Trends in Rehabilitation and Disability:
Transition from a Medical Model to an Integrative Model
Katherine D. Seelman, Ph.D.
University of Pittsburgh
Pittsburgh, PA. U.S.A.
Kds31@pitt.edu
October 31, 2003

Transition from Medical to Integrative Model2

INTRODUCTION
The purpose of this lecture is to introduce and explore four models of disability: thetraditional model, medical model, social model, and integrative model (Seelman, 2002). The
four models often appear in sequential stages in the history of many industrialized countries.
With the exception of the integrative model, the knowledge base for each model tends to exclude
that of the other models. Throughout this presentation, the models are illustrated bycorresponding policies, practices and research, using country-based examples mainly from theUnited States and, to a lesser extent, Japan. These models have implications for professional
education and training of people with disabilities. Conclusions and recommendations will
therefore address professional education and training people with disabilities as well asinternational and country-based policies, practices, research, and collaboration.
TRENDS
A number of international trends illustrate the importance of re-examining disability
models that are operative in countries and international organizations. The first trend involves
conflict between health professionals who identify with the medical model and people withdisabilities who identify with the social model. Throughout the world, people with disabilities,
who have formed a Disability Movement, are criticizing the medical model of disability anddemanding greater participation in decision making (Basnett, 2001). The introduction of theWorld Health Organization’s International Classification of Functioning, Disability and Healthin 2001 suggests that a more integrative model may be emerging within the international
community (World Health Organization, 2001). The integrative model adjusts for some of theTransition from Medical to Integrative Model3

criticisms of the other models and is already influential in country-based policy, practice,research and professional training http://www.dpi.org/en/resources/topics/topics-convention.htm.
The second trend involves technology. Increasingly, access to technology is associatedwith human rights as reflected in the Americans with Disabilities Act of 1990
(http://usdog.gov/crt/ada/adahom1.htm), the proposed United Nations Convention on the Rights
of People with Disabilities (http://www.dpi.org/en/resources/topics/topics-convention.htm), and
the World Summit on the Information Society (http://www.itu.int/wsis;
http://www.geneva2003.org). Policies, practices and research in universal design and design for
all are examples of this trend. Human rights and technology are associated with demands tomake mainstream systems and products, such as communication systems, transportation systems,
and cell phones, accessible. However, accessibility features in mainstream systems and products
may be regarded as “social add-ons”—not competitive in the global marketplace. Human rights
and technology are also associated with policies, practices and research in special or assistive
technology for individuals (e.g., wheelchairs or hearing aids). Interface problems for individuals
with disabilities and technology and interfaces between specialized and mainstream technology
have generated interest among researchers. The Trace Research and Development Center at the
University of Wisconsin is one of a number of centers that conduct research on interfaces(http://trace.wisc.edu/world/gen_ud.html).
A third trend involves rehabilitation research itself. To justify payment, rehabilitation
researchers across disciplines are called upon to show evidence of outcomes, efficacy, andeffectiveness of assistive technology (Fuhrer, 2001). A fourth trend involves the struggles ofsocial welfare program administrators to keep benefit programs solvent while serving growing
numbers of people with disabilities, especially older people. Countries are adopting a mix ofTransition from Medical to Integrative Model4social welfare, civil rights, and other policies to address disability issues (Van Oorscot &Hvinden, 2001; Zeitzer, 2002). Countries are struggling to contain costs of public welfare
systems, but have often failed to adopt policies that may defer, lessen or negate the need for
expensive institutionalization, such as accessible mainstream systems and products. Finally, thefifth trend is poverty—a barrier to the support of disability programs in developing countries
where the majority of people with disabilities live. Many cultures continue to use a traditionalmodel of disability. In the absence of scientific and health infrastructures, disability policy andpractices may be based almost exclusively on culture and religion (Barnes & Mercer, 2003;
Coleridge, 1993; Ingstad & Whyte, 1995).
MODELS OF DISABILITY
Four models of disability are explored in this section: the traditional model, medical
model, social model, and integrative model. The following factors are considered for eachmodel: a) knowledge base, b) roles, c) rules and relationships, d) temporal and spatial parameters,
and e) bias. Corresponding policies, practices and research are identified for each model.
The Traditional Model
The traditional model is based on culturally and religiously-determined knowledge, views,
and practices. Depending on cosmology, social organization and other factors, cultures show abroad range of perspectives which place people with disabilities on a continuum from human tononhuman. For example, some cultures practice infanticide, rejecting the humanity of disabled
infants. The roles people with disabilities may assume within a given culture range fromparticipant to pariah (Barnes & Mercer, 2003; Ingstad & Whyte, 1995). When persons withdisabilities are devalued, they may be perceived as demonic or unfortunate, and often take on theTransition from Medical to Integrative Model5role of an outcast (Coleridge, 1993). The bias of the traditional model is cultural relativity.
Objective, scientifically-based knowledge is not associated with this model.
Across cultures, people with disabilities have been valued differently. In his presidential
address before the American Association of Physical Medicine and Rehabilitation, Thomas E.
Strax, M.D. made the following observation:
From the beginning of time, humankind has wrestled with the paradox of what to do withpeople with disabilities. In ancient times, they were simply put to death. They were aburden on the tribe. In ancient Greece, there were 2 cities. Sparta removed the weak
and the elderly for the good of the rest. In Athens, the warrior class protected the weak(Strax, 2003).
The Medical Model
The medical model is based on scientific views and practice, typically in the medical andhealth knowledge base. The “problem” is located within the body of the individual with adisability. The context of the medical model is the clinic or institution. Persons with disabilities
assume the role of patient, a role that may be of either short-term or long-term duration
depending on several factors, including the individuals’ condition, policies related to
institutionalization and community supports, and professional and social attitudes about
disability. Authority lies with professionals. The bias of the model is the bio-medical perceptionof normalcy and the narrow band of legitimate knowledge, usually medical and health-related.
Explanation of disability is reduced to the impairment level. The perspective of the person witha disability and social factors are not routinely within the knowledge base of the medical model.

