Counseling persons with disabilities

Counseling persons with disabilitiesConsiderations for Counselors in Mental Health and School Settings

Whitney Stonikinis & Rachel BerryWake Forest UniversityDisability statisticsApproximately 15-20% of US population identifies as a person with one or more disability (US Census Bureau, 2008).PWDs compose the largest minority group in the US (Artman & Daniels, 2010).

A note about languageUse the clients language.When in doubt, use person-first language to affirm humanity (Artman & Daniels, 2010).Person with a disability (abbreviation: PWD)Person who uses a wheelchair, person with autism, person who is blindAvoid language that focuses on a perceived deficit. For example, confined to a wheelchair or wheelchair-bound.

-Some people associate the term person with a disability with the medical model and prefer disabled person, a term associated with the social model. Person with a disability seems to be the preferred term in the current literature. Always seek to use the clients preferred language.3Trying to define some termsWhat is ablism?What is impairment?What does disability mean?What does handicap mean?The important thing to remember is that a persons functioning is affected not only by their physical/mental/psychological state but also by society.

According to the World Health Organization:Impairment: abnormalities of body structure or appearance Disability: how an impairment impacts functional performanceHandicap: disadvantages a person with an impairment or disability experiencesYou may see the terms defined this way:Impairment: lacking all or part of a limb, or having a defective limb, organism or mechanism of the bodyDisability: the disadvantage or restriction of activity caused by a contemporary social organization which takes little or no account of people who have physical impairments and thus excludes them from participation in the mainstream of social activities(Oliver, 1996, p.22).4What is a disability?Persons with disabilities have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers hinder their full and effective participation in society on an equal basis with others. (United Nations Enable, 2006)Also need to include short-term disabilities.Whether something is defined as a disability depends on the culture, environment, and expectations of the persons performance in society. Disability is also impacted by the availability of assistance, services, and technologies.Physical Physical: E.g. orthopedic impairment, traumatic brain injury, diseaseSpecial senses (sight, hearing) and speech Special senses: E.g. deafness or hearing impairment, blindness or visual impairment, aphasia, dyslexiaMental: E.g. psychotic disorders, mood disorders, mental retardation, anxiety disorders, somatoform disorders, eating disorders, tic disorders, personality disorders, psychoactive substance dependence disorders, pervasive developmental disorders (e.g. autism), ADD/ADHDCognitivePsychological/EmotionalyMay be visible or invisible.May be present from birth or acquired.May be short-term or long-term.May be constant, or go through periods of exacerbation and remittance5Common disabilitiesADA claims: back/spinal injury, psychiatric/mental impairment, neurological impairment, extremities, heart impairment, substance abuse, diabetes, hearing impairment, vision impairment, blood disorders (Kirshman & Grandgenett, 1997)

In school population: ADD/ADHD, aphasia/dysphagia, apraxia/dyspraxia, auditory processing, autism/Aspergers, cystic fibrosis, cerebral palsy, developmental delays, down syndrome, dyslexia, emotional/behavior disorders, fetal alcohol syndrome, fragile X, hearing impairment, learning disabilities, mental retardation, neurological disabilities, seizure disorders, visual impairment (www.teach-nology.com)Time for a Video!http://www.democracynow.org/2010/6/23/disability_justice_activists_look_at_waysModes of disability conceptualization

Aka Deficit Model8Modes of disability conceptualization

Social modelConceptualizes disability within the social and political context in which people with disabilities experience physical, educational, economic, & societal barriers (Mitra, 2006).PWDs constitute a community that identifies as an oppressed group onto which nondisabled people have projected their embarrassment, hostility, and existential anxiety(Gross & Hahn, 2004).-enabled the creation of a political strategy: i.e. barrier removal-better to pursue social change than medical cure-liberating for people with disabilities9Modes of disability conceptualizationBiopsychosocial modelMost holistic: medical, psychological, social, and environmental factors.Allows medical label to be part of identity.Focuses on how a disability influences a persons functioning.

