Diller Lecture

Examined Lives: Outcomes After Holistic

Rehabilitation
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Yehuda Ben-Yishay and Ellen Daniels-Zide

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New York University—Rusk Institute

This article poses the question whether the attainment of optimal outcomes
following neuropsychological rehabilitation requires that the individual achieve an
"examined self." The author answers the question in the affirmative and provides
data from a retrospective pilot study to substantiate his claim. Implications from the
findings are briefly discussed.

I feel honored to have been asked to deliver the Leonard Diller Lecture. Leonard
Diller is universally respected. As a man who has been working with him closely
for 36 years, I can say, to paraphrase the song, "If you knew Lenny like I knew
Lenny," you would respect and love him even more. Lenny earned his reputation
and the esteem in which he is held the old-fashioned way: with absolute integrity;
a penetrating, analytical mind; scholarship; wisdom; and the absence of a mean
bone in his body. This presentation reflects both his and my long-standing interest
in issues concerning our field, other than how to deal with HMOs.
Initially, Lenny was unaware of the purpose for which I and my colleague,
Ellen Daniels-Zide, undertook the retrospective pilot study which I shall shortly
present here. This gave me the opportunity to use him as a sounding board, as I

Yehuda Ben-Yishay and Ellen Daniels-Zide, Brain Injury Day Treatment Program,
New York University—Rusk Institute.
This article was delivered, with minor modifications, as the Leonard Diller Honorary
Lecture at the 106th Annual Convention of the American Psychological Association,
Boston, August 22,1999.
We express our thanks to Stanley Ferneyhough for performing the statistical analyses
on short notice.
Correspondence concerning this article should be addressed to Yehuda Ben-Yishay,
PhD, New York University Medical Center, 660 First Avenue, New York, New York 10016.
Electronic mail may be sent to Yehuda.Ben-Yishay@med.nyu.edu.

112
Rehabilitation Psychology, 2000, Vol. 45, No. 2, 112-129
Copyright 2000 by the Educational Publishing Foundation, 0090-5550/00/$5.00 DOI: 10.1037//0090-5550.45.2.112
 Examined Lives 113

have done for 36 years. Thus, once again, I have been the beneficiary of Lenny's
unique way of helping me see how our work fits into the larger picture of what is
going on at present in the field of psychology. Here is one illustration of Lenny's
subtle way of expanding my horizons.
"So what are you thinking about nowadays?" Lenny asked me several weeks
ago. "I am thinking about conducting a retrospective pilot study," I replied. "I
would like to find out whether we may be able to distinguish between those
graduates of our program whom I previously (Ben-Yishay, 1993) described as
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having been successful, before they were discharged from our program, in
reconstituting their ego identity (in the Eriksonian sense of having made explicit,
self-defining statements) and those graduates who, by the time of discharge, had
adjusted quite well to their disability but gave no overt signs that they, too, had
reflected on their sense of identity, as had the former."
"What intrigues me," I told Lenny, "is that both subtypes of graduates
subsequently achieved a stable personal and vocational adjustment which persists
to the present day. So the question is, other than living up to the admonition of
philosophers that one should strive to achieve and lead an examined life, have
those lucky "self-examined" graduates gained any particular advantage over
those who merely "adjusted" in terms of practical, post-rehabilitation outcomes
such as their personal, social, and vocational adjustment and the overall quality of
their life?" "But how are you going to test this question?" Lenny asked (knowing
full well that only 25% to 30% of our graduates live close enough to our facility to
be capable of being interviewed in person). "I will select a small sample of
successful graduates of both types, and ask them, over the phone or in person, to
rate themselves on a 10-point scale, in the six areas which are outlined in
Table 1."
After mulling it over a while, Lenny said: "So you are taking this one step
beyond the concern with the ecological validation of the program outcomes
(Rattock et al., 1992). You are into the realm of wellness issues." Next day, I
received from him, through the in-house mail, several articles. These included the
transcript of Seligman's (Proffitt, 1999) lengthy interview with the Los Angeles
Times in which he spells out the major premises of "positive psychology": that if
you teach people to be optimistic and resilient, they are less likely to suffer
depression and will lead a productive life, and that optimism and self-esteem go
hand-in-hand. Included were reprints of three articles. The first was a study by
Green and associates (Green, Bailey, Zinser, & Williams, 1994), who found that
self-acceptance and self-esteem were good predictors of academic performance.
The second article (Ryff & Keyes, 1995) identified six dimensions of wellness:
autonomy, environmental mastery, personal growth, positive relations with oth-
ers, purpose in life, and self-acceptance. In the third paper, Schmutte and Ryff
(1997) point to some interesting relationships between personality dimensions,
such as low neuroticism, extroversion, and conscientiousness, and dimensions of
well-being, such as self-acceptance, environmental mastery, and purpose in life.
After I read these interesting papers (Lenny reads everything and remembers
 114 Ben-Yishay and Daniels-Zide

