~Reprise~
First Published
November 1, 1988
Straight Talk:
What's With Rehab?
Howard Hobbs, PhD, President
Valley Press Media Network

  ( This essay contains 5,732 words)  

    FRESNO STATE -- The rationale for the provision of vocational rehab services by our society is a combination of humanitarian concerns and economic benefits. The relative emphasis on humanitarian concerns and economic benefits has changed over time, differs according to the observer, and it varies across rehabilitation professionals and the agencies for which they work, it appears.
     Humanitarian concerns have provided an important rationale for the provision of vocational rehabilitation. Whether expressed in terms of "human dignity," the "value of every human being," the "right for self-expression and fulfillment," or "equality of opportunity," vocational rehabilitation has been based on an underlying concern for the person as an individual. The economic benefits of vocational rehabilitation have been readily recognized for some time.
     From the "saving of trained manpower that otherwise would be lost" to making people less dependent on the welfare state, to the economic returns to society in the enabling of individuals become or remain employed, the benefits to society of vocational rehabilitation have been stressed. These benefits have been used often by proponents of vocational rehabilitation to back up humanitarian concerns when appealing for public support and more funds. Some observers feel the economic benefits have been the most persuasive justification for vocational rehabilitation.
     The emphasis on economic benefits may be in conflict with humanitarian concerns and arguments and lead to practices which may undermine those concerns, however. The emphasis on economic returns may lead to fewer services provided more quickly to those most easily placed in work situations. A production line practice of rehabilitation may have grown out of the long history of small underpaid staff, trying, with limited financial resources, to help large numbers of people cope with complicated rehabilitation problems.
     Closed cases of successful rehabilitation may be a strongly emphasized goal to the extent that economic returns are stressed. And such a stress may strain rehabilitation counselors to believe they should be helping people but often find organizational policies sometimes seem to emphasize production at the possible expense of people. It appears that within rehabilitation agencies, this issue is often expressed as the possible conflict between "quality" and "'quantity. "
     It can be pointed out that humanitarian and economic concerns may not be directly opposed to each other. On the general level, at which it is assumed that work is essential to human dignity, emphasis on both concerns can be made compatible.
     Benefit-cost ratios vary from study to study based on the assumptions made, calculations of the ratio, and the area in which the study was conducted. Benefit-cost ratios higher than 40 to 1 have been calculated, however. The federal government estimates that for fiscal year 1980 the benefit-cost ratio for rehabilitation services is approximately 10 to 1.
     That is, estimated improved lifetime earnings are ten times the total cost of all closures for the successful or not during 1980. And in the last ten years that ratio has ranged from nearly 14 to 1 down to 10 to 1. However, government audits state vocational rehab agencies have reported that credit for rehabilitation is sometimes liberally taken when it is not necessarily deserved.
     It could be noted that the basic paradigm or rehabilitation has increasingly been questioned, particularly by those within the independent living movement. Those within the movement do not believe that the difficulties faced by those with disabilities are due primarily to their limitations. Instead, the difficulties they feel are due to asocial environment of which rehabilitation is a part that often limits or even oppresses individuals with disabilities. Consequently, those within the movement disagree with the rehabilitation paradigm about what should be done and how it should be done.
     The state vocational rehabilitation department has been one of the most successful rehabilitation agencies in the country in recent years. It ranked near the top in the number of clients served and rehabilitated per counselor and the number of severely disabled individuals rehabilitated per disabled population.
     The agency's operations were cost efficient and effective. Approximately 95 percent of the rehabilitation dollars were spent for services to individuals. Those rehabilitation dollars paid big dividends in the form of increased earnings of the rehabilitated clients. Before rehabilitation, most of the clients were unemployed, and the majority were dependent on family or friends for a living, and a significant percentage were in tax-supported institutions.
     After rehabilitation in a recent fiscal year, the rehabilitated clients were earning more than seven times as much at an annual rate as they had before rehabilitation.
     These figures vary from year to year. They are a rough indication of the cost-effectiveness of rehabilitation. They are not as precise as the benefit-cost ratios discussed above. The figure cited here does not take into account funds spent on clients who were not rehabilitated apparently. And these figures apparently do not take into account the changes in employment during an individual's employment history. Also, apparently, the figures do not reflect the extra taxes the rehabilitated clients are paying or the decrease in public support payments in institutional care involved.
