An integrated model of psychosocial adjustment following acquired disability.

Psychosocial adjustment problems among people with acquired disabilities have been associated with extensive costs in terms of long-term community welfare and health service utilization (Browne, Arpin, Corey, Fitch & Gafni, 1990). Unfortunately, in addition to being reasonably resistant to treatment, adjustment problems represent one of the most significant barriers for rehabilitation outcomes (Putnam & Adams, 1992). For rehabilitation counselors, clients who present with psychosocial adjustment problems can be a source of extreme distress. These clients are often misunderstood and poorly serviced, leading to high levels of dissatisfaction with rehabilitation (Winter & Keith, 1988). Much of this misunderstanding originates from the manner in which psychosocial adjustment is conceptualized and taught to rehabilitation counselors. Specifically, adjustment is most often represented as a linear sequence of stages (Livneh & Antonak, 1990). While stage models may adequately represent the general progression towards adjustment that occurs over time (Davis, 1987), they do not sufficiently address the recurrent nature of the psychosocial adjustment process (Yoshida, 1993). As Rosenthal (1996) noted, linear models do not enable rehabilitation counselors to appreciate or anticipate the "disorder, unpredictability and complexity" (p. 226) of the issues they are likely to encounter in their work.

An alternative approach to conceptualizing adjustment is the recurrent model in which adjustment is viewed as an ongoing cycle. Despite it's intuitive appeal, and a large body of literature supporting the recurrent approach, most discussions of psychosocial adjustment continue to refer to stage models. It is possible that this situation arises because the recurrent model has not been fully articulated. Accordingly, after briefly examining the shortcomings of the linear model, the present paper attempts to integrate current knowledge about psychosocial adjustment within a recurrent framework. By providing rehabilitation counselors with an integrated recurrent conceptualization of psychosocial adjustment following acquired disability, it is hoped that the dominance of stage models in rehabilitation counseling can be challenged. In addition to better preparing rehabilitation counselors for the psychosocial difficulties their clients may experience, the recurrent model proposed in the current paper should assist them in focusing efforts on factors that are likely to be associated with positive outcomes.

Stage Models of Psychosocial Adjustment

Historically, the process of psychosocial adjustment following an acquired disability has been viewed as a sequence of stages (Fortier & Wanlass, 1984), similar to those experienced during the grief associated with one's imminent death or the loss of a loved one (Kubler-Ross, 1969). Although there is disagreement about the total number of stages in this adjustment process, there are significant similarities among the various models in that they usually include three common stages. Specifically, most models describe an initial period of shock and/or denial which is followed by significant distress and concludes with acceptance of one's situation. Although a range of other reactions and emotions (e.g., guilt, hostility) have been included in some variants of the model, there is less consistency concerning these stages (Livneh & Antonak, 1990). According to this linear, developmental approach to adjustment, the appearance of later stages is predicated on the resolution of earlier stages.

Although evidence does support a general trend towards acceptance of disability over time (Linkowski, 1971), stage models have a number of negative implications for the rehabilitation process. For instance, conceptualizing adjustment as a series of unavoidable stages implies passivity on the part of individuals with disabilities and their rehabilitation workers (see also Stewart, 1996). As a result of this implicit passivity, psychosocial interventions may not be implemented while workers wait for the natural progression of time to heal their clients. This situation is likely to be exacerbated by the fact that these models do not comment on the factors that could be motivating or hindering movement through the stages.

Stage models of adjustment also normalize responses such as denial and distress following acquired disability, which may lead rehabilitation workers to expect, or even encourage, such responses. Should these responses not be apparent, or not be resolved during the expected period, clients could be regarded as `abnormal' (Wortman & Silver, 1989). Further, such models are purely descriptive and provide little information about the factors that contribute to individual differences in the adjustment process, despite the likelihood that these factors will provide the key to maximizing the effectiveness of rehabilitation counseling (Kendall & Terry, 1996).

