Disability Orientation of Occupational Therapy Practitioners in Physical Rehabilitation Settings: Tension Between Medical and Social Models in Theory and Practice

Abstract

Importance: To date, little is known about the extent to which occupational therapy practitioners have adopted the core insights of disability studies.

Objective: To examine the degree to which occupational therapy practitioners endorse the medical model of disability versus the social model of disability in theory and in practice.

Design: Cross-sectional study.

Setting: Physical rehabilitation facilities, ranging from hospital to community settings.

Participants: One hundred two Israeli occupational therapy practitioners.

Outcomes and Measures: The Orientation toward Disability Scale, constructed for this study, has two dimensions that distinguish between the medical and social models of disability: locus of intervention (the person or environment) and client involvement (extent to which the practitioner fosters the client’s autonomy in the rehabilitation process). Each dimension addresses both theoretical and practical endorsements.

Results: Greater support for the social model of disability was mostly evident in the client involvement dimension, whereas support for the medical model of disability was mostly evident in the locus of intervention dimension. Over both dimensions, the medical model of disability was significantly more endorsed in practice than in theory. Work setting and prior exposure to the social model of disability were found to affect practitioners’ disability orientation.

Conclusions and Relevance: Occupational therapy practitioners working in physical rehabilitation are still relatively far from fully adopting the critical insights of the social model of disability. This finding is especially relevant when their actual practice, rather than their theoretical views, is considered and when rehabilitation takes place in out-of-home settings.

What This Article Adds: This study offers unique insight into the disability orientation of occupational therapy practitioners, showing a need for more training programs to expose students to the social model of disability. These programs should use critical discussions of the challenges that this model presents to the profession and barriers to implementing it in practice.

This study offers unique insight into the disability orientation of occupational therapy practitioners, showing a need for more training programs to expose students to the social model of disability.

In recent decades, activists, scholars, and professionals have raised concerns regarding the dominance of the medical model of disability in rehabilitation professions, including occupational therapy. Although not ignoring its health-related benefits and the client’s needs for rehabilitation, they have referred to the medical model of disability’s limitations and unintended negative consequences, including its tendency to pathologize disability and constitute it as a deficient and tragic condition (e.g., Shakespeare, 2013). Informed by disability studies (DS), their critique views disability as a sociopolitical phenomenon. In particular, the social model of disability, one of the leading DS frameworks relevant to occupational therapy theory and practice, has two central principles: (1) the origin of disability lies primarily in the social structures and attitudes, and (2) people with disabilities have the right to meaningful control over their own lives, including their rehabilitation (e.g., Oliver & Barnes, 2012).

Various occupational therapy scholars (e.g., Hammell, 2006; Kielhofner, 2005; Phelan, 2011) have called on practitioners to embrace the principles of the social model of disability and to address the challenges that it presents to the profession. Despite these calls, little is still known about the extent to which occupational therapy practitioners endorse the social model of disability in their practice. Notably, previous studies have focused on attitudes of rehabilitation professionals toward people with disabilities (e.g., Brown et al., 2009). In contrast, the orientation toward disability, meaning the extent to which practitioners endorse the medical versus the social model of disability, has yet to be studied.

Recently, a qualitative study found that practitioners point to multiple barriers in translating DS language into their practice (Heffron et al., 2019). Besides the theory–practice gap, the results indicate that some practitioners still hold a narrow interpretation of client-centered practice as “fixing clients” and neglect the bigger picture of clients’ social context and barriers. A mixed-methods study focusing on occupational therapy students found associations between disability orientations and implicit attitudes toward people with disabilities (VanPuymbrouck & Friedman, 2020).

In addition, several factors have been suggested as affecting professionals’ attitudes toward disabilities, such as work setting and professional knowledge (e.g., Au & Man, 2006; Tervo et al., 2004). These factors may also be associated with disability orientation among occupational therapy practitioners and require further exploration.

The current study was designed to advance knowledge regarding the disability perceptions of occupational therapy practitioners and the degree to which these perceptions are implemented. Specifically, we formulated the following three research questions:

To what degree do occupational therapy practitioners endorse the medical model of disability versus the social model of disability in theory and practice?

Are there any differences between occupational therapy practitioners’ perceptions of disability and their actual practice?

Do work setting and exposure to the social model of disability have an effect on occupational therapy practitioners’ perceptions and practices?

