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Disability and Rehabilitation, October November 2007; 29(20 21): 1604 1615

A Good Lives Model of clinical and community rehabilitation

RICHARD J. SIEGERT1, TONY WARD2, WILLIAM M. M. LEVACK1 &


KATHRYN M. MCPHERSON3
1

Rehabilitation Teaching and Research Unit, University of Otago, Wellington, 2School of Psychology,
Victoria University of Wellington, Wellington, New Zealand, and 3Health and Rehabilitation Research Centre,
AUT University, Auckland, New Zealand

Abstract
Aims of the paper. The aim of this paper was to introduce the Good Lives Model, originally developed for offender
rehabilitation, to the clinical rehabilitation community. We argue that this model has considerable promise, both as a
thinking tool and as an integrative framework emphasizing the centrality of the person in clinical and community
rehabilitation for complex and chronic health conditions.
Key findings and implications. The essential features of a good rehabilitation theory are first outlined. These are the general
principles and assumptions that underpin a theory, the aetiological assumptions and the intervention implications. The Good
Lives Model for clinical rehabilitation is then described in terms of these three components of a good rehabilitation theory.
Conclusions and recommendations. The Good Lives Model has considerable promise as a tool for integrating many diverse
aspects of current best practice in rehabilitation while maintaining the individual client as the central focus. At the same time
it is provisional and further theoretical development and empirical support is required.

Keywords: Good Lives Model, rehabilitation theory, primary goods, client-centred rehabilitation

Introduction
The aim of this paper was to introduce the Good
Lives Model, originally developed for offender
rehabilitation, to the clinical rehabilitation community [1]. In a recent paper we argued that theory
development in rehabilitation has lagged behind the
development of an empirical foundation for contemporary rehabilitation [2]. That paper argued that
it is not sufficient to prove what works in
rehabilitation we also need to discover how it
works. An analogy can be drawn to the discovery of a
new medication that is found to be effective for a
particular disease. At first it is sufficient to just know
that this medicine is effective in treating the illness.
However, research quickly turns to understanding
the exact biochemical mechanism and physiological
pathway by which this new drug acts. Understanding
how the new drug works allows for the development

of improved variants of the original treatment. It can


also permit a better understanding of any drug sideeffects and suggest how to minimize potentially
dangerous interactions with other medicines. Thus
understanding how rehabilitation interventions or
programmes work, in addition to knowing how well
they work, should contribute to a more effective,
precise and safe science of rehabilitation1.
Our point here is that a mature science is
characterized by rich theoretical models that coexist
with sophisticated methods of testing these theories
such as occurs in biology and physics. This begs the
question as to how we might set about developing a
theory or theories of rehabilitation. In the absence of
a strong theoretical tradition in our field, one
potentially fruitful strategy for theory development
is to borrow and test out existing concepts, constructs and theories from neighbouring disciplines
such as medicine, philosophy, psychology, and

Correspondence: Dr Richard J. Siegert, Department of Pallative Care, Policy and Rehabilitation, School of Medicine at Guys, Kings College and St Thomas
Hospitals, Kings College London, Weston Education Centre, 3rd Floor, Cutcombe Road, Denmark Hill, London SE5 9RJ. E-mail: richard.siegert@kcl.ac.uk
ISSN 0963-8288 print/ISSN 1464-5165 online 2007 Informa UK Ltd.
DOI: 10.1080/09638280701618794

Good Lives Model


sociology. For example goal-planning is considered
to be a fundamental component in rehabilitation
although much of the theoretical and empirical
justification comes from research in organizational
psychology, sports psychology and education. We
have noted elsewhere that there are risks inherent in
assuming that research on factory workers, athletes
or university students is equally valid when applied to
rehabilitation patients or clients [3 5]. However, as
long as theoreticians are aware of the complexities
involved in transplanting a theory from one context
to another and assuming that the relevant issues are
worked through, this strategy has much to offer.
Also, given the inter-professional nature of rehabilitation it makes sense that other disciplines such as
bioethics, medicine, neuroscience, nursing, and
psychology will have much to contribute to the
theoretical foundations of the field.
One approach, the Good Lives Model (GLM)
developed by Tony Ward and colleagues, [1,6]
seems to demonstrate potential theoretical and
practical value for rehabilitation. The GLM was
initially developed as a model for the rehabilitation of
criminal offenders. For a detailed outline of this
model and how it is relevant to work with offenders
we refer the reader elsewhere [1,6]. Despite GLMs
purpose originally being for a completely different
population, it seems to have potential as a theoretical
framework or thinking tool for integrating many of
the elements of current best practice in clinical and
community rehabilitation. It could be said that the
GLM represents little that is completely new to
rehabilitation. However, in offering a new way of
integrating and thinking about existing components,
it offers new challenges and new ways forward.
The first part of this paper proposes what we
consider to be the essential components of a good
theory of rehabilitation providing a context for
describing the principle elements of the GLM. The
second part of the paper explores the model and how
it might be usefully applied in clinical rehabilitation
arguing its particular relevance to populations of
patients with chronic and complex health conditions
(e.g., stroke, multiple sclerosis, traumatic brain
injury and spinal cord injury), who often face long
periods of rehabilitation and major life adjustments.
From the outset we emphasize that the suggested
application of the GLM to rehabilitation is provisional in nature and has yet to be studied empirically.
It would be premature to begin applying, let alone
evaluating this model, until it is fleshed out further.
This article is the start of that process. As we have
previously argued exploring theories such as the
GLM can hopefully further a science of rehabilitation by generating new ways of explaining clinical
phenomena and developing original hypotheses for
testing scientifically [2].

