REHABILITATION

Each day in the United States, the correctional system supervises over six million of its residents. Approximately two million people are in prison or jail, while four million are on probation or parole. With so many people under its control, a central policy issue is what the correctional system hopes to accomplish with those it places behind bars or on community supervision. A simple response might be that the purpose of these correctional sanctions is to "punish" the criminally wayward. Since the inception of the American penitentiary in the 1820s, however, corrections has embraced as an important goal the transformation of law breakers into the law-abiding—that is, "rehabilitation" or "treatment." At times, the goal of reforming offenders has been dominant; at other times, its legitimacy and usefulness have been challenged and its influence on correctional policy diminished. But even today, after a period in the late 1900s of prolonged advocacy of "getting tough with criminals," rehabilitation remains an integral part of the correctional enterprise and continues to earn support among the public in the United States.

In this entry, we begin by exploring in more detail the concept of rehabilitation. We then use a historical perspective to examine the changing nature and support for rehabilitation as a correctional goal over time. Our attention next turns to the current treatment programs that are found within the correctional system. Perhaps the most important consideration is whether rehabilitation "works" to reduce the likelihood that offenders will "recidivate" or return to crime. Accordingly, we also review the latest research on the effectiveness of treatment interventions. We conclude this entry with comments on the future of rehabilitation as a correctional goal.

What is rehabilitation?

The concept of rehabilitation rests on the assumption that criminal behavior is caused by some factor. This perspective does not deny that people make choices to break the law, but it does assert that these choices are not a matter of pure "free will." Instead, the decision to commit a crime is held to be determined, or at least heavily influenced, by a person's social surroundings, psychological development, or biological makeup. People are not all the same—and thus free to express their will—but rather are different. These "individual differences" shape how people behave, including whether they are likely to break the law. When people are characterized by various "criminogenic risk factors"—such as a lack of parental love and supervision, exposure to delinquent peers, the internalization of antisocial values, or an impulsive temperament—they are more likely to become involved in crime than people not having these experiences and traits.

The rehabilitation model "makes sense" only if criminal behavior is caused and not merely a freely willed, rational choice. If crime were a matter of free choices, then there would be nothing within particular individuals to be "fixed" or changed. But if involvement in crime is caused by various factors, then logically re-offending can be reduced if correctional interventions are able to alter these factors and how they have influenced offenders. For example, if associations with delinquent peers cause youths to internalize crime-causing beliefs (e.g., "it is okay to steal"), then diverting youths to other peer groups and changing these beliefs can inhibit their return to criminal behavior.

Sometimes rehabilitation is said to embrace a "medical model." When people are physically ill, the causes of their illness are diagnosed and then "treated." Each person's medical problems may be different and the treatment will differ accordingly; that is, the medical intervention is individualized. Thus, people with the same illness may, depending on their personal conditions (e.g., age, prior health), receive different medicines and stay in the hospital different lengths of time. Correctional rehabilitation shares the same logic: Causes are to be uncovered and treatments are to be individualized. This is why rehabilitation is also referred to as "treatment."

Correctional and medical treatment are alike in one other way: they assume that experts, scientifically trained in the relevant knowledge on how to treat their "clients," will guide the individualized treatment that would take place. In medicine, this commitment to training physicians in scientific expertise has been institutionalized, with doctors required to attend medical school. In corrections, however, such professionalization generally is absent or only partially accomplished.

The distinctiveness of rehabilitation can also be seen by contrasting it with three other correctional perspectives that, along with rehabilitation, are generally seen as the major goals of corrections. The first goal, retribution or just deserts, is distinctive in its own right because it is nonutilitarian; that is, it is not a means to achieving some end—in this case, the reduction of crime—but rather is seen as an end in and of itself. The purpose of correctional sanctions is thus to inflict a punishment on the offender so that the harm the offender has caused will be "paid back" and the scales of justice balanced. In this case, punishment—inflicting pain on the offender—is seen as justified because the individual used his or her free will to choose to break the law. The second goal, deterrence, is utilitarian and asserts that punishing offenders will cause them not to return to crime because they will have been taught that "crime does not pay." Note that deterrence assumes that offenders are rational, in that increasing the cost of crime—usually through more certain and severe penalties—will cause offenders to choose to "go straight" out of fear that future criminality will prove too painful. This is called specific deterrence. When other people in society refrain from crime because they witness offenders' punishment and fear suffering a similar fate, this is called general deterrence. Finally, the third goal, incapacitation, makes no assumption about offenders and why they committed crimes. Instead, it seeks to achieve the utilitarian goal of reducing crime by "caging" or incarcerating offenders. If behind bars and thus "incapacitated," crime will be impossible because the offender is not free in society where innocent citizens can be criminally victimized.

In comparison, rehabilitation differs from retribution, but is similar to deterrence and incapacitation, in that it is a utilitarian goal, with the utility or benefit for society being the reduction of crime. It fundamentally differs from the other three perspectives, however, because these other goals make no attempt to change or otherwise improve offenders. Instead, they inflict pain or punishment on offenders either for a reason (retribution in order to "get even" or deterrence in order to "scare people straight") or as a consequence of the penalty (incapacitation involves placing offenders in an unpleasant living situation, the prison). In contrast, rehabilitation seeks to assist both offenders and society. By treating offenders, they hope to give them the attitudes and skills to avoid crime and live a productive life. At times, this attempt to help offenders exposes rehabilitation to the charge that it "coddles criminals." This view is shortsighted, however, because correctional rehabilitation's focus is not simply on lawbreakers but also on protecting society: by making offenders less criminal, fewer people will be victimized and society will, as a result, be safer.

Rehabilitation across time

As "deconstructionists" often remind us, important meanings are embedded in the words we select and voice; what we call things, in short, reveals our values and ideologies. It is instructive, then, that in the United States our history is not sprinkled with terms like "punishment institutions" and the "Ministry of Justice." Instead, a look to the past uncovers words such as the "penitentiary," "reformatory," "correctional institution," and "Department of Rehabilitation and Correction." This language shows an important feature of the response that the U.S. system of control has made to criminals across time: there has been, at least in the ideal, a belief that state interventions with offenders should be transforming, turning the wayward into the lawabiding. The question of how such rehabilitation should be achieved, however, has varied across time. Although dividing history into periods truncates reality and leaves out many details of the story, it is useful to see correctional rehabilitation as having three separate eras that can be distinguished by the way in which reformers believed offenders should be transformed. We review these below, and then discuss a fourth period in which rehabilitation came under unprecedented attack.

Reform by regimen: the penitentiary. Although various types of institutions had previously existed, the United States is generally credited with—or blamed for, depending on one's perspective!—the invention of the state-administered, modern prison system (Barnes; Eriksson; McKelvey). Before the 1820s and 1830s, prisons as we think of them today did not exist. Local counties operated jails, but these facilities often had the architecture of a house (with the jailer and his family living on the premises) and were used to detain offenders awaiting trial or punishment. Offenders were typically fined, publicly embarrassed by being placed in the pillory, whipped, banished, or executed, but they were not incarcerated for the purpose of punishment or reform. Indeed, the notion that locking up offenders could serve a larger purpose would have struck colonial Americans as odd (Barnes).

By the 1820s, however, ideas about criminals and what to do with them had changed. As David Rothman (1971) points out, Americans increasingly came to view crime as a product of the "social disorder" that was gripping their communities—communities that were growing larger and more diverse. People did not fully relinquish their religious views and the tendency to equate crime with sin, but they were increasingly persuaded that families and communities were less able to impart the moral fiber needed to resist the criminal temptations that now seemed widespread. Importantly, attributions of crime causation make certain responses to offenders appear more "sensible." Simply put, if social disorder was at the root of the crime problem, then the solution to crime was to place the wayward in an orderly environment.

Such environments, however, had to be created. With idealistic visions of stable colonial communities still fresh in mind, reformers argued that such orderly environments should be based on a clear set of principles—ones they believed reigned a generation or two before: obedience to authority, religion, hard work, and separation from all criminal influences. Bordered by high, thick walls, prisons—or what they tellingly called "penitentiaries"—would provide the ideal setting for this utopian community. The obvious problem, of course, was how to stop offenders from commingling and contaminating one another when they were being concentrated into a "society of captives." In Pennsylvania, reformers solved this problem through the "solitary system," placing offenders in a single cell under what amounted to perpetual solitary confinement. In New York, a "congregate system" was favored in which inmates would sleep alone but eat, work, and attend religious services en masse. Inmate-to-inmate contact was ostensibly prevented through the rule of absolute silence; those who dared to speak were harshly dealt with through the whip.

Advocates of the "solitary" and "congregate" designs engaged in a bitter feud over which approach should be the blueprint for the American penitentiary. From today's vantage point, such disputes might seem excessive, given that the principles underlying each model were identical. But for the 1820s reformers, the details were what mattered. For they were convinced that if they could perfect the daily regimen of the penitentiary—if they could create that orderly community they believed could have amazing curative powers—they could reform inmates and thus rid their society of recidivists. It was, they held, the day in and day out routines that would break the will of offenders and open them up to a spiritual renewal that would prove transforming.

In retrospect, we would deem enforced solitary confinement and silence for years on end cruel and unusual punishment; such practices would be virtually unthinkable by today's standards. Further, some commentators have questioned the motives of these early reformers, noting that under the guise of "benevolence" they applied their disciplinary techniques mainly to the poor, not to those of their own class (see, e.g., Foucault). Still, we should be careful not to be too smug in hindsight. The founders of the penitentiary—whatever their errors in judgment and inability to move beyond their class interests—genuinely believed that they were ushering in a reform that would sweep away the barbarous and demonstrably ineffective punishments of the past. They also were able to rise above feelings of vengeance—feelings that often rear their head today—to articulate an ideal that remained vibrant for the next two centuries: that the reformation of lawbreakers is a worthy goal to undertake (McKelvey).

Reform by individualized treatment: the new penology and beyond. Notions of how best to rehabilitate offenders are dynamic, not static. Three decades or so after the penitentiary was initiated, the idea that the internal design and daily regimen of the prison would have transforming powers could no longer be sustained. In the aftermath of the Civil War, prisons began to fill to the brim, rendering obsolete any hopes of bunking inmates in solitary confinement and of maintaining total silence. Beyond such practical limitations, observers believed the penitentiary's blueprint had a fatal flaw: no matter what offenders did while in prison, they were released when their sentence expired. What self-interest, they wondered, did inmates have to better themselves while under lock and key? It was clear that the earlier theory of reforming offenders was bankrupt.

