Quality of life assessment in the measurement of rehabilitation outcome.

This article provides a review of the current status of the quality of life (QOL) construct and its application in the measurement of rehabilitation outcomes for people with disabilities. Demonstrating positive outcomes of rehabilitation services and interventions is a primary concern in rehabilitation in the current environment of accountability. In addition to rehabilitation counseling's historical federal mandate to demonstrate positive outcomes, an increased focus on consumer rights, increased competition for federal funds, and the emphasis of funding sources on effective and efficient services are driving this concern and the resulting search for appropriate outcome assessment measures and models.

Quality of life has long been recognized as a philosophically important rehabilitation outcome (e.g., Fabian, 1991; Livneh, 1988; Wright, 1980) and considerable effort has been expended in developing practical applications of QOL in rehabilitation practice and outcome measurement over the last 25 years. There remain, however, a number of conceptual limitations and pragmatic barriers to its widespread acceptance and use as a measure of outcome. Among these are the definitional ambiguity associated with the construct (Dijkers, 1997; Fabian, 1991), inconsistent approaches to its measurement, confusion over its distinction from other concepts, and the difficulty associated with the selection or creation of appropriate measurement instruments. In addition, questions remain as to whether QOL measurement is sufficiently valid, reliable, and sensitive to the changes that result from rehabilitation services or intervention.

The purpose of this article is to assist readers in understanding and effectively using QOL in rehabilitation outcome assessment and, ultimately, to increase its appropriate use in this context. To this end this article provides an in-depth exploration of the QOL construct, including both its promise and its limitations in the assessment of rehabilitation outcomes. We begin with an overview of rehabilitation outcome assessment and the application of QOL in this context. Following this we provide a brief review of the history of the QOL construct and its evolution in the social sciences generally and in rehabilitation counseling specifically. In order to enhance conceptual clarity we explore current definitions of QOL and distinguish QOL from constructs that are either (a) conceptually related to QOL e.g., life satisfaction, subjective-well-being, and health-related QOL, or (b) theoretically distinct from QOL but frequently used in rehabilitation outcome measurement (e.g. assessment of functional status, mental health, and psychosocial adaptation). Finally, we discuss the considerations in selecting a QOL instrument for use in rehabilitation outcome assessment.

Outcome Measurement in Rehabilitation

In the health and social service professions, outcome measurement may generally be defined as the measurement of change that results from participation in a program or service, or from receipt of a treatment or intervention. Outcome measurement has a number of important purposes and benefits. Monitoring the outcomes of clinical intervention provides a means of developing standard practices, informs clinical decisions regarding care, and provides a framework for assessing organizational performance (Heinemann, 2005). At the programmatic level, outcome assessment provides the ability to evaluate the effectiveness and efficiency of services and to make comparisons over time and across programs. Outcome assessment at this level also enables justification and the demonstration of accountability to program stakeholders and consumers.

Over the course of the past 30 years the ability to demonstrate accountability through evidence-based outcome assessment has been a steadily growing emphasis within the medical, mental health, and social service professions. Outcome assessment was made a focus in rehabilitation counseling in the Rehabilitation Act Amendments of 1973, in which rehabilitation programs were required to show that they could effectively and efficiently meet service outcome goals (Rubin & Roessler, 2001). In subsequent years this focus has grown and expanded. Performance-based indicators of service outcomes have been established for the state-federal vocational rehabilitation (VR) program in federal legislation including the Rehabilitation Act Amendments of 1992 and 1998 and the Workforce Investment Act (Lewis, Armstrong, & Karpf, 2005).

This legislative focus on accountability has extended beyond the confines of the state-federal VR program to other rehabilitation service providers and agencies. For example, the Ticket to Work and Work Incentive Improvement Act of 1999 made payments to service providers contingent on demonstrated employment outcomes (Lewis et al., 2005). In addition, the emphasis of funding sources on effective and efficient services has increased the necessity of rehabilitation agencies and service providers to be able to demonstrate their effectiveness. For example, the Commission on the Accreditation of Rehabilitation Facilities (CARF) recently increased their requirement for facilities to document their effectiveness through ongoing program evaluation (Lewis et al., 2005).

Changing Perspectives on Rehabilitation Outcomes

Outcome goals in rehabilitation counseling have traditionally been unidimensional and functionally-based (Fabian, 1991; Mermis, 2005). Historically, as a function of its history, the primary outcome goal has been employment. The state federal VR program was developed with the goal of increasing employment among persons with disabilities, and VR agencies have developed services and interventions designed to help meet that goal. Over time, however, the evolution of the profession, and shifts in philosophies, standards, expectations, and professional knowledge have created a need to reevaluate and modify outcome goals, and therefore, outcome measurement.

For example, although evaluation of the effectiveness of the VR program has historically focused on short-term employment outcomes (Chan, Miller, Lee, Pruett, & Chou, 2004), it has frequently been suggested that this narrow focus may provide an insufficient and misleading picture of the benefits of rehabilitation services to consumers (Chapin, Miller, Ferrin, Chan, & Rubin, 2004). As a result, several groups of rehabilitation researchers have suggested a need to broaden and improve the definition of successful rehabilitation beyond employment outcomes (e.g., Gilbride, Thomas, & Stensrud, 1998; Szymanski, Parker, & Butler, 1990). Many researchers have specifically identified QOL as an important component of alternative approaches (e.g., Bishop & Feist-Price, 2001; Rubin, Chan, Bishop, & Miller, 2003; Rubin, Chan, & Thomas, 2003).

Recently, for example, Chart and Rubin (1999; Chan, Rubin, Lee, & Pruett, 2003; Rubin, Chan, Bishop, & Miller, 2003) have advocated for the inclusion of QOL in the framework for assessing rehabilitation counseling outcomes. These researchers have developed a multidimensional rehabilitation planning and outcome assessment system for use in VR agencies in which well-being represents one important indicator of pre- to post-service change. Although this system has not yet been widely applied in VR practice, it is certainly evidence of a trend in the direction of adopting more comprehensive outcome measures, including those with a QOL component.