     The public vocational rehabilitation program began with the vocational Rehabilitation Act of 1920, though federal, state, and private services had been provided before that time.
     The original act was quite modest in scope and in its initial implementation. In anticipation of the federal act, a few states had previously passed enabling legislation in order to take advantage of the federal funds that were to be available on a 50/50 matching basis. Many other states quickly passed such legislation so that within 18 months, 34 states had begun to develop vocational rehabilitation programs.
     The early thrust of state vocational rehabilitation agencies was to serve indigent people with orthopedic difficulties. Some services, such as counseling and guidance, were available to the non poor and limited services were available to those who were physically handicapped, but not orthopedically so. In 1920 federal appropriation to the states was approximately $500,000, and 523 clients were rehabilitated.
     Client eligibility was later expanded to include those who were mentally retarded or mentally ill, those with epilepsy, those socially handicapped as determined by a psychiatrist or psychologist, such as an adult public offender, and those who needed services to maintain their jobs. An emphasis on serving those with severe disabilities was mandated in the Rehabilitation Act of 1973 and 1978, services were extended to those who did not have the potential for employment, but could benefit from services to live independently.
     Services themselves were broadened to include among other things, physical restoration, maintenance expenses, and personal and social adjustment. Special grants were provided for the construction and operation of sheltered workshops, vocational evaluation and work-adjustment centers, and other rehabilitation facilities. During fiscal year 1981 the federal government appropriated more than $800 million to the states on an 80-20, federal/state, matching basis.
     During the fiscal year of 1981 more than one million clients were served and 255,881 were rehabilitated. These figures are down from the historical high of 361,138 clients rehabilitated during the fiscal year 1974. The decline continued during the 1982-1983 fiscal years. Approximately 10,000 rehabilitation counselor served those clients in state agencies, a tremendous growth in personnel from the 143 rehabilitation workers who started in 1930. These statistics reveal a tremendous growth in the 1970s.
     The growth of rehabilitation services provided to consumers in the 1970s is probably a result of a consumer movement sweeping the country at that time. Predating this noticeable growth in rehabilitation services American society has been dramatically changed by the Civil Rights movement of the 1960s, and the 1964 Civil Rights Act with emphasis on equality for racial minorities.
     That movement highlighted the need for disabled persons to assert themselves in demanding their civil rights and demonstrated effective nonviolent means by which they could do so. Disabled persons organized themselves into effective consumer groups and began fighting for their rights. In a short time disabled persons began thinking of themselves as an oppressed minority group.
     They were seen lobbying for disability rights and asking for legislation to fight discrimination against them in the market place and they began to effectively use protest movements of a nonviolent nature to demand implementation of such legislation and they got it. Portions of the Rehabilitation Act of 1973 were patterned directly after the Civil Rights Act of 1964 and is now often referred to as the Civil Rights Act for Disabled Persons.
     This consumer movement gave rise to many succeeding changes in the way rehabilitation services were to be delivered. One of these changes is the recognition by the American Medical Association of a large number of specialties in rehabilitation including counseling, nursing, administration, job placement, independent living,' behavior modification, and so forth. This proliferation of professionals and specialists has been accompanied by a growth in the power and pervasiveness of their influence in society as gatekeepers. It should be pointed out that the growth of private-for-profit rehabilitation services has appeared with the consumer movement.
     In 1972 the National Commission on State Workmen's Compensation Law identified five objectives of a model program to compensate workers who sustained job related injuries. One of their recommendations was that the provision of rehabilitation services to every worker who could benefit from such services. In response individual states adopted a variety of statutes to meet the rehabilitation needs of the injured worker.
     Subsequently private-for-profit companies began to emerge to provide rehabilitation services on a large scale. The increase in private rehabilitation can be attributed, in part, to the expansion of workers compensation benefits to include rehabilitation services but many people also expressed the concept and idea that the proliferation of private agencies has been a direct result of the consumer movement and of weakness in the public rehabilitation system. The rehabilitation process in the private sector contains many elements that are also found in public sector rehabilitation.