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What is a rehabilitation theory?


This section will describe those features required to
develop a working theory of rehabilitation what is a
good rehabilitation theory and what does it do? In
brief, a theory can be considered a description of an
unobserved aspect of the world and may consist of a
collection of interrelated laws or a systematic set of
ideas [7]. Theories are used to both explain and
predict phenomena. Explanation is the application of
a theory in order to help understand certain
phenomena and is backward looking (i.e., it helps
us to understand why a particular outcome happened). By contrast, prediction is forward looking
and is concerned with the forecasting of outcomes
within a person, group, institution, or physical
system. So for example a theory might help us
explain why some people failed to return to work
quickly after a relatively minor lower back injury. Or
a theory might enable us to predict which clients with
brain injury will respond best to specific approaches
to vocational rehabilitation.
We propose that there are three levels or components necessary for any satisfactory theory of
rehabilitation: (a) A set of general principles and
assumptions that specify the values that underlie
rehabilitation practice and the kind of overall aims
for which clinicians should be striving; (b) aetiological assumptions that serve to explain the disablement process and how rehabilitation minimizes
disability and maximizes participation; and (c) the
implications of the first two principles (a and b) for
identifying a mode of action for interventions and
thereby also clarifying both process and outcome
variables for evaluation. It is useful to think of the
three levels as hierarchically structured and each one
necessary for the level below it. To illustrate from the
top down: To be able to set clear treatment targets
(component C) it is necessary to hold some causal
assumptions about the factors that contribute to
disability and also the factors that contribute to or
enhance activity and participation (component B). In
turn, the type of causal assumptions endorsed
depends on the overarching assumptions about
human nature and orientations toward intervention
held by the health workers and services involved
(component A). This proposed framework for a
theory of rehabilitation is presented in Figure 1, with
each component discussed in greater detail below.

Component A: General principles and


assumptions
Metaphysical
Metaphysical assumptions concern the nature of the
entities involved in the rehabilitation process and

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R. J. Siegert et al.

Figure 1. Components of Rehabilitation Theory.

assumptions about their core features. As rehabilitation is a fundamentally human enterprise, one in
which humans help other humans or themselves, the
essential metaphysical concern has to do with human
nature in general. At first glance such philosophical
concerns might appear rather abstract or esoteric
when considered in relation to the practice of
rehabilitation. However, even a casual reading of
the World Health Organizations International Classification of Functioning, Disability and Health
demonstrates certain implicit assumptions about
human nature [8]. For example, the emphasis on
social participation and the inclusion of chapters on
topics such as domestic life, interpersonal interactions, relationships and civic life, all reflect basic
assumptions about what it means to be human and
what is valued in human lives (see Leplege et al. [9]
in this issue).
Another metaphysical assumption is our belief
about the capacity for individuals to change, to grow,
to adapt and even to thrive in oppressive circumstances. Can people learn new and more adaptive
ways of coping after trauma or in the face of chronic
illness? Or is this ability to adapt and develop as a
person in trying circumstances fixed by genes, social
history or personality? As we have noted elsewhere,
even the concept of motivation is a controversial
one in rehabilitation literature [2,3,10]. An important related issue concerns our basic assumptions
about the process of rehabilitation. Is it primarily a
largely technical process (see MacLeod and McPherson [11] in this issue) whereby expert clinicians treat
a passive or dutiful patient or is some notion of

engagement and active participation, even self-help


assumed? Do we consider that the meaning (and
value) of rehabilitation in inpatient facilities is the
same or different to that which happens after
someone leaves hospital and the care of health
professionals (see Cott et al. [12] in this issue)? Is
disability an inevitable consequence of major physical impairment or as proposed in social models more
the effect of societys failure to accommodate people
with disabilities? [13,14] Are the persons feelings
associated with sudden impairment just as disabling
as the impairment or the environment and thus a
potential focus for intervention (see Patston [15] in
this issue)? Each of these questions highlights certain
metaphysical assumptions, mostly implicit, that play
a crucial role in shaping rehabilitation.
Epistemological
Epistemological assumptions spell out what constitutes knowledge and how research that informs
practice should be undertaken. This might include
recommendations about research designs, levels of
evidence, analytic strategies and what types of
evidence are admissible in determining best practice.
The importance of epistemological assumptions is
evident in discussions about the relative value of
qualitative versus quantitative data. Typically in such
discussions, constructivists value personal or lived
experience, while positivists favour more objective
data from psychometrically sound measures. In the
UK, the Medical Research Council has recently
recommended that the evaluation of complex health

