Depression and Physical Rehabilitation

Depression is often expected in our society during physical rehabilitation. This and similar expectations structure the experience of a physical disability. Contradictions in expectations and demands by providers to conform to this paradigm create barriers in the rehabilitation process. Changes in the physical rehabilitation paradigm are briefly suggested. DEPRESSION AND PHYSICAL REHABILITATION In our society depression is expected to follow after a traumatic permanent physical disability (Kerr-Cohn, 1961; Fink, 1967), and it is felt to be a result of concrete losses of body functions and skills. This state often initiates changes in one's self-image, social position, and interpersonal relationships (Barker, et al., 1953; Wright, 1961; Goffman, 1963). It is suggested here that depression is a response which emerges not only from the individual and his perception of the situation, but also as a function of the physical rehabilitation process itself. The source of the depression is a result of the contradictory assumptions and goals inherent in rehabilitation, and as a result depression is expected and maintained by this approach. This type of depression can be traced directly to a social construction of reality (Berger and Luckmann, 1966) that is rarely articulated because of its fusion with the more concrete and localized depression following loss. Examining this system of logic, the therapeutic model, will hopefully open up this subject for discussion in order to minimize the man-made suffering which is presently considered inevitable. THE GOALS OF PHYSICAL REHABILITATION The system of logic underlying the present approach to physical rehabilitation can be stated as follows: The disabled person is invested with a status and dignity which is inherent in all human beings. He, unfortunately, has suffered a loss as a result of a physical limitation which may affect other social and psychological areas of his life. He will usually be depressed soon after incurring this loss but he will hopefully learn to accept and/or cope with this after an appropriate period of mourning. These losses should be minimized so that he can continue in his life as "normal" as possible. A major goal is to participate in the labor market and economy and earn his daily living rather than be supported by others. This is a method for him to be independent, self-sufficient, and worthy of respect. If the reader doubts the validity of this model, a series of quotes by leaders in the field of physical rehabilitation should support the above contentions: A facet of vigorous individualism in American culture tends to support activities such as health services which enhance the worth and dignity of the person, especially if these lead to increased social and economic effectiveness. (Rabbinowitz and Mitsos, 1966:2) (A psychologist states:) "Most people are motivated for health. The handicapped want to be well and normal, considered the same as others; most have a capacity for self-sufficiency when allowed to act for themselves." (Quoted by Alexander, 1970). (An orthopedic surgeon states:) ...that normal people must let handicapped people do what they can for themselves. "They will then feel part of the world .... It helps the handicapped to feel respect for themselves, to have dignity." (Alexander, 1970.) (Vice-president and medical director of a rehabilitation hospital) "The hospital's goal is to return every patient to his family, his community, and, most important, his job." (Quoted by Mateja, 1974) The contradictory and illogical arguments of this approach become apparent when each assumption about disability and rehabilitation is examined in a total context. A person is inherently worthy of respect yet he must "earn'' it through achievement and activity (which he may physically be unable to do). He does not want help from others in order to be independent, yet he must learn to "accept" his dependence. He has undergone a significant personal loss, therefore, he should be depressed. But he should be depressed "correctly": he should not be over-depressed nor underdepressed. Over-depression occurs when the depression takes a course which interferes with institutional demands and expectations. Underdepression occurs when the person is "denying" reality and/or too readily accepts the disabled status. An example of "under-depression" is given by Israel Goldiamond, a professor at the University of Chicago who specializes in behavior modification and Is also a paraplegic. Since he believes that behavior is affected by contingencies and not by emotions, he "refused" to be depressed. When he began suffering from insomnia, the staff told him that, of course, his depression was finding a way to exhibit itself. Due to his habit of keeping records on his medication, he discovered that he had taken himself off tranquilizers and was suffering from withdrawal effects, a fact which had been overlooked in the eagerness of the staff to reinforce their expectations of his disability. (Goldiamond, 1976.) Physical therapy Is a painful, grueling process that is based on the strengthening and maximal use of a person's muscles and physical skills. To endure this training for an often very small change in one's physical functioning is discouraging. The right to decide if one wants to do that much work for that all a reward is often denied the disabled person. Rather he is bulted, told that he must do this for his own good, and told to be motivated for something that may be largely lost. Defeats for physical therapists can be daily comforts for the disabled. An example of the right to decide certain treatments and aides is presented by Ed Roberts, a spokesperson for Berkeley's Center for Independent Living. "Health professionals go through these Incredible fads... For example, they were convinced that using an iron lung was a terrible thing and should be stopped as soon as possible, almost at any cost. Well, I say that's up to me to decide. If not using the tank means I'm going to have something less comfortable and less ventilating, If it means I've got to spend more time concentrating on just breathing, then I'll use the tank." (Quoted by Downey, 1975:25) The individual in a rehabilitation setting, then, is told that he is not physically "normal" and that he should learn to accept his losses and try to re-enter "normal" life. One nurse who is a paraplegic responded to this definition of the situation in this way: