Diversity Issues in Counseling

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DISABILITY-AFFIRMATIVE THERAPY A Beginners Guide DR. RHODA OLKIN Hi, I'm Professor Rhoda Olkin, the author of "What Psychotherapists Should Know About Disability," in which I discuss what I call Disability-Affirmative Therapy. 00:15 (1999). NY: GUILFORD PRESS DR. RHODA OLKIN This training video is aimed at therapists who might not have much experience in working with clients with disabilities, and those who would like to increase their skills in this area. The video is going to show three examples of initial sessions with clients with disabilities. Two of the clients have the same disability, cerebral palsy, but very different levels of impairment. The third client is blind and uses a guide dog. These client interactions show some critical points in an initial session, such as introductions, asking about the disability, and understanding how disability relates to the presenting problem. Disability-Affirmative Therapy, the first session. Why focus on the first session? Because events and interaction between a therapist and a client that occur in the first session can reverberate throughout the therapy. Early mistakes can interfere with and even prevent a therapeutic relationship from ever getting off the ground. We'll see this in one of the examples. Imagine a typical initial session with a new client. Several things are typical in a new session. Let's consider five typical events of a first session. One, the client opens the door to the waiting room. Two, the therapist goes out to meet the client, and they shake hands. Three, they go into the therapy room, where there are a choice of seats. Four, there may be an intake, HIPAA or consent form to fill out. Five, therapy often begins with an open-ended question, such as, "What brings you here today?" These are a few of the initial events that happen very quickly in a first session in the first few minutes with a new client. However, for the client with a disability each of these events may impose barriers. Let's look at them from a disability perspective. As we do, keep in mind an important point. It's not that there is a right or wrong way to do each of these things; there are many right ways, and many wrong ways, but what makes them right or wrong is not some list of guidelines, but rather how they are perceived by a particular client. What makes something "right" or "wrong" is how it works or doesn't work for that client. The client opens the door to the waiting room. How can something so seemingly simple be complicated by disability? Let's take some examples. For a woman with multiple sclerosis with limited hand strength, opening a door may be difficult. If the therapist leaves the client to open it herself, the client may think the therapist is uncaring and feel resentful. If the therapist goes to open the door the client may feel patronized. Again, we see that the issue is not "Should I open the door or shouldn't I open the door?" The issue is that the therapist must be aware of how opening a door or not opening a door has different meaning for people with disabilities than people without disabilities, and for one person with a disability versus another person with a disability. Let's continue with our example. The therapist goes out to greet the client and they shake hands. Well, this is interesting. It is not normative in the disability community to shake hands,

because for us shaking hands can be problematic. A person with a visual impairment may not see your extended hand, a person with cerebral palsy may not have hand coordination, a person on crutches may not have a free hand, and a person with arthritis may, may experience pain upon shaking hands. So within the disability community we might not shake hands. But some clients with disabilities may think that your not shaking their hand is a sign that you think they are "untouchable" because of the disability. This is a common reaction that people with disabilities encounter. Again we see a simple act of, such as shaking hands takes on different meanings for people with disabilities. And again I want to stress that there is no right or wrong way, no absolutes such as always shake hands or never shake hands, but rather there needs to be an awareness of how shaking hands carries meaning about disability sensitivity to the client. In a similar way, you will be making choices as the session starts. These choices might include whether to ask a man in a wheelchair whether he would like to transfer to a seat, to offer a large print copy of your intake form, to offer to read material out loud. Each of these acts and how you do them conveys messages to the client about your comfort level with people with disabilities. Like other minority clients, clients with disabilities may be very sensitive to cues about the therapist's reaction to disability. Disability-Affirmative Therapy, talking about disability. Many people, not just clinicians, are reluctant to bring up disability. We've been taught that it's impolite. But of course therapists bring up many topics that are not typical of casual conversation, such as sexual abuse, alcohol or drug abuse, suicide. And often we find that clients are relieved when we've raised these topics, and by talking about them therapists demonstrate that therapy is a place where the conversation is different. Yet even forthright therapists may feel reluctant to bring up disability. This is true for several reasons. Quite simply they don't have any experience talking about disability. They may feel uncomfortable with disability, and be afraid to say something for fear that it will show their discomfort. They wish not to offend the client by making the disability more salient than it already is. They worry about being politically correct, and don't know what language to use and worry about offending the client. But whatever the reason for the discomfort, the therapist will need to become much more at ease talking about disability. If the therapist remains uncomfortable, it is likely that this discomfort will be displayed to the client in subtle yet perceptible ways. Remember, clients with disabilities are used to subtle cues about how people respond to their disability. The therapist who is at ease about disability will help the client to feel safe to explore in therapy. Let's look at examples of three different clients in the first session. In this first example, the therapist goes through her usual intake procedures, asking all of the routine questions. Initial intake: Nicole and Alette 07:20 [sil.] NICOLE GALBERTH-AVILES Hi. 07:25 ALETTE COBLE-TEMPLE Hi.

