Tag Archives: Rehabilitation & Disability

Rehabilitation & Disability

Retaining family focus

By Laurie Meyers September 23, 2015

“Rose” and “Steve” came to American Counseling Association member Laura Marshak for couples counseling because they felt they had been growing further and further apart ever since their son, “Sammy,” who was now in elementary school, had been born with cerebral palsy. Out of necessity, Retaining-family-focusSteve had become the primary breadwinner for the family, while Rose left her job to provide the extensive care that Sammy required.

Over time, Steve buried himself in his work, while Rose handled Sammy’s daily needs. She shuttled Sammy to his appointments for speech therapy, physical therapy and other specialized services and also took on the task of petitioning Sammy’s school for an Individualized Education Program. Rose felt she was doing all the heavy lifting and resented Steve because she thought he wasn’t helping enough with Sammy’s care. Steve, on the other hand, thought Rose didn’t appreciate how hard he was working to secure their financial future. Angry and resentful, they rarely spent time together as a couple, says Marshak, whose specialties include counseling parents of children with special needs as part of a group practice in Pittsburgh.

“They said it was too hard to find a qualified baby sitter who could handle their son’s medical complications,” recounts Marshak, who is also a counseling professor at Indiana University of Pennsylvania. “In reality, they did not have much to say to each other anymore and had lost an intimate connection.”

According to Marshak, the author of the recently published book Going Solo While Raising Children With Disabilities, Rose and Steve’s story is not unusual. Instead, it is an all-too-common experience shared by many other couples who have children with special needs.

As loved and wanted as these children may be, the unavoidable extra care they require can take a toll not just on parents but also on siblings and the family as a whole. When a child has special needs — whether physical, medical, intellectual, emotional or educational — parents may find it necessary to alter virtually every facet of family life. For these families, it can sometimes seem as if every resource, from time to money to even patience, are continually at risk of being exhausted. Depending on the severity of the child’s disability or special circumstance, the family may need access to intensive medical, health or other services such as occupational or speech therapy; specialized education and possibly job training; and help with daily tasks that other families may take for granted, from basic hygiene to learning and applying social skills.

Because efforts are understandably focused on navigating the day-to-day and moment-to-moment challenges of addressing their child’s special needs, another very important need can often get pushed to the side: maintaining the overall health and well-being of the individual family members and the family unit as a whole. Parents can struggle to take time for themselves while caring for their children. Marriages and partnerships can be tested or neglected. Siblings might struggle to cope with disparate levels of parental attention, feeling they have been left to face life’s challenges on their own. That’s why counselors can play such an important role in helping these families not just meet the special needs of their children, but also attain a better sense of equilibrium.

Addressing behavioral issues

Charmaine Solomon, a licensed professional counselor (LPC) and sole practitioner in Plano, Texas, says that when families of children with special needs come to see her, they are generally looking for help with the day-to-day issues. One issue that comes up frequently is discipline.

“Families with special needs children struggle to discipline in an appropriate manner,” Solomon says. “Because the child has special needs, they [the families] feel like they can’t hold them accountable.”

Solomon, a member of the Texas Counseling Association, a branch of ACA, has a now-grown son who suffered a traumatic brain injury as a child that left him disabled. This personal experience has informed her counseling practice. One of Solomon’s areas of focus is working with children and adults who have special needs such as autism and intellectual disabilities. She is also one of the founding members of My Possibilities, a continuing education day program for adults with special needs located in Plano.

Considering everything else that the parents may be struggling to manage, a child’s acting-out behaviors may seem like a relatively minor problem, particularly when the child is young, Solomon says. However, as the child gets older, this lack of discipline may become virtually unmanageable or, in some cases, even lead to violence, she notes.

