Applications and interpretations

Models of Disability are tools for defining impairment and, ultimately, for providing a basis upon which government and society can devise strategies for meeting the needs of disabled people. They are often treated with scepticism as it is thought they do not reflect a real world, are often incomplete and encourage narrow thinking, and seldom offer detailed guidance for action. However, they are a useful framework in which to gain an understanding of disability issues, and also of the perspective held by those creating and applying the models.

For Models of Disability are essentially devised by people about other people. They provide an insight into the attitudes, conceptions and prejudices of the former and how they impact on the latter. From this, Models reveal the ways in which our society provides or limits access to work, goods, services, economic influence and political power for people with disabilities.

Models are influenced by two fundamental philosophies. The first sees disabled people as dependent upon society. This can result in paternalism, segregation and discrimination. The second perceives disabled people as customers of what society has to offer. This leads to choice, empowerment, equality of human rights, and integration. As we examine the different Models in this and subsequent articles, we will see the degree to which each philosophy has been applied.

We should not see the Models as a series of exclusive options with one superior to or replacing previous sets. Their development and popularity provides us with a continuum on changing social attitudes to disability and where they are at a given time. Models change as society changes. Given this degree of understanding, our future objective should be to develop and operate a cluster of models, which will empower people with disabilities, giving them full and equal rights alongside their fellow citizens.

The Medical Model

The Medical Model holds that disability results from an individual person’s physical or mental limitations, and is largely unconnected to the social or geographical environments. It is sometimes referred to as the Biological-Inferiority or Functional-Limitation Model.

It is illustrated by the World Health Organisation’s definitions, which significantly were devised by doctors:

Impairment: any loss or abnormality of psychological or anatomical structure or function.

Disability: any restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.

Handicap: any disadvantage for a given individual, resulting from impairment or a disability that limits or prevents the fulfilment of a role that is normal for that individual."

WHO Classification of Impairments, Disabilities and Handicaps, 1980

From this, it is easy to see how people with disabilities might become stigmatised as "lacking" or "abnormal".

The Medical Model places the source of the problem within a single impaired person, and concludes that solutions are found by focusing on the individual. A more sophisticated form of the model allows for economic factors, and recognises that a poor economic climate will adversely effect a disabled person’s work opportunities. Even so, it still seeks a solution within the individual by helping him or her overcome personal impairment to cope with a faltering labour market.

In simplest terms, the Medical Model assumes that the first step solution is to find a cure or - to use WHO terminology – make disabled people more "normal". This invariably fails because disabled people are not necessarily sick or cannot be improved by remedial treatment. The only remaining solution is to accept the "abnormality" and provide the necessary care to support the "incurable" impaired person. Policy makers are limited to a range of options based upon a programme of rehabilitation, vocational training for employment, income maintenance programmes and the provision of aids and equipment.

This Functional-Limitation (Medical) model has dominated the formulation of disability policy for years. Although we should not reject out-of-hand its therapeutic aspects which may cure or alleviate the physical and mental condition of many disabled people, it does not offer a realistic perspective from the viewpoint of disabled people themselves. To begin with, most would reject the concept of being "abnormal". Also, the model imposes a paternalistic approach to problem solving which, although well intentioned, concentrates on "care" and ultimately provides justification for institutionalisation and segregation. This restricts disabled people’s opportunities to make choices, control their lives and develop their potential.

Finally, the Model fosters existing prejudices in the minds of employers. Because the conditional is "medical", a disabled person will ipso facto be prone to ill health and sick leave, is likely to deteriorate, and will be less productive that work colleagues.

The Expert/Professional Model

The Expert/Professional Model has provided a traditional response to disability issues and can be seen as an offshoot of the Medical Model. Within its framework, professionals follow a process of identifying the impairment and its limitations (using the Medical Model), and taking the necessary action to improve the position of the disabled person. This has tended to produce a system in which an authoritarian, over-active service provider prescribes and acts for a passive client.

This relationship has been described as that of fixer (the professional) and fixee (the client), and clearly contains an inequality that limits collaboration. Although a professional may be caring, the imposition of solutions can be less than benevolent. If the decisions are made by the "expert", the client has no choice and is unable to exercise the basic human right of freedom over his or her own actions. In the extreme, it undermines the client’s dignity by removing the ability to participate in the simplest, everyday decisions affecting his or her life. E.g. when underwear needs to be changed or how vegetables are to be cooked.

Models of Disability: keys to perspectives II

The Tragedy/Charity Model

The Tragedy/Charity Model depicts disabled people as victims of circumstance, deserving of pity. This and Medical Model are probably the ones most used by non-disabled people to define and explain disability.

