Four Models of Disability, by Michael Gerald, PhD.

Often when we think about or discuss disability, medical conditions, or chronic illness we tend to think of diagnoses. “What do you have?” So, to speak. According to the Americans with Disabilities Act (ADA, 1990) a disability is defined by: the presence of a physical, cognitive, intellectual, or psychiatric condition (or a combination); pervasive impairment in social and occupational functioning; and the potential for experiencing prejudice, discrimination, stigma, and reduced opportunities as a result. The level of impairment an individual with a disability experiences has to do with a combination of their internal resources, their environment, and the course of the medical condition/chronic illness/disability itself. Models of Disability provide a set of guiding assumptions, concepts, and propositions about the nature of phenomena or human experience. Models of Disability help us to explain why or how a disability may be impacting someone. Models of Disability further provide: definitions of disability; the location of the problem; who is responsible for solving it; what the needs are of a person with a disability; policies that may be beneficial in mitigating disability; and who will study and work with persons with disability.

In the present article, I will describe four Models of Disability: Biomedical; Environmental; Functional; and Sociopolitical or Social.

The Biomedical Model is perhaps the most prevalent and readily understood of the models of disability and it is the foundation of the field of medicine. In the Biomedical Model the “problem” of disability lies within the individual and represents some pathology that needs to be cured, usually (although not always) by a healthcare provider. For example, a person with Inflammatory Bowel Disease (IBD) may receive prescription drug treatment for their Crohn’s Disease as well as surgical removal of parts of their bowel in order ameliorate symptoms and restore functioning. Medical supplies, such as ostomy pouches and flanges, certainly are born out of the Biomedical Model of disability. The Biomedical Model, of all the models, has the most objective standards for diagnosis and causal attribution, and has provided persons with disabilities with treatments, surgical options, and other techniques for restoring functioning. However, it is often criticized by persons with disabilities for: not taking the individual’s environment into account; objectifying persons with disabilities and their bodies; and relieving society of any responsibility for disability.

The Environmental and Sociopolitical Models of disability share some similarities in their definition of the problem and interventions to improve functioning for persons with disabilities. The Environmental Model of disability places the “problem” of disability in the individual’s physical environment and postulates the environment can cause, define, or exacerbate disability. Mitigation, therefore, of the consequences of disability requires addressing disabling, unresponsive, or insensitive environments. Curb cutouts for persons who use a wheelchair, grab bars in a bathroom for persons with limited coordination or mobility, or crossing signals that chirp for persons with visual impairments are all examples of environmental adaptations that can help promote functioning in persons with disabilities. The Sociopolitical, or Social, Model of disability views prejudice and discrimination (or attitudes) as causing disability. The “problem” of disability, therefore, lies in discriminatory attitudes of society and its unwillingness to provide equal access for persons with disabilities. The Social Model of disability was the inspiration for the Americans with Disabilities Act of 1990 (ADA) and Centers for Independent Living (CIL). For persons with bowel/bladder dysfunction and resultant ostomies, stigmatizing attitudes towards ostomies can negatively impact adjustment to ostomy surgery, as those attitudes may inhibit their employer from making accommodations or their school from believing they can continue their education.

The Functional Model defines disability in terms of the functional capacity that is affected by a given disability or diagnosis. For instance, a professional pianist who loses a finger is likely to experience much more functional impairment due to the loss than a professional soccer player. Disability, therefore, is mostly determined based on an individual’s functional capacities, their roles and responsibilities, and their environment. The Functional Model approaches treatment of disability and its consequences through adaptive technology, vocational training, and tailored job placement. For persons undergoing ostomy surgery, their level of functioning is impacted depending upon their lifestyle. Someone who is active, exercises a lot, may want to utilize products that allow them to maintain that level of activity, such as belly bands or smaller pouches.

In summary, our models of disability help us as practitioners to identify how a disability may be impacting someone’s life and what interventions would be best suited to mitigate those consequences. Persons with ostomies may not need more surgery or new medication, they may simply need better access to their environments. Persons with ostomies may not need new equipment, they may need help advocating against prejudicial attitudes regarding their ostomy.

For me, personally, as a person with an ostomy, I have always relied on the Functional Model of Disability (even before I knew what that was!) to guide me. What do I want to do? What are my limitations? What could I do to make that possible? My ostomy is permanent, I cannot change that, but in order to work and exercise how I want I can control my diet, how I maintain my pouch, what supplies I bring with me, how much I sleep, and so on and so forth. When working with persons with ostomies, asking questions about what people want to be doing rather than simply asking what is wrong can help better point us toward effective solutions. ●

About the Author

Michael Gerald, PhD, is a licensed Clinical Mental Health Counselor and Certified Rehab Counselor. He is currently employed as an Assistant Professor in Rehabilitation Counseling at Utah State University (USU) in Logan, UT. Michael has provided clinical mental health services as a Crisis Counselor, Substance Abuse Counselor, Correctional Mental Health Provider, and Private Practice Mental Health.

Michael has received compensation from Coloplast to provide this information.

Communicating with Adolescents: our words matter, by Lynn Mohr, PhD. APRN PCNS-BC CPN

When providing healthcare guidance, working with adolescents can present many unique challenges. Many of these challenges can be mitigated with both (a) a better understanding of how adolescents think and (b) how our own communication patterns can impact our message.