In 1870, the leading correctional leaders and thinkers—they were often the same in those days—met in Cincinnati to consider this state of affairs at the National Congress on Penitentiary and Reformatory Discipline. One possibility was to declare that prisons were not instruments of rehabilitation and/or that offenders were not changeable. After all, with social Darwinism and biological theories of crime available, they could have agreed with other commentators that the immigrant masses now behind bars were a "dangerous class." In this scenario, they could have argued that the best use of prisons was to employ them to incapacitate the innately wicked. But they did not. Instead, their belief in rehabilitation remained unshakable. In the face of failure and with prisons in crisis, they affirmed that "the supreme aim of prison discipline is the reformation of criminals, not the infliction of vindictive suffering" (Wines, p. 541).

For many of the Congress's participants, prison administration remained a sacred enterprise. Their Christian ideals prompted them to believe that saving offenders was within their mission; they also were convinced that of "all reformatory agencies, religion is first in importance, because most potent in its action upon the human heart and life" (Wines, p. 542). But proclaiming the power of faith to change lives was not novel. Some other ideas had to emerge to excite correctional leaders—to move them to devise and embrace a "new penology."

As mentioned above, members of the Congress believed they had detected the fatal flaw in the penitentiary design: the use of "determinate" sentences—that is, prison terms whose lengths were determined or specified by judges before an inmate entered prison. Such a system, they argued, provided no incentive for offenders to better themselves. In contrast, the "indeterminate" sentence meant that the date of an inmate's release from prison would be unknown to him or her upon entering an institution. Release would now be contingent on the inmate showing correctional officials that he or she was reformed, something that could only be assessed during the course of the offender's incarceration. With freedom thus hanging in the balance, the system would be arranged to maximize the inmate's commitment to change. As Congress declared, the "prisoner's destiny should be placed, measurably, in his own hands.... A regulated self-interest must be brought into play, and made constantly operative" (Wines, p. 541).

Many other features of the Congress's "new penology" were so forward-looking that they would not be foreign to current-day penal discussions of correctional reform. Thus, the Congress favored the "progressive classification of prisoners"; the use of "rewards, more than punishments"; "special training" in order "to make a good prison or reformatory officers"; access to "education" and "industrial training"; and efforts to reintegrate offenders into society "by providing them with work and encouraging them to redeem their character and regain their lost position in society" (Wines, pp. 541–544).

Pregnant in this set of principles was the conclusion that rehabilitation should be individualized. This idea, however, was expressed more clearly and forcefully closer to the turn of the century. At this time, the Congress's "new penology" was being elaborated by the emerging insights from the nascent social sciences of psychology and sociology. These disciplines brought a secular perspective to the enterprise of reforming offenders. They suggested that it was possible to study the causes of crime scientifically. For any given offender, however, the causes were likely to be multifaceted and found in a unique combination. Two people might commit the same crime—for example, robbery—but the reasons for their acts could be widely divergent (e.g., emotional problems as opposed to exposure to gang influences). Once this premise was accepted, it led logically to the conclusion that successful rehabilitation depended on treating offenders on a case-by-case basis. A single treatment would not fit all lawbreakers because, again, they were all different. Instead, interventions had to be individualized (Rothman, 1980).

What kind of system should be set up to deliver individualized rehabilitation? Above all, individualization required that criminal justice officials have the discretion to fit correctional interventions to the offender and not base it on the offense. Indeterminate sentencing, of course, was essential because it meant that inmates would be released from prison only when they had been cured of their criminal propensities. To determine who should be released and when, a parole board would be necessary. The idea of parole in turn mandated that released offenders be supervised in the community by parole officers whose task it was to counsel parolees and, when necessary, to return to prison offenders who failed to go straight.

Reformers, however, also argued that incarceration was not the appropriate intervention for all lawbreakers; many could be rehabilitated in the community. This belief led to the creation of probation, a practice in which probation officers would both help and police offenders released to their supervision. These officers, moreover, would assist judges in deciding who to imprison and who to place in the community by amassing information on each offender. This portrait was compiled in a "presentence report" that would detail not just the offender's criminal history but also his or her employment record, family background, and personal characteristics.

Because juveniles differed from adults, it also made sense to create a separate juvenile court. This special court most fully embodied the ideals of individualized treatment. Wayward youths were not to be punished by the state, but rather "saved" from a life in crime (Platt). The court would act as a "kindly parent" who would, in essence, step in and help not only youths already involved in illegal acts but also those at risk for a criminal life. The jurisdiction of the juvenile court thus was not limited to youths who had committed a crime. Instead, the court claimed jurisdiction over youths who engaged in deviant acts seen as precursors to crime (i.e., status offenses such as truancy, running away from home, and sexual promiscuity) and over those who were neglected or abused by their parents.

The paradigm of individualized treatment offered a persuasive rationale for reform. This proposal offered to improve the lives of offenders and to protect society by curing criminals who could be cured and by locking up those whose criminality proved intractable. Science and religion, moreover, meshed together to suggest that offenders could be transformed and that mere vengeance would be counterproductive. But in advancing a seemingly enlightened correctional agenda, advocates remained blind to the potential dangers of individualized treatment. First, they assumed that judges and correctional officials would have the expertise to administer this new system—such as knowing what caused an individual's criminality and knowing what intervention would work to effect the offender's reform. Second, they assumed that the officials' discretion would be exercised to advance the cause of rehabilitation. They did not consider that the unfettered discretion given to judges and officials might be abused or used mainly to control, not help, offenders. These problems would later play a role in undermining the legitimacy of individualized treatment, but for the moment they either did not come to mind or were dismissed as naysaying.

Persuasive paradigms do not always translate into concrete policy reforms. By 1900, however, the United States had entered the Progressive Era, which came to be called the "age of reform" because of the diverse social and governmental reforms undertaken in this time span. Thus, at a particularly receptive historical juncture, the "new penology" ideas—ideas that had been embellished since the Cincinnati Congress—presented a clear blueprint for renovating the correctional system. The time was ripe for individualized treatment to be implemented. As is well known, the first juvenile court was initiated in 1899 in Cook County, Illinois. Two decades or so later, all but three states had a special court for hearing juvenile cases, and every state permitted probation for youths. For adults, two-thirds of the states had begun probation and forty-four states had initiated parole. Meanwhile, in little over twenty years, the number of states that allowed indeterminate sentencing had risen from five to thirty-seven (Cullen and Gilbert; Rothman, 1980).

Reform by corrections. By the end of the Progressive Era, then, the notion of individualized treatment had emerged as the dominant correctional philosophy and the basic contours of the modern correctional system—probation, parole, juvenile justice, and all the policies and practices they entail—were in place. As Rothman (1980) painfully details, the ideals of effective rehabilitation were infrequently realized. Shortages of knowledge, trained staff, resources, and institutional commitment often resulted in treatment that was poorly delivered or absent altogether. Still, confidence abounded that rehabilitation was possible and, with sufficient support, could be effective.

This continuing commitment to rehabilitation was embodied in a third period of reform that spanned, roughly, the 1950s to the late 1960s. During this time, prisons were relabeled "correctional institutions," with the name corrections suggesting that the core task of working with offenders was to change or "correct" them. Corresponding to this new vocabulary, a range of treatment programs was introduced into institutions. These included, for example, individual and group counseling, therapeutic milieus, behavioral modification, vocational training, work release, furloughs, and college education (Cullen and Gendreau; Rotman). Especially in the 1960s, "community corrections" became fashionable, as a movement emerged to "reintegrate" inmates into society through halfway houses and other community-based treatment programs. Reflecting the tenor of the times, the Task Force on Corrections, part of a presidential commission studying the nations crime problem, asserted in 1967 that the "ultimate goal of corrections under any theory is to make the community safer by reducing the incidence of crime. Rehabilitation of offenders to prevent their return to crime is in general the most promising way to achieve this end"(p. 16).

Reform rejected: the attack on rehabilitation. The apparent invincibility of rehabilitation as the dominant correctional philosophy was shattered in less than a decade. Treatment programs did not suddenly disappear, and faith in rehabilitation did not vanish. Even so, a sea change in thinking occurred seemingly over-night and policy changes followed close behind. Suddenly it became fashionable to be against "state enforced therapy." Beginning in the mid-1970s, states began to question indeterminate sentencing and call for sentencing in which judicial and parole board discretion was eliminated or, in the least, curtailed. About thirty states still retain some form of indeterminate sentencing, but this is down from a time when every state had this practice. Further, over the last quarter of the twentieth century, every state passed mandatory sentences, "truth-in-sentencing" laws, "threestrikes-and-you're-out" laws, or similar legislation aimed at deterring and/or incapacitating lawbreakers (Tonry). Meanwhile, state and federal prison populations ballooned from 200,000 in the early 1970s to over 1.36 million in 2000 (and to about 2 million counting offenders in local jails). Within the community, the treatment paradigm was challenged by programs that sought not to "correct" offenders but to "intensively supervise," "electronically monitor," or otherwise control them. Even the juvenile justice system did not escape the diminished confidence in rehabilitation. By the end of the 1990s, seventeen states had changed the legal purpose of the juvenile court to de-emphasize rehabilitation, and virtually every state had passed laws to make their juvenile justice systems harsher (Feld; Snyder and Sickmund).

Major shifts in correctional thinking are usually a product of changes in the larger society that prompt citizens to reconsider beliefs they had not previously questioned. The mid-1960s to the mid-1970s was a decade of enormous social turbulence. This period was marked by the civil rights movement, urban riots, the Vietnam War and accompanying protests, the shootings at Kent State University and Attica Correctional Facility, Watergate and related political scandals, and escalating crime rates. As the central state agency for controlling crime and disorder, the criminal justice system—including its correctional component—came under careful scrutiny. It was often seen as part of the problem—as doing too much, too little, or the wrong thing.

For conservatives, the reigning chaos in society was an occasion to call for "law and order." To them, it was apparent that the correctional system was teaching that "crime pays." Under the guise of rehabilitation, criminals were being coddled; judges were putting dangerous offenders on probation; and parole boards were releasing predators prematurely from prison. We needed to toughen sentences—make them longer and determinate—in order to deter the calculators and incapacitate the wicked.

For liberals, however, rehabilitation was not the source of leniency but of injustice and coercion. The prevailing events contained the important lesson that government officials could not be trusted—whether to advance civil rights, be truthful about why the nation was at war, act with integrity while in political office, or rehabilitate the wayward. In this context, judges and correctional officials were redefined as "state agents of social control" whose motives were suspect. Thus, judges were now portrayed as purveyors of unequal justice, using their discretion not to wisely individualize treatments but to hand out harsher sentences to poor and minority defendants. Similarly, correctional officials were accused of using the threat of indeterminate incarceration not to achieve the noble goal of offender reform but to compel offenders to comply obediently with institutional rules that had little to do with their treatment; maintaining prison order thus displaced rehabilitation as the real goal of indeterminate terms. In the liberal critics' minds, it was time to forfeit rehabilitation and embrace a "justice model" that would limit incarceration to short sentences and would grant offenders an array of legal rights to protect them against the ugly power of the state (Cullen and Gilbert). Notions of "doing good" were relinquished and replaced with the hope of creating a correctional system that would "do no harm."

