The International Classiücation of Functioning

Disability and Health (ICF) in Psychiatric Rehabilitation
Kim L. MacDonald-Wilson
Universitv of Marvlana-College Park
Patricia B. Nemec
Boston Universitv

The International Classihcation of Functioning. Disabilitv ana Health (ICF) is a comprehensive
biopsvchosocial classihcation svstem that aescribes functioning. aisabilitv. ana health. It goes be-
vona impairments ana svmptomatologv. which are commonlv highlightea in psvchiatric aisabilitv.
ana allows for a aescription of performance of aailv activities ana of participation in life situations.
with consiaeration of environmental ana personal factors. This makes it particularlv relevant for
rehabilitation. For psvchiatric rehabilitation. given that svmptoms often bear little relationship to
functioning in work roles. the ICF has particular relevance in unaerstanaing how limitations in the
various mental function areas relate to emplovment issues for people with psvchiatric aisabilities.
A framework for conceptualizing psvchiatric aisabilities using the ICF is aescribea. with examples
specihc to vocational functioning arawn from the literature. Implications for clinical practice ana
psvchiatric rehabilitation eaucation are aiscussea.
Rehabilitation Eaucation. Jolume 19. Number 2 & 3. pp. 159-176 (2005)
sychiatric disabilities occur when a mental health
or psychiatric condition interIeres with a person`s
Iunctioning in living, learning, working, and/or so-
cial environments and roles (Anthony, Cohen, Far-
kas, & Gagne, 2002). Traditionally, proIessionals in
the mental health feld Iocused on treating the mental
health condition, that is, the symptoms oI the psychi-
atric 'illness.¨ Descriptions oI psychiatric conditions
were Iormulated to categorize or classiIy various ill-
nesses based upon particular patterns oI symptoms
and signs, resulting in a diagnostic label.
In the United States, this system has dominated the
mental health feld, represented by the prominence
oI the Diagnostic ana Statistical Manual of Mental
Disoraers, which was developed by psychiatrists in
the American Psychiatric Association (APA). Cur-
rently it is in its Iourth edition with a text revision
(DSM-IV-TR: APA, 2000). Nearly all proIessionally
delivered mental health services and health insur-
ance systems in the United States require inIorma-
tion about the DSM psychiatric diagnosis in order Ior
individuals to receive those services. In other coun-
tries, the World Health Organization (WHO) devel-
oped and promoted the International Statistical Clas-
sihcation of Diseases ana Health-Relatea Problems,
currently in its tenth version, known as the ICD-10
(WHO, 2004), which categorizes various health con-
ditions including psychiatric conditions.
These classifcation systems are based on a medi-
cal model perspective oI health and disorder (WHO,
2001). Accurate diagnosis is considered the corner-
stone oI accepted psychiatric treatment, and medi-
cal or psychiatric treatment proceeds Irom this diag-
nosis, Iocusing on prescription oI medications and
Rehabilitation Eaucation
therapies designed to reduce or eliminate symptoms
and to improve overall psychological Iunctioning
(Anthony, Cohen, & Nemec, 1987: MacDonald-
Wilson, Nemec, Anthony, & Cohen, 2001). While
treatments oIten eIIectively addressed the symptoms
oI the psychiatric condition, many areas oI Iunc-
tioning remain aIIected, and traditional treatments
typically have not resulted in improvements in work
Iunctioning, school Iunctioning, or community and
social Iunctioning (Anthony et al., 2002).
Many people with psychiatric conditions experi-
ence disabilities that disrupt their living, learning,
working and social roles. The medical model and its
classifcation systems, both the DSM and the ICD,
are oI limited utility in describing the impact oI the
health condition on the person and his or her Iunc-
tioning in these roles.
The psychiatric diagnoses that are most oIten con-
sidered 'severe and persistent,¨ and are cited most
oIten as those contributing to disability, are schizo-
phrenia and schizoaIIective disorder. Bipolar disor-
der, maior depression, some anxiety disorders, and
borderline personality disorder also are oIten associ-
ated with severity and high treatment costs. Episodic
and unpredictable fuctuations in symptoms oI these
psychiatric disorders contribute to variability in Iunc-
tioning and, Ior many, sporadic work histories (Bar-
on & Salzer, 2000: Cook & Razzano, 2000: Strauss,
HaIez, Lieberman, & Harding, 1985).
People disabled by a psychiatric condition account
Ior one-third oI working-age adults receiving SSI, and
Ior 27 percent receiving SSDI (Burt & Aron, 2003).
Psychiatric disability is the primary disabling condi-
tion Ior 20 percent oI the people who receive services
Irom the State-Federal vocational rehabilitation (VR)
program (Hayward & Schmidt-Davis, 2003). Antho-
ny et al. (2002) reviewed the literature on the impact
oI serious psychiatric conditions on educational at-
tainment and living in the community. Experiencing
a serious psychiatric condition seems to aIIect most
areas oI Iunctioning, and improvements in those areas
were not achieved through traditional treatment ap-
The term 'psychiatric disability¨ is used here in
preIerence to the term 'mental illness,¨ as recom-
mended by the Language Guidelines oI the Inter-
national Association oI Psychosocial Rehabilitation
Services (Iormerly IAPSRS, now the US Psychiatric
Rehabilitation Association). The concept oI 'disabil-
ity¨ is seen as more relevant to rehabilitation than is
the concept oI 'illness¨ (IAPSRS, 2003), and implies
the hope oI reacquiring ability. Terms Iocusing on
'illness,¨ 'disorder,¨ and 'diagnosis¨ refect a medi-
cal model rather than a rehabilitation perspective,
and emphasize symptoms and pathology over Iunc-
tioning and role achievement.
A psychiatric disability results when a psychiatric
condition or disorder interIeres with a person`s ability
to Iunction in a particular role or environment, such
as in work, school, home or community (Anthony
et al., 2002). A classifcation system that Iocuses on
Iunctioning and not exclusively on illness would be
useIul in assisting proIessionals to assess, plan, and
intervene in ways that improve Iunctioning.
