Tag Archives: Rehabilitation & Disability

Wanted: Inclusive licensure process for clinicians with difficult life situations

By Kevin Wreghitt September 11, 2015

Licensure is a “rite of passage” for most mental health professionals. When new professionals graduate with either a master’s or doctorate in counseling, they usually have great expectations of taking the world by storm. There is one pesky reality standing in the way, however.

I am of course referring to going through the multiyear licensure process, which involves taking a board exam and practicing under supervision for several thousand hours. In my case, this process Disabled parkinghas been more burdensome than I ever imagined because I am in a difficult life situation.

My birth was difficult, and I sustained significant brain injury because of a lack of oxygen. As a result, I have quadriplegic cerebral palsy and am confined to a wheelchair. I have random motion and a speech impediment. The use of my hands is poor to nonexistent, and because of this I can do few things for myself, relying on others for all my daily needs.

Nothing has come easily for me, but I have experienced many successes and surprises in my life. This is due to the hard work and perseverance of many people who have worked tirelessly with me and to my own determination to prevail despite the odds. I also demonstrated a few abilities from a young age. For example, I had an interest in helping others who were going through difficulties by listening to them and being present with them. My thought in early adolescence was that I should go into a field where I could help people with disabilities. Through the years, beginning in high school, I had a number of mentors in the counseling field, including some who were disabled themselves, who encouraged me to join the profession.

I always did well in school, attaining high marks and honors in high school and beyond. When I graduated from high school, I went on to college and then graduate school. Because of my disability, it took me about twice the time as other students to complete my undergraduate and graduate degrees. By the time I finally was done, I was in my mid-30s. My major in graduate school was mental health counseling. Upon finishing, I had planned to go through the state licensure process. This is when some of the toughest obstacles in my life began.

 

Hitting a brick wall

There were multiple considerations I had to think about to make my “dream” a reality. For the sake of simplicity, I will boil it down to two general factors. The first was my disability and how I would be successful in gaining employment with my type of challenges. The second factor was going through a licensure process. Both of these factors interact.

I worked with two rehabilitation counselors and other community career counselors plus my own therapist. I went on some interviews, but many of my inquiries simply went unanswered. After six months to a year of being rejected, I became frustrated. I continued looking for another year, at which point I had to quit because I found the whole process soul destroying. From talking to people, I gathered I could not third-party bill because I did not have a license, and this was a major obstacle to obtaining employment in the field.

I was tired at that point of looking around for other placements. So, in 2009, I found a volunteer job as a mental health clinician counseling people with intellectual disabilities. I had to hire my own supervisor because there were no counseling professionals on staff, but I began trying to accrue hours for licensure. I wanted to clear the “examination hump,” so I took that in 2011 and passed.

All this time, I was seeing very few clients because the population served by the day habilitation facility was considered too severe to be counseled. At the same time, I knew I had a total of 3,360 hours to fulfill for state licensure in Massachusetts. With so few clients available, I had difficulty gaining enough hours, even on a six-year part-time basis. During the past six years, I have looked periodically for other volunteer opportunities, but for whatever reason, other places never materialized.

 

The psychological toll

As with any disappointment or heartache in life, this experience has been a daily rollercoaster. It has really caught up with me in the past couple years, and this year has been the hardest so far. I guess that is because I am nearing 50 and it looks doubtful that I will achieve the type of career I dreamed of so long ago. I feel like I am still back in my 20s and no further along in my career aspirations. I still feel like a student or an intern who is just learning when I should be capable of practicing on my own with expertise, specializations and much experience.

I keep wondering how I got into this mess. What didn’t I see or plan for? Where was the point where I went wrong, and should I have known it? Was I ever meant to be a counselor, or was it all just a pipe dream gone terribly wrong? Was all that effort, all these years, all for nothing? Who am I anyway? These are the questions that haunt me daily.

I do not want people to feel pity for me. That is not the purpose of this article. Most of us in the counseling profession know that we respond with empathy not pity. To correct or manage a problem, we first have to understand it and how it impacts people. This is a core principle in our profession, and I hope by briefly explaining how deeply disappointed I am about this whole situation, perhaps counselors can begin to understand this problem — not only for me but for others who find themselves in similar situations, dealing with a disability or other difficult circumstances, who try to obtain a start in the counseling profession.

 

What the literature says

Despite claims that counseling is a scientific field, the profession (and related others that practice psychotherapy) has failed to validate what it takes to be an effective counselor. All the states seem to have differences in the total number of supervised hours needed to qualify for a counseling license, although it seems to be 3,000 on average. I once posed the following question on the ACA Connect forum: “Where did the number 3,000 or more hours and all the subtotals come from and why?” Nobody could or would answer this question.