Thus, both liberals and conservatives opposed rehabilitation, albeit for different reasons: conservatives because they thought it victimized society, and liberals because they thought it victimized offenders. These two groups also agreed that the discretion of correctional officials should be eviscerated and determinacy in sentencing implemented. They both embraced the punishment of offenders. They parted company, however, on how harsh those sanctions should be. Given the "get tough" policies that have reigned in recent times, it is clear that the conservative alternative to rehabilitation prevailed most often and in most jurisdictions (Cullen and Gilbert; Griset).

The story about the attack on rehabilitation has one additional chapter to be told. In 1974, Robert Martinson published an essay in which he reviewed 231 studies evaluating the effectiveness of correctional treatment programs between 1945 and 1967 (see also Lipton, Martinson, and Wilks). Based on this assessment, Martinson concluded that "With few and isolated exceptions, the rehabilitative efforts that have been undertaken so far have had no appreciative effect on recidivism" (p. 25). This rather technical conclusion might have been open to different interpretations—for example, that treatment programs were being implemented incorrectly or that inappropriate interventions were being used. But Martinson then proceeded to ask a more provocative question: "Do all these studies lead irrevocably to the conclusion that nothing works, that we haven't the faintest clue about how to rehabilitate offenders and reduce recidivism?" (p. 48, emphasis added). He stopped short of claiming that "nothing works," but it did not take a deconstructionist to deduce that this was the message he was conveying.

Researchers make many bold assertions, but most are forgotten or subjected to critical scrutiny; neither occurred in Martinson's case: his research immediately received national attention among academics and the media, and his findings were accepted by most observers as obviously true. A few scholars rose up in opposition, such as Ted Palmer, who demonstrated that nearly half of the treatment programs reviewed by Martinson actually reduced recidivism. But given the tenor of the times, people were ready to hear Martinson's "nothing works" message and unprepared to question empirical findings that reinforced what they already believed. With scientific findings on their side, they now could declare that "rehabilitation was dead."

Correctional programs in the United States

Rehabilitation, however, did not die. There have been reports that the commitment to treatment programs has diminished over the past quarter century. The dearth of systematic data, however, leaves open the question of whether the retreat from rehabilitation is extensive or applicable mainly to some types of programs (e.g., college education courses) and to some jurisdictions. Regardless, even a cursory examination of correctional institutions reveals the presence of a diversity of programs. Why these treatment programs have persisted in the face of the attack on, and apparent bankruptcy of, rehabilitation is open to question, but at least three possible reasons can be suggested: institutional inertia, which made eliminating programs and firing staff more work than keeping them; their functionality—treatment programs reduce inmate idleness and thus contribute to institutional order; and a continuing commitment among corrections leaders to rehabilitation (see Lin).

Education and work programs. Perhaps the two most extensively used modes of treatment in American prisons are education and work programs (Silverman and Vega). Undoubtedly, the prevalence of these programs reflects the abiding belief that educational and work skills—and the good habits learned in acquiring these skills—are integral to securing employment and being a productive citizen. Although the results are not unequivocal, the existing research generally suggests that the programs do have a modest impact in reducing postrelease recidivism, especially when targeted at certain inmates (e.g., those with low skills) and when part of a broader strategy—a multi-modal approach—to rehabilitating offenders (Adams et al.; Bouffard, MacKenzie, and Hickman; Wilson, Gallagher, and MacKenzie).

A 1995 survey of state and federal prisons revealed that nearly one-fourth of inmates were enrolled in some kind of educational program (Stephan). It is estimated that U.S. prisons spend over $412 million annually on educational programs ("Survey Summary"). Over fifty thousand inmates are enrolled in "adult basic education," which involves learning in such core areas as mathematics, literacy, language arts, science, and social studies. General Equivalency Development—usually knows by its acronym, GED—is a high school equivalency degree. In 1996, over thirty-seven thousand inmates earned their GEDs ("Survey Summary"). About four-fifths of U.S. prisons offer the GED, while three-fourths provide basic education courses (Stephan). College education courses are available in about one-third of institutions. However, because inmates were legally excluded by 1994 federal legislation from securing Pell Grants to fund their education, participation in college degree programs has declined (Tewksbury, Erickson, and Taylor). In 1996, one survey reported that 14,532 inmates received a two-year associate's degrees and 232 received a bachelor's degree ("Survey Summary").

Inmates also often have access to another form of education: life-skills training. These programs, which are sometimes seen as counseling interventions, are predicated on the notion that upon release to society, many offenders may not have the kind of basic understandings that are integral to functioning in American society. Thus, courses will teach such varied skills as how to apply and interview for a job, how to manage one's money and household, how to live a healthy life, how to parent and be a spouse, and how to secure a driver's license (Silverman and Vega).

Finally, to prepare inmates for employment, many correctional institutions offer vocational education. A 1994 survey of forty-three correctional systems found that over sixty-five thousand inmates were enrolled in programs aimed at training them in vocational skills that could be used to find employment upon release from prison (Lillis, 1994). It is also estimated that nearly two-thirds of all inmates are given a work assignment (Stephan). This duty may include institutional maintenance, working in a prison industry, or laboring on a prison farm. The assumption is that the discipline of working while incarcerated—regardless of whether marketable skills are learned—will translate into steady employment once the inmate is released. This assumption is tenuous and remains to be confirmed. Instead, it seems that the major function of most work programs is to reduce inmate idleness and, in turn, to keep institutions orderly.

Psychological/counseling programs. Beyond programs that attempt to furnish inmates with the skills to live productively in the community, other prison programs attempt to change underlying problems causing, or implicated in, an offender's criminality. Perhaps the most common interventions are drug abuse programs. As many as half of all offenders entering prison report having used drugs in the month before their arrest. One-third of state prison inmates and over 20 percent of federal inmates report being on drugs at the time of their offense for which they were subsequently incarcerated (Maguire and Pastore, p. 508). Further, the war on drugs from the 1980s onward has increased the number of people in prison on drug-related offenses. Between 1979 and 1991, the proportion of drug offenders in state and federal prisons rose from 6 percent to 21 percent (Sabol and Lynch). Not surprisingly, during this same period, it is estimated that the proportion of inmates participating in drug treatment programs rose from 4.4 percent to 32.7 percent (Silverman and Vega).

Some institutions have programs—sometimes called therapeutic communities —that house drug-addicted inmates in a separate unit. In 1994, the federal government began offering funding to states for its RSAT program—Residential Substance Abuse Treatment—which provides drug treatment in such a separate unit ("Reducing Offender Drug Use"). Other inmates live in the general offender population but participate in group or individual counseling. Despite the availability of drug counseling, it still appears that the demand for programming outstrips its supply. "A significant percentage of inmates with drug abuse histories," observes Arthur Lurigio, "are still without treatment" (p. 511).

Correctional institutions frequently provide individual and group counseling aimed at having offenders forfeit their criminal way of life. Over the years, various treatment modalities have been tried. However, a method of increasing appeal—in large part due to growing empirical support for its effectiveness—is cognitive-behavioral treatment (Van Voorhis, Braswell, and Lester; see also Andrews and Bonta). Although they come in various forms, these programs target the criminal attitudes and ways of thinking that foster illegal behavior. The intervention might involve, for example, counselors modeling prosocial conduct and also reinforcing inmates when such conduct is exhibited. Especially for juveniles, "token economies" are sometimes set up in which conforming offenders are given tokens that can purchase privileges. Counselors also focus on the content of offenders' thinking and reasoning. They challenge inmates' antisocial attitudes, rationalizations supportive of criminal behaviors, attempts to externalize blame, and failure to confront the harm they have committed.

Prisons house offenders who are mentally ill. In 1998, an estimated 283,800 inmates were mentally ill, which comprised 16 percent of the state prison population and 7 percent of the federal prison population (Ditton). About 45 percent of these offenders received counseling or therapy while incarcerated; half were taking a prescribed medication; and about a fourth had been in a mental hospital or treatment program (Ditton).

Another large group of offenders who receive special services in prison are sex offenders. There are over 100,000 sex offenders in state and federal prisons. In one survey of correctional systems, more than half reported special facilities for sex offenders (e.g., therapeutic communities, diagnostic centers). Most often, sex offenders receive some form of individual or group counseling (Wees).

We should also note another source of counseling and programming in prisons: chaplains and religious volunteer groups. Part of the formal role of prison chaplains is to provide counseling to inmates. Such counseling often moves beyond religious issues to other problems in the offenders' lives (Sundt and Cullen). Further, various types of "faith-based" programming are found within virtually every correctional system. These might include Bible study, prayer and meditation sessions, peer mentors, and worship services ("Religion Behind Bars"). In Texas, there is a unit within a correctional institution that is, in essence, a "faith based prison" where religious volunteers provide inmates with both religious and support programs (Cullen, Sundt, and Wozniak).

Finally, although most of the focus has been on adult offenders, we should note that many of the programs used in prisons are found as well in juvenile facilities. A survey in 1993 found that a majority of states offered these programs to juvenile offenders: "academic education, vocational training, vocational counseling, organized recreation, substance abuse counseling, mental health counseling, sex offender treatment, abuse counseling, and positive peer culture" (Lillis, p. 14).

Community-based treatment. Although the main focus of this section has been on prison-based programs, some mention should be made of treatment programs conducted in the community. Only two states do not supervise offenders released from prison. Otherwise, inmates returning to the community are placed on parole or mandatory supervised release, and they are monitored by parole officers. Probation is an alternative to incarceration. Convicted offenders who are not sentenced to prison may be placed on probation and, if so, are monitored by probation officers. In some states probation is centralized and thus is a state function; in most states, however, probation is decentralized and is administered by local jurisdictions, such as counties and cities. There are over two thousand probation agencies. In contrast, parole is always administered by a central agency that is part of state government. The federal government, which runs its own correctional system, also supervises offenders in the community. In the United States, there were approximately 700,000 offenders on parole and over 3.2 million on probation in 1999 (Petersilia, 1997, 1999).