Psychiatric Rehabilitation Approach
Psychiatric rehabilitation has been conceptualized
as a process oI assisting an individual to develop the
skills and supports needed to be both successIul and
satisfed in his or her chosen environments (Anthony
et al., 2002). As illustrated in Figure 1, the psychi-
atric rehabilitation process fows through the three
phases oI diagnosis, planning, and intervention. The
psychiatric rehabilitation diagnosis and related inter-
ventions Iocus on skills and supports, as relevant to a
specifc environment, such as a iob.
The process begins by identiIying the desired goal
environment, which then is stated as an 'overall reha-
bilitation goal,¨ including intent, role, setting, and a
timeline. For example, someone might state, 'I intend
to work as a stock clerk Ior a large supermarket chain
within the next eight months.¨ Once the goal is stat-
ed, the assessment process Iocuses on the skills and
supports needed Ior achieving that goal the stock
clerk iob in this example and looks at the degree
to which the person already possesses those skills
and uses needed supports. Skills Ior a stock clerk iob
might include such things as documenting inventory,
using saIe liIting mechanics, and answering custom-
er questions. Supports might include transportation
to and Irom the iob, written instructions, adequate
breaks, and a back support belt. Interventions are de-
signed to increase those skills and supports that Iall
short oI the needed level.
160 MacDonala-Wilson ana Nemec
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The ICF in Psvchiatric Rehabilitation 159
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Conceptualizing Psychiatric Disabilities
Using the ICF
As described elsewhere in this issue (Peterson &
Rosenthal, 2005, this volume), the newest member
oI the World Health Organization (WHO) Iamily
oI health classifcations known as the International
Classihcation of Functioning. Disabilitv ana Health
(ICF) recognizes the interaction between the person,
his or her health condition(s), and the environment,
in a biopsychosocial model that emphasizes Iunc-
tioning and participation in community and society
(WHO, 2001). A complementary classifcation to the
ICD-10 (WHO, 2004), the ICF model extends be-
yond diagnostic inIormation, such as impairments
and symptomatology, and allows Ior a description oI
perIormance oI daily activities and oI participation
in liIe situations, while considering the environmen-
tal and personal Iactors that aIIect both Iunctioning
and health. The comprehensive view oI the ICF holds
promise Ior understanding the complex issues that
limit or Iacilitate success Ior people who have psy-
chiatric disabilities.
The Body Structure and Functions component oI the
ICF can help broaden the Iocus Irom the more typical
medical or psychiatric Iocus on symptoms and pa-
thology, which are the defning descriptive Ieatures oI
the 'health condition¨ or psychiatric disorder. While
present-day science may not be able to identiIy the
exact loss or deviation oI body structure that under-
lies a particular psychiatric disorder, the ICF catego-
ry called Mental Functions, under the Body Structure
and Functions component, appears to capture many
oI the cognitive, emotional and social Iunctions that
are aIIected by psychiatric conditions. Within Chap-
ter 1 under Body Structure and Functions, the section
on Mental Functions includes Global Mental Func-
tions, such as the Iunctions oI consciousness, orien-
tation, intellect, temperament and personality, energy
and drive, and sleep: and Specifc Mental Functions
such as attention, memory, psychomotor, emotional,
perceptual, thought, higher-level cognitive Iunctions,
mental Iunctions oI language, calculation, the mental
Setting an Overall Rehabilitation Goal
e.g.. I intena to work as a (role) in (setting) bv (aate)
Assessment oI Skills
neeaea* vs. present
Assessment oI Supports
neeaea* vs. available
Develop Skills
Develop Supports
Figure 1: The Psychiatric Rehabilitation Approach
Adapted Irom Anthony, Cohen, Farkas, & Gagne (2002)
* 'needed¨ reIers to the skills and resources that are essential Ior the particular individual to achieve success and satisIaction
in the chosen goal environment. Note that whenever the 'needed¨ level is greater than the present or available level,
an intervention is called Ior to increase the level oI skill or support.
Iunction oI sequencing complex movements, and ex-
perience oI selI and time.
Many oI these mental Iunctions appear related to
the cognitive, social, and emotional Iunctions identi-
fed in the literature as related to vocational outcomes
Ior people with psychiatric disabilities, which will
be described later in this article. Specifc skills that
build on these mental Iunctions, especially interper-
sonal and cognitive skills, are Iound in the Activities
and Participation section. They include items such as
listening, acquiring skills, Iocusing attention, solv-
ing problems, and making decisions (Chapter One
on Learning and Applying Knowledge): undertaking
multiple tasks, carrying out a daily routine, handling
multiple stresses and psychological demands (Chap-
ter Two on General Tasks and Demands): receiving
spoken messages, producing nonverbal messages,
conversation, and discussion (Chapter Three on Com-
munication): and basic interpersonal interactions such
as showing warmth or responding to basic cues: com-
plex interpersonal interactions such as initiating and
terminating relationships, maintaining social space,
and Iamily or intimate relationships (Chapter Seven
on Interpersonal Interactions and Relationships).
Environmental issues also are relevant to understand-
ing vocational outcomes Ior people with psychiatric
disabilities. For example, poor vocational outcomes
have been associated with environmental Iactors such
as Iewer reasonable workplace accommodations and
supports, negative societal attitudes toward people
with psychiatric conditions, contradictory disability
policies at the Iederal level related to eligibility and
coverage, disincentives Ior work in the Social Secu-
rity Administration`s disability benefts programs, and
poor collaboration between mental health and voca-
tional rehabilitation systems (Cook & Razzano, 2000:
Dellario, 1985: Fabian, Waterworth, & Ripke, 1993:
Granger, Baron, & Robinson, 1997: MacDonald-Wil-
son, Rogers, Ellison, & Lyass, 2003: MacDonald-Wil-
son, Rogers, Massaro, Lyass, & Crean, 2002: Noble,
1998: Rogers, Anthony, & Danley, 1989).
Despite the comprehensiveness and applicability
oI the ICF to understanding people with psychiatric
disabilities, the felds oI mental health and vocational
rehabilitation remain slow to move Irom a Iocus on
symptoms used Ior diagnosis to the aspects oI Iunc-
tioning that contribute to success or Iailure in work
settings. The ICF is a comprehensive Iramework that
can be used to describe the impact oI health condi-
tions on various domains oI Iunctioning, but is not
well-known and little used in psychiatric rehabilita-
tion. The Iollowing sections present a rationale Ior
using the ICF model in psychiatric rehabilitation by
summarizing the relevant literature on vocational
outcomes Ior people with psychiatric disabilities per-
tinent to each oI the components oI the ICF (health
condition, mental Iunctions, activities and participa-
tion, and contextual Iactors). There is also a discus-
sion about the relevance oI the ICF to psychiatric re-
habilitation clinical practice and education.
