COUNSELING AND DISABILITY

Ability is a natural tendency to do something well such as carry out tasks in daily life (e.g., dress
or feed oneself), work at a job/attend school, or be mobile. Disability is an inability or a limita-
tion that prevents a person from performing some or all of the tasks of daily life, such as taking
care of bodily functions, walking, talking, or being independent of a caretaker. Disabilities are
prevalent in American life. About 20% of Americans “have physical, sensory, psychiatric, or
cognitive disabilities that interfere with daily living” (Livneh & Antonak, 2005, p. 12). Overall,
“disabilities affect 54 million people in the United States, of whom 4.4 million are children”
(Roskam, Zech, Nils, & Nader-Grosbois, 2008, p. 132). Broken down even further,
• more than 9 million Americans with disabilities are unable to work or attend school;
• costs of annual income support and medical care provided by the U.S. government to assist
people with disabilities is about $60 billion;
• disabilities are higher among older people, minorities, and lower socioeconomic groups;
and
• 8 of the 10 most common causes of death in the United States are associated with chronic
illness.
As if these figures were not startling enough, ethnic minority populations suffer from dis-
abilities more than the general population (Smith, Foley, & Chaney, 2008). The reasons are
numerous and include low income and poverty, employment in physically dangerous jobs, lack
of health insurance coverage, low educational attainment, and faulty and inaccurate testing and
assessment (Wilson & Senices, 2005, p. 87).

The Nature of Disabilities

Clients who have disabilities include those whose manifestations are physical, emotional, men-
tal, and behavioral. Disabilities vary widely and include a number of diagnoses such as alcohol
abuse, arthritis, blindness, cardiovascular disease, deafness, cerebral palsy, epilepsy, intellectual
limitations, drug abuse, neurological disorders, orthopedic disabilities, psychiatric problems,
renal failure, speech impairments, and spinal cord conditions. Not all disabilities are visible,
however, and thereby go unnoticed (Davis, 2015).
Unfortunately, people who have disabilities often encounter others who have misconcep-
tions and biases about their limitations (Smith et al., 2008). These individuals may even harass
those who are disabled about their disabilities, especially if the persons have other characteris-
tics, such as a minority sexual orientation (e.g., being lesbian or gay) (Hunt, Matthews, Milsom,
& Lammel, 2006). This type of behavior is cruel and may well affect the person’s “everyday
social interactions” (Leierer, Strohmer, Leclere, Cornwell, & Whitten, 1996, p. 89).
As a result of the treatment they receive in public, a large percentage of persons with dis-
abilities tend to withdraw from mainstream interactions with others and are unemployed or
unable to achieve an independent-living status (Blackorby & Wagner, 1996). In fact, “individu-
als with disabilities as a group may have the highest rate of unemployment and underemploy-
ment in the United States” (Clarke & Crowe, 2000, p. 58). Thus, people with disabilities may
suffer from low self-esteem, lack of confidence in decision making, social stigma, a restricted
range of available occupations, and few successful role models (Enright, 1997). They may also
have limited early life experiences.
Linked to, but distinct from, a disability is a handicap, which is “an observable or discern-
ible limitation that is made so by the presence of various barriers” (Schumacher, 1983, p. 320).
An example of a person who is disabled and who has a handicap is someone who is a quadriple-
gic assigned to a third-floor apartment in a building without an elevator, or a partially deaf per-
son receiving instructions orally.
In working with people who have disabilities, it is important to realize language makes a
difference. People are not their disability. Rather, they have a disability. Thus, person-first lan-
guage is called for. This is language that is designed to emphasize people are more than their
disability, for example, people with mental disorders as opposed to the mentally ill. Such lan-
guage separates the identity of individuals from any clinical diagnosis, disability, or chronic
condition (Granello & Gibbs, 2016).