Good Lives Model


interventions should include both quantitative and
qualitative methods and that these should follow a
preclinical phase that involves a careful review of
the theoretical basis for a specific intervention [16].
Values
Values play a significant role in rehabilitation theory
as they direct the goals of rehabilitation and
constrain therapeutic and research endeavours.
Examples of values in rehabilitation might include
that we should not expose individuals to empirically
unsupported interventions or that all treatments
should be implemented with the informed consent
of patients who understand the relative risks and
benefits. Curtis has argued that the field of rehabilitation is/should be characterized by four core values
[17]: (i) Altruism (helping others based upon a belief
in the dignity and worth of every individual);
(ii) Choice (that facilitates integration, participation
and normalization); (iii) Empowerment (independence and self-determination); and (iv) Equality and
Individualism (autonomy, freedom, responsibility
and self-reliance).
Normative principles
Finally, normative principles regarding the justifications for intervening in the first place underpin all
rehabilitative theories. Normative principles tell us
not how things are, but how they ought to be. What
gives one person or profession the right to intervene
in another individuals life? Under what circumstances are such interventions justified? Are there
situations where it is justifiable to not offer such an
intervention (e.g., in the later stage of certain
terminal conditions or when medical resources are
scarce) or to provide interventions when a person is
unable to provide consent (perhaps due to communicative, cognitive or psychiatric impairments)?

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(Component C). Rehabilitation theories should not


be confused with aetiological theories of a very
general nature (e.g., theories of health and disease)
or of specific types of disorder (e.g., aetiological
factors in stroke).
At one level this seems rather straightforward. The
aeotological factors of stroke would suggest that
insult in the left frontal lobe of the brain can produce
speech impairment and right-sided hemiplegia. Basal
ganglia dysfunction in Parkinsons disease can lead
to rigidity, bradykinesia and tremor. However
rehabilitation outcomes can also vary considerably
for individuals with the same condition and similar
levels of impairment. In certain conditions, such as
lower back pain and mild traumatic brain injury, this
variability in outcome is especially marked. Even in
terminal conditions such as motor neuron disease,
where there is a relatively predictable and rapid
course of the illness, variation exists in the extent to
which individuals and their families are able to cope
with the illness and find some meaningful existence
despite the ravages of the disease. One of the
challenges for rehabilitation theory is to explain
why individuals vary so widely in their responses to
similar pathology and levels of impairment, and to
use this understanding to design more effective
interventions.
The major function of any theory of rehabilitation
would be to provide a comprehensive guide to
clinicians when working with clients and their
families. In this regard, the aetiological components
of such theories are likely to be quite general in
scope, serving only to sketch out the major causal
factors (e.g., physical pathology and impairments,
motivation, impaired executive functioning, nutrition, aerobic fitness, financial deprivation, social
support, public attitudes, legislation and policy,
etc.) that might limit or increase activity and
participation.
Component C: Intervention implications

Component B: Aetiological assumptions


Aetiological assumptions help health professionals
and therapists (and hopefully their clients) to identify
goals for treatment and to understand which goals
are the most important and why. These assumptions
are also important in the process of identifying the
barriers and facilitators for the individual with regard
to their maximal participation in society. The
aetiological components of a rehabilitation theory
will clearly link to the general principles and
assumptions of rehabilitation (Component A) and
will incorporate these in any causal claims. The
aetiological components bridge the gap between core
assumptions (Component A) and the specific rehabilitation intervention for any individual client

The third component of a good rehabilitation theory


and the most salient for practitioners is the implications for intervention the how to do it and how
do you know when youve succeeded guide for
effective rehabilitation strategies. A robust rehabilitation theory needs to specify the most suitable style
and form of treatment; including the approach health
professionals should take when engaging with patients and/or with members of their broader social
network. This might include issues such as the
clinicians approach to therapeutic relationships, the
way clinicians attempt to directly influence patient
motivation, as well as the attitudes they carry with
them in the rehabilitation environment. Implications
for intervention in rehabilitation should include

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recommendations for assessment, so that specific


therapies or treatments can be matched to an
individuals unique constellation of impairments
and activity limitations as well as their strengths
and abilities. For example, given the complex needs
of many individuals in rehabilitation, it is considered
important to involve an inter-professional team (e.g.,
neuropsychologist, nurse, occupational therapist,
physiotherapist, physician, and social worker etc.),
so that a comprehensive assessment of physical,
psychological and social priorities can be made.
Beyond this, however, it is incumbent on a theory
to explain how the intervention itself is supposed to
work. In other words, what are the proposed change
mechanisms at work in the intervention process
itself? This issue has even been referred to as the
black box of rehabilitation, in recognition of the fact
that even when we know what works we frequently
understand little about the process by which interventions achieve their positive outcomes [18]. There
are a number of elements in rehabilitation that might
be considered highly important, such as the use of
the ICF as a standardized language to describe and
discuss functioning and disability [19,20], the
importance of interdisciplinary teams [21] and use
of goal planning for structuring the process of
rehabilitation, building working relationships between stakeholders and enhancing motivation [4].
However the process by which these elements are
linked to the individual patients unique medical,
social and existential circumstances remains vague.
It is even less clear how these elements interact with
characteristics of the individual patient such as
education, motivation, self-efficacy, ethnicity and
cultural background to promote autonomy and
independent living.
A Good Lives Model of clinical rehabilitation
The question of what constitutes or makes for a
good life is one that has occupied philosophers for
centuries although it is only in recent years, with the
growth of the positive psychology movement, that it
has become a major concern for health researchers.
The rise of positive psychology calls for a shift away
from a focus on psychopathology and viewing mental
health as the absence of symptoms toward a greater
concern with the positive aspects of human flourishing such as optimism, resilience, positive responses
to loss or trauma, humour, hope and spirituality
[22]. The GLM is an example of a positive
psychology or strengths-based approach to rehabilitation although it was developed independently of
the positive psychology movement. In the following
discussion, the GLM is described using the components of our proposed framework for a theory of
rehabilitation.