Traditionally, probation and parole officers have been given the dual role of surveillance and treatment—surveillance to detect any signs of continued criminality and treatment to help the offender to overcome criminal propensities and become a solid citizen. The notion of these officers as treatment providers evolved into the social casework model, in which officers would, in essence, be primarily responsible for the rehabilitation of offenders assigned to them. The shortcomings of this model, however, soon became clear. First, heavy caseloads restricted the time that officers had to devote to any one offender; in fact, today the average caseload for probation officers is 124 and for parole officers is 67 (Camp and Camp). Second, officers often lacked the expertise to address the diverse needs of offenders (e.g., drug addiction). Thus, while officers still provide individual counseling—and occasionally run group sessions—they mainly fulfill their treatment function by being a service broker. In this model, their role is to assess offenders and to direct them into programs in the community. Most often, these programs are administered by nonprofit, community-based agencies.

We should note, however, that starting in the 1980s, there was a trend to transform probation and parole from a treatment-surveillance model into a model that sought exclusively to control and punish offenders (Cullen, Wright, and Applegate). Increasingly, officers have been required to conduct drug tests on, secure restitution payments from, and intensively supervise offenders (what one officer called the "pee 'em and see 'em" model). These extra duties, as well as the philosophy underlying their performance, have served in a number of jurisdictions to limit the treatment services provided by probation and parole officers (Petersilia, 1999).

When undertaken, community correctional programs vary in the degree to which they envelop an offender's life. Some programs are residential, lasting from 30 to 120 or more days; some programs offenders report to during the day for treatment; and some programs are attended a few hours each week. A wide range of services are delivered through these various programs. Some programs provide specialized treatment services, such as drug and alcohol counseling, sex offender counseling, psychiatric services, domestic violence counseling, family counseling, vocational and employment counseling (including job referrals), and life skills education. Other programs, especially those that are residential, tend to be multimodal, offering several services aimed at supporting offenders' attempts to "go straight."

Quality of treatment services. Several problems plague efforts to provide effective treatment services to offenders. First, the very existence of program options can vary greatly across correctional institutions and across communities (e.g., large counties have many more treatment options). As a result, programs may not exist to address the specific needs of certain offenders. Second, the availability of places in treatment programs does not always match the supply. Take, for example, the needs of parolees in California. As Joan Petersilia notes, "there are only 200 shelter beds for more than 10,000 homeless parolees, four mental health clinics for 18,000 psychiatric cases, and 750 beds in treatment programs for 85,000 drug and alcohol abusers" (1999, p. 502). Third, the quality or "integrity" of treatment programs varies widely. For example, a prison classroom may be a place where offenders are motivated to learn and secure degrees or a place where they sit impassively, doze off, or read the newspaper (Lin). Fourth, even if designed with the best of intentions, treatment programs may not be based on scientific criminological knowledge and thus may target for change factors that are not related to recidivism (i.e., much like a physician giving a patient medicine for the wrong disease).

Does correctional rehabilitation work?

As noted previously, Martinson's 1974 review of the research on correctional programs poignantly raised the question of whether correctional interventions "work." Harboring negative sentiments toward rehabilitation, many policymakers and criminologists embraced Martinson's critique of rehabilitation and embraced his conclusion that "nothing works" on corrections. Now that more than a quarter of a century has passed, we can provide a more balanced assessment of the question posed by Martinson. The evidence tells us that the heady optimism of early reformers was not warranted, but neither, it appears, is the pessimism of current-day critics of rehabilitation. Simply put, we know more now about what does, and does not, work to reduce offender recidivism (for a summary, see Cullen and Gendreau).

In recent years, correctional interventions have, at times, become more punitive and have sought to achieve recidivism by deterring offenders rather than by changing them. These intervention strategies, for example, have involved the intensive supervision of probationers and parolees, the electronic monitoring of offenders in the community, boot camps for those beginning a life in crime, and "scared straight" programs for juveniles. After considerable research, the evidence is clear: these deterrence-oriented programs do not work to reduce recidivism (Cullen and Gendreau; Cullen et al., 1996; Petersilia and Turner).

In contrast, it is now apparent that rehabilitation programs generally reduce recidivism and, when conducted according to the "principles of effective treatment" (Gendreau), cut reoffending substantially (Andrews and Bonta; Cullen and Gendreau; Lipsey and Wilson; Lurigio). Evidence favorable to rehabilitation has been generated by a statistical technique called meta-analysis. Traditionally, criminologists such as Martinson would read over a group of studies evaluating treatment programs. They would then either describe what the studies found—a narrative review —or try to count how many studies showed that offender treatment worked or did not work—the "ballot box" method. A meta-analysis, however, essentially computes a batting average across all studies, calculating the average impact of treatment on recidivism. Using this method, the existing research, which now involves hundreds of evaluation studies, shows that rehabilitation programs reduce recidivism about 10 percentage points. Thus, if a control group had a recidivism rate of 55 percent, the treatment group's rate of re-offending would be 45 percent.

A group of Canadian psychologists interested in crime—Don Andrews, James Bonta, and Paul Gendreau being its most prominent members—have taken the analysis of effective rehabilitation one step farther. They had two important insights. First, they believed that treatment should focus on changing those factors that are most strongly associated with or "predict" recidivism (e.g., antisocial values and peer associations, low self-control). Second, they hypothesized that rehabilitation programs that "worked" to reduce recidivism should share common features. Thus, it made sense to investigate what distinguished programs that decreased re-offending from those that did not.

Based on meta-analyses of treatment studies, they found that in rehabilitation programs that conformed to the principles of effective intervention, recidivism was about 25 percentage points lower in the treatment as opposed to the control group (Andrews and Bonta; Cullen and Gendreau). These principles include: (1) target the known predictors of recidivism for change; (2) use cognitive-behavioral treatments that reinforce prosocial attitudes and behavior, seek to challenge and extinguish criminal thinking patterns, and provide alternative, prosocial ways of acting; (3) focus treatment interventions on high-risk offenders; (4) try to take into account characteristics of offenders (e.g., I.Q.) that might affect their responsivity to treatment; (5) employ staff that are well trained and interpersonally sensitive; and (6) provide offenders with aftercare once they leave the program (Gendreau).

The future of rehabilitation

In the early 1970s commentators asked, "Is rehabilitation dead?" Attacked by both liberals and conservatives and with seemingly scant empirical support, offender treatment appeared ready to be relegated to the correctional dustbin. Rehabilitation programs, however, did not go away, even if this was often because it was more convenient to keep them than to get rid of them. Indeed, programming continued inside and outside prisons, even though the United States was in the midst of an unprecedented campaign to "get tough" on crime that has resulted in approximately a sevenfold increase in the prison population since the early 1970s (Currie; Mauer). Honest debates can take place over whether the increased imprisonment was necessary and/or effective, but it is clear that merely locking up offenders is not the full answer to America's crime problem. The question thus arises, what else can we do to reduce recidivism and protect public safety?

At least part of that answer will involve attempts to rehabilitate offenders. It is noteworthy that contrary to the claims often made in the media, study after study shows (1) that a sizable minority of the American public believes that rehabilitation should be the main goal of corrections and (2) that a substantial majority believes that treating offenders is an important goal of corrections. To be sure, citizens want dangerous offenders locked away and are not reluctant to support harsh sentences. Still, they also are open to community-based options for nonviolent offenders, and they believe that rehabilitation should be a core part of corrections inside and outside prisons (Cullen, Fisher, and Applegate). In short, the often-stated idea that the "public won't support rehabilitation" simply is not true.

In an age when politicians seem at times to govern by what the polls say, the receptivity of the public to rehabilitation is significant. Still, the question of effectiveness—does rehabilitation reduce recidivism?—will remain central to rehabilitation's future. It is clear that rehabilitation is not a panacea capable of saving every criminal from a wayward life. But it is equally clear that treatment programs are more effective than doing nothing with offenders and more effective than punitively oriented programs. Further, in the last decade or so, criminologists have made important strides in uncovering how best to reform offenders, including those who are serious chronic criminals. This knowledge about the principles of effective intervention is likely to grow and be refined in the future immediately ahead.

Perhaps the largest challenge for the field of corrections is whether the emerging knowledge base on effective rehabilitation will be used or ignored. Implementing effective programs can be daunting when resources are limited, when staff training is poor and not conducted according to any professional standards, and when leaders of correctional systems and agencies are antagonistic to research knowledge. Even so, there are clear signs in numerous jurisdictions around the United States that a "what works" movement is under way. As criminologists articulate a more precise blueprint for how to intervene effectively with offenders, it becomes increasingly attractive to do what works rather than to do what fails. Further, the press for accountability and to use public monies responsibly may well place pressures on even reluctant correctional officials to replace failed practices with "best practices" (Rhine).

There is a final reason why rehabilitation is likely to reassert itself as a correctional philosophy: it appeals to a core theme in American culture—one present across time—that offenders, especially young ones, are not beyond redemption. We are, after all, the very people who founded the "penitentiary," reaffirmed rehabilitation in the "new penology," and chose to call our prisons "correctional" institutions. We are perhaps more skeptical than our predecessors about the extent to which criminals can be reformed. Even so, we share their vision that we lose something as a people when we reduce the correctional enterprise to inflicting pain, ware-housing offenders, and depleting the system of all hope and compassion (Clear). There is, in the end, something ennobling about rehabilitation—something that calls us to do good for offenders not because we must but because such action symbolizes the kind of individuals and nation we wish to be (Cullen and Gilbert).

Francis T. Cullen

Shannon A. Santana

See also Correctional Reform Associations; Deterrence; Incapacitation; Jails; Juvenile Justice: Institutions; Prediction of Crime and Recidivism; Prisoners, Legal Rights of; Prisons: History; Prisons: Correctional Officers; Prisons: Prisoners; Prisons: Prisons for Women; Prisons: Problems and Prospects; Probation and Parole: History, Goals, and Decision-Making; Probation and Parole: Procedural Protection; Probation and Parole: Supervision; Retributivism; Sexual Predators.

BIBLIOGRAPHY

Adams, Kenneth; Bennett, Katherine J.; Flanagan, Timothy J.; Marquart, James W.; Cuvelier, Steven J.; Fritsch, Eric; Gerber, Jurg; Longmire, Dennis R.; and Burton, Velmer S., JR. "A Large-Scale Multidimensional Test of the Effect of Prison Education Programs on Offenders' Behavior." The Prison Journal 74, no. 4 (1994): 433–449.

Andrews, D. A., and Bonta, James. The Psychology of Criminal Conduct, 2d ed. Cincinnati, Ohio: Anderson Publishing Co., 1998.

Barnes, Harry Elmer. The Story of Punishment, 2d ed. Montclair, N.J.: Patterson Smith, 1972.