-arose from a concern that the social model denies relevance of the body (Shakespeare & Watson, 2001)

10Comparisons to other minority groupsSimilarities:History of subjugation, intolerance, discrimination (Artman & Daniels, 2010).Defined through the lens of the majority.Differences:Separate but equal entrances to buildings, restrooms, etc.Symptoms that may require medical maintenance, assistive technology, personal assistance services, etc., that may cost money (Olkin, 2002).

OTHER considerationsFewer options for employment, housing, leisure/recreation activities, social outlets (Olkin & Taliaferro, 2006).PWDs not well-represented in counseling research (Artman & Daniels, 2010).May be barred from taking part in studies & normed research may not apply.For example, a person with a physical disability who experiences fatigue or sleep disturbances may appear depressed using standard inventories, when in fact these are symptoms of their disability.Clinical Considerations:Substance use disordersDepressionSuicideLittle research on the intersection of disability with other factors such as race, ethnicity, sexual orientation, and gender.CLIENT HISTORY considerationsWhat was the family constellation when the client was growing up? How was the client brought up with regard to his or her disability? What was the client taught about advocacy skills and medical decision making? Did the client, as a child, experience medical traumas? What is the romantic and sexual history? What is the abuse history?

From Olkins (2007) Disability-Affirmative Therapy

CONSIDERATIONS FOR CHILDRENMore likely than nondisabled children to grow up in single-parent family. Single mothers of PWDs more likely to be in poor health or depressed (Marini, Glover-Graf, & Millington, 2012).Children may want to separate from their disability in an effort to feel and be perceived as normal (Olkin, 2007).Medical traumas are more common in experiences of children with a disability than nondisabled peers. Adolescents are typically more rejecting of disability than adults.Greater risk for sexual and physical abuse (Olkin, 1999).Often exposed to more non-parental caregivers such as teachers aids or paratransit drivers.May have difficulty communicating about abuse and/or being believed.Disability may be caused by or exacerbated by abuse.ATTITUDES toward pwdsNegativePerpetual childrenObjects of pityMenace or threat to societySick and incompetent Psychological & economic burden to society (Marini, Glover-Graf, & Millington, 2012)Positive (you can decide if these are actually positive)Angelic traitsInspirationalBrave, courageous, spunkyModels of adjustmentMay be called adjustment, adaptation, reaction, or response (Marini, Glover-Graf & Millington, 2012).Olkin: Dislikes term adjustment & proposes that people with disabilities respond to their disabilities throughout the lifespan.Livneh: stage modelVash & Crewe: People can transcend disabilities by coming to terms with their situation, accepting it, and embracing it.StigmaPublic Stigmarepresents the negative reactions and discrimination persons . . . receive from other members of society (Corrigan & Watson, 2002 as cited in Kondrat & Teater, 2009 p. 35)Self-Stigmaexperienced when persons . . . expect to be discriminated against by society and in turn hold prejudicial beliefs about themselves (Corrigan & Watson, 2002 as cited in Kondrat & Teater, 2009 p. 35)Created through: 1) stereotypes 2) prejudice and 3) discriminationDisability IdentityImportant for counselors to listen for the presence or absence of disability identities in their clients narratives (Dunn & Burcaw, 2013)What could this signal for the therapist?Disability identity should guide people with disabilities toward what to do, what to value, and how to act in various circumstances in which their disability is a salient quality (p. 2)Disability identity falls on a spectrum Disability identity may not be continuously activatedTheoretical Approaches to PWDsAssumption of experience of grief and loss as normal part of experience of PWDsNarrative Therapya postmodern, social constructionist approach based on the theoretical construct that individuals create their notions of truth and meaning of life through interpretive stories (Lambie & Milsom, 2010).What is the role of language?Shaping worldview/interpretationDefining/describing experienceCommunication/interactionNo single truth, the world is what we make it

More on Narrative TherapyHumanistic/Phenomenological Approach (Lambie & Milsom, 2010)Active listening skills are a must!RolesClient is the expertCounselor is a participantDo not define client by their problem!Two stages: deconstructive and reconstructive (Kondrat & Teater, 2009)Help clients re-author their lives and relationships (Lambie & Milsom, 2010)Emphasize:StrengthsEmpowermentResponsibility of choiceMore on Narrative TherapyIndividuals experience problems when their personal narratives are problem-saturated (Lambie & Milsom, 2010)Personal NarrativesGive meaning to livesBased on interpretationAids in interpretation of future experiencesPeople tend to emphasize their negative experiencesWhat is the role of dominant society in constructing personal narratives?Does making meaning simply mean finding a silver lining?

