Taking Control: The Psychosocial Benefits of Reablement

Abstract

This chapter discusses the psychosocial theories that underpin the philosophy and practice of reablement services. Prior to a long-term condition an older person will have fulfilled a role (indeed several) and will have taken an active part in community life (Coulter, Roberts and Dixon 2013). When a person is incapacitated by impairment, disability and pain the natural consequence is that they become a ‘user’ of health and/or social care services. This change is often dramatic and involves some distress, often associated with the level of importance an individual places on the activities they are no longer able to carry out. In addition, inpatient care can reduce mobility (Merreywether and Chapman 2013), as well as creating dependence on others for personal care and daily activities (see Chapter 4). Alternatively, and with reablement, a person can regain a sense of control over their lives, which includes psychological, social and physical recovery. There is a need for the person to be engaged in a meaningful process which genuinely advances independent living. However, loss of confidence, feelings of helplessness and an altered self-concept create barriers to regaining control. Societal expectations of recovery (including those of acute health services) can make long-term illness and disability discreditable experiences, inhibiting social engagement and increasing feelings of helplessness. Together with the person, the attitude of reablement workers (anyone who works with a service user in a reablement capacity) is thus a critical factor in social inclusion (In Control 2015) and reablement. Concordance, the respectful partnership between service user and service provider in planning and achieving essential aspects of the reablement process, is a fundamental requirement of reablement. It involves valuing the person and acknowledging the human relationship, promoting self-esteem, a sense of control and confidence to try, without worrying about failure. Immanuel Kant, the eighteenth-century philosopher, identified the importance of treating people as ends in themselves, rather than as means to an end (McCormack and McCance 2010), with important implications for the rights of human beings, irrespective of their earning potential, cognitive abilities, appearance, morality or other attributes of difference. Kant also identified the importance of autonomy, and behaving in ways that protected it, in order to promote respect for the self and for other human beings (Gregor 1997). His view of autonomy was that the individual should be free to make a moral choice, rather than come under the influence of more powerful others, and it is from this that the principle of informed consent in modern health and social care is derived (Lysaught 2004). So, in order to respect the service user, we need to support them to make fully informed choices about their reablement plan and then enable them to pursue those choices, even if we would make different ones. Respect for self and others is strongly echoed in the humanistic values of unconditional positive regard, congruence (or authenticity) and empathy, to promote personal growth or self-actualisation. Unconditional positive regard means valuing the person as an end in themselves, regardless of their status or personal characteristics. Congruence means that a person’s view of themselves as they are (self-image) and the way they would like to be (ideal self) are very similar, so the person feels happy with who they are. Empathy means understanding the world from the other person’s view in order to relate to their emotional feelings and needs. Self-actualisation, or personal growth, is the process of leading a life in which the person feels happy within themselves but looks forward to the next challenge or opportunity for self-development. These values are fundamental to the person-centred therapy of Carl Rogers (1961) and are used to promote the development of cognitive and emotional adjustment. Thus, the person sees themselves as worthy of respect and is able to plan a future that involves growth and development. Differing terms are used for the role of the service user in working with health professionals: adherence, compliance and concordance. Compliance suggests unwilling or unthinking obedience, but not taking medicines or following advice, which affects health outcomes and costs, can be a mechanism by which the service user is blamed for any failure to recover (Bissell, May and Noyce 2004), sometimes earning them the label of being ‘non-compliant’. Adherence means the active choice to follow the advice or prescription of a health professional, and is the term generally used in relation to pharmacological interventions, while concordance is agreement upon a plan of action or care management which incorporates the knowledge and views of the person and the professional (Horne et al. 2005). Outmoded emphasis on the importance of compliance with health and social care professionals, which creates a barrier to open communication, undermines the value of the individual and reinforces their view of themselves as helpless, leading to dependence and disability. These psychoemotional dimensions of disability that oppress people are described by Thomas (2004, p. 38) as ‘being made to feel of lesser value, worthless, unattractive, or disgusting’ and can affect both their self-concept and their understanding of their relationships with others. Consequently, it is essential for all health and social care professionals and support workers who work in reablement to understand these ideas and to value and respect the humanity of the service users with whom they interact. This chapter will provide an explanation and synthesis of key theoretical concepts that underpin a psychosocial understanding of the issues associated with disability, ageing and long-term conditions. Initially, it will explore the idea of the self, and how the psychology of the self influences human thoughts, feelings and behaviours within, and as a result of, the reablement interaction. This will be followed by a broad discussion of ageing theories such as disengagement, active ageing and gerotranscendence as well as elements of positive psychology. Understanding stigma will enable understanding of personal values in order to develop non-stigmatising attitudes and behaviour. Centrally, the need to facilitate the personal motivation and self-efficacy of service users, while enabling them to feel secure and confident, will illustrate the complexity of working with individuals within the context of reablement. Chapter objectives By the end of this chapter you should be able to: • Determine what self-concept is and how it affects the success of reablement and is in turn affected by it • Recognise learned helplessness and how it is reinforced by a loss of control • Outline the ways in which stigma acts as a barrier to reablement • Appraise psychosocial theories of ageing and their implications for reablement • Describe person-centred therapeutic relationships as the foundation of reablement practice