Rehabilitation intervention strategies: their integration and classification.

Rehabilitation Intervention Strategies: Their Integration and Classification

Foremost among the distinguishing features of a profession is its existing systematic body of knowledge (Brubaker, 1981). This body of knowledge, as applied to the human and social science professions, is typically composed of various theoretical approaches to the study of the profession and their practical applications (e.g., appropriate intervention strategies, skills required by practitioners, client-serving community-based clinical settings). In spite of promising developments in the past decade (e.g., Diller, Fordyce, Jacobs, Brown, Gordon, Simmens, Orazem & Barrett, 1983; Dudek & Associates, 1977; Wright, 1980), the field of rehabilitation still appears to be lacking a systematic and coherent view of its most widely adopted intervention strategies (alternatively termed rehabilitation techniques, technologies, practices, or approaches). Several recent endeavors to remedy this situation are however, noteworthy.

Sigelman, Vengroff, and Spanhel (1979), based partially on the work of Dudek and his associates (1977), proposed that rehabilitation technologies and practices can be grouped into four main categories: (1) physical interventions, including such procedures as prosthetics and surgery, (2) training and counseling which refers to educational and psychotherapeutic interventions, (3) environmental manipulation, encompassing removal of architectural barriers, adaptation of transportation systems, etc., and finally, (4) service delivery which appears to tap procedural practices such as rehabilitation planning, follow-up services, and so on. Scofield, Pape, McCracken, and Maki (1980), in their ecological model of psychosocial adaptation to disability, dichotomize intervention strategies into those which are aimed at the person himself or herself and those aimed at the external environment. Moreover, each of these components is further subdivided into smaller units. The person-oriented interventions include techniques aimed at both altering the individual's perception or frame of reference (e.g., perceptual modalities restoration, pain management) as well as techniques geared toward modifying his or her response tendencies (e.g., behavioral modification, systematic desensitization). The environment-oriented interventions, on the other hand, incorporate procedures for altering environmental normative standards (e.g., development of employment opportunities, community education), as well as modifying environmental response tendencies (e.g., employers' biased behaviors, parental verbal statements).

Somewhat akin to Scofield, et al.'s (1980) perspective, Coulton (1981), focusing on health care interventions in her person-environment fit model, suggests a typology of intervention strategies according to both goal of intervention (i.e., change in person or change in environment) and primary target of intervention (i.e., modification of the individual or the environment). She also provides several examples in her four cell typology, which include counseling and providing prosthetic devices (Goal -- change in person; target -- person), behavior modification and milieu therapy (person: environment), teaching individuals to modify their own environment (environment; person), and architectural barrier removal and socio-economic environment modification (environment; environment).

Anthony (1979), in his psychiatric rehabilitation skill development model, places rehabilitation techniques in one or more of the following classes: environmental techniques (i.e., changing physical, social, and work-related environmental conditions), engineering techniques (i.e., using adjunct devices and methods including maps, tools, and medications, to assist in performance of various activities), counseling and psychotherapeutic techniques, didactic techniques, and finally modeling techniques. He and his associates (Anthony & Farkas, 1982, Dion & Anthony, 1987) further divide rehabilitation interventions as to the type of skilled behaviors performed -- Physical (e.g., personal hygiene, use of public transportation), Emotional/Interpersonal (e.g., interpersonal skills acquisition, self-control), and Intellectual (e.g., money management, job-application skills). These three skill behavior domains are further broken down according to the environmental contexts (i.e., living, learning and working) within which they occur, to provide a more refined classification for rehabilitation training programs.

As can be seen from this cursory review of the leading models of rehabilitation intervention strategies, they all may be considered negligent of at least one of the following. First, being too crude (e.g., Sigelman, et al.'s model) and lacking a refined classification system of rehabilitation strategies, based on more explicitly defining properties such as adjustment domains, rehabilitation contexts and the like. More specifically, they appear to be lacking differentiation of the major contexts within which rehabilitation is practiced (e.g., hospital, work, community), or of the domains or spheres of human adjustment (e.g., physical, psychosocial, vocational). Scofield, et al.'s (1980) and Coulton's (1981) models, may be cited in this regard. Second, these models (e.g., Scofield, et al.'s) focus too narrowly on specific components of the rehabilitation experience, such as personal acceptance of disability to the exclusion of others (e.g., family and employer's attitudes). Finally, Anthony's model (1979) is geared specifically toward people with psychiatric disabilities, therefore lacking direct applicability to individuals who sustained the wide range of physically disabling conditions.