Techniques in NT with PWDsMapping the influence of the problem (Lambie & Milsom, 2010)Counselor seeks to understand the problemHelps counselor identify inconsistencies in clients storiesHelps identify strengths of clientExternalizing the Problem (Lambie & Milsom, 2010)the person is not the problem, but the problem is the problem" (Freedman & Combs, 1996, p. 47)Counselor helps client separate from the problem without separating the client from their personal responsibilityExternalizing ConversationListen to the complete story firstName the problemBe aware of intersectionality! (Thomas & Schwarzbaum, 2011)

Intersectionality disability may not be the most important consideration for the client22Other Theoretical Orientations for PWDsAdlerian (importance of belonging)Person-Centered (difficult for less verbal clients) Existential Therapy (transcendence & spirituality)Behavioral, Cognitive & CBTREBT (beliefs, frustration tolerance)Positive PsychologyFamily TherapiesDisability-Affirmative Therapy

Ethics & professional practiceAs of 2012, no evidence-based practices or ethical guidelines for working with PWDs (Foley-Nicpon & Lee, 2012).Critical awareness & knowledgeLanguageRemember person-first language.Try not to over- or under-emphasize disability in a negative or positive way.Its okay to say things like walking or standing to a person who uses a wheelchair. Its okay to say see you later to a blind person. EtiquetteMost PWDs will ask for assistance if they need it.Shaking hands is less common in the disabled community. Greet PWDs the same way you would greet anyone else, but be aware of this.

Ethics & professional practiceSkills DevelopmentIf a client does not bring up his or her disability, the counselor can ask if the client thinks it plays a role in the presenting issue (Artman & Daniels, 2010).Goal is neither to over-emphasize nor under-emphasize the disability.Avoid questions arising from your own curiosity.Find out if the client adheres to a conceptual model of disability & do not try to change their mind (Artman & Daniels, 2010).Do not assume there are normal reactions to disability.Do not hold PWDs to lower standards of achievement.Ethics & professional practiceExpose yourself to PWDs & build relationships.Local Centers for Independent Living (CILs) are good resources.Familiarize yourself with local and national laws and movements.Americans with Disabilities ActIndividuals with Disabilities Education Improvement Act of 2004 (IDEA) focus on youth early intervention, special education, & related servicesBooks & websites:Olkin (1999): What Psychotherapists Should Know About DisabilityMarini, Glover-Graf, & Millington (2012): Psychosocial Aspects of Disability: Insider Perspectives & Counseling StrategiesKenneth S. Pope, PhDs website: http://www.kpope.com/

The most important thing is to let clients know that you want to make counseling accessible & successful for them (Artman & Daniels, 2010).Let clients know to tell you if you can make any modifications & take their concerns seriously.When in doubt, just ask the client.

26Ethics & professional practiceAccessibility & assistive technologiesBuildings must adhere to the Americans with Disabilities Act of 1990 or the Rehabilitation Act of 1973, depending on the type of facility.PWDs may be sensitive about separate but equal nature of entrances and restrooms. These things are still necessary, but be aware of possible reactions.Ensure you have designated parking spots, usable ramps, hallways and offices clear for people with mobility or vision issues.Consider things like opening doors, which may be difficult for people with arthritis or other disabilities. Ethics & professional practiceAccessibility & assistive technologies, contdTTY number or video relay service for clients with hearing or speech impairments.Websites, client recruitment, flyers: consider people with vision impairments, fine motor skill impairments, hearing impairmentsConsent forms, handouts, & publications:Large-print is 16-18 pt. fontThink about contrast (may need to use gray ink on white paper or black ink on gray paper)Audio recordings are helpful for people with reading disorders or cognitive processingProvide CDs of recordings so clients can listen at home with assistive technologyIf you need client to fill out paperwork, you can ask if they would like you to do it for them.

Make sure staff are trained in any assistive technologies.

