By Bernice Lau
Independence – the pot of gold at the end of the rehabilitation rainbow. Or so we’ve been taught. Individuals who are independent are defined as those who do not require or rely on something or someone else in order to live their life (1). As per Johnson and Johnson (1), “Social independence exists when the goal achievement of one person is unaffected by the actions of others and vice versa – resulting in individualistic efforts. On the other hand, social dependence exists when the goal achievement of Person A is affected by Person B’s actions, but the reverse is not true.” The idea of being independent is considered to be an inherent good in the Western world, reflecting the values of predominantly individualistic societies (2); while the idea of dependence is often stigmatized. As a community member however, the idea of complete independence is rarely possible.
Whether it’s calling a plumber to fix a pipe or using a cellphone, we all depend, to some extent, on equipment or people outside ourselves to realize our goals. Thus, the commonly accepted and narrow definition of independence, as stated previously, may not hold true. Instead, a more appropriate term to describe our interconnections and dependencies is interdependence – defined as the outcomes of individuals being affected by each other’s actions (1). In the context of the Canadian healthcare system however, and specifically in rehabilitation, the idea of independence has become a core tenant and a nearly universally accepted goal (3). This article will highlight the hyper-focus of rehabilitation programs and professionals on the achievement of independence as a primary goal, the importance of switching the focus to interdependence to improve patient outcomes, as well as provide suggestions on how such an approach can be implemented: alterations in clinician language and treatment-goal setting to reflect the importance of social engagement.
Independence as a Goal of Rehabilitation
Rehabilitation – born from the days of aiding wounded veterans returning to their civilian lives and reducing the social cost of supporting them (4) – was built on the goal of increasing an individual’s ability to accomplish tasks on their own (5), such as activities of daily living (ADLs) (e.g., bathing, dressing, cooking etc.) (6). This is not to say that such skills should be overlooked, but rather the hyper-focus on these abilities may not be the key to optimizing quality of life. Such a mentality can perpetuate the notion that full independence is something to strive for, which may be unrealistic for some individuals and thus set them up for failure (7). Despite the negative impacts of using independence as an overarching rehabilitation goal, it is common practice and can be seen in both outcome measures and language used by clinicians.
Outcome Measures: Functional Independence Measure (FIM)
When using outcome measures to establish a baseline or monitor functional progress, an individual’s ability to perform tasks without aid from a person or assistive device is highly valued. The Functional Independence Measure (FIM) is an outcome measure used by clinicians to assess an individual’s physical, psychological and social function, and is intended to be used in patients with functional mobility impairments (6,8). Tasks to be assessed include feeding, grooming, bathing, upper body dressing, lower body dressing, and toileting. The clinician assesses and grades the functional status of a person based on the level of assistance they require – with 7 being the highest (no helper, nor use of assistive device) and 1 being the lowest (total assistance). Of note, a score of 6 indicates “modified independence”, defined as use of an assistive device but no helper (8). Such a scoring system implies that the greater level of assistance required by an individual, whether it be from another person or equipment, the lower their level of functioning, which may not necessarily be true. For example, individuals living with any form of amputation may rely on the use of an assistive device, whether it be a mobility aid (e.g., wheelchairs, walkers, canes etc.) or prosthetic, and can perform all the same ADLs as an able-bodied individual. Thus, it can be argued that both individuals are equally as functional, despite the use of a device by the former.
The language used by clinicians can be very impactful on a patient’s perception of themselves and their situation. Specifically, the manner in which clinicians broach the topic of mobility aids can often reinforce pre-existing negative perceptions of such devices. For many, transitioning to the usage of a mobility aid may often be surrounded by a fear of stigma, embarrassment (9) and a loss of control in their lives (10). In a study by Resnik and colleagues, individuals aged 65+ across various ethnic groups perceived physicians as a strong influence in their decisions to use mobility aids (11). Should a discussion be framed using a medicalized approach, portraying device use as mandatory or permanent to overcome a “mobility problem”, this can evoke feelings of inferiority or abnormality. Therefore, there can be many ways in which clinicians can subconsciously reinforce the idea of independence being an inherent good – even in subtleties such as language.
Shifting the Focus to Interdependence
A method in which we can shift our focus away from independence as a universally accepted goal of rehabilitation is embracing the idea of interdependence. As described previously, interdependence appears to be a more accurate representation of our society – we are all in fact interdependent.
As complete independence does not exist, how beneficial is assessing levels of independence as a primary treatment goal/outcome measure? Although improving an individual’s ability to independently perform ADLs may, in some respects, reduce economic burdens to healthcare, there are factors other than physical functioning that must be considered when examining costs to care – one being community participation.
As complete independence does not exist, how beneficial is assessing levels of independence as a primary treatment goal/outcome measure?
Rehabilitation interventions are designed around the assumption that the ability to function independently is naturally followed by community participation, however this is not always the case (12). In “The Essence of Interdependence”, Condeluci explains that rehabilitation programs often leave out some of the most important skills to facilitate community integration: relationship building and creating support systems (13). This is important for reducing depression and emotional distress (14,15), as well as increasing feelings of perceived control and self-efficacy (16); ultimately alleviating economic burdens to the healthcare system (17). Although practicing ADLs may help an individual cook a meal or bathe themselves independently, they may not necessarily be prepared to acquire and retain community roles (13). Hence, we must teach individuals how to be interdependent.
With enhanced community participation, rehabilitation outcomes have shown to be improved through direct enhancements in quality of life and improving mental health (14,15). This has been demonstrated in both people living with disabilities and those without (18). In addition to increasing the awareness surrounding the importance of social engagement, clinicians can further educate on the importance of interdependence via language used and treatment goal setting.