Method

Participants and Procedure

Questionnaires were distributed in all physical rehabilitation facilities in Israel through professional social media groups (N = 600 licensed therapists). The final sample consisted of 102 occupational therapists. Participants received a brief explanation about the study and signed an informed consent form. Ethical approval was obtained from the Hebrew University of Jerusalem’s institutional review board.

Instruments

The Orientation toward Disability Scale (ODS) was adapted from the Perceptions Toward Disability Scale, which was originally constructed to measure the degree to which social workers endorse the medical versus social model of disability (Holler & Werner, 2018). Because these models are not mutually exclusive (Hammell, 2006; Shakespeare, 2013) and because professionals can simultaneously support both to varying degrees (Holler & Werner, 2018), scale items for the two models are conceived as representing separate, yet non–mutually exclusive, scales.

The ODS was adapted to address occupational therapy and rehabilitation. Each scale, Medical versus Social, is composed of two dimensions: locus of intervention and client involvement. The former refers to the extent to which professionals focus their interventions on the person or the person’s environment (e.g., “The intervention needs to be focused on the physical or cognitive improvement of the client”), whereas the latter refers to the extent to which they enable clients to take control over the rehabilitation process (e.g., “Goal setting must be based primarily on the client’s will and priorities”). In addition, the adapted ODS consists of two subscales: Perception (e.g., “The intervention process must focus on removing social barriers”) and Practice (e.g., “In the intervention process, I focus on removing social barriers”). Each subscale includes 19 items: 9 measuring the medical orientation and 10 measuring the social orientation (Table 1).

Table 1.

Components and Item Examples for the Orientation toward Disability Scale

Scale and Dimension	Subscale	Item Examples
Medical
Client involvement	Perception	Goal setting must be based primarily on the knowledge and experience of the therapist.
Client involvement	Practice	I set treatment goals based on my knowledge and experience.
Locus of intervention	Perception	The intervention needs to be focused on the physical or cognitive improvement of the client.
	Practice	In treatment I focus on improving the client’s physical or cognitive deficit.

Social
Client involvement	Perception	Goal setting must be based primarily on the client’s will and priorities.
Client involvement	Practice	I set treatment goals based on the client’s will and priorities.
Locus of intervention	Perception	The intervention process must focus on removing social barriers.
Locus of intervention	Practice	In the intervention process, I focus on removing social barriers.

Following Rubio et al. (2003), the content validity of the ODS was assessed by seven disability experts: four occupational therapists, two social workers, and one legal expert. The experts were emailed a 44-item scale and were asked to review each item and decide whether it represented the medical or social model of disability. The raters were also asked to provide qualitative feedback, including suggestions for redundant, missing, or unclear items. Interrater reliability was satisfactory: Of the items, 22 were agreed on by all seven raters (100%), 8 items by six raters (86%), and 6 items by five raters (71%). Eight items, approved by fewer than five raters, were removed. After receiving the qualitative feedback, 2 items were added, and 8 items were slightly reworded. The final ODS consisted of 38 items (19 each on the Perception and Practice subscales).

Participants were asked to rate their agreement on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). A total score was calculated for the Medical and Social scales by averaging the responses on the relevant items over all dimensions. This calculation was conducted for the Perception and Practice subscales separately. Higher scores reflect greater endorsement of the relevant model (medical or social model of disability). Internal consistency reliability was in the acceptable to good range for all subscales. Cronbach’s α was .72 for the Medical scale’s Perception subscale, .75 for the Social scale’s Perception subscale, .74 for the Medical scale’s Practice subscale, and .81 for the Social scale’s Practice subscale. In addition, background information was collected regarding age, gender, work setting (hospital, community, or home-based therapy), and exposure to the social model of disability in academic courses or professional training.

Statistical Analysis

Data were analyzed with IBM SPSS Statistics (Version 21). To evaluate the differences between medical and social orientation and between perception and practice, we used a paired t test with Bonferroni correction (p = number of comparisons/.05) and Cohen’s d effect size (ES). To evaluate the differences in orientation according to the three work settings, we used analysis of variance (ANOVA) and post hoc Scheffé analyses with η_p² ES. Differences by professional exposure to the social model of disability were tested with an independent-samples t test.