Paul Lowinger published a study in the Journal of the National Medical Association in 1979 saying that nonprofessionals could diagnose 70 percent of psychiatric outpatients and that an even larger proportion (80 percent) of 36 patients evaluated could be treated by nonprofessionals. In 1967 in the American Journal of Public Health, Truax reported therapeutic mastery with five novice counselors who took a 100-hour training course.

In a 2005 study that appeared in the Journal of Consulting and Clinical Psychology, Wampold and Brown found factors such as the therapist’s age, gender, education and experience had little effect on client outcome. Nyman, Nafziger and Smith, writing in the Journal of Counseling & Development in spring 2010, pointed out the possibility that supervised paraprofessionals might be as beneficial as licensed and advanced clinicians. In the March 2014 issue of Counseling Today, R. Tyler Wilkinson commented about the inequities of the licensure process (“The Affordable Care Act and counselor licensure”). It is as if the profession and the states have said to candidates who struggle, “You’re good but not good enough” when some of those candidates could be effective therapists.

It appears to me from this brief analysis that the high bar of total clinical hours is arbitrary and not based on real objective proof. In fact, some research would suggest that one could make due with fewer post-degree clinical hours and still perform just as well as those with the thousands of hours now required. In my view, the licensure laws around the country seem created mostly out of subjective cognitive constructionist criteria rather than being based on objective standardized measures designed to benefit society.

 

Achieving licensure inclusion

The American Counseling Association (along with its divisions and branches), outside organizations such as the National Board for Certified Counselors and the states need to work toward inclusion for licensure. If a person wants a license, he or she should be given every chance to achieve that status. Here are a few ideas:

  • Counselor education programs could have two-year residency periods so that universities would be responsible for placements and assist with supervision after graduation, similar to what medical schools do.
  • All students should be educated about the licensure process as part of their course work or by attending extra seminars. They should also be made aware of alternative career paths within the mental health field in case counselor licensure is not a practical pathway for them.
  • Students with disabilities should be encouraged early on to seek counseling about licensure from faculty.
  • State boards should be consulted early about unique circumstances that may require special accommodations.
  • Achieving licensure should not be the only way to be paid in the mental health field. There should be another certification that is recognized by insurance plans, the government and the profession when an individual obtains a degree and is working toward licensure.
  • The licensure process might be able to be streamlined if a new national standard were adopted, with all states and professional organizations agreeing on a uniform number of hours and other requirements needed for licensure.
  • Some states may need to modify rigid licensure laws to allow licensure boards more flexibility in dealing with special circumstances while still complying with competency standards.
  • A robust and active disability interest network needs to be established within ACA to, in part, advocate for counselors with disabilities.
  • Employers in counseling centers need to be educated about the unique opportunities inherent in employing a counselor with a disability, no matter the severity of the limitation. People striving through adverse situations may make some of the best therapists.

The road toward licensure inclusion will be long, but we have to take on this challenge. The counseling profession preaches cultural diversity, but when a person with a different set of life circumstances comes along, I find there is little consideration given to that person. The profession may drive away capable people by promoting high standards without providing a way for those professionals to succeed.

I understand that the counseling profession has to protect the public, but we can do this while providing extra support in becoming credentialed. For the profession to achieve the ideals ACA has set forth, we need to be more inclusive — not exclusive — in licensure and employment practices.

 

Conclusion

This article asks what the soul of the counseling profession really is. Are we content to exclude potential licensed professionals because they have difficult life situations, or do we welcome them into the practice of counseling? Disability, financial concerns and difficult family situations, among other circumstances, may be keeping some people from achieving licensure.

I do not know if I will ever become licensed, but I hope this article might change the way licensure is handled and give new professionals in difficult life situations a chance at this wonderful achievement. There has to be a way!

 

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Kevin Wreghitt is a mental health clinician counseling people with disabilities in day habilitation and college settings in Massachusetts. Contact him at kevinwreghitt@verizon.net.

 

Bio/neuroethics and counseling: A novel partnership

Kevin Wreghitt May 1, 2012

Bioethics is the multidisciplinary field that applies knowledge of health care policy, law, philosophy, sociology and dispute mediation/resolution to solve moral dilemmas in clinical practice and research in medicine and allied professions. Human cloning and stem cell research, which are hotly debated in society, are examples of bioethical issues. Beginning roughly in 2002, neuroethics emerged as a subdiscipline of bioethics that seeks to solve moral dilemmas arising from neuroscientific research and clinical cases of brain trauma and mental illness.