Sociological critiques have expanded on this theme by suggesting that stage models of adjustment represent a form of social oppression. Specifically, such models encourage people with disabilities to accept fewer alternatives and less personal control than people without disabilities (Dovey & Graffam, 1987). Accordingly, adjustment could be conceived as a process of socialization into the role and status of a `disabled' person (Albrecht, 1976). The most significant criticism of stage models of adjustment is that they do not adequately match the subjective experience of people with acquired disabilities (Yoshida, 1993). Indeed, many people with disabilities believe that they will never "adjust" to their disability because this implies the acceptance of a situation that is unacceptable (Glass, 1994).

The Recurrent Model of Psychosocial Adjustment

Limitations of stage models have led researchers to recognize the ongoing "tragedy" of an acquired disability (Banja, 1992) and the inappropriateness of "time-bound" definitions of the grief process in such circumstances (Wikler, Wasow & Hatfield, 1981). They have suggested that the process of adjustment following acquired disability can be described as `chronic or recurrent' (Davis, 1987) in that sorrow is likely to re-emerge at regular intervals in a repetitive pattern of despair and acceptance (Wikler et al., 1981). In this recurrent approach, adjustment is viewed as a gradual process of learning to tolerate an almost intolerable set of circumstances. Adjustment therefore becomes a continuous life transition rather than a time-limited process (Stewart, Sokol, Healy & Chester, 1986; Taylor, 1983) where chronic grief is considered pathological (Wortman & Silver, 1989).

Articulating the Recurrent Process of Psychosocial Adjustment

Cognitive theories of psychosocial well-being are based on the notion of schemas (Beck, 1967). Schemas are fundamental beliefs and assumptions about the self, others and how the environment works (Beck & Weishaar, 1989) that filter and interpret one's experiences (Stewart, 1996), particularly at times of stress (Beck, Rush, Shaw & Emery, 1979).

Following an unexpected shift in life circumstances as a result of disability (Newsome & Kendall, 1996) the usefulness of existing schemas for understanding the world is likely to be challenged. By necessity, however, individuals will persist with these schemas even though they no longer adequately explain the environment, thus appearing to deny or distort reality. Initially, individuals are likely to be overwhelmed by their inability to interpret their experiences adequately, leading to symptoms such as depression. However, as more information about the new environment is gathered and integrated, new schemas can be developed. Consequently, a more realistic stance towards life can be adopted, together with a brighter outlook on the future and fresh involvement in the community (Karpman, Wolfe & Vargo, 1986).

The recurrent nature of adjustment originates from the fact that new schemas will be developed incrementally and will be revised, modified or completely restructured as the individual consolidates his or her new position in life and has opportunities to explore the environment (Newsome & Kendall, 1996). Thus, the process of adjustment is likely to occur in an iterative manner as different aspects of the new environment are encountered (Charmaz, 1995).

This iterative process is complicated further by the likelihood that the modification of schemas tends to be guided by three major themes (Barnard, 1990; Taylor 1983), each of which will be developed at a different speed and will be challenged or fortified by experiences. These themes include: (1) the search for meaning in the disability and in post-disability life; (2) the need for a sense of mastery and control over the environment, the disability and the future; and (3) the effort to protect and enhance the self and one's post-disability identity. Qualitative researchers have confirmed that within each theme, the experience of adjustment can be best represented as a pendulum motion that gradually moves from one extreme to the other, tending towards a center point over time (Yoshida, 1993). Thus, the recurrent process of adjustment may reflect the turbulence and confusion that prevails while people find a balance between two extremes. For instance, in the search for identity people tend to oscillate between schemas dominated by either self-rejection or self-acceptance (Barnard, 1990).

Yoshida (1993) found that following a permanent disability, individuals alternated between periods of time where they acknowledge only their former `pre-disability' identity at one extreme and only their new `disability' identity at the other extreme. The swing from `pre-disability' to `disability' identity is likely to be prompted by the disappointment and failure that accompanies the `pre-disability' identity. Although the person who existed prior to the injury continues to exist, such traumatic loss transforms individuals in an irreversible manner, meaning that the former self cannot be fully recaptured (Newsome & Kendall, 1996). At the other `disability' extreme, individuals tend to see themselves only in negative terms, leading to diminished self-worth, self-recrimination and severe depression (Charmaz, 1983). It is at this point that individuals with disabilities are extremely vulnerable to the development of negative schemas (Stewart, 1996) that are likely to precipitate a downward spiral into helplessness and chronic psychosocial problems (Cicerone, 1989).

