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1 COUNSELORS KNOWLEDGE, SKILLS, AND AT TITUDES REGARDING INDIVIDUALS WITH DISABILITIES: EXAMINING CONTACT AND A TTITUDES AS PREDICTO RS OF KNOWLEDGE AND SKILLS By ALFRED GRANT MCDOUGALL A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008
2 2008 Alfred Grant McDougall
3 To my mother, Eloise Adams McDougall, my greatest teacher
4 ACKNOWLEDGMENTS I would like to thank the m emb ers of my committee, Dr. Pete r A.D. Sherrard, Dr. Mary Ellen Young, and Dr. John C. Rosenbek. Prior to beginning my doctoral studies, I was advised by many to place extreme importance on the selection of committee members. I was frequently told that this choice would be a primary factor as to how, or if, I made it through the dissertation process. My committee members guidance and i nput were invaluable, a nd their professionalism and motivation were consiste nt from beginning to end. I would also like to thank my committee chair, Dr. Linda R. Shaw. Truthfully, more than once I questioned my decision to pursue this degree. She served not only as a teacher, colleague, and motivator, but also as a role model for my self and many others. Without her guidance, navigating through such academic terrain would have seemed impossible. Space does not permit me to name the numerous friends and colleagues that helped along the way. However, I would be remiss without acknowledging Dr. Robert P. Hosford, Dr. Paula S. Lovett, and Dr. Theodore R. DeRoache. Dr. Hosford and Dr. Lovett were perhaps most instrumental in igniting the spark of my academic pursuits. And throughout the years, each has embodied the role of mentor Dr. DeRoache was, more than anything else, a sounding board for my frequent complaints and struggles. His good humor and insight were medicinal. I would also like to thank my two sons, Sam and Drew. Although their age sometimes prevented them from understandi ng my absence, their tolerance was remarkable. Their presence throughout this process never let me lose perspe ctive on whats really important. Finally, and certainly most of all, I thank my wife, Michele. Her patience, support, encouragement, and love never faltered. She was, without question, the sing le most influential factor in the completion of this study.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 ABSTRACT.....................................................................................................................................8 CHAP TER 1 INTRODUCTION..................................................................................................................10 Statement of the Problem....................................................................................................... .10 Rationale for the Study........................................................................................................ ...11 Significance of the Study........................................................................................................17 Definition of Terms................................................................................................................17 Disability..................................................................................................................... ....17 Licensed Mental Health Counselor................................................................................. 19 Contact.............................................................................................................................20 Research Questions and Hypotheses...................................................................................... 20 Research Question #1...................................................................................................... 20 Hypothesis #1.................................................................................................................. 20 Research Question #2...................................................................................................... 21 Hypothesis #2.................................................................................................................. 21 Research Question #3...................................................................................................... 21 Hypothesis #3.................................................................................................................. 21 2 LITERATURE REVIEW.......................................................................................................22 Demographics of Disability.................................................................................................... 22 History of Mental Health Counseling.....................................................................................25 Counselor Preparation, Training, and Continuing Education .................................................27 Counseling Needs Among Persons with Disabilities............................................................. 29 Models of Disability...............................................................................................................32 Psychosocial Adjustment to Disability................................................................................... 38 Practical Issues of Disability................................................................................................. .45 Health Maintenance Issues..................................................................................................... 48 Social Reactions......................................................................................................................50 Countertransference................................................................................................................52 Legal and Ethical Issues....................................................................................................... ..54 Self Awareness/Beliefs/Attitudes Toward s Indiv iduals with Disabilities.............................. 57 LMHCs Level of Knowledge Regarding Disability.............................................................. 63 LMHCs Level of Skill Regarding Disability........................................................................ 64 Summary.................................................................................................................................65
