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Models of Disability

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 Modelsof disability

Models of
disobiliry
EALTH psychology, like other challenged by research
areas of psychology, is distin_ ment and prediction on the measure.
of disabilig.
guished by its methods of
measurement, its explanatory models
and the potential it offers foi interven_
tions. In this article, I shall arzue that
Chqllengingthe
the dominant model in the fi"eld. the WHOmodel
Wq44 Health Organisarion model Disability measurement
(WHO, 1980) is inadequate to explain
Measures of disability typically idenri$
the phenomena observed, that psycho_ a series of
"ftrllv items relevant to normal ai_
logical models have not been tivitie+ and have a rating system that
developed and tested and that.r"* ur,i
the. frequency oi tt e severiry
testablemodels can be developed by in_ ot Idi:t"1
the deficit. Scores are a weishted
Morie fohnston tegrating psychological and medical sum of the ratings
models.
and the ratinqs"mav
either be by the individual o, ly od_
gavethe 1995 servers - often health professionalj. The

Award Disobility
WHO model would lead one to expect
Presidents' pattems of disability reliably related to
Physical disability is a major health me rmpairment
and to the underlyine
Lectureat the problem.Disabititiesmay arisefrom se_ disease or
netic disorders, from birtt ini.rries, ai a model typically
disorder. The measuremeni
assumes that all items
Society's
Annual result of accidents,following a stroke or
due to diseases which hippen more
are e-quivalent rather than being system_
atically related to each other aid'to the
Conference,Universitygradually. The main app.oach-
-arises to under_ underlyrng impairment and disease or
standing disability from the dlsorder.
of Warwickin April medical model - disabilities occur be_ Williams, Johnston, Willis and Ben_
cause of physical impairments which neft (1976) have proposed that the
1995. have resulted from the underlying dis_ oDserveddata
eas€or disorder. The best kno*n iodel
are not compatible with
either the disease-relatedpaiterns or the
of disabilify, the one which is used bv proposal that items are equivalent. In_
health professionalsworking with ped_ stead we
proposed and found evidence
ple with disabilities, is the WUO mtaet that the data fitted a shared cumulative
(see Figure 1) (WHO, 1980). It defines
model.
disabilify in_termsof deficits in the per_ A cumulative model of disabilitv
formance of activities as the resuli of implies sequential dependenceof itemJ:
physical. impairment following disease one cannot
achieve more difficult items
or disorder.Disability is contrastedwith without achieving easier items. It is not
'physical
impairment' which describes necessary to
decide whether failing to
deficits in the structure or function of get out of bed is worse than failini to
some part of the body, and with ,social
walk one mile: those who cannot"get
handicap' where the-deficitsare in so_ out of
bed inevitably have a worse leiel
cial functioning. of disability becausi they are unable to
Implicit in this simple model is the perform
the other item. In measurement
assumption that disability is the direct terms, it then becomes possible to
result of impairment. However, this as_ achieve
at least ordinal scaling without
sumption is challenged in the clinical engagtng
in value judgements or rela_
practice of rehabilitation, as therapists tive
weightings of dlsabilities: those
seek to minimise disability in the faie of who score x, falJ all items failed by the
enduring impairment. Ii can also be person
scoring (x-1), plqs one additional

Figwe 7: WHO Modet of Disability (WHO,7gg0)

