The founder of RREES and his colleagues have evolved a broad battery of rehabilitation-oriented instruments entitled the Rehabilitation Assessment Series (RAS). Most of these instruments are very brief, economical and all are extremely cost-effective. As depicted in the figure below, the RREES Rehabilitation Assessment and Intervention Process conceptual model evaluates and relates each component and their interactions towards predicting and maximizing rehabilitation outcome. Each of the RREES assessment instruments serves to address a different aspect of the conceptual model within a bio-psycho-environmental paradigm. A number of the instruments are well validated, while validation studies are underway with respect to the others.
Rehabilitation Assessment and Intervention Process Model click here to view a graphical presentation.
The overall aim of this series is to provide a comprehensive evaluation methodology in a manner that serves to guide and expedite the rehabilitation intervention process, monitor its effectiveness, and promote an altered course where indicated. In this sense, the RAS, is a vital disability management tool for all rehabilitation professionals. All instruments within the RAS were developed to serve both the clinical and research needs of psychologists, physiotherapists, chiropractors, rehabilitation medicine specialists, rehabilitation case managers, and allied professions. In light of the symbiotic nature of the RAS instruments, the manuals of all of the related assessment instruments share a unifying conceptual framework embodied in a common theoretical chapter. The common theoretical chapter in each manual is entitled The Rehabilitation Assessment and Intervention Process Model: A Conceptual Framework, which is pretty much reproduced for each respective instrument although the section most pertinent to that particular measure is typically further elaborated upon. The following is a substantially abbreviated overview of the theoretical chapter.
Purpose of the Rehabilitation Assessment and Intervention Process Model
There are two primary purposes of the conceptual model:
- To provide a means to assist in the assessments of impairments, disabilities, and handicaps and the relationships and distinctions between them.
- To provide a means to help identify the underlying “approaches” (perceptions/attitudes) of clients to their recovery and rehabilitation.
Approaches to recovery reflect a spectrum from profound illness behavior and adoption of sick roles, to a realistic acceptance of the underlying impairment and the implementation of strategies to “cope” with residual deficits, thereby minimizing the effects of disability on life-role functioning.
The latter occurs through efforts to maximize activity and abilities, despite the presence of impairments. Approaches to recovery and rehabilitation for clients, for purposes of the model, are known as “subjective-recovery strategy.” In terms of recovery status, individual approaches can vary widely. Some clients, for example, become extremely stoical, pushing on through their symptoms (sometime in the face of possible physical harm). Other clients become overly dependent upon others, or become completely overwhelmed and immobilized, or exhilarated by the challenge of recovery, or uplifted by the affiliation with a “cause” in which an adverse life experience may result in actions that positively benefit others. The conceptual model helps to identify which recovery strategy a given client will adopt and the rationale behind it.
Identifying, Understanding, and Influencing the “Subjective Recovery Strategy”
The model argues that the “subjective recovery strategy” of clients is arrived at based on a complex interplay of both conscious and unconscious factors falling into the following broad categories:
· Premorbid psychosocial, health and personality status
· Severity of the physical and/or emotional trauma/condition (i.e., impairment)
· Nature of the resulting symptoms and disability
· Environmental influences, including stressors and social supports
· Schema: Perceptions regarding impairment/disability, disease, and handicap
· Emotional adjustment process to the impairment/disability
· Coping abilities/resources of the client
In evaluating the above factors, the model argues that it is not enough to understand the “recovery strategy” of clients, but that it is critical to understand and assess the factors that have brought about their recovery status. Once these factors are better understood, then it becomes possible to develop an intervention strategy that will help promote a faster and more complete recovery by addressing the identified barriers.
The following is a brief description of each of the above components within the model.
Premorbid Psychosocial, Health & Personality Status
The first aspect of the model is the determination of pre-traumatic personality variables, emotional status, health status and preexisting life circumstances/experiences. Collectively, the premorbid psychosocial status provides a context within which to understand the client’s response to the injury/condition onset. Pre-morbid health status is addressed both by endorsements of R-SOPAC symptoms indicating the presence of the pertinent symptoms in the past. The Rehabilitation, Neuropsychological and Health Status Inventory (RNHSI, in development) also taps into pre-existing physical and emotional conditions. In addition to being addressed by the RNHSI, the presence of premorbid stressors that may influence personality variables are also evoked directly through the Pre/Post Condition Life Event Survey (PPCLES). Factors such as a limited proficiency in English, limited occupational skills, prior employment problems, and a limited education are specifically addressed in the Rehabilitation Checklist (RCL). These issues may have a bearing on the ability of clients to reintegrate into work roles after a disabling condition necessitates a change in work activities. The RCL also helps to develop a sense of the precondition life priorities of clients by asking them to prioritize their precondition life roles, thus giving some perspective on the personal impact of the impairment/disability. In conjunction with the measures from the RAS, it is encouraged that clinicians use other measures of more enduring personality traits/pathologies to obtain a more complete sense of the premorbid characteristics of clients.