Another factor that has and will continue to drive the need to alter traditional perspectives on rehabilitation outcomes is the rapid evolution and expansion of the profession. Historically intimately linked to the state-federal VR programs (Jenkins, Patterson, & Szymanski, 1998), in the course of the past 85 years the profession has evolved such that rehabilitation counselors are working in an expanding array of additional service delivery settings, including community rehabilitation programs, supported employment programs, private practice and disability insurance settings, psychiatric rehabilitation programs, substance abuse treatment facilities, employee assistance programs, disability management, secondary and university education settings, hospitals and related medical settings, and prisons and other forensic settings. As the scope of rehabilitation counseling practice grows, so will the need to demonstrate and measure effectiveness in different ways and in different practice contexts, including through the measurement of programs' and interventions' impact on consumer QOL.

In rehabilitation counseling, as in all health and social service professions, the use of QOL as an outcome measurement provides a number of important benefits, but some potential limitations as well. In order to understand both it is important to have a comprehensive understanding of this broad construct, including its history and development, and its relationship to and divergence from other related constructs. The following discussion describes the history of the QOL construct in the social sciences.

Historical Development and Evolution of the Concept of Quality of Life in the Social Sciences

Although the search for the underpinnings of happiness and satisfaction with life has concerned philosophers for centuries (Diener & Suh, 1997), the application of the science of QOL and well-being in the social sciences has a relatively recent history. In the post-World War II era, a series of national and international surveys of population well-being were conducted, based on measures of life quality called social indicators. Social indicators are objectively measurable, group-based population statistics, characteristics, or variables such as gross national product, wages, cost of housing, and rate of unemployment (Cummins, 1997a). The main purpose of these early population-based surveys of life quality was to create concise and comprehensive snapshots of the status of large segments of society (Cummins, 1997a) for use in guiding the development of public policy.

Beginning in the mid- 1960s a shift in focus from QOL assessment based on population statistics to assessment based on the perspective of the individual began (Cummins, 1997a; Zhan, 1992). During this time the individual's unique perspective about his or her life circumstances was increasingly recognized as an important component of QOL. In the course of, and partly responsible for this shift in focus from objective to subjective indicators of QOL was the recognition that social indicators accounted for a relatively small percentage of the individual's overall QOL (Day & Jankey, 1996). Simultaneously, it was recognized that in the individual's experience of well-being, objective variables were outweighed by the individual's subjective perception of his or her objective circumstances in the context of changing values and priorities.

During the 1970's a number of highly influential studies (e.g., Andrews & Withey, 1976; Campbell, Converse, & Rogers, 1976; Flanagan, 1978) stimulated the rapid growth of QOL research in the social sciences. These studies explored the nature, dynamics, and components of QOL, life satisfaction, and well-being. A number of significant findings in these studies initiated interest in questions that are still actively being addressed today. These include the idea that, like the objective social indicators, subjective indicators could be reliably measured; that a group of domains important to QOL or life satisfaction could be identified; and that the influence of these domains on the individual's QOL was both subjective and variable over time.

The steady increase in QOL research activity continued into the 1980s and significant advances in theory development were made in this decade. In mental health, medicine, and human services there was increasing recognition of the potential for the application of QOL concepts in policy development, clinical practice, and outcome assessment. As foreshadowed by Schalock, Keith, Hoffman and Karan (1989), who suggested that QOL was "the issue for the 1990's" (p. 25) this momentum carried and continued to build through the 1990's to the present day.

The exponential growth of research with and practical application of the QOL construct in the social sciences and health related fields were essentially mirrored in rehabilitation counseling. References to QOL as an important theoretical and practical construct in rehabilitation were evident, but sporadic during the 1980s (e.g., Crewe, 1980; Wright, 1980; Wright, 1983). During the 1990's, however, QOL became a much more significant focus of attention. Seminal articles by Livneh (1988), Fabian (1991), and Roessler (1990) initiated this focus. These articles identified QOL as a primary and superordinate rehabilitation counseling outcome and a construct with significant potential for guiding the delivery and evaluation of rehabilitation counseling services. With regard to rehabilitation outcome measurement specifically, the trends, identified by Fabian (1991), toward an increased emphasis on consumer-based evaluation, a growing awareness of the limitations inherent in the traditional unidimensional outcome measures, and the recognition of improved QOL as the overarching goal of rehabilitation services formed the basis for the establishment of QOL as a standard framework for outcome assessment.

In recent years, rehabilitation researchers have increasingly identified QOL as a concept of overriding importance in rehabilitation (Bishop & Feist-Price, 2001; Crewe, 1980; Fabian, 1991; Pain, Dunn, Anderson, Darrah, & Kratochvil, 1998; Roessler, 1990; Rubin, Chan, Bishop, & Miller, 2003). Quality of life has been described as "an overarching psychosocial outcome in rehabilitation practice" (Livneh 2001, p. 154), and "the generally accepted philosophical goal of rehabilitation counseling" (Bishop & Feist-Price, 2001, p. 35). Rehabilitation researchers have suggested that QOL can contribute to rehabilitation practice in various components of the rehabilitation process, including vocational evaluation, rehabilitation planning, counseling, and program evaluation (Bishop & Feist-Price, 2001; Fabian, 1991; Livneh, 1988, 2001; Roessler, 1990; Rubin, Chan, & Thomas, 2003; Schalock et al., 1989).

Impressive evidence of the significantly increased attention to QOL in rehabilitation over the past 25 years is reflected in the professional literature. A search of rehabilitation journals for articles containing the term "quality of life" in the title shows that between 1980 and 1990 twenty such articles were published. Between 1990 and 1995, 158 articles were published. Between 1995 and 2000 the number more than doubled to 360, and in the past five years 627 articles were published. (This search did not include such terms as "life satisfaction" or "well-being", which terms would no doubt have dramatically increased the numbers.)

Quality of Life Defined

Nearly all authors reviewing the QOL literature have decried the lack of a uniform or consistently applied definition. Many have also highlighted its vague and overly inclusive characteristics. For example, Campbell et al. (1976) suggested, "quality of life is a vague and ethereal entity, something that many people talk about, but which nobody very clearly knows what to do about" (p. 87). And Feinstein (1987) suggested that QOL represents "a kind of umbrella under which are placed many different indexes dealing with whatever the user wants to focus on" (p. 635). Some writers (e.g., Anderson & Burckhardt, 1999; Farquhar, 1995) have attributed the lack of a single, unified definition of QOL to the fact that researchers in so many different disciplines use the concept with different purposes and different measurement techniques.