The Psychologist May 1996 245

 Modelsof disability
Grade = No. Item Disability Added at Each Grade
Itens Disabled Iten Discrepancies between raters
Renroducibilifv
The above data were based on self-
I Cannot use bus or tsain unaccompanied
0.93 report, but other measures depend on
2 Does not use transport accompanied observation of the activities (i.e. par_
0.93 tridge, Johnston & Edwards, 19g"Dand
Does not walk out of doors unaccompanied
0.93 other currently widely used rales as-
sune that seU-report and observer
4 Cannot dress without help 0.88 assesseddisability are equivalent (e.e.
5 Cannot wash without help
Mahoney & Barthel, 1965).This *ouii
0.92 suggest that different raters are as_
6 Cannot undress without help sumed to have equivalent observations
0.92
of the individuals, disabilities. Given
7 Cannot sit and stand without helo
0.98 the WHO model of the dependence of
8 Cannot use w.c. or commode without helo
disability on impairment, one should
0.99 expect similar ratings from different ob_
9 Does not get out of bed servers/ within the limits of rater
0.99
reliability.
l0 Cannot eat without personal help
0.99 We have examined disability ratings
made by diffurent professionsof the sarie
Coeffi cient of reproducibility 0.9s patients (Johnston,Bromley, Boothrovd_
Coeffi cient of scalability Brooks, Dobbs, Ilson & Riaout, 19gn.
0.77
Raters were asked to describe what the
Table 7: Patterns of
fisab,ility in a community sample of *ri individual had been doing in the pre.
(Williams et a1.,797f/ viow 24 hours and for each-item*.€"*d
failure. Thus the measurement and the whether the patient had performed the
the relatively energy-consumingtask of task unaided, with supirvision, with
statistical analysis of the measurement
private toileting is fypically .etainea the.help of one person, bf tr.vopersons,
indicates an underlying model of the
when le-ssenerg'ydemanding tasks have or had not performed the activity. There
construct of disability - that it is cumu_
been relinquished.The data would ap-
lative - and this can be explicitly tested. was consistent evidence that nurses
pear to suggest that factors associated rated patients more disabled than mem_
We have examined this m6del in a
with value and choicewere involved. bers of the rehabilitation professions
sample of older community residents
who were asked a series of guestions
about their abilities (William's et a/..
1976). The data were examined usine O Nurse
Guttman scaling techniques to t*i C Physiotherapist
-
ll'nether there was eyidence of the hv_
pothesized cumulative '"t
pattern
disabilities. Table 1 gives thb results for
the male sample presenting the items in
the order found. Overall there is sup_
port for a cumulative pattem. The
coefficient of reproducibility indicates 25
that item scores can be predicted from
C)
overall scores and the- coefficient of
scalability indicates that this goes be_
'iF'.2
O P
yond what might be e*pected'simply
from the overall frequenry with which 9 F 20
items are failed. Coefficients of reoro_ 6 b
ducibility for individual items, inditate
rt.9
that each item is working well in the cu_ Q ) o

mulative pattern. Similar evidence of a H X

i:,< l5
cumuiative scale was found for women
- though with different items.
Thus there is support for the hy_ * 3
pothesLed cumuhhve i5.h
model ot
measurement and this is clearly provid_
ing information about ttre undirlvine
zz
L > l
o.o
construct of disability. The data givi n5 d