Psychiatric or diagnostic assessments evaluate the
psychiatric disorder, describing the symptoms and
patterns oI behavior that, when viewed as a whole,
indicate a particular psychiatric diagnostic label. The
ICF does not classiIy health conditions, but health
conditions are a component oI the model that aIIect
Iunctioning, disability, and health. Little attention is
paid to specifc Iunctional limitations in traditional
psychiatric diagnostic assessment, except as a sever-
ity measure oI the impairment when it causes social
and/or occupational dysIunction.
The multi-axial classifcation system oI psychiat-
ric diagnosis frst introduced with the DSM-III (APA,
1980) includes more than symptoms. It considers med-
ical conditions that might be relevant to psychiatric
treatment, identifes psychosocial stressors, and rates
global Iunctioning. However, the Global Assessment
oI Functioning (GAF) scale used Ior Axis V diagnosis
in the DSM-IV-TR (APA, 2000) makes no distinction
between social Iunctioning, occupational Iunctioning,
and symptoms in its rating scale. These Iactors are
considered iointly when choosing a GAF score. The
GAF does not adequately consider people who Iunc-
tion well while still experiencing symptoms.
For example, someone with 'moderate¨ symptoms,
such as occasional panic attacks, who demonstrates
good Iunctioning in all areas, would be rated the same
(51-60 on the 1-100 scale) as someone with absent or
minimal symptoms but 'moderate diIfculty in social,
occupational, or school Iunctioning¨ (APA, 2000, p.
34). In general, the DSM diagnostic system is useIul
in describing symptoms and psychiatric conditions,
162 MacDonala-Wilson ana Nemec
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The ICF in Psvchiatric Rehabilitation 163
but not in describing Iunctioning.
Research does not support the conclusion that psy-
chiatric diagnosis alone is a good predictor oI voca-
tional capacity. While there is suIfcient evidence to
suggest that a diagnosis oI a psychotic disorder is as-
sociated with somewhat poorer vocational outcomes
than a diagnosis oI an aIIective disorder (Arns &
Linney, 1995: Bryson, Bell, Lysaker, & Zito, 1997:
Cook, 2003: Fabian, 1992: Jacobs, Wissusik, Collier,
Stackman, & Burkeman, 1992: Lysaker, Bell, Mil-
stein, Bryson, Shestopal, & Goulet, 1993: Mowbray,
Bybee, Harris, & McCrohan, 1995), these relation-
ships appear modest. Some oI these early studies
must be interpreted with caution since they used the
DSM-III, which was somewhat less reliable than the
DSM-IV (APA, 1994). In addition, several oI these
studies also concluded that measures oI Iunctioning
and system and service delivery Iactors were stronger
predictors than diagnosis.
Symptom measures have shown limited predic-
tive power regarding work Iunctioning (Anthony,
1994: Anthony, et al., 2002: Cook & Razzano, 2000:
Tsang, Lam, Ng, & Leung, 2000). In Iact, psychiat-
ric symptoms bear only a small, although signifcant,
relationship to vocational Iunctioning particularly
negative symptoms (Cook & Razzano, 2000: HoII-
man, Kupper, Zbinden, & Hirsbrunner, 2003: Tsang
et al., 2000). Negative symptoms include social with-
drawal, lack oI motivation, lack oI interest or plea-
sure, and blunted or fat aIIect, in contrast to positive
symptoms such as hallucinations, delusions, or be-
havioral posturing.
In several recent studies, the relationship between
psychiatric symptoms and vocational capacity or
outcomes was able to account Ior only a small pro-
portion oI the variance (10-15 percent) in vocational
outcomes (Anthony, Rogers, Cohen, & Davies, 1995:
Dion, Dellario, & Farkas, 1982: Rogers, Anthony,
Cohen, & Davies, 1997: Rogers, Anthony, Toole,
& Brown, 1991). Other studies have Iound that diI-
Ierences in vocational outcomes could be attributed
to specifc symptoms in interaction with particular
diagnoses, but not to symptoms alone or to diagno-
sis alone (Bell & Lysaker, 1995: Massel, Liberman,
Mintz, Jacobs, Rush, Giannini, et al., 1990).
To summarize, iI diagnosis and symptoms in the
DSM classifcation system have limited utility in pre-
dicting vocational outcomes, proIessionals should ex-
amine other systems that capture Iactors that do appear
related to outcomes, such as those that Iollow. Table 1
on the Iollowing page presents Iactors that relate to vo-
cational outcomes and concomitant ICF components.
Cognitive Iunctions have been Iound to be relevant
to vocational success Ior people with psychiatric dis-
abilities (Ikebuchi, Iwasaki, Sugimoto, Miyauchi, &
Liberman, 1999: MacDonald-Wilson et al., 2002:
Tsang et al., 2000: Wallace, 1986). For the purpose
oI this discussion, the term 'cognitive Iunctions¨ is
used to include the ICF categories oI attention, such
as vigilance, sustained attention, or selective atten-
tion: memory, such as short-term, verbal, visual, or
secondary memory: perception, such as auditory, vi-
sual, or visuospatial: executive Iunctioning, which
the ICF terms 'higher level cognitive Iunctions,¨
such as time management, organization and plan-
ning, iudgment, decision making, and problem-solv-
ing: and language, such as reception, expression, and
verbal fuency. The ICF Mental Functions chapter
includes emotional Iunctions, perceptual Iunctions,
energy, and sleep under Mental Functions, but these
are discussed separately.
