When Chad Betters wants his students to grasp what it means to have a disability, he shares the story of a former client. The woman had been a nurse for 19 years but developed an allergy to latex as a result of her work.
“By developing this condition, the client not only had to adapt vocationally, given that she could not safely work in any health care environment due to the utilization of latex in many of the medical supplies present, but also had to make drastic changes in her life, including modifying her home, her vehicle and even her wardrobe due to the presence of latex components. She also had to learn to be mindful of her environment when out in public because sitting in a restaurant with balloons in the vicinity could trigger allergic symptoms,” says Betters, an assistant professor of rehabilitation counseling at Winston-Salem State University in North Carolina.
After working with Betters, the client was admitted into a legal training program and found work as a paralegal. She had learned how to manage her disability and became an advocate for health care professionals with latex allergies. “It’s a story I share with my students, and it tends to open their eyes to the magnitude of the impact of a disability,” Betters says.
Rehabilitation counseling is a well-established but sometimes misunderstood part of the counseling profession. “Everyone assumes we’re substance abuse counselors,” says Betters, a member of the American Counseling Association and the American Rehabilitation Counseling Association, a division of ACA. “And while we work with individuals with substance abuse issues because [they are] a disability, we work with all disabilities across the board.”
Carolyn Rollins, associate professor in the Department of Counseling and Educational Leadership at Albany State University in Georgia, has also heard the assumption that rehabilitation counselors focus on one specific area, such as substance abuse. But disability comes in a variety of forms, says Rollins, who is a past president of ARCA.
For example, she says, a rehabilitation counselor might help a student with a disability to get the accommodation he or she needs, whether that means taking a test in a quiet environment or using a computer with voice capabilities. The counselor’s role, Rollins explains, is to take a physician’s or other evaluator’s recommendation of what accommodation is necessary and to assist the school or other institution in implementing that accommodation for the client.
According to the ARCA scope of practice, “Rehabilitation counseling is a systematic process which assists persons with physical, mental, developmental, cognitive and emotional disabilities to achieve their personal, career and independent living goals in the most integrated settings possible through the application of the counseling process. The counseling process involves communication, goal setting and beneficial growth or change through self-advocacy, psychological, vocational, social and behavioral interventions.”
Tyra Turner Whittaker, a professor of rehabilitation counseling at North Carolina A&T State University, notes that the number of people with disabilities is vastly increasing, particularly as the baby boomer generation ages and as more veterans return home with disabilities incurred during military conflicts.
Rollins adds that improvements in medical care are allowing greater numbers of people to survive life-threatening situations, but many times, these individuals are left with disabilities. It’s no surprise then that the role of rehabilitation counselors is growing ever more crucial, Rollins says. “A person’s ability to function independently can be enhanced by the knowledge of rehab counselors.”
Employment … and much more
One of the primary goals of rehabilitation counseling is to help clients become gainfully employed, says Amos Sales, professor in the Department of Disability and Psychoeducational Studies at the University of Arizona. As a minority group, 13 percent of people with disabilities live at or below the poverty line, and two-thirds of people with disabilities are unemployed, according to Sales. Of those who are employed, only one in four is employed full time. “You can imagine what that does to a yearly income,” Sales says.
Carrie Wilde, president of ARCA and former chair of the Counselor Education Department at Argosy University in Tampa, Fla., says although the roots of rehabilitation counseling are in helping clients find employment, that isn’t the sole focus. “Now counselors are taking a more holistic approach,” she says. “How are clients doing socially, educationally, how is [a disability] affecting their relationships? It’s not just vocational.”
Whittaker, a member of ACA, adds to that point. “In the past, unfortunately, what happened in the field of counseling [was that] people tended to view rehab counselors as just employment specialists [rather than] counselors who have an expertise in employment,” she says. “For the most part, rehabilitation counselors share the core counseling training that most counseling students have, along with additional training in employment and in the medical and psychosocial aspects of disabilities.”
Rehabilitation counselors assist clients with reintegrating into the community, whether the individuals are dealing with a disability they were born with or one they experienced later in life, Wilde says. She previously worked with clients who had brain injuries, using a holistic approach that encompassed working through the clients’ perceptions of themselves with the disability, adjusting to the disability, improving their self-confidence and becoming more socially comfortable. Wilde says a holistic approach to rehabilitation counseling can also include working with the client’s family members, friends and other support systems.