The growing interest in QOL over the past 20 years has led to the development of thousands of QOL instruments and inventories, which does little to clear up conceptual confusion. For example, in their review of 75 QOL studies, Gill and Feinstein (1994 as cited in Anderson & Burckhardt, 1999) identified 159 assessment instruments. The instruments included measures of pain, handgrip strength, attitudes toward medication, and life satisfaction. As Anderson and Burckhardt suggested, "most people can probably agree that these instruments do not measure a single phenomenon" (p. 299), or if they do, the coherence and consistency of the meaning of this concept (and therefore its utility) must certainly be questioned.

Fortunately, despite the confusion over and difficulty in defining QOL, there appears to be increasing consensus on a number of general points. Because QOL is a construct used in such a wide variety of contexts there may never be a universal consensus about what QOL is and what it is not, but definitional clarity and consensus appear to be more attainable today than ever.

For the purpose of this article, we propose the following definition of QOL: Quality of life represents the subjective and personally derived sense of overall well-being that results from an evaluation of happiness or satisfaction across an aggregate of personally or clinically important domains. Encompassed in this definition are the following points of growing definitional consensus: (a) that QOL is multidimensional in nature, (b) that it is based on the subjective perspective of the individual and reflects values and judgments about domain importance that may change over time, and (c) that it represents an analysis of both subjective and objective indices. These points are discussed in some detail below.

Objective and Subjective Indicators

There is currently a general consensus that QOL measurement should involve a combination approach, including both objective and subjective variables (Cummins, 1997a). The objective component addresses norm-referenced measures of function or well-being, and the subjective the individual's purely phenomenological feelings about well-being. Objective indicators may include social indicators or outward material circumstances such as employment status, salary, marital status, etc., or physical function or symptoms that could be assessed by an external observer. Subjective indicators, on the other hand, provide estimates of satisfaction with life in general or with specific life dimensions (Roessler, 1990). Some researchers (Anderson & Burckhardt, 1999; Diener, Lucas, & Oishi, 2002; Fabian, 1991) have suggested that a measure that includes either only objective indices or only subjective indices would not appropriately be called a QOL measure, but either a measure of health status or physical function (only objective items), or a measure of subjective well-being or life satisfaction (purely subjective items).

It should be noted that there is a difference among instruments in how responses to the objective indicators are scored. Some QOL instruments, such as the Comprehensive Quality of Life Scale, Fifth Edition (ComQol-5; Cummins, 1997b) contain items that assess objective indicators, such as employment status and income, and incorporate the respondent's status on these indicators into the scoring mechanism, such that those who are employed would have a higher score on that item than those who are unemployed. Other QOL instruments, such as the Quality of Life Index (Ferrans & Powers, 1985) also have items that assess work and income, but these items are scored based only on the respondent's subjective satisfaction with the indicator rather than on the actual employment status or income level. This distinction is important to consider in selecting outcome measures, and deciding which form of information is being sought: data about consumer's objective circumstances, or their subjective opinion.

Quality of life as a Multidimensional Construct

Research increasingly supports the idea that QOL is most appropriately measured across a set of domains (e.g., Bowling, 1995; Cummins, 1997a; Frisch, 1999). Support for this idea emerged from studies in which researchers, using a variety of different approaches including literature reviews, large-scale surveys, and interviews, sought to discover what people considered important to their QOL, or how they defined QOL. Over the last three decades, researchers in different fields of human study have increasingly noted the consistency with which a relatively small set of life domains have been identified as contributing to overall QOL (Bishop & Allen, 2003). Among the most frequently and consistently identified domains are physical health, psychological or emotional health, social support, employment, and economic or material well-being (Bishop & Allen, 2003; George & Bearon, 1980; Hughes, Hwang, Kim, Eisenman, & Killian, 1995; Jalowiec, 1990; Padilla, Grant, & Ferrell, 1992).

To a great extent, it appears that the same domains are elicited in studies conducted with persons with various chronic illnesses as those obtained from general populations. "It seems, then, that quality of life has the same basic constituents for all people, although the relative importance of individual dimensions may vary over the life span or during illness episodes." (Anderson & Burckhardt, 1999, p. 301).

The related concept of domain importance (Frisch, 1999; Pavot & Diener, 1993) suggests that satisfaction in highly valued areas of life will "have a greater influence on evaluations of overall [QOL] than areas of equal satisfaction but lesser importance" (Frisch, 1999, p. 1277). Thus, a more accurate and meaningful assessment of QOL results from weighting satisfaction in those specific life domains that are more highly valued or important to the individual. An important assumption underlying this perspective is that satisfaction in more personally important areas of life can in fact mitigate or compensate for dissatisfaction in less important areas (Campbell et al., 1976; Gladis, Gosch, Dishuk, & Crits-Christoph, 1999). This premise has been supported and empirically validated by the work of numerous researchers (e.g., Andrews & Withey, 1976; Campbell et al., 1976; Diener & Diener, 1995; Michalos, 1991) and this approach to measuring QOL has been utilized in several QOL measures (Cummins, 1997b; Ferrans & Powers, 1985; Frisch, Cornell, Villanueva, & Retzlaff, 1992).

Distinguishing QOL from Related Constructs

The terms quality of life, subjective well-being (SWB), and life satisfaction are frequently used interchangeably in the QOL literature, however the terms do represent subtle distinctions and unique theoretical nuances (Frisch, 1999). To a great extent, the difference lies in the distinction between the subjective and objective perspective. Understanding the difference is important in the selection of outcome measures.

The concept of QOL emerged, as discussed above, as a group-based assessment of objectively measured social indicators. Over time, as researchers discovered that such indicators did not significantly account for happiness or satisfaction with life, QOL has come to represent an assessment based on both subjective and objective components. Life satisfaction, on the other had, is derived purely based on the subjective perspective of the individual (Fabian, 1991) and may represent satisfaction with life globally or with specific life domains. Subjective well-being (SWB) incorporates life satisfaction, but also involves emotional and cognitive processes, (as discussed in more detail below). Objective conditions such as health, wealth, and comfort are seen to be potential influences of SWB but not necessarily determinants, and therefore are not a focus of assessment.

Diener et al. (2002) suggest that there are individual differences in the mechanisms by which people evaluate life satisfaction. For example, when asked to rate their satisfaction with life, some people focus on the positive aspects of their life, and others on problem areas. People also differ in the extent to which they weigh their moods and emotions when calculating life satisfaction. Cultural differences also affect the evaluation of life satisfaction. People in cultures in which happiness is an important cultural value give more weight to their most positive life domains, and people in cultures in which happiness is not valued weight their more negative domains (Diener et al., 2002).