Visuospatial processing, as measured by the Block
Design subtest oI the WAIS-R, has been Iound to
be moderately related to work Iunctioning (Brekke,
Raine, Ansel, Lencz, & Bird, 1997). Verbal memo-
ry accounted Ior 20 percent oI the variance in work
perIormance in a vocational rehabilitation program
(Bryson, Bell, Kaplan, & Greig, 1998). Executive
Iunctioning, as measured by the Wisconsin Cara Sort-
ing Test, which measures shiIting cognitive set, was
related to amount oI work perIormed in a vocational
rehabilitation program (Lysaker, Bell, & Beam-Gou-
let, 1995). A global screening measure oI cognitive
Iunctioning called the Repeatable Batterv for the
Assessment of Neuropsvchological Status yielded
signifcant diIIerences between employed and un-
employed participants with psychiatric disabilities
(Gold, Queern, Iannone, & Buchanan, 1999). Mea-
sures oI secondary memory, immediate memory, vig-
ilance, and executive Iunctioning have been shown
to be signifcantly related to community outcome
164 MacDonala-Wilson ana Nemec
Rehabilitation Eaucation
Table 1: Summary of Factors Related to Vocational Outcomes
ICF Component Factors Related To Findings
Vocational Outcome
Health Psychiatric Diagnosis Psychotic disorder modestly related
to poor outcomes: Iunctioning and
service/system Iactors are stronger
predictors than diagnosis.
Symptomatology Negative symptoms are modest pre-
dictors: symptoms or diagnosis alone
not oIten predictive compared to the
interaction oI these Iactors.
Body (Mental)
Functions Cognitive Functions Visuospatial processing, verbal
memory, executive Iunction-
ing moderately to strongly related to
outcomes: atypical antipsychotics
related to cognitive Iunctions, but no
direct evidence yet oI relationship oI
medications to outcomes.
Emotional Functions Emotion Iunctions may be key
mediator between cognitive Iunc-
tions and Iunctional outcomes: no
direct evidence yet oI relationship oI
emotional Iunctions to vocational
outcomes, although tolerating stress
and managing symptoms related to
need Ior workplace accommodations.
Other Functions DiIfculties with sleep related to
reduced productivity in people with
out psychiatric conditions: anecdotal
evidence oI problems with concen-
tration, low energy levels, and sleep
Ior work perIormance.
Activities and Interpersonal Interactions Social skills strongly related to vocat-
Participation and Relationships ional outcomes.

Other Activities and Participation Areas such as selI-care, mobility,
Iamily liIe considered clinically im-
portant in psychiatric rehabilitation,
but need evidence.
Environment Natural and Human-made Environment Reasonable accommodations improve
iob tenure and satisIaction with iob.
Supports and Relationships Supportive relationships anecdotally
reported to be related to outcomes.
Attitudes Negative employer attitudes related
to limited hiring oI people with psy-
chiatric disabilities.
Service Systems Lack oI service system integration
related to vocational outcomes: state
vocational rehabilitation system is
less successIul with people with psy-
chiatric disabilities.
Rehabilitation Eaucation
The ICF in Psvchiatric Rehabilitation 165
(Green, 1996: Green et al., 2000), which included
social and occupational Iunctioning and independent
living. These fndings are signifcant with medium to
large eIIect sizes. The percent oI variance explained
in Iunctional outcome ranged Irom 20 percent to 60
percent. Caution should be used in interpreting fnd-
ings oI such studies, however, given the variability in
the quality oI methodology used to assess cognitive
Iunctioning (Harvey & KeeIe, 2001).
Atypical antipsychotic medications such as clozap-
ine, risperidone, and olanzapine positively aIIect cog-
nitive Iunctioning, especially in the areas oI executive
Iunctioning and verbal fuency, attention, and learn-
ing and memory Iunctions (KeeIe, Silva, Perkins, &
Lieberman, 1999). Little direct evidence exists to
indicate that the use oI medications has an impact
on work outcomes: however, some experts suggest
that medications have a more signifcant impact on
vocational outcomes than the scant research on the
topic indicates (see e.g., Bond & Meyer, 1999). The
perceived value oI medication is supported by one
study, where people with schizophrenia stated that
medications were important to them in their voca-
tional recovery (Russinova, Wewiorski, Lyass, Rog-
ers, & Massaro, 2002).
Research confrms the clinical impression that
people with schizophrenia and other psychoses lack
skills in emotion perception, emotion recognition,
emotion processing, emotion regulation, emotional
experience, and emotional expression (Earnst &
Kring, 1999: Hodel, Brenner, Merlo, & Teuber, 1998:
Mueser, Penn, Blanchard, & Bellack, 1997: Sweet,
Primeau, Fichtner, & Lutz, 1998: Taylor & Liberzon,
1999), as well as motivation and ability to experience
pleasure (Taylor & Liberzon, 1999). Managing emo-
tions and managing symptoms and medications are
oIten mentioned as 'intrapersonal¨ skills that may be
related to vocational outcomes, and have been the tar-
get oI skill training interventions (Wallace, Tauber, &
Wilde, 1999). Tolerating stress and managing symp-
toms are emotional limitations that have been associ-
ated with a need Ior reasonable accommodations in
the workplace Ior people with psychiatric disabilities
in supported employment iobs (MacDonald-Wilson,
Rogers, & Massaro, 2003).
Some psychiatric symptom assessments include
items that encompass emotional Iunctioning, such
as the item 'blunted aIIect¨ in the Brief Psvchiatric
Rating Scale. Analysis oI the literature highlights
maior diIIerences between emotional Iunctions typi-
cally reported in the research literature and emotional
Iunctions listed in the ICF Mental Functions chapter
(see Table 2). Few emotional Iunctions are listed in
the ICF Mental Functions chapter compared to the
number oI cognitive Iunctions listed, in spite oI the
prominence oI the emotional or aIIective Iunction-
ing problems experienced by people with psychiatric
conditions (Kring, 1999: Mueser et al., 1997). The
ICF Emotion Functions appear more descriptive and
symptom-related (e.g., appropriateness oI emotion),
Table 2: Comparison of Emotion Functions in the ICF and the Emotion Processing Literature
WHO ICF (2001) Literature*
Appropriateness oI emotion Emotion recognition
Regulation oI emotion Emotion regulation
Range oI emotion Emotion experience
Emotion perception
Emotion processing
Emotion expression
* Earnst & Kring, 1999: Hodel, Brenner, Merlo, & Teuber, 1998: Mueser, Penn, Blanchard, & Bellack, 1997: Sweet, Primeau,
Fichtner, & Lutz, 1998: Taylor & Liberzon, 1999)
while the emotional Iunctions cited in the literature
appear to represent processes or operations in the
brain (e.g., emotion perception). Individuals with
psychiatric disabilities describe experiencing emo-
tions and expressing emotions as two separate prob-
lems (MacDonald-Wilson, 2005), a distinction that is
not made in the ICF.
