An Integrated Model of Psychosocial Adjustment Following Acquired Disability

Psychosocial adjustment problems among people with acquired disabilities have been associated with extensive costs in terms of long-term community welfare and health service utilization (Browne, Arpin, Corey, Fitch & Gafni, 1990). Unfortunately, in addition to being reasonably resistant to treatment, adjustment problems represent one of the most significant barriers for rehabilitation outcomes (Putnam & Adams, 1992). For rehabilitation counselors, clients who present with psychosocial adjustment problems can be a source of extreme distress. These clients are often misunderstood and poorly serviced, leading to high levels of dissatisfaction with rehabilitation (Winter & Keith, 1988). Much of this misunderstanding originates from the manner in which psychosocial adjustment is conceptualized and taught to rehabilitation counselors. Specifically, adjustment is most often represented as a linear sequence of stages (Livneh & Antonak, 1990). While stage models may adequately represent the general progression towards adjustment that occurs over time (Davis, 1987), they do not sufficiently address the recurrent nature of the psychosocial adjustment process (Yoshida, 1993). As Rosenthal (1996) noted, linear models do not enable rehabilitation counselors to appreciate or anticipate the "disorder, unpredictability and complexity" (p. 226) of the issues they are likely to encounter in their work. An alternative approach to conceptualizing adjustment is the recurrent model in which adjustment is viewed as an ongoing cycle. Despite it's intuitive appeal, and a large body of literature supporting the recurrent approach, most discussions of psychosocial adjustment continue to refer to stage models. It is possible that this situation arises because the recurrent model has not been fully articulated. Accordingly, after briefly examining the shortcomings of the linear model, the present paper attempts to integrate current knowledge about psychosocial adjustment within a recurrent framework. By providing rehabilitation counselors with an integrated recurrent conceptualization of psychosocial adjustment following acquired disability, it is hoped that the dominance of stage models in rehabilitation counseling can be challenged. In addition to better preparing rehabilitation counselors for the psychosocial difficulties their clients may experience, the recurrent model proposed in the current paper should assist them in focusing efforts on factors that are likely to be associated with positive outcomes. Stage Models of Psychosocial Adjustment Historically, the process of psychosocial adjustment following an acquired disability has been viewed as a sequence of stages (Fortier & Wanlass, 1984), similar to those experienced during the grief associated with one's imminent death or the loss of a loved one (Kubler-Ross, 1969). Although there is disagreement about the total number of stages in this adjustment process, there are significant similarities among the various models in that they usually include three common stages. Specifically, most models describe an initial period of shock and/or denial which is followed by significant distress and concludes with acceptance of one's situation. Although a range of other reactions and emotions (e.g., guilt, hostility) have been included in some variants of the model, there is less consistency concerning these stages (Livneh & Antonak, 1990). According to this linear, developmental approach to adjustment, the appearance of later stages is predicated on the resolution of earlier stages. Although evidence does support a general trend towards acceptance of disability over time (Linkowski, 1971), stage models have a number of negative implications for the rehabilitation process. For instance, conceptualizing adjustment as a series of unavoidable stages implies passivity on the part of individuals with disabilities and their rehabilitation workers (see also Stewart, 1996). …