Tag Archives: Rehabilitation & Disability

Rehabilitation & Disability

Fostering resiliency in families and caregivers of individuals with disabilities

By Mariagrazia Buttitta September 26, 2019

It was like the world had collapsed on me, or worse. The words pronounced by my eye specialist felt like a sudden punch to my stomach, leaving me bruised and gasping for air. My life seemed over, or so I thought when I received an eye diagnosis of cone dystrophy at age 14. To this very day, it is emotional to recall the impact that diagnosis had on me and the confused look on my parents’ faces as they heard, for the first time, phrases such as “legally blind” and “disability.”

We all stood there in complete shock. Our faces must have looked ghostly white, perhaps hoping this was a nightmare from which we would soon awake. Instead, we left the office feeling defeated and frightened of what my future would look like, literally. The following day, I gathered all the energy I had left and Googled “cone dystrophy,” learning that it affects roughly 1 out of every 30,000 individuals (according to the National Organization for Rare Disorders). That number did nothing to lift our spirits or morale. My family still feared for my future and, the truth is, so did I.

According to the World Health Organization, nearly 1.3 billion people have a form of vision impairment. Furthermore, the Centers for Disease Control and Prevention reports that 1 in 4 people in the United States lives with a form of disability. So, why did my parents and I feel alone at the time of my diagnosis?

 

Media portrayals of disabilities

Today, it is clear to me that both my cultural background and the way that the media portrays individuals with disabilities might have influenced how my family and I coped with this news.

Growing up in Sicily, I experienced firsthand how my culture viewed disabilities as a weakness. Generally, individuals with physical or mental disabilities were looked down on and were not provided with the same opportunities as other people were. For example, it was assumed that I — someone affected by an eye condition — had less to offer; therefore, I was discouraged from pursuing education. Being the first person in my family with a visible disability did not help us know how to move forward either.

In addition, the media seems to send mixed messages regarding individuals with disabilities. Most of us have compared ourselves with models on magazine covers or wished to be the next Jennifer Lopez or George Clooney. But rarely does our society associate beauty with a physical disability. How many times have you watched TV and noticed someone with a visible disability? GLAAD’s annual report on inclusion notes that less than 2% of the main characters on American TV shows have a disability. A 2015 “Sandy’s View” column for The Chicago Lighthouse website discussed both the positive and negative stereotypes used when representing disabilities in the media. Both stereotypes seem to be extreme — one representing these individuals as victims, and the other representing them as “exceptional” individuals with unrealistic powers.

It is no wonder that my family and I were uncertain about my future. We lacked the proper resources and role models that could have helped us combat some of the negative stereotypes. Despite this, we overcame tremendous obstacles. Having a physical disability did not limit my life, and the realities of my disability only made my parents stronger and more resilient. In addition, it made them more educated about disabilities and cognizant of what other families and caregivers might experience.

 

Accepting and moving forward

Admittedly, my diagnosis of cone dystrophy was life-changing, both for me and my parents. The families of individuals with disabilities may have a difficult time adjusting and can develop their own mental health problems as a result. A study by Juan J. Sola-Carmona and colleagues that looked at 61 parents of blind children found that anxiety is higher and well-being is lower among these parents compared with the general population (published in Frontiers in Psychology, 2016). In general, families with individuals who have a disability are at greater risk of developing psychological problems. However, if these families learn how to cope well, it can increase the strength of the family. Here are the top five things that helped my family and me at the time of my diagnosis:

1) Reaching acceptance: Learning to accept the diagnosis was one of the hardest things for all of us, and I can assure you that it didn’t happen overnight. Acceptance developed with time. Once we traveled to various specialists and knew there was nothing that could be done to cure my vision, we needed to figure out how to live with the diagnosis effectively. After reaching that point of acceptance, we were able to figure out how we would cope and move forward as a family.

2) Seeking professional help: I was a teenager at the time of my diagnosis. The diagnosis was devastating, and it took a negative toll on me. As I got older, I had no faith in my ability to be successful, and that led me to feel helpless and useless.

Counseling proved extremely beneficial to me, but that came later in my life, when I was in my 20s. Talking to someone was therapeutic. My parents were extremely supportive of me, but they were also emotionally impacted by witnessing my struggles. Therefore, it was nice to find a therapist with whom I could talk and share all my emotions without feeling the guilt of hurting anyone else.

Once I gained confidence in myself, it automatically made the process much easier on my parents. I was a happier person to be around. Seeking professional help can be equally effective for family members and caregivers, providing them the time and space to focus on themselves and their own experience.

3) Educating ourselves: We spent hours educating ourselves as a family about my eye condition. We looked at hundreds of websites, articles, journals and magazines. After gaining that understanding and knowledge, we could start educating others about my level of blindness, why I walk with a white cane, and why I have to wear sunglasses all the time.

4) Learning about resources: Neither my family nor I had any idea about the resources available to me. Through research, however, we came across various resources, including the Commission for the Blind. After joining, we learned about still other resources, such as the various tools and technologies that would help me navigate the world with confidence. The resources reassured my parents that I, too, could go to college, get a job, and live a life like people without disabilities.

5) Having role models: Despite the number of individuals with a disability, we can often feel alone or misunderstood. Over time, my family and I met other individuals who, despite being blind or having other forms of disability, managed to live a successful life. As a result, my family and I started to view disabilities differently. No longer did we view my disability as a barrier. More importantly, we learned that we were not alone. My dream of going to college would become a reality.