Some researchers suggest that emotion processing
may be a key mediator between basic neurocogni-
tive abilities and Iunctional outcomes (Corrigan &
Penn, 2001: Green et al., 2000: Kee, Green, Mintz, &
Brekke, 2003). Further research is needed to identiIy
the range oI emotional Iunctions and how symptoms,
emotional Iunctioning, and cognitive Iunctioning are
related to vocational outcomes.
The energy and drive Iunctions listed in the ICF
also can be aIIected by psychiatric conditions. Lack
oI interest in Iormerly pleasurable activities tech-
nically termed anhedonia is a defning Iactor Ior
maior depression, along with changes in appetite and
lack oI stamina. Lack oI initiative, or avolition, is list-
ed in the diagnostic criteria Ior schizophrenia (APA,
2000, p. 312), while high drive, setting multiple loIty
goals, and lack oI impulse control are more likely to
be seen in people experiencing a manic episode.
Sleep disturbances are common Ior people who
have psychiatric conditions, yet are Irequently over-
looked as contributing Iactors to Iatigue and concen-
tration problems. Early morning awakening is com-
mon in depression, and people with anxiety disorders
oIten experience diIfculty Ialling asleep. Nightmares
are Irequently a problem Ior people with post-trau-
matic stress disorder. Even Ior people who are not
diagnosed with a psychiatric disorder, sleep distur-
bances and inadequate sleep create signifcant prob-
lems, including reduced work productivity (Pressman
& Orr, 1997).
Concentration problems and a lack oI energy also
can be the result oI side eIIects Irom psychiatric medi-
cations. Medication side eIIects can cause limitations
in other body Iunctions as well, including blurry vi-
sion, dry mouth, sexual side eIIects, changes in blood
pressure and involuntary movements. Anecdotally,
people with psychiatric disabilities have described
diIfculties on the iob with low energy, trouble con-
centrating, and sleep (MacDonald-Wilson, 2005).
More research is needed to examine the recognition
oI these Iactors and their relationship to vocational
outcomes. Using the ICF to identiIy relevant Iactors
may be useIul as a Iramework Ior identiIying areas oI
assessment in psychiatric vocational rehabilitation.
Reviews oI the literature indicate that social or
interpersonal skills and work adiustment skills are
strongly and consistently related to vocational out-
comes Ior people with psychiatric disabilities (An-
thony & Jansen, 1984: Cook & Razzano, 2000: Tsang
et al., 2000). Good iob interviewing skills also have
been shown to be positively related to fnding em-
ployment (Cook & Razzano, 2000: Jacobs et al.,
1992). One study (Lysaker & Bell, 1995) Iound so-
cial Iunctioning to be one oI the most impaired ar-
eas among people diagnosed with schizophrenia in a
work rehabilitation placement, but also showed sig-
nifcant improvement over time in the program.
Another study (Lysaker et al., 1993) Iound people
diagnosed with schizophrenia or schizoaIIective dis-
order employed in a VA sheltered work setting had
signifcantly lower ratings oI social skills, such as
acting Iriendly, understanding co-workers` behavior,
and conducting workplace relationships, than people
with non-psychiatric disabilities in the same setting.
Emotional and interpersonal problems on the iob, as
compared to the quality oI work, are reported as the
primary reasons that people with psychiatric disabili-
ties leave iobs (Becker, Drake, Bond, Xie, Dain, &
Harrison, 1998: Tsang & Pearson, 1996: Wallace et
al., 1999).
Recent literature on social skills also has defned
a cognitive component to interpersonal interaction,
such as in the receiving-processing-sending model oI
social skills (Liberman, Wallace, Blackwell, Eckman,
Vaccaro, & Kuehnel, 1993: Wallace et al., 1999), or
in studies examining the relationship oI social skills
to neuropsychological measures (Brekke et al., 1997:
Green, 1996: Green et al., 2000: Lysaker, Bell, Zito,
& Bioty, 1995: Vauth, Rusch, Wirstz, & Corrigan,
2004). This raises a question about whether social
Iunctioning and interpersonal skills are only activi-
166 MacDonala-Wilson ana Nemec
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The ICF in Psvchiatric Rehabilitation 167
Rehabilitation Eaucation
ties involving other people, (as classifed in the ICF
under the Activities and Participation components),
or whether these are components oI brain Iunction-
ing (i.e., Mental Functions), or some combination oI
both. Currently, these Iunctions are not specifed in
the Mental Functions chapter oI the ICF, with the ex-
ception oI one item, Global Psychosocial Functions.
The ICF classifes most social Iunctioning as an
Activity/Participation Iactor.
The ICF includes nine domain areas under Ac-
tivities and Participation, some oI which are clearly
dependent on Iunctions, including the Mental Func-
tions already discussed. For example, Chapter One
on Learning and Applying Knowledge includes
thinking, solving problems, and making decisions,
while the 'higher level cognitive Iunctions¨ section
oI the Mental Functions Chapter also includes deci-
sion making, planning and carrying out plans, and
problem solving. However, a strength in a Mental
Functions area, identifed through a cognitive assess-
ment measure, does not automatically translate into
a strength under Activities and Participation. An im-
portant contribution oI the Activities and Participa-
tion component oI the ICF model is the distinction
between capacity and perIormance: what someone
can do, and what someone aoes do.
A basic principle in psychiatric rehabilitation is
the importance oI considering the environmental set-
ting in which a person is being assessed, or in which
a person wishes to be successIul (Anthony et al.,
2002). PerIormance varies based on the environment,
and skills do not automatically generalize Irom one
environment to another (Bellack, Mueser, Gingerich,
& Agresta, 2003). Too oIten, people with psychiat-
ric disabilities have been assessed as unprepared Ior
employment because they do not perIorm activities
deemed important Ior success at work. However, not
arriving on time to a day program that a person does
not like does not predict whether the same person
will arrive on time to an interesting iob that results in
a paycheck. While capacity can be measured in any
setting, perIormance must be measured in the rele-
vant environment. Situational assessment approaches
speciIy observable, measurable behaviors in a work
environment (Hursh, Rogers, & Anthony, 1988).