It can, therefore, be concluded that the absence of a coherent view in perceiving and classifying rehabilitation interventions may result in rehabilitation practitioners adopting strategies which lack systematic reasoning, rationale for selection, fineness, and specificity. Moreover, it could lead, invariably, to confusion in the choice of intervention strategies, thereby impeding dialogue among rehabilitation professionals and ultimately creating divergence among the various rehabilitation disciplines.

Ingredients of a Classification System

for Rehabilitation Intervention Strategies

As is evident from the aforementioned classification efforts, neither clear consensus nor unified approach exists regarding the exact nature and scope of rehabilitation intervention strategies. Several overriding themes, however, are apparent from the review of these and other more narrowly targeted efforts (e.g., Granger & Gresham, 1984; Halpern & Fuhrer, 1984). These themes, in the form of suggested propositions, may be summarized as follows: (1) A classification of rehabilitation intervention strategies should adopt a multidimensional format. In other words, the proposed classification system should address various human interactive domains (e.g., physical, psychosocial, vocational); (2) It should take into consideration the distinction made between individual-oriented and community-oriented interventions. Accordingly, efforts should be maintained along all domains (see proposition 1) to differentiate between those interventions which focus on changing the individual (i.e., client) and those which seek to alter the external environment. (3) Rehabilitation interventions should flow logically, consistently, and directly from previously established rehabilitation goals and objectives. In the sequential ordering of the traditional course of rehabilitation programs (i.e., client problem identification and assessment --> goal(s) setting --> rehabilitation intervention((s) --> outcome assessment), the phase designated as rehabilitation intervention must bear temporal and substantive epistemic proximity to the preceding phase, namely, rehabilitation goal identification and setting, (see also Anthony, 1979; Rubin & Roessler, 1987); (4) A classification system of rehabilitation intervention should be comprehensive and span the gamut from those strategies directed at human dysfunctions at the level of organs responsible for receiving incoming stimuli (i.e., sensory and perceptual modality impairments), through dysfunctions of internal processing mechanisms (i.e., mental and affective disorders, impairments of internal bodily organs), to dysfunctions at the responsive or behavioral domains (i.e., motoric impairments, maladaptive performance of instrumental activities); (5) Rehabilitation interventions, despite the traditional restrictive use of the term, should include medical, physical, psychiatric, psychological, social, educational, vocational, economic, and financial interventions applied by a wide range of people. These should include, but not be restricted to, the person himself or herself, family members, peers, teachers, co-workers, employers, and trained professional helpers.

In addition to the above, for a rehabilitation interventions classification system to possess substantive merit as well as be useful for rehabilitation professionals, it should: (1) Be practical -- the system must be capable of assisting rehabilitation practitioners in organizing and classifying their intervention methods according to problems and needs manifested by various client populations as encountered in a wide range of rehabilitation-oriented community settings. (2) Be generalizable -- it should be applicable across both client populations (e.g., people with physical, mental, emotional, behavioral disabilities) and types of community facilities (e.g., hospital-based rehabilitation units, rehabilitation workshops, state DVR agencies, substance abuse treatment centers, pain clinics). (3) Have a heuristic value -- the system ought to be structured in such a fashion as to allow researchers and practitioners to compare the outcomes of diverse intervention modalities, as well as to make predictions regarding future outcomes (with a certain degree of probability) of specific interventions applied to different client populations served at particular community agencies and facilities. (4) Be thought stimulating -- it should provoke other practitioners, researchers and theoreticians to further exploration of the taxonomy's present status and hopefully result in future efforts at improving and refining it. (5) Use not-overly-technical language -- the system should use simple and "trans-profession" recognized terminology. Domain-specific jargon (e.g., technical medical terminology, Dictionary of Occupational Titles (D.O.T.) numerical classification) should, whenever possible, be discouraged, and the use of non-technical, non-elaborate language be adopted.

The proposed classification, although only in its initial stages of conceptualization, is capable of offering the rehabilitation practitioner several advantages in comparison with the previously discussed models. First, it is multidimensional in format, thus allowing for greater refinement in planning and carrying out rehabilitation interventions. Second, it is structured in such a way as to permit the rehabilitation practitioner direct sequencing among client problem identification (e.g., traumatic brain injury resulting in cognitive deficits in perception, information processing and expression of behavior) goal setting, (e.g., minimizing the effects of these residual cognitive deficits on the client's performance of daily activities within the work and community settings), and interventions (e.g., cognitive rehabilitation, teaching client the necessary ADL skills, assisting client in the transition to a semi-independent or independent living environment, providing client with work adjustment training, and if needed, with job placement, supported employment, and follow-up services).