Understanding adolescent thought and development is the first step to improving patient/provider communication. Usually spanning ages 12-18, adolescence represents a dynamic period in human growth and development. In addition to biological and sexual maturation, teens face questions of personal identity, sexuality, and autonomy (Christie & Viner, 2005). In addition, adolescents also experience a psychological and social shift as they move from the concrete reasoning and individualistic roots of childhood to the abstract reasoning and corporate behaviors which mark adulthood. These sudden changes are often accompanied by feelings of anxiety, awkwardness, and self-criticism which are often compounded by complex peer-relationships and the widening influence of social media (Croll, 2005).

Consequently, adolescents often vacillate between childlike and adult behaviors. In grappling with their changing lives, they become focused on their present realities rather than their long-term goals (Ginsburg, 2018). They seek solace in cultivating experiences and relationships as these provide security and a sense of self. Furthermore, the rapid growth often leads to feelings of invincibility and subsequent poor assessments of “risky” situations and long-term consequences.

While adolescent angst is nothing new, healthcare providers cannot underestimate the role it plays in effective patient communication. To practice developmentally informed adolescent communication Ginsburg (2018) together with my own research offer the following for providers working with adolescents:

1. Remain Calm.
   
   Don’t speak until you have regulated your own emotions. Resist the urge to “strengthen” your message by speaking in loud or condescending tones. Rather than focusing on your own feelings, give the adolescent your full attention. Remember to choose your words wisely as they are powerful.


2. Resist Lecturing.
   
   Patient engagement in risky, inappropriate, or dangerous behaviors often prompts a “lecture” which begins by covering consequences and ends with a “what were you thinking?” Such lectures, however, rely on the skills which teens lack most, such as abstract thinking, long-range planning, and risk-estimation (Ginsberg, 2018). While teenagers may pick up on our concern, they do not connect with our message. Not only are such lectures ineffective in the short term, but long-term they can be disempowering.


3. Ask, Don’t Tell.
   
   Use question language such as “Tell me about? How did that work? I worry that might lead to ….. what do you think?”. Remember to never be shocked or surprised by what an adolescent tells you. Don’t ridicule an adolescent’s question or comments. Instead respond with “I could see why that seems to be something good, and I am concerned about…. What do you think? or I can tell that you are worried about…..” Using the word “but” in a sentence can negate anything positive the adolescent may have tried to explain, so replace “but” with “and”. When something “goes wrong”, ask questions like “What are your plans so this doesn’t happen again?”, “What did you learn from this?”, and “What would you tell another adolescent?” (Mohr, 2012).


4. Acknowledge Existing Wisdom and Reinforce Safe Thought Patterns.
   
   Adolescents don’t crave feedback because of their insecurity, rather because it helps them learn (Ginsberg, 2018). Acknowledge when they have done something well and notice effort. Talk through an issue and ask their opinion on how something might work for them. Take time to discover their story and communicate that you value them. Often adolescents have worked through their own illnesses in creative ways. Positive feedback promotes trust and care.


5. Make Directions Meaningful & Avoid Distractions.
   
   Practice “the pause” after each direction step, allowing space for questions and anxieties to surface. Remember to exercise patience as incorporating new information takes time. Make sure you have accurate information and if you do not, then apologize and move forward. Avoid multitasking behaviors as much as possible.


6. Work with Their Strengths.
   
   Using computer-based programs or video-based learning works well. Build on the need for autonomy by teaching patients how to manage activities such as dating, dancing, work, dress etc. Incorporate their desire for connection and experiences by sharing stories from your own learning, connecting them to other adolescents who have been or are in similar situations, and recommending educational websites or other activities (such as adolescent ostomy camp).


7. Promote a Positive Body Image.
   
   Acknowledge how their appearance might be affected by their illness or treatment. Sharing information about the effects of treatments and medications encourages discussion. Using questions such as “Other adolescents have asked about or shared about …is this something you have wondered about?” These questions encourage the adolescent to express their own concerns and fears. Asking about upcoming activities and if the adolescent has thought about how they will handle can encourage conversations about care rather than anxiety (Mohr, 2012).

In summary, understanding how adolescents think and modifying our communication styles to help promote patient ownership of solutions can make the difference between our teenage patients either absorbing or discounting the information we provide. By meeting teenagers where they are, our interactions have the potential to not only be effective, but also enjoyable as well. ●

References

Christie D , Viner R . ABC of adolescence: adolescent development Br Med J. 2005 ; 330 ( 7486 ): 301-304

Croll J . Body image and adolescents . In: Stang JS , Story M , eds. Guidelines for Adolescent Nutrition Services . Minneapolis, MN : University of Minnesota ; 2005 : 155-166. http://www.epi.umn.edu/let

Ginsberg, K. The Teen Brain; 2018. Center for Communication for Parents and Teens. https://parentandteen.com/category/communication-strategies/

Mohr, L.D. Adolescent Growth and Development Issues in Adolescents with an Ostomy: A primer for WOC nurses. J Wound Ostomy Continence Nurs. 2012;39(5):515-521.

About the Author

Lynn Mohr, PhD APRN PCNS-BC CPN, is an Associate Professor/Associate Department Chair, Women, Children, Family Nursing at Rush University College of Nursing. Dr. Mohr has over 40 years of pediatric experience and her research focuses on the needs of adolescents with gastrointestinal ostomies where she has developed a theoretical framework for how adolescents work thru this experience. Dr. Mohr is a Fellow in the Illinois Institute of Medicine, Oversees Fellow in the Royal Academy of Medicine, London and a Fellow of the CNS Institute. She also is a past national president for the Society of Pediatric Nursing.

Lynn has received compensation from Coloplast to provide this information.