Although not necessarily a universal phenomenon, individuals who manage to avoid this downward spiral are likely to continue moving through a series of continually decreasing pendulum swings while they establish their new schemas. Indeed, Yoshida (1993) found that, in response to the distress associated with the `disability' identity, individuals were likely to swing back towards the former self, but in an exaggerated form. Specifically, individuals reported a period of time when they perceived themselves as `supernormal' and attempted to engage in extraordinary activities without any assistance. This apparent lack of appreciation for the existence of deficits is often referred to as `denial' (Cicerone, 1989). However, in a recurrent model of adjustment, it is equally reasonable to refer to this process as an attempt to retain the meaning, control and identity that was associated with the pre-disability schema. In this regard, the tendency to perceive oneself as performing at a higher level than objective reality might support has been recognized as a hallmark of mental health (Lewinsohn, Mischel, Chaplin & Barton, 1980). Charmaz (1983) concluded that this phase of schema reconstruction encouraged the development of a personally and socially valued identity by negating the images of helplessness and dependence that are usually associated with disability. Similarly, Yoshida found that the purpose of the supernormal identity was for individuals to prove, even if only to themselves, that they were "no worse off than other people" (p.226).

As the need to prove oneself became less intense, it was found that the pendulum moved back towards the disability identity (Yoshida, 1993). Although the disability continued to be evaluated negatively, it was less likely to dominate the entire schema as it had during previous swings. Instead, the disability was likely to be distinguished from other characteristics of the self but was slowly becoming integrated into the individual's schemas. Eventually a `middle-self' was reached where the pendulum stopped swinging, albeit temporarily. At this time, individuals were likely to understand the permanent limitations of their disability while appreciating and nurturing their total selves. According to Yoshida, there appeared to be no limit to the number of times this pendulum process could occur or the duration of each process, a finding that lends considerable support to the recurrent model.

Research has also indicated that there is significant variation both within and across individuals in the speed and quality with which individuals move through the adjustment process (Kendall & Terry, 1996). The literature suggests that this variation is heavily influenced by individuals' available resources (Lazarus & Folkman, 1984). Specifically, access to sufficient resources has been found to encourage the development of more positive schemas and, thus, more appropriate coping efforts, resulting in greater psychosocial well-being (Lazarus, 1993). Presumably, individuals with higher levels of resources will progress through the adjustment cycle at a faster rate with better outcomes and fewer recurrent problems than those with low levels of resources. Typically, the resources that have been found to influence the adjustment process include personal resources (i.e., relatively stable characteristics such as self-esteem or social skills) and environmental resources, such as social and family support or financial security (Kaplan, 1990; Melamed, Grosswasser & Stern, 1992; Moore, Stambrook & Winson, 1991).

Individuals are likely to experience recurrent problems if their resources become depleted as a result of excessive coping demands. Negative psychosocial outcomes in areas such as emotional well-being, social behavior and vocational performance are potential stressors that deplete coping resources (Lazarus & Folkman, 1984). In contrast, positive outcomes will boost the individual's resources, thus influencing subsequent adjustment. In this context, adjustment following a stressful event is likely to become a spiralling process that either improves or declines in a self-perpetuating, cyclical manner.

Implications for Rehabilitation Counseling

Rehabilitation counselors are often trained from a sequential paradigm wherein adjustment is described as a series of stages. These stage models do not adequately address the recurrent nature of psychosocial problems and tend to define adjustment as a universal phenomenon. In contrast, qualitative research suggests that adjustment is a unique process, characterized by continual peaks and troughs as individuals seek to redefine themselves in the face of new challenges and unfamiliar circumstances. For some individuals, this cycle appears to present fewer negative consequences than others, indicating that these individuals either cope more successfully with challenges or are less vulnerable to the deleterious psychosocial consequences of traumatic disability than others.