Working with People Who Have Disabilities

Services for those with disabilities have been strongly influenced by government legislation. In
turn, counselors who work with this specific population have been active in supporting federal
and state legislation. Yet there have been other influences as well.
A distinguishing aspect of counseling with people who have disabilities is the historical
link with the medical model of delivering services (Davis, 2015; Ehrle, 1979). The prominence
of the medical model is easy to understand when one recalls how closely professionals who were
first involved with persons with disabilities treated those who were physically challenged.
However, a number of different models for helping people who are disabled have emerged
(Smart & Smart, 2006). There are four that are most prominent.
The most popular of these models and the closest associated with the medical model is the
biomedical model. This model is steeped in the language of medicine, but it is silent in the lan-
guage of social justice. According to this model, “disabilities are objective conditions that exist
in and of themselves” (p. 30). They are considered deficiencies and residing within an individual
who is totally responsible for the problem. This model basically equates disability with pathol-
ogy. Whereas the model may work best when dealing with physical disabilities, it is “less useful
with mental and psychiatric disabilities” (p. 31).
The second conception of disability is the environmental and functional model. Its focus
is more appropriate for chronic disabilities (i.e., what most disabilities are). In this model, people
carry a label with them (i.e., “disabled”). The label may lead to some degree of social prejudice
and discrimination. Yet, it also places the blame for disabilities outside the individual.
The sociopolitical model is the third model and is sometimes referred to as the minority
model. It assumes that persons with disabilities are a minority group rather than people with
pathologies. “The hallmarks of this model include self-definition, the elimination (or reduction)
of the prejudice and discrimination (sometimes referred to as ‘handicapism’), rejection of med-
ical diagnoses and categories, and the drive to achieve full equality and civil rights under U.S.
law” (p. 34).
The fourth model is the peer counselor model. It assumes that people with direct experi-
ence with disabilities are best able to help those who have recently acquired disabilities.
In working with clients with disabilities to develop or to restore adjustment, the role of
counselors is to assess the clients’ current level of functioning and environmental situation
that either hinder or enhance functionality. After such an assessment is made, counselors
use a wide variety of counseling theories and techniques. Virtually all the affective, behav-
ioral, cognitive, and systemic theories of counseling are employed. Systems theories in such
work have become especially popular in recent years (Cottone, Grelle, & Wilson, 1988;
Hershenson, 1996).
 The actual theories and techniques used are dictated by the skills of counselors as well as the
needs of clients. For example, a client with disabilities who has sexual feelings may need a psy-
choeducational approach on how to handle these emotions, whereas another client with disabilities
who is depressed may need a more cognitive or behavioral intervention (Boyle, 1994). An action-
oriented approach such as Gestalt psychodrama can be especially powerful in helping clients
become more involved in the counseling process and accept responsibility for their lives (Gatta et
al., 2010). Techniques from this tradition, such as role-playing, may be especially helpful.

• Medical/Biomedical
• Environmental/Functional
• Sociopolitical
• Peer Counseling

Models for Working with People Who Have Disabilities

Clients with Specific Disabilities

There are a number of specific disabilities that counselors work with, too many to cover here.
Thus, only four—physical disabilities, intellectual disabilities, ADD/ADHD, and posttraumatic
stress disorder—will be briefly highlighted as examples of specific disabilities counselors
encounter.

PHYSICAL DISABILITIES.  Physical injuries such as spinal cord damage, mild traumatic brain
injury (MTBI), limb loss, or blindness produce a major loss for an individual and consequently
have a tremendous physical and emotional impact (Jones, Young, & Leppma, 2010; Krause &
Anson, 1997). Counseling in such cases may require some combination of occupational, physi-
cal, and cognitive therapies as well as concentration and cooperation on both the client’s and the
family’s part to adjust to the situation.
Livneh and Evans (1984) point out that clients who have physical disabilities go through
12 phases of adjustment that may distinguish them from others: shock, anxiety, bargaining,
denial, mourning, depression, withdrawal, internalized anger, externalized aggression,
acknowledgment, acceptance, and adjustment/adaptation. There are behavioral correlates
that accompany each phase and intervention strategies appropriate for each as well. For example,
the client who has lost a limb is often in a state of shock and disbelief and may be immobilized
and cognitively disorganized initially. Intervention strategies most helpful during this time
include comforting the person (both physically and verbally), listening and attending, offering
support and reassurance, and allowing the person to ventilate feelings (Knittel, 2010). Later
strategies focus on treating the person as a person and not an amputee and encouraging the indi-
vidual to take appropriate risks in life.
In addition to serving as counselors, professionals working with persons who are physi-
cally disabled must be advocates, consultants, and educators. They must confront disabled per-
sons in developing an internal locus of control for their lives. The task is comprehensive and
involves a complex relationship among job functions. Caretakers and support personnel involved
in helping persons with physical disabilities need help themselves in working through the
­recovery process and should be included as much as possible in making evaluations and
­developing plans.
INTELLECTUAL DISABILITIES.  Clients with intellectual disabilities include those who have
mild to severely limited cognitive abilities. In some cases, counselors’ tasks and techniques may
be similar to those employed with adults or adolescents who have physical disabilities (support-
ive counseling and life-planning activities), but young clients with intellectual deficiencies may
require different activities and services. For instance, counselors can help parents of these chil-
dren in working through their feelings about having children with intellectual disabilities. In the
process they help the children as well through promoting positive parental interactions that
encourage maximum development (Huber, 1979).
When working with adolescents or military personnel who have intellectual difficulties
due to head injuries, counselors must address social issues as well as therapeutic activities
(Bergland & Thomas, 1991). As a general rule, increased time and effort in attending to psycho-
social issues are required for working with anyone who has been intellectually impaired, regard-
less of age or the cause of the impairment (Kaplan, 1993).