Table 1. Six Areas of Wellness Assessed

Rating scale
Area 1 10
1. My effort during rehabilitation Nothing special Outstanding accom-
to overcome the difficulties plishment
that were caused by my brain
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injury has been:

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2. Although different from what it Just tolerable Very meaningful

was before my head injury, my
present life is:
3. Since rehabilitation, I have Unproductive life Most productive life
been leading a/an:
4. After rehabilitation I feel that Still not at peace Completely at peace
lam: with myself with myself
5. My social life following Most unsatisfactory Very satisfactory
rehabilitation is:
6. My ability to establish intimate Very poor Excellent
relationships is:

anything that is relevant to the topic at hand), I told him: "You are right, we are
indeed into examining questions of wellness!"
Before I present the results of our retrospective pilot study, I must briefly
define ego identity and outline the key ideas of Kurt Goldstein concerning the
rehabilitation of persons with a brain injury. Goldstein's ideas have guided the
approach as well as the remedial and therapeutic techniques which have been
developed by our program.

DEFINING EGO IDENTITY

We define the sense of identity, or ego identity, as Erikson defined it (1950,

1958, 1959). The concept has a multiplicity of meanings, which are not always
easy to follow. Fortunately, Yankelovich and Barrett (1970) have provided a lucid
and systematic description of the various meanings of Erikson's thinking on the
subject. The concept of ego identity is seen as evolving aspects of personhood.
Ego identity has several distinguishing components or characteristics: (a) identity
as imitation, (b) identity as the persistence of a sense of sameness within oneself,
and (c) identity as self-definition. Each component is briefly described.
Identity as imitation: The earliest roots of ego identity are seen in the
psychological mechanism involving imitation. For example, a little girl puts on
her mother's shoes and hat and declares "I am mommy." This earliest version of
the imitative process becomes more complex as the child matures. "The imitation
may be of persons, acts, values, roles, attributes, styles, etc. It may be a partial
 Examined Lives 115

imitation, as when a little girl scolds her doll in the way she herself is scolded, but
without adopting her mother's mannerisms" (Yankelovich & Barrett, 1970, p.
123). A critical phase of the imitative aspects of ego identity takes place during
adolescence, at which time "the synthesizing ego, acting on the sum of all of these
partial processes, consolidates them, forges them into a unity, and transforms
them to create the unique sense of self known as Ego Identity" (Yankelovich &
Barrett, 1970, p. 124). However, in order to achieve an authentic ego identity,
these fused and internalized meanings must become a part of the person's inner
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being.
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Identity as the sense of continuity: Ego identity requires "the sense of a

persistent sameness within oneself," the subjective sense of coherent memories of
one's "self as a stable structure that endures in time" (Yankelovich & Barrett,
1970, p. 123).
Identity as self-definition: Between adolescence and early adulthood, one's
ego identity metamorphoses into its two alternative (the "regular" or the
"transcendent") forms of self-definition. We may find an excellent illustration of
a "regular" type of self-definition in a quote attributed to the Greek philosopher
Epictetus, who lived and taught in Ancient Rome nearly 2,000 years ago: "You
should explicitly identify the kind of person you aspire to become: What are your
personal ideas? Whom do you admire? What are their special traits that you would
make your own?" (Lebell, 1994, p. 60). As to the transcendent aspect of the fully
evolved ego identity, Erikson (1959) quotes George Bernard Shaw's statement
that his identification was with the "mighty dead." Erikson sees this as an
illustration of ego identity "as presenting a form of transcendence, a way of
reaching beyond one's own self and even beyond the limits of one's own times
and culture" (Yankelovich & Barrett, 1970, p. 132). I have come across two
additional examples of the transcendent forms of self-definition.
Freud once described himself this way: "I often felt as though I had inherited
all the defiance and all the passions with which our ancestors defended their
temple." Freud tiius ascribes two of his central personality characteristics to the
zealous defenders of the Temple in Jerusalem nearly 2,000 years ago. (Unfortu-
nately, I have misplaced the reference for this quote, but, I can assure you—it is
authentic.)
And here is Einstein's self-definition as it is inscribed on a plaque at the
Holocaust Museum in Washington, DC: "A desire for knowledge for its own
sake, a love of justice that borders on fanaticism, and a striving for personal
independence—these are the aspects of the Jewish people's tradition that allow
me to regard my belonging to it as a gift of great fortune." Einstein's self is
defined in terms of a set of values that have been attributed to the tradition of the
Jewish people through the ages.
Erikson, however, cautioned us that this sense of self, or ego identity, though
capable of enduring in time, cannot be taken for granted, for there are a number of
situations in life when the sense of continuity can be disrupted, with severe
consequences. Thus, in describing his encounters with war veterans who suffered
so-called "combat neuroses," Erikson (1950) had this to say: "What impressed
 116 Ben-Yishay and Daniels-Zide