support to a measur€ment model re_

quiring equivalence of items. But z
neither do they support disease/impair_
ment-basedpatterns of disability. There
was no evidence of different patterns
associated with different impairmentg
as the WHO model might leid one to
expect. Instead there was evidence of
single sharedpatterns for each gender. 6 8
we considered an alternative inter_
pretation of the model - that impairment Activities
TSt ,".t. by reducing energy ina tnat
u:rolvlctuals
Figure 2:.Disability Assessmeltsby rchabilitation thetapists (physiotherapists,
might retain activities that PT) and nurses(N). Eacrtdata polfi repesents the nuibn ojLpitiit, gorn
requred little calorie output. However, lozaet ruting by the thercpist or nurse o
fot 73 actioitie". tirii{tr"- ii-it, NAzl
 Models
of divbility
(physiotherapists and occupational current disabilitie, e.g. inability to &ess,
therapists) (Figure 2). For the majority selfr-regulationnrdel
may be explained in terms of cognitive of teirenthat and
of activities, the nurses gave worse rai-
ings. The same pattem was found when
occupational therapists were studied in-
impairments. including attentioial or
memory impairments, which are in tum [{tFHt.T,ltffi
nifful#ffiffi
explained in terms of damage to specific
stead of physiotherapists. regions of the brain. These moddk im-
These data challenge the underlying ply that disabilities may be overcome representations
of are.fu;eclv;.p#,;
assumption in measurement of disabil- by improvements in brain function due rather than the probrem
ity that treats different observers as to recovery from the disorder, or bv thrs model makes
per r. While
equivalent. The results may be ex- no specific predic_
gognitiyg improvements, possibly en- hons.abo.utthe impactJ'seliigil;;;
plained in terms of the observations hange-d by cognitive retraining. bther on disability, we i.ro others
available to different raters: nurses ob- models suggest further possibilities for poryd- tha-t the coping ufo"nthave pro_
'"r.tn"*
serve patients for longer periods, but in intervention; this article illustrates be- -
model.inlluence aiLUiity.
different settings fi6m' rehabilitation havioural, stress and coping, and social
therapists. Altematively, the results _. lt.gprrible to integrate this with
cognition models. the WHO model, by proposing
may be due to differences in the behav- that im_
paumentsdererminementalr?resentatiors
iours elicited by different professions, Behavioural model
alg
due to the different expectations in re- In clinical practice, a behauiouralmodel that coping moderatesin" *fino"_
o"T""^n impairment and disabilitv
habilitation and nursing settings: nurses has proved useful and has been well- ::lp
(rtgure Jr. buch a model would
assist patients in achieving tasks, while illustrated in work on pain behaviour, be abll
to explain the lack of one.to.one .ela_
rehabilitation therapists assist patients including pain-related disability
in performing the task themselves. The (Fordyce, 1988; Williams et al., 1993).-I {9":t ip between impairment u"a
disability found in the scaling and lntei_
issue is not simply a measurement is- have used this model in working with a rater agreement studies by postulating
sue, but begins to seek explanations for girl who was unable to take food bv
that patients' mental repnesentation!
disabled behaviour and to suggest that mouth following head injury {ohnston,
and coping determined which behaviours
the social circumstances influence the 1976).Following several weeks of tube
were performed and in which contexts.
level of disability observed. feeding the transfer to oral feeding was Factors which influenced either the
unsuccessfuluntil a programme of so- mental representationsor the coping re_
Psychologicof cial contingencies foi taicing water by
mouth was introduced. The antecedents
sponses might influence the observed
disability and thus present an opportu_