6 3 METHODOLOGY................................................................................................................. 67 Study Design................................................................................................................... ........67 Selection of Participants...................................................................................................... ...68 Instruments.................................................................................................................... .........69 Contact with Disabled Person Scale................................................................................ 69 Counseling Clients With Disa bilities Survey (CCDS) .................................................... 70 Demographic Questionnaire............................................................................................ 71 4 RESULTS...............................................................................................................................72 Sample Characteristics............................................................................................................72 Descriptive and Preliminary Analyses.................................................................................... 73 Measurement Reliability................................................................................................. 73 Hypothesis 1................................................................................................................... .74 Hypothesis 2................................................................................................................... .74 Correlational Analyses.................................................................................................... 75 Regression Analyses........................................................................................................ 75 Hypothesis 3................................................................................................................... .76 Summary.................................................................................................................................77 5 DISCUSSION.........................................................................................................................81 Summary of Findings............................................................................................................ .81 Research Question #1 Discussion...........................................................................................82 Research Question #2 Discussion...........................................................................................82 Research Question #3 Discussion...........................................................................................84 Limitations of the Study....................................................................................................... ..85 Recommendations for Future Research..................................................................................87 Conclusion..............................................................................................................................88 APPENDIX A EMAIL COVER LETTER.....................................................................................................90 B INFORMED CONSENT........................................................................................................91 C CONTACT WITH DISABL ED PERSONS SCALE .............................................................92 D COUNSELING CLIENTS WITH DISABILITIES SURVEY ..............................................95 E DEMOGRAPHIC INFORMATION.................................................................................... 101 LIST OF REFERENCES.............................................................................................................102 BIOGRAPHICAL SKETCH.......................................................................................................117
7 LIST OF TABLES Table page 4-1 Demographic Variables..........................................................................................................79 4-2 Paired Samples T-Tests for Knowle dge, Skills, and Self -Awareness Subscales................... 80 4-3 Measurement Reliabilities for the CCDS and CDP................................................................ 80 4-4 Pearson Product Moment Correlations Matrix.......................................................................80
8 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy COUNSELORS KNOWLEDGE, SKILLS, AND ATTITUDES REGARDING INDIVIDUALS WITH DISABILITIES: EXAMINING CONTACT AND ATTITUDES AS PREDICTORS OF KNOWLEDGE AND SKILLS By Alfred Grant McDougall May 2008 Chair: Linda R. Shaw Major: Rehabilitation Science The purpose of this study was to examine th e amount of contact licensed mental health counselors (LMHCs) in Florida have with individuals with physical disabilities u tilizing the Contact with Disabled Person Scale (CDP). LMHCs also completed the Counseling Clients with Disabilities Survey (CCDS) in which they de scribed their Self-Awareness/Beliefs/Attitudes, perceived Knowledge, and perceived Skills when tr eating individuals with physical disabilities. Furthermore, this study investigated the amount of contact LMHCs have with individuals with physical disabilities as a predictor of their pe rceived Knowledge and perceived Skills. Lastly, the study examined LMHCs Self-Awareness/Beliefs/A ttitudes toward disability as predictors of their perceived Knowledge and perceived Skills. One hundred, ninety-nine LMHCs participated in the study. LMHCs reported moderate amounts of contact with individu als with physical disabilities, suggesting the possibility that clinicians are interacting with this population on a regular basis. LMHCs reported higher levels of perceived Knowledge about disabi lity than perceived Skills. SelfAwareness/Beliefs/Attitudes regardi ng physical disabilities had the lowest average score of the three scales. Counselors with higher levels of Self-Awareness/Beliefs/Attitudes, as well as
9 higher levels of reported contact wi th individuals with physical disa bilities, had higher levels of perceived Knowledge and perceived Skills. Results from this study support the assumpti on that LMHCs are trea ting individuals with physical disabilities. Findings al so support the possibility that additional training and education may be needed to improve LMHCs Self-Aware ness/Beliefs/Attitudes, Knowledge, and Skills regarding the treatment of individua ls with physical disabilities.
10 CHAPTER 1 INTRODUCTION Individuals with disabilities and physical im pairments are w oven into the fabric of our general population and have beco me one of the largest minority groups in the United States (Hunt & Hunt, 2004). Based largely on the aging of the population, demographic data indicate this minority population will continue to gr ow and place increasing demands on healthcare providers (Waldrop & Stern, 2003). Licensed Mental Health Counselors (LMHCs) provide counseling and psychotherapeutic services to ev ery segment of the population. Because of the diversity of individuals they treat, LMHCs are re quired to participate in educational and training programs that provide exposure to and experi ence in multicultural, minority, and special populations. However, the literature reflects concerns regarding a lack of specialized training that mental health providers re ceive in preparation for providing services to individuals with disabilities. (Allison, Echemendia, Crawfo rd & Robinson, 1996, Huitt & Elston, 1991, Olkin, 1999, Strike, 2002). Statement of the Problem To date, there have been few studies and littl e research regarding m e ntal health counseling for persons with disabilities. The majority of the existing research has focused on the impact or influence of the disability itself as the presen ting problem in counseling (Linton, 1998). Further, the mental health professionals studied in the lit erature pertaining to individuals with disabilities have typically been psychologist s, psychiatrists, or rehabi litation counselors (Atkinson & Hackett, 1998; Brodwin, Orange, & Brodwin, 1994; Hayes, Potter, & Hardin, 1995). A review of literature for this study found no research that specifically examined LM HCs' contact with, or treatment of, individuals with disabilities.