NICOLE GALBERTH-AVILES I'm Nicole. ALETTE COBLE-TEMPLE Hi, nice to meet you. 07:30 NICOLE GALBERTH-AVILES Come on in. ALETTE COBLE-TEMPLE Okay. NICOLE GALBERTH-AVILES Okay. Well, did you have any problems getting here? 07:35 ALETTE COBLE-TEMPLE No. It was very easy. 07:40 NICOLE GALBERTH-AVILES Okay, if you could just tell me I have an intake form uhm, ah, that I usually have people fill out. Would you like to fill it out or would you like me to assist you? 07:50 ALETTE COBLE-TEMPLE Actually, if you could assist me that would be great. 07:55 NICOLE GALBERTH-AVILES Okay, well for starters if you could just tell me what brought you here today? 08:00 ALETTE COBLE-TEMPLE Well, I'm a new mom and just a little overwhelmed with all this scheduling... (crosstalk) 08:15 NICOLE GALBERTH-AVILES Hmm. ALETTE COBLE-TEMPLE and hiring people to help me help with the baby and really setting limits with the childcare provider. So that they know I'm the mother and not them. 08:45 NICOLE GALBERTH-AVILES Okay. You said something about overwhelmed with the scheduling and hiring for assistance and then you said something prior to uhm, "so that they know that you're the mom and they're assisting you. What was that? I'm sorry I didn't understand you. (crosstalk) 09:00 ALETTE COBLE-TEMPLE Setting the appropriate boundaries. 09:05 NICOLE GALBERTH-AVILES Okay, we'll go back to that. I just want to go ahead and finish filling out the form. Have you had previous therapy before? 09:15 ALETTE COBLE-TEMPLE Yeah. NICOLE GALBERTH-AVILES And when was that? 09:20 ALETTE COBLE-TEMPLE I believe 1989.

09:25 NICOLE GALBERTH-AVILES So it's been awhile. ALETTE COBLE-TEMPLE Yeah. NICOLE GALBERTH-AVILES Uhm, have you had any anxiety or nervousness? 09:30 ALETTE COBLE-TEMPLE A little. 09:35 NICOLE GALBERTH-AVILES Depression? ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Any problems sleeping other than the usual mother problems? 09:40 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Okay. Intrusive or obsessive thoughts? 09:50 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Compulsive behaviors? Do you know what those are? ALETTE COBLE-TEMPLE Yeah. (crosstalk) 09:55 NICOLE GALBERTH-AVILES Okay. ALETTE COBLE-TEMPLE No. (crosstalk) NICOLE GALBERTH-AVILES No. Okay. Okay. How about confusion or memory difficulties? 10:00 ALETTE COBLE-TEMPLE No. 10:05 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Family problem? 10:10 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Sexual problems? ALETTE COBLE-TEMPLE No. 10:15 NICOLE GALBERTH-AVILES How about appetite or eating problems? 10:20 ALETTE COBLE-TEMPLE Just not getting enough time to eat. (laugh) 10:25 NICOLE GALBERTH-AVILES Okay. How about alcohol use? ALETTE COBLE-TEMPLE No.

