation Deputy Director & Deputy Director &
Psychology, Andhra Pradesh Programme Co-ordinator Programme Co-ordinator
NCDS, IGNOU, New Delhi NCDS, IGNOU, New Delhi
Prof. Manmohan Singh
Retd. Professor of Psychology
Usmania University, Hyderabad

Associate Block Editor Word Processing

Ms. Ngashangva Pamyaphy Sh. Manoj Kumar
Consultant NCDS,IGNOU
NCDS,IGNOU
July, 2011
 Indira Gandhi National Open University, 2011
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BLOCK INTRODUCTION
Block 2 focuses on the concept of disability and rehabilitation. The concept and
views of disability has varied philosophies, myths and misconception, which has
evolve over the years, from ancient Greek writings, to middle ages till this modern
day scientific era. The Greek philosopher Hippocrates (460 B.C – 370 B.C) was
far ahead of his time and attributed the causes of dreaded diseases of those days
like epilepsy and mental illness to biological aberrations rather than the work of
sorcery, witchcraft, demons, spirits and curse of god which was a prevailing
notion. These myths about the causes of disabilities, like mental illness or any
congenital defects are still prevalent in our culture today. Despite scientific progress
being made in revealing the causes of various disabilities and its management, we
are still grappling with numerous issues, from definition and models of disability
to the philosophies and goals of rehabilitation, with no single comprehensive
working model on disability and rehabilitation. This implies that we are dealing
with a multifaceted problem that requires inter disciplinary endeavors from bio-
medical, social, political and religious perspective. This block will give you an
exposition on various concepts and issues on disability and rehabilitation.
Unit 1 describes the concept of disability. Defining disability lacks consensus,
however we have generally accepted terms that explains disability at different
levels; Impairment (Structural abnormality); Disability (emphasis on functional level)
and handicap (social cultural restrictions). Models of disability reflect different
areas of intervention like medical model, religious model and customer empowering
model.
Unit 2 describes the nature and needs of person with disability. We know from
the previous unit the difficulty in defining and accommodating the expectation and
nature of all disability, as we have a range of disabilities; some have periodical
manifestation, others have chronic course with or without deterioration, some of
them are not obviously visible, others have congenital defects and some are
acquired and so on. Disabled group are the most disadvantage and were deprived
of the facilities available for the general public. This unit also describes causes and
prevention of various disabilities.
Unit 3 describes the concept and evolution of Rehabilitation. Rehabilitation is
helping people with disabilities to reach and maintain optimal level of functioning.
Different models of rehabilitation that includes various perspectives (medical,
psycho-social, integrated, community based, home based, and institute based)
were discussed Areas and types of rehabilitation were also discussed.
Unit 4 explores the paradigm shift in rehabilitation. It discusses how disability as
a concept has evolved over the century, from an exclusively religious or medical
perspective to a more acceptable holistic psychosocial-medical perspective, bringing
about a change in the goals of rehabilitation. The emerging trend of moving along
the continuum of provider driven services to consumer driven demands for better
management and accessibility were also described.
UNIT 1 DEFINITION OF DISABILITY
AND CONCEPT OF IMPAIRMENT
DISABILITY AND HANDICAP
Structure
1.1 Introduction
1.2 Objectives
1.3 Concept of Disability
1.3.1 Impairment
1.3.2 Disability
1.3.3 Handicap

1.4 Concept of Impairment, Activity and Participation

1.4.1 Impairments
1.4.2 Activities and Participation

1.5 Models of Disability

1.5.1 Medical Model
1.5.2 Social Model
1.5.3 Economic Model
1.5.4 Religious Model
1.5.5 Customer/Empowering Model

1.6 Let Us Sum Up

1.7 Unit-End Exercises
1.8 Suggested Readings
Glossary

1.1 INTRODUCTION
This is the first unit of Block -2: Definition of Disability and Concept of Impairment,
Disability and Handicap.
World is constituted of different people and no matter how many times we say
that “each human being is unique”, we cannot deny the strong commonality among
all of us. Nature has given one common feature to each human being and that is
“potential”. In fact each organism is capable of performing something or the other.
It is only the difference of exploring the available capability or potential.
This unit attempts to describe the concept of disability. In India the prevalence
rate of people with disability at present is estimated to be 1.85 percent as per
recent report of NSSO (58th round Jan-Dec, 2002). This percentage might
look negligible to us but when we convert it into number of people as per
Indian population, approximately it amounts to 1.6 crore people with disabilities.
The available services for these many people are not meeting the requirement.
There is a strong need for human resource to cater to the needs of people with
disabilities.
5
Concept of Disability The objective of this unit is to elaborate on the facts related to disability and which
and Rehabilitation you can empathize with it. The experience of being disabled has definitely captured
us at some point of time, either created by self or the environment. It is not always
visible, but one knows what goes through during those moments. Disability has
always been seen as something negative, incapability and a limitation etc, but
history has proved that disability is not any of these.

1.2 OBJECTIVES
After going through this unit, you will be able:
 to describe the concept of impairment, disability
and handicap;
 to explain perspective of disability from
various views like medical, social,
economic and religious; and
 to discuss concept of impairment, activity and
participation.

1.3 CONCEPT OF DISABILITY

It is difficult to say in straight terms what disability is…..it can range from highly
subjective feeling to an objective one.
Questions and Controversies Concerning Definitions of Disability
 Is disability a physical condition that is intrinsic to the disabled person’s
body? Or is disability a disadvantage that a person with physical or cognitive
difference suffers because of society’s discriminatory attitudes and its failure
to create infrastructures accessible to people with differences?
 Is it more important for our society to strive to “cure” disabled people or to
“accommodate” disabled people?
 Are disability activist’s models of disability inclusive enough? Do they
encourage disabled people with a wide spectrum of experiences to join the
conversations about disability? Do they discuss the issues that are central to
the lives of many disabled people?
If these are the conflicts in deciding what makes a disabled different from non-
disabled, then one has to look into the following. This will help to resolve the
conflict to a great extent. The difference is of perception and concept of disability.
Marked deviations physically as well as mentally can make a person stand out of
the average group.
World Health Organization (WHO) defines three key terms which helps in
6 understanding the concept of disability.
Impairment: Impairment is any loss or abnormality of psychological, physiological Definition of Disability and
or anatomical structure or function. Concept of Impairment
Disability and Handicap
Disability: A disability is any restriction or lack (resulting from an impairment) of
ability to perform an activity in the manner or within the range considered normal
for a human being.
Handicap: A handicap is a disadvantage for a given individual, resulting from an
impairment or disability that limits or prevents the fulfillment of a role that is
normal, (depending on age, sex, and social and cultural factors) for that individual.

1.3.1 Definition of Disability

The International Labour Organisation (ILO) defines a person with disability
as an individual whose prospects of securing, retaining and advancing in suitable
employment are substantially reduced as a result of a duly recognised physical or
mental impairment.
According to Helander’s definition “a disabled person is the one who in his or
her society is regarded or officially recognized as such, because of a difference
in appearance and/or behavior, in combination with functional limitation or an
activity restriction”

1.3.2 Models of Disability

After defining the concept of disability, we will now describe the various models
of disability.
1.3.2.1 Medical Model of Disability
According to the “medical model”, disability is “…a negative variation from the
physical norm that necessarily disadvantages the physically distinct subject’s life
and life quality” (Koch). In other words, according to the classic medical notion
of disability:
 disability is a physical condition
 it is intrinsic to the individual (it is part of that individual’s own body)
 it reduces the individual’s quality of life and causes clear disadvantages
 a disabled person is different from what is normal (and her condition is less
desirable than what is normal)
 a compassionate or just society will put resources into trying to cure disabilities
 the medical profession has the greatest responsibility and potential for helping
disabled people
This traditional view of disability is called “the Medical Model of Disability”,
because it sees people as medical problems. As a result disabled people are
expected to see their impairment as their problem, something they will have to
make the best of and accept that there are many things they cannot do.
1.3.2.2 Social Model of Disability
During the last few decades, the field of disability studies has been dominated by
the emergence of the social model of disability. Disability, according to the social 7
Concept of Disability model, is “…a social discrimination that limits opportunities of persons of
and Rehabilitation
difference....[and] results only when physical difference is not accommodated by
society” (Koch).

The social model of disability starts from a different perspective. It ignores how
“bad” a person’s impairment is. Instead it establishes that everyone is equal and
demonstrates that it is society which erects barriers that prevent disabled
people participating and restricts their opportunities. The social model looks beyond
a person’s impairment at all the relevant factors that affect their ability to be a full
and equal participant in society.

The social model of disability enables disabled people to look at themselves in a

more positive way which increases their self-esteem and independence. People
with disability often feel a loss, for all the things they would like to do, but cannot;
a loss of goals and dreams that seem unobtainable. Disabled people often feel
they are a burden on family and friends, and a problem for doctors who cannot
cure them.

Every disabled person faces many barriers that limit their participation in the
society. When these barriers and other people’s negative attitudes are considered,
it is easy to see how disabled people’s opportunities are limited by a multitude of
barriers.

The social model of disability states that the solution is to rid society of these
barriers, rather than relying on curing all the people who have impairments. (in
many case this is not possible or desirable)

For example, people with poor eyesight are given a simple piece of equipment
- a pair of glasses. Without them they would be excluded from full participation
in society and would therefore be disabled.

1.3.2.3 The Economic Model

Under this Model, disability is defined by a person’s inability to participate in

work. It also assesses the degree to which impairment affects an individual’s
productivity and the economic consequences for the individual, employer and the
state. Such consequences include loss of earnings and payment for assistance by
the individual; lower profit margins for the employer; and state welfare payments.

The Economic Model is used primarily by policy makers to assess distribution of

benefits to those who are unable to participate fully in work. The problem for the
users of Economic Model is one of choice. Which is better: to pay the disabled
employee for loss of earnings, or the employer for loss of productivity? The first
carries stigma for the disabled person by underlining their inability to match the
performance of work colleagues. With the latter, difficulties arise in correctly
assessing the correct level of subsidy. The productivity of a disabled employee
may well change, as well as the marginal costs of the total workforce.

1.3.2.4 Religious Model

The Religious Model views disability as a punishment inflicted upon an individual

or family by an external force. It can be due to misdemeanors committed by the
disabled person, someone in the family or community group, or forbearers. Birth
conditions can be due to actions committed in a previous reincarnation.
8
Sometimes the presence of “evil spirits” is used to explain differences in behaviour, Definition of Disability and
especially in conditions such as schizophrenia. Acts of exorcism or sacrifice may Concept of Impairment
Disability and Handicap
be performed to expel or placate the negative influence, or recourse made to
persecution or even death of the individual who is “different”.

It is an extreme model, which can exist in any society where deprivation is linked
to ignorance, fear and prejudice.
1.3.2.5 The Customer/Empowering Model
This model lays emphasis on participatory role of persons with disability in
policymaking, this is the opposite of the Expert Model. Here, the professional is
viewed as a service provider to the disabled client and his or her family. The client
decides and selects what services they believe are appropriate whilst the service
provider acts as consultant, coach and resource provider.
Recent operations of this model have placed financial resources into the control
of the client, who may choose to purchase state or private care or both.
All the welfare schemes and programmes should lead to the empowerment of
persons with disabilities. They should be involved in all decision making processes,
be it education, intervention, vocation and independent living.
The recent United Nations convention on Rights of Persons with Disabilities
(2008), promulgated the slogan:
“Nothing about Us without Us”
The above Discussion about different perspectives of disability would have helped
you to understand that in the recent era of rehabilitation psychology, the social
model has been reinforced a lot. When disability is defined as a natural and
beautiful part of human diversity, that people living with disabilities can take pride
in. It is a belief by most people with disabilities that the barrier to be overcome
is not disability; it is societal oppression and discrimination based on biological
differences (such as disability, sex, race, age, sexuality, etc).
 Change the way people think about disability
 Break down the internalized shame among people living with disabilities, and
 Promote the belief in society that disability is a natural and beautiful part of
human diversity that people living with disabilities can take pride.

 Check Your Progress 1

Note: Write your answers in the space given below:
i) How model or a theory assists in the understanding of disability?
................................................................................................................
9
................................................................................................................
Concept of Disability ii) Differentiate between impairment, disability and handicap?
and Rehabilitation
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1.4 CONCEPT OF IMPAIRMENT, ACTIVITY

AND PARTICIPATION
The most recent approach to understand
disability is the understanding of activity.
A person is disabled because he or she
can not execute a task in a given way.
The degree of participation which results
due to any impairment can cause feeling
of disability in any human being. Now
we are going to discuss the interaction
among impairment, activity and
participation (Fig. 1). We will also discuss
how environment both social as well as
physical play a role in causing restriction
of participation.
1.4.1 Impairments
Impairments are problems in body function or structure as a significant deviation
or loss. These are the manifestation of an underlying pathology. It can be temporary
or permanent; progressive, regressive or static; intermittent or continuous; mild to
severe.
1.4.2 Activities and Participation
Activity is the execution of task or action by an individual. Activity gives a meaning
to life. It makes any person feel of worth for his life. Activity provides a physical
and mental satisfaction. It is a means of communication between body and the
environment. Activity has a direct relation to all basic emotions of life. The functional
capability of an individual makes him successful or unsuccessful. Figure 2 explains
in a graphical presentation that how body structure and person’s level of activity
are influenced by the environmental factor and hence deciding the social
participation.