A number of distinct models of life satisfaction have been devised. Diener et al. (2002) differentiate these into three groups: goal theories, process or activity theories, and genetic and personality predisposition theories. Goal theories suggest that individuals attain life satisfaction, as they perceive that they are moving toward an ideal state or accomplishment of a valued goal. Michalos's Multiple Discrepancies Theory (1985), for example, postulates that happiness is inversely related to the degree of perceived discrepancy between one's current circumstances (or what one has) and one's goals, which may represent (a) what one wants, (b) what one had in the past, (c) what one expects to have in the future, (d) what one expected to have at this point, (e) what relevant others have, (f) what one deserves, and (g) what one needs.

Process or activity theorists suggest that, rather than the attainment of the goal, it is the process of pursuing a goal that leads to satisfaction (Diener et al., 2002). In other words, people are happy when they are engaged in interesting pursuits or activities that match their skill level (Csikszentmihalyi, 1975 as cited in Diener et al., 2002).

Genetic and personality-based theories emerged in response to the observation that (a) at the individual level, life satisfaction or well-being tends to remain fairly stable and consistent, and (b) although life events tend to cause some fluctuation, people tend to return to individual set points, or adaptive levels (Headey & Wearing, 1992). Research related to these observations suggests that there may be a genetic component involved, or, in other words, that happiness and unhappiness are to some extent genetically and biologically-determined (Diener et al., 2002) There is also evidence that some personality traits are related to life satisfaction levels.

Like life satisfaction, which is theoretically incorporated into SWB (Frisch, 1999), SWB represents a purely subjective perspective. Generally, subjective well-being refers to the individual's appraisal of his or her life situation overall- the totality of pleasures and pains (Ormel, Lindenberg, Steverink, & Verbrugge, 1999). More specifically, SWB is understood to represent three components, including life satisfaction, an affective component, or one's emotional reactions to events, and cognitive judgments about satisfaction and fulfillment. Thus, high levels of SWB are associated with the frequent experience of pleasant emotions (positive affect), low levels of negative moods (negative affect), and a high level of life satisfaction. Interestingly, positive affect and negative affect have been shown to have different correlates (i.e., the factors that promote negative affect are different from those that promote positive affect), and thus to be somewhat independent from each other (Diener et al., 2002). As a result, the elimination of negative mental states does not necessarily foster a positive state, or put another way, "the elimination of pain may not result in a corresponding increase in pleasure" (Diener et al., 2002, p. 64).

The question of the validity of subjective measures of life satisfaction or subjective well-being has important implications for their use as outcome measures. Diener et al. (2002) suggest that the validity of SWB measures is supported by findings that SWB scores have been found to converge with several other types of assessment, including expert ratings based on interviews with respondents, and reports of family members and friends.

A separate and quite significant concern about using subjective QOL measures in outcome assessment is the inter- and intra-individual variability seen in these constructs. "Life satisfaction reflects different information for different people and can change depending on what is salient at the moment" (Diener et al., 2002, p. 65). It is clear from the above discussion that the experience of life satisfaction and subjective well-being is susceptible to cultural, cognitive, genetic, biological, and personality characteristics of the individual, but may be minimally influenced by changes in external circumstances. Further, these constructs appear to be relatively stable at the individual level. Thus, they may prove somewhat insensitive as measures of outcome, particularly in response to interventions that target physical, material, or otherwise objective circumstances.

Distinguishing QOL from other Measures

A review of the literature shows that a variety of terms have been equated with QOL, including life-satisfaction, self-esteem, well-being, health, happiness, adjustment, functional status, and value of life (Frank-Stromborg, 1988). Many measures are utilized in the process of rehabilitation counseling, or in rehabilitation outcome assessment, that may conceivably be confused with QOL. These are presented here to clarify the distinctions.

Health-Related Quality of Life. Typically used in medicine and allied health fields, health-related quality of life (HRQOL) represents a subset of the overall quality of life construct, and includes those dimensions of quality of life that are directly related to an individual's health, and that may be the target of intervention. Assessment with this more focused approach to QOL typically encompasses physical, mental, and social functioning and well-being, "including how well an individual functions in daily living (role functioning), as well as specific disease manifestations" (Vickrey, Hays, Hermann, Bladen, & Batzel, 1993, p. 623).

Measures of Health Status. Health status measures are frequently used as outcome measures in the medical and health care fields. The focus of these measures is on objective physical, mental, and functional status. Domains assessed may include physical function, social or vocational function, pain, energy, and mental or psychological function. There is much confusion between health status, health-related QOL, and QOL. According to Anderson & Burckhardt (1999) this confusion began when funding agencies began requiring that quality of life measures be used in outcome assessment, and researchers simply redefined existing measures of health status, disease symptom, and functional status as quality of life or health-related quality of life measures and administered them because they were already available. Adding to the confusion, health status measures are generally multidimensional and frequently include domains that overlap with accepted QOL domains, or else purport to assess well-being. The primary distinction between health status and QOL lies in the distinction between health and QOL.

"Considerable support exists for dispensing with the notion that health is synonymous with quality of life" (Anderson & Burckhardt, 1999, p. 303). For example, poor health status and significant disability appear to be to a great extent unrelated to reported QOL (Johnson, Amtmann, Yorkston, Klasner, & Kuehn, 2004). Health represents only one of many components that people consider when evaluating their QOL, and it is one of varying importance depending on age and health status. That is, health appears to be of less importance when it is good, and greater importance when it is either not good or in danger of becoming worse (see e.g., Campbell et al., 1976; Flanagan, 1978). In addition, there is evidence from several research studies that health care professionals frequently overestimate how important health status is to the overall QOL of the consumer (Anderson & Burckhardt, 1999). "It is important to recognize that although health status and quality of life share some variance, they are distinct concepts worthy of separate measurements" (Anderson & Burckhardt, 1999, p. 303).

Assessments of Functional Status and Functional Capacity.

Functional assessments are frequently used in disability determination and vocational evaluation. The purpose of these assessments is the objective and comprehensive evaluation of physical and vocationally-relevant capabilities (Matheson, Kaskutas, McCowan, Shaw, & Webb, 2001). Typically multidimensional, these vocationally-focused measures assess function in such domains as self-care, mobility, communication, cognition, and purposeful behavior in interaction with the environment (Parker & Bolton, 2005). These measures reflect objective assessment of function, and may be based on self-report or completed by professionals based on observation or interview.