Third, it is comprehensive and can be applied to a wide range of sensory, physical, mental, psychiatric, behavioral, and social disabilities. Fourth, it is geared to be applicable across the various rehabilitation professions (e.g., physical therapy, occupational therapy, rehabilitation psychology, vocational rehabilitation), and settings (e.g., rehabilitation hospital units, vocational rehabilitation agencies, sheltered workshops, private rehabilitation organizations), thus allowing for greater cross-discipline dialogue and understanding, while at the same time offering direct input from paraprofessionals (e.g., family members, peers, co-workers, employers). Finally, the present typology is capable of stimulating further, more elaborate, and invariably more valid classification systems due spawned and integrated into the present system, as the field of rehabilitation grows to include additional client populations, newly developed intervention procedures, and practitioners from related disciplines).

Rehabilitation Intervention Strategies as a

Logical Extension of Rehabilitation Goals

As was previously pointed out (see also Anthony, 1979; Rubin & Roessler, 1987), rehabilitation interventions should bear a direct and logical relationship to the preceding phase in comprehensive rehabilitation -- programming, namely, the rehabilitation goals agreed upon and set forth by client and counselor. Livneh (1988) recently suggested a classification of rehabilitation goals according to three organizing viewpoints. They include the contexts or environments within which rehabilitation is being practiced (i.e., the community and labor force), the activity levels or systems which define human performance (i.e., body-system, self-system, and exterior self-system), and the type of adjustment or functioning anticipated and/or achieved (i.e., physical and psychosocial). Components of the foregoing classification system will be adopted, in their skeletal form, to provide the reader with a somewhat similar system for the purpose of organizing rehabilitation intervention strategies.

Rehabilitation may be conceived as an interactive process whereby people with a wide range of impairments and disabilities (i.e., physical, mental, affective, social, and behavioral) are assisted (e.g., physically, psychosocially, vocationally) in improving the quality of their lives (Crewe, 1980), despite internally and externally imposed limiting conditions and scarce opportunities (Stubbins, 1984). Within this rather broad spectrum, rehabilitation interventions comprise a set of general modalities and specific techniques through which the rehabilitation process is carried out to its successful closure. They then serve as the main vehicle for implementing accumulated rehabilitation knowledge and prevailing social beliefs (and possibly moral values) regarding human existence and change.

The three organizing perspectives adopted for the purposes of the present taxonomy are borrowed largely from taxonomy effects previously advocated by Scofield, et d. (1980), Coulton (1981), and Livneh (1988). They include rehabilitation contexts, adjustment domains, and intervention foci.

Rehabilitation contexts

Various models of classifying rehabilitation contexts or environments have been proposed in the rehabilitation literature (e.g., Anthony, 1979; Diller, et al, 1983; Hershenson, 1977; Livneh, 1988; Sigelman, et al., 1979). In probably the most parsimonious, albeit somewhat simplistic form, rehabilitation environments may be envisioned as dichotomized into community (i.e., where one lives) and labor force (i.e., where one works). The former addresses such issues as home and community management, while the latter pertains to job-related and other productive activities.

Adjustment domains

Traditionally, personal adjustment to disability has been conceived as operating in two functionally-independent domains: physical and psychosocial (Livneh, 1988; Roessler & Bolton, 1978). Physical functioning refers to the body's ability to perform physically within the constraints of the external environment (e.g., intact sensory acuity, successful performance of daily living activities, broad range of mobility). Psychological functioning, on the other hand, is concerned with the person's degree of successfully performing within his or her personal and interpersonal spheres, where emphasis is placed on acquired affective and cognitive skills (i.e., coping strategies) necessary to adapt to life with a disability and the inimical reactions and restrictions imposed by others (e.g., family members, peers, employers).

Intervention foci

In addition to the proposed system's classifying dimensions of rehabilitation contexts and adjustment domains, a third dimension, based on the work previously cited (i.e., Anthony, 1979; Coulton, 1981; Scofield, et al, 1980), warrants consideration. This final dimension is concerned with the distinction often made between person-aimed (internal focus) and environment-aimed (external focus) rehabilitation interventions. Person-aimed interventions are those which consider the client as their main target and accordingly seek to alter him or her (either directly by modifying client's behaviors and response repertoires or indirectly by first changing his or her maladaptive perceptual or cognitive frames of reference). Environment-aimed interventions, alternatively, are those which view the external environment as the prime target for change and, therefore, attempt to modify them to better fit the clients' needs and future goals.

The above three classificatory perspectives may, then, be conceptualized as providing a typological frame through which rehabilitation intervention strategies can more conveniently be classified and compared. Consequently, it was felt that the use of the proposed typology may, with further study and future refinement, assist rehabilitation practitioners in better organizing and planning appropriate interventions with their clients, as well as serving their clients more promptly and efficiently.