11 The number of LMHCs that prov ide services to people with disabilities is unknown. The unique treatment needs for this minority population have been well documented in both medical and psychological literature (Coulehan, Sc hulberg, & Block, 1990; Diamond, 1998; Keitner, Ryan & Miller, 1991; Olkin, 1999; Turner & Mc Lean, 1989; White, Marans, & Krengel, 1998). Yet, research has also shown that generalist be havioral healthcare workers have limited training and education pertaining to this minority population (Brems, 2001; Brodwin et al., 1994; Strike, 2001; Renard, 2001; Rosenau, 2000). From professi onal, legal, and ethi cal standpoints, it is imperative that greater knowledge and understa nding be obtained regarding LMHCs contact with and treatment of clients with disabiliti es. Without such data it is unknown whether additional LMHC training addressing c lients with disabilities is warranted. Rationale for the Study The trad itional types of services provided to individuals with disabilities include special education, medical intervention, vocational as sistance, or counseli ng related to acute psychological adjustment to the di sability (Linton, 1998). Most often, the focus of mental health interventions has been constricted to the acute adjustment and initial acceptance of disability (Olkin, 1999). It is as if persons with disabi lities were viewed as only having disability-focused problems (Renard, 2001, p. 66). However, due to changes in healthcare, political and social sectors, and the movement towards inclusion, LM HCs may be called upon to assist individuals with disabilities with a broader array of mental health concerns. These concerns may include personal growth and enhancement, depression, mari tal or familial issues and other presenting problems that may not be associated with the disa bility itself. Individuals with disabilities may have special needs or cultural issues but should also be expect ed to have needs and issues consistent with the general population. Peopl e with disabilities are likely to request psychotherapy for issues that parallel those prompting non-disabled persons to seek professional
12 help (Leigh, Powers, Vash, & Nettles, 2004). Insu fficient training or edu cation pertaining to the provision of services to individua ls with disabilities might resu lt in the LMHC being unprepared to provide appropria te interventions. Specialists in rehabilitation such as re habilitation psychologists and rehabilitation counselors have traditionally provided mental health services to individuals with disabilities (Olkin & Pledger, 2003). Yet, with the growing trend toward service provision in integrated settings, it is incorrect to assume that only rehabilitation counselors or rehabilitation psychologists will treat this population. It has also been shown that many rehabilitation providers employed in case manager roles refer out for mental health counseling services (Leahy, Chan, & Saunders, 2003; Leahy, Szymanski, & Linkowski, 1993). In this study, individuals with disabilities are considered to be a separate and distinct minority group. The theoretical framework of multicultural counse ling has expanded well beyond racial and ethnic minority groups to encompa ss dimensions such as age, gender, religion, sexual orientation, and disability (Strike, 2001). Multiculturalism and diversity, by whatever name, are currently hot and important topics fo r mental health professionals (Pistole, 2004, p. 39). However, there is a surprising lack of rese arch and data regarding mental health counselors and their exposure to one of the largest of all minority groups individuals with disabilities. It may be appropriate to que stion why LMHCs should need to be prepared to treat individuals with disabilities when there are other specia lizations within the counseling arena that may be better equipped to serve this population (i .e. rehabilitation counse lors or rehabilitation psychologists). There are both ethical and practical reasons that LMHCs should not rely on others to address the mental hea lth needs of individuals with disa bilities. Since the 1960s, there has been a general trend in our society towards inclusion and integration of individuals with
13 disabilities into the general population (Shapiro, 1994). Move ments such as civil rights, consumerism, and de-institutionalization have contributed to greater independence, empowerment, and mainstreaming of individuals with disabilities. Beginning in the late 1960s and early 1970s, indivi duals with disabilities joined together to protest their exclusion from society's mainst ream and to demand more humane, non-medial attention from service delivery systems (Shapir o, 1994). Much of this movement modeled or was concurrent with the civil ri ghts movement led by African-Americans that began in the early 1960s. African-Americans fought the injustice of being to ld where they could sit on a bus. The individual with a disability fought the reality of not being able to use the bus at all. Consumerism added a new dimension to the disa bility rights movement. Individuals with disabilities argued that they were consumers firs t and patients last. They began a fight for the right of autonomy, including deciding for themselv es what services, products, or treatment they wished to purchase or receive. Legislati on like the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 (ADA), and the Workforce Investment Act of 1998 emphasized inclusion of individuals with disabilities and created environm ents where mainstreaming and consumer choice were commonplace (Gilbri de, 2000; Linton, 1998; Shapiro, 1994). The ADA, which will be discussed in greater de tail in the following ch apter, set the stage for widespread, mandatory integration. The purpose of the Act is to ensure that individuals with disabilities have access to public f acilities and services and to fac ilitate equality between such individuals and the general public. The results have been evident in academic settings, public transportation, media, corporate policy, and virtually every aspect of public life in the United States. Our current environment does not require that an individual with a disability go to a special movie theater, restaura nt, bank, or doctor. It therefor e would seem inappropriate to