     However, and partly because of consumer movement, some special skills are more highly emphasized in private rehab. Differences in goals, appropriateness of training to reach rehab objectives, eligibility, nature of case loads, and all of these areas appear to be a result of consumer demand in the private sector. Some of the additional elements of the private rehab process demanded by consumers as a result of the movement coming out of the `70s are (a) the assessment of transferable skills, determination of residual employability, the loss of earning power; (b) the writing of rehabilitation plans of part of settlements; (c) the development of small business proposals; (d) employer assistance programs; (e) disability prevention; (f) affirmative action plans.
     And, of course, as a result of the rehabilitation benefits being provided under the workers' comp plan third party involvement has created a consumer demand for private agencies to work with insurance carriers in private sector rehabilitation. This arrangement makes it possible for the rehabilitation counselor to consider the needs and wishes of consumers involved in the rehabilitation process, attorneys, insurance representatives, workers' compensation board members, and rehab bureau board members rather than focus exclusively on the needs of the client which is an unusual twist to the consumer movement outcome.
     It should be mentioned that the Civil Rights Act of 1964 and related social trends account for more emphasis on accountability in social service programs including the rehabilitation services, for example, significantly reduce segregation and increased affirmative action required each federal agency to direct its attention to the alleviation of problems associated with various consumer groups including the disabled.
     This followed on the heels of the Naderism movement of the '60s the mainstreaming of the mentally ill under legislation 94142 and the independent living vocational rehab movement of the '60s and '70s. For example, in the Civil Rights Act for the Disabled Section 501 deals with affirmative action in federal hiring, Section 502 accessibility into federal and state buildings which were formerly: subject to architectural barriers preventing the disabled entry, and Section 503 affirmative action by federal contract recipients, and Section 504 equal opportunity requiring reasonable accommodation to the handicapped for employment purposes.
     The Commission of Accreditation of Rehab Facilities (CARE) and the Commission on Rehab Counseling Certification (CORE), the IEP of the 94142 legislation and the IWRP required for all rehab plans are all an outgrowth of the consumer movement and resulting legislation of the '60s and '70s.
     In present thinking a disability is a condition thought to be an impairment that has an objective element. It is a medically diagnosed condition. It is intrinsic.
     Present thinking about handicaps is that they are accumulative in their effect of obstacles which disability imposes between the person and the person's maximum functional level. A finding of disadvantaged as to some vital life objective is crucial in obtaining entitlements. This is an extrinsic factor.
     A disability, too, may be thought of as a permanent residual limitation or impairment that may or may not interfere with optimal life adjustment And a handicap, it is sometimes argued, can only be meaningfully appraised in terms of a given cultural or an environmental.
     The condition may be a handicapping disability depending on how the person's perception of the condition and how society deals with the condition interact, in consideration of the person's coping ability. Coping ability would include not only she lacked the internal ability to deal with the stress and problems associated with apparent discrimination against people with disabilities, but also with the ability to use, utilize, and employ assistance and modifications of the environment.
     Rehabilitation counselors in the 1980s have moved beyond harsh or judgmental blame placing on clients. Clients are encouraged to transcend any such tendencies too. Counselors, however, may sometimes place blame in subtle ways, without being fully aware of having done so. And among rehabilitation clients, self-blame for disablement is a common problem. Often, it is unexpressed. When it is voiced it seldom is resolved by simple reassurance. The rehabilitation counselor has the opportunity of bringing this issue into the open in a relatively non-threatening way.
     With respect to responsibility for solutions, rehabilitation counselors have long been aware of the demands on disabled people to change approaches when they move from medical to vocational rehabilitation. A medical model is thrust upon a client while they are patients and they are expected to adopt a compensatory or moral model when they become clients. A part of the cognitive restructuring task of a rehabilitation specialist is the explanation of this changed role and its related expectancies.
     It is important for rehabilitation counselors to be aware of such important issues in order to facilitate client progress in the vocational rehabilitation process. One of rehabilitation's central goals is to empower disabled people to take charge of their own lives to the greatest extent possible.
     The implications, then, of their conclusion that certain attributions of personal responsibility may foster helplessness rather than improved competency are enormous. Most rehabilitation service providers sense now and then that their helping efforts are backfiring and that their attempts to empower are resulting in dependency.