10
Participation is involvement in a life situation. Activity limitations are difficulties an Definition of Disability and
individual may have in executing activities. Participation restrictions are problems Concept of Impairment
Disability and Handicap
an individual may experience in involvement in life situations.
Activity and participation are two sides of a same coin. It is very important for
any person to have a self esteem or feeling self worth. Performing the given role
in life is the contribution from an individual to his society. A person with disability
has already restrictions in execution of a task, on that if participation restrictions
are also eminent than it directly leads to a feeling of worthlessness, left-out,
incapability and hence of being disabled. The main constructs of this aspect are
capacity, performance, and environment.
Thus in the life of person with disability, the role of environment and person himself
are complementary.
A situational factor has two components (Fig 3):
1) Personal factors
2) Environmental factors
Personal factors are those which result due
to the impairment of an individual.
Environmental factors are external factors that make up the physical, social and
attitudinal environment in which people live and conduct their lives

Figure 4:
Environmental factors form part of both the immediate and distant or background
environments. Environment and functioning has direct relation with each other. Any
manifestation of latent health condition may occur through impact of environmental
factors. Even aggravation of existing impairment or activity limitation within an
environmental context may result. Figure 4 clearly depicts how the condition of
disablement is related to all three concepts.

 Check your Progress 2

Note: a) Put to tick 3 to the correct answer.

i) “A negatively variant physical condition which affects the physically variant

subject’s life” this point of view towards disability is given by

a. Medical Model

b. Social Model 11
Concept of Disability c. Economic Model
and Rehabilitation
d. Religious Model
ii) An impairment can be
a. Temporary or permanent
b. Progressive or regressive
c. Intermittent or continuous
d. All of these
iii) Level of social participation is decided by following factors
a. Body Structure
b. Level of activity
c. Body structure, level of activity and environmental factors.
d. Social acceptance

1.5 LET US SUM UP

1. Disability is any restriction or lack (resulting from impairment) of ability to
perform an activity within the range considered normal for a human being.
2. Impairment is at the body structure level.
3. Disability occurs at the functional level.
4. Handicap occurs at the social level.
5. Disability can be perceived from medical, social and economical point of
view.
6. Most recent approach of understanding disability is the understanding of
activity.
7. The functional capability of a human being makes his life successful, hence
it is important to understand activity and participation in the context of disability
8. Body structure and level of activity of a person are influenced by the
environmental factors.
9. A situational factor considers both environmental as well as personal factors.

1.6 UNIT END EXERCISES

i) Collect two case histories of people with disability and make a list of their
impairment, disability and handicaps. Also make a list of activity and analyze
how their participation in it is affected due to their condition.
........................................................................................................................
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12
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ii) Define disability. Critically evaluate models of disability. Definition of Disability and
Concept of Impairment
........................................................................................................................ Disability and Handicap

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1.7 SUGGESTED READINGS

i) Berkowitz, E., and D. Fox. The politics of social security expansion: Social
security disability insurance, 1935–1986. Journal of Policy History 1989;
1(3):233-260.
ii) Caplan, A. L. Is medical care the right prescription for chronic illness? In:
S. Sullivan and M. E. Lewin (eds.), The Economics and Ethics of Long-
Term Care and Disability. Lanham, Md.: University Press of America, 1988,
pp. 73-89.
iii) Engelhardt, H. T. The concepts of health and disease. In: A. L. Caplan, H.
T. Engelhardt, and J. J. McCartney (eds.), Concepts of Health and Disease.
Reading, Mass.: Addison-Wesley, 1981, pp. 31-45.
iv) Foucault, M. The Birth of the Clinic, A. M. S. Smith, trans. New York:
Random House, 1973.
v) Haber, L. D. Issues in the Definition of Disability and the Use of Disability
Survey Data. Presentation at the Workshop on Disability Statistics of the
Committee on National Statistics, National Research Council, Washington,
D.C., 1989.
vi) Institute of Medicine. National Agenda for the Prevention of Disability.
Washington, D.C.: National Academy Press, forthcoming.
vii) Institute of Medicine. Pain and Disability: Clinical, Behavioral, and Public
Policy Perspectives. M. Osterweis, A. Kleinman, and D. Mechanic (eds.),
Washington, D.C.: National Academy Press, 1987.
viii) Jennings, B., D. Callahan, and A. L. Caplan. Ethical challenges of chronic
illness. Hastings Center Report 1988; 2(Suppl.):1-16.
ix) Katz, S. Assessing self-maintenance: Activities of daily living, mobility, and
instrumental activities of daily living. Journal of the American Geriatrics Society
1983; 31(12):721-727.
x) Kundu C.L. (2005) Disability Status in India.
xi) Markowitz, G., and Rosner, D. The illusion of medical certainty: Silicosis and
the politics of industrial disability, 1930–1960. Milbank Quarterly 1989;
67(2, Part 1):228-253.
xii) Nagi, S. Z. Some conceptual issues in disability and rehabilitation. In:
M. OCR for page 32
xiii) S. Linton, (1995). Claiming Disability: Knowledge and Identity. NY: New
York University Press, 199 pp. 13
Concept of Disability Internet References
and Rehabilitation
http://www.southamptoncil.co.uk/social_model.htm
http://www.indiatogether.org/2004/sep/hlt-cagdisabl.htm
http://www.apcdproject.org/Countryprofile/india/india_current.html

GLOSSARY
Impairment : Impairment is any loss or abnormality of
psychological, physiological or anatomical structure
or function.
Disability : A disability is any restriction or lack (resulting from
an impairment) of ability to perform an activity in
the manner or within the range considered normal
for a human being.
Handicap : A handicap is a disadvantage for a given individual,
resulting from an impairment or disability that limits
or prevents the fulfillment of a role that is normal,
(depending on age, sex, and social and cultural
factors) for that individual.
Environmental factors : are external factors that make up the physical,
social and attitudinal environment in which people
live and conduct their lives

14
 Nature and Needs of Persons
UNIT 2 NATURE AND NEEDS OF with Disability

PERSONS WITH DISABILITY

Structure
2.1 Introduction
2.2 Objectives
2.3 Disabilityin India
2.3.1 The Disability Scenario
2.3.2 Rural and Urban
2.3.3 Gender

2.4 Concept of Incidence and Prevalence

2.4.1 Incidence
2.4.2 Prevalence
2.4.3 Persons with Disabilities, Prevalence Rates
2.4.4 Persons with Disabilities, Incidence Rates
2.4.5 Persons with Disability, Onset of Disability Since Birth
2.4.6 Persons with Disabilities, Severity
2.4.7 Persons with Disabilities, Types and Magnitude

2.5 Causes of Disabilities

2.5.1 Prenatal Causes of Disabilities
2.5.2 Perinatal Causes of Disabilities
2.5.3 Childhood Causes of Disabilities

2.6 Prevention and Early Detection Measures

2.7 Unit Summary
2.8 Unit End Exercise
References
Glossary

2.1 INTRODUCTION
Society values uniformity rather than diversity. Thus we tend to see ourselves as
‘normal’or‘deficient’. Thepotential ofhomogeneitylies in thepossibilityof redefining
society’s concept of ‘normalcy’. When people are given the right to belong, they are
given the right to diversity.
Defining disabilityis difficult to accommodate the expectations of all disabled groups.
There are hundreds of different disabilities and there are, as many causes for these
disabilities. Some people are born with disabilities; others become disabled later on
in theirlives.Somedisabilities exhibitthemselves onlyperiodicallylikefits andseizures;
others are constant conditions and are life-long. The severity of some stays the
same, while others get progressively worse like muscular dystrophy and cystic
fibrosis. Some are hidden and not obvious like epilepsy or hemophilia (impairment
of blood clotting mechanism). Some disabilities can be controlled and cured while
others still baffle the experts. Thus, findinga consensus on the different and frequently 15
Concept of Disability varying definitions of disabilities, whether sophisticated or practical, has never been
and Rehabilitation
easy. Some include total or partial impairment of senses and physical and intellectual
capacities while defining disability. Others refer to a handicap or deviation of a social
nature, injury or illness or incapacities to accomplish physiological functions or to
obtain or keep employment. These definitions also reflect the consequences for the
individual cultural, social, economic and environmental- that stem from the disability.
At 00.00 hours of 1st March 2001 the population of India stood at
1,027,015,247 comprising of 531,277,078 males and 495,738,169 females.
Thus, India becomes the second country in the world after China to cross
the one billion mark.
Office of the Registrar General and Census Commissioner, India PRESS RELEASE, Dated
the 26th of March, 2001, New Delhi, PROVISIONAL POPULATION RESULTS - CENSUS
OF INDIA 2001

The magnitude of disability is vast and its impact on the individual, family and
communityis severe. The most vulnerable groups among the persons with disabilities
include very young children, children in general, women and senior citizens with
disabilities. The Persons with Disabilities in India form largest disadvantaged group
like in most countries of the world.As a group they are starved of the usual services
and facilities available to the general public as they have been subjected to long
history of neglect, isolation, poverty, deprivation and at times pity as well. They yet
do not have an effective economic, political or media power in India. These persons
frequently live in poor conditions, owing to inadequate facilities of health, hygiene,
poor means of transport and communication thus; theyfind it difficult to get their due
share.

2.2 OBJECTIVES
After going through this unit, you will be able:
 To describe the relevance of enumeration in the field of disability.
 To discuss the various types of disability and its impact.
 To describe causes of various disabilities and the measures for prevention of
the same.

2.3 DISABILITY IN INDIA

There is no universallyagreed definition of disability. Historically, disabilityhas been
seen primarilyas a medical condition – a problem located within the individual. The
Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation)Act 1995 defines disabilityas one or more of the following: blindness,
low vision, leprosycured, hearingimpairment, locomotordisability, mental retardation
and mental illness. It says that to be considered disabled, a person must suffer from
not less than 40 per cent of any disability as certified by a medical authority. The
medical understanding of disabilityclearly informs the act, but its tight and selective
definitions of disability, and its 40 per cent threshold, means that some keydisabilities,
16 such as autism and other spectrum disorders, haemophilia, thalassaemia, severe
facial disfigurement, and individuals with more mild disabilities, are excluded. Nature and Needs of Persons
(Mainstreamingdisabilityindevelopment: Indiacountryreport,DisabilityKaR,DFID) with Disability

In Indiathe terms ‘impairment’and‘disability’are often usedsynonymously. However

with the social understanding of disabilitygaining widespread acceptance most of us
are beginning to realize the importance to make a distinction between the two terms.
2.3.1 The Disability Scenario
The estimation of disabilityvarya great deal but for policyformulation and provision
of services it is vitally important that reliable estimates of incidence and prevalence
of various disabilities are made in line with accepted definitions of various categories
of disabilities. However, disability is not a well defined condition, and there are
many terminological and conceptual difficulties. This means that the data should be
used with a degree of caution.
In India the disability information has been collected through sample surveys and
censuses. The most recent being the Census of India in 2001 and the National
Sample Survey Organisation (NSSO) which conducted a survey of ‘Persons with
disabilities in India’ during 58th round (July - December 2002).
According to Census 2001 the total number of disabled in India was reported at 21
million which constitute more than 2 percent of total population. The data reported
by the Census 2001 is proportionately high when compared to data reported by
NSSO 2002. The NSSO estimated the number of persons with disabilities in the
country to be 18.49 million which formed about 1.8 per cent of the total population.
Due to the differences in the definitions of disability used by the two institutions
namely the Census of India and National Sample Survey Organizations the data
reported are not comparable.
Secondly, if we look at types of disabled in India as estimated by two organizations,
according to the Census of India the proportion of Seeing Disabled in total disable
population is 48.55 percent, where as according to NSSO, their proportion is 15
percent. Similarly in case of people with Movement Disabled, census estimates at
27.87 percent of total disabled population, where as NSSO estimates them at 57.51
percent. Thus according to Census of India disabled with seeing disabilities are
leading in number in India, where as according to NSS disabled with locomotor
disability are leading. Similarly there are differences in estimates in case of other
disabilities as well.
Table 1: Estimated Number of Persons with Disabilities in India
NSSO 2002 Male Female
Total % Nos % Nos %
Locomotor Disability 10634000 58 6633900 36 4000100 22
Hearing Disability 3061700 17 1613300 9 1448400 8
Speech Disability 2154500 12 1291100 7 863400 5
Blindness 2013400 11 928700 5 1084700 6
Mental Illness 1101000 6 664500 4 436500 2
Mental Retardation 994700 5 625800 3 368900 2
Low vision 813300 4 369300 2 444000 2
Any disability 18491000 100 10891300 59 7599700 41
17
Source: NSSO 58th round (Jul-Dec 2002)
Concept of Disability For budgeting purposes, the Planning Commission uses a figure of 4 per cent of the
and Rehabilitation
population as being disabled. However, the real figure could be substantially higher.
Organisations working in disability do not consider the census data to be accurate.
The reasons for the low figures in the census and sample surveys include:
 Families protective/ hesitant to acknowledge the presence of disabled household
members
 Inabilityof families to identifymild disabilities
 Lack of appropriately trained enumerators
 Women being less likely to see themselves as disabled than men. (Erb and
Harriss-White 2002, Mohapatra and Mohanty 2004)
 Inabilities due to old age not being associated with disability
2.3.2 Rural and Urban
Despite its shortcomings, the census and sample survey clearly reveals that the
majority of India’s persons with disabilities live in rural areas, the Census 2001
indicates 75% and the NSSO 58th round 2002 indicates 73% persons with disabilities
are from rural areas. The incidence rate, prevalence rate of disabilities are marginally
higher in rural areas. India is a land of diversity and disparities. Insensitivity to the
needs of persons with disabilities, lack of opportunities isolating persons with
disabilities from the rural and urban communities appears to be almost uniform.
However unlike in the rural, persons with disabilities from the cities have more access
to rehabilitation and support services. Here again only a small percentage of persons
with disabilities are able to benefit from these affordable and appropriate services
such as access to rehabilitation, education or employment opportunities.
2.3.3 Gender
The Census 2001indicates 58:42 and the NSSO 58th round 2002 indicates 59:41
male: female ratio could also be a reflection of the highly gendered nature of Indian
society as a whole. Nationally, the numbers of women to men are 933 per 1000.
There is a general preference for male children in India. Girls are often neglected
and receive less food than boys. They are also less likely to be educated. If girls and
women in general are not valued, then disabled girls and women are likely to be
even less so. In addition, studies reveal that where men and women have similar
impairments, women are more likelyto continue working and carryingout household
tasks, less likelyto seek medical treatment and see themselves as disabled (Erb and
Harriss-White 2002, Mohapatra and Mohanty 2004).
Check Your Progress 1
i) Despite the shortcomings of census 2001 and NSSO 58th round 2002, what
are the two major findings related to disabilities.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
18
 Nature and Needs of Persons
2.4 CONCEPT OF INCIDENCE AND with Disability
PREVALENCE
2.4.1 Incidence
The number of new occurrences of a condition (or disease) in a population over a
period of time. This is calculated by the formula.