Traditionally used by charities in the competitive business of fund-raising, the application of the Tragedy/Charity Model is graphically illustrated in the televised Children in Need appeals in which disabled children are depicted alongside young "victims" of famine, poverty, child abuse and other circumstances. Whilst such appeals raise considerable funds for services and equipment which are not provided by the state, many disabled people find the negative victim-image thoroughly offensive. In fact Children in Need has been described as "televisual garbage … oppressive to disabled people" M. Oliver quoted in C. Donnellan "Disabilities and Discrimination Issues for the Nineties" 1982. Some go as far as interpreting the tragic portrayal as a means of maintaining a flow of donations and keeping able-bodied people in work.

The Tragedy/Charity Model is condemned by its critics as dis-enabling, and the cause of much discrimination. Speaking on the BBC Everyman programme The Fifth Gospel (date?), Nabil Shaban said: "The biggest problem that we, the disabled have, is that you, the non-disabled, are only comfortable when you see us as icons of pity." Because disabled people are seen as tragic victims, it follows that they need care, are not capable of looking after themselves or managing their own affairs, and need charity in order to survive.

From tragedy and pity stems a culture "care". Although highly praiseworthy in many respects, it carries certain dangers. Numerous charities exist to support and care for people with a particular type of disability, thereby medically classifying, segregating and often – as with the Medical Model – institutionalising many disabled people. Over 400,000 adults in Great Britain are affected by institutionalisation. Given the choice, many, if not most would opt for community life with adequate support.

The idea of if being recipients of charity lowers the self-esteem of people with disabilities. In the eyes of "pitying" donors, charitable giving carries with it an expectation of gratitude and a set of terms imposed upon the beneficiary. The first is patronising; the second limiting upon the choices open to disabled people. Also, employers will view disabled people as charitable cases. Rather than address the real issues of creating a workplace conducive to the employment of people with disabilities, employers may conclude that making charitable donations meets social and economic obligations.

This is not to advocate dismantling charities and outlaw caring, charitable acts, which enrich our society and bring badly needed funds. But we do need to educate charity managers and professionals to review the way they operate and ensure that funds are channelled to promote the empowerment of disabled people and their full integration into our society as equal citizens – requiring our respect and not our pity.

The Social Model

The Social Model views disability as a consequence of environmental, social and attitudinal

barriers that prevent people with impairments from maximum participation in society. It is best summarised in the definition of disability from the Disabled Peoples’ International:

"the loss or limitation of opportunities to take part in the normal life of the community on an equal level with others, due to physical or social barriers."

Its philosophy originates in US civil rights movement and has been championed by The British Council of Organisations of Disabled People and Rights Now, which calls for self-determination. It is advocated in the UK by leading thinkers such as Dr Steven Duckworth and Bert Massie and has been the guiding light for the The Local Government Management Board and the establishment of the new Commission for Disabled People.

It is also referred to as the Minority-Group Model of Disability. This argues from a socio-political viewpoint that disability stems from the failure of society to adjust to meet the needs and aspirations of a disabled minority. This presents a radically different perspective on disability issues and parallels the doctrine of those concerned with racial equality that "racism is a problem of whites from which blacks suffer." If the problem lies with society and the environment, then society and environment must change. If a wheelchair user cannot use a bus, the bus must be redesigned.

To support the argument, short-sighted people living in the UK are not classified as disabled. Eye-tests and visual aids – which are either affordable or freely available – means that this impairment does not prevent them participating fully in the life of the community. If, however, they live in a third-world country where such eye-care is not available they are severely disabled. The inability to read and subsequently learn and gather information would be counted as a severe impairment in any society.

This Model implies that the removal of attitudinal, physical and institutional barriers will improve the lives of disabled people, giving them the same opportunities as others on an equitable basis. Taken to its logical conclusion, there would be no disability within a fully developed society.

The strength of this Model lies in its placing the onus upon society and not the individual. At the same time it focuses on the needs of the individual whereas the Medical Model uses diagnoses to produce categories of disability, and assumes that people with the same impairment have identical needs and abilities. It also offers positive solutions that have been proved to work in, for example, Canada, Australia and the USA.

The Model faces two challenges. Firstly, as the population gets older the numbers of people with impairments will rise and making it harder for society to adjust. Secondly, its concepts can be difficult to understand, particularly by dedicated professionals in the fields of charities and rehabilitation. These have to be persuaded that their role must change from that of "cure or care" to a less obtrusive one of helping disabled people take control of their own lives.

The Social Model’s limitations arise from its failure to emphasise certain aspects of disability. Jenny Morris adds a feminist dimension. "While environmental barriers and social attitudes are a crucial part of our experience of disability – and do indeed disable us – to suggest that this is all there is, is to deny the personal experience of physical and intellectual restrictions, of illness of the fear of dying." (Pride against prejudice, 1991) Black disable people face problems of both racial and disability discrimination within a system of service provision designed by white able-bodied people for white disabled people.