A Typology of Rehabilitation

Intervention Strategies

With the help of a 2x2x2 (rehabilitation contexts -- community and labor force -- x adjustment domains -- physical and psychosocial -- x intervention foci -- person-aimed and environment-aimed) matrix, eight conceptually, albeit somewhat simplified, unique groups of rehabilitation intervention strategies may be created (see Figure 1). Each of these eight cells, although inevitably containing a certain amount of overlapping content with other cells, is nevertheless conceptually independent and has a clearly defined locus of intervention modalities.

Rehabilitation context: community/adjustment

domain: physical/intervention focus: person

The first set of rehabilitation interventions in the proposed typology (see Figure 1) refers to rehabilitation procedures geared toward assisting the client in (re) integrating into his or her community (including the home environment), through the provision of appropriate physical-skills-oriented services directed at the person himself or herself. Various interventions are noteworthy in achieving this purpose. Foremost among them is, perhaps, teaching the client the prerequisite skills needed to perform activities of daily living (ADL skills). Clients are trained in personal/self care skill activities which typically include mastering appropriate ways of eating, drinking, grooming, dressing, bathing, washing, and toileting.

A related set of rehabilitation interventions focus on teaching the client home management skills, including preparing meals, cooking, laundering, cleaning the house, maintaining the yard, and food and clothing shopping. The emphasis here is on the physical performance of each activity (i.e., the instrumental ability to use the body, or parts of the body, to correctly perform the task).

Compensatory skill training (9see, for example, Wright, 1980) also belongs to this group of interventions. The rehabilitation professional (e.g., rehabilitation nurse, physical therapist, occupational therapist, recreational therapist) applying compensatory skill training assists and directs the client in mobility and gait training (e.g., transferring from bed to wheelchair, walking, climbing stairs), as well as in physical fitness training and conditioning. Also included in this category are speech and hearing training (by qualified speech and language therapists), where the focus is on improving organ-specific sensory, motoric, and verbal functioning.

A different approach to improving the client's physical adjustment to living in the community is medical or restorative therapy, typically accomplished through the use of corrective surgical procedures directed at ameliorating bodily deformities and infirmities. The use of biofeedback to reduce or eliminate nagging and maladaptive physical symptoms (e.g., various types of headaches, low-back pain, high blood pressure, uncontrolled seizures) can also be construed as a particular rehabilitation modality aimed at assisting clients physically adjust to community living.

Finally, although somewhat less context-specific, medication to control or alleviate certain biochemical, physiological, and physical symptoms, in addition to the time-limited hospitalization(s) may also be construed as rehabilitation-related interventions involved when community-oriented physical adjustment is of prime concern.

In summary, the above rehabilitation interventions all seek, by utilizing diverse approaches, to teach or assist clients in the performance of instrumental activities that are required in managing and negotiating the physical environment -- both at home and in the community.

Rehabilitation context: community/adjustment:

physical/intervention focus: environment

Under this category of rehabilitation interventions, the focus on assisting the client shifts toward environmental manipulation. Numerous interventions are available for the rehabilitation practitioner who seeks to adopt one or more of these procedures. Foremost among these interventions are concerned with restructuring or altering the physical environment by removing or minimizing the effect of existing architectural barriers, thus providing accessibility to public buildings and other community facilities. Certainly, modification of one's dwelling (e.g., kitchen and bathroom remodeling, stair elimination) are part and parcel of this type of rehabilitation intervention.

A second group of environmental-aimed interventions includes the application of assistive and adaptive equipment to the restoration (albeit non-permanent) of lost perceptual and motoric functions. Hearing aids, teletypewriters, tele-communication devices, communication boards and interpreter services, in the case of auditory impairments (teaching sign language, lip reading, or finger spelling fall more appropriately within the realm of person-focused interventions), are among the devices used to compensate for sensory (i.e., hearing and vision) loss. For visual impairments, reader services, talking books, and the use of the Kurzweil Reading Machine are the most common rehabilitation interventions at this level (Braille instruction and mobility training fit more appropriately within the person-oriented interventions).

Compensation for mobility impairment is typically provided through the use of various orthotic (strengtheners of body parts and joints) and prosthetic (compensators of lost body parts) devices. These include orthopedic braces, walkers, crutches, wheelchairs, below-and above-knee prostheses, artificial feet, below-and above-elbow prostheses, artificial hands, and so on.