models for the behaviour were changed in that
m.rny more opportunities to drink were
nity for therapeutic intervention.'
'
This model would propose that effort
The emotional response to disability offered.by many more people, including
would be expended in reducing discrep_
Perhaps the most frequently used mod- her visitors. Failures were ignored bu-t ancies between menta.l representations
els in psychologicalstudies-ofdisabilify successfuldrinking was rewarded with
and a personal standard. If individuals
have been models which try to explain social reinforcement. Satisfactorydrink-
shared this standard,e.g.by a consensus
the emotionalresponse to disabiliry r;ther
-models ing was achieved in four diys and
that toileting and feeding-oneself were
than the disability itself. The eating in eight days.
most important then one might obtain
used include: Like other psychologists working
o mental health models where rates with such models in the 1920s,I wai the pattem of results found ii the com_
munity study, as individuals would direct
of disorder are assessed; impressed by their value in interven-
. their efforts at the same tasks,with a re-
life-events models where the emo- tions as the methods were, and continue
sulting shared pattem of disability.
tional response to the life.event to be, very effective. The explanations
Leventhal and his colleagueshave
precipitating the impairment/dis- offered within the behaviouial model found that the dominant meital repre_
ability is examined; were adequateto predict the behaviour 'the
. sentations include identity of
stress models where the disability is and intervene for such problems, al-
condition, cause, cure, time.line and
seen as a stressor which elicits the -fto."gt.rit was difficult to explain what consequences.Nurses and rehabilitation
strain erridentas high lwels of distess. had changed in the girt foliowing the
therapists might- observe different per-
This approach, while having validity, introduction of the programme an"dthe -
formances in the same patients by
does,not attempt to explain disability, contingencies.Subsequentcognitive and communicating a different repre_
but the responseto disability. cognitive-behavioural approaches have
sentation of 'cure', with rehabilitation
tackled more complex problems and
Disability as a behaviour therapists eliciting an exercise-based
supplied answers by proposing that
By contrast, the definition of disability view of cure and nurses eliciting a view
cognitions mediate the iela'tionsh"ipbe-
allows one to examine disability as a bi- based on recovery from disead or dis-
tween contingenciesand behavioui. The
haaiour- it is the level of performance of order and possibly incorporathg rest
cognitive models most commonly ap-
activities. Considered as a behaviour. plied to chronic disease have 'been rather than exercise.This might eiplain
rather than simply a result of medical coping models. the different ratings of disability ob-
'
impairment or as a life-event or skes- tained by nurses ani therapists.
sor, disability becomes subject to the Self-regulation and the WHO model
Perceived control and disabiliF
same explanations as might be invoked A coltng model that has frequently been
We have been working on mental rep-
for any other behaviour. If variables applied in health psychology studies of
resentations of controllability in
which explain other behaviours can ex- patients with chiohic diiease is the
populations with disabling conditions,
plain at least some of the variance in
disability, then disability can theoreti-
cally be reduced by changing these
other variables. Unlike the WHO model.
this approach allows the possibility that
patients may benefit from interventions
which reduce their disabilities without
necessarily reducing impairments.
Such a model is inherent in much of
the work of neuropsychologists where Figure'3: Integration of self-regulation anil wHo models of disabilita

