A complete, humanized description of disability requires consideration of context (e.g., physical environment, social interactions, background life), and the factors contributing to function and disability should be sought at the interface of an individual and their context.
Disablement models have not historically embraced the individual-context linkage fundamental to the disability experience. Early models of disability, like the Nagi Disablement Model (Nagi, 1965) and the International Classification of Impairments, Disabilities and Handicaps (WHO, 1980), reflected a mechanistic and medicalized approach to understanding disability (i.e., disability is the result of pathology within the individual). One major criticism of these early models was that they lacked constructs to identify the role of context in disability (Vaz et al., 2017). The social model of disability (Oliver, 2013) emerged in the 1970s as part of the Disability Rights Movement (Gibson, 2016). In this model, disability was something created by social context, systemic structures, and disabling environments (Nicholls, 2022; Shakespeare, 2006). The key limitation with the social model was that it failed to account for how an individual’s lived experience of disability is shaped in meaningful ways by bodily impairment (Shakespeare, 2006; Beaudry, 2016). In summary, neither model fully accounted for the inextricable connection between an individual and their context.
The International Classification of Functioning, Disability and Health (ICF) (WHO, 2001) was introduced in an effort to integrate the medical and social models of disability. Under the ICF framework, biological, individual, and social factors collectively give rise to function and disability. While contextual factors are certainly acknowledged in the ICF, physiotherapy practice remains largely entrenched in medical approaches and in restoring the biological body decontextualized from the social, physical, and cultural environments contributing to function and disability (Chiang et al., 2022; Cormack et al., 2022; Dalboni et al., 2022; Gibson, 2016; Nicholls & Gibson, 2010, Schwab et al., 2022a).
Sarah Schwab (PhD)
University of Cincinnati
A newly proposed philosophical model of disability developed from enactive cognitive science and ecological psychology, the Ecological-Enactive Model of Disability (Toro et al., 2020), provides a useful conceptual framework for better understanding how disability experiences are located at the intersection of an individual and their context. The Ecological-Enactive Model of Disability seeks to understand disability as both situated (context-dependent) and embodied (shaped by the body and its capabilities). According to the Ecological-Enactive Model, the experience of disability arises when the skills a person expresses are often and persistently insufficient to support their activities and social roles in a context. In other words, the experience of disability can be equated with frequent and pervasive experiences of “I-cannot.” Importantly, disability experiences can only be understood if we carefully consider the relationship between an individual’s action capabilities and the social-institutional-physical environment in which they must behave.
The Ecological-Enactive Model avoids pathologizing the body for structural and functional differences by suggesting that individuals with disability can exhibit “normal embodiment” in the sense that they are able to change and adapt motor patterns in response to their context (perhaps through the exploration of what are often deemed “atypical” motor patterns). This contrasts with the traditional reductive strategy of defining bodily normativity with respect to average characteristics of isolated body structures and functions (as would be done by the medical model). On the other hand, pathological embodiment in the Ecological-Enactive Model is experienced by individuals when they are unable to adapt to changing contexts and subsequently place themselves in more controlled situations. Normal embodiment does not mean that there is an absence of difficulty in performing daily tasks, but rather, it entails the ability (at the intersection of the individual and their context) to explore movement solutions when faced with such challenges. Because individuals with disability can experience normal embodiment, disability becomes a form of self-experience, constantly tackling the notions of “I-cannot,” and overcoming those feelings through the discovery of motor solutions that fit their environmental context to facilitate the preservation and development of function and moments of “I-can.”
The EPA Constitution states that physiotherapy must be “thought of and practiced ecologically.” The human cannot be separated from their environment. The Ecological-Enactive Model of Disability provides a disability framework that directly accepts and welcomes this idea. More widespread integration of this promising model in disability and physiotherapy research and practice will require interdisciplinarity, collaborators with disability, representative research designs, a little open-mindedness, and a willingness to think differently about physiotherapy and disability.
For more information on and an extension of the content covered in this blog, please check out our new article: Schwab SM, Spencer C, Carver NS, Andrade V, Dugan S, Greve K and Silva PL (2022) Personal factors understood through the Ecological-Enactive Model of Disability and implications for rehabilitation research. Front. Rehabilit. Sci. 3:954061. https://doi.org/10.3389/fresc.2022.954061
Header image credits: Anas Aldyab https://www.pexels.com/photo/men-playing-soccer-2610962/
Beaudry, J-S. (2016). Beyond (models of) disability? Journal of Medicine and Philosophy, 41:210–28.
Chiang, J.L., Kim, D., Siu, C., White, B., Zhu, M., Switzer-McIntyre, S. & Gibson, B.E. (2022). What is ‘disability’? Exploring the conceptions of internationally educated learners in a Canadian physical therapy bridging program. Physiotherapy Theory and Practice, doi:10.1080/09593985.2022.2113942.
Cormack, B., Stilwell, P., Coninx, S., & Gibson, J. (2022). The biopsychosocial model is lost in translation: From misrepresentation to an enactive modernization. Physiotherapy Theory and Practice, doi: 10.1080/09593985.2022.2080130.
Dalboni, G. L., Garcêz, R. L., Assis, Í. C., & Vaz, D. V. (2022). Conceptions of disability among physiotherapists: An exploratory qualitative study. Physiotherapy Theory and Practice, doi:10.1080/09593985.2022.2042757.
Gibson, B. (2016). Rehabilitation: A post-critical approach. CRC Press.
Nagi, S. (1965). Some conceptual issues in disability and rehabilitation. In: Sussman, M.B. (Ed), Sociology and rehabilitation, p. 100–113. American Sociological Association.
Nicholls, D.A. (2022). Physiotherapy otherwise. Tuwhera Open Access Books.
Nicholls, D. A., & Gibson, B. E. (2010). The body and physiotherapy. Physiotherapy Theory and Practice, 26(8), 497–509.
Oliver, M. (2013). The social model of disability: Thirty years on. Disability & Society, 28(7), 1024-1026.
Schwab, S. M., Andrade, V., Santos Moreira, T., Cavanaugh, J. T., Vaz, D. V., & Silva, P. L. (2022a). Narrowing the physiotherapy knowledge-practice gap: Faculty training beyond the health sciences. Physiotherapy Theory and Practice, doi:10.1080/09593985.2022.2027585.
Schwab, S.M., Spencer, C., Carver, N.S., Andrade, V., Dugan, S., Greve, K. & Silva, P.L. (2022b). Personal factors understood through the ecological-enactive model of disability and implications for rehabilitation research. Frontiers in Rehabilitation Sciences, 3, 954061. doi:10.3389/fresc.2022.954061.