Situational assessment involves observing the person
engaged in work activities in a real or simulated work
environment, and evaluating general worker skills re-
lated to completing iob tasks, interacting with others,
and being responsible.
The ICF items on Activities and Participation rep-
resent a comprehensive list oI areas that might be
considered during a vocational or educational assess-
ment, or perhaps as a schema Ior helping a person
identiIy goal areas. While some areas, such as mo-
bility, do not typically present a problem Ior people
with psychiatric disabilities, the Activities and Par-
ticipation domains oI selI care and domestic liIe (e.g.,
maintaining one`s living space) should be evaluated
Ior areas oI diIfculty. Lack oI selI care, such as poor
personal hygiene, may aIIect someone`s ability to get
or keep a iob. While many aspects oI domestic liIe
are unrelated to work, an unstable living situation can
create diIfculties that spill over into work liIe.
Environmental Iactors clearly play a role as Iacili-
tators and barriers oI vocational success and recovery
Ior people with psychiatric disabilities. Supports and
relationships are oIten cited as key Iacilitators oI re-
covery by people writing about their experience with
psychiatric disabilities and mental health services
(see, e.g., Deegan, 1997: Kramer & Gagne, 1997).
Availability oI employer-provided supports and ac-
commodations as well as supportive relationships
with service providers and Iriends Iacilitate employ-
ment tenure and satisIaction with the iob (Fabian et
al., 1993: MacDonald-Wilson et al., 2002: Russi-
nova et al., 2002). Poverty can present a barrier to
success (Cook, 2003). Negative societal attitudes to-
wards people diagnosed with a psychiatric disorder
also create employment barriers (Burt & Aron, 2003:
Corrigan & Kleinlein, 2005: Diksa & Rogers, 1996),
and contribute to the internalized stigma that low-
ers selI-esteem (Corrigan & Kleinlein, 2005: Link,
Struening, Neese-Todd, Asmussen, & Phelan, 2001),
reduces selI-eIfcacy, and reduces willingness to
seek help (Corrigan & Kleinlein, 2005: Sirey, Bruce,
Alexopoulos, Perlick, Friedman, & Meyers, 2001).
Lack oI adequate services, lack oI integration be-
tween mental health and vocational rehabilitation
systems, and policies that create work disincentive
all create signifcant barriers to vocational success
Ior people with psychiatric disabilities (Cook, 2003).
The likelihood oI becoming employed Ior people
with psychiatric disabilities served by the State-Fed-
eral VR program is lower than Ior people with other
types oI disabilities, such as orthopedic disabilities
(Hayward & Schmidt-Davis, 2003).
Others have Iound that 60 percent oI people with
psychiatric disabilities achieve employment out-
comes, compared to people with orthopedic dis-
abilities (67 percent), people with mental retardation
(69 percent), or people with learning disabilities or
chronic medical conditions (74 percent) (Bolton,
Bellini, & Brookings, 2000). These studies lead some
experts to conclude that the VR system is, at best, oI
'limited eIIectiveness¨ with this population (Cook,
2003: MacDonald-Wilson et al., 2003: Noble et al.,
Although not commonly recognized, certain as-
pects oI the physical work environment can create
diIfculties Ior people with psychiatric disabilities,
making the ICF Environment domain oI 'Natural
and human-made changes to the environment¨ rel-
evant. For example, the high noise levels and bright
lights oIten experienced when working in a cubicle
can cause additional problems with concentration
Ior someone who already struggles with being easily
distracted (MacDonald-Wilson, 1997). Changes in
these environmental Iactors, such as installing noise-
reduction machines or modiIying the lighting, are ac-
commodations that can be considered Iacilitators in
the Environmental component.
Theoretically, the ICF indicates that contextual Iac-
tors have a signifcant impact on Iunctioning, and En-
vironment is specifed in the ICF in a separate chapter
to highlight its importance (Schneidert, Hurst, Miller,
& Ustun, 2003). In assessing Activities/Participation,
guidelines suggest rating Activities and Participation
items in the context oI both standard environments
in rating capacity, and natural environments in rating
perIormance (WHO, 2001).
However, the ICF model does not assign environ-
ment a clear role in the process oI assessing or coding
body Iunctions such as mental Iunctions, although it
is understood that assessment occurs in some context
(Schneidert et al., 2003). While philosophically the
ICF emphasizes that all Iunctioning is an interaction
oI the health condition, the person, and the context in
which the person lives, the ICF ratings oI body Iunc-
tions seem to Iocus on the body in the abstract, rather
than on the body in an environment.
In practice, however, environment is likely to have
a role in rating Mental Functions, as well as in rating
Activities and Participation. Mental Iunctions could
potentially be assessed in a standard environment,
such as on a neuropsychological test administered in
a psychologist`s oIfce, or in a natural environment
such as at home or on the iob site. In a study using
cognitive interviewing to design a selI-report version
oI the ICF checklist on Mental Functions (MacDon-
ald-Wilson, 2005), respondents were asked to rate
how much oI a problem they experienced in the past
30 days on the iob with each mental Iunction. With
Global Mental Functions, some respondents Iound it
hard to answer this question iI the Iunction itselI did
not happen on the iob, such as 'amount oI sleep,¨
even when problems reported with this Iunction oc-
curred at home but created problems at work, such
as when not getting enough sleep resulted in Ieeling
tired at work.
For other Iunctions, some respondents experienced
problems at home, but not at work or vice versa. Re-
porting on Mental Functions varied between natural
environments oI work and home. Clearly, environ-
ment had a role in selI-report oI mental Iunctions,
and environment should be specifed or indicated
when rating mental Iunctions.
At a minimum, the context or specifc environment
in which the assessment oI the Iunction is relevant
should be noted.
