Use of the resiliency model of family stress, adjustment and adaptation by rehabilitation counselors.

Rehabilitation counselors function in a variety of roles while employing many different competencies in the provision of services (Leahy, Chan, & Saunders, 2002). A major function of rehabilitation counselors is the development of counseling relationships to facilitate adjustment to disability. Critical to the adjustment process, but often overlooked, is client resiliency. Resiliency is associated with ability to adapt to disability (Lustig, 1997), which in turn is essential to effective rehabilitation counseling services and successful outcomes (Kosciulek, 1994). Further, one important component of individual resiliency is the resiliency of the family in adjusting when a family member acquires a disability. Recognizing the importance of the family in adjustment to disability, the National Council on Rehabilitation Education (NCRE) has called for family resiliency to become a focus of research in rehabilitation (Muzzio, 2004). The Council of Rehabilitation Education (CORE, 2004) has also recognized the need to understand the impact of the family in rehabilitation in the most recent CORE accreditation standards.

There seems to be consensus among rehabilitation professionals that that the lifelong well-being of individuals with disabilities and chronic illnesses rests in large part on family influences and support. While the importance of working with families within the rehabilitation process has been consistently suggested in the literature, limited progress has been made in actually including families in service delivery (e.g., Degeneffe & Lynch, 2006; Kelly & Lambert, 1992). Rehabilitation professionals continue to focus primarily on the individual, with little emphasis on training and supporting family members in care-taking and supporting roles, an approach that parallels the medical model of care (DeJong, Batavia, & Williams, 1990). Rehabilitation professionals indicate a need for dealing with the psychosocial and cultural effects of disability on the family, but indicate more training is necessary to fulfill these functions (Chan, Leahy, Saunders, Tarvydas, Ferrin & Lee, 2003). Often the family is viewed by professionals as obstructing client ability to deal with adjustment and face the reality of new life situations and demands associated with disabilities and to successfully return to the work world (Freedman & Fesko, 1996). Professionals may not appreciate and understand the impact that families may have on employment choices and behaviors, and may fail to recognize the positive influences of families that may be capitalized upon in facilitating successful transition, adaptation, and employment. Application of a family resiliency model offers an alternative to the more limited individual focus that many rehabilitation professionals often employ.

To illustrate the benefits of one such resiliency model, we provide an overview of the following: (a) the effects of disability on the families; (b) an introduction to the concept of family resiliency and the Resiliency Model of Family Stress, Adjustment and Adaptation; (c) how this model can shape rehabilitation counseling services; and (d) the implications of the Resiliency Model in rehabilitation counseling. By incorporating the information provided herein, rehabilitation counselors can develop a more holistic, comprehensive approach toward optimizing vocational success and life satisfaction among persons with disabilities.

Disability and Family

A number of authorities have long advocated that family involvement is pivotal to the long-term success of persons with disabilities (e.g., Kosciulek, 1994: Wright, 1960). Rehabilitation professionals have recognized that families can be the "most powerful and enduring" (Krauss & Seltzer, 1993, p. 18) influence in the lives of people with disabilities (e.g., Kelley & Lambert, 1992; Power & Dell Orto, 1980). Additional research provides evidence supporting the roles of family in the rehabilitation process. For example, studies have documented relationships of family involvement to recovery from illnesses and disabilities (e.g., McCubbin, Bailing, Possin, Frierdich, & Byrne, 2002; Storer, Frate, Johnson, & Greenberg, 1987). Similarly, correlations have been found between the number of relationship family ties, such as marital status and number of dependents, to rate of recovery, resumption of family roles, and rehabilitation success (Gibson & Ludwig, 1968; Gray, Shepard, McKinlay, Robertson, & Pentland, 1994).