General principles and assumptions


of a GLM of rehabilitation
There are a number of assumptions underlying the use
of the GLM in rehabilitation. We will describe five of
the more significant assumptions here. The GLM
starts from the initial assumption that all human beings
are concerned with seeking certain fundamental or
primary goods (e.g., knowledge, friendship, creativity,
physical health and mastery). Primary goods are
actions, states of affairs, personal characteristics,
experiences and states of mind that are viewed as
intrinsically beneficial to human beings and are
therefore sought for their own sake rather than as a
means to some more fundamental end [6,23].
According to the GLM, these primary goods have
their source in human nature and have evolved
through natural selection to help people establish
strong social networks and to survive and reproduce.
Arnhart [24, p. 29] labels these goods natural desires
because they are so deeply rooted in human nature
that they will manifest themselves in some manner
across history in every human society. Psychological,
social, biological, and anthropological research provide evidence for the existence of at least ten distinct
groups of primary human goods including: [25 31]
. Life (including healthy living and physical
functioning);
. Knowledge;
. Excellence in play and work (i.e., mastery
experiences);
. Agency (i.e., autonomy and self-directedness);
. Inner peace (i.e., freedom from emotional
turmoil and stress);
. Relatedness (including friendship, romantic
and family relationships);
. Community;
. Spirituality (in the broad sense of finding
meaning and purpose in life);
. Happiness;
. Creativity.
Although this list is extensive it is not meant to be
exhaustive. However we argue that the available
research indicates that the goods listed above are
likely to appear in some form on any list generated
[6,25,26,28,31].
In addition to these primary goods, Instrumental or
secondary goods provide particular ways or means of
achieving primary goods. It is possible therefore to
subdivide the primary goods noted above into
subgroups. For example, the good of relatedness
could be further divided into instrumental goods
such as the provision and experience of mutual
support, sexual activity, personal disclosure, physical
comfort, and emotional reassurance.

Good Lives Model


An especially significant characteristic of the GLM
is that the goods are plural rather than singular, and
therefore a fulfilling life will most probably require
access to all (or at least a range) of the primary goods
even though individuals can legitimately vary in the
way they weight or rank them. This means that there
are multiple sources of motivation and that each has
their origin in the evolved nature of human beings. It
is also important to emphasize that the goods
referred to in the GLM model are prudential rather
than moral or epistemic goods. That is, they are
experiences and activities that are likely to result in
enhanced levels of well-being rather than morally
good actions or features of good theories. There is no
assumption in the GLM that individuals are inherently or naturally good in an ethical sense. Rather,
the presumption is that, because of their nature,
human beings are more likely to function well if they
have access to the various types of goods outlined
above. In a rehabilitation context this assumption
simply means that clients will be happier and more
satisfied with their life to the extent that they can
achieve good health, autonomy and self-directness,
meaningful relationships, mastery experiences and
so on.
The second major assumption derived from the
GLM is that while goods in themselves do not have
inherent moral or epistemic value, rehabilitation as a
process aiming to promote achievement of goods is
highly value-laden. That is to say it involves a variety
of different types of values including, but not limited
to, prudential values (what is in the best interests of
individual clients), utilitarian values (what is in the
best interests of the community), and epistemic or
knowledge-related values (what are our methods of
best practice). The construction of a meaningful and
adaptive narrative identity (e.g., after a severe
traumatic brain injury or spinal cord injury) involves
orientating individuals to the range of primary goods
and providing them with the resources to secure
better lives in ways that are personally satisfying and
socially acceptable.
Following on from these first two assumptions, a
third assumption derived from the GLM suggests
that rehabilitation interventions should aim to
promote the individuals relevant goods at the same
times as (and without compromising) independent
living. This is because independent living is in itself
an important part of the primary good related to
agency and autonomy, and therefore should itself be
an objective of rehabilitation. In this way, the GLM is
compatible with DeJongs Independent Living
paradigm for rehabilitation [32]. Thus, when viewed
from the perspective of the GLM, a major aim in
rehabilitation should be to help individuals to
construct a life plan that has the basic primary
goods, ways of effectively securing them built into it

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and does not involve undue dependence on others.