Bouffard, Jeffrey A.; Mackenzie, Doris Layton; and Hickman, Laura J. "Effectiveness of Vocational Education and Employment Programs for Adult Offenders: A Methodology-Based Analysis of the Literature." Journal of Offender Rehabilitation 31, nos. 1–2 (2000): 1–41.

Camp, Camille Graham, and Camp, George M. The Corrections Yearbook 1999: Adult Corrections. Middletown, Conn.: Criminal Justice Institute, 1999.

Clear, Todd R. Harm in American Penology: Offenders, Victims, and Their Communities. Albany, N.Y.: State University of New York Press, 1994.

Cullen, Francis T.; Fisher, Bonnie S.; and Applegate, Brandon K. "Public Opinion About Punishment and Corrections." In Crime and Justice: A Review of Research, Volume 27. Edited by Michael Tonry. Chicago: University of Chicago Press, 2000. Pages 1–79.

Cullen, Francis T., and Gendreau, Paul. "Assessing Correctional Rehabilitation: Policy, Practice, and Prospects." In Criminal Justice 2000—Volume 3: Policies, Processes, and Decisions of the Criminal Justice System. Edited by Julie Horney. Washington, D.C.: National Institute of Justice, U.S. Department of Justice, 2000. Pages 109–175.

Cullen, Francis T., and Gilbert, Karen E. Reaffirming Rehabilitation. Cincinnati, Ohio: Anderson Publishing Co., 1982.

Cullen, Francis T.; Sundt, Jody L.; and Wozniak, John F. "The Virtuous Prison: Toward a Restorative Rehabilitation." In Contemporary Issues in Crime and Criminal Justice: Essays in Honor of Gilbert Geis. Edited by Henry N. Pontell and David Shichor. Saddle River, N.J.: Prentice-Hall, 2000. Pages 265–286.

Cullen, Francis T.; Wright, John Paul; and Applegate, Brandon K. "Control in the Community: The Limits of Reform?" In Choosing Correctional Interventions That Work: Defining the Demand and Evaluating the Supply. Edited by Alan T. Harland. Thousand Oaks, Calif.: Sage Publications, 1996. Pages 69–116.

Currie, Elliott. Crime and Punishment in America. New York: Metropolitan Books, 1998.

Ditton, Paula M. Mental Health and Treatment of Inmates and Probationers. Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice, 1999.

Eriksson, Torsten. The Reformers: An Historical Survey of Pioneer Experiments in the Treatment of Criminals. New York: Elsevier Scientific Publishing Co., 1976.

Feld, Barry C. Bad Kids: Race and the Transformation of the Juvenile Court. New York: Oxford University Press, 1999.

Foucault, Michel. Discipline and Punish: The Birth of the Prison. New York: Pantheon Books, 1977.

Gendreau, Paul. "The Principles of Effective Intervention with Offenders." In Choosing Correctional Interventions That Work: Defining the Demand and Evaluating the Supply. Edited by Alan T. Hardin. Thousand Oaks, Calif.: Sage Publications, 1996. Pages 117–130.

Griset, Pamela L. Determinate Sentencing: The Promise and the Reality of Retributive Justice. Albany, N.Y.: State University of New York Press, 1991.

Lillis, Jamie. "Survey Summary: Youth Count Drops by 15%; Overcrowding Remains." Corrections Compendium 18 (December 1993): 7–14.

——. "Survey Summary: Education in U.S. Prisons—Part Two." Corrections Compendium 19 (April 1994): 10–16.

Lin, Ann Chih. Reform in the Making: The Implementation of Social Policy in Prison. Princeton, N.J.: Princeton University Press, 2000.

Lipsey, Mark W., and Wilson, David B. "Effective Intervention for Serious Juvenile Offenders: A Synthesis of Research." In Serious and Violent Juvenile Offenders: Risk Factors and Successful Interventions. Edited by Rolf Loeber and David P. Farrington. Thousand Oaks, Calif.: Sage Publications, 1998. Pages 313–345.

Lipton, Douglas; Martinson, Robert; and Wilks, Judith. The Effectiveness of Correctional Treatment: A Survey of Treatment Evaluation Studies. New York: Praeger, 1975.

Lurigio, Arthur J. "Drug Treatment Availability and Effectiveness: Studies of the General and Criminal Justice Populations." Criminal Justice and Behavior 27, no. 4 (2000): 495–528.

Maguire, Kathleen, and Pastore, Ann L., eds. Sourcebook of Criminal Justice Statistics—1998. Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice, 1999.

Martinson, Robert. "What Works? Questions and Answers About Prison Reform." The Public Interest 35 (Spring 1974): 22–54.

Mauer, Marc. The Race to Incarcerate. New York: The New Press, 1999.

McKelvey, Blake. American Prisons: A History of Good Intentions. Montclair, N.J.: Patterson Smith, 1977.

Palmer, Ted. "Martinson Revisited." Journal of Research in Crime and Delinquency 12 (July 1975): 133–152.

Petersilia, Joan. "Probation in the United States." In Crime and Justice: A Review of Research, Volume 22. Edited by Michael Tonry. Chicago: University of Chicago Press, 1997. Pages 149–200.

——. "Parole and Prisoner Reentry in the United States." In Prisons: Crime and Justice—A Review of Research, Volume 26. Edited by Michael Tonry and Joan Petersilia. Chicago: University of Chicago Press, 1999. Pages 479–529.

Petersilia, Joan, and Turner, Susan. "Intensive Probation and Parole." In Crime and Justice: A Review of Research, Volume 17. Edited by Michael Tonry. Chicago: University of Chicago Press, 1993. Pages 281–335.

Platt, Anthony M. The Child Savers: The Invention of Delinquency. Chicago: University of Chicago Press, 1969.

"Religion Behind Bars: Survey Finds Variety of Religious Beliefs, Activities within Correctional Institutions." Corrections Compendium 23 (April 1998): 8–21.

Rhine, Edward E., ed. Best Practices: Excellence in Corrections. Lanham, Md.: American Correctional Association, 1998.

Rothman, David J. The Discovery of the Asylum: Social Order and Disorder in the New Republic. Boston: Little, Brown and Co., 1971.

——. Conscience and Convenience: The Asylum and Its Alternatives in Progressive America. Boston: Little, Brown and Co., 1980.

Rotman, Edgardo. "The Failure of Reform: United States, 1865–1965." In The Oxford History of the Prison: The Practice of Punishment in Western Society. Edited by Norval Morris and David J. Rothman. New York: Oxford University Press, 1995.

Sabol, William J., and Lynch, James P. Crime Policy Report: Did Getting Tough Pay? Washington, D.C.: Urban Institute, 1997. Also available through the Internet at http//www.urbran.org/crime/crime.htm.

Silverman, Ira J., and Vega, Manuel. Corrections: A Comprehensive Review. Minneapolis, Minn.: West Publishing Co., 1996.

Snyder, Howard N., and Sickmund, Melissa. Juvenile Offenders and Victims: 1999 National Report. Washington, D.C.: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice, 1999.

Stephan, James J. Census of State and Federal Correctional Facilities, 1995. Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice, 1997.

Sundt, Jody L., and Cullen, Francis T. "The Role of the Contemporary Prison Chaplain." The Prison Journal 23, no. 3 (1998): 271–298.

"Survey Summary: Education Opportunities in Correctional Settings." Corrections Compendium 22 (September, 1997): 4–16.

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Tewksbury, Richard; Erickson, David John; and Taylor, Jon Marc. "Opportunities Lost: The Consequences of Eliminating Pell Grant Eligibility for Correctional Education Students." Journal of Offender Rehabilitation 31, nos. 1–2 (2000): 43–56.

Tonry, Michael. Reconsidering Indeterminate and Determinate Sentencing: Research in Brief. Washington, D.C.: National Institute of Justice, U.S. Department of Justice, 1999.

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U.S. Department of Justice. National Institute of Justice. http://www.ojp.usdoj.gov/nij.

Van Voorhis, Patricia; Braswell, Michael; and Lester, David. Correctional Counseling and Rehabilitation, 3d ed. Cincinnati, Ohio: Anderson Publishing Co., 1997.

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Wilson, David B.; Gallagher, Catherine A.; and MacKenzie, Doris L. "A Meta-Analysis of Corrections-Based Education, Vocation, and Work Programs for Adult Offenders." Journal of Research in Crime and Delinquency 37, no. 4 (2000): 347–368.

Wines, E. C., ed. Transactions of the National Congress on Penitentiary and Reformatory Discipline. Albany, N.Y.: Weed Parsons and Co., 1871.

REHABILITATION

Rehabilitation is one of the basic elements of comprehensive geriatric care. Rehabilitation is indicated when someone is not functioning at their full potential. It involves an assessment of the underlying causes of activity limitation, treatment of the primary impairment to the extent possible, prevention of further disability, and interventions to promote adaptation of the person to their disability. The goal of geriatric rehabilitation is to maximize functional independence.

Rehabilitation in general, and geriatric rehabilitation in particular, is provided by an interdisciplinary team. The basic team consists of one (or more) occupational therapist, physiotherapist, physician, rehabilitation nurse, and social worker. Other disciplines that can be involved either as part of the core team, or on a consultation basis, include dietetics, pharmacy, psychology, recreational therapy, or speech-language pathology. A team that works well together, and whose members have an understanding of and respect for each other’s contributions and strengths, is integral to a successful rehabilitation program.

Assessment

Assessment begins with establishing the patient’s suitability for a rehabilitation program. In order to benefit from a geriatric rehabilitation program, the patient must be medically stable and have a minimum of endurance to undergo at least an hour per day of therapy. Patients must be motivated to participate actively in the program, and must have sufficient cognitive function to be able to learn simple tasks with repetition. They must require the expertise of at least two different rehabilitation disciplines.

The World Health Organization has defined several terms to facilitate communication. These include impairments, which are problems in body function or structure (e.g., an arthritic joint or a stroke). Activity limitations are difficulties an individual has in performance of activities (e.g., being unable to walk safely on stairs). Participation restrictions are problems an individual may have concerning involvement in life situations (e.g., being housebound because the only access requires using stairs, and there is no ramp or elevator in place). The rehabilitation team addresses activity limitations and participation restrictions associated with specific impairments.

It is important to get a good picture of the patient’s weaknesses and strengths in the spheres of mobility, self-care (bathing, dressing), continence, cognition, mood, and social situation. There are many different outcome measurements that are used to record and follow level of function. It is important to be aware of the patient’s previous level of function in order to set appropriate goals. Priority is given to the goals of the patient and family members.