14 assume that an individual with a disability w ould need to go to a special mental health counselor. However, the counselor that treats the individual with a disability should possess adequate knowledge and understanding of this sector of our population. The importance of competence when working with individuals with disabilities is evident when approaching the issue from a theoretical pe rspective. The current theoretical model of disability adopted by the World Health Organizati on incorporates the concep t of disability from a social context (World Health Organization, 2001) That is, disability involves the interaction between individuals with disabilities and their en vironments. Therefore, disability may actually be caused or perpetuated by societys inability or unwillingness to accommodate people with impairments. The condition itself may not be as debilitating as the social environment within which the individual lives. It is imperative that LMHCs possess the competence to set LMHCs apart from the general populati on so that they are not guilty of perpetuating or creating an environment of disempowerment or disability. Changes in the healthcare environment will continue to provide additional opportunities for LMHCs to treat a growing diversity of clie nts. Managed care organizations (MCO) now dominate the landscape of health insurance. MCOs typically offer packages or plans to consumers that include some form of mental he alth treatment (Davis & Freeman, 1996). MCOs have become the primary driving force in toda y's mental health delivery system (Palmo, 1999, p. 217). Because of reduced fees compared to those of many doctorate level mental health professionals, MCOs may view LMHCs as viable, cost saving alternatives (Palmo, 1999). Increasingly, LMHCs are becoming providers on MCO plans, which will increase exposure to a greater diversity of clients. As the provision of care moves to a more integrated model of service, LMHCs will also be working in more diverse settings in the future. Typical
15 employment settings for LMHCs will include a wide range of practice settings and populations (Messina, 1999). As changes in public policy and perceptions oc cur, individuals with disabilities will be afforded greater opportunities to obtain behavioral healthcare, including th e services of LMHCs. Gaining knowledge regarding aspects of LMHCs e xposure to people with di sabilities will assist the profession in understanding th e strengths and possible shortc omings of treatments provided to this population. The rationale for this study is also supported fr om a legal perspective. During the past fifty years, there has been a consid erable amount of state and fede ral legislation passed that has attempted to address discrimination against mi nority populations (Shapiro, 1994). As mentioned earlier, the ADA was created to pr event the discrimination of indi viduals with disabilities. Because LMHCs provide a public service, they are required by the ADA to do so in a manner that is both accessible and non-discri minatory. It is important to understand the extent to which services are provided to persons with disabilities, as well as the level of competence of the LMHC providing those services. Without such data, the profession may be operating in the dark and unaware of possible legal implications. Finally, reasons for this study may be derive d from an ethical standpoint. All LMHCs adhere to some code of professi onal ethics, and in states without licensure, professional codes of ethics are used exclusively to govern counselors actions. Within these codes, there are specific rules governing multicultural issu es and associated appropriate counseling practices. Some people may view multicultural issues as limited to racial and ethnic categories. However, disability should be viewed as a social construct (Olkin, 1999; Renard, 2001; Shapiro, 1994). This view or theory of disability, which will be examined in greater detail in forthcoming
16 pages, is known as the social/minority group mo del. The social/minority group model asserts that the problems lie not within the person with di sabilities, but in the environment that fails to accommodate persons with disabilities and in the negative attitudes of people without disabilities (Renard, 2001, p. 80) Although changes in federal laws and increased protection against disability discrimination ha ve occurred in recent decades, individuals with disabilities remain a minority population that is insuffici ently represented and too often misunderstood (Shapiro, 1994). Persons with disabilities are seen as a minority groupin the same way that persons of color are a minority groupthat has b een denied its civil rights, equal access, and protection (Olkin, 1999, p. 26). LMHCs are ethically bound to provide unbiased, competent treatment to all clients with whom they enter a counseling relationship. In the 2005 American Counseling Association (ACA) Code of Ethics, there are several speci fic references regarding the treatment of individuals with disabilities. When describing appropriate counseling environments, the code requires that counselors strive to provide a site that is accessible to persons with disabilities (American Counseling Association, 2005, p. 7). In the section of the code that deals with nondiscrimination, the code indicates counselors do not condone or engage in discrimination based on age, culture, disability, ethnicity, race, religion/spirituality, ge nder, gender identity, sexual orientation, marital status/p artnership, language preference, socioeconomic status, or any basis prescribed by law (American Counseli ng Association, 2005, p. 10) Currently, no data exist detailing the treatment of i ndividuals with disabilities by LMHC s. Nor is it clear what the level of competence and professionalism of LMHCs for this population might be. As a profession, mental health counselors are ethically bound to explor e and investigate the provision of services to all the populations they serve.
17 Significance of the Study Individuals with disabilities should be afforded the sam e rights and privileges as the general population. Federal laws such as the ADA were construc ted and passed to ensure these rights. While multiculturalism and diversity gain more attention and popularity in the research and practice of mental health pr oviders, a significant population of individuals with disabilities may continue to be left on the outside, looking in. Training relevant to the provision of psychological services to members of ethnic-minor ity groups is far from adequate, and even less emphasis has been given to understanding and se rving the diverse needs of Lesbian, Gay, and Bisexual clients and individuals with sensory or motor impair ments (Allison et al., 1996, p. 386). This becomes a critically important issue if i ndividuals with disabi lities are increasingly seeking behavioral health interventions, including services from LMHCs. If data from this study indicates that LMHCs are indeed se rving clients with disabilities, th en it would also be important to determine the level of perceived competence LMHC s have specific to this client population. Definition of Terms Disability The ADA d efines disability as any type of mental or phys ical impairment that produces substantial limitations in one or more major life activity, or a history of such an impairment, or being regarded as having such an impair ment (ADA, 1990). In 2001, the World Health Organization released th e International Classification of Functioning, Disability and Health (ICF) with the intent of provi ding a common and consistent langua ge and definitions pertaining to health conditions and related issues. The ICF defines disabili ty as an umbrella term for impairments, activity limitations and participation re strictions. It denotes the negative aspects of the interaction between an individual (with a hea lth condition) and that individuals contextual factors (environmental and personal factors) (World Health Organi zation, 2001, p. 213). The
