Counseling Today, Knowledge Share

The therapeutic triad of disability

By Susan Stuntzner, Jacquelyn Dalton and Angela MacDonald July 9, 2018

For many counseling professionals, the exploration of forgiveness, self-compassion or resilience can seem daunting, particularly when determining ways to apply these concepts to people with disabilities and their specific needs. When approaching this task, counselors may ask themselves several questions, including: Where do I start? Which concept is most important? Is one of them more relevant for this population? How can I best help people explore one or all of these concepts? Good questions indeed but not always easy ones to answer.

To help counselors understand each of these concepts, the three authors of this article developed a model called the therapeutic triad of disability. The therapeutic triad provides counselors a means with which to consider one or all of these approaches as a gateway to healing and a pathway to hope for clients.

A personal search for therapeutic approaches

Susan Stuntzner’s experience: I am the director of disability services at Southwestern Oregon Community College and a lecturer for the University of Texas Rio Grande Valley. I have lived with a visible disability for more than 30 years.

In the summer of 1985, I broke my back and found myself paralyzed from the waist down. I was life-flighted to Sacred Heart Hospital in Eugene, Oregon, to undergo emergency surgery. Prior to the surgery, the attending physician told me that I would never walk again. Putting his pronouncement aside, I thought to myself, “Hmmm, maybe, maybe not. Time will tell.”

Following surgery, I was in Sacred Heart for two months while I underwent physical therapy and learned to walk with the assistance of below-the-knee ankle-foot orthotics. Over those two months, I had a lot of time to think about my predicament, how the course of my life had changed and the road ahead of me. I remember having an innate sense that my life would never be the same, that I could not go back to my “old life.”

At the same time, I found myself feeling a sense of hope. I was already anticipating that my life would be filled with new adventures, personal growth, challenges and possibilities. I can’t explain why I felt this way, but I distinctly remember seeing myself at a vital fork in the road, and now my life purpose was to take the “left road” instead of the one on the right. Perhaps this was the start of resilience and the very beginning of great things to come.

Over the next several years, I was faced with a number of experiences that I wasn’t prepared for, nor did I understand them at the time. Most of these experiences could be filed under what we know of today as negative societal attitudes toward people with disabilities: inaccurate beliefs, low expectations, bias, discrimination, oppression and a lack of equitable access to the opportunities and resources enjoyed by people without disabilities. This was a time when no one really discussed the experience of disability or the impact of society and barriers on people with disabilities. As a result, the process of figuring out what I was experiencing or what I should do was ambiguous at best.

That may not be easy for some readers to hear, but I share it because all of these experiences set the stage for what was to come. I just didn’t know it yet. It wasn’t until about a decade later, while I was a master’s student in Portland State University’s counseling program, that I formally learned about the realities and impacts of societal attitudes toward people with disabilities, the coping and adaptation issues that people with disabilities often experience and the changes in relationships and expectations that this population frequently faces. It was at this point that my personal experiences finally “had a face.” I could look at my personal experiences and better understand why life was now very different from a societal perspective.

Jacquelyn Dalton’s experience: I am a rehabilitation counseling educator, and I have had my own experience of living with a disability. However, my story is one of progressive hearing loss and the challenges and difficulties that come with that. I grew up in the “hearing world” but became profoundly deaf in my mid to late 20s. When I was in my late 30s, I pursued and received bilateral cochlear implants. Because of these implants, I am able to hear and to re-enter the world of the hearing person. However, this was not the end of my experience with disability.

Throughout this time, I worked hard to figure out where I fit in the world. My situation was one in which I wasn’t accepted by the culturally or functionally Deaf population, nor did I fit neatly into the hearing world. As time passed, I sought out other means of coping and adapting to changes brought on by my hearing or my lack thereof. I too witnessed the face of societal bias, inaccurate perceptions and the overstepping of personal boundaries.