NICOLE GALBERTH-AVILES Substance abuse? 10:30 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Auditory or visual hallucinations? 10:35 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Anything I've previously mentioned in this list have you had in the past? ALETTE COBLE-TEMPLE Hmm, hmm, depression... (crosstalk) 10:40 NICOLE GALBERTH-AVILES Depression in your past? ALETTE COBLE-TEMPLE ...in the past. Yeah. 10:45 NICOLE GALBERTH-AVILES And when was that? ALETTE COBLE-TEMPLE '88? '89? 10:50 NICOLE GALBERTH-AVILES Is that what brought you into therapy in 1989? 10:55 ALETTE COBLE-TEMPLE Yeah. NICOLE GALBERTH-AVILES Okay. Okay, did you take any medications or anything for that depression? 11:00 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Okay. Any history of family violence? 11:05 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Uhm, family sexual abuse? 11:10 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Suicidal thoughts? ALETTE COBLE-TEMPLE No. 11:15 NICOLE GALBERTH-AVILES Suicidal behaviors or attempts? ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Homicidal thoughts or behaviors? 11:20 ALETTE COBLE-TEMPLE No.

NICOLE GALBERTH-AVILES Okay. Have you been involved in a serious accident in the past two years? 11:25 ALETTE COBLE-TEMPLE No. NICOLE GALBERTH-AVILES Okay. Are you in currently, are you currently involved in any litigation? 11:30 ALETTE COBLE-TEMPLE Yes! NICOLE GALBERTH-AVILES Yes? Okay. We'll come back to that. 11:35 NICOLE GALBERTH-AVILES Have you recently experienced a significant loss? ALETTE COBLE-TEMPLE Yeah. 11:40 NICOLE GALBERTH-AVILES Yes. Okay. Uhm, who? ALETTE COBLE-TEMPLE Uhm, a dear family friend passed away a week ago today. 11:50 NICOLE GALBERTH-AVILES Oh, I'm sorry. Was it something that was expected or, or something that was not expected? 11:55 ALETTE COBLE-TEMPLE Hmm, very unexpected. 12:00 NICOLE GALBERTH-AVILES Now that we've covered some of the basic intake questions, and have a little bit of history, why don't you tell me why you're here specifically today? So you're a new mom? How old? 12:10 ALETTE COBLE-TEMPLE Eleven months. NICOLE GALBERTH-AVILES Are you a single mom or are you married or do you have a partner? 12:15 ALETTE COBLE-TEMPLE Married mom. 12:20 NICOLE GALBERTH-AVILES Okay. And how long have you been married? 12:25 ALETTE COBLE-TEMPLE Almost five years. NICOLE GALBERTH-AVILES Congratulations! Okay, now you said you were overwhelmed with all of the scheduling and hiring for assistants. Is that primarily... (crosstalk) 12:35 ALETTE COBLE-TEMPLE Hmm. NICOLE GALBERTH-AVILES ...what you're doing? Or are you doing it as a couple? (crosstalk)

ALETTE COBLE-TEMPLE Uh hmm. No, I do all the hiring, (crosstalk) 12:40 NICOLE GALBERTH-AVILES Okay. ALETTE COBLE-TEMPLE training, supervising, firing, et cetera. Plus I have two jobs. Ah, (crosstalk) 13:00 NICOLE GALBERTH-AVILES What(ph)? ALETTE COBLE-TEMPLE I'm working full-time on top of that job. I work with teenagers in residential treatment. 13:15 NICOLE GALBERTH-AVILES So you're saying that you have to do the hiring, the training, the supervising and the firing of assistants, plus you have two jobs and you work full-time. (crosstalk) 13:25 ALETTE COBLE-TEMPLE Uh hmm. NICOLE GALBERTH-AVILES Well, that seems very overwhelming. Uhm, so what would you like to work on specifically here? What are your goals to work on here? 13:35 ALETTE COBLE-TEMPLE Well, I recently had an experience where I had to fire someone because they weren't doing, well, two reasons. She wasn't doing her job the right way and she broke confidentiality, which I take very seriously. I have since hired new people... (crosstalk) 14:20 NICOLE GALBERTH-AVILES Uh hmm. ALETTE COBLE-TEMPLE ...and my problem with that when I hired the first batch of assistants, I was on maternity leave so I could. (crosstalk) 14:40 NICOLE GALBERTH-AVILES I'm sorry, wait a minute, could you go back, I didn't understand. ALETTE COBLE-TEMPLE Ah, sure. I was on maternity... (crosstalk) 14:45 NICOLE GALBERTH-AVILES Oh! ALETTE COBLE-TEMPLE ...leave... (crosstalk) NICOLE GALBERTH-AVILES Uh hmm. 14:50 ALETTE COBLE-TEMPLE ...so I was home full-time... (crosstalk) NICOLE GALBERTH-AVILES Uh hmm. ALETTE COBLE-TEMPLE and I could really train the individuals. Now I'm back to work and that my ability to train them is impossible. (crosstalk) 15:15 NICOLE GALBERTH-AVILES Uh hmm.