The issues clients bring with them to rehabilitation counseling are wide ranging, Sales says. In many cases, clients are still working through personal and emotional issues related to having a disability, he says, so a counselor’s training in establishing a relationship while demonstrating empathy and positive regard is crucial.
On the employment end, counselors might work collaboratively with the client to investigate what he or she wants to do, Sales says, possibly by administering a personal interest test. If it becomes evident the client needs retraining or additional education to obtain employment, he says those services can be provided through the state-federal vocational rehabilitation services program, which was set up through the federal Rehabilitation Act.
Employment services with rehabilitation counseling clients might begin with an assessment, which may be administered by the counselor or by someone else, depending on the scope of practice in the counselor’s workplace, Wilde says. After reviewing the assessment of the client’s abilities, she says the rehabilitation counselor might offer the client employment services, such as working on interview skills, or send the client to another agency for additional training or services.
Rehabilitation counselors often work with potential employers or the client’s coworkers as well, she adds, helping to set up accommodations for the client in the workplace. The counselor’s level of involvement in the workplace largely depends on the client’s ability to articulate his or her needs to the employer, Wilde says. “We as rehabilitation counselors do not want to add to the stigma that may already be associated with a disability,” she says. “The more we can have clients do for themselves, the less disruptive it is.”
In working with an employer, the rehabilitation counselor’s goal is to find out what can be changed in the client’s environment or support system to allow the individual to do the work, Wilde says. For example, if an employee was injured and can no longer handle heavy lifting, a rehabilitation counselor might work with the employer to modify the person’s job description. Wilde had one client who couldn’t bend well because of a disability, so she collaborated with his employer to make adjustments to the equipment with which the client worked.
The economy remains a complicating factor, Betters says. “Individuals without disabilities are having trouble finding employment,” he says. “When there are disabilities, that just compounds it.”
Whittaker offers a recommendation to counselors providing vocational counseling to rehabilitation clients. “Truly listen to the client’s story — where they’ve been and where they hope to go,” she says. Clients often want to share their backgrounds as well as their future aspirations, she explains, and counselors should show the patience to first listen before assisting clients in meeting those goals.
Returning power to the client
Sales views people with disabilities as an oppressed minority group — a group that “experiences a particular need to feel more power in their lives.” Giving power back to individuals with disabilities is such a passionate topic for Sales that in 2007 he wrote a book about it: Rehabilitation Counseling: An Empowerment Perspective, published by ProEd and available through ACA.
“They have been denied power throughout their lives,” Sales says of clients with disabilities. “They have dealt with the medical model all their lives where they’ve been told what they can do and cannot do. Because of mobility issues, they’ve been denied access. All of those things feed into being in a lower power position. They come to counseling with a need to be more empowered.”
Ironically, the field of rehabilitation counseling had very paternalistic beginnings, Sales says, with counselors viewed as the “experts” who would determine vocational goals for clients. Thankfully, times have changed, he says, and today there is a greater push toward client empowerment.
The first step rehabilitation counselors can take in empowering clients is to assume the role of partner rather than of expert, Sales says. That’s a paradox in the counseling profession, he says, because counseling students work hard to become knowledgeable about all sorts of emotional issues and how to overcome them. “But where you subtly cause problems and actually oppress clients is by making decisions for them, by moving them more toward the counselor’s own thoughts and opinions,” he says.
If the counselor acts as the expert, Sales warns, clients are more likely to make choices on the basis of what they think the counselor wants them to do rather than on what they believe would be in their own best interests. “If they’re comfortable with you and they are seeking advice, that’s good,” he says. “But if you move them too quickly based on your thinking and expert knowledge, that’s not good.”
To create a more empowering counseling process for persons with disabilities, Sales offers several recommendations, including responding to the individual instead of the disability and using the Rogerian approach of empathy, congruence and positive regard. Try to put as much power as possible back into the clients’ hands, he advises counselors, and support clients in assuming more power over their own personal change as well as over their environment. Depending on the individual issues and needs of each client, rehabilitation counselors can use a wide range of effective counseling theories and approaches, but Sales says feminist theory pairs particularly well with an empowerment approach.