Often expressed as X cases per given population base (e.g. 10,000 or 100,000)
The incidence rate uses new cases in the numerator; individuals with a history of a
condition are not included. The denominator for incidence rates is the population at
risk. Even though individuals who have already developed the condition should be
excluded, incidence rates are often expressed based on the average population
rather than the population at risk.

2.4.2 Prevalence
The measure of a condition in a population at a given point in time. Prevalence can
also be measured over a period of time (e.g. a year). This second type of prevalence
is called period prevalence; it is a combination of point prevalence and incidence.
Prevalence data provide an indication of the extent of a condition and may have
implications to the provision of services needed in a community. Both measures of
prevalence are proportions - as such they are dimensionless and should not be
described as rates (Friis & Sellers, 1999). This is calculated by the same formula as
above.
The Relationship between Prevalence & Incidence

2.4.3 Persons with Disabilities, Prevalence Rates

The disabilityprevalence rates amongdifferent agegroups have indicatedbothpositive
and negative aspects. While the prevalence rates have shown declining trends both
for rural and urban areas, up to the age group of 14 years in 2002 as compared to
1991, but on the other hand the prevalence rates for the age groups of 15-44 years 19
Concept of Disability have registered increase both for rural and urban areas in 2002 as compared to
and Rehabilitation
1991. The causes for the increasing trends in the prevalence rates among the age
groups of 15-44 years, needs to be looking into, in order to prevent increasing
trends in prevalence rates among the most productive age groups. The prevalence
rates have decreased sharply for the age groups of above 60 years, both in rural and
urban areas in 2002 as compared to 1991, indicating improved healthcare support
for population above 60 years. The analysis of the age wise prevalence rates depicts,
healthcare measures and other protective measures through community awareness
in the earlyage groups and olderage groups have preventeddisabilities. But increasing
prevalence rates in the working age groups indicate effects of industrialization and
transport sector without appropriate safety measures in place. Mechanization,
transport development, haphazard industrialization growth and environmental
degradation have made workers exposed to accidents and other disabilities. Hence
protective measures need to be devised to safeguard exposure to disabilities in the
fast development scenario.

The young adults and middle age group population are prone to disabilities due to
environmental degradation, pollution and industrialization processes accentuated by
haphazard development without taking appropriate measures of preventing ecological
imbalances and providing safetymeasures. Development of transport sector without
following appropriate traffic rules, regulations and other qualitative measures have
enhanced accidental disabilities. Immediate medical care for the accidental cases is
non-existent in majority of the rural areas, leading to permanent disabilities.
Unfortunately social model of barrier free community awareness is not in place,
hence these disabled people are without any community support and they remain
segregated / excluded from the communityactivities. The prevalence rate for males
depict significant decline in 2002 among majority of states as compared to 1991.
However the decline was more pronounced for urban areas as compared to the
rural areas. In case of rural areas prevalence rates for males were high for Orissa,
Himachal Pradesh, Haryana, while the rates were lowest for the eastern states,
Jharkhand, Andhra Pradesh, Karnataka, Madhya Pradesh and Rajasthan. Other
states recorded medium level of prevalence rates. In the case of urban areas, the
prevalence rates for males were low and uniformly distributed among the Union
territories and states except for Kerala and West Bengal, which recorded a high
prevalence rates. The prevalence rates for women have also depicted declining
trends in 2002 as compared to 1991 for majority of states in India. However in the
case of rural areas the coastal states of Orissa, Kerala, Tamil Nadu and Andhra
Pradesh and mountain states of Himachal Pradesh and Uttranchal recorded higher
prevalence rates in 2002 compared to other states. Least disability prevalence rates
among rural areas were recorded in Bihar, West Bengal, all Eastern states, Madhya
Pradesh, Rajasthan and Jammu and Kashmir in 2002.
In the case of urban areas disability prevalence rates for women were comparatively
higher for Kerala, Tamil Nadu, Orissa, Chattisgarh and West Bengal.All other states
and Union territories recorded lower disability prevalence rates among women.
20
 Table 2: The Prevalence Rates (Number of Persons with Disabilities per Nature and Needs of Persons
100,000 Persons) with Disability

Rural Urban Total of Rural & Urban

Male Female Total Male Female Total Male Female Total

2118 1556 1846 1670 1331 1449 2000 1493 1775

Source: NSSO 58th round (Jul-Dec 2002)

1.4.4 Persons with disabilities, Incidence Rates

The disability incidence rates (The number of persons whose onset of disability by
birth or after birth has been during the specified period of 365 days preceding the
data of the survey collected by the NSSO enumerators, per 100,000 persons)
were 90, and 69 respectively in 1991 and 2002, according to the (NSSO rounds
47th and 58th in 1991 and 2002). Incidence rates have also decreased for both
gender groups in rural and urban areas during 1991- 2002. The incidence rates of
persons with disabilities have declined from 90 to 69 in the rural areas and from 83
to 67 in the urban areas during 1991-2002. Thereby depicting a decline in the
overall incidence rate especially among rural areas. Declining incidence rates depict
significant healthcare measures are in place especiallyamong infants and children for
control of polio and other communicable diseases which were responsible for
disabilities in later stages. Similarly community awareness has helped in achieving
better immunization coverage, healthcare and other preventive measures for
preventing disability among children and old people.
Table 3: Incidence Rate (per 100,000 Persons) 1991-2002
YEAR RURAL URBAN BOTH R+U
M F M+F M F M+F M F M+F
2002 77 61 69 75 58 67 76 60 69
1991 99 81 90 90 75 83 98 79 90
Source: NSSO Rounds 47th 1991, and 58th 2002.

2.4.5 Persons with Disability, Onset of Disability Since Birth

Nearly 1/3rd of Persons with Disabilities have acquired disability since their birth
depicting impact ofheredity, defective gene mutation, congenial defects, inappropriate
services at the time of delivery and low level of nutrition and healthcare provided to
the pregnant mothers during their pregnancy period.

Both rural and urban areas have reported around 33% disability cases since birth.A
number of cases of inappropriate methods adopted at the time of delivery were also
reported through several sample surveys as one of the causes of disability since
birth. Hence measures for appropriate immunization coverage and nutritional food
for the pregnant mothers needs to be given top priority to reduce disability rates at
the time of birth.

21
Concept of Disability Table 4: Onset of Disability Since Birth (per 1000 Persons with
and Rehabilitation
Disabilities) 1991-2002

YEAR RURAL RBAN BOTH R+U

M F M+F M F M+F M F M+F
2002 335 315 327 303 298 301 328 311 321
Source: NSSO Rounds 58th, 2002.

Figure 1: Prevalence Rate of Persons with disabilities

Figure 2: Incidence Rate of Persons with disabilities

2.4.6 Persons with Disabilities, Severity

Fortunatelyabout 60% persons with disabilities can function without aid/ appliances,
while 13% cannot function even with aid and appliance and another 17% can take
self care with the help of aid and appliance. Significantly 10% disabled have neither
tried nor have access to aids and appliance and hence cannot take self-care.
Significantly the proportion of severely disabled who can not function even with the
help of aid/ appliance have come down from 25% in 1991 to 13.1% in 2002 in rural
areas and from 20.4% in 1991 to 14% in 2002 in urban areas. This indicates extent
of disability has shown declining trends probably due to immediate support and
healthcare provided to the disabled.

2.4.7 Persons with Disabilities, Types and Magnitude

The NSSO data 58th round in 2002 covered mental persons with disabilities in
addition to the visual, hearing, speech and locomotor persons with disabilities. Visual
disabled were further categorized into the blind and the low vision groups. Similarly
persons with mental disabilities were categorized into mental retardation and mental
22 illness groups. The NSSO 58th round data depicts 57.50% disabled were having
locomotor disability, while 10.88% were blind, 4.39% were having low vision, Nature and Needs of Persons
16.55% were having hearing impairment, 11.65% had speech disability, 5.37% with Disability
were mentally retarded and 5.95% were mentally ill.
The proportion ofpersons with disabilities has shown a significant decline for disability
types like visual, hearing and speech. However the magnitude and proportion of the
locomotor disability has increased during 1991- 2002. The decline registered in
visual disability has been significant during 1991-2002. Its proportion has come
down from 24.79% to 15.28% during this period, indicating significant efforts from
governmentandcivilsocietyorganizationtopreventvisualimpairmentthrougheffective
preventive healthcare programmes from early age groups. The proportion of hearing
impairment has also declined during this period. Its proportion was 16.55% in 2002
as compared to 20.06 % in 1991. Although actual magnitude of speech persons
with disabilities has increased during 1991-2002, yet the proportion of this disability
has also declined from 12.17% to 11.65%.
However locomotor disability has registered increase. Its share has gone up to
57.50% in 2002 from 55.30% in 1991. The increase in the magnitude and proportion
of the locomotor persons with disabilities during 1991-2002 reflects effects of
development processes like mechanization, industrialization, extension of varied
transport services etc; In the process of development, this disability types requires
appropriate protection and rehabilitation services though network of healthcare
services with highly professional and trained staff, extension services for providing
equal opportunities fortheir social and economic welfareand conducive environment,
and provision of rehabilitation centres.
The magnitude of mental persons with disabilities, which includes mental retardation
and mental illness together constitute 11.33% of the total persons with disabilities in
2002. 5.37% were mentallyretarded with learning and other disabilities, while 5.95%
were mentallyill.
Figure 3: Types of Disabilities

Types of Definition
Table 5: Persons with Disabilities in India, Types and Magnitude
1991-2002 (Percentages)

23
Concept of Disability
and Rehabilitation

Note: The percentages may not add up to 100 % as multiple disabilities was also recorded for
a large number of persons with disabilities.

Check Your Progress 2

i) Mention the list of disabilities covered in the NSSO data 58th round in 2002
................................................................................................................
................................................................................................................
................................................................................................................
ii) Which disabilities has shown decline during the time period between 1991 to
2002?
................................................................................................................
................................................................................................................
................................................................................................................

2.5 CAUSES OF DISABILITIES

There are two main reasons that professionals strive to find the causes of disabilities:
first, the identification of a specific cause can help in treating the condition, and
second identification of the cause of a disability may help prevent the occurrence of
such disabilities in future generations. Two major categories to classify the known
causes of disabilities: biomedical or constitutional, and socio-cultural/environmental.
Disability may be developmental or acquired and may arise from prenatal damage,
perinatal factors, acquired neonatal factors and early childhood factors. These may
include genetic factors, infections, traumatic or toxic exposure or nutritional factors,
which result in perinatal or postnatal damage.

24 Figure 4: Causes of Disabilities

2.5.1 Prenatal Causes of Disabilities Nature and Needs of Persons
with Disability
Chromosomal abnormalities often cause miscarriages, but may occasionally result
in a babywith some kind of disability; Down Syndrome. Some disabilities are caused
by specific genes that create damaging biomedical conditions. The resulting
destruction from Rh factor as a cause of disability may be limited, causing only mild
anemia, or excessive, causing cerebral palsy, deafness, mental retardation, or even
death.
Moreover, the mother’s emotional state can influence the fetus’s reactions and
development. The prenatal environment is almost always a safe and nourishing one
for adeveloping baby, but thereare some environmental influences,which can damage
a fetus. These influences include external agents, infections, toxins, and maternal
health.
2.5.2 Perinatal Causes of Disabilities
Drugs such as pentobarbital or meperidine (Demerol) are one method of pain control.
If taken just prior to delivery of a baby, they may make the infant less attentive, at
least temporarily. Infants born earlier than the 38th week of gestation and weighing
less than 2 Kg. are referred to as premature. The long-term effects of prematurity
on development depend on how early the infant is born (gestational age), its birth
weight, the type of postnatal care it receives, and the quality of its environment
during earlyand middle childhood. Oxygendeprivation mayoccur duringa prolonged
or difficult birth, and, because the brain suffers damage very quicklywithout a fresh
and adequate supplyof oxygen, brain damage can result. Several sexuallytransmitted
diseases can be contracted by a baby during the trip through the vagina.
2.5.3 Childhood Causes of Disabilities
The types of injuries children are most likely to experience change with the age of
the child. Childhood diseases can retarda victim’s future development; like Meningitis,
Encephalitis, Mumps, Chicken pox, and Measles. Children are placed on a continuum
from constitutionally invulnerable to vulnerable and environment are classified on a
continuum from facilitative to non-facilitative; socio-environmental conditions, poor
nutrition and starvation, poor housing, limited social interaction, lack of exposure to
reading and writing, and cultural differences.

2.6 PREVENTION AND EARLY DETECTION

MEASURES
Prevention activities forcontrollingdisabilitycan be categorized as primary, secondary
and tertiary prevention. Primary efforts are directed toward reducing the actual
occurrence of disabilities and they employ measures that prevent the conception of
a disabled individual or delay the disabling process. It includes genetic counseling,
pre-pregnancy planning, improved prenatal, peri-natal and postnatal care,
immunization programs, and primaryprevention in the environment.
25
Concept of Disability
and Rehabilitation

Figure 5: Primary prevention efforts

Secondaryprevention strategies aim at reducing the duration or severityof disability.

These activities provide early identification of the disabling condition followed by
prompt treatment and intervention to minimize the development of disability.