Parents who focus on punishment when their child with special needs is acting out or showing aggression may find themselves locked in an escalating punishment cycle until seemingly the only solution left is to ground the child for life, says Erik Young, an LPC in West Chester, Pennsylvania. He has worked with individuals with special needs and their families for the past 20 years, including in a rehabilitation center, a life-skills training organization, a behavioral health care organization and, for the past four years, as a private practitioner. Young and his wife have also provided foster care for several children with special needs.

When parents come to Young for assistance with their children’s behavioral problems, he helps them develop a behavioral plan, which will vary according to the child’s problem behavior and capabilities. For example, many children with intellectual disabilities possess poor verbal communication skills, and their inability to communicate effectively may be part of the behavior problem, he says. Young frequently works on communication skills with the child and parents, giving the child a book or tablet device with pictures that the child can use to indicate what he or she wants.

Discipline strategies will vary from child to child, says Solomon, but should typically focus on reward and reinforcement rather than exclusively punitive measures. For example, parents should focus on what the child really enjoys, such as spending time on an iPad, and start by setting a time limit on the activity, Solomon explains. If the child displays the desired behavior, the limit will be increased, but problematic behavior will result in decreased time with the pleasurable activity, she says.

When appropriate, Young likes to use cognitive behavior therapy (CBT) to uncover what the trigger or cause of the child’s behavior problem might be. Conversely, it may be that a child’s behavior is not truly problematic but is simply angering or frustrating to the parent for some reason, so he will also use CBT to help the parent understand why. Young will then develop a behavioral plan that may include teaching the child and parents strategies for anger management, emotional regulation and so on.

Robert Jason Grant, an LPC and sole practitioner in Nixa, Missouri, also works with both the child (mainly children who are on the autism spectrum) and the child’s parents to explore factors that contribute to behavioral issues. For instance, he explains, punishment for certain behaviors isn’t successful with children who have autism because these children engage in impulsive behavior.

“[The behavior] is not thought out and may even be a surprise to the child,” says Grant, a member of ACA. “They may not even have time to think about consequences.”

Instead, Grant says, behavioral work should focus on what is causing or contributing to the problem. Because children with autism typically possess little or no ability to regulate emotions or process sensory input, emotional and sensory dysregulation are often the main contributing factors to these children’s discipline problems, he says.

“What tends to create dysregulation, and how do we change that?” Grant asks. “Is it environmental? Do we need to provide sensory breaks? … A sensory break could be something as simple and basic as a private quiet room, let’s say in school, where the child can go to be by [himself or herself], with no other people and no one coming to talk.”

Sometimes, all these children need is to “reset,” Grant says, and that can take as little as 10 minutes.

Grant also works with children and parents to tackle the dysfunction head on. He has designed a specific approach that he calls AutPlay, which is a combination of behavior and play therapy for children who have autism. The play therapy tools he uses include objects such as weighted vests, weighted balls and other sensory toys because children who are on the autism spectrum find these items soothing, he says. Parents can use these toys at home to continue the therapy, and that is important because dysregulation requires constant maintenance, he says.

The benefits of effective discipline go beyond managing specific behavioral issues, Solomon says. When parents discipline a child who has special needs, they are teaching him or her how to tell right from wrong and also how to accept instruction, she asserts. Knowing how to make decisions and how to follow instructions contribute to a child’s sense of independence, adds Solomon, who believes that parents should always be working toward increasing the child’s level of independence.

For instance, some children with special needs may require help feeding or dressing themselves beyond the age that is typical for completing those activities independently, Solomon says. Although it is often easier to continue to dress and feed a child who has difficulties, parents should keep working toward teaching the child to do these things on his or her own, she asserts. Solomon acknowledges that this process can take a little — or a lot — longer, but in many cases, she says, the child will eventually have the capability to do it. The same holds true for many other self-care and independent activities that will ultimately benefit the child, she says.

Letting children with special needs do everything they are able to do can also bolster their self-image, says Susan Stuntzner, an assistant professor in the School of Rehabilitation Services and Counseling at the University of Texas, Rio Grande Valley. On the flip side, automatically doing everything for a child who has a disability can send negative messages about his or her capabilities and value and also create a sense of learned helplessness, she says.

