community-based rehabilitation

community-based rehabilitation, consumer-driven effort to restore independence and agency in persons with sensory, psychiatric, physical, or cognitive disabilities outside a medical or institutional context. Community-based rehabilitation may be supported by advocacy-based organizations or not-for-profit residential programs and can take place in a variety of settings, including drop-in centres, health and mental health centres, religious settings, public parks and other outdoor venues, employment settings, and homes of people with disabilities. Community-based rehabilitation programs can focus on just about any disability, ranging from autism, intellectual disabilities, learning disabilities, and deafness to drug addiction, schizophrenia, and depression as well as to traumatic brain injuries and spinal cord injuries. Community-based rehabilitation allows counselors to vary the contexts of practice based on the specific needs and backgrounds of persons with disabilities. Doing so increases the likelihood that rehabilitation services will be culturally and contextually anchored and therefore relevant to the persons receiving services.

Grassroots community leaders, advocates, and professionally trained individuals from a wide range of disciplines can practice community-based rehabilitation. Those include occupational therapists, physical therapists, rehabilitation counselors, developmental therapists, community psychologists, social workers, nurses, public health professionals, and physicians specializing in physical medicine and rehabilitation.

The community-based rehabilitation movement

Internationally, the community-based rehabilitation movement began with two World Health Organization (WHO) initiatives of the 1970s and ’80s: (1) the primary health care (PHC) campaign Health for All by the Year 2000, introduced in 1978, and (2) the community-based rehabilitation movement that emerged, in part, from the PHC campaign. Generally, the PHC campaign focused on efforts to raise the level of health in the world by increasing access to health care in less-developed countries. The community-based rehabilitation movement reflected an international recognition that rehabilitation is a key aspect of the campaign for global health. The international nature of the movement emphasized the need for consideration of the cultural contexts of participating countries. In addition to the PHC initiatives, WHO later helped improve access to rehabilitation services in less-developed countries by delivering simple, low-tech, community-based rehabilitation services.

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Events in the community-based rehabilitation movement in the United States played an influential role in shaping rehabilitation practice. In that country the community-based rehabilitation movement derived from the deinstitutionalization and community mental health initiatives of the late 1960s and early ’70s. For many years, rehabilitation had almost exclusively occurred in hospital and clinical settings. Early community-based initiatives followed the medical model of treatment. Although in theory they embraced concepts of community participation, in practice many used professionally developed strategies that failed to include the voices of community members in program planning and implementation. In response to a growing dissatisfaction with such community-based services among persons with disabilities and rehabilitation counselors, a community development model was proposed in the late 1980s and early ’90s. The community-based rehabilitation movement then began to shift from a treatment-of-deficit model that isolated and stigmatized persons with disabilities to one that promoted societal integration and the improvement of the everyday lives of individuals with disabilities. With that shift, community-based rehabilitation emphasized a strength-based model of social inclusion, political equality, and the translation of clinical and technological knowledge into relevant health-care information and self-help skills.

Practice of community-based rehabilitation

The practice of community-based rehabilitation varies along a continuum ranging from institutional medical-treatment approaches to community-integrated participatory approaches. Medical treatment may involve biomechanical approaches to rehabilitation, including manipulating the body or teaching and assisting patients with movement and daily living skills. Medical approaches are criticized by disability rights activists and those scholars, researchers, and practitioners who support a more consumer-centred or participatory approach to rehabilitation. They argue that treatment-based rehabilitation approaches are similar to clinic-based approaches that promote the isolation and stigmatization of persons with disabilities, the only difference being that rehabilitation occurs with fewer resources and within community contexts. They argue further that medical approaches assume that persons who provide treatment are experts. Recipients of services, or patients, are dependent on experts to direct the course of therapy, which promotes feelings of helplessness. Conversely, proponents of the medical approach to rehabilitation argue that some persons with disabilities are too severely disabled to direct the course of their own treatment. Also, a lack of adequate resources prevents implementation of more consumer-driven rehabilitation services.

Alternatively, participatory community-based rehabilitation service approaches emphasize empowering consumers to function more independently. They encourage people with disabilities to advocate for their rights as citizens who are consumers of health care. Participatory approaches work to reduce professional-client power hierarchies by engaging consumers as leaders and treatment providers. Participants are encouraged to organize in order to develop, implement, and evaluate empowerment-oriented community-based services, not only for each other but also for the larger health care and social communities in which they interact. According to researchers William Boyce and Catherine L. Lysack, true participation involves a process of personal as well as social transformation, in which decision making takes place in the hands of the consumer group and social conditions are thereby affected or changed. That approach is typically associated with social action projects that emphasize the achievement of local consumer-driven goals. The central tenet of that approach to rehabilitation is that it begins with the problems and needs of community members, rather than with the professional’s conceptualization of those problems.

Professionals who use participatory approaches to community-based rehabilitation are active knowers and members of the communities within which they work. They fulfill those roles by becoming community organizers, meeting facilitators, educators, peer trainers, community advocates, activists, or resource persons for technical or material aid. The professionals allow the consumers to dictate the essential elements of the therapy process. The necessary requirements for legitimate empowerment within the therapeutic relationship are flexibility in establishing the variety of possible roles assumed by both service providers and consumers and the relinquishing of power by service providers to consumers when establishing those roles.

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For many international rehabilitation programs, participatory approaches to community-based rehabilitation are based on the idea that all persons with disabilities deserve opportunities to participate and benefit from society equal to those enjoyed by persons without disabilities. In addition, they work to correct society’s misperceptions about persons with disabilities by demonstrating that persons with disabilities are capable of not just participating in society but contributing to it.

Integrative approaches

A growing number of integrative community-based approaches to rehabilitation have been developed based on the reconceptualization of persons with disabilities as citizens instead of patients. Those approaches seek to combine education, training, practice, and advocacy efforts. One well-known example of an integrative approach to community-based rehabilitation is supported employment. Since the early 1980s, supported-employment programs have enabled thousands of people with disabilities to become employed in their communities. Prior to supported employment, persons with significant disabilities who wanted to work were often placed in sheltered workshops. They earned only pennies an hour in piecework wages. Supported-employment programs promote a more-integrated life and higher quality of life by helping persons with disabilities pursue job opportunities in traditional work environments at pay equal to that of nondisabled persons.

Job specialists work with consumers, exploring their vocational aspirations and supporting them in their efforts to find jobs. Once consumers have a job, they receive on-the-job training and support. Eventually, support is faded out and consumers work independently. Job specialists in supported-employment programs work to remove the barriers that persons with disabilities face in obtaining employment. Job specialists work to remove the consumers’ internal barriers by increasing their feelings of self-efficacy and self-esteem. Job specialists also work to reduce external barriers to employment by advocating for their consumers as capable contributors to society. In addition to the benefits to consumers and to businesses, which receive dedicated and capable employees at reasonable pay rates, supported-employment programs benefit society by reducing the stigma associated with having a disability. Promoting real-life interactions between disabled and nondisabled individuals can lower the stigma and build positive relationships.