Intervention

Intervention begins with prevention of further injury. This means preventing the complications that can arise from bedrest following the initial problem (stroke, hip fracture, medical illness). If older people are left convalescing too long, they become at risk for infections, pressure ulcers, and muscle atrophy. Early mobilization is essential. Risk factors for future falls, fractures, or strokes are identified and addressed, if possible, to try to prevent any further impairment.

The physiotherapist (PT) can design an exercise program to increase flexibility, strength, balance, and endurance. PT’s evaluate and train the patient in getting up from sitting, walking, stepping over curbs and going up stairs, using walking aids as necessary. The occupational therapist’s (OT) emphasis is on self-care skills, including bathing, dressing, and eating. They also focus on instrumental activities of daily living, such as cooking, housekeeping, using the telephone, and money management. The OT assists with education, training, compensatory skills, and adaptive equipment. The social worker plays a crucial role in discharge planning and as the primary communicator between the rehabilitation team and the family. Rehabilitation nurses encourage independence by providing physical or verbal assistance. They monitor skin care, bowel and bladder management, and provide guidance about medications.

Discharge planning begins as soon as the patient’s condition stabilizes and the likely functional outcome becomes clear. A home visit by a PT or OT may be useful to determine accessibility of the home environment and appropriate home modifications. Important considerations are the amount of support available (which can be a problem when the spouse is also frail and elderly) and the extent of care needs. Family meetings with representatives from the rehabilitation team, as well as community care providers, are often necessary to set up needed home help prior to discharge.

Stroke rehabilitation

Rehabilitation following a stroke should begin as soon as possible, to avoid the complications of immobility and to allow for maximal functional gains. Most functional recovery occurs within the first two to six months following a stroke, and early prediction of outcome is useful to set appropriate goals, facilitate discharge planning, and anticipate the need for home adjustments and supports. Muscle strengthening and general conditioning can reduce impairment and disability. Task-oriented exercise may be more meaningful to elderly patients and can contribute to motor recovery and gait retraining. Many stroke survivors have persistent activity limitation of the affected arm. Immobilization of the unaffected arm combined with intensive training of the affected one is occasionally used to improve arm function. Another approach involves facilitation of appropriate movement patterns in the affected arm. Depression is common after stroke and, unless treated, can interfere with recovery. Swallowing dysfunction should be looked for by an OT or speech-language pathologist.

Hip fracture rehabilitation

Falls and hip fractures are unfortunately common in frail elderly patients, and hip fracture rehabilitation is an important concern. Breaking a hip can result in nursing home placement or even death. An important predictor of being able to return home is pre-fracture mobility. Ongoing communication with the orthopedic surgeon is important to establish hip precautions, to avoid dislocation of an artificial joint, and for guidance on when the patient can begin to bear his full weight on the operated leg. Older patients may be unable to cooperate with partial weight-bearing restrictions, because of poor balance, weakness, or cognitive impairment. Although pain must be adequately treated, it is important to avoid overmedication and delirium in frail older adults. Fear of falling can become a limiting factor, and confidence must be addressed. Strengthening exercises (sometimes including treadmill gait retraining), balance training, and walking aids are standard components of hip fracture rehabilitation. Therapy can continue on an outpatient basis.

Inpatient rehabilitation can take place on the acute care unit (medical or surgical) or on specialized geriatric rehabilitation wards. If the patient is well enough to go home, outpatient rehabilitation can be facility-based or home-based. In some areas, geriatric day hospitals offer an intermediate solution to frail patients who have returned to the community. The types of geriatric services available vary depending on local preference, economics, and cultural attitudes toward the elderly. Particularly as the population ages, resources may not keep pace with needs. Outcome in geriatric rehabilitation very often depends upon the type and degree of social support available to the patient.

Susan Freter

See also Balance and Mobility; Geriatric Medicine; Hip Fracture; Occupational Therapy; Physical Therapy; Stroke; Walking Aids; Wheelchairs.

BIBLIOGRAPHY

Barer, D. ‘‘Rehabilitation.’’ In Geriatric Medicine and Gerontology, 5th ed. Edited by J. C. Brocklehurst. London: Harcourt Brace, 1998. Pages 1521–1550.

Brummel-Smith, K. Clinics in Geriatric Medicine: Geriatric Rehabilitation. Philadelphia, Pa.: W. B. Saunders Co., 1993.

LÖkk, J. ‘‘Geriatric Rehabilitation Revisited.’’ Aging Clinical and Experimental Research 11 (1999): 353–361.

Steinberg, F. U., and Dean, B. Z. ‘‘Physiatric Therapeutics: Geriatric Rehabilitation.’’ Archives of Physical Medicine and Rehabilitation 71 (1990): S278–S280.

Taub, E.; Uswatte, G.; and Pidikiti, R. ‘‘Constraint-Induced Movement Therapy: A New Family of Techniques with Broad Application to Physical Rehabilitation—A Clinical Review.’’ Journal of Rehabilitation Research and Development 36 (1999): 237–251.

Weber, D. C.; Fleming, K. C.; and Evans, J. M. ‘‘Rehabilitation of Geriatric Patients.’’ Mayo Clinic Proceedings 70 (1995): 1198–1204.

World Health Organization. ICIDH-2: International Classification of Functioning and Disability. Beta-2 draft. Geneva: World Health Organization, 1999. www.who.int/icidh

Zuckerman, J. D.; Fabian, D. R.; Aharanoff, G.; Koval, K. J.; and Frankel, V. H. ‘‘Enhancing Independence in the Older Hip Fracture Patient.’’ Geriatrics 48 (1993): 76–81.

Rehabilitation

3000 ■ AMERICAN COUNCIL OF THE BLIND

Attn: Coordinator, Scholarship Program
1155 15th Street, N.W., Suite 1004
Washington, DC 20005
Tel: (202)467-5081
Free: 800-424-8666
Fax: (202)467-5085
E-mail: [email protected]
Web Site: http://www.acb.org
To provide financial assistance to undergraduate or graduate students who are blind and are interested in studying in a field of service to persons with disabilities.
Title of Award: Arnold Sadler Memorial Scholarship Area, Field, or Subject: Disabilities; Education, Special; Law; Rehabilitation, Physical/Psychological Level of Education for which Award is Granted: Graduate, Undergraduate Number Awarded: 1 each year. Funds Available: The stipend is $2,000. In addition, the winner receives a Kurzweil-1000 Reading System. Duration: 1 year.
Eligibility Requirements: This program is open to students in rehabilitation, education, law, or other fields of service to persons with disabilities. Applicants must be legally blind and U.S. citizens. In addition to letters of recommendation and copies of academic transcripts, applications must include an autobiographical sketch. A cumulative GPA of 3.3 or higher is generally required. Selection is based on demonstrated academic record, involvement in extracurricular and civic activities, and academic objectives. The severity of the applicant's visual impairment and his/her study methods are also taken into account. Deadline for Receipt: February of each year. Additional Information: This scholarship is funded by the Arnold Sadler Memorial Scholarship Fund. Scholarship winners are expected to be present at the council's annual conference; the council will cover all reasonable expenses connected with convention attendance.

3001 ■ AMERICAN FOUNDATION FOR THE BLIND

Attn: Scholarship Committee
11 Penn Plaza, Suite 300
New York, NY 10001
Tel: (212)502-7661
Free: 800-AFB-LINE
Fax: (212)502-7771
E-mail: [email protected]
Web Site: http://www.afb.org/scholarships.asp
To provide financial assistance to blind undergraduate and graduate students who wish to study in the field of rehabilitation and/or education of the blind.
Title of Award: Delta Gamma Foundation Florence Margaret Harvey Memorial Scholarship Area, Field, or Subject: Education, Special; Rehabilitation, Physical/Psychological; Visual impairment Level of Education for which Award is Granted: Four Year College, Graduate Number Awarded: 1 each year. Funds Available: The stipend is $1,000. Duration: 1 year.
Eligibility Requirements: This program is open to legally blind juniors, seniors, or graduate students. U.S. citizenship is required. Applicants must be studying in the field of rehabilitation and/or education of visually impaired and blind persons. Along with their application, they must submit an essay that includes the field of study they are pursuing and why they have chosen it; their educational and personal goals; their work experience; any extracurricular activities with which they have been involved, including those in school, religious organizations, and the community; and how they intend to use scholarship monies that may be awarded. Deadline for Receipt: April of each year. Additional Information: This scholarship is supported by the Delta Gamma Foundation and administered by the American Foundation for the Blind.

3002 ■ AMERICAN FOUNDATION FOR THE BLIND

Attn: Scholarship Committee
11 Penn Plaza, Suite 300
New York, NY 10001
Tel: (212)502-7661
Free: 800-AFB-LINE
Fax: (212)502-7771
E-mail: [email protected]
Web Site: http://www.afb.org/scholarships.asp
To provide financial assistance to legally blind undergraduate or graduate students studying in the field of rehabilitation and/or education of visually impaired and blind persons.
Title of Award: Rudolph Dillman Memorial Scholarship Area, Field, or Subject: Education, Special; Rehabilitation, Physical/Psychological; Visual impairment Level of Education for which Award is Granted: Graduate, Undergraduate Number Awarded: 4 each year: 3 without consideration of financial need and 1 to an applicant who can submit evidence of financial need. Funds Available: The stipend is $2,500 per year. Duration: 1 academic year; previous recipients may not reapply.
Eligibility Requirements: Applicants must be able to submit evidence of legal blindness, U.S. citizenship, and acceptance in an accredited undergraduate or graduate training program within the broad field of rehabilitation and/or education of blind and visually impaired persons. Along with their application, they must submit an essay that includes the field of study they are pursuing and why they have chosen it; their educational and personal goals; their work experience; any extracurricular activities with which they have been involved, including those in school, religious organizations, and the community; and how they intend to use scholarship monies that may be awarded. They may also include documentation of financial need. Deadline for Receipt: April of each year.

3003 ■ ASSOCIATION FOR EDUCATION AND REHABILITATION OF THE BLIND AND VISUALLY IMPAIRED OF OHIO

c/o Marjorie E. Ward
1568 Lafayette Drive
Columbus, OH 43220
E-mail: [email protected]
Web Site: http://www.aerohio.org/schgrts/schol-grant.htm
To provide financial assistance to Ohio residents who are working on an undergraduate or graduate degree in a field related to rehabilitation of the blind.
Title of Award: AERO Personnel Preparation Scholarships Area, Field, or Subject: Counseling/Guidance; Education, Special; Rehabilitation, Physical/Psychological; Visual impairment Level of Education for which Award is Granted: Four Year College, Graduate Number Awarded: 1 each year. Funds Available: The stipend is $1,000. Duration: 1 year; nonrenewable.
Eligibility Requirements: This program is open to undergraduate and graduate students in rehabilitation counseling, rehabilitation teaching, orientation and mobility, or education of students with visual disabilities. Applicants must be residents of Ohio, although they may be studying in any state. Undergraduates must have at least junior standing. All applicants must have a GPA of 3.0 or higher. Along with their application, they must submit 1) a short essay explaining why they have chosen their specific field as their profession and what they would like to contribute to the field; 2) a short description of volunteer or paid involvement with individuals with visual disabilities or any other disability; 3) transcripts; and 4) 3 letters of recommendation. Deadline for Receipt: April of each year.