Research investigating predictors of outcome of chronic illness and disability has increasingly recognized the importance of families, both in terms of their influence on the recovery of the individual and the effects of the illness or disability on other family members (Degeneffe & Lynch, 2006; Storer et al., 1987). Both individuals and families are greatly affected by the diagnosis, with some studies suggesting that families are even more substantially affected than individuals with the illnesses or disabilities (e.g., Kay & Lezak, 1990; Kosciulek & Lustig, 1998). Logically, Florian and Krulik (1991) described family members of persons with disabilities as a targeted treatment population requiring intervention. Family members may experience an array of adverse physical, psychological, and social difficulties, including depression, anxiety, reduced social support, difficulties related to role changes, substance use, communication difficulties, and physical health problems (Degeneffe & Lynch, 2006; Kosciulek & Lustig; 1998; Lezak, 1986). These difficulties may in part be due to the increasing cost of chronic illness and disability and a system that has shifted the burden of many responsibilities onto families that were previously provided by traditional health car professionals (Shewchuk & Elliott, 2000). Conversely, the literature also suggests that illnesses and disabilities present opportunities for growth, challenge, and satisfaction (Benner & Wrubel, 1989; Folkman, Lazurus, Dunkel-Schetter, DeLongis,-& Gruen, 1986; Machamer, Temkin, & Dikmen, 2002; Perlesz, Kinsella, & Crowe, 1999). Successful adaptation to disabilities on the part of families can result in a sense of mastery and self-efficacy, and family functioning may actually improve over time (Kreutzer, Gervasio, & Camplair, 1994). The effects of disability and chronic illness on family functioning undoubtedly vary dramatically, as each family brings to the situation a unique set of physical, psychological, and social resources and limitations.

McCubbin, Thompson, Thompson and Fromer, (1995) stated that adaptation to the stress that comes with illness or disability is heavily influenced by family resources and coping abilities. Similarly, Lazrus and Folkman's (1984) cognitive theory of psychological stress and coping identifies appraisal and coping as critical indicators of long term outcomes. Other authors note that family experience with care-giving for an adult involves an enormous increase in unexpected stresses and burdens (e.g., Krauss & Seltzer, 1993). Kosciulek and Lustig (1998) found that family members are affected at least as greatly as those experiencing a disability in terms of stress, psychosocial adjustment, and depression. Further, Lezak (1986) found that the ongoing difficulties of families in dealing with disabling conditions usually fall into one of four types: (a) coping with the emotional, personality and behavioral changes in the family member with a disability; (b) the lack of information and supportive services for the family; (c) the financial burden; and (d) the emotional strain associated with prolonged care-taking. Over time, these factors often lead to increased levels of depression, poor communication, and alcohol and drug abuse among family members (Degeneffe, 2001; Kozloff, 1987).

Unfortunately, at difficult times related to illness and disability, many families indicate that dealing with rehabilitation professionals can add to the emotional stress and is often not helpful in resource acquisition (Hein, Lustig, & Utuk, 2005; Kosciulek, 1994). Families are often unsure of their roles in dealing with rehabilitation professionals. On the one hand, they may be told that the family member needs to enhance independence to again be successful occupationally. This leads to the family being leery of over-involvement, which could hamper growth or increase dependence. On the other hand, lack of resources, such as transportation to work or limited social networks, may force families to take on additional roles in supporting the individual. Therefore, while the family is often expected by society to assume expanded roles in support and caretaking, they are often not recognized by society or rehabilitation professionals for the time and energy that they are committing to the family member with a disability (Lustig & Thomas, 1997). Finding appropriate ways to more fully include the family and acknowledge their contributions in reintegration to work then becomes the challenge for rehabilitation counselors.

Family Resiliency in Adjustment to Disability

Fundamental to the philosophy of rehabilitation counseling is the focus on client assets and resources (Riggar & Maki, 2004). One commonly overlooked client resource is the resiliency to adapt to a disability, and one important component of an individual's resiliency is the family (McCubbin & McCubbin, 1991). For example, a focus on coping strategies as a part of a family resiliency model can help individuals and families deal with the intense accumulation of demands that is often associated with chronic illness and disability. For rehabilitation counselors, understanding of the experience of disability can be facilitated through the application of a resiliency model. Lustig (1997) used resiliency to illustrate the critical influence that families typically play in the lives of adults with cognitive disabilities, and Kosciulek (1994) applied the concept of resiliency to families with a member who had experienced a head injury. Likewise, there is a direct link between family stress and child behavior, and family stress has been found to be associated with depressive mood in parents and caregivers (Ekberg, Griffith & Foxall, 1986). Others have shown that ongoing emotional and behavioral deficits in a family member with a disability are major sources of family stress (Dell Orto & Power, 1994), which affect family system functioning and can be understood through the resiliency model. Finally, resiliency can have positive effects on stress experienced by family members, as frequently documented in the literature, such as the finding that increases in perceptions of social support on the part of mothers is associated with a decrease in depressive symptoms (Murata, 1995).