For this to occur a successful rehabilitation plan
must ensure the necessary internal and external
conditions exist. This may require developing the
internal conditions through physiotherapy, occupational therapy and education (e.g., enhancing mobility and general fitness, mastering activities of daily
living and vocational retraining) and also promoting
the external conditions through advocacy, working
with community agencies and influencing government policy (e.g., financial resources, assistive
technology and accessible environments).
A fourth major assumption is that the process of
rehabilitation requires not just the targeting of
problems in clinical rehabilitation this being
specific impairments and activity limitations but
that it will often entail the holistic reconstruction of
the self. The GLM emphasizes an overarching
construct of personal identity and its relationship to
an individuals understanding of what constitutes a
good life. According to theory and research on
identity development and personal strivings, individuals self-conceptions directly arise from their basic
value commitments and the way in which they are
expressed in their daily activities [27,28,33]. In other
words, people acquire a sense of who they are and
what really matters from what they do. Individuals
who have survived a spinal cord injury are faced with
a large number of challenges such as learning to
manage their bladder and bowel functions and
achieving independent mobility in some form (most
likely using a wheelchair or powerchair). At another
level however, they also have to learn to live their life
in a body that has changed immeasurably and
irrevocably. As well as acquiring the knowledge and
skills to manage their changed physical and medical
needs, there is also a requirement for a massive
existential adjustment to be made. What this means
for rehabilitation workers is that it is not enough to
simply equip individuals with skills of daily living, it
is essential that they also provide patients with
opportunities to reconstruct their identity, developing one that gives them a sense of meaning and
fulfillment. One vivid example of this was portrayed
in the award-winning documentary Murderball that
told of the exploits of the United States wheelchair
rugby team. Involvement in this competitive contact
sport provided these young quadriplegic men with an
identity that was as much about being an elite athlete
as about being a quadriplegic. Ylvisaker and Feeney
[34] have argued in this regard that a central issue in
working with many young men after traumatic brain
injury is how they can develop a new identity that is
both acceptable to society and also consistent with
their pre-injury persona. Further, Nochi [35] has
demonstrated using a grounded theory approach
how successful reconstruction of personal identity

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can be an important aspect of recovery following


traumatic brain injury and Ellis-Hill has detailed a
similar finding in stroke [36]. Nochi has also argued
for the importance of rehabilitation professionals
considering how this self-narrative may help or
hinder positive adjustment after a TBI.
A fifth assumption required by the GLM is that
human beings are multifaceted, comprised of a
variety of interconnected biological, social, cultural,
and psychological systems that are interdependent to
a significant degree. What this means is that complex
animals such as human beings can only flourish
within a community that provides emotional support, material resources, education, and even the
means of survival. The complexity of human
functioning means that an adequate explanation of
something as important as disability will require
multiple levels of analysis and theoretical perspectives. In particular, the interdependency of human
behaviour points to the necessity of adopting an
ecological framework. This is because of peoples
reliance on other life forms and cultural resources.
According to Steiner (2002, p. 2), Ecology is, by
definition, the reciprocal relationship among all
organisms and their biological and physical environments. People are organisms [37]. In our view,
thinking of the cultural, social, and personal circumstances as ecological components helps to keep in
mind the fact that human beings are moral agents
who purposively interact with their environment and
develop in a dynamic and interactive manner.
Therefore, disability emerges from a network of
relationships between individuals and their local
environment and is not simply the consequence of
individual pathology/impairment. Hence the GLM is
consistent with those social models of disability
which argue that the process of disablement is as
much about societys social and political response to
people with physical and/or mental impairments as it
is about any unique characteristics of those disabled
individuals e.g., [14].
The assumption that human beings are interdependent and that, therefore, a satisfactory understanding of behaviour will always involve an
appreciation of the contexts in which they exist, has
important implications for therapists when designing
rehabilitation programmes. Thus, according to the
GLM, any assessment and intervention should take
into account the match between the characteristics of
the individual and the likely environment he or she
will be released into. In other words, we assert that
when seeking to promote independent functioning it
is necessary to grasp the specific contexts in which
individuals live and the unique challenges they face.
At a macro level, as suggested by the social
perspective on disability mentioned above, this might
mean that rehabilitation professionals assume an

advocacy role in pursuing a fully inclusive society,


addressing issues such as the accessibility of buildings and public transport services [38] (and see also
Sullivan and Main [39] in this issue). At a micro
level, this might include for instance the specific
consideration of a patients community environment
and activities in this environment when selecting
goals for physical rehabilitation [40].
Applying the GLM to rehabilitation requires that a
treatment plan be explicitly constructed in the form of
a good lives conceptualization. In other words, it
should take into account the individuals strengths,
primary goods, and relevant environment; specifying
exactly what competencies and resources are required to achieve these goods. An important aspect
of this process is respecting the individuals capacity
to make certain decisions for himself/herself, and in
this sense, accepting his or her status as an
autonomous individual. Using the GLM, each
individuals preference for certain primary goods
should be noted and translated into his or her daily
routine (e.g., the kind of work, education and further
training, and/or the types of relationships identified
and selected to achieve primary goods).
Aetiological assumptions of the Good Lives
Model
The aetiological component of a GLM of rehabilitation is general in nature, links the basic assumptions
just discussed with implications for clinical practice,
and functions to give rehabilitation professionals a
cognitive map or overview of the rehabilitation
process. The GLM assumes that all people actively
search for and strive to achieve certain primary
human goods in their environment.
Crucial to understanding this model and for its
application in clinical practice is the related concept
of instrumental or secondary goods. Secondary
goods provide particular ways of achieving primary
human goods. For example, relatedness (i.e., the
desire to meaningfully connect as an individual with
other people) is considered a primary good and
different means of achieving it such as romantic
relationships, parenthood, and friendship are instrumental or secondary goods.
Goals are considered to be primary or secondary
human goods in a concrete form. In a sense goals are
how we operationalize the goods we consider are
most important to us. For example, an individual
who prizes the primary goods of knowledge and
excellence (in work or play) may have the goal of
completing a PhD. Similarly, a person recovering
from a stroke may place great value on the primary
good of agency (i.e., autonomy and self-directedness) and have the goal of living independently again
in their own dwelling. Moreover, people recovering