Family needs

As children become more self-sufficient, this generally eases the pressure on parents. But parents of children with special needs sometimes come to believe that they are the only ones who can — or should — provide adequate care for their child, Solomon says. Unfortunately, being constantly on call, and with no relief in sight, tends to only cause more problems, she says.

Young says that although families may initially come to counseling for help with a specific problem such as discipline, he also probes for any other stressors with which the family is having difficulty coping, either as a group or individually.

There really is no way to fully prepare for the needs of a child with a disability until you have to do it, he says. Families are suddenly faced with the need to obtain — among other things — health, medical and disability services, Young explains. Further complicating matters is the fact that there is no one central place to obtain services. Disability and educational assistance vary from state to state, and health and medical services are usually secured through insurance plans with varying levels of benefits, Young and Solomon point out.

In addition to coordinating outside services, parents must come up with a plan for meeting the child’s daily needs, Young says. Children with special needs may require additional help with daily activities such as getting dressed or even eating. Children with disabilities may need constant care, meaning someone has to be watching them at all times, Young adds. This means spouses and families may have to engage in tough discussions and make significant compromises. For instance, who stays home to provide care to the child? Who will be on call to take the child to any therapy that he or she might require? To address these needs, one parent will often stop working, which can creates an additional source of stress: money and finances.

Caring for a child with special needs can be a 24-hour job that many families assume they can and should engage in alone, Solomon says. But if all of the family’s time and attention is spent on taking care of the child, who is taking care of the family?

“Oftentimes, families are trying to figure out how to tend to their family member’s needs and concerns to the point that they forget they have their own set of needs,” says Stuntzner, an ACA member who also writes and speaks about living with a disability. “As a result, families … may experience personal or caregiver burnout.” In fact, if parents consistently ignore their own needs, they may eventually grow resentful of how much help their child requires, she warns.

Young works with families who are dealing with a child’s special needs or circumstances to help them recognize that they don’t have to do it alone and that resources are available to them. He points out that he, or any other counselor, can offer the family a neutral source of support — someone to talk to who doesn’t have any kind of emotional attachment or agenda but understands what the family is going through. Because Young also has connections (from his time working in a rehabilitation center and a behavioral health care organization) to state and local agencies that help provide services, he can point these families in the right direction. He even keeps a binder of business cards that he has gathered over time, based on personal or client experience, for tradespeople such as plumbers and handymen who are used to coming to homes with children with special needs and who won’t be disturbed by outbursts or other behaviors that might be regarded as outside the norm.

A system of support

When Grant works with parents of children with autism or other special needs, he always emphasizes the importance of self-care. He teaches parents how to conduct a self-care inventory so they will start actively thinking about caring for themselves.

Encouraging family members to engage in self-care sometimes requires a shift in perspective. For instance, self-care can mean something as small as taking a few moments during the day to indulge in something the individual really enjoys, Young notes. “Instead of a week on the beach — because that’s probably not going to happen — what can they do during the day? [It’s] just little moments that can be refreshing,” he says.

When a child is born with special needs, becomes disabled or is diagnosed with a disorder, Young says, it is common for extended family members and friends to draw back at first, often because they feel like outsiders and aren’t sure what they can do to help. So Young encourages families who have a child with special needs to actively reach out to others, explaining that maintaining a solid social network is crucial for both emotional and practical support.

“I often take my clients through the process of listing all potential resource people — no matter how disconnected — and talk about what they might be able to contribute,” he explains. “Then we go about ‘recruiting’ them so to speak. Find ways to utilize their talents and, thus, spread the stress. People generally want to help when they can. They may just need guidance.”

That’s why Young tells these families to let their networks know what they need specifically. “Take an executive role. You are president,” Young urges his clients. “These people are your Cabinet, your advisers. Make sure you’re getting them to do what you want.”