The importance of understanding the role of family in the adjustment to disability and chronic illness process is underscored by the general shift in the health care system from hospital-based to community-based care, coupled with a shortage of paraprofessionals available to provide this type of care (McCann & Wadsworth, 1992; Paraprofessional Healthcare Institute, 2001). An estimated one in three Americans provide care each year for a family member with an illness or disability, and this number will continue to rise, paralleling the increasing frequency of chronic illness and disability (Hoffman, Rice, & Sung, 1996). Specifically, advances in health care have extended the lives of those with the most severe disabilities and chronic illnesses, while at the same time extending the length of time that families are responsible for care (e.g., Wolitski, Valdiserri, Denning, & Levine, 2001). Consequently, families of persons with disabilities and chronic illnesses are often faced with a lifelong myriad of problems, including the symptoms of the illness, the demands of care-giving, the limits of the health care delivery system, and social stigma (Marsh et al., 1996).

The Resiliency Model of Family Stress, Adjustment and Adaptation (McCubbin, Thompson, & McCubbin, 1996) would appear to hold promise in facilitating understanding of the ways in which families and individuals with disabilities can positively adapt and maintain a satisfactory quality of life. The Resiliency Model is similar to guiding philosophies in rehabilitation in emphasizing functional abilities within the family system (e.g., an emphasis on strengths as opposed to the traditional deficit approach that characterizes medical models). The premise of the Resiliency Model is to understand what a family does well and to then to build upon this base to help the family become more effective in problem solving, coping, and adjustment (McCubbin & McCubbin, 1991). Literature suggests that family adaptation to a diagnosis of disability can be enhanced by understanding three family factors: a family's social support, their appraisal of the illness or disability, and their coping and problem solving abilities (e.g., Kosciulek, 1994).

The Resiliency Model has been applied to a wide array of family stressors. In regards to the stress associated with disability and chronic illness, McCubbin, Thompson, Thompson, and Fromer (1995) describe adaptation to this type of stress as being heavily influenced by resiliency factors, because they assist families in managing the increased demands associated with disability and chronic illness. In addition, a long history of empirical support for applying this model to families involved in rehabilitation has accumulated. For example, Kosciulek (1994) found that a family's social support, appraisal of the illness or disability, coping skills, and problem solving abilities are linked to adaptive family adjustment. Litman (1966) and Safilios-Rothchild, (1970) found relationships of family resiliency to rate of recovery and resumption of family role and rehabilitation. Resiliency was also seen to enhance compliance with medical treatment and other preventive and rehabilitation regimens (DiMatteo, & DiNicola, 1982).

The application of the Resiliency Model in rehabilitation will provide rehabilitation counselors with a framework for understanding clients and their families from a positive, strengths perspective, a perspective consistent with the guiding philosophy of rehabilitation emphasizing the functional, adaptive abilities of people with disabilities. This model will provide rehabilitation counselors in understanding and identifying areas to target for intervention and service when working with families, allowing counselors to assist families in enhancing resiliency factors. Fortunately, the literature suggests that family resiliency factors can in fact be enhanced with proper interventions. For example, Fink (1995) suggested that counselors could help a family build their resources in numerous ways, such as assisting them in identifying and mobilizing existing resources and learning to utilize adaptive coping skills, which may enhance a sense of control and well-being. Indeed, the degree to which the individual with a disability and the family's coping abilities are enhanced to effectively handle demands will likely lead to more successful rehabilitation outcomes (Elliott, Shewchuk, & Richards, 1999).

The Resiliency Model and the Rehabilitation Counselor Interconnection 

A rehabilitation counselor can begin to understand a family's resiliency strength by making family resiliency a part of the initial assessment. In addition to assessing the functional capacities of a client, the resiliency strengths of a family can also be assessed with the use of resiliency, coping, and adaptation inventories, such as the Family Information Sheet (FIS), the Problem Checklist (PCL), and the General Functioning Scale of the Family Assessment Device (FAD-GF) (McCubbin & McCubbin, 1991). This assessment information can be used, along with functional, psychological, and vocational assessments that are normally incorporated into rehabilitation planning, such as the Individual Plan for Employment (IPE) developed in state vocational rehabilitation practice.