Other forms of rehabilitation interventions are also available to assist in physical adjustment to community living, where the focus is on environmental manipulation and the primary goal is reducing stress and daily demands. The provision of adaptive modes of both public (e.g., busing) and private (e.g., adapted vans) transportation is one such example. Other forms of intervention include the provision of housing (e.g., group homes, half-way houses) and house-maintenance (e.g., day care, child care, Visiting Nurse Association, to clients about the availability and accessibility of these community resources and services to actually arranging for their timely provision. Additional interventions may be more specifically directed toward leisure time activities including plans for participation in social clubs and pursuing sport and recreational interests.

Finally, financial support in the form of income maintenance and by providing legal assistance (e.g., SSI and SSDI benefits, worker compensation awards, health and medical care benefits, welfare payments, medicaid) also enables the rehabilitation practitioner to assist the client to better adapt to community living.

Rehabilitation context: community/adjustment:

psychosocial/intervention focus: person

Clearly, the chief mode of intervention available to the rehabilitation practitioner who seeks to assist the client with psychosocial adjustment to life with a disability, or in coping with others' reactions to it, consists of the provision of guidance and counseling services. The various forms of personal adjustment counseling psychotherapeutic interventions (e.g., individual, marital, sexual) are all geared toward helping the client to achieve a better emotional and/or cognitive adjustment to a recent or remote traumatic experience. Behavioral therapy, as another mode of counseling, attempts to modify (i.e., decrease or eliminate) maladaptive and inappropriate behaviors through a wide range of procedures (e.g., behavioral contracting, systematic desensitization, aversive therapy).

Counseling strategies are often, although in a somewhat arbitrary manner, divided into intrapsychic (intrapersonal) and extrapsychic (interpersonal) forms of intervention (Shepperson Mauger & Zinober, 1975). Intrapsychic counseling techniques usually have as their main goal the achievement of certain theoretically-bound statuses including positive self-concept, functional coping skills, emotional stability (i.e., the reduction of negatively-felt affective states such as depression, anxiety, or anger), accurate self-perception, self-insight (awareness), reality acceptance, and disability (or functional limitations imposed by disability) acceptance. The latter goal is often approached through values clarification, life goals reprioritization or several of Beatrice Wright's (1983) widely recognized procedures (i.e., enlarging the scope of values, subordinating physique, containing disability effects, upholding asset values).

Extrapsychic counseling techniques, on the other hand, are particularly concerned with the ability to communicate with others (e.g., family members, friends) by possessing appropriate and socially-sanctioned interpersonal skills. Social skills training (Hersen & Bellack, 1976) is often the technique of choice in this context.

In addition to the rapidly growing number of counseling intervention variants, didactic strategies also appear to gradually occupy a major role in assisting clients to adjust psychologically to community living based on the tripartite model of explaining (telling) -- demonstrating (showing) -- practicing (doing), those teaching strategies have been applied to a wide range of problems and contexts. Included among these procedures are teaching clients decision-making, problem-solving, time-management, goal-setting, financial management, and budgeting skills. Similar techniques include modeling, where emphasis is placed on either the model's middle link (i.e., observation by the client of a video-taped or in-vivo models, or the two posterior links (i.e., observation of a demonstrating model followed by a performance of the activity). Role playing or psychodramatic exercises focus more naturally on the final link (i.e., practicing).

Providing clients with information about the implications of their disability, is also relevant. Objective medical findings on the nature of the client's impairment, residual functional limitations, remaining functional assets, prognosis and expected duration of impairment, etc., can be of utmost importance in the early stages of rehabilitation. Application of procedures advocated by the more traditional medical model include the administration of psychotropic medications, electro-convulsive therapy, and time-limited hospitalization.

Several other related interventions exist which borrow heavily from principles advocated by the above rehabilitation strategies. These interventions include relaxation, or stress-reduction training, self-control training (mainly concerning inappropriate thoughts and feelings, and asocial or antisocial behaviors), assertiveness training, and pain-management training (Fordyce, 1976). Finally, compensatory academic (cognitive) skill training seeks to improve educational (e.g., reading, writing, and arithmetic) skills, typically by applying special education teaching principles and methods.

In summary, the interventions discussed in this section are all concerned with the emotional, cognitive, and when appropriate, behavioral levels of adjustment (i.e., performance) needed by the individual to successfully adapt to community living. These interventions have, as their ultimate goal, the bridging of the gap between the requirements for adaptive community living and the person's present psychosocial skill level.