Figure 6: Tertiary prevention

Tertiary prevention aims at limiting or reducing the effects of a disorder or disability

that is already present. It involves long-term care and management of a chronic
condition, e.g. rehabilitation or correction of the disability.
The rehabilitation of people with disabilities is the responsibility of the Ministry of
Social Justice & Empowerment. Services, assistance schemes and concessions are
provided in collaboration with other ministries in the Government of India.
The key areas where service initiatives have been taken are:

2.6.1 Prevention, Early Identification and Intervention

Prevention, intervention and rehabilitation are part of a continuum. Prevention must
be the priority of any government in order to reduce the incidence of disability.
The Integrated Child Development Services (ICDS) scheme was launched in 1975-
76. Its objectives were to improve the nutritional and health status of children in the
0-6 age-group, provide nutrition and health education for all women within the age
range of 15-44, and enhance the capability of mothers to tend to the health and
nutritional needs of children.
The National Health Policy (1983) incorporated the WHO-sponsored Expanded
ProgrammeofImmunisation.Theuniversal immunisationprogrammeisadriveagainst
diphtheria, pertussis, neonatal tetanus, tuberculosis, poliomyelitis and measles. The
Pulse Polio programme has been undertaken nationwide for all Indian children (0-5
years) irrespective of their immunisation status. The target is complete eradication of
polio.
The National Iodine Deficiency Disorder Control Programme of 1986 aimed to
prevent occurrence of goitre, mental retardation and hearing impairment.
The Child Survival and Safe Motherhood Programme (1992) educates communities
about pre-natal, peri-natal and post-natal care of the mother and infant in order to
prevent infant mortalityand developmental disabilities. The government has also set
up a network of Primary Health Centres in the country.
Efforts for early identification of disabilityhave been made both by government and
26
non-government organisations (NGOs). Government hospitals are expected to have
the expertise and equipment to screen and identify disability. Positive steps towards Nature and Needs of Persons
early identification of disability include the organisation of eye camps, and the with Disability
involvement of anganwadi workers (nursery teachers in rural and urban poor areas),
village communities and mass media.Appropriate screening and assessment tools
have been developed.
Early intervention through infant stimulation, physiotherapy, occupational therapy,
speech and language therapy, parent counselling and training, has been provided by
many government hospitals and clinics run by NGOs. But these services are located
in major cities and large towns only.
The role played by the National Institutes (autonomous bodies functioning under the
Ministry of Social Justice & Empowerment) is significant in prevention, detection
and early intervention. The government has set up four National Institutes, one each
for hearing impairment, visual impairment, locomotor disabilities and mental
retardation.Afifth is being considered for multiple disabilities.
Check Your Progress 3
i) Premature infant were born earlier then the ....................... week of gestation
and weighting less than ........................
ii) What are the objectives of integrated child development services (ICDS).
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

2.7 SUMMARY
The disability incidence rates (The number of persons whose onset of disability by
birth or after birth has been during the specified period of 365 days preceding the
data of the survey collected by the NSSO enumerators, per 100,000 persons) was
69 in NSSO 2002 survey. The incidence rate was marginally higher in rural areas
and similarly the incidence rate is reported to be higher among men than women
(Male 76/ 100,000 and Female 60/100,000).
The disabilityprevalence rates amongdifferent agegroups have indicatedbothpositive
and negative aspects. While the prevalence rates have shown declining trends both
for rural and urban areas, up to the age group of 14 years in 2002, on the other hand
the prevalence rates for the age groups of 15-44 years have registered increase
both for rural and urban areas in 2002.
Some disabilities can be prevented, others cannot. By the application of known
techniques, a large number of disabilities can be prevented, or their severityreduced.
Primary prevention is extremely effective because it targets the whole population,
and, if it is successful, the disability addressed never occurs. Secondary and tertiary
prevention efforts are also extremely valuable as they focus on specific groups with
definite needs, and deal with their immediate situations. Some methods of disability
prevention are controversial, but others involve the development of good health
habits, good parenting skills, and adequate social supports. 27
Concept of Disability People with disabilities are not a rarity. In fact, disabilities affect the lives and
and Rehabilitation
livelihoods of one tenth of the world’s population.Yet, little has been done to publicize
the relationship among disabilities, various indicators of development and their
cumulative, indisputable impact on the qualityof our lives.
The direct consequence of this attitude has been the relegation of disability and
development initiatives to the lowest rungs on the agendas of various governments,
financial agencies and other stakeholders.As a result, people with disabilities, who
are potential and willing contributors to family and national economic activity are
instead condemned to the margins of society and remain a perceived and actual
burden.
New modes of living, a dramatic increase in accidents at home and outside, on
agricultural farms andinindustrial units,misuseandabuseofdrugsandotherchemicals,
failure of health services to considerablyreduce mortality of mothers and new–born
children and a host of other factors associated with advanced, modern and
industrialised societies are adding to the partial or total disabilities caused by fatal
and non-fatal accidents.
From the above discussions, it is clear that the estimates on disability vary a great
deal. For policy formulation and provision of services it is imperative that reliable
estimates of the incidence and prevalenceof various disabilities bemade in accordance
with accepted definitions of various categories of disabilities.
With thestrengtheningof preventive measures andcoordinated efforts at their universal
application the rate of disability should get reduced.
Theneedis tostrengthenthedisabilitymovement andempowerpeoplewithdisabilities.
In a countrylike India, it means that various departments of the government, such as
education, health, transport, building works and employment, work in conjunction.
It also means that the world’s largest democracy must listen to the voice of people
who have been on the margins, and bring them into the mainstream.
Unit End Exercises
i) Define the term incidence and prevalence
ii) Describe various causes of disabilities during different stages of life
iii) What are the different types of prevention?
iv) Mention few initiatives taken by government which aims at prevention of
disabilities.
References
1. Defining Disabilities: NSSO v/s Census by Kishor Bhanushali, Assistant
Professor – Economics, Mahatma Gandhi Labour Institute,Ahmedabad
2. Disability - Challenges Vs Responses byAli Baquer,Anjali Sharma
3. DisabilityStatus in India - Case Studyof Delhi Metropolitan Region*, Bupinder
Zutshi, PhD, Center for the Studyof Regional Development, Jawaharlal Nehru
University, New Delhi, India, September 2004.
4. Information & Guidance Booklet for Persons with Disabilities. Published by
Rehabilitation Council of India, New Delhi
28
5. Kundu, C.L. (2000) Status of Disability in India 2000. Rehabilitation Council Nature and Needs of Persons
of India, New Delhi with Disability

6. Nagaraja, M.N ( 1996): Impact of hearing handicap and its rehabilitation

management, Bihar Journal of Otolaryngology, Vol.16
Internet References
i) http://www.disabilityindia.org/nsso-census.cfm )
ii) Census 2001 - http://www.censusindia.net/t_00_003.html
iii) http://www.disabilityindia.org/StatusBookFrame.cfm
iv) http://www.infochangeindia.org
DisabilitiesIstory.jsp?recordno=2851&section_idv=19
v) http://www.geocities.com/mahesh_mobility/pwd_india.htm
vi) http://www.unescap.org/esid/psis/disability/decade/publications/z15001p1/
z1500102.htm

29
Concept of Disability
and Rehabilitation UNIT 3 CONCEPT AND EVOLUTION OF
REHABILITATION
Structure
3.1 Introduction
3.2 Objectives
3.3 Definition
3.4 Models of Rehabilitation
3.4.1 Medical Model
3.4.2 Psycho-social Model
3.4.3 Integrated Model
3.4.4 Community Based Rehabilitation Model
3.4.5 Home Based Rehabilitation Model
3.4.6 Institute Based Rehabilitation Model

3.5 Areas of Rehabilitation

3.5.1 Cardiac Rehabilitation
3.5.2 Pulmonary Rehabilitation
3.5.3 Cancer Rehabilitation
3.5.4 Musculoskeletal Rehabilitation
3.5.5 Alcohol Abuse Rehabilitation
3.5.6 Psychiatric Rehabilitation
3.5.7 Disability Rehabilitation
3.5.8 Neurological Disorders Rehabilitation

3.6 Types of Rehabilitation

3.6.1 Occupational Rehabilitation
3.6.2 Physical Rehabilitation
3.6.3 Aquatic Rehabilitation
3.6.4 Cognitive Rehabilitation

3.7 Role of Rehabilitation Professional

3.8 Goals of Rehabilitation
3.9 Lets Sum Up
3.10 Unit-End Exercises
3.11 Suggested Readings
GLOSSARY

3.1 INTRODUCTION
This is the third unit of Block 2: concept and evolution of rehabilitation. In this
chapter we will discuss definition, different areas and different goals of a
rehabilitation program.
This chapter reviews some of the basic factors that determine the direction and
30 effectiveness of rehabilitation and which are important for its scientific development.
In the last two units of this block you came across the concept of disability and Concept and Evolution of
different needs of persons with disability. Now let us discuss the concept of Rehabilitation
rehabilitation, which takes us a step further. Till we discussed what disability is and
now we will understand how a person with disability can be rehabilitated.
The word rehabilitation can be applied to many things: crumbling building, disgraced
politicians, convicted burglars, frail old ladies and injured soldiers in battle. In the
present context rehabilitation has been perceived from the point of view of disability
rehabilitation and rehabilitation of victims of psychological and physical trauma or
illness.
Rehabilitation services have passed through a long journey and it has witness
many changes and shifts in the field. Let us understand the basic facts of
rehabilitation.

3.2 OBJECTIVES
In this unit we will introduce you to the concept of rehabilitation, areas, types, role
of rehabilitation professional, models of rehabilitation.
After going through this unit you should be able to:
l define what rehabilitation is;
l discuss where rehabilitation services are applicable;
l explain who is eligible to do rehabilitation and what the roles of rehabilitation
professional are;
l explain the different models of rehabilitation; and
l discuss the goals of rehabilitation.

3.3 DEFINITION
3.3.1 Definition of Rehabilitation
Rehabilitation of people with disabilities is a process aimed at enabling them to
reach and maintain their optimal physical, sensory, intellectual, psychological and
social functional levels. Rehabilitation provides disabled people with the tools they
need to attain self independence.
It is focused on helping people who have disabilities achieve their personal,
career, and independent living goals through a counseling process. Rehabilitation
Counselors can be found in private practice, in rehabilitation facilities,
universities, schools, government agencies, insurance companies and other
organizations where people are being treated for congenital or acquired
disabilities with the goal of going to or returning to work.
It can be defined in two quite different ways;
1. A process of active change by which a person who has become disabled
acquires the knowledge and skills needed for optimal physical,
psychological and social function.
2. The application of all measures aimed at reducing the impact of disabling
and handicapping condition and enabling disabled and handicapped people
to achieve social integration. 31
Concept of Disability
and Rehabilitation 3.4 MODELS OF REHABILITATION
The purpose of this part is to introduce and explore four models of disability: the
traditional model, medical model, social model, and integrative model (Seelman,
2002). The six models often appear in sequential stages in the history of many
industrialized countries.

3.4.1 Medical Model

The medical model is based on scientific views and practice, typically in the
medical and health knowledge base. The “problem” is located within the body
of the individual with a disability. The context of the medical model is the
clinic or institution. Persons with disabilities assume the role of patient, a role
that may be of either short-term or long-term duration depending on several
factors, including the individuals’ condition, policies related to institutionalization
and community supports, and professional and social attitudes about disability.
Authority lies with professionals. The bias of the model is the bio-medical
perception of normalcy and the narrow band of legitimate knowledge, usually
medical and health-related. Explanation of disability is reduced to the
impairment level. The perspective of the person with a disability and social
factors are not routinely within the knowledge base of the medical model.

3.4.2 Psycho-social Model

The social model is based on knowledge of the experience, views and practices
of people with disabilities. The model locates the problem within society,
rather than within the individual with a disability. From the perspective of the
social model, disability is conceived more as diversity in function or the result
of discrimination in policies, practices, research, training, and education.
Individuals with disabilities are the authorities. They assume a range of roles—
especially the advocate role—to pursue full expression of educational and
employment opportunities and citizenship. Rules are determined within a
framework of choice and independent living with strong support from organized
disability communities. The biases of the social model include: limiting the
causes of disability either exclusively or mainly to social and environmental
policies and practices, or advancing perceptions of disability in mainly
industrialized countries that emphasize individual rights rather than advancing
broader economic rights that may reflect the needs of impoverished developing
countries (Albrecht, Seelman, & Bury, 2001; Barnes & Mercer, 2003).

3.4.3 The Integrative Model

The Integrative Model has a broad knowledge base ranging from medicine to
literature which is informed by the experience of people with disabilities. The
Integrative Model is “under construction”. From the integrative perspective,
individuals with disabilities have many roles, including citizen and patient,
among many others. There are a number of evolving policies and practices
that are representative of this model. Some of them are represented in the
World Health Organization International Classification of Functioning, Disability
and Health, the U.S. Institute of Medicine’s Enabling America: Assessing
the Role of Rehabilitation Science and Engineering, and the NIDRR Long-
Range Plan (Brandt & Pope, 1997; National Institute on Disability and
Rehabilitation Research, 1999; World Health Organization, 2001).
32
Policies and Practices Concept and Evolution of
Rehabilitation
While retaining general health, welfare, special education, and employment policies
and practices of the first and second stages, countries are in various stages of
transition to a civil rights approach and related universality of design applications
in systems and markets. International organizations, such as the World Health
Organization, have developed a more universal approach to disability. The following
interpretation of the ICF illustrates its universality and integrative characteristics
(Schneider, 2001):
Universal Model - not a minority model
Integrative Model - not merely medical or social
Interactive Model - not linear progressive
Parity - not etiological causality
Inclusive - contextual, environment & person
Cultural applicability - not western concepts alone
Operational - not theory driven alone
Life span coverage - not adult driven (children-elderly)
Human Functioning - not merely disability

3.4.4 Community Based Rehabilitation Model

The general concept about CBR is that it is a quick, cheap episodic distribution
of some appliances for physically disabled people living in a rural area. Many
government as well as non government agencies, with all good intentions to
rehabilitate disabled people, resorts to quick fix solutions, with no long lasting
impact in the community. Rehabilitation, considered as functional restoration, can
be achieved only by empowering the disabled as well by enriching their community.
Rehabilitation, which is based in the community, thus acquires a deeper meaning.
It amounts to development of the community as a whole, empowering the disabled
persons to achieve their complete potential, enabling them to integrate into the
fabric of the community and make decisions for themselves. This could also
involve dealing with both physical and architectural barriers within the community.
Empowering the disabled persons may involve medical, social, vocational and
educational inputs. Enriching the community involves education, creating awareness,
providing basic resources, changing attitudes and building constructive approaches
towards disability and related problems.