me most was the loss in these men of a sense of identity. They knew who they
were; they had a personal identity. But it was as if subjectively their lives no
longer hung together—and never would again" (p. 38). This is in line with
Laing's (1962) observation that the (Eriksonian) sense of self is capable of
dissolution in certain pathologic conditions, manifesting itself as generalized
feelings of unreality; a blurred sense of selfhood, only precariously differentiated
from the rest of the world; a lack of temporal continuity; and feelings of
emptiness. Those of us who work with individuals with brain injury frequently
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observe either what appears to be a total dissolution or, at the least, a severely
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damaged sense of identity, in the Eriksonian sense.

KURT GOLDSTEIN'S VIEW OF THE

REHABILITATION PROCESS

Goldstein's (1942, 1952, 1959) view of the rehabilitation process may be

summarized as follows.
1. When it is impossible to restore the organism to its full, preinjury integrity,
providing structure and order will minimize the chances that the person will
experience catastrophic responses. This will make it possible for the person to feel
that he or she is "healthy."
2. A catastrophic response is a symptom of disordered functioning of the whole
organism which shows all the characteristics of severe anxiety. A catastrophic
response is the behavioral manifestation of a threat to a person's very "existence"—
or, we might say, identity—due to the failure to cope.
3. However, to achieve the feeling that one is healthy requires a transformation
of personality that enables the individual to accept the need for living with
restrictions without feeling victimized and to emerge feeling that life is worth
living.
4. Living in an environment that has been structured and ordered by others
limits, by necessity, both that person's functional autonomy and his or her
lifestyle. Acceptance of living with such restrictions, thus, can be achieved only if
the individual makes a conscious and voluntary choice to do so.
5. It is therefore our (i.e., the rehabilitation professionals') task to help the
individual realize that to attain the feeling that he or she is healthy, the person
must accept living with restrictions.
6. This has significant consequences for therapy. Due to the impairments of
both the cognitive and emotional functions of the person with brain injury, a
particular task of therapy is to help the person become aware of and understand
the nature and the functional consequences of his or her problems as much as
possible in concrete, detailed terms. Awareness and understanding of one's
deficits, thus, helps the person bear the restrictions.
7. A further consequence for therapeutic interventions is that, in attempting to
rehabilitate the individual, we must decide which symptoms can be remedially
tackled and which should be left alone.
 Examined Lives 117

8. Finally, we have to evaluate which of the many psychotherapeutic ap-

proaches and techniques that have been found useful with neurologically intact
individuals are suitable for individuals with brain impairment. Therapy will be
successful only if the person can adequately participate in the therapeutic
transaction and properly assimilate its intended cognitive, behavioral, and emo-
tional modifications.
The NYU day program is the present-day embodiment of Kurt Goldstein's
notion of an ordered environment (Ben-Yishay, 1996). Its "therapeutic commu-
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nity" structure (Ben-Yishay et al., 1978, 1985; Ben-Yishay, 1999; Ben-Yishay &
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Gold, 1990; Ben-Yishay & Lakin, 1989; Ben-Yishay & Prigatano, 1989; Zide &
Ben-Yishay, 1999; Ben-Yishay & Diller, 1981), combined with its specially
developed cognitive and therapeutic remedial techniques (Ben-Yishay & Diller,
1983; Ben-Yishay, 1978-1983; Ben-Yishay & Gold, 1990; Prigatano & Ben-
Yishay, 1999), help achieve the "transformation of the individual's personality [to
enable him or her] to bear restrictions" that Goldstein (1959, p. 10) considered
essential to enable a person with a brain injury to feel that he or she is healthy
again.

METHOD

Participants

From the master list of our 300 graduates to date, we selected about two dozen
individuals whom we designated as "self-examined" and an equal number of
individuals whom we designated as "adjusted." (The criteria for designating an
individual as either self-examined or adjusted are outlined further below.)
Because of time constraints, we decided to limit the number of subjects in each
group to the first 12 who could be interviewed at the appointed time. We selected,
for either group, only subjects who are known to us to have had an uninterrupted
work adjustment since their discharge from our program. Of the total 24
participants in this study, 8 were seen in person, 4 of whom belonged to the
self-examined group and 4 to the adjusted group. The others were interviewed by
phone.