Measures of Mental Health, Mood, or Anxiety Disorders.

Measures of mental health, mood or anxiety disorders, including scales to assess depression or anxiety, are frequently used in the process of rehabilitation assessment and as outcome measures to assess the efficacy of counseling techniques or interventions. Such assessments are an important component of outcome assessment, and can be seen in the above discussion to be related to, but distinct from QOL and SWB. For example, experiences of positive and negative affect are considered elements of SWB, but positive affect is not in and of itself SWB. Similarly, affect may be considered a component of QOL, and positive affect a correlate of high QOL, but is not in itself QOL. Thus although mental health may be conceived as an important element of QOL, it is only one element in the broader context of QOL, which makes QOL a more comprehensive and informative approach to assessment (Bishop, 2005a).

Psychosocial adaptation. Recently several rehabilitation researchers have linked QOL and psychosocial adaptation, positing that QOL represents an appropriate and useful framework for assessing and understanding the process of psychosocial adaptation to disability or illness (e.g., Bishop, 2005 a & b; Devins, 1994; Devins & Shnek, 2000; Livneh, 2001). These authors, in their respective approaches, have clarified that the constructs are similar, but conceptually distinct.

Benefits, Limitations, and Considerations in Applying QOL in Rehabilitation Outcome Measurement

The Commission for Rehabilitation Counselor Certification's Scope of Practice for Rehabilitation Counseling (CRCC, 2005) suggests that rehabilitation interventions are comprehensive and holistic, and designed to allow counselors to address problems in a variety of life dimensions. Rehabilitation counselors serve, by definition, persons with chronic or permanent illnesses and disabilities. Our goal is not the cure of illness, but the reduction of barriers, the enhancement of function, the promotion of independence and autonomy, and, in short, improving the quality of life. Given the scope and purpose of rehabilitation services, the comprehensive and multidimensional nature of QOL assessment makes it a uniquely appropriate means of assessing rehabilitation outcomes. At the same time however, the complexity and breadth of the QOL construct, and the wide variety of instruments that exist for its measurement, may lead to inappropriate and ineffective applications in outcome measurement, resulting in erroneous or otherwise problematic conclusions. In this section we discuss both the benefits, the potential limitations, and the important considerations in selecting and using QOL in rehabilitation outcome assessment.

Quality of life has been described as the "ultimate rehabilitation goal" (Livneh, 2001 p. 154), and "the generally accepted philosophical goal of rehabilitation counseling' (Bishop & Feist-Price, 2002, p. 35), and improving QOL has been identified as the goal of all rehabilitation programs (Fabian, 1991). There are two distinct ways of interpreting such broad statements. The first is that the many outcomes that have historically been identified with the provision of rehabilitation services (e.g., independence, community integration, employment, improved function) may effectively be incorporated into the overarching QOL paradigm (e.g., Livneh, 1988; 2001). The second is that the direct purpose of rehabilitation counseling interventions is to enhance the QOL of persons with disabilities. Both interpretations have important implications in considering how (and whether) QOL may be effectively applied in outcome measurement, and this distinction is also helpful in elucidating potential benefits and limitations.

Benefits of and Rationale for QOL as Rehabilitation Outcome

In the former interpretation quality of life is conceived as a higher order philosophical goal in rehabilitation, and one that subsumes or incorporates the various existing rehabilitation goals identified above in a unifying and comprehensive framework. Because QOL is a multidimensional construct, involving assessment of psychological, social, economic, physical, and other domains that may be targeted in rehabilitation counseling, it is an inherently efficient approach to outcome measurement. That is, it encompasses many alternative, frequently unidimensional approaches to outcome assessment, and provides more information than any one such measure in isolation. This comprehensive nature of QOL is clearly in accordance with the holistic approach that is espoused in rehabilitation counseling and an advantage in outcome assessment.

In addition, QOL assessment has the capacity to provide information from both the objective and subjective perspective. Outcome measurement in rehabilitation has traditionally relied primarily on objective and functionally-based measures. Bishop and Feist-Price (2001) suggested that even in the assessment of QOL, rehabilitation researchers have traditionally focused on the objective indicators. Research has consistently shown, however, that there is little correlation between "objective" indices of QOL (e.g., employment status or material well-being) and such subjective measures as well-being, perceived QOL, life satisfaction, or personal happiness (Michalos, 1991; Myers & Diener, 1995). Although neither perspective is, in isolation, capable of giving comprehensive information about change, the importance of considering the subjective view, rather than focusing solely on objective indices has been consistently emphasized in the rehabilitation literature (Frank-Stromberg, 1988; Noreau & Sheppard, 1995; Rubin, Chan, Bishop, & Miller, 2003; Rubin, Chart, & Thomas, 2003; Smart, 2001).

Rubin, Chan, Bishop, and Miller (2003) suggested that part of the consumer's motivation for pursuing rehabilitation services is the expectation that his or her life will improve as a result. This expectation on the part of the consumer should not be a foregone conclusion on the part of the profession. It is a generally accepted idea that employment leads to an increased QOL as a secondary result of the increased income, autonomy, productivity, and social participation that employment provide. However, it has been made clear in the present article that external circumstances, such as employment and income, account for a relatively small amount of the total variance in QOL. In fact, it is certainly conceivable that an inappropriate or unsatisfying job, such as one that does not meet the consumer's economic status, intellectual, or other needs may in fact lead to a reduced QOL, and current, objective outcome measures would be unable to detect this outcome.

Certainly there may be settings and situations in which information about objective phenomena or external circumstances is appropriate, such as in rehabilitation settings where increased physical functioning is the sole goal of treatment. Alternately, there may be instances in which a purely subjective approach is preferred, such as may be the case in consumer satisfaction research. Generally, however, because both sides of this equation are needed to judge the complete impact of an intervention or service, and because the perspective of the consumer is increasingly being valued and sought, it is preferable to include measures, such as measures of QOL, that include both components.

In terms of the psychometric qualities of QOL measures, the validity and general psychometric quality of QOL measures must be assessed on an individual basis when selecting measures for use. Speaking generally, however, the validity and reliability of numerous QOL instruments has been demonstrated (e.g., Atkinson & Zibin, 1996) and their utility and value in outcome assessment well established. Further, the preponderance of QOL measures available, often identified as a limitation to conceptual clarity, may serve as a benefit in the context of outcome assessment, allowing more effective matching of interventions with expected outcome.