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Worst and Best Practices
In the West during the twentieth century, examples of worst and best medical research
practices for people with disabilities can illustrate the strengths and weaknesses of the medical
model. Worst practice examples can be drawn from most countries and regions.
•

Willowbrook Experiments, U.S.: This study was designed to follow the natural
progression of a disease—in this case viral hepatitis. Children with disabilities wereintentionally infected with the virus and then studied during the progression of thedisease. A particularly disturbing aspect of the research was that it was reviewed andapproved by the New York State Departments of Mental Hygiene, Mental Health, theArmed Forces Epidemiological Board and the New York University School of Medicine,in addition to the Willowbrook School. Although parental consent was given, the consent
was based upon the school’s declaration that there was room for new students at theschool only in the experimental unit (http://members.aol.com/bercar/caramain.htm).

•

The Holocaust and People with Disabilities: There is evidence to show that people withdisabilities were systematically exterminated and were the subjects of medical
experiments during the World War II Nazi period in Germany (Forgotten crimes: The
holocaust and people with disabilities, 2001).
Most countries and international organizations also have many examples of best practices

within the medical model. These include:•

Breakthroughs in biomedical and technological sciences and clinical applications thathave saved lives and extended the lifespan of individuals with disabilities (National
Institute on Disability and Rehabilitation Research, 1999)•

Research policy reform (http://ohrp.osophs.dhhs.gov/irb/irb_guidebook.htm)•

International Classification of Impairments, Disabilities and Handicaps (ICIDH)(International Classification of Impairments, Disabilities, and Handicaps, 1980)
After the Second World War, the international community adopted reforms and provided

guidelines for research. These policies include the Nuremberg Code of 1947, the United Nations
Universal Declaration of Human Rights of 1948, and the World Medical Association Declarationof Helsinki of 1964. Later, some countries began to adopt policies such as institutional review
boards to protect research subjects.