3.4.5 Home Based Rehabilitation Model

This model provides rehabilitation services at home for people with severe to
profound level of disability. Situations where the person has limited accessibility
to outside services, this model can provide quality services.

3.4.6 Traditional Rehabilitation Model

The traditional model is based on culturally and religiously-determined knowledge,
views, and practices. Depending on cosmology, social organization and other
factors, cultures show a broad range of perspectives which place people with
disabilities on a continuum from human to nonhuman. For example, some cultures
practice infanticide, rejecting the humanity of disabled infants. The roles people
33
with disabilities may assume within a given culture range from participant to pariah
Concept of Disability (Barnes & Mercer, 2003; Ingstad & Whyte, 1995). When persons with disabilities
and Rehabilitation
are devalued, they may be perceived as demonic or unfortunate, and often take
on the role of an outcast (Coleridge, 1993). The bias of the traditional model is
cultural relativity. Objective, scientifically-based knowledge is not associated with
this model.
In this way we can say that different models of rehabilitation may suit to
different needs of people with disability. Hence following an integrative approach
would give maximum benefit to the person with disability.
Check Your Progress 1
i) Enumerate on different models of rehabilitation.
.................................................................................................................
.................................................................................................................
.................................................................................................................
ii) What is rehabilitation?
.................................................................................................................
.................................................................................................................
.................................................................................................................

3.5 AREAS OF REHABILITATION

We will now look into different areas where rehabilitation services are applied.
3.5.1 What is Cardiac Rehabilitation?
Cardiac rehabilitation is a physician-supervised program for people who have
either a congenital (present at birth) or acquired heart disease. Cardiac rehabilitation
can often improve function, reduce symptoms, and improve the well-being of the
patient.
What conditions can benefit from cardiac rehabilitation?
Some of the conditions or procedures that may benefit from cardiac rehabilitation
may include, but are not limited to, the following:
 heart failure
 angina pectoris
 heart attack (myocardial infarction)
 post-open heart surgery
 post-heart transplantation
 angioplasty
 stent placement
 implanted pacemaker
 congenital heart disease
 arrhythmias (abnormal heart rhythms)
34 The cardiac rehabilitation program:
A cardiac rehabilitation program is designed to meet the needs of the individual Concept and Evolution of
patient, depending upon the specific heart problem or disease. Active involvement Rehabilitation
of the patient and family is vital to the success of the program.
The goal of cardiac rehabilitation is to help the patient return to the highest level
of function and independence possible, while improving the overall quality of life
- physically, emotionally, and socially. These goals are often met by:
 Decreasing cardiac symptoms and complications.
 Encouraging independence through self-management.
 Reducing hospitalizations.
 Stabilizing or reversing atherosclerosis (plaque buildup in the blood vessels).
 Improving social, emotional, and vocational status.
 improve cardiac symptoms
 reduce blood cholesterol levels
 reduce cigarette smoking
 improve psychosocial well-being and reduce stress
 reduce death due to heart disease
3.5.2 What is Pulmonary Rehabilitation?
Pulmonary rehabilitation is a physician-supervised program for people who have
chronic lung diseases such as emphysema, chronic bronchitis, asthma,
bronchiectasis, interstitial lung disease, or lung tumors. Pulmonary rehabilitation
programs can often improve function, reduce symptoms, and improve the well-
being of patients.
The pulmonary rehabilitation program:
A pulmonary rehabilitation program is designed to meet the needs of the individual
patient, depending upon the specific lung problem or disease. Active involvement
of the patient and family is vital to the success of the program.
The goal of pulmonary rehabilitation is to help patients return to the highest level
of function and independence possible, while improving the overall quality of life-
physically, emotionally, and socially. These goals are often met by:
 Decreasing respiratory symptoms and complications.
 Encouraging independence through self-management.
 Improving physical conditioning and exercise performance.
 Improving social, emotional, and vocational status.
 Reducing hospitalizations.
3.5.3 Cancer Rehabilitation
What is cancer rehabilitation?
Cancer rehabilitation is a physician-supervised program for people who have
undergone treatment for cancer. People who have survived cancer may have
physical, emotional, and social issues that affect their quality of life, no matter
what kind of cancer they have been treated for. Cancer rehabilitation programs
can often improve function, reduce pain, and improve the well-being of cancer
survivors. 35
Concept of Disability The cancer rehabilitation program:
and Rehabilitation
A cancer rehabilitation program is designed to meet the needs of the individual
patient, depending upon the specific type of cancer and treatment. Active
involvement of the patient and family is vital to the success of the program.
The goal of cancer rehabilitation is to help patients return to the highest level of
function and independence possible, while improving the overall quality of life -
physically, emotionally, and socially. These goals are often met by:
 managing pain.
 improving bowel and bladder function.
 improving nutritional status.
 improving physical conditioning, endurance, and exercise performance.
 improving social, cognitive, emotional, and vocational status.
 reducing hospitalizations.
In order to help reach these goals, cancer rehabilitation programs may include the
following:
 using medications and pain management techniques to reduce pain
 exercise programs to help build strength and endurance
 patient and family education and counseling
 activities to improve mobility (movement) and decrease sleep problems
 assistance with activities of daily living (ADLs) such as eating, dressing,
bathing, toileting, handwriting, cooking, and basic housekeeping
 smoking cessation
 stress, anxiety, and depression management
 nutritional counseling
 management of chronic illness or complications due to cancer treatments
 vocational counseling
3.5.4 What is Musculoskeletal Rehabilitation?
A musculoskeletal rehabilitation program is a physician-supervised program
designed for people with impairments or disabilities due to disease, disorders, or
trauma to the muscles or bones. Musculoskeletal rehabilitation programs can
often improve functional capacity, reduce symptoms, and improve the well-being
of the patient.
What conditions can benefit from musculoskeletal rehabilitation?
Some of the conditions that may benefit from musculoskeletal rehabilitation may
include, but are not limited to, the following:
 amputation
 trauma injuries such as sprains, strains, joint dislocations, and fractures
 back pain
 osteoporosis
 arthritis
36
 bone tumors
 repetitive stress injuries such as tendonitis and carpal tunnel syndrome Concept and Evolution of
Rehabilitation
 joint injury and replacement
The musculoskeletal rehabilitation program:
A musculoskeletal rehabilitation program is designed to meet the needs of the
individual patient, depending upon the specific problem or disease. Active
involvement of the patient and family is vital to the success of the program.
The goal of musculoskeletal rehabilitation is to help the patient return to the
highest level of function and independence possible, while improving the overall
quality of life - physically, emotionally, and socially.
In order to help reach these goals, musculoskeletal rehabilitation programs may
include the following:
 fitting and care for casts, braces, and splints (orthoses), or artificial limbs
(prostheses)
 exercise programs to improve range of motion, increase muscle strength,
improve flexibility and mobility, and increase endurance
 gait (walking) retraining and methods of safe ambulation (including the use of
a walker, cane, or crutch)
 help with obtaining assistive devices that promote independence
 patient and family education and counseling
 pain management
 stress management and emotional support
 nutritional counseling
 ergonomic assessments and work-related injury prevention
 vocational counseling
3.5.5 Alcohol Abuse and Dependence Rehabilitation
Alcohol abuse and dependence is a disease that is not easy to cure. An
individual dependent on alcohol would most likely exhibit one of the most
common symptoms of alcoholism, which is denial. For a medical practitioner
to effectively diagnose one as an alcoholic in need of treatment, the individual
will have to truthfully answer questions pertaining to his alcohol use. It is not
unusual for the disease to have progressed beyond the early stages before the
alcoholic is forced into accepting alcohol abuse rehabilitation.
Uncontrolled consumption of alcohol is a severe indication of an alcohol
dependence. This level of alcoholism can cause social problems as well as
possibly life-threatening events. Even when drinking alcohol potentially causes
trouble, someone afflicted with alcoholism would still pursue drinking for some
reason. They experience an uncontrollable craving for alcohol that turns into
out-of-control drinking. And when they are not able to drink, they experience
intense withdrawal symptoms that cause them to drink themselves even more
into frenzy. Alcoholism is progressive. The more alcohol a person drinks the
more tolerant to its potency the body becomes. And so, the feelings associated
with alcoholism, feelings that alcoholics crave for, that were attained after a
certain amount of alcohol is consumed will take much more amounts of alcohol
consumption to achieve after some time. 37
Concept of Disability Alcohol abuse rehabilitation facilities are available nationwide. All it takes to
and Rehabilitation
take this step towards rehabilitation is for the alcoholic to admit to alcohol
addiction and to decide on taking a 180 degree turn from alcoholism. While
there are a lot of alcohol abuse rehabilitation facilities to help alcoholics, there
are still a lot of alcoholics either refusing treatment or dropping out of treatment.
What makes for an effective treatment for alcoholism? There are several
ingredients to a successful potion for alcoholism:
1. Early intervention. The sooner alcoholism is detected and admitted, the better.
It is easier to cure addition that has not yet taken root in a person’s system.
2. Personalized assessment and treatment. Alcoholism is a personal concern.
The triggers and underlying problems are usually uncovered using an approach
that is specifically tailored to a particular patient. Even family members are
to be involved in the treatment programs.
3. Coming into agreement with patients. As a psychological tool, this strategy
is used to manage behaviour by rewarding positive behavior and punishing
negative behaviour in a program of “contracts” or agreements.
4. Cognitive behavioural therapy. This teaches a person to recognize particular
situations that trigger alcohol consumption and to help them shift their reactions
away from alcohol during these situations.
5. Continuous care. Treatment for alcohol dependent cannot be achieved in a
short time. It is a long-term commitment to turn away from alcohol permanently.
Continuous consultations and regular participation in support groups are
known to result in a longer period of abstinence.
6. Patient determination. This is the single most important ingredient to an
effective cure to alcohol dependent. A person who is afflicted with alcohol
addiction should have the strong desire to walk away from the addiction. An
unwavering stance against the lure of alcohol will spell the success of any
alcohol treatment program.