 

A counselor’s perspective on disabilities

Throughout my graduate studies in a clinical mental health counseling program, I took note of a significant gap in how professionals are trained to work with those impacted by a visible disability. So, from there, I was on a mission: I rolled up my sleeves and got to work.

First, I interviewed Judy Schwartzhoff, a licensed clinical social worker with more than 30 years of experience in the mental health field, to ask her point of view on this subject. I posed several questions to her, including “How competent do you feel working with individuals, families, and caregivers of those affected by a visible disability?” and “Do you feel there are enough trainings provided to help deal with these clients?”

Her response didn’t surprise me one bit: “As mental health practitioners, we are often trained to treat the  emotional side of things, but I agree that we could use more knowledge and training in this area. However, if we do come across the issue, we tend to overlook the disability and stick with the emotional problem because that’s what we are trained in. We continue to separate mental health issues from physical disabilities, but sometimes, the two go hand-in-hand. As professionals, we need to expose ourselves to a diverse population and become more inclusive and know how to deal with different abilities as well as be able to assist their families and caregivers.”

I walked out of the office feeling determined and ready to put my thoughts on paper. Having witnessed, firsthand, the impact this issue had on my parents, I had to bring light to this issue. I immediately asked myself, a soon-to-be mental health professional, a question: What can I do to ease some of the worries and anxieties surrounding individuals affected by a different ability and their families and caregivers?

 

What mental health practitioners need to know

The chances of working with clients who have a visible disability, or their families or caregivers, are high. The truth is, we all will experience a form of loss in physical functioning at one point or another. This could be as simple as experiencing hearing or vision loss as we age. Even so, mental health professionals may feel incompetent if they’re lacking the proper resources and knowledge regarding these clients’ needs.

The day of my diagnosis, I recall a sense of fear and worry hovering over me. My parents had similar feelings, but they also experienced other emotions such as disbelief, sadness and confusion. An article by Josephine Defini in VisionAware described how blindness really affects the entire family as a whole — and I believe this truth can easily be applied to any form of disability.

As mental health professionals, we must be cognizant that each member of the family (or caregiver) might be experiencing a different state of mind and level of acceptance. Therefore, each person may require additional time to process and cope with the diagnosis. As practitioners, we want to be cautious not to assume that all family members are dealing with the news in the same manner or that they are even ready to deal with it at all. As a recent graduate counseling intern, I’ll acknowledge that I catch myself wanting to fix clients’ problems right away. I need to remind myself that everyone has his or her own timeline for healing and processing.

What follows are my top five recommendations for mental health professionals:

1) Use a psychosocial assessment: A psychosocial assessment can be helpful to gather information about the level of acceptance, skills needed to cope, resources, and any other observations noted for the individuals and their families or caregivers (Defini). By gaining this insight, mental health professionals will have a better understanding of what services are needed. For example, when working with an individual who uses alcohol as a way of coping with their issues, co-occurring treatment can be offered. Understanding the client’s individual experience of a disability can reduce bias or assumptions.

2) Use person-first language: In a 2014 article for the American Counseling Association’s VISTAS, Susan Stuntzner and Michael T. Hartley suggested that counselors use person-first language and avoid using negative phrases that could make clients feel less empowered. This would include saying “person with a disability” rather than “disabled person,” for example. In addition, don’t jump to conclusions about how clients feel about their disability. For example, don’t assume that they feel any weaker or have lower quality of life because of the disability. Speaking from my own experience, I think that being open and asking your client to educate you is also important. Everyone deals with a disability in a different way. Ask your clients what they prefer, and do not assume anything.

3) Know your resources: As mental health professionals, it is fundamental to know the resources that can be most helpful to clients. For example, as Defini suggests, if someone is experiencing vision loss, be sure to know the proper state services or local community programs that are available, such as rehabilitation, vocational rehabilitation, or low vision services. As mental health professionals, it might be impossible to know all of the resources out there, but we can be knowledgeable about who might have that information. Listed at the bottom of this article are some resources that may be helpful to you and your clients. Don’t be afraid to seek out information about resources that are more specific to each client’s needs and location.

4) Understand the adjustment process: It is important for mental health professionals to understand their clients’ adjustment process, including awareness of when they found out about their disability and how they coped. If individuals or their families or caregivers are not yet ready to process anything, they might not be able to utilize available resources to the best of their ability. Depending on how well adjusted they feel, the treatment will vary. Specifically, if they just found out about the disability, counseling might need to focus on the grieving process rather than on finding services and moving forward. Additionally, understand the individual’s barriers and that of their caregivers or family members (Stuntzner and Hartley).

5) Know the proper techniques: Be competent and knowledgable about what techniques can assist your clients. Many techniques used center around self-compassion, forgiveness and resiliency (Stuntzner and Hartley). Family counseling may also be helpful to clients and their family members because it gives each individual the opportunity to be open about their needs with each other and the counselor. One intervention may be to have families engage in activities together (e.g., take a meditation class, go to dinner, see a movie, visit a museum) to keep the disability from overtaking their lives.

Mental health professionals shouldn’t be afraid to use their own judgment to see what their clients and clients’ family members or caregivers may need. Every person copes with a disability differently, and everyone is going to need different strategies, so get to know the needs of your clients and their families or caregivers.

 

Conclusion

I wish that I could go back in time and wipe clean the past — especially the day I received my diagnosis — to remove the fear and anxiety my parents felt. Sadly, I can’t. But as a recent graduate counseling student, career counselor intern, author, motivational speaker, and mental health and disability advocate, I aim to help decrease the pain and fear that others may experience. I plan to do this by educating individuals who have disabilities, as well as their families and caregivers, and by setting as example, because a disability does not have to define or determine our future or the future of our loved ones. As figure skater Scott Hamilton once said, “The only disability in life is a bad attitude.”