Finally, although some have criticized the use of quality of life measures as an unnecessary and extraneous frill compared with measures of symptoms, functional status, health status, or other more specific outcomes, measures of QOL and domain-based life satisfaction may have a generally unconsidered predictive and preventative benefit. For example, QOL and SWB measures have the potential to predict and identify persons at high risk for health problems, relapse, and impaired functioning in school, work, and social relationships (Frisch et al., 2005). "Domain-based life satisfaction/QOL scales significantly predict such practical, 'bottom-line' outcomes as job performance and satisfaction as many as 5 years in advance; job accidents, and productivity, school performance [and] future health problems and related expenditures" (Frisch et al., 2005, pp. 67-68). The significant implications of these recent findings for rehabilitation counseling have not yet been explored.

Limitations and Considerations

The alternate interpretation of the broad statements above, (i.e., that the direct purpose of rehabilitation counseling interventions is to enhance QOL) may be associated with several limitations and cautions. For example, if improving QOL is the direct target of rehabilitation intervention, the measurement of this outcome using the broad QOL construct will certainly be limited and prove problematic unless (a) QOL is operationalized in very specific terms, and (b) the interventions are indeed specifically designed to increase QOL. The former condition is achievable, although over specification may decrease the utility of the QOL construct. The latter condition is much less likely to occur for a number of reasons.

First, the origin of rehabilitation counseling as a profession is steeped in pragmatism. The state-federal VR program was established in and to a great extent owes its longevity to, the argument that VR is economically advantageous. Although the profession has evolved and grown more independent of its identity with the state-federal VR program and the associated explicit focus on employment outcomes, QOL is still generally considered a secondary benefit, rather than primary outcome goal of rehabilitation services.

Second, according to Dubos (1976 as cited in Anderson & Burckhardt, 1999), rehabilitation interventions do not directly determine QOL. Rather, they help people to achieve a level or state of independence, health, function, participation, or adaptation that allows the individual to live life on their own terms- to provide the support needed so that the maximum QOL, as defined by the individual, can be achieved. Quality of life is a complex and highly individual phenomenon. It is impractical to broadly suggest that interventions aimed at increasing QOL will produce this effect across groups of consumers. This is particularly true in the case of purely subjective measures, such as life satisfaction and subjective well-being which, as discussed above, are influenced by a number of factors external to rehabilitation intervention. Thus, in many situations the combined approach of assessing changes in both subjective response and objective circumstances will prove more useful and productive.

Finally, conceptual clarity and shared conceptual understanding is essential to outcome assessment. Yet, as has been frequently noted, conceptual clarity has been particularly problematic in the application of the broad and inconsistently defined QOL construct in outcome assessment. This lack of conceptual and definitional clarity of QOL represents perhaps the most significant barrier to its effective implementation in outcome assessment; however, this concern perhaps serves more appropriately as a caution than a limitation. Those who would use QOL in rehabilitation outcome assessment will benefit from understanding the concepts involved, and making careful choices about the specific instruments that they select for their purpose.

Considerations in Selecting a QOL instrument for Outcome Measurement

In order to measure the benefit or efficacy of rehabilitation interventions it is necessary first to identify clear conceptual definitions of the outcomes, and then to identify and select appropriate measures to assess these concepts (Anderson & Burckhardt, 1999). Selecting effective outcome measures requires consideration of a number of factors related to the program or intervention to be assessed, the preferred outcome, and the rationale for the outcome assessment. The selection of the outcome measure should reflect the goals of the program or intervention. A number of questions specific to QOL instruments must also be considered.

Questions regarding the matching of the instrument to the outcome include which perspective is to be sought, which domains are to be assessed, and the form of the information. Is it important for the purpose of the assessment to reflect the subjective opinion or response of the consumer, or more objective changes in function, status, or circumstances, or both? If information is to be collected across a number of domains, those that are an important focus of assessment should be identified, and a measure that incorporates those domains should be selected.

Because QOL can be defined in a variety of ways, it is necessary to review instruments and ascertain the perspective of the instrument developers. As was identified above, some measures of 'quality of life' use this definition very loosely.

The format and length of the assessment should be considered taking into account the population being assessed. Some measures may be very brief, but not provide the required or desired information, and others may be so long as to be daunting, leading to a reduced response rate and an overabundance of extraneous information. The language and reading level required are also important considerations.

As with all mental health and health assessments, there is generally information available from the instrument publishers or developers about the psychometric qualities of QOL instruments. Considerations include whether the instrument has been developed and tested in the same or similar populations to the one being evaluated, and whether the reliability and validity statistics reported for the instrument are adequate both generally and in relation to the specific population of interest (Anderson & Burckhardt, 1999).

Conclusion

The utility and advantages of using quality of life measures as outcome measures in rehabilitation has been well established. This application of the QOL construct is congruent with the philosophy of rehabilitation as a profession that values a person-centered and comprehensive approach. Indeed, it often appears that QOL is, as has been suggested, the professions ultimate goal and purpose, and an ideal concept to apply in our planning, service delivery, and outcome assessment. The enthusiasm that is often associated with QOL, however, should be tempered with an understanding of its conceptual intricacies and practical limitations.

Gladis et al. (1999) suggested a number of important questions about applying QOL in psychotherapeutic and psychopharmacological outcome assessment that may be paraphrased for the present context as follows: Should counselors and their consumers feel that the job is not done (or not done well) if specific rehabilitation goals (e.g., employment) are met but other areas of the consumer's life are not fully satisfying? Should we be in the business of assessing aspects of life that bear no obvious connection to specific rehabilitation goals? And should we "worry that quality of life cannot be reduced to a single score or set of scores in that the unique and changeable set of everyday experiences that gives rise to feelings of well-being or discontent (like the companionship of a pet, a bad commute, or noisy neighbors) cannot be captured by a scale, however comprehensive?" (Gladis et al., p. 329). Such questions represent legitimate and important concerns. But they must be weighed with the significant value to our profession of committing ourselves to the broader, more informative, more comprehensive, and more consumer-centered approach of QOL assessment. Such a commitment will certainly involve a change from current methods to a new way of thinking, but these changes will be grounded in a perspective that is, in fact, as old as the profession.

References

Anderson, K.L., & Burckhardt, C.S. (1999). Conceptualization and measurement of quality of life as an outcome variable for health care intervention and research. Journal of Advanced Nursing Research, 29, 298-306.