Procedure

We designated as "self-examined" those program graduates who, by their

overall attitude, behavior, and explicit verbal assertions, have demonstrated that
they had reflected upon their postrehabilitation sense of self and arrived at a
subjectively satisfying self-definition, in the Eriksonian sense. Such self-
definitions were provided in speeches delivered at "graduation" ceremonies in
the presence of family, friends, and invited professionals. (We have retained over
the years the videotapes, as well as the typed transcripts, of all of these graduation
 118 Ben-Yishay and Daniels-Tide

speeches.) Following are six illustrations of the type of individuals whom we

designated as self-examined or who were deemed to have attained a reconstituted
ego identity.
Sample 1. G. was a Ist-year college student at the time he commenced our
program. Following rehabilitation, he became a food-truck vendor. After 7 years
of successful entrepreneurship, he decided to resume college studies toward a
business degree. Reportedly, he is doing well both academically and socially. G.'s
program graduation speech included the following statement: "I have always had
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a lot of street smarts. My brain injury gave me a lot of deficits, but I remain smart;
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I never lost my smarts." G.'s self-definition included an acknowledgment of the

impairments and limitations that were caused by his brain injury, while maintain-
ing that his former cognitive-personality attribute of "street smarts" remained
unaltered and continues to exert a controlling influence on his current career
choices.
Sample 2. Prior to his brain injury, R. was a successful immigration attorney
and community leader. Initially, during his struggle to make peace with his
disability, R. repeatedly expressed a desire to emulate his "Uncle Jimmy" (who,
despite being severely incapacitated by polio, led a calm, cheerful, and dignified
existence which had earned him the admiration of his extended family). In his
graduation speech, R. asserted that "I felt a bond with each of these young people
[referring to three of his young peers in our program], like with my own children,
nieces, and nephews. They [his peers] found in me a role model to t h e m . . . . By
inspiring them . . . I will also help myself." R.'s self-definition as a role model for
his children, nieces and nephews, and his brain-injured peers was a triumph of
self-transformation in the service of restoring his self-esteem, tt helped him find
new meaning in his life. In proving successful in emulating his "Uncle Jimmy,"
R. was able to accept, with a degree of equanimity and philosophical detachment,
the loss of his former athletic agility (he is, at present, hemiplegic), the loss of his
considerable verbal eloquence (he is severely dysarthric), and the loss of his
previous self-sufficiency (he still requires some assistance in the execution of
self-care activities). Becoming a role model for the uncomplaining and dignified
practice of humanistic rather than competitive values helped R. restore his sense
of identity. Further, it also affords him the opportunity to continue being a leader
and setting an example for others to follow.
Sample 3. S. was a former bank executive who, after 10 months of rehabili-
tation, resumed part-time work in a lower level clerical capacity. S. could only
work for 3 to 4 hours a day because longer hours precipitated seizures. Yet, she
persisted at her part-time work for years. S.'s demeanor was always pleasant, her
morale was high, and she performed her (simple) work conscientiously and with
great care for its quality. S.'s speech, upon graduating from our program, included
the following self-defining statement: "I gave my hundred percent to everything I
have ever done. . . . I gave my rehabilitation a hundred and fifty percent; this is my
best. . . . I value [the outcomes of her rehabilitation] highly.. .. This is me." Thus,
despite her intermittent seizures and the drastically reduced level of sophistication
of her postrehabilitation part-lime work, S. finds meaning and dignity in her
 Examined Lives 119

present life by applying in her present circumstances a preinjury personality

characteristic of investing herself fully in all of her endeavors. Whereas her
preinjury behavior was motivated by the (explicit or implicit) value that those
things that were important to her deserved her "one hundred percent" effort,
post-rehabilitation, this has been transmuted into "I value highly what I now can
do, because everything into which I invest myself fully becomes important and
meaningful to me."
Sample 4. J., formerly a hard-working, ambitious, and competitive econom-
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ics student, struggled mightily to achieve self-acceptance following his head