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The influential ICIDH, which identified the cause of disability within the individual, wasadopted by many users including policy-makers (social security benefits, employment,
occupational health), demographers, epidemiologists and statisticians (surveys), and healthplanners (utilization, resources). Even before the adoption of the ICIDH, health professionals
created policy and designed surveys and utilization practices within the medical model.
Throughout the twentieth century, countries adopted general social welfare and health policies(which usually included people with disabilities) as the first stage in a series of disability policies
which would later include general and specialized education, employment, and accessibility
policies for disabled people. Examples of social welfare and health policy include Japan’s Social
Insurance System developed beginning in 1922 and the Social Security Act adopted in the
United States in 1935 (Miyatake, 2000).
Measurement Tools
Development and use of research measurement tools, such as the Functional
Independence Measure (FIM), and concepts such as the normal curve reinforced the medical
model. These tools were designed to measure impairment at the body level with the goal of
curing the cause of the impairment—or at least minimizing performance difficulties. The testsites are usually clinics, rehabilitation centers or other controlled sites. The following is
illustrative of measurement bias:

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The distance walked is a key component of the health-related quality of life measure for
the FIM. The measure focuses on the independent function of the person without contextual
supports.
Professional Training
The knowledge base used to educate health professionals is rigorous and routinely limited
to medicine and the health sciences. Therefore, health professionals may develop a view of
disability that differs substantially from the reality of many disabled people. The following is aquotation from a medical doctor before he became disabled and afterward:<I began> to examine his nervous system…felt a sense of horror come over me. You
can’t feel anything here on your shoulder? You can’t move your legs? I next met thisman in a spinal cord unit in 1985 as I was pushed to the computer next to him in
occupational therapy. A few months earlier, I had severed my cervical spinal cord
playing rugby and I was a quadriplegic—slightly more impaired than was my former
patient. Now, 15 years after becoming disabled, I find myself completely at home withthe concept of…being me. Now I know that my assessment of the potential quality of lifeof severely disabled people was clearly flawed (Basnett, 2001).

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Disabled people may develop a view of health care that is very different from the oneheld by professionals. While professionals may view people with disabilities as patients, people
with disabilities often accept their disabilities and move away from the patient role to resume liferoles of worker, student and parent within the community.
Legacy of the Medical Model
The medical model is based on a narrow range of views and practices involving healthand welfare. Research and research tools are useful for medical purposes but not as useful forsocial purposes, such as measuring accessibility and participation. Professional education andtraining, to the extent that it has not incorporated information about quality of life andaccessibility, has resulted in a “dual perspective” situation. Therefore, there is a widening gapof understanding between professionals and patients who are at some stage of transformation andrecovery (Gabard & Martin, 2003).
The Social Model
The social model is based on knowledge of the experience, views and practices of people
with disabilities. The model locates the problem within society, rather than within the individualwith a disability. From the perspective of the social model, disability is conceived more asdiversity in function or the result of discrimination in policies, practices, research, training, andeducation. Individuals with disabilities are the authorities. They assume a range of roles—
especially the advocate role—to pursue full expression of educational and employment
opportunities and citizenship. Rules are determined within a framework of choice andindependent living with strong support from organized disability communities. The biases of thesocial model include: limiting the causes of disability either exclusively or mainly to social andTransition from Medical to Integrative Model

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environmental policies and practices, or advancing perceptions of disability in mainly
industrialized countries that emphasize individual rights rather than advancing broader economic
rights that may reflect the needs of impoverished developing countries (Albrecht, Seelman, &Bury, 2001; Barnes & Mercer, 2003).
Policies and Practices
While retaining health and welfare policies of the first stage of disability policy, countries
are in various stages of transition from the medical model to the social model. Internationalorganizations, some industrialized countries, and some developing countries have adopted
second and third stage policies and practices of special laws in education, employment, civilrights, and accessibility. The United Nations began adopting disability human rights
declarations in the 1970s in support of the principle of normalization of the lives of people withdisabilities. Most countries in the second stage of disability policy have adopted special
education and employment policies such as Japan’s School Education Law of 1947 and theIndividuals with Disabilities Education Act of 1975 in the U.S., which involved civil rights andmainstreaming of most children with disabilities {Statistical Abstracts, 2003; Education in Japan,2001}. Japan and the U.S. are among countries that have adopted special employment-relatedlaws, such as Japan’s Human Resources Development Promotion Law of 1969 and the U.S.
Rehabilitation Act of 1973 which also involved civil rights (Employment and its Promotion of
Disabled Persons in Japan: A Guide to Employment for Employers and Disabled Persons,1999). Most of these laws provided services which were controlled by professionals. In thethird stage, some countries began to move from special needs policies to a civil rights policy
such as the Americans with Disabilities Act of 1990 in the United States. Others continued witha health, welfare, special education and special employment approach and often added policies toTransition from Medical to Integrative Model