Conceptually, the Resiliency Model accepts that under typical conditions and circumstances, families will often encounter considerable stress. Families learn over time how to deal with these every day stressors, such as difficulties at work, having a baby, or trying to keep the house clean, with each of the family members filling different roles and functions. When a new major stressor confronts the family, such as a family member developing a disability, the normal traditional functioning system becomes unbalanced. The Resiliency Model examines variables that assess whether family members will be readily able to incorporate this stressor into their lives in a productive and functional way. In particular the model measures: (a) the existing resources the family has developed in dealing with life and stressful events, (b) the family's general appraisal towards the disabling event, and (c) the family's overall problem solving and coping skills. Each of these areas will be reviewed, within the focus of how rehabilitation counselors can incorporate the model into their practice.

Building Resources

The first step in building resources within a family is to identify and acknowledge their existing resources, which the family can build upon. An examination of these resources can be a part of the initial interview process. One barrier to building resources and to family collaboration in rehabilitation programs is a lack of information and communication from rehabilitation professionals encountered in the process (Ell, 1996). A counselor can help clarify what to expect during the rehabilitation process overall and for any significant transitions, such as the beginning of supported employment. By providing realistic time frames, families can better judge whether the services that they are receiving are adequate and they can be better able to make family decisions about the future. Families indicate that surprises are the hardest things with which to deal (Dyson, 1996). Families encountering disability have numerous surprises, without having the extra suspense from service providers who can provide time frames for service provision and reduce uncertainties.

Another way of neutralizing the surprise factor is having the rehabilitation counselor teach families what it will be like to deal with service providers. This can be done through helping families determine what employment goals are important to them, such as financial, status, and safety goals, and develop questions for service providers. The counselor can then role-play service provider interactions with the family, using the questions that they have generated to determine how best to get the information that they are seeking, which can also give families an enhanced sense of control. In addition, counselors can facilitate family decisions about services by providing information to families about available service providers to facilitate informed choices. A rehabilitation agency can facilitate this process by producing written information for client and family use that answers specific questions about services, time frames for employment, and expectations that a client should have regarding the agency. Finally, acquiring information from support groups on the typical expectations for recovering from particular disabling conditions can help a family to have more realistic expectations, based on shared experiences from other families, regarding agencies, specific programming, and time-lines.

Helping the Family Reframe the Event

A family's adaptation is the outcome of their efforts to bring a new level of balance, harmony, and coherence to the family following the introduction of a new stressor, such as chronic illness or disability (McCubbin & McCubbin, 1991). Rehabilitation counselors can help facilitate this adaptation by families and help clients obtain more successful outcomes by understanding that family stress is commonplace following a disabling event. Stress is a critical factor that must be considered in family assessment, intervention methods, and outcome measurement (Kosciulek, McCubbin, & McCubbin, 1993).

Initially, a counselor should help normalize the disabling event and the feelings the family is having associated with the event. Change is difficult for all people, and it is normal to feel stress, anger, and disbelief after a major disabling event occurs (Mathis, 1984). An important aspect of adjustment to the disability is the realization that the initial anxiety and stress can fade eventually. However, the anxiety and stress usually will increase for the first year while employment and identity development change is occurring (Kozloff, 1987). Thus, for the first year, many families feel out of control and anticipate family demise as a result of the event (McCubbin & McCubbin, 1991). Rehabilitation counselors who can help the family see both the troubles and tribulations that a disability brings can help a family cope more effectively. A family dealing with a disability has numerous reasons to thrive. For example, a disability may bring about a number of opportunities for a family to become closer and overcome employment obstacles together. This opportunity can result in increased family cohesion, increased self-efficacy skills, and more successful employment outcomes. By acknowledging what may be troubling the family, instances of new insight, and steps toward successful outcomes, counselors can help families take a more balanced view of a disability, seeing it as a part of their family experience, rather than a barrier to cohesiveness.

