The ICFBest of both worlds or the medical model in

disguise?

David Webb

DSARC Conference, Sydney, June 2009

ICF = International Classification of Functioning, Disability and Health (WHO 2001)

• aims to be an “operational” model of disability

• supersedes (medical model) ICIDH

• claims to be a marriage of social and medical models, giving the best of both worlds

• has many fine elements to it ... but ...

Health Condition(disorder or disease)

Body Functions Activities ParticipationAnd Structures

Environmental Factors

Personal Factors

The ICF

Health Condition(disorder or disease)

Body Functions Activities ParticipationAnd Structures

Environmental Factors

Personal Factors

Medical diagnosisThe ICF

Health Condition(disorder or disease)

Body Functions Activities ParticipationAnd Structures

Environmental Factors

Personal Factors

Impairment

Medical diagnosisThe ICF

Body Functions Activities ParticipationAnd Structures

Personal Factors

Impairment

Health Condition(disorder or disease)

Medical diagnosis

Environmental Factors(Physical, Social,

Attitudinal)

The ICF

Body Functions Activities ParticipationAnd Structures

Impairment

Health Condition(disorder or disease)

Medical diagnosis

Personal Factors

Empty

Environmental Factors(Physical, Social,

Attitudinal)

The ICF

Body Functions Activities ParticipationAnd Structures

Impairment

Health Condition(disorder or disease)

Medical diagnosis

Personal Factors

Empty

Environmental Factors(Physical, Social,

Attitudinal)

Disability

The ICF

Social Model of Disability

Person

Disability

Society

Disability arises through the interaction of a person with the society they live in – i.e. it is not an attribute of the person.

Social Model of Disability

Person

Disability

Society

Impairment

More precisely, disability is social discrimination against a person with an “impairment” ...

Social Model of Disability

Person

Disability

Society

Impairment

More precisely, disability is social discrimination against a person with an “impairment” ...

Which makes disability a human rights issue ...

Social Model of Disability

Person

Disability

Society

More precisely, disability is social discrimination against a person with an “impairment” ...

Impairment

Which makes disability a human rights issue ...

Which has now led to the CRPD!

Strong and weak versions of social model

Strong• disability is entirely due to environment• i.e. without social discrimination,

“impairment” is just a health issue

Weak• recognises social factors ... but also ...• impairment contributes to experience of

disability

Very weak version accuses strong model of denying the (biological) reality of impairment – e.g. Tom Shakespeare.

Body Functions Activities ParticipationAnd Structures

ICF - revisited

Impairment

Health Condition(disorder or disease)

Medical diagnosis

Personal Factors

Empty

Environmental Factors(Physical, Social,

Attitudinal)

Disability

Body Functions Activities ParticipationAnd Structures

Impairment

Health Condition(disorder or disease)

Medical diagnosis

Environmental Factors(Physical, Social,

Attitudinal)

Disability

ICF - revisited

Body Functions Activities ParticipationAnd Structures

Disability

Impairment

Health Condition(disorder or disease)

Medical diagnosis

Environmental Factors(Physical, Social,

Attitudinal)

PersonICF - revisited

Problems

• the person – and their personhood – is absent

• “health condition” (medical diagnosis) is the defining characteristic, which many PWD reject

• impairment is physiological, anatomical

(medical)

• impairment is “deviation or loss”

• disability is abnormality rather than diversity

Beware – the “health” in WHO

• WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

• but frequently the usage of “health” in WHO documents could only mean “medical health”

• e.g. “health condition”

• which in turn is then defined in narrow, biological, physiological, anatomical terms – i.e. medical

• e.g. “impairment”

• “including psychological functions” ... leading to ...

Special problems for psychosocial disability

• not recognised without a psychiatric diagnosis

• but science of psychiatric diagnosis is

contested • psychological distress reduced to biological

impairment of the brain

• psychiatric diagnosis as discrimination:

• environmental factor contributing to

stigma

• foundation of psychiatric force

Social Model of Disability - revisited

Person

Disability

Society

Impairment

Social Model of Disability - revisited

Person

Disability

Society

(Imputed) Impairment

Person

Disability

Society

Activity limitations

Participation restrictions

Functionaldisability

Social Model of Disability - revisited

(Imputed) Impairment

Person

Disability

Environment

Activity limitations

Physical

Social

Attitudinal

Barriersor

Facilitators

Participation restrictions

Functionaldisability

Social Model of Disability - revisited

(Imputed) Impairment

Person

Disability

Environment

(Imputed) Impairment

Activity limitations

Physical

Social – incl. medical

Attitudinal – incl. medical

Participation restrictions

Functionaldisability

Social Model of Disability - revisited

Conclusions

• the ICF has many strengths and uses and is not going to go away any time soon

• but at its core (i.e. health condition) the ICF is still ultimately a medical model of disability

• it is not an alternative to the social model of disability with its emphasis on human rights

• medicalisation of disability remains a negative environmental factor

• as CRPD notes, concept of disability is evolving

• social model can accommodate ICF strengths rather better than vice versa