Some of these issues were readily noticeable the moment I acquired a service hearing dog named Ainsley. Although providing a vital service and need, Ainsley suddenly made my hearing loss “visible” to the outsider and onlooker. With this experience came the presence of well-known issues that most people with disabilities encounter: strangers staring or gawking at them, invasive personal questions, unkind remarks and social intimidation tactics. To cope with these unexpected and difficult experiences, I began my own journey of exploration, which led to the discovery of mindfulness, meditation practices and Buddhist teachings.

What is the therapeutic triad?

The therapeutic triad of disability is a model and an approach to counseling that comprises three specific components: forgiveness, self-compassion, and resilience. Those who have embraced it have described it as a lifesaving strategy. People have told us that the therapeutic triad helped them move from a place of despair, darkness, anxiety and uncertainty to one of strength, hope and self-confidence. Through the therapeutic triad, these individuals discovered the power of forgiveness, self-compassion and resilience — and the interconnectedness of each component — on a journey of self-growth and personal healing.

So, how did the therapeutic triad come about? In 2012, Susan was looking for a way to expand the use of forgiveness among people with disabilities. This led her to the exploration of forgiveness as a potential component of resilience. Not seeing a lot available on either component in relation to people with disabilities or as part of an integrated approach, she started to work on it.

One outcome of this exploration and research process led to the development of Susan’s second book, Reflections From the Past: Life Lessons for Better Living. The book looks at a number of specific resilience-based strategies that people can use in everyday life. Each skill is categorized and housed within a specific resilience domain to help readers better understand the connection. Some of the skills presented focus on spiritual practices and forgiveness.

From there, an opportunity presented itself to Susan to explore the applicability of self-compassion to the field of rehabilitation counseling and to the process of counseling people with disabilities. Soon thereafter, she participated in one of Kristin Neff and Christopher Germer’s intensive trainings for individuals wishing to delve deeper into the therapeutic value and vitality of self-compassion. Neff and Germer are co-founders of the Center for Mindful Self-Compassion.

Occurring simultaneously, yet unknowingly, with Susan’s experience, Jacquelyn was undertaking her own personal exploration of mindfulness, meditation, compassion and self-compassion. Her life experiences led her to consider Buddhist practices, with some of her initial work being influenced by scholars such as Sharon Salzberg, Ron Siegel, and Pema Chodron. As part of these studies, she became mindful of the importance of compassion, acceptance and forgiveness in people’s lives. Later, she added to this understanding by familiarizing herself with Neff’s work and attending one of her workshops on self-compassion. Each of these pieces helped Jacquelyn better understand the interconnectedness between mindfulness, compassion, forgiveness and resilience, which she later started to apply to disability, trauma and other life challenges.

Angela MacDonald, a licensed mental health specialist and clinician at Frontier Behavioral Health, journeyed through her own experiences and exposure to forgiveness, self-compassion and resilience as part of her education and counselor training.

Throughout our individualized paths, we started to see the interconnectivity between these three therapeutic skills and approaches and, thus, the therapeutic triad of disability was developed. Each component of the therapeutic triad — forgiveness, self-compassion, resilience — is a portal or gateway to therapeutic healing and serves as a pathway to the other components. This is because people often begin therapeutic work in one area, only to discover that they could benefit from looking at other issues that are better addressed by one of the other two components.

For example, as part of their collaborative resilience intervention research, Angela and Susan have exposed people with various disabilities to a 10-week resilience-based skills intervention, “Stuntzner and Hartley’s Life Enhancement Intervention: Developing Resiliency Skills Following Disability” (developed by Susan in collaboration with Michael Hartley of the University of Arizona). Over the course of 10 weeks and 10 different modules, these individuals learned and applied specific resilience-based skills to their lives. Modules six and seven focused on forgiveness and self-compassion, respectively. While learning about these skills, many individuals became acutely aware of their need to work on forgiveness and self-compassion as key components to their healing, making them willing to explore one or both at a later date.

Angela regularly works with numerous people, individually and in a group context, on resilience and forgiveness. She witnesses people become more open to forgiveness after doing some initial work on resilience or sees people recognize the need for self-compassion after they have started learning how to forgive. It is amazing to watch people grow and draw from all three components as part of the therapeutic experience.