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make buildings and information more accessible {Heyer, 2000;
http://www.dinf.ne.jp/doc/japanese/law/etc/z00003.htm;
http://www.dinf.ne.jp/doc/japanese/law/etc/100002e/100002e01.htm).
Measurement Tools
The social model perspective incorporates research that examines problems of quality oflife, user satisfaction, participation, and accessibility of various domains of the environment.
The perspective also examines problems of participation of people with disabilities in the
research process, including survey research. Researchers have explored methods to interview
people with disabilities in survey research. Section 508 of the U.S. Rehabilitation Act asamended in 1998 may require federal electronic-based surveys to be accessible to people withdisabilities, not only in the collection of survey data, but also in the analysis and reporting stages{Hendershot, 2003}. New research tools have emerged to measure quality of life andsatisfaction, including the Quebec User Evaluation of Satisfaction with Assistive Technology
and the Psychosocial Impact of Assistive Devices Scale (Cook & Hussey, 2002; Scherer, 2002).
Researcher David Gray has been involved in the development of measures of the environment(grayda@msnotes.wustl.edu). The following are examples of his work:

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In this example, Gray changes the outcome measure from capacity to participation, which
focuses on the individual’s ability to function in his or her own environment. Although people
with disabilities may score low in clinical tests of capacity, they may participate in many life
activities including work, education, and family and community life.

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In this example, Gray shows the location on the normal curve of people with mobility
disabilities without good assistive technology.

In this example, Gray shows the location on the normal curve of people with disabilities
with good assistive technology.

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In the example above, Gray shows the location of people with disabilities on the normal
curve when they have assistive technology, personal assistance and receptive environments.
A number of the Rehabilitation Engineering Research Centers (RERC) of the National
Institute on Disability and Research (NIDRR) have developed assistive technologies anduniversal design products that have increased participation of people with disabilities(http://www.naric.com/search/pd/). For example, the RERC on Universal Design and the Built
Environment (http://www.ap.buffalo.edu) has developed a squat toilet and a visitable house as
the following graphics show:Transition from Medical to Integrative Model

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Research efforts have also worked toward the development of accessible communication
devices. Title IV of the Americans with Disabilities Act charged the telephone companies with
provision of interstate and intrastate telephone relay services that will provide deaf, hard-ofhearing and speech-impaired persons with telephone service functionally equivalent to service
for hearing persons. The private sector has competed for contracts to develop and mange relay
services. The CapTel System shown below is now in the testing stage.
(http://www.ultratec.com/infoCapTel.html) This system can be used by people with somedegree of hearing loss because it works like a telephone but also displays every word the caller
says during the conversation.

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Researchers have also modeled stages of change in organizations as they move towards
accessibility. The Center for Rehabilitation Sciences & Technology at the University of
Wisconsin at Milwaukee (http://www.uwm.edu/CHS/atoms/) developed a model called A3. The
A3 model conceptualizes stages in which organizations meet the needs of people with disabilities,
focusing on the physical and virtual environment, consumer products, services and systems. The
A3 Model includes three elements: advocacy, accommodation and accessibility. The advocacy
stage has the following characteristics:
•
•
•
•
•

Minimal anticipation of needs
Reactive to “complaints”
Sometimes the person with the disability advocates
Other times someone else advocates for the person with the disability
People with disabilities receive a different “product” than people without disabilities

The next stage is accommodation. Characteristics of accommodation include the following:
•
•
•
•
•

Anticipation of needs
Prepared to meet needs“Complaints” are reduced as there is a system in place
People with disabilities still receive a different “product” than people without disabilities
Likely requires additional time, money, effort, etc.