     Therefore, characteristics of good rehabilitation counseling include the professional counselor's confrontation with the issue and irony of human social interaction that help can reduce both the actual and perceived capabilities or recipients and thereby render them helpless. It becomes quite important for the rehab counselor to assist the client in reducing anxiety by helping the client face and realistically accept the problems that seem insurmountable.
     It is likewise important for the rehab counselor to work with the client to help achieve emotional and intellectual acceptance of of limitations imposed by the disability. And help clients to understand or change feelings about themselves and others. And to help clients deal with interpersonal relationships so as to better understand their nature and quality and impact upon vocational planning. All of these functions, of course, are limited by the definition of the counseling relationship involved. Rehabilitation counseling covers a wide array of services to many different types of clients and communities. Not all of these communities are work oriented.
     It should be pointed out, too, that counseling between the rehab counselor and the client is not directed at personality reconstruction but is conceptually directed toward preparation for job placement regardless of the community or client type.
     An effective counseling relationship will involve the client in the planning implementation and delivery system as an equal partner. One model for use of this technique is the problem solving activity focus.
     Certainly the number of clients served by the counselor truly affects the amount of time planning and quality of service delivered. It is advantageous for the rehabilitation counselor to have a reasonably small caseload in order to provide the highest quality individualized attention for the client.
     For some rehabilitation clients who are suffering from the effects of severe disability, the rehabilitation counselor represents probably a significant person in the relationship process. In that relationship the counselor's responsibility is seen as one who secures and organizes relevant information about the client and involves the client in the rehabilitation planning process throughout.
     With that client's involvement the counselor then develops a plan that integrates both the rehabilitative agency's services and the service from other agencies and/or community-based private professionals as needed. Rehabilitation counseling is a difficult task in and of itself but it is seen as insufficient if it is limited to simply the development of a plan. Rehab counselors must also see to it that the plan created for their clients and with the assistance and cooperation of their clients are carried out and that clients are satisfied with services rendered even if such require the counselor to act as an advocate in affirmative action matters for the client.
     So, vocational rehabilitation counseling appears to be a continuous type of learning process involving the interaction in a nonauthoritarian fashion between two individuals counselor and the counselee are not only concerned with the solution of the immediate problem, but also with planning new techniques for meeting future problems.
     While the counselee has need for anxiety reduction concerning his vocational problem or set of problems, psychopathology is as set forth above, not involved and the counselee is capable of learning new attitudes and appraising vocational realities with reference to his unique assets and liabilities without first requiring as measure of personality restructuring. Although. psychotherapy may result, vocational planning, not psychotherapy is a primary orientation of` the counseling process. The counselor serves this process as the reinforcing agency, or facilitator of the counselee's activities -is a resource person and an expert on techniques for discovering additional data relevant to the vocational planning task.
     A good counseling is learning oriented, purposeful, a process carried on by means of one to one conversation, in which a competent rehabilitation counselor seeks to assist the client to learn more about himself and to accept himself and to learn how to put such understanding into effect in relation to more clearly perceived realistically defined goals so that the client ray then react in terms of present realities and demands and be a happier and more productive member of his society.
     The first portion of the evaluation of a client involves the medical review. An accurate medical report of the client's physical and mental impairment gives the counselor a guide in establishing eligibility, determining the needs of the client, and working out a suitable plan or tentative plan for placement. A medical appraisal is obtained for every client served.
     A psychological evaluation is also obtained for each client. Psychological evaluations are required by most physicians and are recommended in most cases. The extensiveness of this evaluation is individually determined. By using standardized procedures such as aptitude and achievement tests and interest or personality inventories the counselor can obtain information that will be helpful in planning with his client.
     The client's sociocultural background and environment and his present situation are also subject of the evaluation. This data should be viewed in considerable detail because of the client's past adjustment at school, home, and in the community and these can provide many indicators of the type of adjustment he will make in the future.
     Vocational history and work history is a most important part of the evaluation as well. The counselor should have complete data on past job performance, length of each job, why the client left his job, and what he learned to do, the extent of job training, etc. Review of these factors can supply information relative to the client's vocational interests, skills, transferable skills, work habits, and occupational maturity.
     The counselor can expect to be able to use medical records for a better understanding of the following issues: (a) findings diagnoses and recommendations contained in medical reports; (b) how the client interprets his condition and what he has given on his self-report; (c) how physical restoration may improve the client's employability; (d) the residuals of a disabling condition, limiting effects, physical stability of the client, and the progress of the client under treatment. In the initial interview the counselor should secure from the client all printed information about his disability including information concerning its onset, symptoms, its remission, its exacerbating the treatment he had for it, and other significant past illnesses.