3.5.6 Psychiatric Rehabilitation

Psychiatric rehabilitation can be a complex and formidable task. Without proper
training and exposure to effective psychiatric rehabilitation strategies, the unprepared
rehabilitation professional will easily be overwhelmed and may have difficulty
contributing to successful intervention planning with individuals who have psychiatric
disabilities. Moreover, the rehabilitation professional may lack the skills necessary
to effectively negotiate important adaptations for the individual with the psychiatric
disability on the worksite, with co-workers and employers alike (McReynolds &
Garske, 2002). The current unemployment rate for individuals with psychiatric
disabilities is more than 85 percent (Nobel, Honberg, Hall, & Flynn, 2001), in
part because individuals with psychiatric disabilities often struggle with a wide
variety of challenges and needs which likewise challenge the rehabilitation
professional. Strategies for helping people with psychiatric disabilities have
changed significantly in recent years. Successful work assistance approaches
appear to have a number of common characteristics and include individualized
career planning, help with job access, and aid in job retention; peer support;
coordination with other social services and benefits; and assurances of confidentiality
(Carling, 1995).
38
The recovery model, as described by Pratt, Gill, Barrett, and Roberts (1999) and Concept and Evolution of
as touted by Deegan (1988) and Anthony (1993), is a fundamental shift in Rehabilitation
perception regarding individuals with psychiatric disabilities. Recovery is viewed
as a “reformulation of one’s life aspirations and an eventual adaptation to the
disease” (Pratt, et al., 1999, p. 91). Within this concept of recovery lies the belief
that individuals with psychiatric disabilities can and do adjust to psychiatric
disabilities by a process of acceptance of the disability and the development of
a positive self-image. Further bolstering the recovery model are developments in
improved medications, the use of supported employment, and the debunking of
long-held myths perpetuating stigma and discrimination of individuals with psychiatric
disabilities.
According to Bond (1995), psychiatric rehabilitation provides individuals with
psychiatric disabilities the opportunity to work, live in the community, and enjoy
a social life, at their own pace, through planned experiences in a respectful,
supportive, and realistic atmosphere. Psychiatric rehabilitation typically involves
helping individuals to gain or improve necessary interpersonal skills and provides
a level of support required for clients to obtain their goals. The mission of psychiatric
rehabilitation, therefore, is to assist persons with long-term psychiatric disabilities
increase their functioning so that they are successful and satisfied in the environments
of their choice with the least amount of ongoing professional intervention (Anthony
et al., 1990).
According to Lamb (1988), no part is more important than giving clients a source
of mastery over their internal drives, their symptoms, and the demands of their
environments. You will see now different models used by United States that have
provided individuals with psychiatric disabilities opportunities of community
integration;
Clubhouse Model
The Clubhouse Model is a comprehensive group approach that focuses on practical
issues in informal settings (Bond, 1995). Clubhouses are community-based
rehabilitation programs for people with psychiatric disability offering vocational
opportunities, planning for housing, problem-solving groups, case management,
recreational activities, and academic preparation. Individuals can learn or regain
skills necessary to live a productive and empowering life. The Clubhouse Model
provides for the societal, occupational, and interpersonal needs of the person as
well as medical and psychiatric needs (Fountain House, 1999).
Developed at the Fountain House in New York, transitional employment (TE) is
an integral part of the Clubhouse approach. Clients, or members as they are
called, are placed in part-time entry-level positions for three to nine months and
are supervised by one another and/or rehabilitation professionals. Members work
at a place of business in the community and are paid the prevailing wage rate by
the employer. The placements are part-time and limited generally to 15 to 20
hours a week. The program is designed to develop a client’s self-confidence,
current job references, and improve work habits necessary to secure permanent
employment (Anthony et al., 1990). TE continues to be an effective rehabilitation
strategy in many mental health systems (Bond, 1995).
Individual Placement and Support (IPS)
The Individual Placement and Support (IPS) program was developed at the New
Hampshire-Dartmouth Psychiatric Research Center (Becker & Drake, 1993). 39
Concept of Disability The IPS Model recognized that “work is so many things to so many people, we
and Rehabilitation
might define it simply as a structured, purposeful activity that we usually do in
exchange for payment” (p. iii, Becker & Drake, 1993). The model draws from
several psychiatric rehabilitation intervention models (e.g., ACT, choose-get-keep)
in which clients choose from a range of work possibilities including full-time to
various levels of part-time work to pre-vocational activities. Competitive
employment is generally encouraged; however, non-paid employment options are
likewise given consideration when deemed most appropriate for the particular
individual’s needs.
The vital component of the IPS model incorporates the success-driven concept
of follow-along support provided by a core group of people who function as a
team. The team generally consists of employment specialists, rehabilitation
counselors, psychiatrists, and other mental health staff as needed. The treatment
team approach provides a more seamless method of service delivery versus
receiving separate services from various professionals in a non-coordinated manner.
Clients are encouraged to be active and fully involved in the job-search process
and are then supported through their employment with on-going follow-along
(Becker & Drake, 1993).
Community Support System
The National Institute of Mental Health (NIMH) began the community support
system (CSS) initiative in 1977. The intent was to assist states and communities
in developing a broad array of services to assist people with psychiatric disability.
This initiative eventually became known as the NIMH Community Support Program,
with case management as one of the essential services (Anthony et al., 1990).
One of the leading models of CSS is the assertive community treatment (ACT)
approach that works with clients on an individual basis providing services primarily
in the client’s home and neighborhood rather than in offices. ACT programs are
staffed by a group of professionals who work as a treatment team in the community
(Bond, 1995). In most ACT teams, staff provides a range of services to clients
in their natural surroundings which includes, but are not services limited to, assisting
with social service agencies, medication management, housing, employment, family
issues, and teaching clients coping skills (Chinman et al., 1999). ACT, first
developed in Madison, Wisconsin, has spread throughout the United States in
recent years, especially in the Midwest (Bond & McDonel, 1991). The ACT
team maintains frequent contact with clients and assists with client’s concerns
around activities of daily living (i.e., budgeting money, shopping, housing, taking
medication, employment, problem solving on the job).
Community-based treatment of persons with psychiatric disability, as provided in
the ACT model, focuses primarily on the teaching of basic coping skills necessary
to live and function as autonomously as possible in the community. These coping
strategies consist of activities of daily living, vocational skills, leisure time skills,
and social or interpersonal skills (Bond, 1995). Several characteristics of the
ACT approach make it distinctive. The first of these is assertive outreach in which
staff members initiate contacts rather than depending on clients to keep
appointments. A second characteristic of ACT is its emphasis on continuity and
consistency whereby care is ongoing and the services are integrated. Finally, ACT
programs combine treatment and rehabilitation in a comprehensive and
interdisciplinary approach (Bond, 1995). This case management approach has
40
been widely adopted across the United States, especially for persons with Concept and Evolution of
psychiatric disability. Rehabilitation

Supported Employment
Supported employment (SE) is another promising approach to helping people
with psychiatric disability to succeed in the community. SE is one of the models
of vocational rehabilitation that has been successful in helping individuals with
psychiatric disability secure competitive employment (Ahrens, et al., 1999). It
emphasizes direct placement in a community job, assistance in locating the job
with the consumer, and ongoing job-related problem-solving and support after
consumers obtain work. Individual placement is the key vocational strategy
nationwide (Wehman & Revell, 1996). An evaluation of an SE program for
persons with psychiatric disabilities found that clients were able to exercise more
control over their career choices due to the client-centered approach used in SE
programs (Block, 1992). By 1995, a national survey had identified 36,000 persons
with mental illnesses who were employed in SE jobs (Wehman, Revell, & Kregal,
1997).
Supported Education
Although long overdue, another vocational improvement for people with psychiatric
disability is in the area of education. Supported education programs have surfaced
and expanded in the last few years, partly in response to problems experienced
by people with psychiatric disability in more traditional vocational rehabilitation
approaches (Moxley, Mowbray, & Brown, 1993). Like supported employment
and supported housing, supported education takes a rehabilitation approach in
providing assistance, preparation, and advocacy to individuals with psychiatric
disabilities who desire to pursue post-secondary education or training (Mowbray,
Bybee, & Shriner, 1996).
Supported education as a program model has been nationally recognized as a
promising method to improve employment rates (Anthony, 1994). A variety of
supported education approaches have been identified, of which two of the most
common are the structured classroom and on-site support (Mowbray, Moxley, &
Brown, 1993). In the structured, or self-contained classroom, students attend
classes with other students with psychiatric disability. In the onsite support model,
students attend regular classes. Support is provided by the staff of the educational
facility (Unger, 1990) and according to Mowbray and Megivern (1999), supportive
education programs can and do work.

3.5.7 Disability Rehabilitation

Rehabilitation of people with disabilities is a process aimed at enabling them to
reach and maintain their optimal physical, sensory, intellectual, psychological and
social functional levels. Rehabilitation provides disabled people with the tools they
need to attain independence and self-determination.
With total world population of 650 million, persons with disabilities constitute
the largest majority. As per United Nations report, 10 percent of population
in underdeveloped countries is facing disabilities of one or the other type. If
we include family members, advocates and all those affected by the problem
of disabilities this is as high as 25 percent of population. Moreover, this
number is constantly increasing through population growth, medical advances
and aging process, says World Health Organisation (WHO). 41
Concept of Disability When a large section of population is facing the problem of disability of one
and Rehabilitation
or the other type, social and economic costs of sidetracking them will be
very high. The concept of rehabilitation embodied the democratic and
humanitarian ideal that each individual is important and each member of the
community should contribute to society to the fullest extent. A person’s
handicap may be due to any type of disablement, i.e., either birth defects,
sickness, diseases, industrial and road accidents or the stresses of war,
work and daily life. Likewise, people are also handicapped by social and
cultural disadvantage i.e., social, financial or educational. Whenever any of
these conditions cause difficulties in life adjustment, the person is handicapped.
The process of rehabilitation enables the person with handicap to attain
usefulness and satisfaction in life. Rehabilitation programmes are concerned
with helping the disabled person as a human being who requires specialized
help to enable him to realize his physical, social, emotional and vocational
potential. The objective of long-range planning for rehabilitation is to achieve
maximum adjustments of the maximum number of disabled persons in
maximum walks of life when the formal rehabilitation process is completed
through good teamwork among medical, surgical, physiological, social,
educational and vocational personnel. International Labour Organisation
convention defines Rehabilitation of disabled is essential in order that they
be restored to the possible physical, mental, social, vocational and economic
usefulness of which they are capable (ILO 1955 recommendation).

Considering the size of population of persons with disabilities, it is necessary

to have proper rehabilitation strategies. In designing country specific
rehabilitation strategy, knowledge of rehabilitation practices followed in
different countries and best practices world over is of significant importance.

“Role of Family in Rehabilitation of Persons with Disabilities”: Disability

affects family in all areas, including financial, social and educational. The
success of the rehabilitation process depends on the role of family. Every
family needs counseling and it should be given from time to time. It not only
clears the myths and misconceptions about disability but also helps in
understanding the disability, rehabilitation process and expectations.

“A Review of Community-Based Rehabilitation Evaluations: Quality of Life

as an Outcome Measure for Future Evaluations”. The five basic principles
of CBR are covered here. They are (1) utilization of community resources
(2) knowledge transfer (3) community involvement (4) referral services and
(5) coordinated approach toward education, health and social system as an
outcome measure for rehabilitation evaluations.

Inclusive Education considers as to how empowerment of disabled is being

carried through rehabilitation process of inclusive education, where disability
is not viewed as something invoking pity or in need of a cure. Social model
presents disability as a consequence of oppression, prejudice and
discrimination by society against disabled people. The disabled can be
transformed from passive community gears to productive human resources,
capable of making a useful contribution in social development, with the help
of education.

“Consumer Rights with Special Reference to the Disabled” explains the diversity
of the issue relating to disabled as consumer by rehabilitation process through
42
consumer rights. Since the Indian consumers are naive and disorganized, Concept and Evolution of
business enterprises exploit them for their personal benefits, where the Indian Rehabilitation
consumer suffers due to traditional attitude of silence. Study revealed that
persons with disabilities had good knowledge about the consumer rights and
they had utilized the consumers rights to a large extent. Variable barriers
which affected the extent of utilization of the benefits were age, marital status,
education, occupation, family income and type of school.

3.5.8 Rehabilitation of Neurological Disorders

What conditions may benefit from neurological rehabilitation?
The nervous system is vulnerable to various disorders. It can be damaged by
injuries, infections, degeneration, structural defects, and tumors, as well as disorders
in the circulatory system. Disorders of the nervous system, which may be helped
by physical medicine and rehabilitation, may include, but are not limited to, the
following:
 vascular disorders - stroke, transient ischemic attack (TIA), subarachnoid
hemorrhage, subdural hemorrhage and hematoma, and extradural hemorrhage
 infections - meningitis, encephalitis, polio, and epidural abscess
 structural, trauma, or neuromuscular disorders - brain, head, or spinal cord
injury, Bell’s palsy, cervical spondylosis, carpal tunnel syndrome, brain or
spinal cord tumors, peripheral neuropathy, muscular dystrophy, myasthenia
gravis, and Guillain-Barré syndrome
 functional disorders - headache, seizure disorder, dizziness, and neuralgia
 degenerative disorders - Parkinson’s disease, multiple sclerosis, amyotrophic
lateral sclerosis (ALS), Huntington’s chorea, and Alzheimer’s disease
The neurological rehabilitation team:
Neurological rehabilitation programs can be conducted while a person is a hospital
inpatient, or on an outpatient basis. The neurological rehabilitation team revolves
around the patient and family. The team helps set short- and long-term treatment
goals for recovery and is made up of many skilled professionals, including the
following:
 neurologist/neurosurgeon
 orthopedist/orthopedic surgeon
 physiotherapist
 internist
 rehabilitation nurse
 dietician
 physical therapist
 occupational therapist
 speech therapist/language therapist
43
Concept of Disability  psychologist/psychiatrist
and Rehabilitation
 recreational therapist

 audiologist

 chaplain

 vocational therapist

The neurological rehabilitation program:

The goals of a neurological rehabilitation program include helping the individual to

return to the highest level of function and independence, and improving the overall
quality of life for that individual - physically, emotionally, and socially. A typical
neurological rehabilitation program helps to accomplish and/or may include the
following:

 assistance with activities of daily living (ADLs) such as eating, dressing,

bathing, using the toilet, handwriting, cooking, and basic housekeeping

 speech therapy (to help patients who are having trouble speaking, expressing
their thoughts, or swallowing; to improve speech patterns, enunciation, and
oral communication, in general)

 counseling (to deal with anxiety and depression)

 bladder and bowel retraining

 activities to improve control and muscle balance in the trunk, pelvis, and
shoulder girdle

 an exercise program (to improve function, safety, and efficiency of movement;

to prevent or postpone weakness caused by lack of use; to manage spasticity
and pain; to maintain range of motion; to develop the maximum potential of
muscle, bone, and respiration)

 social skills retraining

 gait and balance retraining

 nutritional counseling

 involvement in community support groups

 activities to improve cognitive impairments, such as difficulties with

concentration, attention, memory, and poor judgment

 education regarding the disease and disease process

 goal setting (both short and long term)

Having discussed about the different areas of rehabilitation, you may realize
that the scope of rehabilitation is wide. Each area is explicit and needs a
specialized understanding.
44
Check Your Progress 2 Concept and Evolution of
Rehabilitation
Answer the Questions in the given space.
i) What is the under lying view in the recovery model described by Pratt Gill
Barett and Roberts (1999).
.................................................................................................................
.................................................................................................................
.................................................................................................................
ii) What are the strategies of psychiatric rehabilitation?
.................................................................................................................
.................................................................................................................
.................................................................................................................
iii) What are the five principle of community based rehabilitation?
.................................................................................................................
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.................................................................................................................

3.6 DIFFERENT TYPES OF REHABILITATION

As you know rehabilitation is a process used to give a healing touch to the
patients who are suffering from physical and mental disorders, addiction, etc.
Rehabilitation program helps the patient to get back to his/her normal life and
earn a livelihood. Rehabilitation plays an important role in the lives of addicts
and persons who have suffered from diseases or accidents. Rehabilitation
plays a key role in the lives of people who have suffered from a trauma. This
program is given to patients based on their needs. Every person’s requirements
vary so the program is subjective. Personal attention is given to each patient
and his or her development is monitored on regular basis.
According to the needs, the rehabilitation programs are divided into various
types. Rehabilitation types are as follows:
 Occupational Rehabilitation: This rehabilitation is given to patients who
have lost basic skills after a major accident or a paralytic stroke. These skills
are needed to perform daily routine activities like cooking, reading, writing,
calculating. This happens in majority of cases where there is some injury to
brain. Co ordination becomes a problem for these patients and they need to
visit an occupational therapist. The therapist gives treatment in form of
medication, exercises to strengthen the muscles. The patients can take help
from a psychologist and counselor.
 Physical Rehabilitation: This sort of rehabilitation is used for patients who
have suffered from bone and muscle injuries. The physiotherapist helps a lot
in giving the right exercise regime to strengthen the muscles of back neck,
shoulder, etc. This injury can happen due to accidents, sports, etc. A lot of
treatment and technology is available in physical rehabilitation. The recovery 45
Concept of Disability time differs from person to person and so does the type of injury. The
and Rehabilitation
patients have to follow religiously the given exercise patterns.
 Aquatic Rehabilitation: This is a new trend in rehabilitation yet it is successful
in treating problems in joints. The therapists treat the patients by giving
various water exercises like swimming, water aerobics, etc. This helps in
giving strength, flexibility and mobility to the muscles of legs. Many patients
with arthritis, joint pain, and paralytic stroke are treated with the help of this
rehabilitation. The program is customized according to an individual’s needs
and he or she is treated to recover from the injury so that he or she has a
normal life.
 Cognitive Rehabilitation: This type of rehabilitation is given to patients
who have suffered from brain injury. To help them to get back to routine
activities, they are treated with the help of neuropsychological approach. In
this program, the patients are given counseling and mental exercises. This
program looks at cognitive, social, moral and emotional aspects of the brain
injury that has made the patient dependent. This rehabilitation helps a patient
to get back to his normal life prior to injury. The person can go back to his
or her studies or job after recovering fully.
 Physical Therapy This is a very broad category of therapy that involves
most strengthening and coordination work designed to overcome any physical
weakness that the patient is left with after surgery. Physical therapists, for
example, work with patients who have had hip or knee replacements to
increase their strength and flexibility so that they can walk again. Although
brain surgery does not directly affect the muscles and joints in the same way
that a hip replacement does, it can require much of the same recovery for
two reasons. First, anytime a patient is immobilized in a hospital bed for
some time they lose strength. If that immobilization is extended the patient
may need some PT to get strong enough to safely go home. More common
for brain surgery is that the control of some muscle or set of muscles is
weakened for neurological reasons. Put simply, the muscle is healthy but the
neural pathway (the nerves or areas of the brain that control the nerves) are
damaged in some way. It is not unlikely that a neural pathway can be
damaged but not destroyed; therefore, the muscles affected seem to be
dramatically weakened. This can be thought of as the brain just not being
able to “get enough of a signal” to the muscle to fully activate it. In these
cases, therapy can be very effective at exercising that pathway and helping
it to become more useful. This is the same process that a stroke patient will
go through. In many cases PT will also include balance, coordination, gait
training and overall strengthening.

3.7 ROLE OF REHABILITATION PROFESSIONAL

Having discussed the areas and types of rehabilitation, it is now apparent, what
role rehabilitation professional plays? They provide counseling, guidance and
case management services to persons with disabilities to assist them in achieving
their psychological, personal, social, and vocational goals. Rehabilitation professional
determine the impact of disability on goal attainment; evaluate vocational interests,
aptitudes, and skills of clients; and provide appropriate services to maximize
career options and quality of life. After conferring with the client’s physicians,
46
psychologists, occupational therapists, and the employer, a rehabilitation program Concept and Evolution of
is initiated. The rehabilitation program may include mental health or adjustment Rehabilitation
counseling services; independent living assistance; locating and coordinating services
in physical and mental restoration, academic or vocational training, and government
services; job analysis or modification; and other services targeted to the individual
needs of the individual with a disability. The rehabilitation program may range
from a week to several years depending on the nature of the problem and the
needs of the client.
The rehabilitation professional’s role is to provide an array of services
that enhances the quality of life of people with disabilities.
 Counseling: The professional has a foremost job of helping the clients to help
themselves. The process of counseling provides the very first platform where
the rehabilitation process begins.
 Coordinating: Rehabilitation Professionals also works as liaison agent between
different kinds of rehabilitations processes a case is going through.
Intercommunicating among the different professional gives further direction in
rehabilitation and makes the whole process meaningful and more effective.
 Problem-solving: Rehabilitation Professional also assists actively during problem
solving processes. As the case most of the time looses reality touch in
traumatic conditions, professional can help to bring the client in a clarity
mode and hence make wider possibility of better problem solving.
 Case management: each Rehabilitation Professional involved in a case has
the responsibility of managing the case in terms of holistic care and not just
limiting it to one single area of rehabilitation.
 Vocational counseling: Rehabilitation Professional has another major role of
bringing the client back to vocational independence. Vocational Counseling
is an important function done by all rehabilitation professional as the residual
capacity of the case may not allow him or her to perform in similar way as
before the trauma. Professional has to provide emotional understanding as
well as practical aspects of residual potential in the client.

3.8 GOALS OF REHABILITATION

As we discussed, the role of rehabilitation professionals and the efficacy of role
implementation. Now we will discuss how they make their role effective by
establishing appropriate goals. The rehabilitation team or therapist sets both short-
term and long-term goals for each problem. For example, a person with a hand
injury may have restricted range of motion and weakness. The short-term goals
may be to increase the range of motion by a certain amount and grip strength by
so many pounds. The long-term goal may be to play the piano again. Short-term
goals are set to provide an immediate, achievable target. Long-term goals are set
to help people understand what they can expect from rehabilitation and where
they can expect to be in several months. People are encouraged to achieve each
short-term goal, and the team closely monitors the progress. The goals may be
changed if people become unwilling or unable (financially or otherwise) to continue
or if they progress more slowly or quickly than expected. In general any
rehabilitation program focuses on the following goals;
47
Concept of Disability 1. Restoring the residual potential after the trauma as much as possible.
and Rehabilitation
2. Reduce number of hospitalization in cases of physical illnesses.
3. Enabling the case to get back into the routine life as soon as possible.
4. Re-establishing the emotional stability of the case.
5. Educating the client about the present condition and required changes or
modifications in the life style.
6. Educating the client about the necessary rehabilitation procedures at work
place as well as at other occupational settings.
7. Rehabilitation also has an important goal of enabling the family members of
the case to cope up with the present situation and changed role of the client.
Check Your Progress 3
i) What is the scope of rehabilitation?
.................................................................................................................
.................................................................................................................
.................................................................................................................
ii) What are the different types of rehabilitation?
.................................................................................................................
.................................................................................................................
...........................................................................................................................

3.9 LET US SUM UP

Rehabilitation of people with disabilities is a process aimed at enabling them to
reach and maintain their optimal physical, sensory, intellectual, psychological and
social functional levels. Rehabilitation provides disabled people with the tools they
need to attain self independence.
There are four important models of rehabilitation; medical model, psycho-social
model, home based rehabilitation model and community based rehabilitation model.
Rehabilitation has a wider scope as it takes place in cases of physical illnesses,
psychological or physical trauma as well as in disability.
Rehabilitation can be done using different modalities based on the need of the
client. It can use occupational therapy, balance therapy, physiotherapy, counseling
and cognitive training.
Rehabilitation Professional has wide variety of role to play and has a particular
mission in the rehabilitation process. His role can range from therapy provider to
advocating the needs of a person with disability.
Rehabilitation program can loose its effectiveness if it exists without goals. A goal
whether short term or long term leads to structured program and to great extent
assures the success of the rehabilitation procedure.
48
 Concept and Evolution of
3.10 UNIT-END EXERCISES Rehabilitation

1. Prepare a chart of model of rehabilitation and analyze them in terms of

efficacy and usage in different conditions.
2. Based on role of rehabilitation professional, develop a chart of desired qualities
and characteristics of rehabilitation professional.

3.11 SUGGESTED READINGS

http://www.who.int/topics/rehabilitation/en/
www.wikipedia.com
Mohopatra C. S., 2004 ‘Disability Management in India’ National Institute for the
Mentally Handicapped (NIMH).

GLOSSARY
Community Rehabilitation : Refers to a community-based agency that
Program (CRP) provides specialized vocational rehabilitation
services.
Competitive Employment : Describes full- or part-time work in the
competitive labor market in an integrated
setting, for which payment is at or above
the minimum wage but not less than the
customary wage, and the level of benefits
paid by the employer is equal to that for the
same or similar work performed by people
who do not have disability.
Vocational Rehabilitation (VR) : Services provided to people with disabilities
seeking assistance in gaining competitive
employment.
Rehabilitation : Rehabilitation of people with disabilities is
a process aimed at enabling them to reach
and maintain their optimal physical,
sensory, intellectual, psychological and
social functional levels. Rehabilitation
provides disabled people with the tools
they need to attain independence and self-
determination.
Physical Rehabilitation : This sort of rehabilitation is used for
patients who have suffered from bone and
muscle injuries. The physiotherapist helps
a lot in giving the right exercise regime to
strengthen the muscles of back neck,
shoulder, etc.

49
Concept of Disability
and Rehabilitation UNIT 4 PARADIGM SHIFT IN
REHABILITATION
Structure
4.1 Introduction
4.2 Objectives
4.3 Concept of Paradigm Shift
4.3.1 History of Disability

4.4 Paradigm Shift in Rehabilitation

4.4.1 Right Based Approach
4.4.2 Consumerism
4.4.3 Robotics

4.5 Let Us Sum Up

4.6 Unit-End Exercise
4.7 Suggested Readings

4.1 INTRODUCTION
This is the fourth unit of Block 2: Paradigm Shift in Rehabilitation.
Any concept after its emergence goes through many dimensional changes. The
infancy of a concept goes through the process of maturation and evolves in terms
of its meaning and perspectives. Similarly the field of rehabilitation has seen many
changes in its due course of development as an independent entity. Let us understand
how the journey of rehabilitation started from a mere medical model and developed
into a multiphase model of services.
Paradigm shift (or revolutionary science) is the term first, coined by Thomas Kuhn
in his influential book, “The Structure of Scientific Revolutions” (1962) to describe
a change in basic assumptions within the ruling theory of science. It is in contrast
to his idea of normal science. This concept is no longer limited to hard science
and now applicable to humanities as well. There has been a paradigm shift in the
rehabilitation services as it changed the basic assumption itself.

4.2 OBJECTIVES
In this unit we will introduce you to the concept of paradigm shift in rehabilitation.
After going through this unit you should be able to:
 describe what rehabilitation is;
 explain earlier models of rehabilitation; and
 discuss the changes and the emerging trends in the field of rehabilitation.

50
 Paradigm Shift in
4.3 CONCEPT OF PARADIGM SHIFT Rehabilitation

Let us understand the concept of paradigm shift.

A radical change in thinking from an accepted point of view to a new one,
necessitated when new scientific discoveries produce anomalies in the current
paradigm; a radical change in thinking from an accepted point of view to a new
belief. In social sciences also the similar process occurs, newer ideas and
innovations produce anomalies in the current paradigm and it brings revolutionary
changes.
Paradigm shift in the rehabilitation of persons with disability is imperative, which
is founded on the rights based and empowerment approach. It’s no more only
service based approach but the consumerism is also entering into the field of
rehabilitation.