Andrews, F., & Withey, S. (1976). Developing measures of perceived life quality: Results from several national surveys. Social Indicators Research, 1, 1-26.

Atkinson, A.J., & Zibin, S. (1996). Quality of life measurement among persons with chronic mental illness: A critique of measures and methods. Retrieved May 12, 2005 from: http://www.phac-aspc.gc.ca/mh-sm/mentalhealth/pubs/quality_of_life/ index.html.

Bishop, M. (2005a). Quality of life and psychosocial adaptation to chronic illness and acquired disability: A conceptual and theoretical synthesis. Journal of Rehabilitation, 71(2), 5-13.

Bishop, M. (2005b). Quality of life and psychosocial adaptation to chronic illness and acquired disability: Preliminary analysis of a conceptual and theoretical synthesis. Rehabilitation Counseling Bulletin, 48, 219-231.

Bishop, M., & Allen, C.A. (2003). Epilepsy's impact on quality of life: A qualitative analysis. Epilepsy & Behavior, 4, 226-233.

Bishop, M., & Feist-Price, S. (2001). Quality of life in rehabilitation counseling: Making the philosophical practical. Rehabilitation Education, 15, 201-212.

Bishop, M., & Feist-Price, S. (2002). Quality of life assessment in the rehabilitation counseling relationship: Strategies and measures. Journal of Applied Rehabilitation Counseling, 33 (1), 35-47.

Bowling, A. (1995). What things are important in people's lives? A survey of the public' judgment to inform scales of health related to quality of life. Social Science and Medicine, 41, 1447-1462.

Campbell, A., Converse, P.E., & Rogers, W.L. (1976). The quality of American life: Perceptions, evaluations, and satisfaction. New York: Russell Sage.

Chart, F., & Rubin, S. (1999). Developing a multidimensional program evaluation system in rehabilitation. (A field initiated project proposal submitted to National Institute on Disability and Rehabilitation Research.) Rolling Meadows, IL: Foundation for Rehabilitation Education and Research.

Chan, F., Miller, S., Lee, G., Pruett, S., & Chou, C. (2004). Rehabilitation research. In D. Maki & T. Riggar (Eds.), Handbook of rehabilitation counseling (pp. 159-170). New York: Springer.

Chan, F., Rubin, S.E., Lee, G., & Pruett, S.R. (2003). Empirically derived life skills factors for program evaluation in rehabilitation. Journal of Applied Rehabilitation Counseling, 34(4), 15-22.

Chapin, M.H., Miller, S.M., Ferrin, J.M., Chan, F., & Rubin, S.E. (2004). Psychometric validation of a subjective well-being measure for people with spinal cord injuries. Disability and Rehabilitation, 26, 1135-1142.

Commission on Rehabilitation Counselor Certification. (2005). Scope of practice for rehabilitation counseling. Retrieved May 15, 2005, from: http://www.crccertification.com/scope.

Crewe, N.M. (1980). Quality of life: The ultimate goal in rehabilitation. Minnesota Medicine, 63, 586-589.

Cummins, R.A. (1997a). Assessing quality of life. In R.I. Brown (Ed.), Assessing quality of life for people with disabilities (pp. 116-150). Cheltenham, England: Stanley Thornes.

Cummins, R.A. (1997b). Comprehensive Quality of Life Scale-Adult (5th ed.-ComQol-A-5). Melbourne, Australia: Deakin University School of Psychology.

Csikszentmihalyi, M. (1975). Beyond boredom and anxiety. San Francisco: Jossey-Bass.

Day, H., & Jankey, S. (1996). Lessons from the literature: Toward a holistic model of quality of life. In R. Renwick, I. Brown, & M. Nagler (Eds.), Quality of life in health promotion and rehabilitation. London: Sage.

Devins, G.M. (1994). Illness intrusiveness and the psychosocial impact of lifestyle disruptions in chronic life-threatening disease. Advances in Renal Replacement Therapy, 1(3), 251-263.

Devins, G.M., & Shnek, Z.M. (2000). Multiple sclerosis. In R.G. Frank & T.R. Elliott (Eds.), Handbook of rehabilitation psychology (pp. 163-184). Washington D.C.: American Psychological Association.

Diener, E., & Diener, C. (1995). Most people are happy. Psychological Science, 7(3), 181-185.

Diener, E., & Suh, E. (1997). Measuring quality of life: Economic, social, and subjective indicators. Social Indicators Research, 40, 189-216.

Diener, E., Lucas, R.E., & Oishi, S. (2002). Subjective wellbeing: The science of happiness and life satisfaction. In C.R. Snyder & S.J. Lopez (Eds.), The handbook of positive psychology (pp. 63-73). Oxford: Oxford University Press.

Dijkers, M. (1997). Measuring quality of life. In M.J. Fuhrer (Ed.) Assessing medical rehabilitation practices: The promise of outcomes research (pp. 153-180). Baltimore, MD: Paul H. Brooks Publishing Co.

Dubos, R. (1976). The state of health and the quality of life. The Western Journal of Medicine 125, 1-2.

Fabian, E.S. (1991). Using quality of life indicators in rehabilitation program evaluation. Rehabilitation Counseling Bulletin, 34, 344-356.

Farquhar, M. (1995). Definitions of quality of life: A taxonomy. Journal of Advanced Nursing, 22, 502-508.

Feinstein, A.R. (1987). Clinimetric perspectives. Journal of Chronic Diseases, 40, 635-640.

Ferrans, L.E., & Powers, M.J. (1985). Quality of Life Index: Development and psychometric properties. Advances in Nursing Science, 8(1), 15-24.

Flanagan, J.C. (1978). A research approach to improving our quality of life. American Psychologist, 33, 138-147.

Frank-Stromborg, M. (1988). Instruments for clinical nursing research. Norwalk, CT: Appleton & Lange.

Frisch, M.B. (1999) Quality of life assessment/intervention and the Quality of Life Inventory (QOLI). In M.R. Maruish (Ed.), The use of psychological testing for treatment planning and outcome assessment (2nd ed., pp. 1227-1331). Hillsdale, N J: Lawrence Erlbaum.

Frisch, M.B., Clark, M.P., Rouse, S.V., Rudd, M.D., Paweleck, J.K., Greenstone, A., & Kopplin, D.A. (2005). Predictive and treatment validity of life satisfaction and the Quality of Life Inventory. Assessment, 12, 66-78.