Daniel Buchman of the National Core for Neuroethics at the University of British Columbia said this about his field: “Neuroethics has deep roots in ancient philosophical discussions of mind and brain and has joined this history with contemporary thinking in biomedical ethics and neuroscience devoted to elucidating ethical challenges prior to and during the transfer of new research capabilities to the bedside.” The use of psychiatric drugs and other treatments for patients who are mentally ill, issues related to neuroscience and national security (such as brainwashing) and the use of “designer drugs” to change one’s personality or enhance cognitive function are examples of neuroethical issues.

In clinical or consultative ethics cases, which revolve around an identified patient/client and his or her cognitive status, counselors can play an important role by uncovering the psychological issues belonging to that person and the people around him or her and explaining how those characteristics might influence bioethics or neuroethics decisions. Therapists could assist bio/neuroethicists, the courts and others in keeping those psychological variables “in check” and preventing irrational behavior from being destructive to the ethical decision-making process.

What often receives less consideration, however, are the psychological factors of the participants trying to reach bio/neuroethical decisions. For instance, what types of psychosocial interactions occur between the individuals involved in clinical bio/neuroethical discussions? It is reasonable to suspect that issues such as personal values and cultural issues are presented, but is that enough? Are there situations that go beyond the capabilities of bio/neuroethicists and require more of a mental health approach?

Case of persistent vegetative state

According to a 1991 Multi-Society Task Force on PVS (persistent vegetative state) as cited in The New England Journal of Medicine, individuals are considered to be in PVS when they have been unconscious for longer than 12 months due to brain trauma and also have a poor prognosis. Higher cognitive processes are nonfunctional, with awareness of self and the environment being absent. These patients cannot communicate or follow commands in any way. Sensory experiences may occur but have no conscious meaning.

One of the most famous cases concerning PVS centered around Terri Schindler Schiavo, who died on March 31, 2005, almost two weeks after her feeding tube was removed and her hydration cut off under court order. Terri’s death was preceded by a lengthy court battle between her family and her husband, Michael. The psychosocial questions and issues surrounding the Schiavo case are numerous. What was the state of the marriage between Michael and Terri before she suffered massive brain damage and was put on life support in 1990? What did life and death mean to each participant in the conflict?

Perhaps psychometric testing (for example, the Minnesota Multiphasic Personality Inventory, or MMPI-2) could have assisted in identifying who was best mentally fit to make decisions on Terri’s behalf. Was Michael Schiavo violent toward Terri as some claimed? More questions could be added as possible psychological influences. None of these issues came out in the bioethics proceedings.

Clearly, PVS cases are complex, and the mental health of each participant and the family as a whole has to be taken into account. Mental health and ethics professionals need to ensure that a careful psychological examination takes place, and the courts should require such assessments. The people involved in PVS cases are dealing with heart-wrenching experiences, and psychological assistance is needed.

Health care system implications

On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, and a few days later, he signed the Health Care and Education Reconciliation Act. Among other major reforms, these two laws allow for 32 million Americans to obtain health insurance who do not currently have coverage. The future of health care delivery is in question, not only because of new governmental regulations and bureaucracy, but because our wavering economy might influence any outcome as well.

New moral and legal questions will challenge the fields of bio/neuroethics in the United States because of health care reform. For example, will new regulations interfere with best practices in medical and mental health services? Will vulnerable populations have difficulties accessing needed specialized treatments and services? Perhaps treatments that are offered now will be excluded or reduced because of cost or rationing. If some of these negative consequences take place, there might be emotional fallout. Everybody hopes the new policies will benefit our health care system, but counselors should remain cognizant of the potential pitfalls of this new system — especially because no one really knows yet how or if it will work.

The field of neuroplasticity has offered discoveries on how patients can rebuild neural networks, even after brain damage, through certain therapeutic experiences and targeted exercises. There are neuroethical concerns, however, that some systematic difficulties might impede clinical practice. In the fall 2009 Focus newsletter of the Center for Health Care Policy and Ethics at Creighton University in Nebraska, Caroline Gaudet and Trisha Cochran said, “Given the limited length of stay and reimbursement for in- and outpatient rehabilitation services, clinicians have a sense of urgency to get their patients as functional and independent as possible as quickly as possible, often having to teach compensatory behaviors instead of fostering neural recovery.”

Counselors need to be sensitive to ethical and societal questions that might affect their clients who have various types of illnesses. Sociological changes such as health care reform can usher in much hope and, simultaneously, significant concern. Such opposing outcomes probably depend on what people expect medical or mental health care to do for them. As another example, professionals who work with psychiatric clients know that any change in their environment might cause these individuals anxiety and perhaps trigger a total relapse of their conditions. Changes in the U.S. health care system might become a direct or indirect trigger for such challenges.