With a support network, parents can also build a system of respite care. Once a child is used to being with a caregiver, the parents can take breaks, possibly even getting away for a day trip or weekend vacation, Solomon says.

Sometimes families won’t seek any kind of support because they feel ashamed of their struggles, Solomon says. Rather than isolate themselves further, she encourages these clients to seek out others families of children with special needs. She suggests that parents contact local mental health agencies to find support networks.

Young says that lately he has been providing more couples counseling than family counseling because the primary issue for many of his families who are dealing with special needs is actually a problem with the parents’ marriage or partnership. The stress of caring for a child with special needs can take a particular toll on a couple’s relationship, he points out.

Solomon agrees, noting that respite care isn’t just important for parents as individuals but also as a couple. When providing focused care to a child with special needs, it can be particularly challenging to find the time or the energy to just be a couple, she says. Identifying someone who can provide caregiver support can allow couples to take much-needed time for date nights or even a short trip, she adds.

Parenting styles can also drive a wedge between couples who are caring for a child with special needs, says Young, who uses talk therapy with couples. If parents can’t agree on how best to care for or discipline their child, it creates a continual source of conflict, he says. Young helps couples learn to communicate with each other about what they want and need and how best to compromise, if needed.

“I like to use a variety of techniques that hone active listening and clear communication skills and trust,” he says. “One favorite technique I learned at an attachment therapy conference is to have the couple sit in chairs facing each other. One person communicates a brief statement, then the other person has to repeat it back. Then they switch roles. Even this simple exercise can highlight when assumptions are being made and communication is being blocked.”

Young also specifically addresses differing parenting styles with couples, such as when one partner is more authoritarian and the other is more nurturing. He works with these couples to develop a joint parenting style that is balanced — both authoritative and nurturing.

Young also works with the parents in session to practice planning for specific concerns. He asks them to think about how they were raised and how that influences the way they parent today. This exercise helps to spur conversations that can uncover differences in the way they view parenting, he says. Young then helps the couple to negotiate these differences.

Sometimes it’s not parenting style — but substance — that causes the problem. Solomon says disparate distribution of parental responsibility is often a source of tension in families managing special needs. She regularly sees mothers who take all the responsibility for caregiving — either by choice or necessity — which leaves little time for other relationships. Solomon tells her clients that parents need to share responsibility. For example, when possible, fathers should take a turn accompanying the child to therapy. If the mother is the sole caregiver during the day, the father should give her a break by taking on extra duties at night.

Marshak’s couple, Rose and Steve, offered an example of disparate responsibilities — or at least that was how it appeared to Rose. With Marshak’s help, the couple began to discuss the underlying tensions and motivations that had led them to their crisis point.

When Sammy was first born, Rose was deeply depressed and wanted to talk about her grief with Steve, explains Marshak, who co-authored the 2007 book Married With Special Needs Children: A Couple’s Guide to Keeping Connected with Fran Prezant, a speech and language pathologist and researcher on disability issues. Steve, however, preferred to avoid discussion and bury himself in his work. Rose thought Steve’s silence meant that he didn’t care about her or Sammy, but focusing on work and providing for his family was actually Steve’s coping mechanism to deal with his grief. As time passed, Rose spent her time learning as much as she could about cerebral palsy and seeking support through a network of other mothers who had children with the disease. Steve worried constantly about how to financially support his family in the present and how to make sure there would be money for his son in the future in case Sammy couldn’t support himself. So Steve worked even harder.

Guided by Marshak, the couple discussed all of these issues in counseling. Rose began to understand that work was Steve’s way of coping with his feelings of grief and worry and that even though he wasn’t sharing his grief verbally, that didn’t mean he wasn’t hurting. Steve learned to become more expressive with his feelings.