18 ICF views disability as a multidimensional phenome non that exists due to an interaction between people and their environment. Disability is a complex phenomena that is both a problem at the level of a persons body, and a complex and primaril y social phenomena. Disability is always an interaction between features of the person and feat ures of the overall context in which the person lives, but some aspects of disability are almost entirely internal to the person, while another aspect is almost entirely external (World Health Organization, 2001, p. 34). Although generally accepted as benchmark defi nitions, for the purposes of this study, the ADA and the World Health Organization definitions are modified. Both organizations include mental impairments and dysfunctions as part of their definitions of disability. However, previous researchers have shown that counselor s may have a tendency for responding in an overinclusive manner when referring to their clients disability status (L eigh et al., 2004; Renard, 2001). Counselors may respond as if their client s, by virtue of seeking their services, are exhibiting a psychological dysfunction equal to a disability (Renard, 2001). That is, a client with a diagnosis of adjustment disord er may, in the counselor's opinion, be viewed as having a type of disability. Therefore, for the purposes of this st udy, the scope of the defini tion of disability will exclude psychological conditions and be narrowed to sensory, motor, and/or physical health conditions. Sensory disabilities include vision, hearing a nd speech. Motor disabilities include muscle dysfunction or impairment, para lysis, neurological disorders or conditions, and loss or impairment of functional abilitie s of the body. Physical health conditions include chronic pain, recurring headaches or migraines, orthopedic disorders, cancer, he art disease, and other medical conditions that have a significan t negative influence on an indivi duals life. This study will
19 utilize a definition of disability that is exclusive to sensory, motor, and/or physical health dysfunctions or impairments. Licensed Mental Health Counselor For the purposes of this study, the broad term of counselor has been narrowed to licensed mental health counselor. This definition would preclude other types of behavioral healthcare specialists or counselors such as marriage and fa mily therapists, social workers, psychologists, psychiatrists, as well as substance abuse and addictions, vocational, rehabilitation, and school counselors. In the interests of professionalism and identity, on ly mental health counselors who have obtained their respective state licensure are considered. For l ogistical purposes, the population of LMHC's was limited to thos e within the state of Florida. There is no single definition of a LMHC th at is accepted or endorsed by all states, agencies, or associations. There are however common themes and concepts found in most all definitions that are central to the role. The LMHC utilizes scientific and behavior theories, methods, and techniques to prevent and treat undesirab le behavior and enhance mental health and human development (Florida Department of J uvenile Justice, 1998). The U.S. Department of Labor (2006) defines the role of mental heal th counselors as one th at emphasizes prevention and promotes optimum mental health. They are trained in a variety of therapeutic techniques used to address a wide range of issues, incl uding depression, addicti on and substance abuse, suicidal impulses, stress management, problems w ith self-esteem, issues associated with aging, job and career concerns, educati onal decisions, issues related to mental and emotional health, and family, parenting, and marital or other relati onship problems. (U.S. Department of Labor, 2006, para. 7). It is worthy to note the broadness of the definitions a nd the wide scope of practice of LMHCs. Diversity in the client population is likely, give n the wide parameters of practice. For
20 the purposes of this study, LMHC's were defined as licensed mental health counselors currently possessing licensure within the state of Florida. Contact This term describes the professional or personal interactions between LMHC's and individuals with disabilities. Th is term is not meant to specify whether or not the individual is a client or has received ongoing services from the LMHC. It is hypothesized that some LMHCs will have an initial interaction or an intake sessio n or sessions with an individual with disabilities and will then refer the client or refrain from providing services. However, these LMHCs would have been exposed to such client s and the result of that exposure is of inte rest in the current study. The term contact is used in this study to describe pr ofessional and/or pe rsonal interactions or exchanges between LMHCs and individuals with disabilities who may be clients. Research Questions and Hypotheses The purpose of this study is to examine the am ount of contact LMHCs have with individuals with disabilities, and to descri be LMHCs Self-Awareness/Beliefs/Attitudes, perceived Knowledge, and perceived Skills when treating individuals with disabilities. Furthermore, this study will investigate the amou nt of contact LMHCs have with individuals with disabilities as a predictor of their per ceived Knowledge and Skills. Lastly, the study will look at LMHCs Self-Awareness/Beliefs/Attitudes toward disability as a predictor of their perceived Knowledge and Skills. Research Question #1 What is the amount of contact with indi viduals with disabili ties reported by LMHCs? Hypothesis #1 LMHCs will report between minimum and mode rate amounts of contact with individuals with disabilities.
21 Research Question #2 Do LMHCs rate their levels of Self-Awa reness/Beliefs/Attitudes, perceived Knowledge and perceived Skills in different ways? Hypothesis #2 LMHCs will describe themselves as having higher levels of SelfAwareness/Beliefs/Attitudes toward disability-related issues than perceived Knowledge and perceived Skills, and will describe their levels of perceived Knowledge of disability and disability-related issues to be higher than their perceived Skills, with perceived Skills rated the lowest of the three variables. Research Question #3 Does the amount of contact LMHCs have w ith individuals with disabilities and their Self-Awareness/Beliefs/Attitudes toward disability predict their perceived Knowledge and Skills when working with indivi duals with disabilities? Hypothesis #3 LMHCs who report more frequent contact wi th individuals with disabilities and have high Self-Awareness/Beliefs/Attitudes scores will report higher levels of perceived Knowledge and Skills when working with individuals with disabilities. Thus, both amount of contact and Self-Awareness/Beliefs/Attitudes will be predictors of LMHCs perceived Knowledge and Skills when working with indivi duals with disabilities.