The benefits

People who practice forgiveness, self-compassion or resilience will experience a number of benefits, some of which are unique to that particular component and some of which overlap with the other components. To give counselors an idea of the benefits that these three components offer, let’s first consider some of the similarities.

The therapeutic triad, regardless of where people begin, affords clients the opportunity to increase their self-insight into the thoughts, feelings and choices that they have and make. As a result, clients may come to recognize that they engage in thoughts, feelings and behaviors that are not helping them heal or move forward. When this happens, people can decide what they are going to do instead.

An example of this was evident in the resilience intervention work that Susan and Angela conducted. By the third week of the intervention on resilience-based skills, participants had covered the meaning of resilience, the role of attitudes and beliefs, and the role of locus of control. It was during this time that a group member said, “You know? These exercises are really helping me see how I think and feel. I had no idea that I harbored this much negativity and that I talked to myself this way.” When the group member shared this insight, we asked him to be “kind and accepting” of his personal discovery and to realize that he also now had an opportunity to do something different.

Forgiveness, self-compassion and resilience can be used to help people reduce negative thoughts (e.g., mental rumination, self-judgment, critical thinking) and feelings (e.g., anger, anxiety, depression, hostility), diminish fears and decrease negative psychological reactions to the disability. They can also help people heal emotional hurt, feel less socially isolated and more connected to others, improve social relationships (including the relationship that people have with themselves), improve self-esteem, find hope, develop the ability to sit with their pain, and be kinder and more accepting of themselves.

In addition, each of these components may be a portal to another. For instance, when people work on forgiveness, they often realize they are not self-compassionate; thus, it provides a way to start working to change that. If resilience is the starting place, people often discover an accompanying need to work on forgiveness or self-compassion.

Jacquelyn has made similar observations pertaining to the interconnectedness of these skills in her work with military veterans. One veteran with posttraumatic stress disorder who is recovering from alcoholism told her, “The VA [Department of Veterans Affairs] tells you about resilience, but no one really shows you how to do it. It was not until you gave me information on self-compassion that I started to feel better. It was through this exposure to self-compassion that I then realized that some work on forgiveness was in order. I now see that the more I work on self-compassion, the more forgiveness I am able to experience.”

Overcoming barriers

Counselors working with people on the therapeutic triad have some options in the ways they can explore and address the barriers that people encounter as a part of the triad process. Like the benefits that people encounter, some of the barriers may be similar across the therapeutic components, whereas others will likely differ. Thus, counselors may want to consider which approach is best tailored for each person’s needs and situation.

For instance, some may decide to use an educational or more formalized approach in exploring and discussing potential barriers. Such an approach may be particularly useful in psychoeducational settings or as part of group counseling. Others may decide to use the exploration of barriers as a key feature of preparing clients for work on forgiveness, self-compassion or resilience. Still others might address “barrier identification” work on an individualized level and discuss them as they surface in the counseling relationship.

Susan and Angela, as part of their individualized and collaborative work, constantly revisit which approach works best for the situation, the person and the therapeutic context. In their collaborative group work, they have used a combined educational and self-assessment identification process. In the group setting, they typically educate group members about some of the barriers that people experience when working on a skill such as forgiveness, self-compassion or resilience. This is followed by the opportunity for group members to self-assess and explore their own personal barriers.

Susan and Angela have found that this combined educational and self-assessment identification process helps people realize that it is OK to encounter some kind of barrier. People learn that barriers are part of the human condition and their presence does not warrant adding additional layers of shame, guilt or self-criticism to a person’s self-concept. In the end, people are empowered to make a choice to do something different. To help counselors better understand the plethora of barriers people may experience as part of the therapeutic triad, we will provide some examples.