 

Resources

https://www.familyresourcenetwork.org/

https://nfb.org/

https://sites.ed.gov/idea/parents-families/

https://www.psychologytoday.com/us/groups

https://www.cdc.gov/ncbddd/developmentaldisabilities/links.html

rarediseases.org page on cone dystrophy

 

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Mariagrazia Buttitta is an author, motivational speaker, and mental health and disability advocate. She holds a master’s degree in counseling education from the College of New Jersey and is national certified counselor candidate. Contact her at buttitm1@tcnj.edu and through her website at embracingyourdifferences.com.

 

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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.

Counseling Connoisseur: Revisiting the Spoon Theory

By Cheryl Fisher July 1, 2019

“If opening your eyes, or getting out of bed, or holding a spoon, or combing your hair is the daunting Mount Everest you climb today, that is okay.” – Carmen Ambrosio

 

Tara, 36, wakes up and rolls out of bed. Her pain factor is a five out of 10. She feels well rested after spending the past two days in bed–the result of working an 8-hour day and going to dinner with friends. Today she will try to finish her laundry and run errands. The lupus flare-up appears to have subsided–for now.

Kevin, 28, a graduate student, is not as fortunate. He struggles to keep up with the demands of a full-time job and graduate school. Kevin has weeks when he is able to manage both. However, today, he has become physically and emotionally paralyzed by his autoimmune disorder and struggles to bring even his thoughts together. He is contemplating taking an academic leave of absence until his health improves.

Carmen, 57, has been living with multiple sclerosis (MS) for over 20 years. Each day she wakes up and takes inventory of her physical and emotional well-being. Some days are better than others. However, the uncertainty of her health has prompted her to seize the moment and engage fully in her craft as an author.

For Tara, Kevin, Carmen, and thousands of others, the challenge of managing their chronic conditions while also meeting the demands of daily life can be daunting. To those around them, they look perfectly healthy. Smart and ambitious, they excel when they are feeling well. However, without warning they can be thrust into the throes of physical, emotional and cognitive dysfunction, rendering them unable to get out of bed, let alone handle professional, academic or personal responsibilities and obligations.

The Spoon Theory Revisited

In an attempt to help her dear friend understand what living with lupus feels like, writer and activist Christine Miserandino crafted The Spoon Theory to explain how energy is limited by chronic illness. Miserandino uses spoons as a metaphor for energy. According to the theory, a person has a certain number of spoons representing energy each day, and each activity depletes a portion of those spoons. In this way, individuals are encouraged to ration and pace their spoon/energy usage in order to accomplish their daily activities. This theory has become widely accepted, and some individuals have even coined the name “Spoonies” for those with conditions that restrict energy. However, the Spoon Theory relies on myths about chronic illness and energy.

Myth 1: There is a set number of spoons each day.

The amount of energy (spoons) needed to function is not prescribed in a daily dose. Clients may wake up and feel that they are armed with a picnic basket filled with spoons. Then a few hours later, they crash and burn and are entirely depleted of whatever resources they thought they had. It is as if the bottom fell out of the basket without warning.

As Jennie, a blogger for The Mighty, an online support community for people facing health challenges, describes in her post, “Why the spoon theory doesn’t fit my life,” what seems like a high energy day can suddenly turn into total depletion:

“Often I wake in a morning and think, ‘Yes! Today is a good day!’ Then, within hours, or even minutes, the tides have turned. Maybe my spoons are ninjas? Maybe the borrowers have been rifling through my stash? Whatever it is, I can go from having just enough energy to less than zero quicker than a scrambling fighter jet. Sometimes it’s due to a weather change; sometimes it’s stress. Often I have no clue whatsoever what happened.”

Myth 2: Spoons can be banked for another day

The Spoon Theory suggests that rest will help bank energy for the next day. This sounds like it makes sense, right? However, chronic illness doesn’t play fair. Resting for a day or two may result in feeling even more fatigued the following day. This makes it difficult to plan activities for the day, week or month. For example, my own daughter, who was recently diagnosed with lupus, confided that some days she wakes up feeling energized only to crash within hours and be wholly depleted the remainder of the day or even the next few days. It is frustrating to both the person who has the illness and those around them who may want to make plans. At times, life is only manageable in chunks of minutes versus days.

Myth 3: Activities require a specific number of spoons

One of the challenges of the Spoon Theory is that it is impossible to quantify (in spoons) the amount of energy it takes to accomplish any given activity. The amount of energy expended is influenced by other variables, including pain threshold. For example, getting dressed for the day may be as easy as slipping into an outfit one day, but feel like donning a suit of armor the next. So, although the activity for both days is identical, the depletion of energy is vastly different. Therefore, preparing for energy expenditure can feel like a futile effort.

 

How counselors can help

Living with the day-to-day uncertainties of a chronic illness can be isolating, alienating and frustrating. Making plans with friends and family must be spontaneous and depends on the illness effects du jour. Counselors can assist clients and families who are impacted by chronic illness by validating their experiences, providing psychoeducation, and stepping up to advocate on local, regional and national levels.

Validate

By nature, counselors are exceptional listeners who are able to hear and identify the concerns of the client. Additionally, we can validate the challenges experienced by the client. Clients may feel anger and resentment at how their condition may restrict activities. They may feel isolated and alone. Friends and family who were present at the initial diagnosis may have returned to their busy lives. This often may leave the client feeling abandoned and alienated. Validating the difficulties of navigating chronic illness allows the client to feel heard and understood.