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injury. After 10 months in our program, J., helped by his strong religious faith,
found a way to make peace with his existential situation. Initially, he resumed
work as a clerk at a health club. About 3 years later, he became employed as an
international telephone operator. Concurrently, he began part-time studies toward
a degree in rehabilitation counseling. After 10 years of persistent studies, J.
graduated and became employed as a rehabilitation counselor at a well-known
rehabilitation center. J.'s end-of-program speech included the following assertion:
"The Lord intended [that I become severely incapacitated] so [that] I can be a role
model [to others] for graceful acceptance." J.'s self-definition (to use the Erikso-
nian concept) was of the "transcendent" variety. Having resolved the question of
why he became the victim of a severely incapacitating motor vehicle accident, J.'s
competitive tendencies were transmuted into a "mission" to serve God by serving
as a role model for acceptance.
Sample 5. C. was a physician and professor at a midwestern school of
medicine. After 1 year of rehabilitation in our program, C. returned to assist
colleagues in research and, somewhat later, also to teach medical students the
clinical art of communicating with patients and their families. C. has authored a
best-selling book on her experiences during rehabilitation and is presently a
much-sought-after speaker on the subject. C.'s speech at the end of the first
20-week cycle of treatments contained the following: "Successful rehabilitation
really means learning to accept myself... it requires me to examine who I am and
come up with a less limiting definition than physician. Regardless of my [future]
vocational potential, I need to expand my identity beyond my life's work." C.'s
reconstituted self-definition revealed a critical "shift": from the prior central
feature of C.'s ego identity ("physician") to (also preexisting) "passions" such as
her love of gardening, poetry, music, and friendships.
Sample 6. M. was a Ist-year college student, on scholarship, when she
became injured. For nearly 3 years postinjury, she struggled unsuccessfully to
resume her college studies. She discharged herself against medical advice from a
rehabilitation program in her state, refusing to own up to her limitations. Attempts
at earning some money as a cashier at a supermarket resulted in failure as well.
Finally, through the active and vigorous intervention of her attorney and with the
support of her mother, M. enrolled into our program. One year later, M. resumed
her college studies, became successfully employed in a clerical capacity, estab-
lished independent living, graduated cum laude from college, and is presently
pursuing graduate studies. M. was a lifelong achiever, scholastically and in sports.
 120 Ben-Ylshay and Daniels-Zide

She was a champion long-distance runner during her high school years and at
college prior to her injury. Her speech included the following self-definition:
The old me did strive to be successful in what I did. In my preinjury life, I measured
[success] on a scale geared for speed and agility.... I have had to revise my preinjury
"ruler" to a new, more appropriate measurement for success . . . I will be pleased
[making progress] no matter how small [the steps].... I have the hardy strength and
strong character of a cross-country runner.
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As her statement clearly showed, M.'s struggle to reconstitute her ego identity
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involved, for her, a most difficult and painful process: She had, as she put it, to
adopt a new "ruler" (or yardstick) for measuring success in life. This entailed a
shift from a competitive view (Was she the best student? The fastest runner?) to a
subjective one (i.e., finding meaning and satisfaction in her rehabilitation gains,
no matter how small or slow). To make this transformation, M. invoked two "old"
personality attributes ("hardy strength and the strong character of a cross-country
runner") which, preinjury, served her competitive drive for excellence but, at
present, help her find meaning in her life.
We designated as "adjusted" those individuals who had responded well to the
remedial interventions of the program, endorsed our recommendations concern-
ing the type of work they ought to engage in postdischarge from the program, and
adjusted well to their disability but showed no overt signs of defining themselves
in the Eriksonian sense, and their graduation speeches contained no explicit,
self-defining assertions.
Subjects were told that the purpose of this study was to "find out how you view
your present life." Each was asked to update his or her vocational status and to
rate himself or herself, along a 10-point scale, in the six areas which were outlined
above. The six statements were read slowly, and the best (a rating of 10) and the
worst (a rating of 1) responses were carefully explained to the subjects. Before the
subject provided his or her ratings, we made certain, through use of verification
techniques, that the subject clearly understood the meaning and the intent behind
each of the six statements. Subjects were encouraged to be deliberate and accurate
in their self-ratings.
Having obtained the self-ratings from the 24 subjects, we pulled out from their
charts the transcripts of the final "oral report card" and a copy of our final
discharge report, which were prepared before these subjects commenced their
respective vocational trials. At the end of an individual's treatment, he or she
receives an oral report card. In the presence of peers, significant others, and the
entire staff, the individual is presented with a detailed and carefully nuanced
assessment (arrived at by team consensus) of his or her achievements in the areas
of awareness and understanding of the consequences of the brain injury; mallea-
bility to the remedial interventions of the staff and peers; adequacy and reliability
of application, in one's functional life, of the compensatory skills that were
learned in the program; and acceptance of one's disability. We operationalize
acceptance as (a) a cessation of "mourning" or agitation over the incurred losses,
(b) morale, (c) satisfaction with the outcomes of one's rehabilitation, (d) capacity
 Examined Lives 121

for enjoyment, and (e) improved self-esteem. The substance of the oral report card
is further elaborated in the final discharge report. These documents were given to
a student who was naive as to subject assignment to either the self-examined or
the adjusted group. The student was instructed to consult the oral report card and
the final report of each subject and, using a prepared cumulative weighted scale
schema (see Table 2), assign an overall rating of acceptance of the disability, as
could be ascertained from these documents.
In addition to the subjects' self-ratings in the six wellness areas and the naive
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student's rating of each of the 24 subjects, in terms of their acceptance of