22 CHAPTER 2 LITERATURE REVIEW The following literature review contains 14 sections that will provide a greater understanding of various aspects LM HCs and their interactions with clients with disabilities. These sections include: 1) dem ographics of disability; 2) a histor ical look at the field of mental health counseling; 3) LMHC preparation, training, and conti nuing education; 4) counseling needs among individuals with disabilities; 5) models of disability; 6) psychosocial adjustment to disability; 7) practical issues of disability; 8) health maintena nce issues; 9) social reactions; 10) countertransference; 11) legal and ethical issues; 12) self-awareness/beliefs/attitudes towards individuals with disabilities; 13) LMHCs level of knowledge re garding disability, and; 14) LMHCs level of skill utilized in trea ting individuals with disabilities. Demographics of Disability Approxim ately one in five citizens in th e United States, or approximately 49.7 million people, has some type of disability (U.S. Bureau of Census, 2000). A conservative estimate of approximately 36 million or 15% of Americans has activities that are limited by some form of disability (LaPlante, 1996). The National Organi zation on Disability report ed that approximately 20% of adults with disabilities reported the onset of disability between birth and adolescence. About 25% reported an onset in early adulthood and the remaini ng 53% reported onset after age 40 (National Organization on Disability and Harr is Survey of Americans With Disabilities, 2000). Based upon the aging of the population and th e prevalence of disability in older segments of the population, demographic forecasts indicate that an increasing prop ortion of the population will be persons with disabilities (Renard, 2001). Kaye et al. (1996) noted two trends that contributed to a probable increase in the prevalence of disabi lity in the United States; a gradual
23 demographic change toward an aging population and an increase in disa bilities reported among young adults. The prevalence of disability has been found to vary among factors that include gender, age, ethnicity, and location or place of residence (LaPlante & Carlson, 1996). Among children and youth, a larger number of boys than girls have disabilities. This may in part be due to boys being more frequently diagnosed with learning disabili ties, mental retardati on, and attention deficit hyperactivity disorder (Strike, 2001). The a dult and elderly population of individuals with disabilities is quite the opposite. A greater number of women than men have disabilities due to the greater average life expect ancy of women (Harsh, 1993). Approximately 8% of the age group 5 through 20, or approximately 5.2 million, has some form of disability. Approximately 42% or 14 million individuals age 21 through 64 ha s some form of disability (U.S. Census Bureau, 2000). An examination of the vocational aspects of the demographics of disability reveals disturbing information about this minority population. In 2000, the unemp loyment rate in the United States was less than 5% (U.S. Department of Labor, 2000). At about that same time, approximately 75% of individuals with disabilities were unemployed while roughly 11% of those with disabilities were considered unable to work or substantially limited in their ability to work (Kraus, Stoddard, & Gilmartin, 1996). With in the age group of 21 to 64, only 57%, or approximately 30.6 million individuals with disab ilities ages were employed. Those individuals with disabilities that do work can expect to earn, on average, 57% less than non-disabled workers (Stoddard et al., 1998). Another survey noted that only 35% of people with disabilities, ages 1864, worked full or part-time compared to 78% of non-disabled individuals in that same age range (National Organization on Disabi lity and Harris Survey of Amer icans With Disabilities, 2004).
24 These facts and figures point to the persistence of an uneven playing field of opportunity for persons with disabilities, a nd they underscore the importance of ongoing efforts toward vocational development and integration for person s who have disabilities (Renard, 2001, p. 61). More recent studies have show n that employment discrepanc ies between individuals with disabilities and the non-disabled population have improved, albe it far too modestly. Looking back four years, or ten years, to our earlier N.O.D./Harris surveys, we see Americans with disabilities heading in the right direction. Bu t people with disabilities remain pervasively disadvantaged (National Organization on Disability, 2004, p. 1, para3). Because this authors study utilizes a sample population from the state of Florida, it is important to examine disability statistics specific to that state. According to the 2000 U.S. Census, Florida is in the middle of the spectrum in most disability categories of the survey. The highest percentage of individuals with disabil ities, ages five and over, reside in Arkansas, Kentucky, Mississippi, and West Virg inia. The lowest rates of disa bility, ages five and older, belong to Alaska, Minnesota, and Utah. There are approximately 3.3 milli on non-institutionalized individuals with disabilities, ages five years and older, living in the state of Florida (U.S. Census Bureau, 2000). This constitutes 22.2% of the population, ages 5 and over. In cert ain areas of Florida, th e percentage is even higher. For example, the 2000 U.S. Census noted that Miami, Florida had the second highest percentage of individuals w ith disabilities (29.4%) among U.S. metropolitan areas with populations greater than 100,000. In Florida, approximate 8.7% of the population between the age of 5 to 20 years old has a disability. Within the state, 21.9% of individuals ages 21 to 64 have a disability. Approximately 40% of individuals ages 65 and older, living in Florida, have a