Rehabilitation Context: community/adjustment:

psychosocial/intervention focus: environment

When psychosocial adjustment to community living is of main concern and the focus is on environmental-aimed modes of intervention, counseling and psychotherapeutic approaches invariably take the form of group counseling, where the goals include counseling people who manifest similar types of problems or disabling conditions (see Dell Orto, Lasky, & Marinelli, 1977; Lasky & Dell Orto, 1979, Seligman, 1982, for applications to rehabilitation settings). In addition, self-help or peer-group counseling, family counseling; counseling parents, children, and/or spouses of rehabilitation clients regrading changes in social role expectations; and, in general, providing supportive services to the family as a whole, are all part of the rehabilitation practitioner's clinical armamentarium.

Other forms of rehabilitation interventions include the use of community settings, such as group homes, half-way houses, and hospital day care center (see, for example, Beard, Propst, & Malamud, 1982; Bond, Dincin, Setze, & Witheridge, 1984) for assisting deinstitutionalized psychiatrically- and mentally-impaired patients to gradually adjust to living in the community. In addition to community placement, these former patients are often equipped with assistive devices which include charts, maps, graphs, and written directions to compensate for certain mental and emotional disabilities (see Anthony, 1979, for further discussion of these engineering techniques).

From a broader social perspective, environmental-focused rehabilitation interventions may extend to attempts at modifying prevailing socio-economic conditions. These may include implementation of social policy changes and public education campaigns geared toward reducing disability-related social stigma and attitudinal barriers. The rapidly growing systems of trans-professional rehabilitation networking (Carroll, Borstein, & Hoffman, 1984), and social support networking (Coulton, 1981) should also add to efficient and coordinated delivery of rehabilitation services to people with disabilities.

Lastly, on the legal front, attempts to ensure the rights of persons with disabilities through the use of consumer advocacy (e.g., trusteeships, guardianship, protectorship) could also be regarded as externally-based rehabilitation interventions (Wright, 1980) seeking, as were all other interventions discussed in the present section, to upgrade the level of psychosocial adjustment of community-bound disabled clients.

Rehabilitation context: labor force/adjustment

domain: physical/intervention focus: person

A certain similarity exists between rehabilitation interventions of this and the community integration categories (i.e., person-aimed interventions seeking physical adjustment in the community) since they merely differ in their contextual applications (home and community vs. workplace). The present category encompasses rehabilitation technologies which have as their common goal the (re) integration of the client into the world of work (i.e., the successful performance of gainful and/or productive activities). Among the more commonly used interventions in this domain can be found the teaching and training of clients in specific uses of work tools (e.g., manipulation of small objects and tools, hand and finger dexterity, eye-hand coordination), and training of clients to perform required job tasks (i.e., physically operating various types of equipment and machinery). The focus, therefore, is on teaching clients how to physically (rather than cognitively) perform the instrumental activities associated with various job tasks and activities.

A second rehabilitation approach for assisting clients in physical adjustment to the work environment focuses on compensatory skill training in negotiating and managing the physical environment of the workplace. Similar to the previously discussed community-oriented compensatory skill training, skills taught in the present context include functional mobility within the workplace (e.g., moving about the work plant, climbing stairs and ladders), as well as physical fitness training to improve work stamina and tolerance necessitated by the particular jobs performed.

Rehabilitation context: labor force/adjustment

domain: physical/intervention focus: environment

Intervention strategies pertaining to this category include those directed as assisting rehabilitation clients physically perform their job task requirements by manipulating the work environment. Rehabilitation engineering applications which include the development of job-related artificial aids (e.g., prosthetic and orthotic devices, sensory loss-compensatory mechanical and electronic devices) often serve this purpose. In addition to the restoration of job-related lost functions, these environment-oriented interventions also center on altering the work environment by removing architectual barriers through structural changes on the work site and by altering the client's job responsibilities and requirements (e.g., job-task modifications, job restructuring, job rescheduling, providing transportation to and from work) (Wright, 1980). These job modification interventions have as their primary goal the reduction of job stress and, consequently, improved adaptation to the rules and regulations of the world of work.

An extension of the latter approach is the provision of transitional sheltered (workshop) employment and supported work/employment programs (i.e., competitive work in integrated work settings with the provision of support services; Lam, 1986). Both approaches are geared toward achieving a gradual transition into full-time, competitive, gainful employment. Relatedly, instituting token economy programs (see, for example, Esser & Botterbusch, 1975; Fernandes, Fischer, & Ryan, 1973); to selectively reinforce clients' job-appropriate activities in the workshop is also relevant in this context, although the latter may be construed as a psychosocially-targeted intervention as well.