     Generally the counselor then has two uses for medical information; first to determine eligibility, and second, to help the client make a realistic vocational plan for his best use of his residual capacity. The psychological evaluation of a client forms an integral part of the client-counselor relationship and panning process.
     Socially, physically, and economically, clients have encountered frustrating circumstances that have led to conflicts. These frustrations and conflicts may have resulted either from their disability, from their attitude toward their disability, or from social pressures.
     The psychological effects of a physical disability may be classified as (a) psychological effects arising directly from the disability; (b) psychological effects arising from the client's attitude toward his disability, (c) psychological effects arising from the attitudes and behaviors of others toward the disabled person.
     In a client's adjustment to disability the physically disabled either compensate for their limitations, succumb to the social expectations, or idolize normal standards and utilize something called an "as if" behavior. In addition to using psychological tests, there are mangy other things that the counselor can do to gather information for the total psychological evaluation of each client which include: (a) review of educational experiences; (b) assessment end personality dimensions in addition to the paper /pencil and projective personality tests.
    The physical and sociocultural environment should also be inevitably explored by the counselor. The crucial importance of the environmental factors in shaping personality development has well been summarized by sociological researchers. The full understanding of a client's disability requires complete and careful selected information concerning the extent of the client's disability and the nature of his response to this and other life experiences. A social history is usually necessary for diagnosis of the total problem and is the background against which the probable solution to the disabled person's problem is formulated.
     The social evaluation should be as thorough as possible. It reflects the life and the individual characteristics of the client and should contain the following types of information: (a) identifying data; (b) referral source; (c) present illness; (d) previous medical histories; (e) personal and family history; (f) early life and cultural climate of home; (g) education; (h) work history; (i) present family relationships and economic situation; (j) personality and habits. To this end, psychometric assessment of each individual's past performance is still the best measure of future work behavior. The goal of all rehab services is to change things, whether in the person with the disability or in the environment, such that the person can return to or enter the field of work to the highest degree possible for independent living.
     The importance of a thorough vocational evaluation in working with clients cannot be over estimated. In this final phase medical, social and psychological information are united with specific vocational data in an attempt to arrive at the ultimate goal of the rehabilitation process -- successful vocational outcomes and placements.
     The psychological effects of a physical disability may be classified as (a) psychological effects arising directly from the disability; (b) psychological effects arising from the client's attitude toward his disability, (c) psychological effects arising from the attitudes and behaviors or others toward the disabled person.
     In a client's adjustment to disability the physically disabled either compensate for their limitations, succumb to the social expectations, or idolize normal standards and utilize something called an "as if" behavior.
     In addition to using psychological tests, there are may; other things that the counselor can do to gather information the total psychological evaluation of each client which include: (a) review of educational experiences; (b) assessment and personality dimensions in addition to the paper/pencil and projective personality tests.
     The physical and sociocultural environment should also be inevitably explored by the counselor. The crucial importance of the environmental factors in shaping personality development has well been summarized by sociological researchers. The full understanding of a client's disability requires complete and careful selected information concerning the extent of the client's disability and the nature of his response to this and other life experiences.
     A social history is usually necessary nor a diagnosis of the total problem and the background against which the probable solution to the disabled person's problem is formulated. The social evaluation should be as thorough as possible. It reflects the life and the individual characteristics of the client and should contain the following hypes of information: (a) identifying data; (b) referral source; (c) present illness; (d) previous medical histories; (e) personal and family history; (f) early life and cultural climate of home; (g) education; (h) work history; (i) present family relationships and economic situation; (j) personality and habits.
     The importance of a thorough vocational evaluation in working with clients cannot be overemphasized. In this final phase medical, social, and psychological information are united with specific vocational data in an attempt to arrive at the ultimate goal of the rehabilitation process--successful vocational outcomes and placements.
     To this end psychometric assessment of vocational traits has been found helpful. It is thought that past performance is still the best measure of future behavior in work settings.
     The goal of all rehab services is to change things, whether in the person with the disability or in the environment, such that these persons, can return to or enter the field of work or at least have the opportunity to participate in the highest possible degree of independent living.