28Ethics & professional practice Scheduling appointmentsConsider transit schedules, as some PWDs use public transit or paratransit.People with sleep disorders or fatigue may prefer appointments at a certain time of day.Consider temperature sensitivities: PWDs may not be able to go out during extreme temperatures consider telephone or webcam therapyEthics & professional practiceIn the counseling settingAllow space for a wheelchair or space to transfer from wheelchair to office chair. Ask what the person prefers.May need to adjust seating if the client cannot sit for long periods of time.Consider adjusting lighting and temperature provide fans or blankets if you cannot control the thermostat.Avoid strong smells that could bother allergies, respiratory issues, chemical sensitivities.For clients with cognitive impairments, allow time to process. You may offer handouts, recorded information, or a place to take notes.Ethics & professional practiceCountertransference & counselor reactionsFear about your own vulnerability / Existential angstDiscomfort with physical symptoms or cosmetic indicatorsVictim-blaming (especially if disability is a result of bx counselor deems inappropriate)Anxiety about offending your clientPerceive bx as prejudice-inducing (see client as acting fearful, helpless, passive, dependent, seeking attention)The client likely has experienced or currently experiences these reactions from others in their life.Other videos of interest

The Examined Life (Judith Butler)http://www.youtube.com/watch?v=k0HZaPkF6qE

A Sequence of Good Intentions (Park McArthur)http://vimeo.com/29662741 referencesArtman, L.K., & Daniels, J.A. (2010). Disability and psychotherapy practice: Cultural competence and practical tips. Professional Psychology: Research and Practice, 41(5), 442-448.Corrigan, & Watson. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16-20.Dunn, D. S., & Burcaw, S. (2013). Disability identity: Exploring narrative accounts of disability. Rehabilitation Psychology. Foley-Nicpon, M., & Lee, S. (2012). Disability research in counseling psychology journals: A 20-year content analysis. Journal of Counseling Psychology, 59(3), 392-398.Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York, NY: Norton.Kirshman, N.H. & Grandgenett, R.L. (1997). ADA: The 10 Most Common Disabilities and How to Accommodate. LegalBrief Law Journal, 2. Retrieved April 1, 2013 from http://legalbrief.com/kirshman.html. Kondrat, D.C., & Teater, B. (2009). An anti-stigma approach to working with persons with severe mental disability: Seeking real change through narrative change. Journal of Social Work Practice, 23(1), 35-47. doi: 10.1080/02650530902723308Lambie, G.W., & Milsom, A. (2010). A narrative approach to supporting students diagnosed with learning disabilities. Journal of Counseling & Development, 88, 196-203.Marini, I., Glover-Graf, N.M., & Millington, M.J. (2012). Psychosocial aspects of disability: Insider perspectives and counseling strategies. New York, NY: Springer.Oliver, M. (1996). Understanding disability: From theory to practice (Vol. 25). New York, NY: St. Martins.Olkin, R. (2007). Disability-affirmative therapy and case formulation template for understanding disability in a clinical context. Counseling and Human Development. Retrieved April 1, 2013 from HighBeam Research: http://www.highbeam.com/doc/1G1-175350872.html.Olkin, R. (2002). Could you hold the door for me? Including disability in diversity. Cultural Diversity and Ethnic Minority Psychology, 8, 130-137. doi: 10.1027/1099-9809.8.2.130Olkin, R. (1999). What psychotherapists should know about disability. New York, NY: The Guilford Press.Olkin, R., & Taliaferro, G. (2006). Evidence-based practices have ignored people with disabilities. In J.C. Norcross, L.E. Beutler, & R.F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions (pp. 353-359). Washington, DC: American Psychological Association.Thomas, A.J., & Schwarzbaum, S. (2011). Culture and identity: Life stories for counselors and therapists. Thousand Oaks, CA: Sage.United Nations Enable. (2006). Frequently asked questions regarding the convention on the rights of persons with disabilities. Retrieved from http://www.un.org/disabilities/default.asp?id=151U.S. Census Bureau. (2008). Number of Americans with a disability reaches 54.4 million. Retrieved April 1, 2013 from http://www.census.gov/newsroom/releases/archives/income_wealth/cb08-185.html. www.teach-nology.com