Results

Background Variables

Of the participants, 90% were women, consistent with the gender distribution of occupational therapists in Israel (Ministry of Health, 2016). Approximately 50% of the therapists had up to 8 yr of work experience. They worked in hospitals (45%), community clinics (20%), and home care (12%); the remaining 23% worked concurrently in at least two types of setting. More than half (57%) reported having been exposed to the social model of disability in academic or professional courses.

Descriptive Profile of the Orientation toward Disability Scale

With regard to therapists’ perceptions, the mean total Medical scale score was 3.45 (SD = 0.52). Breaking down into dimensions, the mean scores (SDs in parentheses) on the client involvement and locus of intervention dimensions were 2.98 (0.65) and 3.68 (0.65), respectively. The mean total Social scale score was 3.68 (0.48), and the mean scores on the client involvement and locus of intervention dimensions were 4.35 (0.53) and 3.39 (0.62), respectively (Tables 2 and 3).

Table 2.

Comparisons Between the Medical and Social Scales (N = 102)

Subscale and General Score or Dimension	M (SD)		t	df	p	Cohen’s d
Subscale and General Score or Dimension	Medical Scale	Social Scale	t	df	p	Cohen’s d
Perception
General score	3.45 (0.52)	3.68 (0.48)	−3.55	101	.01	0.46
Client involvement	2.98 (0.65)	4.35 (0.53)	−16.37	101	.00	2.30
Locus of intervention	3.68 (0.65)	3.39 (0.62)	3.46	101	.01	0.44
Practice
General score	3.70 (0.52)	3.77 (0.51)	−0.92	100	.36	0.13
Client involvement	3.20 (0.63)	4.18 (0.56)	−10.44	100	.00	1.54
Locus of intervention	3.95 (0.65)	3.60 (0.61)	3.94	100	.00	0.55

Table 3.

Comparisons Between the Perception and Practice Subscales (N = 102)

Disability Orientation and General Score or Dimension	M (SD)		t	df	p	Cohen’s d
Disability Orientation and General Score or Dimension	Perception Subscale	Practice Subscale	t	df	p	Cohen’s d
Medical
General score	3.45 (0.52)	3.70 (0.52)	7.62	100	.00	0.48
Client involvement	2.98 (0.65)	3.20 (0.63)	4.34	100	.00	0.34
Locus of intervention	3.68 (0.65)	3.95 (0.65)	6.46	100	.00	0.41
Social
General score	3.68 (0.48)	3.77 (0.51)	−2.00	100	.05 a	0.18
Client involvement	4.35 (0.53)	4.18 (0.56)	3.46	100	.01	0.31
Locus of intervention	3.39 (0.62)	3.60 (0.61)	3.72	100	.00	0.34

After the Bonferroni correction, the significant score interpretation is p ≤ .025 and, thus, nonsignificant.

With regard to their practice, the mean total Medical scale score was 3.70 (0.52). Breaking down into dimensions, the mean scores on the client involvement and locus of intervention dimensions were 3.20 (0.63) and 3.95 (0.65), respectively. The mean total Social scale score was 3.77 (0.51), and the mean scores on the client involvement and locus of intervention dimensions were 4.18 (0.56) and 3.60 (0.61), respectively (see Table 2).

Differences Between the Medical and Social Scales

To assess the degree to which occupational therapy practitioners were likely to endorse the social or medical model of disability in perception and practice (Research Question 1), we performed paired-samples t tests. Differences between the models were examined in relation to the general scales and to the dimensions separately.

As can be seen in Table 2, for the Perception subscale, the general mean score was significantly higher for the Social scale than the Medical scale, with a medium ES. Looking at each dimension separately revealed that occupational therapy practitioners provided significantly higher endorsement for the social model of disability in the client involvement dimension and higher endorsement for the medical model of disability in the locus of intervention dimension, with large and medium ESs, respectively.

For the Practice subscale, no significant difference was found between the general mean scores of the Social and Medical scales. However, occupational therapy practitioners provided significantly higher endorsement for the social model of disability in the client involvement dimension, and higher endorsement for the medical model of disability in the locus of intervention dimension, with large and medium ESs, respectively.

Differences Between Perception and Practice

To compare occupational therapists’ perceptions of disability and their actual practice (Research Question 2), we conducted a paired-samples t test (see Table 3). As can be seen in Table 3, endorsement of the medical model of disability was higher in practice than in perception for both the general scale and the dimension scores. With regard to the social model of disability, no significant difference was found between perception and practice. However, in the client involvement dimension, the score was higher in perception than in practice, and vice versa in the locus of intervention dimension.