The present version oI the ICF does not classiIy
Personal Context Iactors, but includes it as a con-
struct within the conceptual Iramework oI the ICF
(Peterson & Rosenthal, 2005, this volume). Personal
Context comes into play Ior people with psychiatric
disorders through such Iactors as culture or personal
experience oI trauma. One`s worldview may have a
signifcant impact on work Iunctioning. For example,
how one`s culture values work or past negative expe-
riences with authority fgures may aIIect one`s inter-
est in setting rehabilitation goals, identiIying personal
strengths, interacting with supervisors, or accepting
168 MacDonala-Wilson ana Nemec
Rehabilitation Eaucation
The ICF in Psvchiatric Rehabilitation 169
Rehabilitation Eaucation
ICF: Relevance to Clinical Practice in
Psychiatric Rehabilitation
The ICF Activities and Participation domains
oI 'maior liIe areas¨ and 'community, social, and
civic liIe¨ are similar to the domains Ior generating
an overall rehabilitation goal in the Psychiatric Re-
habilitation Approach (Anthony et al., 2002), which
are identifed as living, learning, working, and social
environments. An overall rehabilitation goal is the
primary area oI rehabilitation Iocus, and represents
the role and setting where a person wants to be in the
next six months to two years.
Highlighting environmental context in the ICF
model parallels the Functional Assessment process
practiced in the Psychiatric Rehabilitation Approach
(Anthony et al., 2002). In this approach, all Iunction-
ing is evaluated in the context oI a specifc environ-
ment, and a person`s use oI skills in one environment
is not assumed to predict use oI skills in a diIIerent
environment. In using the ICF, it is important to know
the context, since a rating oI 'not a problem at work¨
may indicate that a specifc Iunction is no problem ei-
ther at work or at home, or it may be that the Iunction
is not required on the iob but the person experiences
some degree oI problem with it at home.
The ICF can be used as a guide or Iramework Ior
conducting assessments that are relevant Ior voca-
tional outcomes. IdentiIying Iactors that both the lit-
erature and individuals with psychiatric conditions
report as related to work perIormance and outcomes
can assist evaluators in choosing assessment instru-
ments and methods that can easily map to the com-
prehensive listing oI mental Iunctions, as well as
relevant Activities, Participation, and Environment
Iactors. This Iramework can guide assessment plan-
ning and improve the eIfciency oI any assessments
that are conducted. Comprehensive assessments that
are not targeted to the relevant inIormation are ex-
pensive, time-consuming, and may have a negative
impact on the individual`s continued involvement in
and motivation Ior rehabilitation.
Targeting specifc areas oI need also Iacilitates the
eIfcient selection oI interventions. Because a review
oI the various interventions that might beneft a per-
son with specifc limitations is beyond the scope oI
this review, the reader is reIerred to the relevant lit-
erature (Anthony et al., 2002: Bellack et al., 2003:
Fischler & Booth, 1999: Liberman et al., 1993: Wal-
lace et al., 1999: Wykes, Reeder, Williams, Corner,
Rice, & Everitt, 2003).
People with psychiatric disabilities experience a
high risk oI cognitive limitations, and those limita-
tions are likely to interIere with the learning oI new
skills, such as those related to technical aspects oI
the iob or to interpersonal skills. Research suggests
that implementation oI cognitive remediation prior to
skills training may alleviate symptoms and cognitive
defcits, but no conclusive positive benefts on learn-
ing new skills have been Iound (Wykes et al., 2003).
In some cases, supports and accommodations may
moderate the relationship between cognitive limita-
tions and work perIormance (McGurk, Mueser, Har-
vey, La Puglia, Marder, & Davis, 2003).
Examples oI many types oI these supports can be
coded in the ICF Environment component, such as
Technology, Supports and Relationships, and Ser-
vice Systems and Policies. In other cases, develop-
ing compensatory skills may address the limitation
experienced. Selecting the intervention that would
most likely be eIIective is an important component oI
eIIective rehabilitation services.
The ICF provides a useIul Iormat Ior guiding a
comprehensive assessment, but has some shortcom-
ings. A number oI the original mental Iunctions in the
ICF Checklist appear to refect underlying Iunctions
related to symptoms (pathology or impairment). In
Iact, the ICF included many oI these symptoms as
examples oI problems in the original defnitions oI
the mental Iunctions.
Although designed to be neutral in identiIying and
defning items in the ICF to Iocus on health and Iunc-
tioning, the infuence oI pathology and a Iocus on
symptoms are evident in the development oI the ICF
Mental Functions items. It may be that proIessionals
who were oriented toward the medical model iden-
tifed maior symptoms that seemed to interIere with
Iunctioning, and then created mental Iunctions worded
neutrally but designed to encompass those symptoms
(see Table 3). The current classifcation involved peo-
ple with psychiatric disabilities on the International
Mental Health Task Force, who Iormulated concepts
and confrmed the relevance and sensitivity oI the lan-
guage used in the ICF (Kennedy, 2003).
Annex 2 in the ICF suggests that, at the user`s dis-
Rehabilitation Eaucation
cretion, coding scales can be developed to capture the
positive aspects oI Iunctioning (WHO, 2001, p.223)
that have been Iound important in vocational assess-
ment and vocational outcomes research. Even so, it
is arguable that the ICF is Iocused on problems in
Iunctioning, refecting a medical model approach,
emphasizing pathology, rather than a rehabilitation
approach, evaluating both strengths and limitations
relative to Iunctioning in an environment. In a study
using cognitive interviewing to develop a selI-report
version oI the Mental Functions Chapter oI the ICF
(MacDonald-Wilson, 2005), respondents with psy-
chiatric disabilities had emotional reactions to many
oI these 'clinical¨ terms, and recommended remov-
ing the proIessional iargon and oIIensive words.
Finally, the ICF is complex and diIfcult to use Ior
individuals with little training on its structure and
application (Peterson, 2005: Reed et al., 2005). The
ICF is detailed, and without proper training may pose
problems Ior some proIessionals (Chopra, Couper,
& Hermann, 2002). There is an eIIort underway in
the American Psychological Association to develop
a procedural manual to use in clariIying the meaning
oI individual items (American Psychological Asso-
ciation, 2003: Reed et al., 2005), but it is too early
to know the impact such eIIorts will have on proIes-
sionals beginning to use the ICF.
In addition, it is important to understand that the
nature oI psychiatric disabilities and the impact oI
these conditions on multiple areas oI Iunctioning is
also very complex. Assisting individuals in their re-
covery oI roles important to them requires thoughtIul
consideration oI the multitude oI personal, environ-
mental, and health Iactors that aIIect Iunctioning in
those roles. The ICF can be used as a Iramework Ior
identiIying these multiple Iactors, choosing relevant
areas Ior assessment, and developing skills, supports,
and other interventions needed to help the person to
achieve those valued roles.