These concepts relate more to traumatic accidents than to diseases. They serve to characterize the nature and complexity of the event in physical and psychological terms. Recognizing physical and psychological trauma helps establish some expectancy regarding the “normal” course and response to the event and thereby helps in determining client deviance from expectation. Although initially conceptualized as relating to a traumatic injury, one might argue that with diseases such as AIDS that carry very frightening, life-threatening, and/or socially stigmatizing connotations, these concepts remain very much applicable. Physical and psychological trauma are further defined as follows:
· Physical Trauma: The degree of actual physical severity of an injury/disease, from a minimal to significant life threat, and
· Psychological Trauma: The degree of potential physical severity of an injury/disease that would be expected from the perspective of the average person as the traumatic event is unfolding. The degree of psychosocial trauma is related from a minimal to significant life threat, regardless of the actual physical outcome.
A related concept is that of more subjectively defined “psychological trauma” that serves to gather information regarding various aspects of the traumatic experience from the perspective of clients. The Impact of Trauma Scale, part of the Rehabilitation Assessment and Intervention Process Model, now in its developmental stages, will serve to gather this type of information.
This is a broad category encompassing a variety of perceptions that a client holds regarding issues related to impairments, disabilities, and handicaps. Included in this category are the following defined concepts:
· Illness Schema: How clients perceive their primary symptoms/recovery barriers, and the underlying cause, nature, and course of these primary symptoms/recovery barriers.
Whether the clients’ perceptions of illness conform to or deviate from the objective findings of clinicians may facilitate or impede the rehabilitation process. For instance, a client with a strictly soft-tissue injury may think he or she has cancer and that activity may cause more damage. This perception and fear would then interfere with the treatment of choice for soft-tissue injury, which is to maximize activity in the context of the expected full recovery. The RCL, R–SOPAC, and RNHSI all contribute to assessing this type of perception of clients.
· Disability Schema: How clients perceive their functional limitations and, when given multiple impairments, determine which one(s) is/are responsible for which limitations.
Measures such as the Oswestry Low Back Pain Disability Index (Fairbank, Davies, Couper, & O’Brien, 1980) and the related Neck Disability Index (Vernon & Mior, 1990), among others, serve to estimate the level of disability severity. However, few, if any, scales adequately seek the input of clients in attempting to apportion the single or multiple causes within each area of functional disability. The RCL in conjunction with the R–SOPAC and R-ADLS measures serve this function.
· Handicap Schema: How clients perceive their functional disabilities relative to their most important precondition life roles and other life roles.
The RCL addresses this important area. The RNHSI also provides clients with an opportunity to indicate specific difficulties in the primary life roles of work and student life, as well as to indicate the degree to which they were engaged in these activities related to these roles, both premorbidly and subsequent to injury.
· Coping Schema: How clients perceive their abilities to cope with individual symptoms and their overall conditions.
The R–SOPAC’s primary objective is to detail this issue.
· Recovery Schema: How clients perceive their prognoses and the resources/services/treatments required to bring about positive outcomes.
Both the RCL and RNHSI contribute to the understanding of clients in this regard.
· Existential Schema: How clients perceive their conditions in the overall context of life (i.e., has their life meaning been crushed or enhanced by the onset of their conditions?).
To date, no specific measure has been developed to address this issue directly. However, it is indirectly addressed by indications of the degree of primary life-role dysfunctions within the RCL and by evidence of emotional pathologies (e.g., anxiety, depression) on the RNHSI or other measures. Such factors suggest significant disruptions of the sense of self of clients and, hence, of life purpose.
Coping Skills, Activity Level
The degree to and manner through which clients cope with their symptoms is considered in this aspect of the model. The degree of client perceived coping abilities relative to distinct symptoms and symptom clusters is captured by the R–SOPAC. The manual for the instrument (in preparation) reveals an aspect of coping generally not reflected to date in the broader application of coping theories on the rehabilitation assessment process. In evaluating the efficacy of a symptom-based coping measure, the authors provide evidence that a higher degree of sensitivity and responsiveness to appropriate treatment can be identified using a measure like the R–SOPAC, as compared to alternative symptom-rating measures. The R-ADLS comprehensively addresses activities of daily living and relates any activity limitations to specific symptoms.
Changes in activity level are also considered an important adjunct in determining the ability of clients to cope through less direct means. The notion is that the higher the post-condition activity level and the closer that this comes to the precondition level, then — assuming that clients have reached a sustainable level — the more successfully the client appears to be coping (i.e., coping is defined as maximizing activity in spite of the presence of symptoms/impairment). As such, it is crucial that activity levels be measured in premorbid and post-condition terms, as is the objective of Pre/Post Life-Area Change scales of the RNHSI, as well as by the Life-Role Disability section of the RCL, and the Pre/Post measures of the R-ADLS.