Educate

While we are able to sit with the client and the emotional, cognitive and physical pain of chronic illness, we can also provide psychoeducation that may promote strategies for better self-care. For example, helping clients grieve the old lifestyle and create a new normal that is shame-free and includes strength-based coping skills that allow them to deploy greater flexibility in the face of those “not-so-great days.”

Counselors can also help clients locate resources in the community, such as support groups or career assistance. They can provide education to family and friends about the uncertainty of living with chronic conditions that tax energy. For example, helping significant others understand that staying in bed all day is not indicative of a character flaw or laziness but a real depletion of energy (those spoons again!).

Advocate

Counselors can contribute to efforts for institutional changes that will benefit clients by participating in legislation and signing petitions. We can attend hearings and provide testimony to the needs of our clients. Finally, counselors can use their voice and power to advocate for clients by participating in any number of activities to increase awareness or fund research.

Conclusion

The Spoon Theory attempts to explain the energy consumed by chronic illness. In reality, it oversimplifies the complexity of day-to-day functioning. Perhaps one of the gifts of counseling is to provide a relationship without conditions where the client is valued beyond the constraints of the illness and a place that welcomes vulnerability and recognizes the courage of showing up each day in spite of the challenges. Perhaps the act of counseling is — as Brené Brown suggests — joining the client in the “arena” and experiencing their pain and disappointment. Perhaps even in the complexity and uncertainty of living with chronic pain and illness, the counselor can help clients recognize that showing up each day if worth the challenges.

Finally, perhaps in the midst of the discomfort of the seeming betrayal of the body and mind, the best gift counselors offer to their clients is as author Hannah Brencher says in her book,  If You Find This Letter: My Journey to Find Purpose Through Hundreds of Letters to Strangers, “… the permission to feel safe in their own skin. To feel worthy. To feel like they are enough.”

 

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Related reading, from the Counseling Today archives:

The tangible effects of invisible illness

Assessing depression in those who are chronically ill

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

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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.

 

Leading an anti-bullying intervention for students with disabilities

By Katherine A. Feather and Tiffany M. Bordonada January 10, 2019

For more than 40 years, bullying in schools has remained relatively stable and today is recognized as a serious social problem. In 2014, the Centers for Disease Control and Prevention (CDC) and the Department of Education released the first federal standardized definition of bullying, which includes unwanted aggressive behavior, observed or perceived power imbalance, and repetition of behaviors or high likelihood of repetition. In addition, the CDC and Department of Education acknowledged direct and indirect modes of bullying and four types of bullying that school-age children can experience: physical, verbal, relational and damage to property.

According to the National Center for Education Statistics (2015), approximately 1 in 4 students in the United States reported having been bullied at school. However, evidence suggests that school-age children with disabilities are two to three times more likely to be bullied than are their peers without disabilities (for more, see the three-volume set Disabilities: Insights From Across Fields and Around the World). It is absolutely critical for professional counselors to assist those who are targeted and support proactive interventions that decrease bullying for students with disabilities.

Intervention strategies that are grounded in social learning theory and established on client-centered, community-based and experiential methods have been shown to be successful with children who have disabilities. Such interventions have a positive effect on children’s self-efficacy, self-determination and social skills. Furthermore, counselors can adapt experiential-based activities to provide these students with opportunities to learn new skills, make decisions, experience successes and take calculated risks. Finally, counselors need to recognize the strengths of students with disabilities, teach them to feel comfortable with who they are and empower them to implement bullying prevention skills.

This article will outline proactive prevention in terms of experiential group activities that focus on self-efficacy, self-determination and social skills training when working with school-age children with disabilities. The experiential group activity we will be describing was originally developed by Able SC, an empowerment and advocacy organization in Columbia, South Carolina, for people with disabilities. We collaborated with Able SC and tailored the activity to meet the needs of middle school and high school students with disabilities.

Aims

The experiential activity includes four primary objectives that positively affect self-efficacy, self-determination and social skills. The objectives are to help students:

1) Identify and understand various bullying behaviors

2) Recognize the warning signs when a person is being bullied

3) Learn strategies to manage bullying

4) Learn steps to take in the here and now to address bullying

Preconditions

Prior to engaging group members in the experiential activity, several preconditions should be met. First, counselors must have a strong therapeutic alliance with the participants before engaging them in the group activity. Second, counselors should provide proper accommodations to address the unique needs of the group members. Third, counselors must be willing to be creative and flexible to adapt the experiential activity to the individual strengths of the group members. Fostering a strengths-based approach is imperative when helping school-age children with disabilities to explore their self-efficacy. Finally, counselors must display competence with multicultural social justice counseling before working with children with disabilities.

The process

The first part of the group facilitation process involves assisting group members with understanding the various types of bullying (i.e., physical, verbal, relational and damage to property). The role of the group leader is to facilitate a discussion about these various bullying types, which may prompt group members to recognize specific examples. Additionally, the group facilitator should discuss the importance of recognizing real or perceived power imbalance and determining how often the power differential occurs. In other words, was this a one-time incident, or was it done repeatedly to hurt the individual? The group facilitator must guide students in understanding these two concepts that help to define bullying: observed or perceived power imbalance and repetition of behaviors. The group facilitator should also assist students in understanding the confusing distinction between when someone is joking versus when someone is actually engaging in bullying behavior.