Rose and Steve also worked to re-establish their romantic connection by going out as a couple again and trying to view each other as the individuals with whom they had fallen in love — not just as Sammy’s parents, Marshak says. Over time, as they re-established their bond as a couple, they also started to adjust their roles, including sharing more of the responsibilities related to Sammy’s educational and medical needs. Rose even resumed some of the leisure activities she had given up when she felt she was solely responsible for Sammy’s care.

Speaking to siblings

When working with a family who has a child with special needs, it is also important for counselors to take time to focus on the needs of family members who may get overlooked, or at least feel like they are overlooked — siblings.

Grant sometimes works with siblings on their own so they will know they have an outlet for their struggles and frustrations. “One of the biggest challenges [for siblings of a child with special needs] is the feeling of having to take a step back, of giving up things for their sibling,” he says.

Out of necessity, the child with special needs is the family’s biggest area of focus. To the child’s siblings, this circumstance can seem not only unfair but also as if the parents are choosing to favor the child with the disability or special needs, Grant adds.

When Solomon’s son who is disabled was a child, his siblings struggled with feeling forgotten. “I had to teach my [other] sons the difference between ‘have to’ and ‘want to,’” she recalls. Solomon sat down with her sons and explained that it wasn’t a matter of wanting to spend less time with them but rather that their brother needed more of her time.

As the siblings of a child with special needs get older, they may also start to worry about or feel responsible for their brother or sister, Grant says. He regularly teaches siblings games that they can play with their brother or sister who has special needs that will help the child to cultivate specific skills. One such game is called Social Skills Fortune Tellers.

Grant teaches the “neurotypical” sibling — the fortune teller — how to make an origami structure with tented triangles that can be manipulated with the fingers so that different sides or flaps of the triangle show. Each flap holds a social skill to practice. The fortune teller manipulates the origami and reveals a skill, which the siblings then practice, Grant explains. As an alternative, the origami can also be used for emotions, he says. When a particular emotion is revealed, both the neurotypical sibling and the sibling with special needs can share a time when they felt that particular emotion or make a face that demonstrates that feeling.

Grant also uses family play therapy techniques to allow siblings — and all family members — to express how they are feeling or what they are thinking about issues such as how autism is affecting the family or how the parents are parenting. One technique is called “color my feelings.” Each family member uses a white piece of paper with a heart drawn on it. The family members color the hearts with whatever color best represents their feelings, he explains. The family members then share their hearts, allowing everyone an opportunity to talk about the feelings they are having and why they are experiencing those feelings.

Lifelong support

It is painful to contemplate, but there will come a time when the parents are no longer there to help their child with special needs, Solomon says. That is why she is adamant about encouraging her clients to plan for that future now.

Solomon tells parents that they need to consider questions such as: Who will take care of the child? What services will the child need? Where will the child live? Where will the money to pay for the child’s needs come from?

She helps parents learn what guardianship is and urges them to start planning immediately for the lifelong financial needs related to providing for someone with a disability. Solomon also notes that it is important for parents to apply for disability services well ahead of time. Once a child graduates, he or she loses any benefits, such as ongoing speech therapy, that the child’s school provides, she points out. Solomon adds that in Texas, there is currently a 12-year waiting list for state services.

Young also helps families come to grips with the reality of planning for a child’s ongoing support once the parents are gone or are no longer able, for health or other reasons, to continue providing care. Although he acknowledges it is a difficult conversation to have, he sits down with families and helps them develop a long-term plan by investigating options such as sheltered workshops and group homes. Young also emphasizes the wisdom of financial planning with insurance agencies that specialize in estate planning and special needs trusts.

From Solomon’s perspective, this planning process also comes back to encouraging children with special needs to develop as much independence as possible and teaching them skills to help prepare them for the future, just as parents do with any child.

“Just like with another child [without special needs], you ask, ‘Have you done your homework? Practiced your instrument?’ With the child with special needs it’s, ‘Did you practice doing your buttons? Did you take a shower?’” she says. It’s still homework, she adds, but homework of a different sort.