Transition from Medical to Integrative Model
The third stage is accommodation. Characteristics of accommodations are:••••Proactive
Recognition that better design can reduce the need for individual accommodation
Everybody receives the same “product”
People with disabilities do not require additional time, money, effort, etc.

The stages are conceptualized in the following illustration:

Education and Training
The social model is based on a knowledge base of experiences of individuals withdisabilities living in society. Adoption of the social model has led to demands to educate andtrain architects, designers, engineers and lawyers, as well as people with disabilities. Productdesign curricula may include the following considerations (see figures below):17

Transition from Medical to Integrative Model18

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Engineers have begun to receive clinical training. The University of Pittsburgh School of
Health and Rehabilitation Sciences provides training in the Center for Assistive Technology andthe University of Pittsburgh School of Law has launched a Disability Law curriculum.
(http://www.shrs.pitt.edu/index2.html; http://www.cat.pitt.edu/;
http://www.law.pitt.edu/about/index.html). A number of universities, including the University ofPittsburgh, have added a Disability Studies curriculum (http://www.uic.edu/orgs/sds/ ). The best
example of education and training within the social model is illustrated below:

Transition from Medical to Integrative Model20

An example of community integration within the social model is illustrated below:

The Integrative Model
The Integrative Model has a broad knowledge base ranging from medicine to literature
which is informed by the experience of people with disabilities. The Integrative Model is “underconstruction”. From the integrative perspective, individuals with disabilities have many roles,
including citizen and patient, among many others. There are a number of evolving policies andpractices that are representative of this model. Some of them are represented in the World
Health Organization International Classification of Functioning, Disability and Health, the U.S.
Institute of Medicine’s Enabling America: Assessing the Role of Rehabilitation Science andEngineering, and the NIDRR Long-Range Plan (Brandt & Pope, 1997; National Institute on
Disability and Rehabilitation Research, 1999; World Health Organization, 2001).

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Policies and Practices
While retaining general health, welfare, special education, and employment policies andpractices of the first and second stages, countries are in various stages of transition to a civilrights approach and related universality of design applications in systems and markets.
International organizations, such as the World Health Organization, have developed a more
universal approach to disability. The following interpretation of the ICF illustrates its
universality and integrative characteristics (Schneider, 2001):
Universal Model
Integrative Model
Interactive Model
ParityInclusive
Cultural applicability
OperationalLife span coverage
Human Functioning- not a minority model- not merely medical or social- not linear progressive- not etiological causality- contextual, environment & person- not western concepts alone- not theory driven alone- not adult driven (children-elderly)- not merely disability

The components of the ICF encourage a broad and integrative classification. The threecomponents of the ICF are body components, activities and participation, and environment. ICF
researchers will be challenged to identify the relationships among the components.
The Disability Movement is pressing a number of international organizations forconventions and statements of principle committed to full integration of people with disabilities
in society. The UN is being pressed to adopt a convention on the rights of people withdisabilities (http://www.dpi.org/en/resources/topics/topics-convention.htm). The World Summit
on the Information Society is being pressed to adopt a section on disability within the draft
Declaration of Principles (http://www.dpi.org/en/resources/topics/topics-convention.htm). Manyof these initiatives have precedent in U.S. law. The Americans with Disabilities of 1990 (ADA)
recognizes the full civil rights of people with disabilities (http://usdog.gov/crt/ada/adahom1.htm).