As the language used by clinicians can have a strong impact on the patient’s perspectives of their situation and themselves, clinicians must aim to portray receiving support (either from another individual or an assistive device) in a positive manner. For example, to overcome stigmas associated with mobility aid use, the clinician should take a nonmedical, non-disability approach (9). This involves framing the usage of mobility aids as a means to enhance autonomy, safety, comfort, and facilitate performing more ADLs (11) as opposed to necessitating their usage due to an individual’s lack of ability to perform an activity. Therefore, the clinician’s ability to present the idea of requiring assistance in a constructive manner, emphasizing a broadening of opportunities, can ultimately instill a greater sense of self-efficacy and confidence amongst individuals who use mobility aids (9,10) – ultimately improving a patient’s capacity to form relationships.
Similarly, clinicians can incorporate this line of thinking into a patient’s treatment goals. As opposed to aiming solely for the ability to accomplish tasks without support from others, clinicians can discuss additional goals with the patient to improve an individual’s capacity for social engagement (15). This includes connecting the individual to resources and groups to establish links with others who share similar conditions, hobbies, interests etc. (13). Furthermore, clinicians can play a role in challenging the stigma surrounding disability and employment by helping the individual demonstrate their capability to accomplish many work-related tasks, creating opportunities for such demonstration, or disclosing the effects of an injury or condition to an employer where it is likely to be helpful (15). Through a better understanding of the social consequences of a patient’s condition, clinicians can empower patients to form relationships and support networks, thereby facilitating interdependence and improving overall quality of life.
If rehabilitation programs and professionals aim to provide holistic care – we cannot let our focus be solely on independence in ADLs. Rather than aiming only to assess and treat people and then discharge them when they are independent on motor tasks, rehabilitation should, if necessary, help connect people to others (13). This necessitates the shift in focus from independence to interdependence, by incorporating goals of social engagement and support network building. Through changing the narrative surrounding rehabilitation, the idea of interdependence can be emphasized as being both good and necessary for positive health outcomes.
Featured illustration by Mimi (Yuejun) Guo for rehabINK.
To refer to this article, it can be cited as:
Lau B. Independence to Interdependence: Changing the Narrative of Rehabilitation. rehabINK. 2021:11. Available from: https://rehabinkmag.com
- Johnson DW, Johnson RT. New Developments in Social Interdependence Theory. Genetic, Social, and General Psychology Monographs. 2005 Nov;131(4):285–358.
- Triandis HC. Individualism-collectivism and personality. Journal of Personality. 2001 Dec;69(6):907–24.
- Crabtree J. What is a worthy goal of occupational therapy? Occupational Therapy in Health Care. 2000;12(2–3):111–26.
- Mosey AC. Involvement in the rehabilitation movement–1942-1960. American Journal of Occupational Therapy. 1971 Aug;25(5):234–6.
- Dunn DS. The Social Psychology of Disability. 2014.
- Heinemann AW, Linacre JM, Wright BD, Hamilton BB, Granger C. Relationships between impairment and physical disability as measured by the functional independence measure. Archives of Physical Medicine and Rehabilitation. 1993 Jun;74(6):566–73.
- Gibson BE. Parallels and problems of normalization in rehabilitation and universal design: enabling connectivities. Disabilty and Rehabilitation. 2014 Feb 25;36(16):1328–33.
- Linacre JM, Heinemann AW, Wright BD, Granger CV, Hamilton BB. The structure and stability of the Functional Independence Measure. Archives of Physical Medicine and Rehabilitation. 1994 Feb;75(2):127–32.
- Aminzadeh F, Edwards N. Exploring seniors’ views on the use of assistive devices in fall prevention. Public Health Nursing. 1998 Aug;15(4):297–304.
- Gooberman-Hill R, Ebrahim S. Making decisions about simple interventions: older people’s use of walking aids. Age Ageing. 2007 Sep;36(5):569–73.
- Resnik L, Allen S, Isenstadt D, Wasserman M, Iezzoni L. Perspectives on use of mobility aids in a diverse population of seniors: implications for intervention. Disability Health Journal. 2009 Apr;2(2):77–85.
- White GW, Lloyd Simpson J, Gonda C, Ravesloot C, Coble Z. Moving from Independence to Interdependence: A Conceptual Model for Better Understanding Community Participation of Centers for Independent Living Consumers. Journal of Disability Policy Studies. 2010 Mar;20(4):233–40.
- Condeluci A. The essence of interdependence. UCP of Pittsburgh; 1999.
- Siegert RJ, Ward T, Levack WMM, McPherson KM. A Good Lives Model of clinical and community rehabilitation. Disability Rehabilitation. 2007;29(20–21):1604–15.
- McClure J, Leah C. Is independence enough? Rehabilitation should include autonomy and social engagement to achieve quality of life. Clinical Rehabilitation. 2021 Jan;35(1):3–12.
- Paukert AL, Pettit JW, Kunik ME, Wilson N, Novy DM, Rhoades HM, et al. The roles of social support and self-efficacy in physical health’s impact on depressive and anxiety symptoms in older adults. Journal of Clinical Psychology in Medical Settings. 2010 Dec;17(4):387–400.
- Wheeler JRC, Janz NK, Dodge JA. Can a disease self-management program reduce health care costs? The case of older women with heart disease. Medical Care. 2003 Jun;41(6):706–15.
- Gooden-Ledbetter MJ, Cole MT, Maher JK, Condeluci A. Self-efficacy and interdependence as predictors of life satisfaction forpeople with disabilities: implications for independent living programs. Journal of Vocational Rehabilitation. 2007;27(3):153–161.