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disability, the authors also assigned to each individual an overall quantitative

index of the level of vocational success that was attained by the individual
subsequent to rehabilitation. This 10-point schema is described in Table 3.
Furthermore, we noted each subject's age at entry into our program, the time
since discharge from our program, and a number of psychometric measures which
were obtained at discharge from the program. Tables 4 and 5 show the preinjury
occupations of the two groups of subjects and their occupational attainments
postrehabilitation.

Statistical Analyses

To test whether the six areas of wellness in which subjects were asked to rate
themselves were redundant, Spearman rho correlations were performed on the

Table 2. Rating Schema for Acceptance

Behavioral manifestation Rating
1. Cessation of "mourning"-agitation over Always (2)
incurred losses: able to speak calmly about At times only (1)
the brain injury Never (0)
2. Morale: able to maintain a cheerful and Always (2)
optimistic outlook on the future At times only (1)
Never (0)
3. Satisfaction with rehabilitation outcomes: Consistently unqualified and
expressions of satisfaction with positive (2)
accomplishments in rehabilitation Qualified and/or circumscribed
(1)
Consistently negative (0)
4. Capacity for enjoyment: exhibits a capacity Fully and often (2)
for enjoying pleasurable activities and At times and to a limited
laughter degree (1)
Never (0)
5. Restored self-esteem: assertions that self- Frequent and unqualified (2)
esteem has been restored by rehabilitation Infrequent and/or qualified (1)
Absent (0)
 722 Ben-Yishay and Daniels-Zide

Table 3. Schema for Assigning Vocational Index

Vocational-productivity level attained Status Rating
Performs work requiring academic training, Gainful 10
before-after rehabilitation Subsidized-volunteer 9
Performs work requiring higher level reasoning Gainful 8
and interpersonal skills Subsidized-volunteer 7
Performs work requiring on-the-job training, Gainful 6
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higher-middle level clerical or skilled Subsidized-volunteer 5

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Performs lower level clerical or semiskilled Gainful 4

work Subsidized-volunteer 3
Performs part(s) of job description, open 2
workplace
Sheltered workshop 1
Unproductive in any capacity 0
Note. Level of vocational activity has remained uninterrupted since discharge from rehabilitation.

ratings in each area. The ratings of the self-examined and the adjusted subjects
were compared via Mann-Whitney U test. Due to the nature of the data and/or the
small sample size in each group, the Mann-Whitney U test was also used to test
whether the two groups differed in terms of the age of the subjects upon entry into
the program, their assigned cumulative weighted scale scores in acceptance of the
disability, their overall vocational index (as rated at present), and the psychomet-
ric test scores obtained before discharge from our program. Finally, to test
whether the level of acceptance of a person's disability, at the point of discharge
from our program, correlated with that person's subsequent vocational success,

Table 4. Composition of the Examined-Self Group

Occupation before injury Occupation after rehabilitation
1. Physician; professor, medical school Professor, medical school (S)
2. Physician Peer counselor (V)
3. Attorney Peer counselor (V)
4. Attorney Peer counselor (V)
5. Student Pharmacist (G)
6. Teacher Teacher (G)
7. Graduate student Speech therapist (G)
8. Graduate student Speech therapist (G)
9. Student Teacher (G)
10. College student Graduate student
11. Accountant Midlevel clerical (G)
12. Engineer Teacher's assistant (G)
Note. S = subsidized; V = volunteer; G = gainful employment.
 Examined Lives 123

Table 5. Composition of the Adjusted Group

Occupation before injury Occupation after rehabilitation
1. Attorney Librarian assistant (V)
2. Attorney Attorney (G)
3. Engineer Homemaker-peer counselor (V)
4. Student Teacher's assistant (G)
5. Student (architecture) Carpenter (G)
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6. Accountant, MBA Low-level clerical (S)

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7. Student Restauranteur (G)

8. House painter House painter (G)
9. Student School bus driver (G)
10. Student Realtor (S)
11. Administrator Higher level clerical (G)
12. Student Art student (S)
Note. V = volunteer; G = gainful employment; S = subsidized.