Rehabilitation context: labor force/adjustment

domain: psychosocial/intervention focus: person

As in its corresponding community context, the present category of labor-force aimed rehabilitation interventions employs two primary strategies -- guidance/counseling and teaching. Counseling, as applied here, takes the form of vocational counseling with emphasis upon exploration of interests by assisting the client to become more aware of his or her vocational preferences, achieving positive self-concept of one as a worker and/or contributing member of society, acceptance of occupational-related functional limitations, and so on. In addition to these internally-oriented (i.e., intrapsychic) vocational explorations, the rehabilitation practitioner also uses externally-oriented (i.e., extrapsychic) counseling modalities, where the main concern is with the ability of the client to interact appropriately with coworkers, supervisors, and employers. The focus here is, clearly, on the emotional-cognitive domain of human communication. Finally, behavioral modification techniques (e.g., modeling, time out, positive reinforcement, shaping) may be applied to reduce maladaptive job-related behaviors (e.g., tardiness, lack of punctuality, daydreaming, absenteeism, short attention span).

Occupational-oriented didactic approaches, as the term implies, are typically concerned with the teaching of specific job skills. The scope of job-skills acquisition may range from preliminary (pre-placement) skills, such as teaching clients job seeking skills, job application skills, job interviewing skills, to the more technical, cognitive skills required to perform the particular tasks comprising the work itself (e.g., operating machinery, following blueprints and diagrams, selecting proper tools, computing dimensions, accurately perceiving spatial relationships). Other vocational training and preparation strategies often encountered in rehabilitation practice are on-the-job training (OJT), work readiness training, work/vocational adjustment (Rubin & Roessler, 1987; Bolton, 1982), work conditioning, and work hardening (Matheson, Ogden, Violette, & Schultz, 1985), all concerned with successful and satisfactory vocational placement. The teaching of prevocational (i.e., educationally-aimed) skills which are ultimately applied to job-related tasks (e.g., verbal and numerical proficiency, clerical perception), also constitute a rehabilitation intervention strategy within the person-focused, labor-force context.

Rehabilitation context: labor force/adjustment

focus: environment

The final category to be discussed within the present typology of rehabilitation interventions refers to occupational-oriented, psychosocial-domained rehabilitation approaches, where the emphasis is placed upon manipulation of environmental conditions. Noteworthy among these strategies are the attempts made by rehabilitation practitioners to create employment opportunities for their clients. These attempts may range from conducting regional labor market analyses to participating in meetings with local employers and businessmen. In addition, rehabilitation personnel acquainted with recent legislative developments are often called to aid employers and school personnel with affirmative action requirements and applications of rehabilitation laws (e.g., implementation of Public Law 93-112, sections 501 to 504; the amendments -- PL 93-516; PL 94-142; PL 95-602).

The focus on the pre-vocational environment also entails the provision of a non-restrictive learning environment to students where special education and rehabilitation professionals can be of significant importance to school personnel. Financially, an environmental-oriented intervention may be adopted when the client is provided with educational and vocational training costs while he or she is attending academic institutions or vocational/technical schools.

Finally, employee assistance programs (EAPs), in which emphasis is centered on assisting employees with developing preventive measures to impending problems as well as coping with crisis situations (e.g., substance abuse problems, supervisor-supervisee conflicts, marital discords affecting work performance) could also be construed as environmental-based psychosocial interventions seeking to assist either in job development or in job maintenance.

Example

The following example briefly illustrates how the proposed classification system operates.

Mr. Smith is a 36 year old single individual, with a 10th grade education, who sustained a severe injury to his lower left leg while performing his regular work duties as a journeyman carpenter at a building construction site. He then underwent a series of surgeries, resulting in amputation of the injured leg. Medical information indicated the Mr. Smith could not return to his prior employment, nor could he engage in jobs requiring heavy lifting or prolonged periods of standing and walking. In addition, job analysis of Mr. Smith's prior work revealed no transferability of skills to other lighter and less exertional jobs. Finally, Mr. Smith admitted to having no other work skills or experience, and he frequently complained of feeling useless and depressed.

Psychological testing (i.e., the Symptom Checklist - 90, the Handicap Problems Inventory) indicated the presence of elevated levels of depression and anxiety with manifestations of low self-esteem and self-blame. Vocational interest inventories (i.e., the Strong-Campbell Interest Inventory, the Career Occupational Preference Survey) and vocational aptitudes tests (i.e., the GATB), demonstrated interests in clerical and bookkeeping activities, with above average aptitude scores on the numerical and clerical perception scales of the GATB.