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The ADA also provides assistive technology and accessibility of communications with importantroles in the realization of rights and opportunities. The United States has regulated thecommunications industry to assure access. The original Communications Act of 1934 recognized
universal access for all people in the United States. In 1996, the new Telecommunications Act
was amended to include rules requiring telecommunications manufacturers and service providers
to make their products and services accessible to people with disabilities, if readily achievable(http://www.access-board.gov/telecomm/html/telfinal.htm). The United States has also createdmarket incentives to motivate industry to make its systems and products accessible(http://www.section508.gov/). As Section 508 of the Rehabilitation Act requires, the UnitedStates government constitutes a large market for accessible technology and employs the federal
procurement system to purchase it (http://www.ittatc.org/laws/255.cfm). Section 508 requires
access to electronic and information technology provided by the Federal government. The law
applies to all federal agencies when they develop, procure, maintain or use electronic andinformation technology. Federal agencies must ensure that technology is accessible toemployees and members of the public with disabilities to the extent it does not impose an “undue
burden”. Section 508 speaks to various means for disseminating information, including
computers, software and electronic office equipment. It applies to, but is not solely focused onfederal pages on the Internet or the World Wide Web. It does not yet apply to web pages ofprivate industry.

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Applications of technology within the integrative model appear below. The first example
is a mammogram at Magee Women’s Hospital in Pittsburgh made accessible for patients withdisabilities:

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Other examples show President Clinton viewing an accessible voting kiosk and the CEOof Microsoft viewing accessible equipment:

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Measurement Tools and Principles
Disability is not inherent in measurement tools designed with the integrative model inmind. Psychological, social and environmental factors must be incorporated into assessmentsthat are based on an integrative model. Assessment measures that are consistent with the
integrative model assume a real world context of school, family, employment. Health service
performance measures should be based on consumer outcomes. Some measures of disability
may be disability specific in which case they may change the perception of the capability of theindividual. David Gray illustrates this point below (grayda@msnotes.wustl.edu):

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Researchers at the RERC at the University of Buffalo (http://www.ap.buffalo.edu) havedeveloped a prototype database on anthropometry of wheelchair users.

Researchers at the Department of Rehabilitation Sciences and Technology, School of
Health and Rehabilitation Sciences have developed a Virtual Reality Tele-Rehabilitation System
for Analyzing the Accessibility of the Physical Environment.

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The slide below shows the need for research in outcomes for assistive technology.

Education and Training
The ICF has become a useful framework on which to base coursework for individuals
across a wide number of fields, including the health professions, social work, psychology, andDisability Studies. Over thirty ICF-related courses have been identified in universities in the
United States and Canada (icf_clearinghouse@listserv.cdc.gov). For example, the University ofPittsburgh Department of Occupational Therapy has adopted the ICF as the foundation for
curriculum design.

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CONCLUSIONS, OPPORTUNITIES AND CHALLENGES
In the international area, the following policy, research and practice opportunities andchallenges exist:•

Monitor UN Implementation of the Standard Rules and enact a UN Disability Human
Rights Convention•

Incorporate a statement on accessibility for people with disabilities into the World
Summit on the Information Society draft principles•

Support developing countries in provision of programs and participation for people withdisabilities•

Develop the ICF measures for social and environmental factors so that assessment
measures assume a real world context of school, family, employment•

Base health service performance on consumer outcomes•

Generate global marketplace incentives and standards to support universal design,
usability and accessibility in product design and sale•

Add disability to surveys of health, income, employment and education
In addition to the above the domestic area provides the following opportunities andchallenges:•

Commit public and private research and development funding to technological inclusionof people with disabilities•

Promote technological inclusion by linking technology policy to civil rights•

Monitor research policies to protect people with disabilities in research conducted abroadwith domestic research funding•

Create a government marketplace for usable and accessible systems and products•

In the practice area, the following opportunities and challenges exist:•

Promote science, technology and education and training opportunities for people withdisabilities•

Integrate the perspective of people with disabilities and social and environmental factors
into curriculaTransition from Medical to Integrative Model•

Broaden the range of disciplines that address disability to include engineers, designers,
lawyers•

Adopt the ICF as a framework to develop health-related professional education

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In research, the following opportunities and challenges exist:•

Develop measures of social factors and environmental domains•

Develop accessible survey research process and questions about social behavior andenvironmental accessibility•

Develop evidence-based practice•Develop assistive technology outcome measures

Opportunities for collaboration exist:•

Develop strategies based on the Tokushima Agreement between Japan, the United States,
Australia and Europe

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