To foster another mode of understanding, the group facilitator can also engage group members in a role-play demonstration to act out the different types of bullying. If the participants find it difficult to participate in the role-play, group facilitators can provide examples of the types of bullying to ensure support for students during the demonstration. In addition, it is important to identify the individuals involved with the bullying episode (i.e., bully, target and bystander) to provide clarity during the role-play. For instance, the group facilitator should discuss with group members how the bystander can be the most influential person in the situation either by acting as a solution to the problem or by instigating the bullying. Finally, the group leader encourages group members to identify characteristics of being a bully.

This will help students to recognize these traits so they can avoid engaging with those who display such behaviors.

The second part of the experiential group activity consists of identifying warning signs that an individual might be being bullied. These signs include:

  • Physical signs (e.g., cuts, bruises, scratches, headaches or stomachaches, damaged possessions, missing possessions)
  • Emotional signs (e.g., withdrawal or shyness, anxiety, depression, aggression, suicidal ideation)
  • Behavioral signs (e.g., changes in eating or sleeping habits, nightmares, no longer wanting to participate in school or activities that he or she once enjoyed, bullying siblings)
  • Academic signs (e.g., changing the manner in which he or she gets to school, being driven to school instead of riding the bus, having a noticeable drop in grades)

After determining the group’s understanding of the warning signs, the group facilitator can propose an experiential group activity in which the group members identify strategies to manage bullying. The group facilitator can engage the students in a role-play scenario in which the target initially fights back. The facilitator should then prompt a dialogue on the positive and negative consequences of engaging in this approach. Next, the group facilitator encourages the group to identify nonviolent strategies that the target can use in the same scenario. This will prompt group members to recognize how implementing a nonviolent approach to bullying can be an effective option.

Next, the group facilitator needs to co-construct with the group members prevention strategies to manage bullying behavior. A few general prevention tactics include:

  • Telling an adult
  • Walking away
  • Ignoring the bully
  • Avoiding the bully by interacting with friends or avoiding places the bully is known to be

Group members should be taught to understand the differences between the roles of bully, target and bystander and recognize appropriate prevention strategies that they can use if they find themselves in any of these categories. For example, the group facilitator could encourage the group members to identify effective prevention strategies specifically for the bystander role. These strategies include telling the bully to stop, helping the target to walk away, recruiting friends to intervene and getting an adult.

To reiterate, it is important to provide group members with specific scenarios to ensure that they understand the differences between the three roles and know which prevention strategies are appropriate for each scenario. Furthermore, have group members share times when they have fallen into the specific category of bully, bystander or target to guarantee that they are addressing their personal experiences with bullying.

Additionally, the group facilitator can engage the group in a role-play exercise to review the three categories and to collaboratively identify:

1) The bullying behavior

2) How the target reacted to the bullying

3) How the bystander(s) reacted

4) How the bully responded to the situation

5) Whether the bullying was managed in an effective way

6) How the bullying scenario could have been handled differently

7) How the group members would feel as the target in the scenario

This role-play provides group members with a greater sense of self-awareness as it relates to self-determination, self-efficacy and social skills. In addition, the role-play increases empathy toward others because group members vicariously experience the thoughts, feelings and behaviors of the target.

Finally, the group facilitator can engage the group members in personal action plans to reinforce what was previously reviewed and to address steps to manage bullying (for a detailed figure outlining the personal action plan, see Katherine A. Feather’s 2016 article “Antibullying interventions to enhance self-efficacy in children with disabilities,” published in the Journal of Creativity in Mental Health). The facilitator asks the group members to independently acknowledge personal situations in which they have been bullied; their thoughts, feelings and reactions to the experience; how they handled it; and what they could have done differently. Once they have completed the chart, group members are prompted to share their stories if they feel comfortable. The personal action plan is an important part of the experiential activity because it gives group members something tangible they can take with them to remind them of what they have learned and that they can reference in the future.

Finally, at the discretion of the group facilitator, group members are encouraged to discuss assertive communication and the various communication styles, such as the difference between “I” and “You” statements. This particular discussion can transition into recognizing the importance of self-advocacy and one’s ability to make informed choices. The group facilitator can end the session by reinforcing individual empowerment and emphasizing the group members’ potential to manage bullying. The tools used to combat bullying speak to the group members’ self-efficacy, showing them that they have the ability to exert control over their own behavior, motivation and social environment (as explained by Albert Bandura in his 1977 article “Self-efficacy: Toward a unifying theory of behavioral change”).

Modifications to the process

Counselors who use this experiential activity may wish to adapt the group in the following ways:

1) Assess whether a particular student would be a better candidate for individual counseling and modify the activity for individual, rather than group, counseling.

2) When implementing the experiential training, augment the activity to meet the needs of the group participants. For example, for the personal action plan, participants can use numerous mediums to complete the activity (e.g., act out the steps, cut out pictures from a magazine, draw, write, use note cards with words, use assistive technology, discuss steps verbally).

3) Delivery of the experiential group activity must be based on students’ presenting characteristics to ensure full understanding of the material. For example, counselors need to address a comprehensive range of needs among students with disabilities. Therefore, counselors can provide additional scenarios of the components for the activity. This will encourage repetition and opportunities for practice. Counselors are also encouraged to collaborate with school personnel to ensure that they are meeting the needs of the student and integrating all necessary interventions to promote student success.

4) This experiential group activity may not be applicable for all students with disabilities. We suggest that counselors consult and collaborate with school staff to gauge the appropriateness of the intervention for individual students.   