3004 ■ COURAGE CENTER

Attn: EMPOWER Scholarship Program
3915 Golden Valley Road
Minneapolis, MN 55422
Tel: (763)520-0214; 888-8-INTAKE
Fax: (763)520-0392
E-mail: [email protected]
Web Site: http://www.courage.org
To provide financial assistance to students of color interested in preparing for a career in the medical rehabilitation field.
Title of Award: Encourage Minority Participation in Occupations with Emphasis on Rehabilitation Area, Field, or Subject: Rehabilitation, Physical/Psychological Level of Education for which Award is Granted: Undergraduate Number Awarded: 2 each year. Funds Available: The stipend is $1,500. Duration: 1 year.
Eligibility Requirements: This program is open to ethnically diverse students accepted at or enrolled in an institution of higher learning. Applicants must demonstrate a career interest in the medical rehabilitation field by completing at least 200 hours of career-related volunteer service. They must have a GPA of 2.0 or higher. Selection is based on career intentions and achievements, not academic rank. Deadline for Receipt: April of each year. Additional Information: This program is also identified by its acronym as the EMPOWER Scholarship Award.

3005 ■ EPILEPSY FOUNDATION

Attn: Research Department
4351 Garden City Drive
Landover, MD 20785-7223
Tel: (301)459-3700
Free: 800-EFA-1000
Fax: (301)577-2684 E-mail: [email protected]
Web Site: http://www.epilepsyfoundation.org/research/grants.cfm
To provide funding to undergraduate and graduate students interested in working on a summer research training project in a field relevant to epilepsy.
Title of Award: Behavioral Sciences Student Fellowships in Epilepsy Area, Field, or Subject: Anthropology; Behavioral sciences; Counseling/Guidance; Economics; Epilepsy; Nursing; Political science; Psychology; Rehabilitation, Physical/Psychological; Social work; Sociology Level of Education for which Award is Granted: Graduate, Undergraduate Number Awarded: Varies each year; recently, 4 of these fellowships were awarded. Funds Available: The grant is $3,000. Duration: 3 months during the summer.
Eligibility Requirements: This program is open to undergraduate and graduate students in a behavioral science program relevant to epilepsy research or clinical care, including, but not limited to, sociology, social work, psychology, anthropology, nursing, economics, vocational rehabilitation, counseling, and political science. Applicants must be interested in working on an epilepsy research project under the supervision of a qualified mentor. Because the program is designed as a training opportunity, the quality of the training plans and environment are considered in the selection process. Other selection criteria include the quality of the proposed project, the relevance of the proposed work to epilepsy, the applicant's interest in the field of epilepsy, the applicant's qualifications, and the mentor's qualifications, including his or her commitment to the student and the project. U.S. citizenship is not required, but the project must be conducted in the United States. Applications from women, members of minority groups, and people with disabilities are especially encouraged. The program is not intended for students working on a dissertation research project. Deadline for Receipt: March of each year. Additional Information: This program is supported by the American Epilepsy Society, Abbott Laboratories, Ortho-McNeil Pharmaceutical Corporation, and Pfizer Inc.

3006 ■ MARYLAND HIGHER EDUCATION COMMISSION

Attn: Office of Student Financial Assistance
839 Bestgate Road, Suite 400
Annapolis, MD 21401-3013
Tel: (410)260-4594
Free: 800-974-1024
Fax: (410)974-5376
E-mail: [email protected]
Web Site: http://www.mhec.state.md.us/financialAid/ProgramDescriptions/prog_devdis.asp
To provide scholarship/loans to students in Maryland who are interested in working on a degree in a designated human services program.
Title of Award: Maryland Developmental Disabilities, Mental Health, Child Welfare, and Juvenile Justice Workforce Tuition Assistance Program Area, Field, or Subject: Counseling/Guidance; Criminal justice; Criminology; Disabilities; Education, Special; Gerontology; Law enforcement; Mental health; Nursing; Occupational therapy; Physical therapy; Psychology; Rehabilitation, Physical/Psychological; Social work Level of Education for which Award is Granted: Graduate, Undergraduate Number Awarded: Varies each year. Funds Available: The maximum stipend is $2,000 per year for students attending a 2-year institution or $3,000 per year for students at a 4-year institution. The total amount of all state awards may not exceed the cost of attendance as determined by the school's financial aid office or $17,800, whichever is less. Recipients must agree to work in a Maryland community-based program that is licensed by the Developmental Disabilities Administration or approved by the Mental Hygiene Administration, or in a residential program that is licensed by the Department of Human Resources or the Department of Juvenile Justice. The service obligation must begin within 6 months of graduation. The total service requirement is 2,000 hours if the award amount is $1,999 or less, 3,000 hours if the award amount is $2,000 to $3,999, or 4,000 hours if the award amount is $4,000 or more. If the service requirement is not completed, the award must be repaid with interest. Duration: 1 year; may be renewed if the recipient maintains satisfactory academic progress and remains enrolled in a human services degree program.
Eligibility Requirements: This program is open to high school seniors and full-time and part-time undergraduate and graduate students. Applicants and their parents must be Maryland residents attending a college or university in the state in 1 of the following human services degree programs: aging services, counseling, disability services, mental health, nursing, occupational therapy, physical therapy, psychology, rehabilitation, social work, special education, supported employment, vocational rehabilitation, or any other concentration in the healing arts or a program providing support services to individuals with special needs including child welfare and juvenile justice. Financial need is not considered in the selection process. Deadline for Receipt: June of each year.

3007 ■ NATIONAL AMBUCS, INC.

Attn: Scholarship Coordinator
P.O. Box 5127 High Point, NC 27262
Tel: (336)852-0052
Fax: (336)852-6830
E-mail: [email protected]
Web Site: http://www.ambucs.org
To provide financial assistance to undergraduate and graduate students who are interested in preparing for a career serving disabled citizens in various fields of clinical therapy.
Title of Award: AMBUCS Scholarships for Therapists Area, Field, or Subject: Occupational therapy; Physical therapy; Rehabilitation, Physical/Psychological; Speech and language pathology/audiology Level of Education for which Award is Granted: Four Year College, Graduate Number Awarded: Approximately 400 each year, with a total value of $225,000. Funds Available: Most of these awards range from $500 to $1,500 per year; 1 scholarship of $6,000 for 2 years is also awarded. Funds are paid directly to the recipient's school. Duration: 1 year.
Eligibility Requirements: This program is open to U.S. citizens who have been accepted at the upper-division or graduate level in an accredited program that qualifies the students for clinical practice in occupational therapy, physical therapy, speech language pathology, or hearing audiology. Programs for therapy assistants are not included. Applicants must submit college transcripts for the last 3 semesters, a 500-word essay on their interest in therapy as a career, and a statement of family financial circumstances. Selection is based on financial need, commitment to local community, demonstrated academic accomplishment, character for compassion and integrity, and career objectives. Deadline for Receipt: April of each year. Additional Information: This program was established in 1955; since then, the association has awarded more than $5 million for more than 9,900 scholarships.

Rehabilitation

Resources

Illness and trauma that lead to disability or functional loss can lead to an individual’s need for a changed lifestyle to accommodate his reduced level of ability. A stroke, for example, can lead to partial paralysis; chronic arthritis can result in the inability to stand or to use one’s hands; an automobile accident can cause blindness or can result in an individual’s confinement to a wheelchair. To retrain someone who has experienced any of these incidents requires a rehabilitation team.

Through history disabled individuals have been ridiculed, sheltered, offered care, taught to fend for themselves, or killed. The ancient Greeks killed children born crippled. In the Middle Ages the French accorded privileges to the blind. Throughout its history the church provided a place for the disabled to live and receive care. In the sixteenth and seventeenth centuries England established hospitals and passed laws to assist the disabled. The Poor Relief Act of 1601 in England outlawed begging and provided the means to assist the poor and the disabled. Through these means the disabled became less dependent upon public assistance and learned self-sufficiency. Almshouses were established to house and treat the infirm and this idea was brought to the New World. Pilgrims built almshouses in Boston in the 1660s.

The influx of wounded and maimed soldiers during World War I (1914–1918) added impetus to the rehabilitation movement. In 1918, the United States government initiated a rehabilitation program for disabled veterans of the Great War. The aim was to enable the wounded to find jobs, so physical aspects of rehabilitation were stressed with little emphasis on psychological ramifications. The program was advanced following World War II (1939–1945) to include the psychosocial aspects as well as the physical when veterans were trained for work and received counseling for reintegration into the community. Continued demands for such services have been brought about in this century by industrial accidents, auto accidents, sports injuries, and urban crime. Also, the life expectancy of people in developed countries has increased and with it the probability of contracting a chronic condition from stroke, heart attack, cancer, or other debilitating situation.

In 1947, the American Board of Physical Medicine and Rehabilitation recognized rehabilitation as a physician specialty. A rehabilitation specialist is called a physiatrist. In 1974, the American Nurses’ Association established the Association of Rehabilitation Nurses, giving recognition to nurses in the field.

Rehabilitation of the chronically ill or injured individual does not stress cure, but focuses on training the individual to live as independently as possible with the condition, taking into consideration that the condition may change for the worse over time and the disability progress. This means that physical training must be accompanied by shoring up the individual’s psychological outlook to accept the condition, accept society’s lack of understanding or even rejection, and still to attain the maximum degree of autonomy.

Rehabilitation begins with the assessment of the patient’s needs. An individual who was right-handed may lose the use of that arm and need to be trained to use the left hand for writing and other functions that his right arm normally accomplished. Such training consists greatly of iteration, the repetition of simple movements and acts to establish the nerve pathways that have not existed before. Mechanical devices requiring fine degrees of eye-hand coordination to force fingers to maneuver in ways unaccustomed.

Patients are encouraged to take advantage of mechanical aids on the market to ease their lifestyle. Opening a jar with one hand, for example, is easily accomplished using a permanently mounted device that grasps the lid while the patient turns the jar. Doorknobs can be replaced by levers. Counter tops can be lowered and extended to provide room for the wheelchair patient to work or eat from them. Handles make getting into and out of a bathtub possible for the elderly or disabled person. Lighted magnifiers provide the means for the visually handicapped to read or carry out other tasks.

