Counseling persons with disabilities

1. Counseling persons with disabilities Considerations for Counselors in Mental Health and School Settings Whitney Stonikinis & Rachel Berry Wake Forest University

2. Disability statistics • Approximately 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).

3. A note about language… • Use the client’s 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 blind” • Avoid language that focuses on a perceived deficit. For example, “confined to a wheelchair” or “wheelchair-bound”.

4. Trying to define some terms • What is ablism? • What is impairment? • What does disability mean? • What does handicap mean? • The important thing to remember is that a person’s functioning is affected not only by their physical/mental/psychological state but also by society.

5. What 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 person’s performance in society. • Disability is also impacted by the availability of assistance, services, and technologies.

6. Common disabilities • ADA 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/Asperger’s, 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)

7. Time for a Video! • http://www.democracynow.org/2010/6/23/disability_justice_activists_look_at_ways

8. Modes of disability conceptualization

9. Modes of disability conceptualization

10. Modes of disability conceptualization • Biopsychosocial model • Most holistic: medical, psychological, social, and environmental factors. • Allows medical label to be part of identity. • Focuses on how a disability influences a person’s functioning.

11. Comparisons to other minority groups • Similarities: • 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).

12. OTHER considerations • Fewer 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 disorders • Depression • Suicide • Little research on the intersection of disability with other factors such as race, ethnicity, sexual orientation, and gender.

13. CLIENT HISTORY considerations • What 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 Olkin’s (2007) Disability-Affirmative Therapy

14. CONSIDERATIONS FOR CHILDREN • More 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 teacher’s aids or paratransit drivers. • May have difficulty communicating about abuse and/or being believed. • Disability may be caused by or exacerbated by abuse.

15. ATTITUDES toward pwds • Negative • Perpetual children • Objects of pity • Menace or threat to society • Sick and incompetent • Psychological & economic burden to society (Marini, Glover-Graf, & Millington, 2012) • Positive (you can decide if these are actually “positive”) • Angelic traits • Inspirational • “Brave”, “courageous”, “spunky”

16. Models of adjustment • May 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 model • Vash & Crewe: People can transcend disabilities by coming to terms with their situation, accepting it, and embracing it.

17. Stigma • Public Stigma • “represents the negative reactions and discrimination persons . . . receive from other members of society” (Corrigan & Watson, 2002 as cited in Kondrat & Teater, 2009 p. 35) • Self-Stigma • “experienced 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) discrimination

18. Disability Identity • Important for counselors to listen for the presence or absence of disability identities in their client’s 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 activated

19. Theoretical Approaches to PWDs • Assumption of experience of grief and loss as normal part of experience of PWDs • Narrative Therapy • “a 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/interpretation • Defining/describing experience • Communication/interaction • No single truth, the world is what we make it

20. More on Narrative Therapy • Humanistic/Phenomenological Approach (Lambie & Milsom, 2010) • Active listening skills are a must! • Roles • Client is the expert • Counselor is a participant • Do 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: • Strengths • Empowerment • Responsibility of choice

21. More on Narrative Therapy • Individuals experience problems when their personal narratives are “problem-saturated” (Lambie & Milsom, 2010) • Personal Narratives • Give meaning to lives • Based on interpretation • Aids in interpretation of future experiences • People tend to emphasize their negative experiences • What is the role of dominant society in constructing personal narratives? • Does making meaning simply mean finding a silver lining?

22. Techniques in NT with PWDs • Mapping the influence of the problem (Lambie & Milsom, 2010) • Counselor seeks to understand the problem • Helps counselor identify inconsistencies in client’s stories • Helps identify strengths of client • Externalizing 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 responsibility • Externalizing Conversation • Listen to the complete story first • Name the problem • Be aware of intersectionality! (Thomas & Schwarzbaum, 2011)

23. Other Theoretical Orientations for PWDs • Adlerian (importance of belonging) • Person-Centered (difficult for less verbal clients) • Existential Therapy (transcendence & spirituality) • Behavioral, Cognitive & CBT • REBT (beliefs, frustration tolerance) • Positive Psychology • Family Therapies • Disability-Affirmative Therapy

24. Ethics & professional practice • As of 2012, no evidence-based practices or ethical guidelines for working with PWDs (Foley-Nicpon & Lee, 2012). • Critical awareness & knowledge • Language • Remember person-first language. • Try not to over- or under-emphasize disability in a negative or positive way. • It’s okay to say things like “walking” or “standing” to a person who uses a wheelchair. It’s okay to say “see you later” to a blind person. • Etiquette • Most 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.

25. Ethics & professional practice • Skills Development • If 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.

26. Ethics & professional practice • Expose 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 Act • Individuals with Disabilities Education Improvement Act of 2004 (IDEA) – focus on youth – early intervention, special education, & related services • Books & websites: • Olkin (1999): What Psychotherapists Should Know About Disability • Marini, Glover-Graf, & Millington (2012): Psychosocial Aspects of Disability: Insider Perspectives & Counseling Strategies • Kenneth S. Pope, PhD’s website: http://www.kpope.com/

27. Ethics & professional practice • Accessibility & assistive technologies • Buildings 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.

28. Ethics & professional practice • Accessibility & assistive technologies, cont’d • TTY 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 impairments • Consent forms, handouts, & publications: • Large-print is 16-18 pt. font • Think 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 processing • Provide CDs of recordings so clients can listen at home with assistive technology • If you need client to fill out paperwork, you can ask if they would like you to do it for them.

29. Ethics & professional practice • Scheduling appointments • Consider 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 therapy

30. Ethics & professional practice • In the counseling setting • Allow 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.

31. Ethics & professional practice • Countertransference & counselor reactions • Fear about your own vulnerability / Existential angst • Discomfort with physical symptoms or cosmetic indicators • Victim-blaming (especially if disability is a result of bx counselor deems inappropriate) • Anxiety about offending your client • Perceive 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.

32. 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

33. references Artman, 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). Disabilityidentity: Exploringnarrativeaccounts of disability. RehabilitationPsychology. 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. LegalBriefLaw 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: 10.1080/02650530902723308 Lambie, 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. Martin’s. 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: 10.1027/1099-9809.8.2.130 Olkin, 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=151 U.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