Adjustment to disability: A cognitive-behavioral model for analysis and clinical management

Profound psychological reactions are frequently seen following the onset of severe disability. Stage models of adjustment, although limiting when used dogmatically, can serve as a helpful guideline for intervention when integrated within a framework that also addresses the sequence of associated irrational beliefs. This article proposes a three phase model for analyzing and facilitating the adjustment process which follows disability. Adjustment is analyzed along cognitive, emotional, and environmental dimensions.The first stage immediately follows the onset of incapacitating disability and is termed the Pre-encounter phase. From a rational emotive perspective, the individual in this phase has not yet acknowledged that an activating, or disabling event has occurred. Acknowledgment is limited to brief contact which is then followed by excessive arousal and extreme distortions in evaluative capabilities. Shock and denial are characteristic of this phase. During this stage, strategies for clinical management are specified with a stronger emphasis on targeting the environment and belief system of the rehabilitation team than the beliefs of the patient.The second stage is referred to as the Post encounter phase during which the disabling condition has been acknowledged as a valid activating event. Periods of anxiety, depression, and expressed anger are common at this time. The final stage is coined the Rational re-encounter phase and is highlighted by repeated re-encounters with various forms of the disabling activating event and anticipated activating events. During this phase the patient is more able to benefit from a traditional psychotherapeutic approach which has been tailored to the specific pattern of irrational beliefs often exhibited in response to life with a disability.