Good Lives Model


from major physical trauma, or adjusting to life with
a chronic health condition, will often have to reassess
these goals and their best means of achieving them in
the light of their changed physical, cognitive, social
and financial circumstances.
A GLM of rehabilitation assumes that a central
task for client and therapist is the development of a
good life plan. A good life plan (GLP) is a plan that
contains all the primary goods and means of
achieving them that match the individuals history,
abilities, preferences and social mileu. The key task
in developing a successful good life plan will be
anticipating the major internal (i.e., personal) and
external (i.e., environmental) barriers to achieving
the plan and equipping the individual with the
necessary internal skills and external resources to
implement their own GLP. This is where traditional
components of rehabilitation interventions (e.g.,
physical retraining, spasticity management, medical
management, continence management, nursing interventions, etc.) can intersect with a GLM of
rehabilitation. The point here is that these interventions need to be targeted towards addressing barriers
to achieving a GLP rather than being viewed as oneoff solutions to discrete symptoms or problems. In
this sense the major value of the GLM is as an
integrative framework that unites a broad range of
rehabilitation interventions and processes with the
client at the centre.
Experience to date in applying a GLM approach in
the rehabilitation of criminal offenders suggests that
problems in planning, developing and sustaining a
good life frequently arise at the level of secondary
goods rather than the primary ones. In other words
sometimes it is the activities or strategies, the means
used to obtain certain primary goods that create
problems not the primary goods themselves. For
example, consider the situation of an older adult with
an above-knee amputation who seldom leaves their
house and becomes reliant upon health professionals
as their principle source of warmth and support. Like
most people, this person is actively pursuing the
primary good of relatedness in order to improve
their wellbeing. However in this case the means of
obtaining this primary good, the secondary good,
results in increased dependency on health professionals rather than the development of a network of
supportive and enduring relationships with peers.
Hence a key element of this older adults GLP
should be to involve support in developing the
personal skills (e.g., self-confidence) and practical
resources (e.g., referral to community groups) to
build a social network.
An individual might also suffer from a lack of
scope in their life plan, with omission or sacrifice of a
number of important goods. For example, in a
phenomenological investigation of return to work

1611

following traumatic brain injury, Levack, McPherson


and McNaughton reported cases where the pursuit
of full-time competitive employment resulted for
some individuals in the exclusion of other aspects of
their daily lives (such as their relationships or
physical health etc.), ultimately culminating in
catastrophic personal events for those involved [41].
Some people may also have conflict among the
goods being sought and thus experience psychological distress and unhappiness. For example the goods
of autonomy and relatedness might sometimes clash
as an individual with a disability learns how to
balance their need for self-determination with their
need for love and support.
Lastly, yet another problem can occur when a
person lacks the capabilities (e.g., knowledge, insight,
judgement) to form or implement a GLP in the
environment in which he or she lives, or to adjust his
or her goals to changing circumstances. This is a
common issue with TBI survivors with frontal lobe
damage who may have limited insight into their own
behaviour and its impact upon other people. For
example, one of the authors worked with Jack, a
young male TBI survivor, who kept being asked to
leave the apartments he shared with other young
adults because of his inconsiderate behaviour. This
social rejection was perplexing to Jack and he became
increasingly alienated and angry and was eventually
arrested for assaulting his landlady. After a long
period in a highly structured supportive living
situation, regular counseling, social skills group
training and stress management he was able to live
successfully with his peers. Thus it was only after
developing these capabilities (insight, social skills,
stress management) that he was able to self-manage
his own emotions and behaviour well enough to live
at close quarters with other young adults. The
problem of capability deficits has both internal and
external dimensions. The internal dimension refers
to factors such as skill deficits while external
dimension points to a lack of environmental opportunities, resources, and supports. In Jacks case he
was only able to learn these skills after a prolonged
period in a highly structured and supportive environment.
In summary, the aetiological commitments of the
GLM stem from a naturalistic view of human beings
as goal seeking, culturally embedded animals who
utilize a range of strategies to secure important goods
from their environments. It would seem that when
the internal or external conditions necessary to
achieve valued outcomes (goods) are consistently
unavailable, individuals tend to become frustrated
and disillusioned. The aetiological commitments
serve to orientate health professionals toward key
issues for the client and require supplementation
from specific theories to supply more fine-grained