4.3.1 History of Disability

Bodily difference has for centuries determined social structures by defining certain
bodies as the norm, and defining those which fall outside the norm as ‘Other’;
with the degree of ‘Otherness’ being defined by the degree of variation from the
norm. In doing this, we have created an artificial ‘paradigm of humanity’ into
which some of us fit neatly, and others fit very badly. Life outside the paradigm
of humanity is likely to be characterized by isolation and abuse.
The lives of people with disability have not only been constructed as ‘Other’, but
frequently as ‘the Other’ of ‘the Other’. People with disability are marginalized
even by those who are themselves marginalized.
While it is difficult to know where our constructions end and the reality begins (for
the constructions shape the reality), it is clear that other stories and constructions
which might have created different realities have been selectively ‘forgotten’.
Historically, Models of inclusion – which suggested that disability is accepted as
being normal - have been erased from disability history. Disability activists are
now facing the task of re-creating a culture which celebrates and embraces
difference.
The history of disability has been characterized by the progressive development
of several models of disability: the religious model of disability, the medical/genetic
model of disability, and the rights-based model of disability. These models, or
constructions of disability, have set the parameters for our response to people
with disability. Through time, these models have become more sophisticated, yet
their essence remains constant - otherness.
The Religious Model of Disability
In all societies around the globe, the roots of understanding bodily difference have
been grounded in religious references. These embodied states were seen as the
result of evil spirits, the devil, witchcraft or God’s displeasure. Alternatively, such
people were also often perceived to be of angelic or beyond-human status to be
a blessing for others.
Therefore, themes which embrace notions of sin or sanctity, impurity and wholeness,
undesirability and weakness, care and compassion, healing and burden have formed
the dominant bases of groups of people who, in a contemporary context, are 51
Concept of Disability described as disabled. In the past, various labels have been used for such people.
and Rehabilitation
These include crippled, lame, blind, dumb, deaf, mad, feeble, idiot, imbecile, and
moron.
Religious communities, often within the local precincts or parishes, responded to
these groups of people in various ways. These included the promotion and seeking
of cures by such actions as exorcisms, purging, and rituals and so on; or providing
care, hospitality and service as acts of mercy and duty to “needy strangers”.
However, important changes were to occur with the evolvement of the modern
era profoundly influenced by the enlightenment and industrialization. During this
time, religious values and modes were challenged by the uprising of reason and
rationality.
The Medical Model of Disability
As medical and scientific knowledge expanded profusely, the doctor and the
scientist replaced the Godmen as custodian of societal values and curing processes.
Work and production became the ideal value system. Human worth was to be
determined by perceived work value and profitability; and lifestyles and lives
became dictated by the mechanistic practices. Universality replaced particularity,
reason replaced mystery, and knowledge and state of the mind superseded the
live experience of the body. ‘Normality’, then, became determined by the ideal
of the youthful, able, male body; and otherness to this ideal became hierarchically
placed as inferiority. Therefore, difference became redefined as deviance
commanding control.
Events of this era were to have a major impact on the lives of those with bodily
limitations. The lives of such people were reduced to little more than a medical
label, and their futures defined by a medical prognosis. People with disability then
became a class requiring physical removal from the “able-bodied” norms of what
was developing as an urbanized society. As some commentators note, this was
the era when cripples disappeared and disability was created.
As certain groups of people came to be viewed as unproductive and incapable,
institutions were established as places with a dual purpose: (a) where such people
could be placed whilst other family members could meet worker’s obligations;
and (b) where such people could be skilled to become productive members of
society.
With the modern era, there was an increasing emphasis on scientism and social
Darwinism; and this resulted in the roles of special institutions shifting from agents
of reform to agents of custody for social control and institutional segregation for
those now described as sub-normal. Institutions became the instruments for the
facilitation of social death. Through a presumed scientific status, care for people
with disability became depoliticized, technicalised and professionalized, predicated
on notions of tragedy, burden and helpless dependency.
In the post-industrial and post-enlightenment era, disability has been regarded as
an individual affliction predominantly cast within scientific and medical discourses.
Therefore, “disability” has come to be defined and signified as a power-neutral,
objectively observable attribute or characteristic of an “afflicted” person. According
to this model, it is the individual, and not society, who has the problem, and
different interventions aim to provide the person with the appropriate skills to
52 rehabilitate or deal with it.
In recent years with the focus on normalization principles since the 1970’s, the Paradigm Shift in
locus of an individualized conceptualization has shifted from the institution to Rehabilitation
community-based facilities and care. However, the medical perspective of disability
remains wedded to the economy, whereby personal capacity and ability are often
assessed as incapacity and inability so as to determine a person’s eligibility for
financial assistance and benefits, and access to personal resources. An economic
view narrows the complexity of disability to limitations and restrictions, with
implications of whether “flawed” people can be educated or productive.
Lack of access to adequate material resources perpetuates a charity discourse
which depicts certain people as in need of help, as objects of pity, as personally
tragic, and as dependent and eternal children. It is a discourse of benevolence and
altruism; wherein perceivably helpless people are viewed as instruments for good
and virtuous works of mercy and compassion by the more “privileged” members
of society.
The Rights-Based Model of Disability
In more recent times, however, the notion of ‘disability’ has come to be
conceptualized as a socio-political construct within a rights-based discourse. The
emphasis has shifted from dependence to independence, as people with disability
have sought a political voice, and become politically active against social forces
of disablism. Disability activists, are engaging in identity politics, have adopted the
strategies used by other social movements commanding human and civil rights,
against such phenomena as sexism and racism. And these strategies have brought
gains, but within certain limitations.
From the mid 1980’s, some countries have enacted legislation like Persons With
Disabilities Act (1995) in India which embraces a rights-based discourse rather
than a custodial discourse; and which seeks to address issues of social justice and
discrimination. The legislation also embraces the conceptual shift from disability
being seen as an individualized ‘medical problem’ to rather being about community
membership and participation, and access to regular societal activities such as
employment, education, recreation and so on. Where access is inappropriate,
inadequate, difficult or ignored, advocacy processes have been initiated to address
situations and promote the people’s rights.
Yet, rights-based discourse, although employed as a political strategy, has also
become a way of constructing disability by locking people with disability into an
identity which is based upon membership of a minority group. Entitlements thus
become contingent upon being able to define oneself as a person with disability.
And the conceptual barrier between ‘normal’ and ‘abnormal’ goes unchallenged,
so that while one may have entitlements legislatively guaranteed, ‘community’
which cannot be legislated for, remains elusive.
Looking to the Future
While rights-based discourse, at a strategic level, has brought some additional
entitlements to people with disability, it has not significantly altered the way in
which disability is constructed and so, despite legislative changes, some people’s
lives have not necessarily changed. In fact, new challenges such as genetic
technology and reproductive technology threaten to further alienate the whole and
integrated person (the body, mind and spirit) from the medically, or scientifically,
diagnosed ‘person’ (the condition). We are now seeing the emergence of a genetic
model of disability, a revamped medical model, which ‘promises’ to actually 53
Concept of Disability expand the population of people with disability to include people whose impairment
and Rehabilitation
is their ‘bad’ genes and their disability is the social response of avoidance,
discrimination and even elimination which their impaired genes elicit in others.
Rights-based discourse fails to meet these challenges for, rather than seeking to
dismantle the entire concept of disability, it actually relies upon such a construction
to support its claims for rights and entitlements.
Some writers argue that we need to go beyond conceptions of constructed
disability to a notion of universalism whereby, according to Canadian writer,
Bickenbach, disability is actually a fluid and continuous condition which has no
boundaries but which is, in fact, the essence of the human condition. And, as a
condition which is experienced by us all, at some stage in our lives, disability is
actually normal. This view is also supported by the Indian philosopher, Sarkar,
who argues that bodily differences should not be allowed to mask our essential
humanity.
At the level of our physical existence, diversity is a natural condition and the need
is for us to welcome and embrace diversity outside of a hierarchical classification
of difference. Yet, at another level, difference is simply a construction of ideology,
not a state of reality - since we are all interconnected and have flowing through
each of us the same life force. According to Sarkar, “the force that guides the
stars you too”. Yet, the history of disability has been a history of seeking to
construct hierarchical difference out of an essential reality of oneness. The challenge
is to create the reverse.
 Check Your Progress-1
Note Write your answers in the space given below.
i) What do you understand by paradigm shift?
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
ii) How was disability perceived in past?
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

4.4 PARADIGM SHIFT IN REHABILIATION

We will now view the Paradigm Shift in Rehabilitation in recent years.

4.4.1 A Right Based Approach

Success of the rehabilitation programmes largely depends on the quality of life
54 of the persons with disabilities.
Principles in Quality of Life Assessment: Paradigm Shift in
Rehabilitation
 Quality of life for people with developmental disabilities consists of the same
aspects of life as for all other people.
 Quality of life is based on common aspects of life for all humans, but it also
reflects, from person to person, varying degrees of importance placed on
those aspects of life.
 Quality of life for all people reflects how satisfied they are with aspects of
life that are important to them.
 People live in environments. Thus, quality of life results from the interconnection
between people and the environments in which they live.
Table 4.1: Typology of Paradigm Shift (Rao 2002)

Ready or not, here comes the future” says Carlson & Goldman (1991) in
2020 Visions: Long View of a Changing World. Futuristic philosophers invite
people to develop world views which enable them to be innovative and
successful. Individuals gain a sense of empowerment and direction by projecting
into the future and looking at social, technological, and environmental challenges.
Trends often move with domino effect from one field to another; thus, increasing
the predictability of new paradigms.
If we analyze the figure 4.1 we can understand clearly how the whole dimension
of rehabilitation has changed in the present era. It is no more charity based
service, in fact the approach is not\w right based. Rather than focusing only
on medical model the focus has shifted to holistic approach as only relieving
pain is no more important. The meaning of human life has gain more relevance
in the present approach to rehabilitation.

4.4.2 Consumerism
It is a paradigm operating today with consumer power demonstrated
unmistakably within the commercial marketplace. Grass roots political efforts 55
Concept of Disability remain a mainstay in the democratic process. Rising consumer movements
and Rehabilitation
play important roles in most segments of society. Now, perhaps medical and
allied health professionals will be ready to pay attention to a newly emerging
brand of consumerism. Increased awareness influencing the rise of health-
related consumerism within the rehabilitation field will enhance professional
effectiveness.
A cursory understanding of the history of disability leaves one with the
impression that humankind has often responded to societal deviance with fear,
denial, and devaluation. Rubin and Roessler (1988) cite examples of early
negative attitudes toward disabled persons dominating Greek and Middle Age
societies some of which still prevail. History teaches that when particular
behaviors or attributes are perceived to be detrimental to a society ostracism
becomes the New Paradigm: Consumerism
Since people with disabilities are an integral part of society, a cornerstone of
the movement projecting consumerism into the healthcare delivery system is
acceptance of disabilities as a valued part of life. Marcel Proust utilizes an
appropriate metaphor in pointing out “that the real act of discovery consists
not in finding new lands but in seeing with new eyes” (Barker, 1992). The
essential rehabilitation task of renewing human lives remains the same, but a
new way of viewing that task makes important differences in how it will be
executed.
People with disabilities were mandated to decide which services they would
consume. Clients became consumers.
Consumerism: Pros and Cons
In the contemporary society, there is a significant paradigm from clientism to
consumerism. In the lead article, Webster’s dictionary defines a consumer as
one who spends, wastes or destroys. By contrast, the word “client” signifies
a person who engages another to act on his or her behalf.
The old paradigm views the client as the one receiving rehabilitation, the recipient
of professional services. The new paradigm envisions consumers empowered to
choose and purchase services. Therefore, definitions may influence one’s choice
of the word client or consumer. Yet, the focus of the new paradigm becomes one
of empowering those with disabilities rather than supporting the old hierarchial
system of professional/disabled person.
Today, activist use the word “consumer”, to indicate that rehabilitation has a
paternalistic past and goes on to suggest that rehabilitation is in the midst of a
revolution toward a more humane and creative discipline that focuses on both
independence and productivity. Consumer empowerment may be the primary
focus of the future.
Factors Influencing Consumerism
In providing dignity of life to Persons with Disabilities, profound changes in
our country’s political policies and economic priorities must occur. All individuals
will be required to take an active role for full participation in all segments of
society to become reality. It requires a long term commitment.

56
Cultural and Racial Diversity Paradigm Shift in
Rehabilitation
Cultural and racial diversity will continue to challenge the full availability of
human resources.
Aging of the Population
Older members of society facing adjustments to aging require services extending
beyond traditional views of rehabilitation. Merging the needs of the aging
population with those of disabled persons as advocated by Zola (1989) adds
strength to consumers’ role. Universal policies recognizing that the entire
population is at risk for chronic illness and disability will prevent perpetuation
of segregated, unequal parts of society. Recognition that everyone with a
disability will age, and everyone who ages will acquire one or more disabilities
is yet another challenge which broadens the view of those persons providing
and receiving services.
The Women’s Movement
With more money to spend and with more women in political and decision-
making positions, women’s consumer power is beginning to command attention
(Aburdene & Naisbitt, 1992). The voices of women have been muted for
centuries and women’s place has been largely in the home. Now the greater
numbers of women in the workplace put them at greater risk for work-related
injury. The presence of women will increase their eligibility for rehabilitation
services.
Legislative Initiatives
The activation of the consumer axiom resulted in enactment of civil rights
legislation protecting concerns of Persons with Disabilities. It includes assurance
of equal opportunity for employment, provision of certain public services and
transportation, public accommodation, and telecommunication.
Technological Factors
The communication and technological revolutions also influence consumerism.
Technological advances enable persons with disabilities to function
independently with computers and telecommunications providing access to
otherwise unaccessible information. These tools increase opportunities for
achievement, information access, and networking.
Environmental Factors
With technological advances come environmental problems (Gordon & Suzuki,
1991). Machines use energy, much of which is in limited supply. Yet, consumers
continue to demand quality and excellence in service delivery, sometimes
losing sight of these environmental issues.
Other environmental concerns include removal of transportation, educational,
and architectural barriers. To provide universal access, disabled persons must
be considered in designing buildings, public transportation systems, and public
services such as housing, medical care and employment opportunities. These
basic individual rights are part of the driving force behind consumerism.

57
Concept of Disability 4.4.3 Robotic Therapy: A Paradigm Shift
and Rehabilitation
The infancy of therapeutic robotics is easily demonstrated: Of course, the application
of robotics to rehabilitation has a longer history, but as mentioned earlier, the
strong and sustained growth of activity in recent years is due to a significant shift
away from assistive technology for people with disabilities toward robotic therapies,
which use the technology to support and enhance clinicians’ productivity and
effectiveness as they try to facilitate the individual’s recovery. The magnitude of
this change goes far beyond the usual ebb-and-flow of activity in technology-
related fields.
Conclusion
The approaching twenty-first century brings challenging new ways of seeing
the world, new paradigms which see “the fruitful darkness”. Attitudes and
methods conveying a value for the full expression of life shift focus to egalitarian,
consumer-oriented models of service delivery accentuating individual adequacy
and acceptability. The new paradigm moves services along the continuum
from provider-driven services to consumer-driven demands for quality and
accessibility.
 Check Your Progress 2
Note Write your answers in the given space below:
i) What are the criteria of differentiation between traditional approach and
contemporary approach?
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
ii) How technology has added new paradigm in rehabilitation services?
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

4.5 LET US SUM UP

Rehabilitation of people with disabilities is a process aimed at enabling them to
reach and maintain their optimal physical, sensory, intellectual, psychological and
social functional levels. Rehabilitation provides disabled people with the tools they
need to attain self independence.
Rehabilitation no longer follows a charity based model rather it has become more
right based approach.
Consumerism, changed attitude towards people with disability and latest technology
58 has brought more professionalism in the field.
 Paradigm Shift in
4.6 UNIT END EXERCISES Rehabilitation

1. Collect information about older practices of rehabilitation and differentiate

them with contemporary practices.

4.7 SUGGESTED READINGS

i) Aburdene, P., & Naisbitt, J. (1992). Megatrends for women. New York:
Villard Books.
ii) Barker, J.A. (1992). Future Edge: Discovering the New Paradigms of
Success. New York: William Morrow and Company.
iii) Carlson, R., & Goldman, B. (1991). 2020 Visions: Long View of a
Changing World. Stanford, CA: Stanford Alumni Association.
iv) Mohopatra C. S., 2004 ‘Disability Management in India’ National Institute
for the Mentally Handicapped (NIMH).
v) Rao, L. Govinda (2002). Human Resource Development in Rehabilitation
Organizations-a Study of select non-governmental organizations dealing with
disabled persons in Andhra Pradesh. Ph.D. Thesis submitted to Jawaharlal
Nehru Technological University.

59