Assessment & early planning with the family in vocational rehabilitation.

Assessment & Early Planning with the Family in Vocational Rehabilitation 

There has been an increasing focus in the rehabilitation literature on the importance of understanding and involving families in the rehabilitation process, (Bray, 1977; Cook & Ferritor, 1985; Cottone, Handelsman, & Walters, 1986; English, 1983; Lindenberg, 1977; Moore, 1984; Power & Dell Orto, 1986; Shellhase, & Shellhase, 1980; Sutton, 1985; Versluys. 1980; Zisserman, 1981). Although the family has been found to be a critical variable in rehabilitation outcome (Bolton, 1981; Bray, 1977; Lindenberg, 1977; Moore, 1984), vocational rehabilitation professionals do not actively work with the families of their clients (Emener & Rubin, 1980; Kneipp & Bender, 1981; Lindenberg, 1977). Various reasons for this discrepancy include: (a) lack of encouragement for family services by administrators (Kniepp & Bender, 1981; Lindenberg, 1977), (b) insufficient case service funds (Kniepp & Bender, 1981), (c) lack of education and in-service training in the provision of family services (Lindenberg, 1977). and (d) the complexity of family rehabilitation (Cook & Ferritor, 1985).

The purpose of this article is to present a systems framework for understanding families and some practical techniques for assessing families. Vocational rehabilitation counselors do not need to be family therapists, but they must understand the family environment that is an integral part of the client's world in order to provide the best services possible to the client. One of the most effective ways for vocational rehabilitation counselors to learn about the family environment is to have the family's participation in the vocational rehabilitation process.

A Family Systems Model

A systems perspective has been found useful in understanding the complexities of family interactions in rehabilitation settings (Cottone, 1986; Lindenberg, 1980; Power & Dell Orto, 1980; Steinglass, 1982). Family systems theory is a conceptual model built around a set of core concepts (Steinglass, 1984). The most important core concept is that the family can be viewed as an operational system. In other words:

Individuals within the system are not entirely free to behave according to their individually determined drives, motivations, personality attributes, etc., but rather are constrained and shaped in their behavior by the nature of the relationships they have with other elements of the family system. (P. 582)

In order to understand the behavior of one individual in a family, that behavior must be examined within the context of the whole family.

The second core concept is that families grow and develop. Families have characteristic life cycles or patterns of growth and development, as do individuals. For example, Carter and McGoldrick (1980) identify 6 stages in the family life cycle: 1) between families - the unattached young adult, 2) the newly married couple, 3) the family with young children, 4) the family with adolescents, 5) launching children and moving on, and 6) the family in later life. Generally, families tend toward greater organizational complexity and predictability over time.

The third core concept relates to the idea of control and regulation. The premise is that families behave in patterned and predictable ways because they operate according to regulatory principles. These built-in regulatory mechanisms serve to establish a sense of stability and resistance to change.

Family identity is a theoretical construct that describes some of these underlying regulatory mechanisms. Gonzalez, Steinglass & Reiss (1987) describe family identity as "those characteristics, or values, or priorities, or activities that make a family unique, that make it feel most like itself" (p. 20). For example, the Jones family enjoys hiking and camping and consider themselves "outdoorsy" people. Family identity is made up of several categories of family behavior that provide a concrete way of talking about and understanding family identity. These categories are family routines, family rituals, and family problem-solving style.

Often a disability can disrupt some or all of these patterned behaviors, which in turn causes difficulties for families. A goal for the vocational rehabilitation counselor is to help the family achieve a healthy balance between meeting the requirements of the disability and maintaining its identity. Continuing with the example of the Jones, when the teenage son in the family was left paralyzed from an accident, the family discontinued the outdoor activities they had previously enjoyed together because they felt that the son could no longer participate. Unexpressed anger and resentment regarding this turn of events could build in the family and inhibit the rehabilitation process. However, the counselor can show the family that the son can continue to go camping with appropriate adaptations and modifications. In this way, both client and family needs can be met.

The concept of family identity is useful to the vocational rehabilitation counselor in several ways. It serves as a guide to collect and prioritize data about the family. It also helps in identifying situations in which the family can be an asset or an impediment to the counselor. Consideration of familial influences early in the vocational rehabilitation process helps the counselor develop and implement a rehabilitation plan that is likely to be more successful for both client and family.

Encouraging Family Participation

Encouraging families to participate in the vocational rehabilitation process is not always easy. Gonzalez, Steinglass and Reiss (1987) have found that often, families with a member who has a disability have unarticulated concerns that affect the families' willingness to participate.

Involvement in the vocational rehabilitation process may be perceived as a threat to family stability for two reasons. First, families are reluctant to change routine ways of responding to the disability that were developed during the early phase of the disability even when they recognize that certain patterns are no longer working well. Second, families often believe that open discussion of the impact of the disability on family life and expression of feelings such as disappointment, anger, guilt, resentment, and helplessness would threaten client and family stability.

Other reasons for families' reluctance to participate in the vocational rehabilitation process relate to interfacing with the professional community. Often families feel criticized by an offer of help, especially if the help is of a psychological nature. Families seem to be unwilling to put themselves in a situation in which they feel that their flaws may be exposed. Also, most families report having negative experiences with at least one part of the medical care delivery system. If vocational rehabilitation is seen as a part of this system, families are hesitant to set themselves up for another potentially negative experience. Lastly, families are often unable to find time for another illness-related activity because they are already on tight schedules produced, in part, by the extra demands of the disability. In view of these typical response patterns, it is apparent that the manner in which families are approached and the establishment of a solid family-counselor relationship are critical components of any family-focused vocational rehabilitation intervention.