1612

R. J. Siegert et al.

explanations. Clearly, further theoretical development and empirical research is required here to
develop this aspect of the GLM as it is applied to
clinical rehabilitation.
Intervention implications
There are a number of implications for assessment
and intervention in rehabilitation that arise from a
GLM perspective. However, given the novel and
rather tentative status of this approach for clinical
rehabilitation, we will limit these to just a few.
Perhaps the most obvious implication of the GLM
for clinical and community rehabilitation is that each
client should have their own individual GLP and that
this plan should form the overarching, integrative
framework for that persons rehabilitation (i.e.,
replace what might be considered the concept of a
traditional rehabilitation plan). One of the distinguishing features of a GLP when compared with a
more traditional rehabilitation plan would be in the
inclusion of primary goods and the focus on specific
means to achieve these. While some authors have
described the inclusion of long-term goals in the
development of a rehabilitation plan [21,42 44],
these long-term goals have tended to focus on
issues relating to secondary goods (e.g., to return
home, to walk again, to return to work) rather
than on primary goods. More compatible with a GLP
would be the approach to rehabilitation planning that
have included some consideration of a patients life
goals as primary goods when selecting the more
intervention-focused short-term goals of treatment
[45,46].
It is assumed in the GLM of rehabilitation that
motivation is a crucial factor in successful rehabilitation outcomes and that motivation is directly related
to the acquisition of primary goods. Put simply it is
through determining which primary goods are most
highly valued by a patient or client that health
professionals can learn what motivates that person.
In other words, the individuals particular strengths,
interests, values (i.e., weightings of goods), social
and personal circumstances and home environment
should be taken into account when constructing a
rehabilitation plan. Again, this concept relates to the
work that has occurred around the application of life
goals in rehabilitation. Nair [46] has argued that a
patients motivation to participate in a rehabilitation
programme may depend in part on the degree to
which the rehabilitation goals align with their own
life goals. Further to this however and while GLM
interventions may still be implemented in a systematic and structured way, therapeutic tasks within ward
or outpatient programmes should be shaped to suit
the person in question based on their own life plan.
For example, while an individual in a programme for

traumatic brain injury might receive a standardized


social skills module, individualized self-directed tasks
might be geared to his or her particular needs and
issues.
Applying the GLM to clinical and community
rehabilitation also requires the delineation of several
other considerations that could underlie the construction of rehabilitation programmes. These are:
1.

2.

3.

4.

5.

Patients or clients are whole individuals


notwithstanding their physical, cognitive or
psychological impairments. They have valuable experience and a variety of strengths that
can benefit society and themselves. Interventions should promote and facilitate these
contributions whenever possible.
The absence of certain human goods (e.g.,
self-efficacy/sense of agency, inner peace,
personal dignity/social esteem and social
relatedness) is assumed to be strongly associated with and predictive of higher levels of
disablement.
Maximizing participation and reducing disability can best be achieved by assisting
individuals to develop the skills and capabilities (both internal and external) necessary to
achieve the full range of human goods.
Rehabilitation is therefore seen as an activity
that should add to an individuals repertoire of
personal functioning, rather than an activity
that simply removes symptoms or manages a
problem. Rehabilitation is certainly about
reducing or minimizing impairments to increase activity and participation, but it is also
about reinforcing existing personal strengths
and building new capabilities to achieve these
ends.
The GLM offers a promising framework or
integrative model for rehabilitation professionals to think about their work, its goals
and the best means of achieving them.

In other words, the GLM can be viewed as a guide to


achieving a more holistic approach to rehabilitation,
based on the core idea that the best way to reduce
disablement is by helping individuals live more
personally fulfilling, successful, and productive lives.
In addition, rehabilitation is tailored to each clients
GLP while still being administered in a systematic
and structured way. For normative and practical
reasons, individual clients need only undertake those
treatment activities that provide the ingredients of
their own, particular plan. At stake here is both the
development of a therapeutic alliance and the fit
between therapy and clients specific issues, abilities,
preferences, and contexts. In the GLM approach, the
goal is always to create new skills and capacities

Good Lives Model


within the context of individuals life plans and to
encourage fulfillment through the achievement of
human goods.
A particular strength of the GLM is that it has a
strong developmental and historical orientation, and
therefore stresses the continuity between the old preinjury or pre-illness self and the construction of a new
self. This continuity of an individuals self-narrative
may be especially important for people facing massive
life transitions and adjustments due to trauma or
degenerative neurological conditions and indeed we
have found it to be a construct of importance to people
with a range of chronic conditions [47,48]. The GLM
suggests that this continuity is important and occurs
because individuals basic commitments and values
(i.e., overarching goods) remain essentially the same,
and it is simply the means by which they are sought
that is different. It is our commitments and associated
life plans that define who we are, and provide a
compass by which we navigate our way through life.
Thus, in the GLM there is respect for individuals
history and past selves, which is in keeping with
cultural and social perspectives that place great value
on the past and its meaning. Consequently, a key
process in assessment for rehabilitation will be working
collaboratively with the client to clarify their own goals,
life priorities and their aims for rehabilitation within
the context of a past, present and future. In particular,
it is essential to understand how a client prioritizes and
operationalizes the primary human goods described
earlier in this paper. If this area is not explored,
assessment may concentrate only on impairments and
vulnerabilities and fail to recognize the importance of
understanding how an individual can become fulfilled
[49]. It would therefore seem crucial (if rehabilitation
is to be person-centred rather than problem-centred),
for the assessment of impairment, risk and vulnerability to be balanced with an assessment of the
individuals strengths, goals, and conception of the
good life [6]. This approach also demands rehabilitation processes be flexible enough to incorporate an
individuals pre-existing personality rather than attempt to replace this personality with one that is
compatible with how health professionals would like
patients to behave. This point has also been argued by
Ylvisaker and Feeney with regard to rehabilitation for
adolescent men with traumatic brain injury [34].
To date no standardized, psychometric instrument
exists that can reliably or validly make such as
assessment. There are measures such as Emmons
Personal Striving Assessment Packet, which attempts to
ascertain a persons major goals or personal strivings
in life, which might be useful. Yet, even if such
instruments emerge, a reliance on questionnaires
may limit the depth of data gathered, and the rapport
established with the individual client. As such, a
clinical interview is likely to remain the core