Kendall's coefficient of concordance (chi-square) procedure was performed on

the cumulative weighted scale score in acceptance and the vocational index.

RESULTS

The following questions were examined.

1. Were the six areas ofwellness rated by the subjects independent from one
another? As can be seen from Table 6, the correlations among the six variables
were few. Furthermore, except for a single case (satisfaction with current social
life and the rating of one's ability to establish intimate relationships), the
magnitude of the correlations was of a low order. We may reasonably assume that
the six areas assessed represent only partially overlapping areas of inquiry into the
issue of wellness following rehabilitation. (We hypothesize that this would be

Table 6. Spearman Rho Correlation Coefficients of Six Quality of Life

Self-Ratings (« = 24)
Rating 1 2 3 4 5 6
1 . Effort to overcome — .184 .503* .115 -.036 -.039
2. Meaningfulness of life — .443* .388 .435* .272
3. Productivity — .369 .374 .429*
4. At peace — .214 .265
5. Social life — .667**
6. Intimacy —
* p < .05 (two-tailed). ** p < .01 (two-tailed).
 124 Ben-Yishay and Daniels-Zide

confirmed when we collect a sufficiently large number of ratings to permit a factor

analysis.)
2. Did the two groups differ in wellness ratings, either in individual areas or in
total score? As shown in Table 7, with the exception of the item concerning the
effort to overcome one's deficits, the "self-examined" subjects rated themselves
higher than the "adjusted" subjects in all other areas and in total score.
3. Did the two groups differ in terms of the level of acceptance of the disability
at the time of discharge from the program and in terms of the level of vocational
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success attained subsequently? The answers to both questions were unequivo-

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cally affirmative: Members of the self-examined group received acceptance

ratings that were far superior to the ratings received by the adjusted group
(Mann-Whitney U test; z = -4.017, p < .0001). Likewise, the self-examined
group received superior vocational index scores (Mann-Whitney U test;
z = -2.897, p < .004). Clearly, the self-examined subjects were deemed to have
attained greater acceptance of their disability by the end of the program and to
have achieved relatively higher levels (in terms of sophistication-complexity) of
work adjustment following discharge from the program.
4. Could the foregoing differences between the two groups be attributed to
either clinical-demographic differences or to a difference in the overall level of
cognitive competence of the subjects of the two groups? The data do not support
this: (a) The two groups did not differ either in terms of age at the time of entry
into the program (Mann-Whitney U test; z = —0.579, ns) or years since their
discharge from the program (Mann-Whitney [/test; z = —0.825, ns); (b) as can
be seen from Table 8, the two groups were found to be fairly evenly matched (in
terms of their test scores) on several measures of higher level reasoning.
5. Did acceptance of disability at the time of discharge from the program
correlate with the level of vocational success attained subsequently? On this
question, results differed: For the self-examined group, acceptance at discharge
was a predictor of level of vocational success (Kendall tau = .739, p < .01). But
for the adjusted group, there was no significant correlation between level of
acceptance of one's disability at discharge from the program and subsequent

Table 7. Differences Between the Self-Examined and the Adjusted Subjects in

Terms of Self-Ratings in Six Areas of Wellness: Mann-Whitney U Test
Variable z pa
Effort to overcome — 1.162 ns
Meaningfulnessoflife -1.960 <.05
Productivity -2.878 <.004
At peace -2.362 <.01
Social life -1.840 <.06
Capacity for intimacy -2.670 <.008
Sum of all ratings -3.367 <.OQ1
a
Two-tailed.
 Examined Lives 125

Table 8. Differences Between the Self-Examined and the Adjusted Subjects in

Terms of Six Psychometric Measures Obtained at Discharge:
Mann-Whitney t/Test
Variable z
WAIS-R
Verbal IQ 0.000
Performance IQ -0.906
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Categorical reasoning
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Sum of highest level categorical responses —0.957

Sum of flexibility (shifting responses) -1.300
Differential aptitude: abstract -0.313
Watson-Glazer Critical Thinking Test -1.328
Note. All differences were nonsignificant. WAIS-R = revised Wechsler Adult Intelligence Scale.

vocational attainment (Kendall tau = —.100, ns). A qualitative analysis revealed

that 2 subjects of the adjusted group who rated themselves fairly low in
acceptance at discharge from the program achieved (years after discharge) higher
than initially anticipated vocational success. (These 2 subjects were single while
they attended the program, but, years later, they were found to be married and
socially well adjusted.)

