Introduction

When we, as a profession, consider ways to advance psychotherapy, we must begin by striving for nothing less than fair, accessible, and clinically competent services for all populations—especially those who have historically been underserved and underrepresented. One such population that is frequently overlooked and underappreciated on a global realm are persons with disabilities (PWD), who form the largest minority in the country (United States Department of Labor, 2017). In the United States alone, the Centers for Disease Control and Prevention (2019) reported that there are more than 61 million adults with a registered disability. The authors defined the term “disability” as a physical and or mental limitation that impacts one or more major life activities. This statistic equates to one in four U.S. adults, or 26% of our nation’s adult population (CDC, 2019). 

The American Psychological Association’s Guidelines for Assessment of and Intervention With Persons With Disabilities (2012) described the lack of training psychologists receive as it pertains to disability. This is concerning in and of itself given the considerable amount of individuals living with disabilities. Limited training available in serving clients with disabilities further hinders the profession’s ability to advance. For our profession and psychotherapy as a whole to progress and provide the culturally responsive services to which our clients are entitled, the profession and clinicians must engage in a conversation about disability education, concerns, rights, and areas of advocacy. 

Societal Messages

From a young age, children with disabilities hear they are different in various settings (i.e., school, doctors, society). Many professionals continue to operate from the medical model, which emphasizes “fixing” what is considered broken. This can imply that if something cannot be fixed, the person is “broken.” These environmental messages experienced by children with disabilities establish their worldview of themselves and others (Chapel, 2005). Environmental messages do not seize in childhood; they continue throughout the lifespan into adulthood with more complexities as the PWD experiences the world around them. 

PWD deal with challenges and issues within their families, environment, and society. Depending on the family’s understanding of disability and the various identities held, those negative messages can be perpetuated and further oppress the PWD’s abilities and strengths. Families often have a negative understanding of disability based on the information they receive from professionals, which can also be influenced by cultural beliefs. Depending on the limitations of the PWD, families may assume the individual to be incapable. Due to these experiences, an understanding of how to work with clients with disabilities and the systems they navigate is vital to addressing concerns while providing culturally responsive care (Tapia-Fuselier & Ray, 2019). Providing sensitive care begins with understanding the barriers faced by PWD. 

Environmental Barriers

The CDC (2019) describes different types of environmental barriers that exist, thus placing greater hardships on PWDs. These include: 

1. Attitudinal barriers (such as the use of stereotypes, stigma, discrimination)
2. Communication barriers (such as means of communication that are inaccessible to PWD)
3. Physical barriers (such as those that hinder mobility)
4. Policy barriers (lack of familiarity or not adhering to enacted laws and regulations)
5. Programmatic barriers (such as difficulties with the provision of healthcare services and programming)
6. Social barriers (such as unequal employment rates and a lessened likelihood of graduating high school)
7. Transportation barriers (often due to inaccessibility; CDC, 2019).

Wright (1983) provided that the gravity of one’s limitations can be amplified or reduced based on environmental conditions and that we cannot accurately consider concerns pertaining to coping and adjusting to one’s disability without first acknowledging the specific problem(s) within a social and physical environment. While clinicians without disabilities will not be able to truly understand the magnitude of barriers and their effects on persons with a disability, we must empathize and stay with clients in the process of maneuvering through various systems and encourage change on a communal level (Marini et al., 2018).

Psychosocial Attitudes

While perceptions and beliefs about disabilities vary depending on one’s location and country of origin, there are a plethora of reasons as to why disability-based stigma continues to exist across the globe. Values, beliefs, family members, places of worship, education systems, and the media can influence attitudes (Joe & Miller, 1987). In addition, outside factors such as perceptions of physical attractiveness, competencies and abilities, and communication skills can influence us (Gresham, 1982; Longo & Ashmore, 1995; Yuker, 1988). 

We may perceive an increase in comfort to those who are most similar to us based on age, ethnicity, educational attainment, and socioeconomic status (Gosse & Sheppard, 1979; McGuire, 1969; Rabkin, 1972; Sue & Sue, 1999). Such factors, along with previously held beliefs, can influence one’s perception and attitudes toward other individuals—especially those with disabilities. 