25 disability. According to 2000 census data, approxi mately 58% of individuals with disabilities, ages 21 to 64, are employed in the state of Florida. As indicated previously, Florid a falls in the middle of the range for most categories of disability in the United States. The number a nd percentage of non-inst itutionalized individuals with disabilities in the state represents a consid erable presence. This number is expected to increase in the 2010 census (Waldrop & Stern, 2 003). As this population grows, the likelihood of these individuals seeking ment al health services is also ex pected to increase (Oliveira, Milliner, & Page, 2004). Along with psychology, marriage and family therapy, social work, psychiatry, and rehabilitation couns eling, mental health counseling is one of the specialty fields which individuals with disabi lities (not unlike the general population) may utilize. History of Mental Health Counseling Mental health counseling is one of the younge st behavioral health provider professions (Pisto le, 2001). In the United States, the roots of the profession can be traced to what is now known as the American Counseling Associati on (ACA). Several groups of counseling specialties formed this organization in 1952 and it has become the worlds largest association devoted exclusively to representing professional counselors. In 2000, the U.S. Department of Labor reported there were approximately 67,000 ment al health counselors in the United States (U.S. Department of Labor, 2006). Currentl y, the ACA represents approximately 52,000 counselors in the United States. In 1963, the Community Mental Health Center s Act was passed which provided funding for community-based, mental health facilities sta ffed by practitioners at the masters level. The majority of these professionals were without specific training in th e fields of psychology, psychiatry, or social work. As with the growth and development of any human service profession, traditional foundations needed to be established. First, a professional organization
26 was needed to promote the representation and furt her the cause of this gr oup of professionals. Secondly, a uniform code of ethics outlining appr opriate practice parameters was needed. Third, the development of licensure and credentialing for the individuals of the profession must be established. Without such representation and or ganization, these counselor s were operating in an environment of professional disenfranchisement and invisibility (Pistole, 2001). By the late 1970s, this group of counselors organized their pu rsuit of visibility, re cognition, and identity. As a result, in July of 1978, the American Mental Health Counselors Association (AMHCA) was founded to establish and promote recognition, st andards and accountability, and professional status for practice-oriented counselors (Beck, 1999). In 1983, AMHCA joined the ACA as one of its 18 divisions that provide specific professional identities and are or ganized around specific practice areas. The creation of AMCHA helped provide an id entity for mental health counselors. The organization then set its sights on providing the opportunity for licen sure, a credentia l previously established in the fields of social work a nd psychology. This issue became increasingly important as the trend toward third party paymen ts for counseling services grew in popularity. Counselors found it difficult, if not impossible, to obtain reimbursement for their services without some form of licensure. As a resu lt, one of AMCHAs primary goals became the licensure of mental health counselors in al l 50 states (Pennington, 2003). By 2007, only one state had not obtained some form of counseling licensure law. As mental health counseli ng grew as a profession, the population served by these counselors and the settings in which the services were provided also evolved. As a result of the changes in the funding of mental health services, the parameter a nd scope of services offered by LMHCs expanded (Kelly, 1996). Employment settings for LMHCs now include health
27 maintenance organizations or managed mental hea lth care centers, larg e multi-disciplinary group practices, senior care and elderl y housing and service centers, psychiatric hos pitals inpatient or outpatient service, court systems, correctional systems, public and private schools, universities and colleges, and in-house mental health counseli ng services contracted by large corporations or governmental agencies (Messina, 1999). Indeed, the growth of mental health counseling as a profession has increased the exposure and access that practitioners have to the public. It has also brought about an increased diversity in the individuals served by these counselors. Counselor Preparation, Traini ng, and Continuing Educa tion To prepare for the provision of counseling services, students training to become LMHCs must earn a masters degree from an accredited counseling program. The main accrediting body for such academic programs is the Council fo r Accreditation of C ounseling and Related Educational Programs (CACREP). Since its in corporation in 1981, CACREP has established academic training and experience standards for fu ture mental health counselors. CACREP Standards are written to ensure that students develop a professiona l counselor identity and also master the knowledge and skill s to practice effectively (C ACREP, 2001, Introduction section, para. 2). Social and cultural dive rsities are part of the eight core curricula training areas required by CACREP. Educational institu tions that adhere to CACREP st andards require all counseling students to learn advocacy proce sses needed to address institutio nal and social barriers that impede access, equity, and success for clients (CACREP, 2001, Section 2, Unit K, 1-g). In addition to the common core requirements of all counselors, CACREP standards require mental health counseling students to obtai n knowledge and skills pertaining to the role of racial, ethnic and cultural heritage, nationalit y, socioeconomic status, family structure, age, gender, sexual orientation, religious and spiritua l beliefs, occupation, and physical and mental status, and equity
28 issues in mental health couns eling (CACREP, 2001, Standards for mental health counseling section, # 6). Curricula and academic training in the areas of minorities, diversity, and multiculturalism are addressed in and required by CACREP programs. However, recent research has shown that training in CACREP programs in the areas of disability has been sparse, lacks coverage, or has been biased (Rosenau, 2000). Although nowadays disability is often mentioned among the types of diversity for which counselors shoul d routinely receive training and continuing educational opportunities, disability is the least covered diversity i ssue in terms of course content and opportunities for supervised practice experience (Renard, 2001, p. 72). Smart and Smart (2006) noted that the disability experience, despite the large number of individuals with disabilities, remains invisible in most university curricula (p. 36). Another accrediting body for educational progr ams preparing future counselors is the Council on Rehabilitation Education (CORE). CORE accredits graduate programs in rehabilitation counselor education. In many states, including Florida, such programs may provide training and coursework that fulfills the academic qualifications necessary to earn licensure in mental health counseling. Becau se of the overall focus on rehabilitation and disability issues in CORE programs, individuals qualifying for ment al health counseling licensure through these programs may have a grea ter understanding or le vel of competence in providing psychotherapeutic services to clients with disabilities. However, the majority of LMHCs do not fulfill their academic qualifications for mental health counseling licensure w ithin CORE accredited programs. Most students in counselor training programs, with the exception of specia lties such as rehabilitation counseling or rehabilitation psychology, are not required to learn about individua ls with disabi lities (Smart &