Considerations

Counselors must intervene in a timely manner by recognizing, assessing and engaging students in activities that will combat bullying and provide them with the skills to be successful in the school environment. However, counselors must be sensitive to group membership. Therefore, counselors may want to consider making the group available to peers without disabilities. Inclusive practices may buffer against bullying by providing peer models to students with disabilities, as well as by promoting social competence among all students. Isolating students with disabilities does not provide them with the practice and validation they need to develop appropriate social skills. Thus, combining students with disabilities and their peers without disabilities fosters an inclusive approach and ultimately enhances a community of knowledge and understanding.

Finally, prior to implementing this experiential activity, we encourage counselors to become familiar with the social model of disability and the capabilities framework versus the medical model of disability. The social model of disability is a different way of viewing the world and challenges the typical attitudes toward disability. Fostering a capabilities approach validates the ideologies of inclusion that stress equality, acceptance and valued participation. The capabilities approach is a holistic social justice initiative that assesses disability on the basis of one’s abilities and functioning within society. Counselors need to recognize the impact that society has on the individual and the barriers that students with disabilities face on a daily basis.

 

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Helpful resources for counselors

  1. PACER’s National Bullying Prevention Center (pacer.org/bullying/resources/students-with-disabilities)
  2. StopBullying.gov page on bullying and youth with disabilities and special health needs (stopbullying.gov/at-risk/groups/special-needs)
  3. “Bullying and Disability: An Overview of the Research Literature” (tinyurl.com/BullyingAndDisability)

 

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

Katherine A. Feather is a licensed professional counselor in Arizona and an assistant clinical professor in the Department of Educational Psychology at Northern Arizona University. Contact her at Katherine.Feather@nau.edu.

Tiffany M. Bordonada is an assistant professor in the Department of Counseling and Human Services at the University of Scranton. Contact her at Tiffany.Bordonada@scranton.edu.

 

Letters to the editor: ct@counseling.org

 

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Understanding and working with service dog handlers

By K. Lynn Pierce October 8, 2018

It happens almost as soon as Emily steps through the door of the grocery store. “What do you think you’re doing in here with that?” an employee demands loudly while moving to block her path. He’s pointing in anger at the black Labrador retriever beside her. As Emily comes to a halt, her service dog, Todd, automatically sits. He’s braced slightly against her leg to help her balance.

“We don’t allow dogs,” the employee states emphatically. “It’s a health code violation.”

“This is a service animal. He provides medical alert to assist me with my disability and is permitted to accompany me by the Americans with Disabilities Act [ADA].” The well-rehearsed line flows from Emily’s mouth even as she feels herself flushing, aware that people are staring as they pass. She wants desperately to move farther into the store, out of the way.

“Well, what about your papers or ID? I need to see some proof,” the employee insists, crossing his arms and looking at Emily in clear disbelief.

Emily replies, trying to stay calm. “The ADA doesn’t permit businesses to ask for proof of disability, and there are no registries or certifications for service animals.”

As the employee blusters and scoffs, Emily signals to Todd, who stands and walks with her around the employee. Thankfully, he does not follow them, but Emily still pushes down a wave of panic that he might call the police or that someone else might try to make her leave the store before she can get what she needs.

It’s the end of a long day, but partway to the checkout counter, Emily realizes that she forgot to grab bread to go with tonight’s dinner, so she and Todd head down the front aisle to the bakery. Along the way, Emily does her best to block out the delighted cries, sounds of surprise and conversations that break out as she and Todd pass. Emily hears one couple wondering whether she is a dog trainer because she doesn’t look like she’s blind. What could be wrong with her?

While looking at the choices of dinner rolls on display, Emily is startled by a shrill voice behind her. “Oh, what an adorable puppy! Can I pet him?”

Emily turns to see a woman already reaching toward Todd, who, on cue, backs partially behind Emily as she steps forward in front of him. “No, ma’am, please don’t distract him. He’s working.”

“Oh, it’s all right. I love dogs,” says the woman, now trying to reach around Emily’s leg to get to Todd.

“He is working,” says Emily firmly. “Please leave us alone.”

“Well, there’s no need to be so rude about it. Why would you bring a dog if you didn’t want people to pay attention to it?” exclaims the woman, glaring at Emily as she walks off in a huff.

Emily goes directly to a self-checkout to avoid more interactions with employees. By the time she reaches the car, Todd is alerting her that her heart rate is elevated. Emily sits in the car for a few minutes, shaking and breathing heavily before she feels safe to head home.

This is a common experience for people with disabilities who require service animals. For these individuals, their service animals are their lifeline, but all too often, they experience disproportionate discrimination, invasive questioning and other unwanted attention. Service dogs are becoming more common, particularly for people who have invisible disabilities. Consequently, it is more important than ever that counselors become comfortable working with service dog teams and know how to respond when clients ask whether a service dog would be helpful for them.

Defining a service animal

It is helpful to first understand what a service animal is not. Service animals are frequently confused with emotional support animals and with therapy animals.

Emotional support animals are pets that are permitted to live with or travel with someone who has a disability. They are not required to be trained in any specific way, and animals other than dogs can be designated as emotional support animals.

Many counselors are already familiar with therapy animals because they are often used in animal-assisted therapy. Therapy animals are simply animals that are used by their handlers to assist others, frequently in mental health or medical settings, but also in courtrooms and during crisis or disaster response scenarios. Often, the facility in which the handler works will impose general training or temperament requirements for therapy animals, but these animals are not expected to do specific tasks.

