Rethinking Rehabilitation: Two Kinds of Agency Could Reshape How We Treat Disability

Rehabilitation medicine has long promised a vision of care that treats the whole person rather than the damaged body part. At the heart of that promise sits the International Classification of Functioning, Disability and Health, or ICF, the framework adopted by the World Health Organization to describe human functioning in bio-psycho-social terms. Yet a new theoretical analysis published in Humanities and Social Sciences Communications argues that the ICF, for all its ambition, remains vulnerable to a familiar failure mode: medical reductionism, the tendency to collapse disability back into bodily dysfunction and to treat rehabilitation as little more than the restoration of physical capacity. The paper, authored by Jiahao Mei of the School of Philosophy and Sociology at Jilin University in Changchun, China, proposes a conceptual repair that could change how clinicians, social workers, and disability advocates think about what rehabilitation is actually for.

The core of Mei’s argument is that the ICF’s two most socially significant components, Activity and Participation, lack sufficient social-theoretical grounding. On paper, the distinction between them looks straightforward: Activity refers to the execution of tasks or actions by an individual, while Participation refers to involvement in life situations. In practice, however, the boundary between the two has proven notoriously blurry, and without a robust account of the disabled person’s own agency, both concepts can drift back toward a purely clinical reading. When that happens, rehabilitation professionals may measure success by what a patient can physically do in a therapy gym, while the patient’s own goals, choices, and life projects recede into the background. Mei contends that this is not merely a terminological inconvenience but a philosophical gap with real clinical consequences.

To fill that gap, the paper integrates Rutger Claassen’s agency-based capability approach into the ICF. The capability approach, developed originally in welfare economics and political philosophy by Amartya Sen and Martha Nussbaum and refined by Claassen, evaluates well-being not by what resources a person holds or what mental state they occupy, but by the genuine opportunities they have to do and be things they value. Claassen’s distinctive contribution, as Mei deploys it, is to place agency itself at the center: a person is not simply a beneficiary of opportunities but an active author of their own life, who sets goals, makes commitments, and acts on them within specific social practices. This move matters for rehabilitation because it reframes the patient not as a passive recipient of functional restoration but as someone whose capacity for self-directed action is itself a legitimate target of care.

The resulting framework makes a precise and, on its face, elegant pairing. Activity is linked to what Mei calls participatory agency: the capacity for autonomous goal-setting and action within a particular social practice. A social practice, in this sense, is an organized domain of life with its own norms, roles, and expectations, such as paid employment, parenting, sport, or community volunteering. Participatory agency means being able to decide what one wants to achieve within such a practice and to act on that decision. Participation, by contrast, is linked to navigational agency: the capacity to move between practices, to negotiate the competing demands they impose, to exit arrangements that turn out to be oppressive, and to pursue structural reform when the practices themselves are the problem. Navigational agency is thus a higher-order capacity, one that operates across the landscape of a person’s life rather than within any single domain of it.

Underpinning this pairing is a second conceptual distinction, between autonomy and freedom. Autonomy, in the capability framework, concerns a person’s internal capabilities: the developed capacities for reflection, evaluation, goal formation, and committed action that make self-direction possible. Freedom concerns the external opportunities that a person actually faces: the real options available in their social and material environment. The distinction gives clinicians and researchers an analytical tool for locating exactly where a disabled person’s agency is being constrained. A person may possess strong internal capabilities, for example, yet find their freedom curtailed by inaccessible workplaces, discriminatory attitudes, or inflexible service systems. Conversely, a person may face abundant external options but lack the internal capabilities, perhaps eroded by prolonged illness, depression, or institutionalization, to seize them. Identifying which side of the divide is blocking agency determines what kind of intervention is appropriate, and by whom.