Modifications to automobile controls may enable the injured person to drive, thus divorcing him from the need for transportation to be provided. A ramp may need to be constructed to allow his wheelchair access to his home. The wheelchair-bound individual may need to relocate from a multistory living facility to one that is on one floor or one that has an elevator. Even carpeting must be evaluated. The person in a wheelchair may have difficulty wheeling across a deep, soft carpet. A more dense, firm floor covering can save energy and time.

Many injured patients can be rehabilitated by fitting a prosthesis, an artificial limb. Once the body has healed from amputation of the limb, the prosthesis can be fitted and training begun. Muscles that control the movements of the artificial limb must be trained to respond in a way that moves the prosthesis naturally. This requires seemingly endless repetitions of muscle contractions to afford effortless control of the prosthesis.

While physical training progresses, psychological counseling seeks to instill a value of self worth, to counter depression, to reassure the patient that he will be able to function adequately in society and in his career. The initial reaction to a debilitating injury or disease is one of anger at having been so afflicted and depression at the loss of function and freedom and fear that former friends will shun him or that family will exhibit undue sympathy. Counseling seeks to counter all these feelings and bolster the patient’s confidence in himself. His changed station in life, losing function because of a stroke or being confined to a wheelchair because of an accident, will be jarring to his coworkers and friends, but usually they will accept the new person and adapt to his requirements.

Beyond the patient, his family also will require counseling to explain the patient’s status, his limitations, his needs, and the family’s optimal response. Coping day in and day out with a seriously handicapped family member can be grueling for the average family. Assessment of family attitudes, finances, and acceptance of the patient is crucial. The burden of caring for the patient may fall upon the shoulders of one member of the family; the wife, for example, who must care for a severely handicapped husband.

KEY TERMS

Prosthesis— A man-made replacement for a lost limb or other body part. An artificial leg is a prosthesis, as is a replacement heart valve.

Prosthetist— One who designs and fits a prosthesis and helps to train the recipient in its use.

Unending days of tending someone who requires close care can be physically and psychologically devastating. However, most family members can carry out their tasks and provide care if they receive some relief at intervals. Rehabilitation, therefore, also may include arrangements for a home health aide part time to provide personal time for the patient’s caregiver.

Rehabilitation, therefore, far from merely providing the patient lessons on controlling a wheelchair or learning to walk on crutches, must take into account his environment, his mental status, his family’s acceptance and willingness to help, as well as his physical needs. A replacement limb will never achieve the level of function of the original limb, but the prosthesis can serve adequately given sufficient training.

Resources

BOOKS

Ryan, Tony. “Using a Whole System Approach to Service Development in Rehabilitation.” In The Mental Health Review. Pavillion Publishing: Brighton, UK: December 2005.

Larry Blaser

Rehabilitation

Victims/survivors of genocide, crimes against humanity, and other serious violations of human rights and international humanitarian law often suffer physical and psychological effects, sometimes long after the traumatic events. Massive trauma causes such diverse and complex destruction that only a multidimensional, multidisciplinary integrative framework can adequately describe it, and only such an approach can optimally treat its effects. Typical reactions may be powerful negative feelings, painful physical sensations, or horrific imagery of the events. Many studies document the serious, chronic, sometimes life-long, and even multigenerational effects of massive trauma, including fear, paranoia, depression, anxiety, and personality changes. Starvation, untreated disease, experiences of persecution, psychological shock (or numbing), and head injury may interfere with the recall and verbal description of traumatic experiences.

Although ordinary stressful life events tend to release a strong need for sharing, victims/survivors of extreme traumatic events often encounter a societal imposed silence and thus share neither their experiences nor the aftermath. One study of torture victims by Weisaeth and Lind found that fewer than one out of ten victims disclosed details of their experiences to their close relatives. Even when released from captivity, victims continue to suffer stress over, for example, possible recapture or reprisals from agents of the state who had violated their human rights in the first place. The pervasive conspiracy of silence following trauma is detrimental to survivors' familial and sociocultural (re)integration and healing. It intensifies their already profound sense of isolation and mistrust of society, and makes the task of mourning their losses impossible. Further, survivors' rehabilitation can never be fully achieved if the society in which they live continues to tolerate serious or systematic human rights violations.

However, the needs of victims will require understanding more than their perceptible symptoms. Understanding their specific experience of physical and psychological trauma, the nature of the crime, and their cultural, economic, personal, and group historical backgrounds is also necessary.

Medical and trauma practitioners recognize that approaches to treatment must reflect the victim's personal experience of physical and psychological trauma. Experts, many of whom are vicariously traumatized by survivors' experiences, emphasize a holistic approach in which trust and the doctor/patient relationship are critical. Treatment strategies are most effective when they utilize local sources of social, cultural, and organizational support. Rehabilitation following egregious violations of human rights must not only address the traumatized individual, but also the family, local community, society, nation, and the international community. The individual needs to know that society as a whole acknowledges and understands what has happened. A true healing process includes apology, reparations, education, commemorations, and other ways of acknowledging what has taken place.

Genuine rehabilitation must include redress and justice as well as the restoration of dignity to the victim/survivor, and must be established in a sociopolitical context in which the experience and pain are shared by the larger society. The story must be told accurately, the public records secured, and mechanisms for monitoring and preventive intervention established to ensure nonrepetition and break the intergenerational chain of transmission.

It is increasingly recognized that impunity for perpetrators contributes to social and psychological problems and impedes healing by adversely affecting bereavement, inducing self-blame, and eroding society's moral codes. Justice denied exacerbates the victim/survivor's psychic wounds. Impunity for the wrongdoers becomes an additional traumatic factor that renders closure impossible and leads to a loss of respect for law and government, and an increase in crime. Further systematic exploration of how survivors experience efforts to bring perpetrators to justice and provide compensation, and how these efforts impact healing, is needed.

Despite the widespread recognition of the importance of physical and psychological treatment to aid the recovery process and restore the dignity of victims, their number far exceeds the available services, even in the most developed countries. Often services that do exist come too late. In many of the countries emerging from mass conflict, the few available programs are usually transitory, have not been well integrated into the health and social services sectors of the countries, and are often externally financed. As a result, many laudable initiatives are not sustainable and may not be able to address the long-term and often multigenerational needs of victims of mass trauma. In other cases the special needs of trauma victims have not been dealt with separately and what general services exist are not tailored to meet their needs.

The plight of victims of the worst crimes has created an international impetus to develop a legal framework to guarantee respect for their rights. In 1985 the United Nations (UN) General Assembly unanimously adopted "the Victims' Charter," the UN Declaration of Basic Principles of Justice for Victims of Crime and Abuse of Power. It galvanized support for the recognition of the rights of victims, in particular their rights of access to justice and redress, restitution, compensation, and assistance. This led to the UN Commission on Human Rights' appointment of an independent expert to further study the issue of victim redress. As of 2004 the draft of the basic principles and guidelines on the right to remedy and reparation for victims of violations of international human rights and humanitarian law is under discussion for adoption by the Commission. Most recently the Rome Statute of the International Criminal Court has recognized that justice serves not only a retributive but also a reparative function; it enshrines victims' rights to restitution, compensation, and rehabilitation and provides the Court with a mandate to give effect to these rights.

Significant strides have been made in recognizing the rights of victims of the worst crimes, and there is an increasing appreciation of the complexity of their needs. However, much remains to be done to realize these rights and provide those who have suffered the most abominable crimes with the critical multidimensional and multidisciplinary help they need.

SEE ALSO Compensation; Reparations; Restitution

BIBLIOGRAPHY

Danieli, Yael (1985). "The Treatment and Prevention of Long-Term Effects and Intergenerational Transmission of Victimization: A Lesson from Holocaust Survivors and Their Children." In Trauma and Its Wake, ed. C. R. Figley. New York: Brunner/Mazel.

Danieli, Yael (1988a). "Confronting the Unimaginable: Psychotherapists' Reactions to Victims of the Nazi Holocaust." In Human Adaptation to Extreme Stress, ed. J. P. Wilson, Z. Harel, and B. Kahana. New York: Plenum.

Danieli, Yael (1988b). "The Use of Mutual Support Approaches in the Treatment of Victims." In Grief and Bereavement in Contemporary Society. Vol. 3: Support Systems, ed. E. Chigier. London: Freund Publishing House.

Danieli, Yael (1988c). Remembering for the Future, Theme II: The Impact of the Holocaust on the Contemporary World. Oxford: Pergamon Press.

Danieli, Yael (1992). "Preliminary Reflections from a Psychological Perspective." In The Right to Restitution, Compensation and Rehabilitation for Victims of Gross Violations of Human Rights and Fundamental Freedoms, ed. T. C. van Boven, C. Flinterman, F. Grunfeld, and I. Westendorp. Netherlands Institute of Human Rights Special Issue No. 12:196–213.

Danieli, Yael (1994). "As Survivors Age—Parts I and II." National Center for Post Traumatic Stress Disorder Clinical Quarterly 4(1):1–7; 4(2):20–24.

Danieli, Yael (1998a). "Justice and Reparation: Steps in the Process of Healing." International Review of Penal Law 14:303–312.

Danieli, Yael, ed. (1998b). International Handbook of Multigenerational Legacies of Trauma. New York: Kluwer Academic/Plenum.

Danieli, Yael, ed. (2002). Sharing the Front Line and the Back Hills: International Protectors and Providers, Peacekeepers, Humanitarian Aid Workers and the Media in the Midst of Crisis. Amityville, N.Y.: Baywood Publishing Company.

Danieli, Yael, Elsa Stamatopoulou, and Clarence J. Dias, eds. (1999). The Universal Declaration of Human Rights: Fifty Years and Beyond. Amityville, N.Y.: Baywood Publishing Company.

Ochberg, F. M., ed. (1988). Post-Traumatic Therapy and Victims of Violence. New York: Brunner/Mazel.

Weine, S., Y. Danieli, D. Silove, M. Van Ommeren, J. A. Fairbank, and J. Saul (2002). "Guidelines for International Training in Mental Health and Psychosocial Interventions for Trauma Exposed Populations in Clinical and Community Settings." Psychiatry 65(2):156–164.

Weisaeth, L., and I. Lind (1990). "A Follow-up Study of a Tortured Norwegian Ship's Crew." In Proceeding of the 2nd International Wartime Medical Services Conference, ed. J. E. Lundeberg, U. Otto, and B. Rybeck. Stockholm, Sweden: Swedish Defense Research Institute (FOA).

Yael Danieli