Work Setting

To examine the effect of work setting on disability orientation, we used ANOVA. For the Medical scale, the general score and locus of intervention dimension showed an effect of work setting. These differences were found for both subscales: for the Perception subscale, general score, F(2, 97) = 7.43, p = .01, η² _p = .13; locus of intervention, F(2, 97) = 9.31, p > .01, η² _p = .16; for the Practice subscale, general score, F(2, 96) = 8.35, p < .01, η² _p = .15; locus of intervention, F(2, 96) = 10.71, p < .01, η² _p = .18. Post hoc analyses showed that endorsement of the medical model of disability was significantly lower in home-based therapy than in both hospitals and community clinics. For the client involvement dimension of the Medical scale and for all scores on the Social scale, no significant differences were found.

Educational Exposure to the Social Model of Disability

To examine the effect of exposure to the social model of disability, we performed an independent-samples t test. For the Practice subscale, significant differences were found between occupational therapists with and without such exposure. These differences were found with regard to both the general score, t(99) = 2.96, p = .004, Cohen’s d = 0.44, and locus of intervention dimension, t(99) = 2.96, p = .004, Cohen’s d = 0.59, of the Social scale. In both cases, practitioners exposed to the social model of disability tended to favor them more than did those without similar exposure. For the Perception subscale, a significant difference was found between therapists with and without such exposure. Specifically, on the locus of intervention dimension, participants exposed to the social model of disability tended to score higher on items endorsing the social model of disability, t(100) = 2.06, p = .04, Cohen’s d = 0.41. No significant differences were found between practitioners with or without exposure in all other scores.

Discussion

Despite calls to integrate the social model of disability into occupational therapy, the question remains as to what extent occupational therapists endorse this model in theory and practice. The research results exhibit a complex picture in which therapists simultaneously endorse both the medical and the social models of disability and in which the tendency to endorse one model varies between different dimensions. Specifically, greater support for the social model of disability was mostly evident in the client involvement dimension, yet support for the medical model of disability was mostly evident in the locus of intervention dimension. Over both dimensions, the medical model of disability was significantly more endorsed in practice than in theory. Work setting and prior exposure to the social model of disability were found to affect therapists’ orientation.

Differences Between the Medical and Social Orientations to Disability Are Dimension Dependent

As previously stated, greater support for the medical model of disability was measured for the locus of intervention dimension, meaning that occupational therapists, in both theory and in practice, tended to focus their intervention on improving their clients’ bodily dysfunction while placing less emphasis on tackling social barriers.

These findings resonate with commentaries and studies suggesting that the profession is still dominated by individualistic thinking and practices (Hammell, 2006; Kielhofner, 2005; Phelan, 2011). This approach leads occupational therapists to focus their interventions “on changing individuals’ behaviours, skills, or abilities to overcome or adjust to their circumstances” (Gerlach et al., 2018, p. 36).

These findings are also indicative of the profession’s preoccupation with clients’ independence. Some of the ODS items referred to practices aimed at promoting the independence of people with disabilities and the support given by therapists to these practices. These items reflect the central role that therapists assign to the goal of independence. This outlook is also reflected in the instruments that therapists use in rehabilitation, such as the FIM™, which emphasize the goal of independence and define it narrowly in terms of physical capacity (Hammell, 2006). According to Gerlach et al. (2018), these “normalized best practice processes” (p. 36) are where the profession’s individualist orientation is often (re)constructed.

Although not rejecting the positive aspects of independence, the social model of disability criticizes the hegemonic and unreflective place of this goal among health professionals, including occupational therapy practitioners. This preoccupation with independence, narrowly defined as performing tasks without help from others, reinforces the false dichotomy between ability and disability and ignores the interdependent nature of life (Phelan, 2011). Most important, it lies in contrast to service users’ relational aspirations because they tend to prioritize the goal of self-control rather than that of self-care activities.

In the client involvement dimension, therapists expressed a social orientation in both theory and practice. Although this finding is encouraging and in line with other studies (e.g., Larsen et al., 2019), a word of caution is warranted, considering that this study was restricted to the therapists’ viewpoints and did not include the clients’ perspectives. The few studies that have incorporated clients’ perspectives found a substantial professionals–clients gap (e.g., Maitra & Erway, 2006), which is an issue that requires further study.