From these distinctions Mei derives a three-tier capability pathway that structures the proposed rehabilitation framework. The first tier comprises basic capabilities, the foundational capacities, such as elementary mobility, communication, and self-care, on which more complex agency depends. The second tier is participatory agency, in which the person sets and pursues goals within concrete social practices. The third tier is navigational agency, in which the person manages the relations among practices, negotiates conflicts among their commitments, and, where necessary, challenges or leaves arrangements that undermine their life projects. The pathway is not a rigid developmental ladder; a person may work on multiple tiers simultaneously, and setbacks at one tier can cascade. Its value is diagnostic and directional: it tells the rehabilitation team what kind of capability is at stake in a given clinical situation and what mix of professional support is most likely to expand it.

To show the framework at work, Mei offers illustrative analyses of acute and chronic rehabilitation. In acute settings, such as recovery from stroke or traumatic injury, the framework directs attention to patient-defined goals from the outset: rather than asking only how far a patient can walk or how much grip strength they have regained, the team asks what practices matter to that person and what participatory agency within them requires. Meaningful choice becomes a clinical variable, not an afterthought. In chronic rehabilitation, where functional restoration may plateau but life continues, the framework shifts attention to navigational agency: how a person with a long-term condition moves between work, family, and community roles, negotiates the demands each places on limited energy, and exits or reformulates arrangements that have become oppressive. In both cases, structural barriers, from inaccessible transport to inflexible employment norms, enter the clinical picture alongside bodily function, because they are genuine constraints on the capabilities the framework is designed to expand.

One of the most practically consequential features of the analysis is its account of who does what. The framework clarifies the complementary roles of rehabilitation professionals, social workers, and peer support in expanding agency. Rehabilitation professionals are naturally positioned to work on basic capabilities and, increasingly, on participatory agency, helping patients rebuild the internal capacities needed for goal-directed action within valued practices. Social workers, with their expertise in navigating institutions and mobilizing resources, are the natural allies for navigational agency, helping patients move between systems, negotiate entitlements, and confront structural obstacles. Peer support, meanwhile, offers something neither profession can: lived knowledge of how others have negotiated similar transitions, which can model both participatory and navigational agency for people who are newly disabled or facing a changed life situation. The framework thus gives interdisciplinary rehabilitation teams a shared conceptual map on which each member’s contribution has a defined place.

Crucially, Mei insists that the framework is not a prescription for individual responsibility. The analysis emphasizes that individual agency depends on enabling social conditions and on collective action, rather than on the isolated efforts of the disabled person alone. This point carries political weight. If agency is the product of an interaction between internal capabilities and external opportunities, then a society that provides neither accessible environments nor meaningful options cannot fairly demand that disabled individuals simply try harder. The framework, by making the social conditions of agency explicit, offers a basis for connecting disability rights with rehabilitation practice: the same analysis that guides a clinician’s treatment plan also identifies the structural reforms that rehabilitation alone cannot deliver but that disabled people’s organizations can pursue.

The paper is a work of conceptual analysis rather than an empirical trial, and its influence will depend on whether the proposed framework can be operationalized in assessment tools, service design, and outcome measurement. But its ambition is clear and, in the current moment of rehabilitation science, timely. By giving the ICF’s Activity and Participation components explicit social-theoretical content, Mei’s framework aims to orient rehabilitation toward what many disabled people say they actually want: not merely restored function, but expanded opportunities to pursue lives they value. If the field takes that orientation seriously, the measure of successful rehabilitation may slowly shift from the therapy gym to the whole of a person’s social world, and the ICF may finally deliver on the bio-psycho-social promise written into its name more than two decades ago.

Subject of Research: Integrating participatory and navigational agency into the ICF bio-psycho-social framework for rehabilitation

Article Title: Activating the ICF: integrating participatory and navigational agency into bio-psycho-social rehabilitation

Article References: Activating the ICF: integrating participatory and navigational agency into bio-psycho-social rehabilitation. (n.d.). https://doi.org/10.1038/s41599-026-09415-x

Image Credits: AI Generated

DOI: 10.1038/s41599-026-09415-x

Keywords: ICF, rehabilitation, disability, capability approach, agency, participatory agency, navigational agency, bio-psycho-social model, autonomy, social practices, disability rights, Jiahao Mei