When it comes to service animals, there are a number of misconceptions. One of the most common myths is that service animals require a special certification or license or official documentation. In reality, there is no registry or certification for service animals that has any legal meaning. Another myth is that service dogs must be a certain breed or size, but there are actually no restrictions. In fact, many small breeds make excellent medical alert dogs and don’t require the space considerations that larger breeds do.

So, what is the definition of a service animal? According to the ADA, a service animal is a dog that has been individually trained to work or perform tasks for a person with a disability. A disability as defined by the ADA is a legal term, not a medical one. Under the ADA, a person with a disability is someone who has a physical or mental impairment that substantially limits one or more major life activities.

Service animals are not pets; under the law, they are considered to be necessary medical equipment. They can be in public with their handler because their handler has a right to equal public access under the law, and the service animal performs tasks required by the handler to achieve that access. This means that outside of a few specific limitations, service animals are allowed to go anywhere that a wheelchair, walker or other assistive device can go. Just as wheelchairs are custom fit for their users, service animals are specifically trained for an individual’s needs through a set of trained tasks.

Trained tasks are not actually defined by the ADA. The only thing the ADA clearly states is that comfort is not a task. This is very important, so let me elaborate. Counselors may have cause to think about and discuss with a client whether a service dog would be helpful for that client. However, if after researching categories of tasks, the answer to the question of “What would a service dog do for my client?” is anything like, “It would make them feel better when they experience anxiety,” then the client cannot utilize a service animal.

Because the ADA defines only what a trained task is not, organizations such as the International Association of Assistance Dog Partners provide lists of common tasks. Generally, these tasks are broken down into categories on the basis of what the tasks accomplish (hearing, mobility, guide, medical alert, psychiatric assistance, etc.) or what “kind” of service animal might perform them. Because counselors are not typically experienced in training dogs, it is easier to start with determining broad categories of tasks that counselors believe might be helpful for their client. It is best to focus on tasks that would help the client in public because the point of public access with a service dog is that the dog is actively mitigating the client’s disability and is therefore required. Counselors are likely to find several “bonus” tasks that would provide great additional benefit, but these are best added once it is clear that a service dog is necessary for the client to successfully function independently in public places.

Working with prospective handlers

In assessing whether a service animal is a good fit for a client, a simple first test is to ask:

1) Is my client disabled under the definition set forth by the ADA?

2) Is my client a suitable candidate for a service animal?

3) Are there trained tasks a service dog could perform that would help mitigate my client’s disability?

Often, the first question will provide counselors with the overall answer. If the client isn’t disabled, then that person won’t be able to use a service animal. If the client is disabled, then the focus moves to the question of whether the client is a suitable candidate for using a service animal.

Some basic considerations for arriving at an answer to the second question include whether the client is physically and financially able to care for a dog, whether the client can handle major life changes at this point and the client’s overall degree of resiliency. Service dog programs agree that potential contraindications include suicide attempts by the client in the past year, severe paranoia or psychosis and any other situation that might put the dog’s safety at risk. A good candidate might have a history of bonding strongly with canines. It is also important to determine whether the client is in a stable enough position to be able to effectively use a service animal.

Then we arrive at the question of trained tasks, which is essentially, can the client be helped by a service dog? In assessing a client, a counselor might ask what the client’s disability is preventing the person from doing. A possible answer would be that the client has posttraumatic stress disorder and is hypervigilant. The client experiences flashbacks and becomes stuck in place. Sometimes the client becomes disoriented and cannot remember where he parked. Additionally, at home the client disassociates without warning and cannot get to his medication. He also has nightmares and disrupted sleep.

For this client, possible trained tasks to be used in public might include a “watch my back” command, in which the service dog would alert the handler to people approaching from behind, and a “search” command, in which the dog could search an enclosed area such as an office for other people. The dog would also be trained to respond to and eventually alert the handler to flashbacks by sensing shifts in breathing and body language or other cues specific to the client. For example, the dog could be trained to lick the handler’s face if it does not receive a response from the handler. It could also alert other known people, such as the client’s spouse or co-workers, that the client needs assistance. In responding to a flashback or other episode, the dog could be trained to lead the handler to the exit of the building, either automatically or upon receiving a “find the way out” command. In instances in which the handler can’t locate his car, the dog could be trained to “find the car” and lead the handler there.

Some bonus tasks performed at home by the service dog might include waking the handler from nightmares and retrieving medication from a known location. The dog could also use the known “search” command upon returning home if the handler was concerned that an intruder might be present. Perhaps the handler also has a secondary concern of mobility issues from knee and back problems. In that case, more mobility tasks such as balance feedback and bracing to help the handler get out of chairs could be added to the service dog’s responsibilities, along with some named items for retrieval such as “phone,” “remote” and “keys.”

This service animal would clearly be a huge comfort to the client, but we can recognize that it would be performing many tangible trained tasks beyond comfort, thus setting it apart from a regular pet or an emotional support animal. This is what justifies the animal working with its handler in public as medical equipment under the law.

Getting a dog

What steps should be taken after determining that a client would be helped by a service animal? Most handlers are best served getting their first dog from a program rather than attempting to train the dog themselves, unless they possess extensive training experience or have connections to the right people to provide the training. The organization providing the service animal will likely want documentation and a release of information from the counselor if the client’s disability is related to a mental health-based diagnosis rather than a concern that is primarily medical. Be aware that scam programs do exist. It is important to look for red flags, such as programs that want a large sum of money upfront or that won’t allow prospective clients to visit a training or to be connected with current clients.