The counselor can encourage families to participate in the vocational rehabilitation process by approaching them in a manner that communicates sensitivity to their experiences. Some specific techniques have been proven effective in initiating contact with families (Dew & Hill, 1987). The counselor needs to be non-judgmental, show a non-patronizing interest in the family, avoid labelling the family as having a problem, and communicate to the family that they are important and an integral part of the vocational rehabilitation process. It is often best to intervene during transition times when families are more likely to be amenable to help. Good transition times may be when a young person with a disability is leaving school or when an older person is leaving a residential facility for home. It can also be useful to set up a home visit prior to an office visit. Often families feel less threatened when they first meet a professional if they are in their own "territory." It is also helpful to talk to family members as a group instead of letting one or two members speak for the entire family. When the counselor finds a family eager to become involved, all members should be immediately included if the client agrees.

Family History

All rehabilitation counselors conduct an initial interview with their clients to collect the basic information for developing a feasible rehabilitation plan. Taking a family history can be easily introduced into the initial interview. Traditionally, limited information is gathered such as a) present marital status or significant other, b) ages and level of independence of children, and c) a brief summary of the current living situation. However, vocational rehabilitation counselors may find it very useful to expand the family history in order to gain a more complete understanding of the client (Dew & Hill, 1987). This information may be obtained from the client, family, or both. Several areas related to the client's early years need to be explored. The family configuration in which the client grew up can provide indications about the stability of family life. For example, was the client raised in a single parent, two parent or step-family, or perhaps by grandparents? Often family structure has been disrupted by illness, death, or divorce. Information about the developmental stage at which the client had to deal with such a critical life event and the client's adjustment to the event can provide insight into the client's coping skills. Also, information about siblings such as number of siblings and half-siblings, the client's rank in birth order, and history of mental and physical illness in siblings can help identify how other siblings have developed within the family system. If there has previously been a disabling condition, the family's response to it may then foreshadow their response to the current disability.

The client's more recent family history is also relevant. Significant events in the last five years, such as marriages, births, and deaths are stressful events that can affect a client's vocational adjustment. By understanding the influence of such events, the counselor can prevent them from becoming obstacles to vocational success. Knowledge about the emotional and physical health of parents provides information about the client's role models and about the client's role in the family. Education levels and occupations of family members may suggest the vocational expectation focused on the client.

Another significant area to explore during a family history interview is a family participation in the care of the person with the disability or illness. Always, it is important to inquire about the client's perception of the family's adjustment to the disability. Specifically, the counselor will want to discover which family members are viewed as most supportive (emotionally and financially), how the client thinks the family views him or herself and the disability, and how the client feels about involving family members in the vocational rehabilitation process.

Family Interview

In addition to the information that can be gathered from a family history, data collected in a family interview can be especially valuable. Hearing various family members' perspectives on past and current problems often allows the counselor to make a more realistic and useful assessment of family life. During the course of the interview, the counselor will want to evaluate family adjustment, areas of family strengths and problems, and potential intervention strategies.

During the interview the vocational rehabilitation counselor can build discussion around the categories of family behavior--routines, rituals and problem-solving style--from the family systems model. "Family routines are those patterns of behavior in families that are repeated pretty much the same way every time and are important to the family" (Dew & Hill. 1986). These include mealtimes, role assignments, division of labor, etc. Questions that a counselor might ask to obtain information regarding routines include: How is meal preparation handled? Who does the cleaning, shopping, driving? Who disciplines the children, who plays with the children? This information is important because it illustrates the expectations that family members have of each other. Specifically in terms of work, it can be useful to find out how important it is for the client to work and what would happen if the client had to leave home for training.

Family rituals are different from family routines. In any family, rituals may include the holiday celebrations, birthday celebrations, vacations, etc. These activities have more organizational and symbolic importance than do routines and hence they convey a lot about what is valued in a family. Some questions that may get at these types of behavior include: How has the family lifestyle changed as a result of the disability? For example, does the family still make the five-hour drive to the grandparents' for Thanksgiving dinner and do they still take their usual vacation?

Family problem-solving style is the third aspect of family behavior that can be useful to a rehabilitation counselor. "By asking about how simple, day-to-day problems are resolved in the family, the counselor can see how the family may react to the kinds of problems and pragmatic issues that come up around managing a disability" (Dew & Hill. 1986). For example, does the family jointly discuss an issue, do the parents make a decision that is handed down to the rest of the family members, or does each member make an independent decision? Asking about the family's short-and long-term plans can provide indications about the family's goals and expectations.

By examining each of these categories of behaviors that comprise family identity, the vocational rehabilitation counselor develops a clearer understanding of the client and family. When this information is obtained as part of the assessment phase of the vocational rehabilitation process, the individualized rehabilitation plan is likely to be more successful because family obstacles can be anticipated and prevented. Figure 1 summarizes the key areas the rehabilitation counselor should include in the interview process.

Summary

Although it is generally recognized that family involvement in the rehabilitation process is important for a more successful outcome, "how-to" information on working with families is sparse and may partially account for the current lack of provision of family services. The family systems model is a useful theoretical framework for understanding families and it lends itself well to clinical applications. The concept of family identity and its component parts--routines, rituals and problem-solving style--is helpful in organizing family data that is collected during the assessment phase. With family participation, the vocational rehabilitation counselor can develop a plan that will help the family achieve a healthy balance between meeting the requirements of the disability and the needs of the family, which in turn increases the likelihood of a successful vocational rehabilitation outcome for the client.