A family that sees the disability as a family problem, as opposed to only a problem of the individual's with a disability, generally shows more appropriate coping over time (McCubbin & McCubbin, 1991). Kosciulek (1994) noted that by continuing to involve family members in activities and helping them in accepting the family member where they are now, not dwelling on past employment identity, helps families to handle issues more appropriately. Showing examples of similar families who have successfully negotiated the road to employment and adaptation after disability may help the family see that positive changes do occur and that their concerns are shared by others. Life with a disability may need to be different, but it need not be less meaningful and fulfilling.

Enhancing Problem Solving and Coping Skills

Initially, it is important for rehabilitation counselors to understand and acknowledge the problem solving and coping skills that a family has used successfully thus far in life. Counselors need to incorporate what a family does well (e.g., open communication style, strong work ethic and history) and build on these family strengths. With the onset of disability, effective communication becomes much more important. A counselor may want to teach a family how to have more open communication and investigate what family members are feeling during this transition time. By acknowledging to the family that all members have been affected by the event, a counselor will help the family open up and accept their feelings and any changes in role functioning (Kozloff, 1987). Counselors can also help families assess situations that may not have arisen before to help them deal with appropriate social interaction, sharing of medical information, and the new financial burdens that chronic illness and disability often bring.

Additionally, rehabilitation counselors can help families in setting long-term goals. Lezak (1986) noted that, without goals, the burden of disability on the family over time could create additional stress and strain. Hence, by being pro-active in goal setting, a family can help prevent future crises. One method of applying foresight is having the family set realistic goals for each member and then analyzing how the disability may affect the pursuit and achievement of these goals. For example, it is common after an individual becomes disabled for one parent to quit working to help care for the individual. If this withdrawal from the workforce is going to cause future resentment and anger, other alternatives may need to be identified by the family such as hiring a caretaker or working part-time until the family stabilizes. In this way, the long-term family adaptation to disability can be more positive.

Rehabilitation Counselor Implications

Effects on Counselor Time Commitments

In working with consumers where it is appropriate for family involvement, rehabilitation counselors should consider a few changes in their normal routine in order to nurture a successful relationship for all involved. First, counselors should be aware that helping with adjustment to disability issues with families will take more work in the beginning of the relationship but should lead to less time-intensive involvement later in the process. A counselor who meets with the family and provides resource information, goal setting, and coping skills interventions will be spending more time than is typical in the assessment and early phases of the process. Additionally, the counselor may have to make work-hour adjustments to ensure the whole family can be present for initial meetings. However, this up front work should have time-saving implications for the counselor in the long run. The family will understand resources and help the client become the empowered director of his or her rehabilitation and employment plan. All involved will better understand and have written timetables for different transition periods, so counselors will receive fewer frantic calls concerning service delivery. In addition, consumers with less anxiety, better emotional health, and feelings of support will often follow through on their commitments more consistently (Fogarty, Roter, Larson, Burke, Gillespie, & Levy, 2002). Most encouraging, a client and family that is able to receive and use information in the beginning will be less likely to encounter difficulties during important transition times, such as the first experience with supported employment, because they will have already discussed issues that would normally cause stress. Thus, families will typically be more confident in their abilities due to a sense of ownership and the greater control that they experience in the rehabilitation process.

Effects on Counselor Burnout 

Attending to family needs and influences might also contribute to lessening burnout among practitioners. Rehabilitation counselors have long noted the high stress that comes with the job, which leads to burnout and high turnover rates in the profession (Garske, 1999; Layne, Hohenshil, & Singh, 2004). Using the Resiliency Model could allow rehabilitation counselors greater flexibility to shift some of their responsibilities into more proactive work with clients and families that may be highly rewarding to counselors. This proactive approach should also result in fewer crises and need for crisis management and job salvaging, which is stressful to both client and counselor. In addition, every rehabilitation counselor has stories of unproductive, stressful family involvement with clients. By understanding family dynamics and incorporating them into the rehabilitation process, the counselor will be minimizing one of the most stressful aspects of counseling.

