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 people with disabilities. 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.
Models are influenced by two fundamental philosophies. The first sees people with disabilities as dependent upon society. This can result in paternalism, segregation and discrimination. The second perceives people with disabilities as customers of what society has to offer. This leads to choice, empowerment, equality of human rights, and integration.
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 came about as “modern” medicine began to develop in the 19th century, along with the enhanced role of the physician in society. Since many disabilities have medical origins, people with disabilities were expected to benefit from coming under the direction of the medical profession. Under this model, the problems that are associated with disability are deemed to reside within the individual. In other words, if the individual is “cured” then these problems will not exist. Society has no underlying responsibility to make a “place” for persons with disabilities, since they live in an outsider role waiting to be cured.
The individual with a disability is in the sick role under the medical model. When people are sick, they are excused from the normal obligations of society: going to school, getting a job, taking on family responsibilities, etc. They are also expected to come under the authority of the medical profession in order to get better. Until recently, most disability policy issues have been regarded as health issues, and physicians have been regarded as the primary authorities in this policy area.
There is a direct correlation between the medical model in disability public policy, most notably in the Social Security system, in which disability is defined as the inability to work. This is consistent with the role of the person with a disability as sick. It is also the source of enormous problems for persons with disabilities who want to work but who would risk losing all related public benefits, such as health care coverage or access to Personal Assistance Services, since a person loses one’s disability status by going to work.
The medical model also 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 Organization’s (WHO’s) definitions, which was devised by the medical profession:
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 fulfillment of a role that is normal for the individual.
From this, it is easy to see how people with disabilities might become stigmatized 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 recognizes that a poor economic climate will adversely affect 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 labor market.
In simple terms, the Medical Model assumes that the first step solution is to find a cure or to use WHO terminology, make a disabled people more “normal”. This 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. Policymakers are limited to a range of options based upon a program of rehabilitation, vocational training for employment, income maintenance programs and the provision of aids and equipment.
This Functional Limitation (Model) Model has dominated the formulation of disability policy for years. Although we should not reject out-of-hand its therapeutic aspects which may alleviate the physical or mental condition of many people with disabilities, it does not offer a realistic perspective from the viewpoint of people with disabilities 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 institutionalization and segregation. This restricts disabled people’s opportunities to make choices, control their lives and develop their potential.
This model is similar to the Medical Model; it regards the person with a disability as in need of services from a rehabilitation professional who can provide training, therapy, counseling or other services to make up for the deficiency caused by the disability. Historically, it gained acceptance after WW II when many disabled veterans needed to be re-introduced into society. The current Vocational Rehabilitation system is designed according to this model.
People with disabilities have been very critical of both the medical model and the rehabilitation model. While medical intervention can be required by the individual at times, it is naïve and simplistic to regard the medical system as the appropriate focus for disability related policy matters. Many disabilities and chronic medical conditions will never be cured. Person with disabilities are quite capable or participating in society and the practices of confinement and institutionalization that accompany the sick role are simply not acceptable.
Expert/Professional Model of Disability
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 person with a disability. 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.
Customer/Empowering Model of Disability
This is the opposite of the Expert Model. Here, the professional is viewed as a service provider to the personal with a disability and their family. The person with a disability decides and selects what services they believe are appropriate while the service provider acts as consultant, coach and resource provider.
Recent operations of this model have placed financial resources into the control of the person with a disability, who may choose to purchase state for private care or both.
Economic Model of Disability
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 the 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 terns, a socially desirable policy of increasing participation in employment. Classical economic laws of supply and demand stipulate that an increase in the labor market results in decreased wages. Arguably, extending access to work through equal opportunities reduces an employer’s labor costs, but other factors come to play.
The value of labor 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 recognize compensations for any loss in employing less-productive disabled employees through kudos, publicity, customer alignment and expansion arising from their presentations as an organization with community values. However, employers are not generally altruistic and hold the economic viability and operational effectiveness or their organization 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 employees for loss of earnings, or the employer for the loss of productivity? The first carries stigma for the person with a disability by underlining their inability to match the performance of work colleagues. With the latter, difficulties arise in 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 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 stigmatization of people with disabilities as a burden on public funds rather than partners in creation of general social prosperity.
Social security benefits are not designed to remove people with disabilities from poverty. The policymaker needs to balance equity (the right of the individual to self-fulfillment 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, globalization and extraordinary events such as wars
The Tragedy/Charity Model depicts people with disabilities 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 children with disabilities are depicted alongside young “victims” of famine, poverty, child abuse and other circumstances. While such appeals raise considerable funds for services and equipment which are not provided by the state, many people with disabilities find the negative victim-image thoroughly offensive. In fact Children in Need has been described as “televisual” garbage…oppressive to people with disabilities. 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.
Because people with disabilities 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 of “care”. Although highly praiseworthy in many respects, it carries certain dangers. Many 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 – institutionalizing people with disabilities. Give the choice, many, if not most would opt for community life with adequate support.
The idea of 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 patronizing; the second limiting upon the choices open to people with disabilities. Also, employers will view people with disabilities 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.
The Moral Model is historically the oldest and is less prevalent today. However, there are many cultures that associate disability with sin and shame, and disability is often associates with feelings of guilt, even if such feelings are not overtly based in religious doctrine. For the individual with a disability, this model is particularly burdensome. This model has been associated with shame on the entire family of a person with a disability. Families have hidden away their loved ones with disabilities, keeping them out of school and excluded from any chance at having a meaningful role in society. Even in less extreme circumstances, this model has resulted in general social ostracism and self-hatred.
The Religious Model views disability as a punishment inflicted upon an individual or family by an external force. It can be due to misdemeanors committed by the person with a disability, someone in the family or community group. Birth conditions can be due to actions committed in a previous reincarnation.
Sometimes the presence of “evil thoughts” is used to explain differences in behavior, especially in conditions such as schizophrenia. Acts of exorcism or sacrifice may be performed to expel the negative influence, or recourse made to persecution or even death of the individual who is “different.”
In some cases, the disability stigmatizes 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.
Rights Based Model
In more recent times, however, the notion of “disability” has come to be conceptualized as a socio-political construct within a rights-based discourse. The emphasis has shifted from dependence to independence, as people with disabilities have sought a political choice, and become politically active against social forces of ableism Disability activists, in engaging in identity politics, have adopted the strategies used by other social movements commanding human and civil rights, against such phenomena as racism and sexism.