Models of Disability: keys to perspectives III

The Social Adapted Model

This is a new model, built upon the Social Model, but incorporating elements of the Medical Model. It accepts that impairments identified be the latter are significant, but stipulates that far more problems are created for disabled people by social and environmental causes. Not all problems of impairment can currently be addressed, but if we recognise our environment as discriminatory we can do much to change it so that disabled people are enabled to higher achievement.

Unlike the Social Model, the Social Adapted Model recognises that the inability of some disabled people to adapt to the demands of society may be a contributory factor to their condition. However, it still maintains that disability stems primarily from a social and environmental failure to account for the needs of disabled citizens. The advantage of this Model is that it does not concentrate on individuals’ limitations, but takes account of peoples’ capabilities and potential.

The Economic Model

Under this Model, disability is defined by a person’s inability to participate in work. It also assesses the degree to which impairment affects an individual’s productivity and the economic consequences for the individual, employer and the state. Such consequences include loss of earnings for and payment for assistance by the individual; lower profit margins for the employer; and state welfare payments.

The Economic Model is used primarily by policy makers to assess distribution of benefits to those who are unable to participate fully in work. In recent years, however, the preoccupation with productivity has conflicted with the application of the Medical Model to classify disability to counter fraudulent benefit claims, leading to confusion and a lack of co-ordination in disablement policy.

The challenge facing the Economic Model is how to justify and support, in purely economic terms, a socially desirable policy of increasing participation in employment. Classical economic laws of supply and demand stipulate that an increase in the labour market results in decreased wages. Arguably, extending access to work through equal opportunities reduces an employer’s labour costs, but other factors come into play.

The value of labour is based upon its contribution to marginal cost, i.e. the cost of producing the last unit of production. This only works when employees make an equal contribution to marginal cost. However, evidence suggests that disabled employees make a lower contribution than their work colleagues do, resulting in losses in production and lower profits for the employer.

Employers may recognise compensations for any loss in employing less-productive disabled employees through kudos, publicity, customer alignment and expansion arising from their presentations as an organisation with community values. However, employers are not generally altruistic and hold the economic viability and operational effectiveness of their organisation as higher priorities than demonstrating social awareness. Their economic option is to pay disabled employees less or have the losses met through subsidy.

The problem for the users of Economic Model is one of choice. Which is better: to pay the disabled employee for loss of earnings, or the employer for loss of productivity? The first carries stigma for the disabled person by underlining their inability to match the performance of work colleagues. With the latter, difficulties arise in correctly assessing the correct level of subsidy. The productivity of a disabled employee may well change, as well as the marginal costs of the total workforce.

This leaves one outstanding difficulty for the socially minded economist. How do we achieve an equitable, effective, value-for-money distribution of disability related benefits? It is likely that there will be people with disabilities that prevent them from doing working. There will be others whose productivity levels are so low that the tax benefits to the public purse are outweighed by the employment subsidy. In economic terms, these people are unemployable and should be removed from employment to supplementary benefits, saving the expenditure on the subsidy. But is this socially acceptable? This apparent conflict has created ambiguity in agreeing social security goals and has led to stigmatisation of disabled people as a burden on public funds rather than partners in the creation of general social prosperity.

Social security benefits are not designed to remove disabled people from poverty. The policy maker needs to balance equity (the right of the individual to self-fulfilment and social participation through work) and efficiency. The true value of the Economic Model is maintaining this balance in the macroeconomic context of trade cycles, inflation, globalisation and extraordinary events such as wars.

The Customer/Empowering Model

This is the opposite of the Expert Model. Here, the professional is viewed as a service provider to the disabled client and his or her family. The client decides and selects what services they believe are appropriate whilst the service provider acts as consultant, coach and resource provider.

Recent operations of this Model have placed financial resources into the control of the client, who may choose to purchase state or private care or both.

The Religious Model

The Religious Model views disability as a punishment inflicted upon an individual or family by an external force. It can be due to misdemeanours committed by the disabled person, someone in the family or community group, or forbears. Birth conditions can be due to actions committed in a previous reincarnation.

Sometimes the presence of "evil spirits" is used to explain differences in behaviour, especially in conditions such as schizophrenia. Acts of exorcism or sacrifice may be performed to expel or placate the negative influence, or recourse made to persecution or even death of the individual who is "different".

In some cases, the disability stigmatises a whole family, lowering their status or even leading to total social exclusion. Or it can be interpreted as an individual’s inability to conform within a family structure. Conversely, it can be seen as necessary affliction to be suffered before some future spiritual reward.

It is an extreme model, which can exist in any society where deprivation is linked to ignorance, fear and prejudice.