Upon completion of this series of psychological and vocational evaluations and obtaining the appropriate medical reports from Mr. Smith's treating physician, physical therapist, and occupational therapist, the following goals (and related intervention strategies) were agreed upon and set forth by Mr. Smith and the interdisciplinary rehabilitation team: (1) Provision of a permanent prosthesis -- fitting Mr. Smith with the appropriate below-the-knee prosthesis (Rehabilitation context: community; Adjustment domain: physical; Intervention focus: environment). (2) Improving mobility in the home and the community -- teaching Mr. Smith appropriate forms of mobility (e.g., gait training) to compensate for his amputation limitations (community; physical; person-focus). (3) Alleviation of depression and anxiety -- using personal counseling methods with Mr. Smith to promote adjustment to disability and coping with related life stresses (community; psychosocial; person-focus). (4) Obtaining a GED (as a pre-vocational goal) -- referring Mr. Smith to the appropriate educational institution to receive the necessary academic training for obtaining his high school equivalency diploma (labor force; psychosocial; person-focus). (5) Obtaining an associate degree in bookkeeping -- financially assisting Mr. Smith in enrolling at a local community college (i.e., acquisition of technical job-related skills), for a two-year bookkeeping program (labor force; psychosocial; person-focus and environment-focus). The latter two interventions, (#4 and #5) may be alternatively conceived as a broader single intervention constituting a vocational (adjustment) counseling strategy. (6) If needed, an additional long-term goal may address a counselor-initiated job placement of Mr. Smith by directly providing him with the necessary job-seeking, job-application and job-interviewing skills coupled with appropriate follow-up services (labor force: psychosocial; person-focus).

Summary and Conclusions

The typology suggested in this paper is only an intermediate and modest step toward the integration and classification of existing rehabilitation intervention strategies. A typology of currently-practiced rehabilitation interventions ought to be conceived from a multidimensional perspective. Accordingly, it should be structured around several interactive domains including, but not necessarily limited to, contexts in which the practice of rehabilitation is being applied (community and labor force), domains of human functioning (physical and psychosocial), and locus of intervention (person- vs. environment-focus). In addition, in order to be useful, such a typology should maintain a direct logical and temporal sequential ordering to previously identified rehabilitation intervention goals. It should also be comprehensive, pertaining to all facets and spheres of rehabilitation (e.g., physical, psychological, social, educational, vocational, financial), as well as generalizable across populations of people with disabilities and individuals with whom they come into direct contact.

This proposed typology is certainly in need of further refinement and clarification. For example, confusion often results from the conceptual overlap which exists between certain rehabilitation goals and rehabilitation interventions. More specifically, the distinction which is often drawn between these two phases of the rehabilitation process (i.e., goals and interventions), is far from perfect. Several traditional rehabilitation goals (e.g., vocational training, work adjustment) may be construed not only as goals in their own right, but also as strategies for implementing other goals (e.g., job placement, satisfactory work performance). This conceptual overlap is not merely limited to the domain of vocational rehabilitation, but also extends to psychosocial rehabilitation (e.g., personal adjustment counseling, assertiveness training). Clearly, a finer, yet more elaborate, distinction between the two phases, expanding in scope to include consideration of both process and outcome goals and their consequential relationship to the intervention strategies implemented and to the measurement (i.e., assessment) of rehabilitation outcomes, is called for.

Another area in need of future refinement concerns the extant content overlap among several of the categories used to construct this typology. The distinction between the community and the labor force contexts appears, at times, somewhat arbitrary. For example, should learning-aimed (i.e., educational) interventions be considered general and transituational enough to fall within the community category? Or should they be conceived, as was suggested here, to be pre-vocational strategies and thus belonging to the labor-force domain? Similarly, is the distinction often made by previous authors (e.g., Coulton, 1981; Scofield, et al., 1980) and also adopted here, between person-aimed and environment-aimed rehabilitation interventions, practically and conceptually defendable? For example, although counseling is considered by many as the cornerstone of person-aimed intervention modalities, isn't it, as a matter of act, applied by an outside (i.e., environmental-based) agent (i.e., counselor, psychotherapist)? These questions, and others, must await further conceptual developments in the field. At its present status, however, the typology suggested in this paper may furnish the rehabilitation practitioner with a broad perspective on the structure and inter-relatedness of rehabilitation intervention strategies. Relatedly, the typology suggested in this paper is presently being incorporated by the author into a rehabilitation counseling training program's curriculum, with future plans to offer short-term, in-service workshops and seminars at local public and private rehabilitation agencies and facilities.

Coupled with the knowledge of the clinical assessment of the client's presenting problems and the identification and prioritization of rehabilitation goals, the proposed typology of rehabilitation interventions could provide the practitioner with additional armamentarium in his or her search for the delivery of more comprehensive and efficient services to people with disabilities.