     Vocational evaluation, then, purports to help achieve this goal through extensive assessment of each individual's work potential through observation of behavior determination of potential for training and restoration or placement and through helping to change behavior in order to upgrade employability and change self-esteem perceptions.
     Vocational placement functions would include (a) job analysis; (b) occupational information; (c) job development; (d) selective placement; (e) job engineering if necessary, and so forth.
     Most vocational counselors have preplacement exploration and placement understanding and placement action as necessary steps in development of placement programs. With placement understanding being crucial to the success of the plan two sequential elements must be considered: (1) work choice, and (2) job identification.
     Vocational rehabilitation services can be divided info at least three different forms: (a) private nonprofit; (b) pubic; and (c) private for profit.
     The most significant difference between the public and private for profit sectors lies in the type of clients each group currently serve. These distinctions in clients are derived from the unique objectives of each sector.
     Private for profit organizations were developed to serve companies that were liable for the rehabilitation of industrial injured workers without regard to the degree of severity of that disability. And in actual practice, many of the most severely disabled workers were not feasible for long-term vocational rehab and were offered cash settlements as compensation.
     Private for profit organizations typically serve individuals who have had a history of employment. Most companies wish to reemploy the disabled workers to avoid high compensation costs as well as to demonstrate corporate concern for their work force.
     So private for profit organizations had both a client with a work history and a likely preestablished vocational placement strategy. Contrasted with this is the public mandate of the state vocational rehab organizations to serve all eligible handicapped citizens, a mandate which broadens the range to include, for example, the developmentally disabled persons who usually have had neither employment histories nor established vocational solutions.
     So public agencies are also under a mandate to serve severely disabled individuals as a priority, so that their problem solution activity may be long range and more expensive.
     A second difference is in philosophy. It appears that the private for profits have had a return to work objective as a priority for some time. And state vocational rehab agencies deal with a large percentage of clients who have never worked, consequently this service philosophy and program must differ.
     So the development of a recommendation for a selection of a rehabilitation facility for a counselor should keep these comparisons in mind. Also, California has mandated since1976 that rehabilitation provisions within its workers compensation law be provided for private agencies.
     The State of California maintains a compensation unit but serves only about 5 percent of the state's compensation case load. So, depending where you are located recommendation on a placement in a particular rehab facility could be influenced by such factors.
     For example, in Ohio they have established Industrial Commission which handles both the compensation and rehabilitation services under the control and direction of the state. Getting back to the idea of client placement.
     One of the more critical rehabilitation services is client placement. Private agencies have taken a leadership role in establishing effective placement programs, particularly since their general philosophy is that a return to former employment is the strategy of choice.
     This has meant a history of service to business and industry that could be utilized by public agencies if a collaborative arrangement were to be established. However, the public agencies often have developed considerable placement contacts and may have established industrial accounts or production relationship with United States Employment Service.
     These openings can be made available in collaboration with private agencies for access by their clients seeking employment. Workers compensation and private insurance claim benefits are probably more readily suited to a private for profit or private nonprofit agency.
     Certainly, regardless of the selection criterion for the agency involved qualification of the vocational counselor should be the highest priority. Certification as a rehabilitation counselor and possession of a master's degree in rehabilitation counseling or one of she behavioral sciences along with several years of experience should be considered as minimal qualifications for working as an expert in rehabilitation counseling.
     The agency itself should be certified by national accrediting agencies for the rehabilitation purpose intended. The number of cases assigned per counselor in a particular agency should also lie considered where quality of service is a high priority of the consumer.
    The Fresno Rehabilitation Counseling Master's Degree Program was ranked among the top 20 with, No.1. going to Michigan State University. According to Dr. Charles Arokiasamy, coordinator of the Rehabilitation Counseling and Evaluation Center in the School of Education and Human Development, reports that George Searles, the center's director, and a staff eight counselors and technicians staff the Center in the Atrium of the Education Building. Arokiasamy's team assists individual students by helping them identify job suitability using non-verbal language techniques. The center conducts work-simulation tests that require the clients to perform clerical tasks like sorting and filing. From the tests which check for skills such as manual dexterity, the Center develops a vocational plan that is compatible with a client's mental and physical and capacities for work.