Rohwerder (2018) found that disability stigma can often be attributed to misunderstandings and lack of familiarity with causes and types of disabilities, misperceptions about the abilities of persons with disabilities (e.g., not being able to contribute financially or engage in intimacy), and both proposed and enacted policies that do not support persons with disabilities. For example, historically, of the disability categories, persons with physical disabilities have been found to be least stigmatized, followed by individuals with cognitive disabilities, individuals with intellectual disabilities, and individuals with mental illnesses (Antonak, 1980; Charlton, 1998; Tringo, 1970). While invisible disabilities are becoming more accepted by society through mental health advocacy efforts, they continue to remain highly stigmatized due to misperceptions about invisible disabilities and what they entail. Many of the negative attitudes toward disability can ultimately be attributed to lack of contact and positive exposure to persons with disabilities, as well as a lack of knowledge base and education about disabilities. 

While Olkin (1999) explained that a first impression, appearance, and the severity of one’s disability could, in fact, influence attitudes, initial negative attitudes lessen upon familiarity with the individual and an understanding that disability is but one trait. Increasing contact, familiarity, and accurate learning opportunities about disabilities (that are not based on media portrayals) can, and have, been shown to result in more positive attitudes toward PWDs and disabilities as a whole.  

Internalized Biases

Before exploring the ways to improve serving PWD in psychotherapy, we must address internalized biases about PWD. Take a moment to consider the meaning placed on the word “disability.” Often, people create an image in their mind of what they see when they read the term “disability.” The image that appears may be representative of what society depicts as someone with a disability or based on personal experience. Examining the thoughts and feelings that we associate with the image are important to further work through biases about PWD. 

Individuals without disabilities tend to concentrate on what they perceive to be adverse aspects of having a disability (Smart, 2009). If not checked, can influence clinicians’ work with clients and their families (Hartley, 2012). Therefore, therapists must strive to increase knowledge and competencies when working with the disability community. 

Exploring self as the therapist is essential to address necessary conversations with clients with disabilities regarding their disability and intersecting identities. If internalized biases are not explored or addressed, clients with disabilities may encounter difficult experiences with a therapist, which could further oppress their disability identity. By working through misconceptions of PWD, therapists have more internal resources to inquire and manage aspects of the client’s life that may be difficult or uncomfortable to discuss (i.e., sex, relationships, barriers, life plan, etc.). Applying the information presented will lead to more thoughtful and responsive care for PWD. 

Recommendations

• The use of expressive arts provides an opportunity to bridge PWD’s experience with a disability. 
• Participate in psychology-focused and interdisciplinary-based training focused on serving clients with disabilities.
• Update the intake paperwork process to be more accessible (i.e., online platform, large print, simple language, etc.).
• Ensure there is access to the clinic entrance, waiting room, and therapy room (signs, movable furniture, adjustable lighting) for mobility aids.
• Provide referrals and resources for axillary services to reduce healthcare barriers.
• Have access to interpreters (in-person or video relay), translation services for linguistically diverse and Deaf/deaf or hard of hearing clients.
• Consider cultural perspectives from family/partner(s) toward PWD disability.
• Apply an intersectionality framework when working with this population as all aspects of identity, including disability status, need to be considered.
• Identify ways to engage in advocacy (through legislative votes, conversations about accessibility, etc.).
• Utilize the APA’s Guidelines For Assessment of and Intervention With Persons With Disabilities and ARCA Disability-Related Counseling Competencies to ensure culturally responsive care.

Conclusion

Marini and Stebnicki (2018) described the extensive literature regarding the impact perceived adverse conditions can have on an individual, which is why clinicians must be willing to address social justice concerns hindering client development and growth within various realms of their lives. It is not enough for therapists to help clients adjust to living in a non-disabled world, as our work will then be left “unfinished or incomplete” (Marini & Stebnicki, 2018). As our profession continues to serve marginalized and underserved populations, such as persons with disabilities, increased education, training, and advocacy must remain at the forefront of our work.

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Daniel Balva