Concepts of disablement

Disablement will be used here as an overall term to cover any type of interference with activities by illness. This is often of more concern to the patient than the symptoms of the illness itself, since the fear of long-term dependence upon others is usually present, even though not voiced in the early stages. The question arises whether to leave the description and assessment of disablement to different members of the team as it arises in various forms, or whether in addition to encourage reference to one of the systematic descriptive schemes that are now available. Even if not used as fully as their authors intend, these have the merit of serving as checklists or reminders for the whole team, to ensure that the many different effects of the illness have been considered.

Two widely used descriptive schema are the International Classification of Impairments, Disabilities and Handicaps ( ICIDH),(B and a broadly similar framework described by Nagi(26) that is often used in the United States, particularly by neurologists. These are best regarded as descriptive conceptual frameworks rather than classifications, sharing a basic structure of several levels of concepts. For the ICIDH, these are impairment, disability, and handicap.. Impairment is interference with physical or psychological functions (that is, parts of the whole person), disability is interference with activities of the whole person in relation to the immediate environment (also often figuring in other instruments as 'activities of daily living'), and handicap is the social disadvantage resulting from disability. Although the 1980 version of ICIDH was not fully developed as either a classification or as a set of rating scales, the idea of thinking about interference with activities at different but related levels is very sensible.(27)

As noted in Fig 1, these three concepts can be put alongside the sequence of ideas that leads from complaints, through symptoms to the identification of disorders or diagnoses. This may represent a causal sequence in some individuals, and this is clearest in acute physically based illnesses. But for many patients encountered in psychiatric practice, whose illnesses often have prominent social components, causal relationships may be absent or even in the opposite direction. For instance, sudden bereavement, i.e. loss of a social relationship, may be the clear cause of interference with the ability to perform daily activities (disability), and also of uncontrolled weeping (an impairment of the normal control of emotions). Social handicaps can also be imposed unjustifiably by other persons, as when a patient who is partly or fully recovered from long-standing psychiatric illness and quite able to work is refused employment due to the prejudice of a potential employer.

Fig. 1 Analysis and integration of information

Many mental health workers find that to use a scheme of this sort helps to clarify how different aspects of a patient's problems fit together. Similarly, the different members of the team may be able to see more clearly how their activities with the patient and family complement one another, since the different concepts in the framework correspond approximately with the interests of different health disciplines. Social workers will focus on assessment of work and social relationships, occupational therapists will have a special expertise in the assessment of daily activities, and clinical psychologists are skilled in the assessment of cognitive and other psychological functions. Researchers in the various health disciplines have naturally devised rating scales that reflect their own interests and ideas, independently of the ICIDH or other overall schema, but it is usually found that such scales correspond quite closely with one or other of the concepts just discussed. Because of this, the ICIDH has received wide international recognition as a useful way of approaching assessment, and is now being revised. (28) The reluctance of both researchers and clinicians to adopt a standard set of terms to cover the various levels or concepts continues to be a problem; the reader needs to be aware that the terms impairment, disability, and handicap are often used synonymously by different authors.

The description of social and interpersonal relationships is in principle included in comprehensive schemas such as the ICIDH and that of Nagi, but many separate instruments that cover relationships in great detail have been devised over the years by psychotherapists, family therapists, and others. (29,30 and 3!>

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