The Psychologist May 1996 207

 Modelsof disability
and examining the relationship between
puceptions of control and disability. In
the first study (Partridge & Johnston,
1989), we demonstrated that patients
suffering from a stroke or wrist fracture
had greater recovery of function if they
had higher beliefs in personal control
over their recovery.Perceivedconhol over
recovery and level of disability were as-
sessedat the begirning of the rehabiliation
period. At follow-up their levels of dis-
ability were predicted by perceived
control beliefs, even allowing for their
initial levels of disability. This finding
has been replicated in a larger sample of
stroke patients, assessingperceived con-
trol one month after discharge (Johnston,
Morrison, MacWalter & Partridge, sub-
mitted). Thesemental representationsof
their condition were indeed predictive
of subsequentrecovery six months after
discharge, even allowing for initial dis-
ability levels. Thus there is support for
the hypothesis that mental repre-
sentationspredict disability.
It was important to examine
whether this correlational finding re-
flected a causal pathwav, both from the
point of view of^undersianding the phe-
nomenon and as a basis for
intervention. For example, perceived
control might predict disability because
it was associated with additional re-
sources available in the patients'
environment, not because it ciused it.
The opportunity for an experimental
study arose in work with patients with
chronic pain (Fisher & Johnston, in
press). We manipulated levels of
perceived control and observedchanges
in disability levels, working within the
clinical psychologist'sclinical interview.
Using a procedure similar to mood in-
duction techniques, patients were
randomly allocated to recall occasions
when they had experiencedeither high
or low levels of control, and this
achieved the changes in perceived con-
trol predicted. The measureof disability
in this study was a lifting task, assess-
ing the amount of time that the weight
was held. Levels of disability were as-
sessed before and after the control
manipulation and results confirmed the
hypothesis: increased perceived control
led to reduced disability and vice versa.
This offers some support to the hy-
pothesis that control beliefs are causal.
Notice that these results are incom-
patible with the simple medical WHO
model: levels of disability have been al-
tered without altering physical
impairment. However, the results are
compatible with the integrated model
proposed in Figure 3. This model pro-
poses that the impact of mental
representationsis mediated by coping.
So in the study just described, one
would speculate that pafients having
the increasecontrol manipulation coped
with the lifting task differently from the
reduce control group.
However, other data are not suppor-
tive of this part of the model. In the
study of stroicepatients (Johnstonef al.,
submitted), perceived control predicted
disability at six months and it was hy-
pothesized that the mediating coping
responsewould be engagement in, and
practice of, rehabilitation exercises.
However, perceived control did not pre-
dict engagement in rehabilitation and
engagement in rehabilitation did not
predict disability. Further, there was no
evidence that general coping styles me-
diated the relationship between control
representation and disability. Similarly,
in studies of patients with neurological
diseases (motor neurone disease and
multiple sclerosis),representationshave
predicted outcomes when coping re-
sponses have not (Earll, Johnston &
Mitchell, 1993; Earll & Johnston, 1994;
Earll, 7994).Others using the self-regu-
lation model have similarly found that
representations but not coping were
predictive of disability (Petrie & Moss-
Morris, 1994).
It seems unlikely that this series of
results can be interyreted as spurious
failures to support the model. They
have involved a variety of conditions
and a variety of measures.They do all
deal with conditions where there is no
medical treatment and therefore, where
beliefs that coping responsesaffect out-
comes may be weak. However, the
model does not obviouslv incorporate
these findings. By makin! ttte moaet
explicit, it has been possible to chal-
lenge implicit notions of the process.
Coping does not appear to be taking the
role that seems to be implied in some
current thinking on disability, but cop-
ing models have drawn attention to the
role of mental representations.Thus we
need to look beyond coping models.