Young says it is important for counselors to empathize with parents about the challenges of raising a child with special needs. At the same time, he encourages parents to let go of the idea of what “could have been” and instead embrace the child that they have because each child with special needs also has his or her own beautiful gifts.

Stuntzner, who is also a member of the American Rehabilitation Counseling Association, agrees. “Coping well does not mean the family has not felt or experienced negatives or difficulties,” she says. “Rather, it is an indication that through the experience of a loved one’s disability, they have found a way to work with the situation so that it brings the family together instead of pulling it apart.”

 

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Additional resources

The American Rehabilitation Counseling Association, a division of the American Counseling Association, is an organization of rehabilitation counseling practitioners, educators and students who are concerned with enhancing the development of people with disabilities throughout their life span and in promoting excellence in the rehabilitation counseling profession’s practice, research, consultation and professional development. To learn more, go to the ARCA website at arcaweb.org.

The International Association of Marriage and Family Counselors, also a division of ACA, is an organization whose members help develop healthy family systems through prevention, education and therapy. For more information, visit iamfconline.org.

Other resources include:

  • “Disability Awareness,” an ACA podcast presented by Robbin Miller. To access the podcast, go to the Knowledge Center section of ACA’s website (counseling.org) and click on “Podcasts.”
  • Yes You Can!: Art-Centered Therapy for People With Disabilities, an ACA DVD presented by Judith A. Rubin. To purchase the DVD, go to the ACA bookstore (counseling.org/publications/bookstore).
  • “Autism Spectrum Disorder,” an ACA Practice Brief written by Carl J. Sheperis, Darrel Mohr and Rachael Ammons. To access this brief, go to the Knowledge Center section of ACA’s website (counseling.org), click on the “Center for Counseling Practice, Policy and Research” and then “Practice Briefs.”

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To contact the individuals interviewed for this article, email:

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

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.

 

Focusing on ability, not disability

By Amy L. Cook, Laura A. Hayden and Felicia L. Wilczenski April 29, 2014

My junior high school teacher once told me to reach for the stars in life and said I could accomplish anything I put my mind to. Now, I really do believe this!” — Courtney Vinson’s story from Think College, a project of the Institute for Community Inclusion at the University of Massachusetts Boston

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This excerpt from Courtney Vinson’s story describes her pathway to college and the workplace despite being diagnosed with an intellectual disability (ID) and told by educators that she had limited future options.

According to the American Association on Intellectual and Developmental Disabilities (AAIDD), ID is characterized by significant impairment of intellectual functioning (IQ of 70-75 or lower) and significant impairment of adaptive behavior, with onset occurring before age 18. During Courtney’s senior year in high school, she applied and was accepted to the Pathway program at UCLA. Pathway is a two-year certificate program for students with intellectual and other developmental disabilities that offers a combination of educational, job-related and social experiences.

Pathway is just one of more than 250 college campus-based programs that are offered to students with ID. Some of these programs feature inclusive postsecondary educational options, meaning that students with ID are integrated into mainstream college classes and campus activities rather than being separated from the campus community. Courtney is now employed full time at a resort hotel and feeling proud of her achievements.

The prevalence of ID has burgeoned due to the diagnosis of autism spectrum disorder having increased by almost 300 percent during the past decade. Given the high incidence rate, school counselors need to be in position to assist students with ID in making successful postsecondary transitions. While many educators may have focused on these students’ disabilities, school counselors can recognize their strengths and encourage positive pursuit of postsecondary options.

Federal legislation, including the Individuals with Disabilities Education Act (IDEA) and No Child Left Behind, mandates educators to present students with disabilities with appropriate postsecondary transition opportunities, including “further education, employment and independent living” (IDEA). However, according to findings from the National Longitudinal Transition Study-2, conducted by SRI International (formally Stanford Research Institute), students with ID are less likely to graduate high school and achieve competitive employment than their peers without a disability.