Rollins is also an advocate of empowering clients. “Rehabilitation counseling is a profession in which we strongly believe in the autonomy of the client, and the client’s role in the process is very important,” she says. “The client ought to be able to have a role in the outcomes of the treatment and to define [his or her] own needs.” Clients should be actively involved in the rehabilitation process, Rollins says, and counselors should work from a strengths-based model, with the counseling relationship building on the assets the client brings to the table.
Earlier in her career, Wilde remembers empowering a 32-year-old client who was rebuilding his life after a self-inflicted gunshot wound to the head. The client was living in a nursing home when Wilde began working with him, but after approximately two years of rehabilitation counseling, the man found employment and began living on his own again. “It was the belief that he could do more for himself that got him out of the nursing home,” Wilde says. “Empowering clients to do more for themselves and feel good about themselves is central to rehabilitation counseling.”
A complicating factor
For about three years, Betters has been researching the relationship between disability and obesity. The nation’s waistline is growing, and that can complicate the situation for people with disabilities, he says. “As our country is becoming more and more a victim of the obesity epidemic, we are going to have to accommodate this in what we do as rehabilitation counselors because it is multiplying, compounding and increasing the magnitude of disability that clients are bringing to the table.”
Advancements in health care have helped minimize obesity’s effect on mortality, which is positive, Betters says, but the flip side of the coin is that obesity is increasing morbidity, making it more of an issue within rehabilitation counseling. Obesity can complicate rehabilitation after a person suffers a disability, and it can also stem from incurring a disability.
Betters points to research showing that people who enter workers’ compensation programs after an injury come out with higher body-mass indexes than before they began. “Those individuals are then at a greater likelihood of sustaining a re-injury,” Betters says. “It’s almost a downward spiral.” The American lifestyle already promotes obesity, Betters says, and when someone has a disability, lack of activity, dietary changes from a tighter budget and mental anxiety only increase the likelihood of the person becoming obese.
The implication for rehabilitation counselors, Betters says, is that job placement for the client becomes even more difficult. The more limitations a person has related to obesity — such as fatigue, taking diabetes medication or dealing with orthopedic pain because of weight — the harder it becomes to find a suitable employment match. Betters adds that individuals who are obese also face greater employment discrimination. “Obesity’s implications compound everything,” he says.
The obesity epidemic isn’t going to drastically diminish anytime soon, Betters tells rehabilitation counselors. In fact, data points to it getting worse. “As rehab counselors, we can’t expect clients to come in the door with a game plan that they’re going to take responsibility to manage [their weight] or have an action plan during rehab,” he says. “Rehab counselors didn’t sign up to work as nutritionists or exercise trainers, but we need to start including those aspects at least in the discussions if it’s relevant.”
Does Betters recommend that rehabilitation counselors address the issue of weight with clients, even though it remains something of a taboo topic? “If it’s going to prohibit or limit their employability, my position is yes,” Betters says. “It should be treated as any other issue, concern or obstacle in the client’s return-to-work process.”
Although rehabilitation counselors aren’t experts in diet and nutrition, Betters suggests opening the discussion by asking clients how obesity might be impacting their disability. Rehabilitation counselors may also be able to assist clients by making appropriate referrals. For example, although it isn’t the norm, Betters says some workers’ compensation systems are providing gym memberships to clients to assist them with weight-loss efforts.
All counselors, regardless of specialty, can benefit from understanding the work of rehabilitation counselors, Whittaker says. “All counselors will encounter individuals with disabilities at some point, whether the disability is physical, cognitive, mental or developmental in nature. My suggestion would be to have compassion. Often due to burnout or dealing with our own life issues as counselors, the level of empathy toward others can be adversely impacted. It is vital for all counselors to fight for [clients’] opportunities as you would fight for your own children or parents.”
Whittaker thinks all counselors should have at least one course that focuses on disability issues but also believes that each counselor should operate within his or her own scope of practice. “If a private practitioner has a client with a disability who presents with issues beyond their scope of practice, I would definitely say refer the client to a qualified rehabilitation counselor,” Whittaker says.
If a mental health counselor is working with a client who has an identified disability and isn’t progressing as well as he or she should and the reasons why aren’t apparent, Rollins recommends consulting with a rehabilitation counselor. “Rehab counselors and mental health counselors work well together,” she says. “They can work on a plan to advance the client’s goals. The rehab counselor also might be able to come up with other sources of support for that person.”