Mentol
representqlions
ond disobility
Social cognition models: The Theory
of Planned Behaviour and disabilitv
What is required to fit these data is a
model which postulates that mental
representations, including perceived
control, predict behaviours including
t
I
performance of activities such as those
used to assessdisabilitv. The most obvi-
I ous choicesare social iognition models,
including Azien's (1988) Theory of
Planned Behaviour which has been ap-
plied successfully to health behaviour,
e.g. in explaining why people engage in
exercise, or give up smoking. This the.
ory would predict that behaviours,
including behaviours described as dis-
ability, are determined by a
----) combination of behaaiouralintention and
TheoryofPlanned Beheviour
. perceioe d behaaiour
al contr ol.
Applying this theory to disability,
+ WEOmodel one would predict that the person with
impaired joints due to arthritis would
not walk because of a combination of
I proposednew relationships lack of intention to walk and the belief
that they cannot walk. While at first
Figure 4: Integrateil moilel of disability: WHO model anil glance one might assume that all dis-
Theory of Platned Behaoiour abled people would have the intention

208 May 1996 The Psychologist

 Modelsof disability
such as manipulating a wheelchair
through a doorway, but fail.
Various suggesticns have been
made for further cognitive variables ac-
ting in the final parts of the model. For

ffi&
application to disability, I propose two
additional variables:
r Internal Representations of the
Behaviour;
e Extemal Eliciting Cues.
Internal Representations of the Be-
to perform normal everydaY tasks, in viours and some similarities in the pat- haviour (IRB) refers to availability of
facf this is not the case.Having failed to tem of disabilities observed in people the components of the behaviour at
perform the task, PeoPle maY give uP with diverse impairments would result. some level within the individual, in-
ihe stmggle and even when there is re- Thus the shared Pattern observed in cluding how and when it is enacted; it
covery from impairment, the activity Table 1 might occur because PeoPle is not enough to intend to do what you
may not be performed
'longer becausethe indi- maintain the intention to perform beha- believe vou c,rn do if vou do not in fact
vidiral no has the intention. viours which are highly valued and one know hbw to do it, ai illustrated by the
According to the model, the intention would have to deduce that feeding one- example of the patient with unilateral
would bJdetermined by of a combina- self, getting out of bed and toileting neglect.
tion of changes in attitudes to the oneself were high, shared values. Such a Many theories include a concept of
'when I walk it is paintul shared value might also be influential this kind, rangrng from theories of skill,
behavbur(e.g.
and I dislike parn'), subiectiaenorm for via the subjective norm: if most people habit, action plan, implementation in-
'my sPouse does not believe that independent feeding and tention and behavioural conceptions of
the behwiour (e.g.
wish me to walk much and I am haPPY toileting are important, then they are cognitive rehearsal. IRB incorporates
to conor with his wishes') andperceiaed likely to communicate that expectation ideas about the knowledge of how to
'I to each individual, and this would ex- perform the behaviour and would in-
control oaer the behaaiour(e.g. am not
confident that I can walk'). Repeated plain the shared Pattem of disabilities clude the internal rePresentation
failure to perform the behaviour might observed. resulting from skill acquisition or habit
reduce perceived behavioural control Friends' and helPers' exPectations retraining methods which can be im-
and thereby intention. mieht play an important role via the portant in regaining control over tasks
-norm
This can be illustrated bY the re- sud'iective in changing the inten- such as walking following impairment.
sponseof one woman who was visited tion from setting to setting. In the study It also includes some elements of the
diring the stroke study. During the fol- of inter-rater agreement reported ear- conceptof'action plan'as proposedby
low-up visit, the woman demonstrated lier, one would Postulate that Schwarzer (1992) to bridge the gap be-
that she could now perform a particular rehabilitation therapists had higher ex- tween intention and action, in that it is
hand activity which she had not been Dectations than nurses. While the model a mental representation of a task to be
able to perform until that morning. Her ilso allows the possibility that patients enacted.Gollwitzer (1993)has proposed
expectaiion that the researcher would were less highly motivated to comply that'implementation intention' may
asl he. to perform the action (subiective with nurses,this does not fit clinical ob- mediate behaviour in the Theory of
norm) made her think of trying the task servation so well. The model would Planned Behaviour. He proposes that
(htention). Thus having overcome the predict that patients would be less suc- this works by ensuring that the beha-
in the crifical
underlying impairment was not enough iessful in overcoming disability where viour is remembered
to ensure-thal she overcarne the dis- there were no expectationsof them, in situation as the situation triggers the
'implementation intention' which has
abiliry and addition of the cognitions of either a neglectingor an over-Protective
the Theory of Planned Behaviour offer a environment. invblved anticipation of the scene of
more complete exPlanation. Current critiques of the Theory of action. As operationalued,'implemen-
Planned Behaviour point to its failure to tation intention' is an IRB' The IRB
The Theory of Planned Behaviour and predict behaviour adequately.One can conceDtis also consistent with informa-
the WHO model: an integrated model seehow the model might fail in predict- tion'from behavioural intervention
The Theory of Planned Behaviour can ine disability too, as it is possiblefor a progranunes/ where behavioural con-
be readily- integrated with the WHO palrient both to have the intention and iru.Iittg, cognitive rehearsal and other
model by proposing that physical im- to perceive that they have control over imaginlry techniques, as well as actual
pairment influences representations the behaviour,but itill to be unable to behivioural rehearsal including graded
irytrichln tum determine behavioural in- perform the activity. For example, a pa- exposure, are methods that serve to
^tient
tentions and behaviour assessed as with unilateral neglect following a stringthen the internal representationof
disabiliry Gigure 4). stroke can confidently attemPt a task, the behaviour and have been shown to
It is simple to imagine how an ac- increasethe likelihood of the behaviour'
quired o. itth"tit"d inipairment might The final component, External Elicit-
liad to attitudes towards performing ing Cues GEC) are environmental cues
normal activities of daily living and oit iege.s to action. EEC are akin to the
perceptions of conLrol over these acti- antecEients as specified in behavioural
vities- that would result in a low analyses and are necessary to explain
intention to perform the behaviour. So whv disabilitv may occur in some situ-
-others.
someone with spina bifida might find ations but not in For example,
that walking typically results in failure oatients learn that different behaviours
and, given a distite of failure, would ire expected in the physiotherapy and
devel6p a negative attitude toward nursing environments.
walking. For difficult activities, one ThJ model can be used to make
would expect them to be Performed some additional senseof the experience
only if they were of high value. Then of the girl having the behavioural pro-
one might expect patterns of disability granune to regain her ability to drink.
to refle& cultural values for the beha- The girl learns a more favourable