In an attempt to close these gaps, educational institutions have increased postsecondary educational options for individuals with ID, including offering greater access to higher education through concurrent enrollment between high schools and universities. Such programs provide students with ID the opportunity to attend college and enroll in college classes, participate in college-based activities (for example, clubs, intramural sports and extracurricular activities) and, in some cases, reside on campus. Additionally, in 2008, Congress passed the Higher Education Opportunity Act with the goal of increasing accessibility to higher education for students with ID. This federal legislation has resulted in the development and implementation of inclusive college education options nationwide. The goal of these postsecondary education programs is to prepare these students for gainful employment and enhance their independent living skills.

The school counselor’s role

According to the U.S. Department of Education, the number of students with disabilities receiving federally funded special education services in public schools has increased from 8.3 percent to 13.1 percent during the past three decades. More than 463,000 children with ID are now receiving such services. Given the burgeoning population of students with disabilities and federal legislation that mandates improved higher education accessibility for these students, school counselors will increasingly be called on to share their expertise in college and career preparation and to assist in developing appropriate transition plans for students with ID.

The American School Counselor Association (ASCA) position statement on students with disabilities says that the professional school counselor’s role includes “providing assistance with developing academic and transition plans for students in the IEP,” or individualized education program. Staying aligned with the ASCA National Model, school counselors can support students with ID in achieving postsecondary educational and vocational goals in a variety of ways, including through individual and small group counseling, consultation to teachers and parents, and advocacy for children with ID.

Cognitive behavioral interventions can be used to help students with ID modify their thinking, feeling and behavior. Specifically, these interventions can be applied to help these students reduce their anxiety and increase positive characteristics that contribute to success, including development of an internal locus of control. When engaging in individual and group counseling, school counselors can use cognitive behavioral interventions to help students with ID recognize their strengths and rephrase negative thinking into positive thinking and subsequent positive self-talk. In small groups, students can help each other recognize strengths and reinforce rephrasing of negative thinking into positive thinking and self-talk. School counselors can serve as group facilitators by praising rational and positive self-talk when it is displayed, while providing a safe and calm environment for these students to share their concerns and feelings about postsecondary transition. For example, school counselors can help students with ID to identify negative feelings or self-talk (for example, “I don’t think I can succeed in college”) and turn it into positive feelings or self-talk (“I know I can succeed in college because I have sought help when I’ve needed it in high school”). In addition, school counselors can provide these students with tangible steps for reframing negative comments (for example, “Identify one way you have been successful in school in the past”).

School counselors can provide consultation to teachers and parents concerning the current needs of students with ID. This might include offering guidance on how to identify those needs (understanding the defining characteristics present in children with ID), and preparing and sharing material that identifies learning strategies that are helpful for students with ID. It might also include facilitating and delivering workshops with guest speakers who can share strategies to help support adolescents with ID with their postsecondary educational and vocational goals.

As students with ID are preparing to graduate from high school, school counselors can also emphasize to teachers the importance of providing these students with emotional encouragement and strength-based feedback that communicates a belief in their ability to succeed. The more information school counselors can share with teachers and parents, the higher the likelihood that students with ID will be properly prepared to face the challenges of the final year of high school, make appropriate postsecondary plans and feel supported throughout the transition.

Counselors can also promote awareness of the unique needs of this population by advocating on their behalf with current teachers, university admissions committees and future employers. When writing letters of recommendation, counselors can highlight the strategies these students have used to succeed academically — strategies that will further benefit them as they pursue their postsecondary educational goals.

Postsecondary educational options

A variety of postsecondary educational opportunities are available for students with ID. School counselors can collaborate with special educators, parents and school psychologists to ascertain students’ needs and ensure an appropriate fit when exploring postsecondary options. Options range from separate programs held on college campus grounds wherein students with ID take courses separately from their mainstream peers, to inclusive programs that permit students with ID to enroll in or audit regular college classes, participate in college activities/clubs and intramural sports and, in some cases, reside on campus. For students residing nearby a higher education institution that supports students with ID, opportunities may also exist for concurrent high school and college enrollment. Currently, eight higher education institutions across Massachusetts have formed partnerships with roughly 40 high schools in which students with ID are offered the opportunity to attend college while completing their high school education. Through these partnerships, students acquire a deeper understanding of interest areas related to their career goals, develop self-sufficiency in negotiating the complexities of the university and broaden their social contacts and use of free time.