DISCUSSION

This retrospective pilot study has demonstrated that—in the context of a

holistic, therapeutic milieu type of day program of neuropsychological rehabilita-
tion—tiiose judged successful in reconstituting their ego identity (operationalized
as having provided an explicit self-definition) rated higher in acceptance of their
disability and achieved a (relatively) more successful vocational adjustment than
those persons who have provided no overt signs of an examined self but who,
nevertheless, made an excellent functional adjustment following rehabilitation.
Analyses of the data have clearly shown that these different rehabilitation
outcomes could not be attributed to statistical artifacts. Namely, the differences
between the "self-examined" and the "adjusted" subjects were not due to
differences in age at entry into the program, the time elapsed since discharge from
the program, or level of cognitive competence.
How could these results be understood? The most obvious conclusion is that
the program's therapeutic community structure and its integrated specialized
remedial and therapeutic techniques have achieved (at least for some subjects)
what Goldstein (1959) felt was one of the principal missions of rehabilitation for
individuals with brain injury: In order to feel that one is healthy again, one must
be helped to successfully "transform" one's personality so that one can accept
voluntarily the limitations that brain injury imposes. And yet, despite these
 726 Ben- Yishay and Daniels-Zide

limitations (Goldstein called them "restrictions"), the person values what he or

she has been able to achieve through rehabilitation and views his or her present
life as meaningful and worth living.
In this context, it behooves us to revisit some ideas that were propounded three
decades ago by Dembo and associates (Dembo, 1960; Dembo, Leviton, & Wright,
1956). Dembo stated that when a person sustains a disability, a feeling of loss
ensues. The person mourns the loss of something valuable. As a corollary, he or
she comes to feel devalued—as a person—as well. Acceptance of one's disability
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does not mean a passive resignation to an unfortunate state (and the loss of one's
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value in society). Rather, it is the product of an active psychological process. It

involves the overcoming of one's feeling of being devalued by reexamining and
redefining one's value system. This transformation can come about only when the
persons prove successful in redefining their standards of judging what is valuable
in an individual. If the person persists in comparing himself or herself with who or
what he or she was prior to the injury, self-acceptance is unlikely to occur. Nor
would the person be able to view the results of rehabilitation as being very
meaningful and emotionally satisfying. If, however, the person's value system
shifts from a comparative perspective to an assets perspective (i.e., if the persons
come to appreciate in themselves their preserved personality attributes and to
value their current ability to make some meaningful contributions to either loved
ones or to society), then the road to genuine acceptance is open. Our program
interventions, we submit, are accomplishing this task, at least for some of our
graduates.
The unequivocal finding that the self-examined subjects were deemed, by staff
consensus, to have attained greater acceptance of their disability, and that the very
same subjects have also achieved higher levels of vocational adjustment follow-
ing discharge from rehabilitation, provides further confirmation of previously
published findings from our setting (Ben-Yishay & Diller, 1993; Ezrachi, Ben-
Yishay, Kay, Diller, & Rattock, 1991; Rattock et al., 1992). As was shown in those
studies, the role of acceptance is crucial for successful postrehabilitation
adjustment.
This study, in its present scope, has several limitations, which will be
addressed in future follow-up studies. First, there may have been a bias in the way
respondents rated themselves on the six quality of life questions (i.e., did they
answer the way they thought we would like them to answer?). Second, were the
small sample sizes of the two groups representative of our total pool of graduates?
Third, the quality of life instrument (i.e., the six questions that were posed to the
subjects) remains to be validated. Fourth, it will be interesting to know how
successful graduates of other holistic programs (in the United States, Israel, and
Europe) would respond to these questions.
Finally, we may ask, What value is there in looking at outcomes from the
ego-identity perspective? Two points come to mind. The first point is that the
conventional way of viewing outcomes in terms of parameters of self-care,
ambulation, speech, and the ability to perform work-related tasks (to the exclu-
sion of concerns with an individual's sense of personhood and the ability to derive
 Examined Lives 127

some satisfaction from their new, i.e., different life) misses the bigger picture of
rehabilitation. It also deprives rehabilitation professionals of a meaningful way to
determine when and whether the person has reached full rehabilitation potential.
The second point, a corollary to the first, is that looking beyond the present
situation to the time when the promotion of wellness becomes a practical concern
of health delivery systems, we should begin to seriously think about developing
wellness targets in the field of neuropsychological rehabilitation, as well as
objective and valid tools capable of measuring progress toward those targets of
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wellness.
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Received December 2, 1999

Revision received January 4, 2000
Accepted January 6, 2000