Finally, rehabilitation counselors, by facilitating family resiliency training with several families at once, can create time savings for counselors, while also bonding a network of families that are experiencing similar emotions and can support one another. One of the most difficult aspects of disability for the family is the increasing demands on family members and role changes both inside and of the family (Kozloff, 1987). By allowing different families to meet together with the counselor or through existing support groups, counselors can help families strike a balance in life. Balance will help families deal with the stressful situations which normally arise, and this should also reduce stress and strain for counselors, leading to greater job satisfaction and less turnover (Layne et al., 2004)

Required Changes to Accomplish Greater Focus on Families

Some institutional and individual changes may have to be implemented in rehabilitation service delivery to make a focus on family resiliency successful. First, rather than viewing the consumer as an individual, the consumer should be viewed as an individual who is a part of a greater community and family. By training counselors in a family resiliency model, they will better understand the ways that families impact clients at crucial transition times in life. Counselors will see how these influences, if capitalized upon properly, can help clients to be successful in their attainment of rehabilitation and employment goals. The Council on Rehabilitation Education (CORE) has recognized the need for family influences through requiring coverage of family counseling topics in the curriculum of graduate programs in rehabilitation counseling.

A second change would occur in assessment with clients. By using family inventories in the initial stages of counseling, along with other assessment procedures, counselors can include resiliency interventions as a part of the larger employment plan. By identifying families who are at risk, counselors can identify services and support that may facilitate the process. Without initial assessment of families, counselors may be perplexed by lack of follow-through by clients, why employment goals were not met by the client, or why a supportive family has suddenly stopped helping the client attain goals (e.g., no longer providing transportation for the client to work). The family would also be more empowered to make long-term employment goals work for the family and the client because they feel both a part of these plans and because they understand what it will take to make the goals become reality.

Counselors can help facilitate these changes in the family in additional ways to support the initial resiliency training. By educating families and clients about available support groups, and making these groups accessible for families, a counselor can help build a community network of individuals and families. Counselors often have more contact with varied community agencies than they are aware. By promoting vocational rehabilitation service provider fairs, for example, counselors can help a family with limited time resources to access numerous providers in one location at one time. A requirement that attendance at these fairs is mandatory can be written into contracts with service agencies to assure high cooperation among providers in participating.

Conclusion

The family has a great deal of influence over the course of events and on adaptation, as well as substantial responsibility for care and support, when one member has a chronic illness or disability and is returning to the world of work. How the family copes and adapts to the disability may be one of the most important factors in facilitating positive employment outcomes for people with disabilities. By giving rehabilitation counselors a theoretical framework for dealing with high-risk families, more positive outcomes can result.

The importance of family to the rehabilitation process is becoming increasingly recognized. Family development and dynamics have become core knowledge areas that every rehabilitation counselor should posses, according to the Council on Rehabilitation Education (CORE, 2004) standards for graduate programs. As more programs begin courses on family counseling, the Family Resiliency Model can become a template for understanding the potential influences of families in the rehabilitation process, providing a basis for building on family strengths and understanding the circumstances that will affect the lives of the individual and family after the onset of the disabling event. By being proactive in addressing family concerns and difficulties, counselors will save themselves much time and stress. Additionally, by paying closer attention to family stress, counselors will be better able to anticipate the development of serious dysfunction in the family system, which is so common following a disabling event (Kosciulek & Lustig, 1998; Lazarus & Folkman, 1984). Finally, job retention rates should be higher for individuals who have had positive family adaptation to the disability because they are better able to deal with the day to day stress that comes with working and dealing with a disability, contributing to positive employment outcomes (DeVaney-Serio, Kreutzer & Gervasio, 1995).

Future research should focus on the effectiveness of this model, both for individuals with disabilities and the families of which they are a part. Included in this research should be an examination of nontraditional families and their resiliency strengths. Also, exploring the success of this model in different communities may facilitate understanding of changes that can be made to make service delivery more appropriate and effective. The authors have theorized that focusing on family, using the Family Resiliency Model, would be time effective for rehabilitation counselors, and studies should examine the long term effectiveness of applying this model in terms of counselor stress and burnout, successful rehabilitation and employment outcomes, job satisfaction, and quality of life.

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Michael P. Frain

Florida Atlantic University 

Gloria K. Lee

State University of New York-Buffalo

Norman L. Berven

University of Wisconsin

Tim Tansey

Michigan State University 

Molly K. Tschopp

Ball State University

Julie Chronister

San Francisco State University 

Michael Frain, 777 Glades Road, Boca Raton, FL 33431 E-mail: [e-mail]