For example, the Inclusive Concurrent Enrollment (ICE) Partnership Program at the University of Massachusetts Boston (UMB) aims to improve opportunities for postsecondary education for students with ID. This initiative involves inclusive concurrent enrollment for high school students ages 18-22 who are receiving special education in high school. Educational coaches from the high school facilitate the transition to the postsecondary setting. The students with ID are enrolled in college courses, which they either audit or take for credit. Their career development is fostered through job shadowing, paid and unpaid internships, and integrated competitive employment.

UMB staff collaborated with educational coaches from Boston Public Schools (BPS) to implement this program through a grant from the Massachusetts Department of Elementary and Secondary Education. During the fall 2012 semester, seven BPS students participated by auditing classes based on their interests — for example, creative writing, art history, sociology and so on. Five of these students completed the courses. During the spring 2013 semester, seven additional students from a nearby city enrolled in courses of their choosing. Additionally, a mentoring program pairing students in the ICE program with matriculated undergraduate students was initiated during that semester. Moreover, in an attempt to ensure best practices, a professional development workshop concerning universal design for learning was conducted for UMB faculty with the assistance of UMB’s Institute for Community Inclusion. In addition, an interagency advisory council was formed to provide guidance and feedback.

Initial results suggested that these students learned to advocate for themselves by arranging course accommodations through the UMB disabilities services center. The students also engaged in activities outside of the classroom (for example, pool, gym and track), and three of the students used their identification cards to visit the library housed on UMB’s campus. All of these students had the same access to the academic and social support services as UMB’s general student population. Postsecondary education for students with ID serves as a transition to adult roles and responsibilities.

Conclusion

As is evident from Courtney’s story of postsecondary success and entrance into the workforce, we cannot afford to marginalize any person. Everyone needs to contribute, and school counselors can share their expertise when supporting students with ID in exploring postsecondary options.

Some educators may think that students with ID are being set up to fail if they are encouraged to pursue postsecondary education — particularly inclusive postsecondary options. School counselors, on the other hand, are in position to recognize and celebrate these students’ interests and motivation to obtain postsecondary education just like their peers without disabilities. School counselors understand developmental changes and appreciate that students with ID pass through the same adolescent-to-adulthood transitions as students without disabilities. Consequently, these students need the same stimulation and support.

Through effective postsecondary opportunities, students with ID gain soft skills such as self-advocacy, self-confidence and self-determination that are critical for future employment. Postsecondary options, and particularly inclusive postsecondary educational programs, have resulted in improved outcomes such as better employment opportunities for individuals with ID. School counselors can play an important role in preparing students with ID to be independent adults and ready for college. The role of school counselors needs to be broadened beyond serving just the general student population to one that is inclusive and fulfills the needs of students with ID throughout the postsecondary transition planning process. For more information, refer to the AAIDD website at aaidd.org and the Think College website at thinkcollege.net.

 

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Amy L. Cook is an assistant professor in the Department of Counseling and School Psychology, College of Education and Human Development, at the University of Massachusetts Boston. Contact her at amy.cook@umb.edu.

 

Laura A. Hayden is an assistant professor and school counseling program director in the Department of Counseling and School Psychology, College of Education and Human Development, at the University of Massachusetts Boston. Contact her at laura.hayden@umb.edu.

 

Felicia L. Wilczenski is a professor and interim dean of the College of Education and Human Development at the University of Massachusetts Boston. Contact her at felicia.wilczenski@umb.edu.

 

Letters to the editor: ct@counseling.org

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

By 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.

 

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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.