This recurrent conceptualization of adjustment has several implications for rehabilitation counseling practice. First, the model suggests that rehabilitation counselors must make provisions for long-term follow-up services that can function in a "revolving door" manner. Rehabilitation counselors must liaise with community-based services and access natural supports to establish a network that can be easily activated as recurrent adjustment problems occur. Second, the recurrent model implies that rehabilitation counseling must be driven by a humanistic and phenomenological approach to understanding human behavior that acknowledges the unique experience of each individual. Further, this approach values the notion that individuals will strive for their optimal level of functioning and that they are the `experts' in their own adjustment process.

Third, the model advocates that a primary focus for rehabilitation counseling is the development of resources, the maintenance of strengths and the `expansion of opportunities' (Newsome & Kendall, 1996) to encourage the development of positive schemas. Specifically, individuals who have minimal resources should be adequately `resourced' to increase their ability to cope with the future adjustment problems they are likely to experience. This focus will support the ongoing process of positive schema development rather than a downward spiral of helplessness and depression (Cicerone, 1989). Finally, the recurrent approach suggests that rehabilitation counselors should adopt a systemic model in their work such as that suggested by Cottone (1987) rather than employing the linear, psychomedical paradigm "which has been pervasive in the history of rehabilitation" (Cottone & Emener, 1990, p. 91). A systemic, ecological model would focus counselors towards the identification of environmental as well as personal coping resources which are crucial to adjustment.

Implications for Research

Although the above conclusions are appealing, there is a paucity of empirical research in this area. The complex phenomenon of psychosocial adjustment following disability clearly warrants more detailed investigation.

To validate the ideas expressed in the current paper, further research must be conducted in two major areas. First, research must examine the adjustment process from a more in-depth qualitative perspective, to determine whether or not the proposals outlined in the current paper accurately reflect the subjective experience of people with acquired disabilities. Unfortunately, adjustment research to date has typically focused on descriptive outcome studies using repeated measurements of psychosocial outcome or studies employing linear statistical analyses to predict psychosocial outcome. Although informative, such studies tend to support the stage model of adjustment and do not explore the subtle experiences and variations across individuals that would be the focus of qualitative research. Second, it is important to determine whether or not the adoption of a recurrent conceptualization of psychosocial adjustment can lead to rehabilitation practices that are more acceptable to clients and are able to precipitate better adjustment. To address this research question, longitudinal research is necessary, using a matched-group design where only one group of rehabilitation counselors had been instructed in the application of the recurrent model of adjustment.

Conclusion

While it is acknowledged that psychosocial adjustment following acquired disability is a process that occurs gradually over time, it is likely that the process is circular or recurrent rather than sequential. The current paper has attempted to integrate existing knowledge about psychosocial adjustment into a coherent recurrent model that rehabilitation counselors can use to guide their understanding of clients who are experiencing psychosocial difficulties. The model suggests that adjustment is recurrent because individuals who have sustained a disability must reconstruct the schemas with which they view themselves and their experiences. This reconstruction process fluctuates as each new experience is confronted, leading the individual through a cyclical or pendulum motion characterized by a series of peaks and troughs. There is also evidence that adjustment will differ, both across and within individuals, depending on the level of coping resources they have access to at any point in time.

Qualitative research suggests that the recurrent approach to adjustment more closely approximates the experience of individuals with acquired disabilities than stage models. Thus the recurrent model is likely to engender a more humanistic understanding of the psychosocial adjustment process among rehabilitation counselors, enabling them to respond sensitively and helpfully to individuals who are experiencing difficulties. Finally, because the proposed recurrent model can account for the individual variation that is observed among people with acquired disabilities, it can provide useful information for rehabilitation programming. It is suggested that such a model, when thoroughly researched, should be adopted in the training of rehabilitation counselors.

Acknowledgement

This paper was funded in part by the Motor Accident Insurance Commission of Queensland.

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