ADD OR ADHD.  Attention deficit disorder (ADD) and attention deficit/hyperactivity dis-
order (ADHD) are disorders that interfere with learning and day-to-day functioning. These dis-
abilities have a neurological base and begin in childhood, influencing the emotional, social, and
behavioral adjustment of children, with more boys than girls impacted. ADD and ADHD are
found in various forms (e.g., ADHD, which affects between 3% and 5% of school-age children,
has three subtypes: inattentive, hyperactivity-impulsivity, or a combination of the first two
subtypes) (Brown, 2000). Unfortunately, 50% to 80% of children with ADHD continue to have
symptoms into adolescence and some even into adulthood (Wender, 1998).
Difficulties associated with ADHD such as “distractibility, impulsivity, disorganization,
and interpersonal problems … persist and sometimes worsen with age” (Schwiebert, Sealander,
& Dennison, 2002, p. 5). Thus, ADHD can have an impact throughout the life span. Heightened
levels of frustration, anxiety, distress, depression, and diminished self-concepts are other symp-
toms that may happen as a result.
Since ADD and ADHD have become more widely known in recent years, a number of
strategies for working with children and adults who are so impaired have been developed by
clinicians in educational and community settings. For instance, counselors may help students
with ADHD prepare for postsecondary education and vocational entry by giving them cues in
mnemonic form on how to behave in certain situations. One such cue is the mnemonic SLANT,
which may be used to help those who have learning problems focus on classroom lectures
(Mercer, Mercer, & Pullen, 2011). The letters stand for
S = “Sit up straight”
L = “Lean forward”
A = “Activate thinking and Ask questions”
N = “Name key information and Nod your head to validate the teacher/speaker”
T = “Track the teacher or speaker”
Overall, counselors who work with clients with ADD and ADHD need to be aware that
many facets of personality may be shaped by the multiple effects of these disorders. Treatment
may be a long-term process that is multidimensional in nature (Erk, 2000). Interventions for
children or adolescents with ADHD include, but are not limited to, (a) parent counseling and
training, (b) client education, (c) individual and group counseling, and (d) social skills training
(Brown, 2000).
 Medical treatment may also be necessary. Proper medication “often results in increased
attentiveness and decreased impulsivity and overactivity” (Brown, 2000). Stimulant medica-
tions, such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline
(Cylert), are usually the first medications chosen for ADHD. However, not all children who have
ADHD need medications. In addition, if medications are prescribed, they should always be given
first in small dosages. Counselors need to be up-to-date on the latest medications and other treat-
ments for this disability in order to enhance the lives of clients they serve and their families.

PTSD.  Posttraumatic stress disorder or PTSD is “characterized by the reexperiencing of an

extremely traumatic event, usually by way of nightmares and intrusive thoughts of the incident.
In addition, symptoms of increased arousal and avoidance of stimuli associated with the trauma
must be present” (Jones, Young, & Leppma, 2010, p. 373). PTSD is often prevalent in soldiers
returning from a war zone and in such situations is the result of the intense horrors and traumas
such individuals have experienced. However, PTSD is found among all segments of the popula-
tion and is more common among women than men. There are approximately 7 million people in
the United States with PTSD (Shallcross, 2009b).
PTSD is usually treated with counseling and antianxiety or antidepressant medications.
Sometimes eye movement desensitization and reprocessing (EMDR) is used.
Clearly, counselors with clients who have disabilities must be versatile. They must not
only provide services directly but also coordinate services with other professionals and monitor
clients’ progress in gaining independence and self-control. Thus, counselors need skills from an
array of theories and techniques and adaptability in shifting professional roles.

