'On autonomy and participation in rehabilitation'

Cardol, de Jong and Ward have written a paper emphasizing autonomy as the ultimate goal in rehabilitation, being a basis for participation but adding a personal perspective. By retaining the highest possible level of autonomy, participation can be maximized. They also clearly distinguish executional autonomy (the ability to act as one wishes) from decisional autonomy (the ability to make decisions without external restraint). It is pointed out that a disabling illness may diminish executional autonomy but not necessarily decisional autonomy. As mentioned, an important product, but also a basic element for a successful decisional autonomy is self-realization. The paper by Cardol and coworkers only touches upon the coping process being an essential element of rehabilitation. By realizing the capacity and opportunities after a disease or injury leading to chronic disability, the person goes through a coping process, more or less successful, with an ultimate aim of being partly reorientated towards new and vital life goals. In that process, the rehabilitation personal has an important role, both by giving the clinical background and prognosis of the disability, but also by providing new ideas and opportunities for modi®ed or new activities. Also in that process, it is important to maintain the autonomy of the disabled person. As pointed out by the authors, at the onset of a disease a comforting and directive approach may take priority over enablement, but at a later stage these strategies could severely restrict autonomy. Rehabilitation personal must be aware that this may reduce autonomy in decision making during the coping process, specially if the same personal takes part at diVerent stages in the rehabilitation process. In spite of lack of continuity, a change of rehabilitation setting as well as of personal may therefore be to an advantage at a speci®c stage in the rehabilitation. Another important aspect in the rehabilitation process, especially when the person has left the initial rehabilitation period and is living with her/her disability in the community, are the environmental factors. There has an in ̄uence, more or less, on all activities in daily life and on the ability to participate in diVerent life roles. Also with respect to modi®cations of the environment, the autonomy of the persons must be taken into account. As an example, adapting the ̄at or house or moving to another apartment better equipped for disabled persons, may increase the possibility for activity and reduce dependence, e.g. to move in and out of the house. However, it may at the same time have an impact on the social situation in losing contacts with neighbours, which will be of disadvantage. Increased participation in one situation may lead to reduced participation in another situation. Autonomy is to be able to make the decision, which may be very di cult, especially if the disabled persons has some reduction of cognitive abilities. Cardol and coworkers write that money is the single most important means of enhancing autonomy for disabled people, as for others. This might be true for achieving basic needs of food, housing, transportation etc. When this is achieved in a manner maintaining the autonomy, other aspects such as personal relationships and family might be as important. For many disabled persons the helper, from the family or from the community, or the assistant are perceived as the closest persons. The attitudes of those persons are therefore of ultimate importance for autonomy and participation. An important reform was made in Sweden in the early 90’s, the so called Handicap reform, where one of several rights given to a disabled person with a certain level of disability, was to have personal assistants and get economical support for that. The assistants we employed either by the disabled him/herself, a cooperative agent or a community organization. The important feature is that the disabled person is the leader of the work of the assistants and can ask them to do what is looked upon as DISABILITY AND REHABILITATION, 2002; VOL. 24, NO. 18, 975 ± 976