The Psychologist May 1996 209

 Modelsof disability
afritude toward drinking as it results in
valued outcomes and a more favourable
subjective norrn as she learns that both
family and staff wish her to perform
this behaviour. Increasing her opportu_
nities to leam served to re-deveiop her
intemd representationof the behaviour
quickly.
Social factors, such as the influence
of the nurses and rehabilitation thera_
pists operate in two main ways. First.
the subjective norrn refers to ihe indil
vidual's beliefs about the expectations
of others and their motivation to com_
ply - sterdam, Iulv 1994.
.with -their expectations pafients
might well see different professions as
Byi"g different expectafions. Second,
different professions will offer differeni
eliciting cues: thus a nurse may offer an
arm for support while a physiotheraoist
offers a stick to enable-the patieni to
complete the task for themselves.
This model of disability attempts to
integrate medical and rehabiliiation
models of disabiliry with psychological
models. It also aims to int6giate be[av_
ioural and social cognition models.
There is no reason why such models
should not be integrated other than the
historical reasonof their separatedevel_
opment. This is a working model _ a
model which fits current data on dis_
ability, which has not been explicitly
tested but which makes new prediction's
about factors which will infliuence dis-
$ility in addition to the physiological
Iimits of physical impairment'imphdh in
the simple WHO model.
Conclusions
The dominant WHO model of disabilitv
used in medical and rehabilitation settings
proposes that disability is determine?
by impairment resulting from diseaseor
disorder. As it stands, this model is in_
gapable of explaining many of the
Stugr in the field, inituaing observed
shared cumulative patterns oi aisaUitity
and systematic discrepancies between
the ratings of .tisability inaae Uy different
health professions. Some of the prob_
Iems can be overcome if disabiliw is
examined as a behaviour (rather than as a
causeofernotional distress)and psycholoei_
cal models of behaviour can Ueiriteeratfo
with the WHO model of disabilitvl
l,eventhal's self-regulation'model
proposes that mental representations in_
coping. If coping in tum affects
.flupncg
o"n y16"r, ircluding disability, then, in_
egmting this modelwittr ttre WHOmoaet
inboduces factors which might moderate
the impact of impairment 6n disabilitv.
However, this approach did not safi6_
tastority explain the results of studies
where copint did not predict disabilitv.
but mental representationsdid.
A new approach is proposed based
on social cognition moaeG of behav_
rour.
.While a variety of models is
av.ruable, examination of the Theory
of
Planned Behaviour suggests ttrat tnis
210
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model might be useful in studying dis_ Medical lournal, 14, 6t-65. (Also in
ability. lntegrating it with ttiu fuHO fohnston, M,.
Y.igtt, S. & Weinman, I. e9g5i. Measuies in
model leads to predictions that impair_ Health Psychology: portfolio.
"- A Llsn's Windsor:
ment inlluences attifudes, subiective NFER-NeGon.)
norms and perceived behavioural con_ Partridge, CJ. & |ohnston, M. 0989). perceived
trol over the behaviours characterized control and recovery from physical disability. BriF
tsh llurnal of Cliniul psychology,2S,*A.
as disability and that these cognitions
determine the individual,s inteition to l*ldq", C.f., fohnston, M. & Edwards, S.
(1982).Recovery from disability after stroke:
perform the behaviour. This intention is nor_
mal pattems as a basis for evaiuation. The l_ancet,
proposed as the main proximal determi_ L,373-375.
nant of the perform-ance, with other f9t{e X. & Moss-Morris, R. o994). The impact
factors, including perceived behavioural or rlness perceptions on disability in chrorui fa_
control, internal representations of the 9g"u slmdrome. Paper preented at the
behaviour and ext-ernal eliciting cues,
lntematio_nalSociety of BehaviouralMedicine, Am_
?lT ffi"g":ing the observeddfibiliry. Schwarzer, R. (1992).Self-efficaryin the adoption
This model can account for current and maintenance of health behaviour. fneor'J.ut
empirical observations which chal_ approaches and a new nodel. In R. Schwarzer
lenged the simple WHO model and GGG.d.t:.Self-.ffi.cary:
Thought Control of Action. Lon_
makes predictions relevant to impair_
qon: ilemlsDhere
ments and disabilities which have not Williarns, RG.A., fohnston, M., Willis, L.
&
as yet been tested.
Bennett, A.E. (t976). Dsability: a model and a
measurementtechniq\e. Bitish oumnl of prnm_
_ I
ttae and SocialMedicine, 30.7t_78.
Acknowledgemenls $li*,
D.A., Nicholas, M.K., Richardson,
C.E., Justins, D.M., Chanberlain,
I would like to thank my rmearch collaborators: l:Y" _P_ith_el
J.H., Harding, V.R., Ralphs, J.A., Iones, S.C.,
Louise Earll, Keren Fisher, Joan FouJkes, Hafrm ureudonne, I., Featherstone,
f.D., Hodgson,
uudmMdsdottir. Jane Knight, Roshan Madmahan, D.R., Ridout, K.L. & Shannon, f.Nf.
<iqS3)_
val. Morrison, Sheina Orbell, Cecily partridge, Ev.at.u3lionof a cognitive behaviour programme for
Pollard, Wurdy Srmpson and
Beth
Julie WiUiuir, ,"J rehabilita-ting pati€nts with chronii piin. Britisft
Momg.lodres that have supported this research:
lournal of GmeralPractice,43,513_51g.
Dnnsn Heart tomdation, Chest Heart and Stroke
(scotland), Department World Health Organisation Ogg0).Intemational
:c-ssfiltign of Health,
Ltassllcatrcn of Impairments. Disabilities and
Medical Reearch Comcil, Motor Neuone Disease
Association, Nuffield provincial Hospitals Hand.rcaps. Geneva:WHO.
Truil
and the ftottish Home and Heatth Depirtment.
Professor lohnston is taith the School
of
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