The Utility of ICF for Rehabilitation
Education: Teaching Psychiatric Rehabilitation
Rehabilitation counseling education programs that
teach psychiatric rehabilitation should not limit their
Iocus to diagnosis and medication, using a medi-
cal model exclusively, emphasizing pathology and
symptoms. A medical model is an appropriate and
desired Iocus Ior treatment, and eIIective treatment
oIten is an important contributor to rehabilitation and
recovery. However, rehabilitation counseling educa-
tors should not make the mistake oI equating psychi-
atric treatment with psychiatric rehabilitation.
The relevance oI Contextual Factors is too oIten
overlooked, particularly in evaluating work environ-
ments and the sociocultural context oI the worksite,
or in defning social expectations and natural supports
available at work. By teaching Iuture practitioners
about cultural Iactors, Ior example, and about how
shortcomings in existing systems and policies aIIect
vocational success rates Ior people with disabilities,
rehabilitation counseling educators are preparing stu-
dents to Iace real world challenges.
Recognizing the relevance oI context should spur
170 MacDonala-Wilson ana Nemec
Table 3: Examples of Mental Functions and Related Psychiatric Symptoms
Mental Functions Psvchiatric Svmptom Examples
b147 Psychomotor Iunctions Catatonia, posturing
b152 Emotional Iunctions Lability oI emotion, fattening oI eIIect
b1560 Auditory perception Hallucinations
b1601 Form oI thought Ideational perseveration, tangentiality
b1602 Content oI thought Delusions, somatization
b1603 Control oI thought Rumination, thought broadcast, thought insertion
b1800 Experience oI selI Depersonalization, derealization
Rehabilitation Eaucation
The ICF in Psvchiatric Rehabilitation 171
Table 4: Illustration of Application of the ICF
ICF Categorv Phvsical Disabilitv Psvchiatric Disabilitv
Health Condition Rheumatoid Arthritis Schizophrenia
Body Structure/Function StiII, swollen ioints Brain/ventricle anomalies
Chronic pain DiIfculty with organization
Fatigue Low energy level
Activities Able to manage selI-care Able to learn new skills
DiIfculty with stairs Uses public transportation
Drives car w/no problem DiIfculty in relationships
Participation Active in church Unemployed
Employed: accountant Attends clubhouse program
Salsa dancing Volunteers at SPCA
Context: Environmental Lives in a 1-story home Lives in Supported Apartment
Large, close Iamily Few Iriends
Has health insurance SSI/SSDI, work disincentives
Sees Rheumatologist Fragmented Service Systems
Voice-activated soItware Negative public attitudes
Context: Personal Male, head oI household Female, divorced, no children
Native Spanish-speaker History oI domestic violence
Good sense oI humor Artistic talent
Rehabilitation Eaucation
educators to increase curriculum content on cultural
competence and advocacy in modiIying environ-
ments and supports in order to provide students with
the tools needed to make changes in practice, pro-
grams, and systems.
The ICF provides a comprehensive schema Ior
teaching about psychiatric disabilities and psychiat-
ric rehabilitation, while emphasizing strengths and
limitations in Iunctioning. Rehabilitation counselors
can use the ICF as a Iramework Ior gathering inIor-
mation and organizing intakes and reports.
Table 4 (on the preceding page) provides a compari-
son oI examples oI someone with a physical disability
and a psychiatric disability in describing the Iunction-
ing oI the individual. The example does not list all the
available inIormation on each person, but illustrates
the type oI inIormation that might ft in each section.
Using Iunctional data to conceptualize the impact oI
schizophrenia on someone`s vocational Iunctioning
provides more useIul inIormation than using only a di-
agnostic label or list oI symptoms experienced.
Rehabilitation educators can introduce the ICF
Iramework to students, ask students to use the Irame-
work in describing people with whom they work,
assessments they plan to conduct, and interventions
they choose to implement with individuals involved
in services. The rehabilitation counselor has a pri-
mary role in addressing Iunctioning oI individuals
with psychiatric disabilities, and may need to educate
other mental health and rehabilitation proIessionals
about the Iunctional issues that people with psychiat-
ric disabilities Iace in achieving their goals. The ICF
provides a common language that all proIessionals,
including medically oriented ones, can use to Irame
the scope oI assessments and interventions needed to
assist people in their recovery.
The biopsychosocial approach embedded in the ICF
makes salient the need Ior evaluations oI cognitive,
social, and emotional Iunctions in order to get a thor-
ough and balanced picture oI work capacity. The ICF`s
Iocus on Iunctioning argues Ior observation oI actual
perIormance in the relevant work setting as necessary
Ior an accurate reading oI vocational potential, as is
used in situational assessment approaches. Psychiat-
ric rehabilitation interventions that Iocus on increasing
skills and providing needed supports and accommoda-
tions become more obvious choices when an assess-
ment Iocuses on Iunctioning and perIormance rather
than emphasizing diagnosis and symptoms.
The ICF is a tool that rehabilitation educators can
use to teach students about psychiatric rehabilita-
tion and the impact oI psychiatric conditions on
health and Iunctioning. It is a comprehensive model
that shiIts the Iocus oI practitioners Irom a medical
model highlighting diagnosis and symptoms to a
biopsychosocial model that considers the interaction
oI the health condition, the person, and the environ-
ment, and their combined eIIect on Iunctioning. The
Mental Functions chapter and several chapters in Ac-
tivities and Participation in particular have relevance
Ior the cognitive, emotional, and social Iunctions that
the literature has identifed as related to vocational
outcomes Ior people with psychiatric disabilities. In
addition, the ICF emphasizes the importance oI envi-
ronmental and personal Iactors that have an impact
on Iunctioning, reminding us to examine those bar-
riers and Iacilitators that can also become the target
oI interventions to improve vocational outcomes Ior
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Authors` Note
The authors wish to acknowledge the editorial assis-
tance oI John Hilburger oI the Illinois Institute oI Tech-
nology. Communication regarding this manuscript
should be directed to Kim L. MacDonald-Wilson,
University oI Maryland College Park, 3214 Beniamin
Building, College Park, MD 20742, 301-405-0686,
Fax: 301-405-9995, email: kmacdona(
176 MacDonala-Wilson ana Nemec

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