AFFILIATION, CERTIFICATION, AND EDUCATION OF COUNSELORS

WHO WORK WITH PEOPLE WHO HAVE DISABILITIES
Counseling with People Who Have Disabilities
Rehabilitation counseling, a specialty in the counseling profession, is particularly focused on
serving individuals with disabilities (Parker & Patterson, 2012). Those who specialize as counsel-
ors with the disabled must have knowledge of medical terminology as well as helping skills to be
effective. Rehabilitation is defined as the reeducation of individuals with disabilities who have
previously lived independent lives. A related area, habilitation, focuses on educating clients who
have been disabled from early life and have never been self-sufficient. Rehabilitation counseling
is a multidimensional task whose success is dependent on many things. “The rehabilitation coun-
selor is expected to be a competent case manager as well as a skilled therapeutic counselor”
(Cook, Bolton, Bellini, & Neath, 1997, p. 193). The ultimate goals of rehabilitation services are
successful employment, independent living, and community participation (Bolton, 2001).
Many rehabilitation counselors belong to the American Rehabilitation Counselor
Association (ARCA; [Link]/). Before the founding of ARCA, there was a void for a
professional counseling organization within rehabilitation. Soon after World War II, ARCA was
organized as an interest group of the National Vocational Guidance Association (NVGA).
ARCA became a part of the American Counseling Association (then APGA) as the Division of
Rehabilitation Counseling (DRC) in 1958 and as ARCA in 1961.
The Council of Rehabilitation Education (CORE) up until the summer of 2017 tradi-
tionally accredited institutions that offered rehabilitation counseling. However, under an agree-
ment reached between CORE and the Council for Accreditation of Counseling and Related
Educational Programs (CACREP), the counseling profession’s two major accrediting organiza-
tions, in 2015 a plan to merge was reached and in July 2017, CACREP began carrying on the
mission of both organizations as CORE Standards were reformatted to fit into the CACREP
review process. The merger of CORE and CACREP meant all counselors, regardless of the set-
tings in which they practiced, would receive knowledge of disabilities.
Historically, federal legislation has been the impetus through the years in establishing ser-
vices for people who are disabled. For example, in 1920 Congress passed the Vocational
Rehabilitation Act, which was mainly focused on working with physically disabled Americans. In
more recent times, the Americans with Disabilities Act (ADA) of 1990 is another key piece of
legislation. This act helped heighten awareness of the needs of millions of people in the United
States with disabilities and increased national efforts in providing multiple services for people with
mental, behavioral, and physical disabilities. The Individuals with Disabilities Education Act
(IDEA) of 2004 was another important measure, especially in regard to education. IDEA requires
educational institutions to provide a free and appropriate public education (FAPE) for all students
with disabilities. According to the U.S. Department of Education, this act has opened up education
to approximately 12% of students between the ages of 6 and 17 years (Lambie & Milsom, 2010).
Likewise, the Ticket to Work and Work Incentives Improvement Act (WIIA) of 1999 enhanced
the ability of consumers with disabilities to make a choice of service providers between private
nonprofits, state rehabilitation agencies, and private proprietary providers (Kosclulek, 2000).

Counselors Who Work in Rehabilitation

A counselor who works in rehabilitation must be a professional with a clear sense of purpose
(Parker & Patterson, 2012; Wright, 1980, 1987). There are several competing, but not necessarily
mutually exclusive, ideas about what roles and functions such counselors should assume. In the
late 1960s, Muthard and Salomone conducted the first systematic investigation of the work activ-
ities of counselors in rehabilitation, then known as rehabilitation counselors (Bolton & Jaques,
1978). They found eight major activities that characterize the counselor’s role and noted a high
degree of importance attached to affective counseling, vocational counseling, and placement
duties (Muthard & Salomone, 1978). In this survey, rehabilitation counselors reported spending
the majority of their time in counseling and counseling-related activities just as counselors in
other specialties did. The same appears to be true today, although there is more paperwork.
In 1970 the U.S. Labor Department listed 12 major functions of rehabilitation counselors,
which are still relevant for counselors who focus their practices on rehabilitation.
1. Personal counseling.  This function entails working with clients individually from one
or more theoretical models. It plays a vital part in helping clients make complete social and
emotional adjustments to their circumstances.
2. Case finding.  Rehabilitation counselors attempt to make their services known to agen-
cies and potential clients through promotional and educational materials.
3. Eligibility determination.  Rehabilitation counselors determine, through a standard set
of guidelines, whether a potential client meets the criteria for funding.
4. Training.  Primary aspects of training involve identifying client skills and purchasing
educational or training resources to help clients enhance them. In some cases, it is neces-
sary to provide training for clients to make them eligible for employment in a specific area.
5. Provision of restoration.  The counselor arranges for needed devices (e.g., artificial
limbs or wheelchairs) and medical services that will make the client eligible for employ-
ment and increase his or her general independence.
 6. Support services.  These services range from providing medication to offering individ-
ual and group counseling. They help the client develop in personal and interpersonal areas
while receiving training or other services.
7. Job placement.  This function involves directly helping the client find employment.
Activities range from supporting clients who initiate a search for work to helping less
motivated clients prepare to exert more initiative.
8. Planning.  The planning process requires the counselor to include the client as an equal.
The plan they work out together should change the client from a recipient of services to an
initiator of services.
9. Evaluation.  This function is continuous and self-correcting. The counselor combines
information from all aspects of the client’s life to determine needs and priorities.
10. Agency consultation.  The counselor works with agencies and individuals to set up or
coordinate client services, such as job placement or evaluation. Much of the counselor’s
work is done jointly with other professionals.
11. Public relations.  The counselor is an advocate for clients and executes this role by
informing community leaders about the nature and scope of rehabilitation services.
12. Follow-along.  This function involves the counselor’s constant interaction with agencies
and individuals who are serving the client. It also includes maintaining contact with the
clients themselves to ensure steady progress toward rehabilitation.
The incorporation of CORE into CACREP and the new emphasis in all counseling fields
and settings on ability, disability, and rehabilitation is a step forward in the evolution of the pro-
fession. It means that counseling, like most of its related helping professions, is becoming more
united, broad, and focused in working with individuals, groups, families, and society in a com-
prehensive and effective way.