Other counselors may also find a rehabilitation counselor’s expertise particularly helpful when trying to determine if a disability exists. Although certain physical disabilities are easy to discern because of the presence of wheelchairs or crutches, Rollins says many clients struggle with “invisible” disabilities that counselors might not readily identify in the absence of client disclosure. “Consequently, some dimensions of the client’s behavior or issues may be unclear and remain unexplored,” she says. “The counselor may view the being unmotivated or uncommitted to treatment, lazy or unwilling to fully engage. Some disabilities may be undiagnosed, or the social stigma attached to some disabilities can affect a client’s willingness to disability. A rehabilitation counselor will identify clues from the client’s history, as well as behaviors that may suggest the presence of a disability, even though the client has not disclosed. … The rehabilitation counselor will then explore the impact of the disability issues and assist the client in addressing those issues to reduce their impact in successfully resolving the counseling issues.”
Counselors who don’t specialize in rehabilitation counseling would also benefit from understanding the state-federal vocational rehabilitation services system to properly prepare to help clients with disabilities who are seeking employment and other supports, Betters says. Many counselors don’t realize the vast amount of resources within the system, he says. If the issue is related to finding, maintaining or advancing in employment, the system can provide assistance with medical concerns, education, transportation, retraining and much more.
Above all else, Betters says, it’s important to recognize clients as individuals with disabilities, not disabled individuals. “They’re capable of doing almost anything if they have the appropriate accommodations,” he says.
Sales agrees. “You can become more preoccupied in understanding the disability than in understanding the person,” he says. “Be very cautious to not address the individual as their disability.”
Wilde’s most valuable lesson learned as a rehabilitation counselor was to let clients take the lead. “My clients have taught me so much,” she says. “They are the experts on their experiences, so I take my lead from there. I’m there to challenge them and support them, but it’s looking at what the client has to offer, seeing beyond the disability and seeing the potential for what they’re able to do. It’s a privilege to work alongside clients as they go through that process.”
Employment isn’t an issue only for rehabilitation clients — it’s also an issue for rehabilitation counselors. To help new rehabilitation counseling professionals looking for work or even seasoned professionals seeking something new, Tyra Turner Whittaker, a professor of rehabilitation counseling at North Carolina A&T State University, offers a rundown of job opportunities for those trained in rehabilitation counseling.
1) One major employment option, Whittaker says, is working for a state agency, whether it’s a state vocational rehabilitation agency or a state agency for the blind or deaf and hard of hearing.
2) Look into opportunities with the Department of Veterans Affairs.
3) Because rehabilitation counselors have special expertise in career and employment counseling, they can consider working as a career counselor or employment specialist, Whittaker says. “You can use that knowledge and skill set to help individuals find careers or assist companies in executing their employment development programs, which are desirable services in this current economic climate.”
4) Work as a vocational expert on behalf of insurers, defendant or plaintiff attorneys, or through the Social Security Administration. “Similar to medical experts utilized in the legal system, vocational experts offer vocational professional expertise on the impact of a personal injury on the claimant’s future earning capacity,” Whittaker says.
5) Addictions counseling is another option for counselors trained in rehabilitation counseling, Whittaker says, although rehabilitation counselors might need additional licensure and/or training in addictions counseling depending on their state’s requirements. North Carolina A&T offers a certificate program in rehabilitation counseling and behavioral addictions. The program provides specialized training to rehabilitation counselors in the areas of alcohol and drug abuse, gambling addiction, sex addiction, eating disorders and criminal behavior.
6) Life-care planning is yet another option. “This is an area of specialty in rehabilitation in which the counselor works with people with catastrophic injuries or illnesses,” Whittaker says. The counselor’s role would be to develop a care plan that delineates every specific need the individual has or will have, along with the cost of those needs from the point of injury through the remainder of the client/claimant’s life.
7) Finally, Whittaker points to disability management as a rewarding employment option. Rehabilitation counselors would have the opportunity to work with an employer in the areas of disability intervention and prevention within the workplace.
To order a copy of Sales’ Rehabilitation Counseling: An Empowerment Perspective (order #72868), visit the ACA online bookstore at counseling.org/publications or call 800.422.2648 ext. 222. The cost is $39.95 for ACA members and $49.95 for nonmembers.