Frisch, M.B., Cornell, J., Villaneuva, M., & Retzlaff, P.J. (1992). Clinical validation of the Quality of Life Inventory: A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4, 92-101.

George, L., & Bearon, L. (1980). Quality of life in older persons. New York: Human Sciences Press.

Gilbride, D.D., Thomas, J.R., & Stensrud, R. (1998). Beyond status code 26: Development of an instrument to measure the quality of placements in the state vocational rehabilitation program. Journal of Applied Rehabilitation Counseling, 29, 3-7.

Gill T.M., & Feinstein A.R. (1994). A critical appraisal of the quality of quality of life measurements. Journal of the American Medical Association 272, 619-626.

Gladis, M.M., Gosch, E.A., Dishuk, N.M., & Crits-Christoph, E (1999). Quality of life: Expanding the scope of clinical significance. Journal of Consulting and Clinical Psychology, 67(3), 320-331.

Headey, B., & Wearing, A. (1992). Understanding happiness. A theory of subjective well-being. Melbourne: Longman Cheshire.

Heinemann, A.W. (2005). Putting outcome measurement in context: A rehabilitation psychology perspective. Rehabilitation Psychology, 50, 6-14.

Hughes, C., Hwang, B., Kim, J., Eisenman, L.T., & Killian, D.J. (1995). Quality of life in applied research: A review and analysis of empirical measures. American Journal on Mental Retardation, 99, 623-636.

Jalowiec, A. (1990). Issues in using multiple measures of quality of life. Seminars in Oncology Nursing, 6, 271-277.

Jenkins, W., Patterson, J.B., & Szymanski, E.M. (1998). Philosophical, historical, and legislative aspects of the rehabilitation counseling profession. In R.M. Parker & E.M. Szymanski (Eds.), Rehabilitation counseling: Basics and beyond (3rd ed., pp. 1-40). Austin, TX: Pro-Ed.

Johnson, K.L., Amtmann, D., Yorkston, K., Klasner, E.R., & Kuehn, C.M. (2004). Medical, psychological, social, and programmatic barriers to employment for people with multiple sclerosis. Journal of Rehabilitation, 70, 38-49.

Lewis, A., Armstrong, A.J., & Karpf, A.S. (2005). Using data to improve outcomes in rehabilitation practice. Journal of Rehabilitation Administration. 29, 107-121.

Livneh, H. (1988). Rehabilitation goals: Their hierarchical and multifaceted nature. Journal of Applied Rehabilitation Counseling, 19(3), 12-18.

Livneh, H. (2001). Psychosocial adaptation to chronic illness and disability: A conceptual framework. Rehabilitation Counseling Bulletin, 44(3), 151-160.

Matheson, L.N., Kaskutas, V., McCowan, S., Shaw, H., & Webb, C. (2001). Development of a database of functional assessment measures related to work disability. Journal of Occupational Rehabilitation, 11, 177-199.

Mermis, B.J. (2005). Developing a taxonomy for rehabilitation outcome measurement. Rehabilitation Psychology, 50, 15-23.

Michalos, A.C. (1985) Multiple Discrepancies Theory (MDT). Social Indicators Research, 16, 347-413.

Michalos, A.C. (1991 ). Global report on student well-being: Volume I. Life satisfaction and happiness. NY: Springer-Verlag.

Myers, D.G., & Diener, E. (1995). Who is happy? Psychological Science, 6, 10- 19.

Noreau, L., & Sheppard, R. J. (1995). Spinal cord injury, exercise and quality of life. Sports Medicine, 20, 226-250.

Ormel, J., Lindenberg, S., Steverink, N., & Verbrugge, L.M. (1999). Subjective well-being and social production functions. Social Indicators Research, 46, 61-90.

Padilla, G.V., Grant, M.M., & Ferrell, B. (1992). Nursing research into quality of life. Quality of Life Research, 1, 341-348.

Pain, K., Dunn, M., Anderson, G., Darrah, J., & Kratochvil, M. (1998). Quality of life: What does it mean in rehabilitation? Journal of Rehabilitation, 64(2), 5-11.

Parker, R.M., & Bolton, B. (2005). Psychological assessment in rehabilitation practice. In R.M. Parker, E.M. Szymanski, & J.B. Patterson (Eds.), Rehabilitation counseling: Basics and beyond (4th ed., pp. 307-334). Austin, TX: Pro-Ed.

Pavot, W., & Diener, E. (1993). Review of the Satisfaction with Life Scale. Psychological Assessment, 5, 164-172.

Roessler, R.T. (1990). A quality of life perspective on rehabilitation counseling. Rehabilitation Counseling Bulletin, 34, 82-90.

Rubin, S.E., & Roessler, R.T. (2001). Foundations of the vocational rehabilitation process (5th ed.). Austin, TX: Pro-Ed.

Rubin, S.E., Chan, F., Bishop, M., & Miller, S. (2003). Psychometric validation of the Sense of Well-Being Inventory for program evaluation in rehabilitation. Professional Rehabilitation, 11(2), 54-59.

Rubin, S.E., Chan, F., & Thomas, K.R. (2003). Assessing changes in life skills and quality of life resulting from rehabilitation services. Journal of Rehabilitation, 69(3), 4-9.

Schalock, R., Keith, K., Hoffman, K., & Karan, O. (1989). Quality of life: Its measurement and use. Mental Retardation, 27, 25-31.

Smart, J. (2001). Disability, society, and the individual. Gaithersburg, MD: Aspen.

Szymanski, E.M., Parker, R.M., & Butler, A. (1990). Sensitivity of client outcome measures in relating state vocational rehabilitation agency counselor performance to level of counselor education. Rehabilitation Education, 4, 93-107.

Vickrey, B.G., Hays, R.D., Hermann, B.R, Bladin, P.F., & Batzel, L.W. (1993). Outcomes with respect to quality of life. In J. Engel, Jr. (Ed.), Surgical treatment of the epilepsies (2nd ed., pp. 623-635). New York: Raven Press, Ltd.

Wright, G. (1980). Total rehabilitation. Boston: Little, Brown Wright, B.A. (1983). Physical disability." A psychosocial approach. New York: Harper & Row.

Malachy Bishop

University of Kentucky 

Martha H. Chapin

East Carolina University 

Susan Miller 

Florida State University 

Malachy Bishop, Ph.D., CRC, Department of Special Education and Rehabilitation, 220 Taylor Education Building 0001, University of Kentucky, Lexington, KY 40506. Email: [e-mail]