1613

recommended approach. In applying the GLM to


rehabilitation for criminal offenders the method of
presenting a list of primary human goods, asking
them to choose their priorities has been tried and
found ineffective. In our experience, such a task has
been approached as if it was a test rather than an
opportunity for self-exploration. Rather, an open
ended interview, where the assessors intentions and
the rationale for the interview is made transparent
with opportunity for discussion rather than one way
reporting has seemed more successful. There are
two primary procedures for identifying the major
human goods that form the basis of individuals core
commitments. The first is to note what kind of goals
were most evident in their general life functioning
pre-injury or pre-illness onset. This form of assessment strategy is similar to the scientific detection of
fundamental goals and is based on careful observation guided by research findings and theory e.g.,
[28]. This requires a judgement about the intentions
underlying individuals behaviour and their overall
purposes in particular contexts. While goals cannot
simply be inferred from behaviour in any straightforward sense it is clear that what people do in
conjunction with the norms regulating particular
interactions provides evidence concerning their
goals. The second assessment strategy is to ask a
series of increasingly detailed questions about the
things (i.e., activities, situations, experiences) individuals value in their lives and what they put their
energies into day to day. Asking about family
members and people they know whom they admire
or dislike, also seems quite helpful and is particularly
relevant for working with clients/patients unable to
express such things for themselves. Additionally, we
have also found that extending the range of inquiries
to the realm of metaphor or the fictional can be
useful at times. This may be achieved by asking
clients what individuals either fictional (e.g., from
television, movies, novels, historical etc) or real (e.g.,
historical or public figures) they most admire and
why. Additional questions include who would they
most want to be like, and why? Who they would most
like not to resemble, and why? And so on. The
advantage of these questions about possible selves is
that they can tap into possible life scripts when
articulating an explicit self-narrative is particularly
difficult2 [50]. For more information on this
approach we refer the reader elsewhere [33,51 53].
In order to make a more comprehensive assessment of each individuals potential for achieving a
good life the assessing clinician should have an
understanding of the following areas:
1.

Is there restricted scope? That is, is the


individual focusing on some goods to the
detriment of other goods, so that his or her life

1614

2.

3.

4.

R. J. Siegert et al.
seems to lack adequate balance and range of
priorities? For instance, we referred earlier to
some TBI patients, who try so hard to return
to full-time employment that the resultant
exhaustion, headaches and irritability jeopardize their family life, their work life or even
self-care [41].
Are some human goods pursued through
inappropriate means? That is, has the individual chosen strategies for achieving goods,
which have turned out to be counter-productive? An example of this might be a situation
where an individual with a severe disability
becomes reliant upon alcohol or drugs as a
means of achieving the goods of inner peace
and happiness.
Is there conflict among the goods articulated?
For instance, does the individual prioritize
goals that cannot co-exist easily? An example
of this might be a situation where a person
with severe cognitive or psychiatric problems
wants to be fully autonomous in their life, but
also wants to be physically healthy and meaningfully productive, when their impairments
limit their ability achieve this independently.
Emmons has clearly described the stress that
results from a lifestyle that is inconsistent with
ones most valued goods [28].
Does the person have the capacity or capabilities to enact their life plan and achieve their
stated life goals? Is the plan realistic in light of
their abilities, likely opportunities, deep preferences, and values? Is intervention required
in order to retrain capabilities or alter their
environment in such as way as to enable that
person to progress in their life plan?

An exploration of a clients life plan can assist the


clinician to formulate a rehabilitation plan that
provides the opportunity for greater life satisfaction
and well-being. If individuals are able to see how the
plan will directly benefit them in terms of goods that
they value, then the GLM suggests they will be far
more likely to engage enthusiastically in treatment.
Given the importance of motivation and engagement
to successful treatment outcomes it seems reasonable
to assume that the perception of treatment relevance
will be associated with more successful outcomes.
Conclusion
The Good Lives Model seems to have considerable
potential for rehabilitation as a theoretical framework. It proposes a new way of thinking about
rehabilitation that aims to integrate several existing
aspects of best practice while maintaining the
individual client as the central focus. At the same

time it is new and quite provisional and further


theoretical work is necessary to flesh out how it might
be applied in different clinical rehabilitation contexts.
At that stage it would be essential to test the GLM
empirically and to examine whether it actually
produces better outcomes. However, in the meantime, we would argue that it prompts some useful
questions about how person centred rehabilitation
can actually be without a clear identification of what
it is for each person to have a good life.
Notes
1. In this article we use the term rehabilitation to refer to a longterm process for people with serious and complex health
conditions such as multiple sclerosis, spinal cord injury and
traumatic brain injury. We are not advocating the Good Lives
Model for rehabilitation of minor or straightforward injuries.
2. We are currently carrying out a feasibility study using metaphor
as a way of engaging people with TBI in goal setting, drawing
on the work of Ylvisaker and Feeney [34]. For more
information contact Kathryn.McPherson@aut.ac.nz

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