The Treatment Outcome Variables of the RNHSI also look at the perceived locus of control over recovery, overall coping ability, and the degree to which clients feel confident in engaging in activity as a recovery strategy.
Emotional Coping Process
Although the scales are not necessarily constructed for the specific purpose of “diagnosing the stage of loss” (and, in fact, the notion of loss “stages” has been challenged by some) the aspects of irritability/anger control, depression, and anxiety are nevertheless measured by each of the RCL, R–SOPAC, and RNHSI. Included in this aspect of the Rehabilitation Assessment and Intervention Process Model and operationalized in the RCL, R-SOPAC and RNHSI is the assessment of emotional pathology, which may result both directly and indirectly from the impairment.
Psychosocial Environment: Stressors
As discussed above in the context of the bio-psycho-environmental model, it is well-established that factors in the familial, social, and work environments of clients often play a major role in shaping the pattern of recovery. Both significant life events, as well as “daily hassles,” have been studied as providing a link between psychosocial stressors and health status (Kanner, Coyne, Schaefer, & Lazarus, 1981). Within the Rehabilitation Assessment Series, PPCLES presents significant pre- and post-condition life events/stressors that may be influencing the recovery process.
Several aspects of the RCL and several of the subscales within the RNHSI serve to expose relevant premorbid, post-condition, and coexisting stressors that may contribute to disabilities. The RNHSI contains measures addressing such issues as “Comfort with Disabled Role,” “Vocational Rehabilitation Barriers,” “Pre/Post Significant-Other Status,” among others.
RAS Variable Interactions–“Subjective Recovery Strategy”
Interactions among the concepts outlined above have been frequently established (Zarski et al., 1987; White et al., 1992; Bordieri & Comminel, 1989; Rossi, 1986; Weinstein, 1978). As discussed above, and depicted in the graphical presentation, the Rehabilitation Assessment and Intervention Process Model reflects a comprehensive and cohesive presentation of such established and hypothetical interactions between the model’s variables. The model postulates that results of such interactions ultimately influence the “Subjective Recovery Strategies” of clients, which, in turn, plays a major role in determining the outcome of their rehabilitation. By evaluating each component, and by evolving a sound clinical understanding of the dynamics behind the recovery stance of clients, clinicians will be in a superior position to plan and implement effective interventions.
It is the intention of the Rehabilitation Assessment and Intervention Process Model to facilitate the differentiation of those who are likely to recover early from those who may be at risk for a prolonged recovery for a variety of reasons. The following list suggests a few types of “Subjective Recovery Strategies.” While some authors have offered methods through which to measure similar recovery postures, the current model presents a more fluid and comprehensive method to determine the dynamics involved in the evolution of the status of clients. As well, the model identifies more specific rehabilitation interventions to target. It is important to emphasize that, to date, the recovery states suggested below have yet to be fully validated for the instruments. At present, they may be considered working hypotheses to be considered for clients, which require corroboration through clinical interviews and additional psychometrics. Where indicated, the various measures of the RAS provide profiles with respect to each of these recovery stances.
1. Adaptive Copers: Such clients exhibit minimal premorbid risk factors, an appropriate understanding of their condition, and an appropriate balance of gradual increases in activity level.
2. Impatient Strivers: Such clients exhibit premorbid compulsive/workaholic tendencies, may minimize their symptoms, overestimate their limitations, and are prone to aggravating their conditions due to attempts to return to normal activities prematurely.
3. Emotionally Overwhelmed: Such clients feel their coping resources have become overwhelmed in the aftermath of their conditions and, therefore, exhibit prominent anxiety and/or depressive disorders of a non-specific nature (e.g., neither specific phobia nor posttraumatic stress disorder).
4. Emotionally Traumatized: Such clients have experienced the onset of their condition as emotionally traumatic and meet some or all of the criteria for posttraumatic stress disorder, conversion disorder, or specific phobia.
5. Comfort with Disabled Role (Weinstein’s Conceptualization): Such clients have settled or may be about to settle comfortably into a disabled role due to either appropriate circumstances (e.g., retirement) or secondary-gain issues. Such clients are assumed to be less influenced by a conscious process than the malingering profile given below.
6. Malingerers: Such clients consciously manipulate or exaggerate their disability status solely for monetary or related gains.
In sum, the RAS can play a critical role in determining the “recovery stance” of clients. Understanding such a stance may facilitate an enhanced therapeutic alliance between therapist and client and can help to address roadblocks in the recovery process. For a more comprehensive review of the above theoretical model and related reference citations, please see the Conceptual Chapter within any of the RREES assessment product manuals.