Other bioethical issues

Beyond the neurological areas, there are other bioethical issues that may require mental health attention. For example, should medical providers assist in ending the life of terminally ill patients? With biotechnological advances and societal changes, the bioethical, psychological and medical issues of death and dying have become more complicated than they once were for persons with terminal illness and their families. Recommending that patients have feeding tubes implanted or making decisions concerning who should receive an organ transplant presents both bioethical and mental health implications.

These represent only a couple of examples of the bioethical issues that health care clinicians face daily. We should ask ourselves whether counseling and therapy might help to improve the prevalence of healthy and ethical outcomes in these scenarios. Counselors must bear in mind that there are often competing values between the patient, the health care team, the family and society in many such situations.

Counseling initiatives and strategies

Organizations such as the American Counseling Association have the opportunity to promote clinical practice, research, legislative advocacy and education in this specialized area. People vying for guardianship in court (for example, in the Schiavo case) should be psychologically screened so the party that is most mentally fit for the task can be identified.

It might be beneficial for ACA to partner with other organizations such as the American Society for Bioethics and Humanities; the American Society of Law, Medicine & Ethics; the Neuroethics Society; and the National Bioethics Advisory Commission to create initiatives that would foster integration between our respective fields. We could partner with these organizations to devise new protocols for cooperation between bio/neuroethicists and counselors. More training opportunities on bioethical issues for the counseling profession would also be beneficial. Perhaps some counselors might want to earn another degree in bio/neuroethics and develop a subspecialty in clinical or research areas.

Health care workers who come into contact with these types of cases supposedly receive ongoing bio/neuroethics training. This does not mean, however, that such staff could not use additional emotional support as well. This could involve values clarification classes as well as individual or group psychotherapy. A mental health clinician, independent of the case being considered, could be included in bio/neuroethical discussions to identify and assist with the psychological issues that may arise.

Offering a grief model might be helpful. Part of the difficulty might be that each person is at a different place along the grief journey. The father may have accepted the reality, while the mother might be in denial and a nurse could be bargaining. Counselors have to help identify and reconcile the psychosocial variables in any health care dilemma.

The patients who can participate in the decision-making process should be in counseling/therapy to help them cope with what is happening to them. The counselor might have to assist these patients in reshaping their expectations to bring about a resolution. Bear in mind, “incompetence,” if imposed, is a legal term — not a medical or psychiatric diagnosis. Even though the legal profession pronounces some people to be incompetent, it doesn’t necessarily mean the person cannot think for himself or herself. However, he or she may need added support in making decisions. The person should not be dehumanized by the label of incompetence or by the bio/neuroethical process, and counselors can play a role in ensuring that does not occur.

It will be important in the coming years for counselors to monitor changes in the U.S health care system, not only as these changes pertain to the counseling profession but to medical professions as well. Starting in 2014, when health care reform goes into full effect, some clients might experience confusion and distress. Counselors will be needed to help individuals navigate both expected and unforeseen challenges. If systematic difficulties become acute or long term — necessitating rationing of services, for example — this could lead not only to a medical crisis but to a mental health crisis as well. If so, strategies and changes to the counseling profession might need to be developed.

In the beginning of the bio/neuroethics process, the individuals involved should be made aware that they have biases that will come out. People should be encouraged to pinpoint their own motives and the meaning of the actions they take. For those who want to hide behind the objective professional cloak, they should be reminded of their humanity and that their motives will ultimately escape from the mental iron curtain. Finally, the legal profession might need to be educated about the influence of psychological factors in these dilemmas. The Schiavo case illustrates what can happen when such psychic forces are overlooked.

Conclusion

I’m writing this article not as a bio/neuroethical expert but rather as a casual observer of the process and a newcomer to the counseling profession. I am also a quadriplegic due to cerebral palsy from birth, so I can empathize with people with disabilities who might feel that others are in control of the quality of their lives. It is frustrating to know others are in charge of making choices on one’s behalf, even though some patients/clients might not be as aware of this due to their inability to comprehend. Counselors can play a significant role in assisting patients/clients, families and professionals to cope with bio/neuroethical issues. I think it would be worth the effort.

Kevin Wreghitt is a mental health clinician and a Massachusetts mental health counselor licensure candidate at Coastal Connections Inc., an adult developmental disability day program. He has an interest in counseling clients with neurological injuries. Contact him at kevinwreghitt@verizon.net.

Letters to the editor: ct@counseling.org

Seeing potential, not disability

Lynne Shallcross August 1, 2011

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.

Working together

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.”

Branching out

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.