ALETTE COBLE-TEMPLE And nobody thinks that like, when I am home and the baby starts crying. I don't want them to engage with the child . I want them to bring my daughter to me. Ah, basically, they need to be my hands but, and let me take care of her emotional needs. (crosstalk) 16:00 NICOLE GALBERTH-AVILES Oh, then(ph)p. (crosstalk) ALETTE COBLE-TEMPLE Just, so, it's just frustrating that they're not listening to my requests and I'm not sure it's how I'm telling them. I write it down but it's not getting across and I think part of it is you know when I'm not home... (crosstalk) 16:35 NICOLE GALBERTH-AVILES Uh hmm. ALETTE COBLE-TEMPLE they do have to attend to her needs. So when I come home, they have to switch roles too. 16:55 NICOLE GALBERTH-AVILES Uh-huh. ALETTE COBLE-TEMPLE Does that make sense? 17:00 NICOLE GALBERTH-AVILES I believe so. So, when you're not at home, when you're at work, they're supposed to take care of the child but when you're home, you want them to be your hands and you want them to bring the child for, to you for, and you can emotionally comfort your child . 17:10 ALETTE COBLE-TEMPLE Exactly. 17:15 NICOLE GALBERTH-AVILES Okay. And that's not happening? ALETTE COBLE-TEMPLE Not without having to constantly remind them. 17:25 NICOLE GALBERTH-AVILES Uh-huh. ALETTE COBLE-TEMPLE And just so overwhelmed with everything else, that after two months they should know the routine. 17:40 NICOLE GALBERTH-AVILES Oh, it's been two months. ALETTE COBLE-TEMPLE Yeah. NICOLE GALBERTH-AVILES Oh, I see. 17:45 ALETTE COBLE-TEMPLE Yeah. NICOLE GALBERTH-AVILES So, you mentioned that you're having problems with certain assistants. How many assistants do you have? 17:50

ALETTE COBLE-TEMPLE I currently have five assistants. 17:55 NICOLE GALBERTH-AVILES Five. What do you think about the idea of maybe having an assistant or some of your assistants actually come in with you? 18:05 ALETTE COBLE-TEMPLE You know that's a definite possibility. It might help to have a third party perspective. 18:15 NICOLE GALBERTH-AVILES Okay, why don't you give that some thought if that would be helpful for you. 18:20 ALETTE COBLE-TEMPLE Uh hmm. DISABILITY-AFFIRMATIVE THERAPY Dr. Rhoda Olkin DR. RHODA OLKIN Let's consider what worked between this therapist and this client. First, the therapist gets right down to business, seemingly finding the disability fairly inconsequential for the task at hand. This conveys that the disability is not so prominent that it will overshadow other tasks. Second, the therapist offers a choice of two accommodations, asking whether Alette would like to fill out the intake form herself or have the therapist assist her. This keeps control with the client who is most knowledgeable about her own needs, and conveys sensitivity on the part of the therapist. Third, as the client begins to tell her story of why she's coming to therapy the speech involvement in her cerebral palsy sometimes makes it hard to understand her. The therapist seems natural and at ease in asking the client to repeat something she didn't catch. This small act is enormously important, as it communicates to the client that the therapist is listening carefully and wants to understand her, both literally and figuratively. Fourth, by asking all the routine questions, without deciding to omit any, the therapist doesn't make any preconceived notions about people with disabilities and doesn't allow that to distort the intake process. And in fact we learn that Alette, a woman with a significant disability, has a job, is married, and has a baby . When Alette shares the reason for seeking therapy, it turns out that it is quite disability related. She is having trouble getting the kind of assistance that she'd like in the home. When she's at work her assistants interact with the baby , comfort, soothe and feed the baby but when Alette is home, she would like to be quite naturally in the mother role and she needs the assistants to bring the baby to her for these activities. The therapist conveys flexibility in raising the question of whether it would be helpful to have any of the assistants join Alette in the therapy. But she leaves this up to the client, again, respecting her choice. Let's look at how the session ends.