Accreditation bodies such as Assistance Dogs International can help limit the risk in choosing an organization. These accreditation bodies assist training programs by setting standards for the required level of obedience training, thus helping to ensure that the animal will be safe to work in public. They also have agreements concerning their obligations to clients should needs change or challenges arise.

When choosing a service animal organization, clients should read and understand the contract as well as the policies and practices of the program thoroughly before committing because there may be fundraising requirements or extensive policies regarding gear, care, travel and so on. Generally, clients will have custody through an organization that maintains ownership of the dog. Therefore, it is important to ask for information concerning who makes the call on when a dog retires, whether animals retire into handler care and what the process is for getting a successor dog, in addition to all of the requirements for being a handler through the organization.

The experiences of handlers

Very little research is available on the experiences of service dog handlers. There is prevalent stigma against service animals, however. In her 2017 study of just under 500 handlers, sociologist Meghan Mills found that the majority of participants (68 percent) reported discrimination during daily tasks. Mills also reported that 77 percent of respondents indicated the legitimacy of their service dog had been questioned, and nearly half said they had not used their service dog in public “sometimes” because of unwanted attention.

The experiences of handlers appear to be affected by factors such as gender, race, age and geographic location. It is common for handlers to experience negative reactions from their friends, family members and communities. This can be especially true for those with invisible disabilities who may already have the legitimacy of their illness questioned regularly. Service dogs are not as common as other assistive devices, and this can draw additional attention. The social norm in the United States of pet dogs being prohibited in most public spaces compounds this experience. Even when handlers start with strong support networks, the constant discrimination they face over time can lead either to their exclusion by others or to self-imposed isolation to avoid these experiences.

Because people tend not to understand public access laws or how to interact appropriately with service dog teams, handlers are often characterized as demanding or rude for protecting their legal rights or safety. In online service dog forums, handlers regularly ask how to be strategic about telling strangers not to distract a dog who needs to be watching for medical alert (for example, a dog trained to give early warning for a seizure). These handlers do not want to endanger themselves, but they have been told that they are being unreasonable to expect strangers not to talk to, bark at or call their dog.

New handlers in programs or on their own will practice being assertive and calm, repeating the law and educating in the face of people yelling and threatening to call the police. As a result, handlers can put unreasonable expectations on themselves and their dogs to be flawless. Handlers may be concerned that an off day or a small mistake could make their access and the access of other teams more difficult.

Working with teams

Counselors who understand the role of service dogs have a unique opportunity to model positive social interactions for handlers. Showing respect through appropriate etiquette to service dog teams is a simple step that will communicate understanding and put service dog handlers at ease.

The core of service dog etiquette is not interfering with the animal’s focus by talking to, petting or otherwise engaging the dog. In the same way one would not comment on a person’s wheelchair or cane, it is rude to focus too much on a service dog or to ask too many questions. The presence of a service dog, as necessary medical equipment, is not an invitation for conversation about the client’s disability or about service dogs (either in general or about the handler’s in particular). Handlers may be sensitive to these questions because they commonly are asked by others in inappropriate settings. As with any other client, it is best to build rapport first, then ask more probing questions once a relationship is established. In support of building a therapeutic relationship, I’d recommend that counselors say something along the following lines: “I’m not going to ask you things I don’t need to know about your service animal, but is there anything you would like to tell me about how you want me to interact with you as a team while we’re working together?” This would be a polite way for counselors to align themselves with these clients while also signaling understanding of and respect for their boundaries.

If counselors are aware that a client is a service dog handler, it is important to think in advance about the potential barriers the team may face in a counseling setting. For example, if the waiting room becomes uncomfortable because another client is being too curious or is distracting the service dog, consider whether there is another location where the client could go to wait for the session. Educating other counselors and staff in the practice on basic etiquette is also important because it removes the responsibility from the client. If a client who is a handler is going to participate in a group, spend time beforehand discussing how the client would like to be supported in setting boundaries with the other group members. This step could improve the outcome.

As previously noted, many service dog teams experience frequent discrimination. Over time, some handlers become fearful of entering new environments because of the potential of access concerns or other negative interactions. Some handlers have been threatened or experienced violence simply for having a service animal. Conflict may also result from the handler not allowing people to pet or interact with the service animal or from refusing to be illegally removed from a building. Many teams have been attacked by pet dogs or by dogs that are claimed to be service animals. It is worth counselors evaluating for trauma responses within this demographic because, over time, the constant alienation can build up, even without the experience of acute incidents.

Handlers may also have lost the support of family or friends or access to some of their spaces because of this treatment decision. Loss of access can be due to lack of ADA coverage (as is the case in religious spaces) or due to elements of specific environments in which the social cost of advocacy may outweigh the gain of access. It is important that counselors not place the burden of education exclusively on handlers and understand that in some situations, there is no clear path forward to gain access once it has been denied. This means that counseling with handlers may involve elements of grief counseling.

There are interventions used in training programs that can deepen the bond in a team and help handlers be more effective in using their service dogs. Some of these interventions target specific symptoms, whereas others address interpersonal and environmental processing through the team bond. Counselors working with long-term clients who are handlers may be served by seeking consultation and supervision in this area.

 

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K. Lynn Pierce recently started her counselor education and supervision doctoral program at Pennsylvania State University. She is a service animal handler of four years and provides consultation and workshops for mental health and related professions around service dog inclusion and integration. Contact her through her website at klynnpierce.com.

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

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.

 

 

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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).

 

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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

 

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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.