Disparity Between Perception and Practice

The disparity found between occupational therapists’ perception of disability and their actual practice, with mostly higher endorsement of Medical versus Social scale items, might suggest that although therapists aspire to implement a social-based practice, in reality they face various barriers that prevent them from doing so. In the current study, we did not examine these barriers; however, other researchers (e.g., Durocher et al., 2016; Townsend et al., 2003), mostly focusing on challenges to realizing the client-centered approach, have identified a variety of obstacles. These obstacles are connected not only to the client level (e.g., type and severity of impairment) but also to the practitioner level (e.g., limited training) as well as to the workplace and policy levels (e.g., workload, lack of administrative support). Further work is needed to better understand these systemic constraints (Durocher et al., 2016).

Explanatory Variables

Therapists working in a home-based setting tended to endorse the social model of disability more than did their colleagues working in hospitals and community clinics. This finding is consistent with much of the literature, which has highlighted the ability of this real-life setting to help practitioners consider more contextual factors (Doig et al., 2011). The question is, What do these differences mean in terms of preferred practices in acute rehabilitation settings? It is only natural, and professionally justified, that in hospitals and community clinics, practitioners focus their efforts on improving clients’ skills and performance. Seen this way, this focus is the result of the fact that these settings pursue objectives more oriented to skill recovery.

Moreover, as Kielhofner (2005) rightly emphasized, “focusing away from reducing the impairment might disenfranchise individuals of wanted opportunities to minimize their impairments” (p. 492). However, one should not lose sight of the fact that rehabilitation is not only about cure but also about “learning to live well with an impairment in the context of one’s environment” (Hammell, 2006, p. 127). Hence, focusing on clients’ skills does not mean overlooking more social, contextual factors, such as clients’ family or physical environment (Doig et al., 2011). Although not an easy task, striking the right balance and integrating both medical and social aspects is therefore important for optimizing rehabilitation gains.

In addition, we should also note that the effect of work setting was only partial. For example, with regard to the client involvement dimension, differences between rehabilitation settings were not observed. This finding differs from those of other studies (e.g., Maitra & Erway, 2006) that showed that client-centered practice was less evident in inpatient settings. Finally, a positive effect on endorsement of the social orientation was demonstrated for prior exposure to the social model of disability. This encouraging finding suggests a potential transformative mechanism through education (Heffron et al., 2019; Shakespeare & Kleine, 2013).

Limitations and Future Directions

The first limitation of the current study is the use of a convenience sample, which limits the generalizability of its findings. Note, however, that the final sample constituted a large segment of the target population and reflected many of its sociodemographic features. A second limitation is the use of self-reports. Because various studies (e.g., Maitra & Erway, 2006) have found discrepancies between occupational therapy practitioners’ points of view and those of their clients, future research will need to add service users’ assessments and clinical observations. A third limitation is that our instrument was limited to examining practitioners’ perception of and practice with their clients, overlooking more macrostructural aspects of social-oriented interventions (e.g., lobbying for policy change). The macrostructure is central to the social model of disability and is crucial if practitioners are to tackle occupational injustices (Phelan, 2011). Future studies will need to explore this issue in detail.

Our last limitation relates to the fact that the social model of disability is composed of a set of theoretical strands, each stressing different aspects of the social construction of disability (Hammell, 2006; Shakespeare, 2013). Many of these aspects, such as the notions of power, ableism, identity, and normality, have not been sufficiently covered by our instrument. Further research is required to explore practitioners’ perceptions of these notions.

Implications for Occupational Therapy Practice

The results of this study show that practitioners, educators, and policymakers should be required to

Mind the gap between their perceptions and implementation of the social model of disability in adult rehabilitation settings, especially regarding locus of intervention and particularly in out-of-home rehabilitation settings;

Critically reflect on the challenges that this model presents to the profession and the barriers to implementing it in practice; and

Increase exposure to the social model of disability.

Conclusion

This study contributes new knowledge regarding the extent to which occupational therapy practitioners endorse the social model of disability. Its findings show that practitioners are still relatively far from fully adopting the model and its critical insights. This is particularly true when their actual practices are considered and when rehabilitation takes place in out-of-home settings.

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