When exploring forgiveness, it is often difficult for people to ask for help in learning to forgive. Forgiveness is difficult because it is a personal process in which people are asked to face and address deep hurt and painful experiences. This process is compounded by the fact that some people believe that forgiveness is for the “weak” or that it is too hard to achieve. Others mistakenly believe that forgiveness is only for people who are religious or spiritual. Still others find it hard to forgive because they cannot “let go” of the pain or because they harbor feelings of blame toward themselves, others or God.

People commonly experience barriers in the cultivation of self-compassion when they hold on to negative thoughts and feelings, have difficulty letting go of the past or engage in critical or judgmental thinking about themselves. Some people cannot find their way to a self-compassionate way of life because they spend most of their time thinking only of themselves, feeling sorry for themselves or believing they do not deserve self-compassion.

Because of the nature of resilience and the reasons that people find themselves attracted to it, the barriers encountered may be different than those encountered for forgiveness or self-compassion. Part of this is because people tend to work on resilience following a life-changing or traumatic event, not when life is going well. Some common barriers include:

  • Believing a situation or event is unfair and that the choices you make will not result in a difference
  • Blaming other people for your situation
  • Feeling that you do not deserve what is happening to you, especially when you have done all of the “right” things
  • Continually asking “why” something is happening rather than working on potential solutions

Therapeutic strategies for skill cultivation

Counseling professionals interested in pursuing forgiveness, self-compassion or resilience work with clients are encouraged to consider a few initial questions, followed by employing some strategies as part of the therapeutic relationship.

  • Which of these — forgiveness, self-compassion or resilience — is most relevant to the person’s situation?
  • How do these skills relate to the person’s experience of living with a disability and its associated life changes?
  • Does the person seem more receptive to one of these approaches than the others?
  • What beliefs or practices does the person have or follow that can aid in this exploration?
  • In the given situation, which of the skills is most important for positive coping and adaptation to disability?
  • How can I help the person start on one area and use it as a portal for healing in another?
  • Do I cover each of these skills separately or as an integrated part of an intervention?

Professionals who are counseling clients with disabilities can choose from a number of strategies, especially given the multiple paths for cultivating forgiveness, self-compassion and resilience. The key is to find those that work for the person and that are relevant to the individual’s experiences. As previously mentioned, each of these skills often opens the door to another, so there is no one right place to begin.

Having said that, Susan and Angela have found that it often helps people to consider forgiveness and self-compassion after doing some initial work on resilience. Part of this may be because many of those with whom they have worked were exposed to forgiveness and self-compassion while learning resilience-based skills. As part of the process to build resilience, people often realized their need to work on the other two components.

Counselors may elect to work with people individually, in groups or in a way that accesses some of both. Counselors can approach the therapeutic triad from a psychoeducational approach, an intensive therapeutic approach or a specific counselor theory. They can also infuse techniques such as educational topic sessions, self-assessments/insight-driven exercises, bibliotherapy, specific exercises geared toward skill cultivation, interventions, meditation and spiritual practices, writing and reflection exercises, and therapeutic homework.

 

 

****

To learn more, visit The Thoughtful Counselor podcast archives (thethoughtfulcounselor.com/all-episodes/) for a two-part conversation that Mike Shook facilitated with Susan Stuntzner and Angela MacDonald about the intersections of disability and forgiveness, self-compassion and resilience (episode dates: Feb. 17 and Feb. 21).

 

****

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Susan Stuntzner is the director of disability services at Southwestern Oregon Community College and a lecturer for the University of Texas Rio Grande Valley. She is a licensed professional counselor (LPC), licensed mental health practitioner, certified rehabilitation counselor (CRC), national certified counselor (NCC) and board certified telemental health provider. Contact her at susan.stuntzner@socc.edu.

Jacquelyn Dalton is an assistant professor in the Texas Tech University Health Sciences Center within the Department of Clinical Counseling and Mental Health. She is a CRC and an NCC.

Angela MacDonald is a licensed mental health specialist and clinician at Frontier Behavioral Health. She is an LPC, CRC and NCC.

 

Letters to the editor: ct@counseling.org

 

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Leave a Reply

Your email address will not be published.