CASE EXAMPLE
George and the Game
George was an energetic rehabilitation counselor. He liked working with people who needed
rehabilitation services. He was exemplary at placing these people in proper educational and job
settings. The problem with George was that he had no follow-through. Although he was inter-
ested in those he helped, he thought that follow-up was a waste of time. As a result, many of his
clients were not as successful as they might have been.
What do you see as the place of follow-up in counseling, especially rehabilitation counsel-
ing? Are there ethical considerations to keep in mind? Is a failure to follow up with a client the
same as abandonment? Why or why not?

Summary and Conclusion

The specialties of counseling in the areas of abuse, adjustments as opposed to dysfunctional behaviors
addiction, and with those who have disabilities are and maladjustment. Prevention programs and treat-
unique and yet interrelated. They emphasize the ment strategies are crucial in working in these three
dynamics and differences behind wellness and areas.
The treatment of abusers, whether it is for maladies. Treatment facilities include those for bo
physical or substance abuse, is an important focus in inpatient and outpatient clients.
counseling. The abuse of individuals (children, sib- Counseling with people who are disabled
lings, spouse/partners, or older adults) is all too similar to abuse and addiction counseling in tha
prevalent and carries with it physical and psycho- focuses on both prevention and the provision
logical scars that have deep and negative conse- treatment services. Counselors who work in this ar
quences for those involved. Abuse of substances, are distinct in their client population and in some
such as alcohol, tobacco, and drugs (whether legal or their terminology and treatment techniques but a
not), has a deleterious impact on individuals, fami- universal in working with all those affected by t
lies, and society in general. When abuse transitions disabilities involved. Counseling that focuses
into addiction, the result is even more devastating. rehabilitation is the specialty that has traditiona
Physiological as well as process addiction carries been tied in with working with people who have d
with it neglect of important human functions and abilities, just as addiction and offender counseling
interactions, and the cost in personal development most associated in working with abusers and tho
and interpersonal fulfillment and enjoyment is who are addicted.
tremendous. Counselors should remember that people w
To work with members of abuse and addiction are abused or who are abusers, addicted, or have d
populations, counselors must focus on prevention abilities are more than the actions or symptoms th
and treatment. Prevention can come through educa- bring them to counseling. The people behind t
tional programs warning of dangers associated with focus of treatment have thoughts, feelings, and nee
these two ways of behaving. Treatment programs, on as well as potentials that counseling can constru
the other hand, focus on interrupting dysfunctional tively address. Empowering these individuals a
actions in a systematic way. They may include indi- the society in which they live to be more producti
vidual counseling; cognitive, behavioral, or spiritu- is crucial. Thus, the emphasis of counseling in the
ally oriented groups such as Alcoholics Anonymous; special areas is the same as counseling otherwise
or family counseling and programs run by profes- to promote wellness and well-being on multip
sionals who have been involved in the same levels.

MyCounselingLab® for Introduction to Counseling

Try the Topic 16 Assignments: Substance Abuse Counseling.