29 Smart, 2006). This standpoint was supported by Rosenau (2000), who conducted a content analysis of the most frequently used textbooks in counselor education programs. The study indicated that these texts rarely address disability issues. Further, if disability concerns are addressed, they provide biased presentations of persons with disabilities (Rosenau, 2000). Counseling Needs Among Persons with Disabilities When exa mining the demographics of disabi lity, it is suggested that mental health professionals across disciplines wi ll encounter clients with disa bilities in the community, in vocational settings, and in highe r education (Strike, Skovholt, & Hummel, 2004). This is in part due to the combined effects of civil rights movements, me dical advances, and assistive technologies (Barnes et al., 1999; Mackelprang & Salsgiver, 1 999; Oliver, 1996). Individuals with disabilities are engaging in a broader range of social and voca tional roles and activities than ever before. As this minority group grows, it is inevitable that its exposure and involvement in everyday life among non-disabled individuals will continue to grow as well. Although there are great strides to be made for equality to exist between disabled and non-disabled populations, it is evident that the two populations share more experiences and environments as time marches on. Thus, the composition of the general public increasingly includes rather than excludes persons with disabilities, and counseling pr ofessionals who work as generali sts must be prepared to work effectively with the pub lic in all its diversity (Renard, 2001, p. 65). Literature suggests that mental health pr ofessionals are becoming more aware of the presence of individuals with disa bilities and the large percentage of the population they represent (Henderson & Bryan, 1997, Kemp & Mallinckro dt, 1996, Renard, 2001, Stri ke et al., 2004). Psychologists are increasingly r ecognizing persons with disabil ities as the largest minority group in the United States and acknowledging disa bility as an inevitable part of human experience, thereby reshaping psychological rese arch and practice (Str ike et al., 2004, p. 321).
30 However, data also exist that indicates an alarming lack of preparedness or adequate awareness of disability issues by mental health professi onals (Rosenau, 2000). Yet, since census data indicates a growing percentage of the population is individuals with disabilities, and this population is becoming more and more mainstr eamed, it seems reasonable to assume that individuals with disabilities woul d encounter problems similar to those in the general population. This is not to say that there are no significant differences between the disabled and non-disabled populations. However, it may not be the disabi lity itself that create s these differences and divisions. Research has shown that prejudicial attitudes exhi bited by non-disabled persons can create and maintain social distance from pers ons with disabilities (Abrams, Jackson, & St. Claire, 1990, Olkin & Howson, 1994; Westbrook, Legge, & Pennay, 1993). This social distance, along with discriminati on and medical, vocational, and e nvironmental issues can create credible needs for counseling and guidance. Individuals with disabilities are less likely to be married or coupled, less socially ac tive than desired, and report si gnificantly lower levels of life satisfaction (Jans & Stoddard, 1999). Because LMHC's often assist clients in coping with and resolving these types of personal development pr oblems, it seems likely that individuals with disabilities would seek their services. In a 2004 follow-up article to the 2004 Nationa l Organization on Disabi lity/Harris Survey of Americans with Disabilities, the organization summarized the findings regarding overall life satisfaction of individuals with disabilities (National Organization on Disability, 2004). A disturbing trend was noted when comparing disa bled and non-disabled individuals. Between 1986 and 2004, there is evidence of slow and mode st progress in regards to overall life satisfaction for individuals with disabilities. Yet, there are persistent gaps between the advantages experienced by non-disabled people and disadvantages enco untered by individuals
31 with disabilities. The percentage of non-disabled individuals who are very satisfied with life was reported to be 61%. Only 34% of individuals with disabilities reported being very satisfied with life. Three times as many indi viduals with disabilities versus non-disabled individuals live in poverty (26% versus 9%). Individuals with disa bilities are twice as likely to drop out of high school (21% versus 10%). They are almost three times as likely to go without adequate healthcare (18% versus 7%). It is important to remember that th ese data were gathered during a time when legal changes occurred designed to create an environment fo r improved life quality among individuals with disabilities. The 2004 National Organization on Disability /Harris Survey of Americans with Disabilities also examined the outlooks or expect ations that individuals with disabilities held about the future. Approximately 41% of indivi duals with disabilities expected their overall quality of life to improve in the coming four y ears. Yet, most likely due to age and increased impairments, 35% expected their lives to get wo rse. The study noted that, by contrast, 76% of non-disabled persons expected thei r quality of life to improve. On ly 8% of non-disabled persons believed that their lives would get worse (Natio nal Organization on Disab ility/Harris Survey of Americans with Disabilities, 2004). Data such as this is not meant to associate disability with poor quality of life, depression, victim roles, or pity. Nor should it be assumed that disabilities are the sole determining factor or even a major contributing factor in the overall quality of life of a ny person. It is also important to note that not all individuals with disabilities seek mental health counseling for strictly disability-related prob lems. Kemp and Mallinckrodt (1996 ) conducted a study that found mental health clinicians falsely assumed that certain disab ility-related issues were important to the client when, in actuality, they were not.
32 This focus on the disability or issues related to the disability resulted in the absence of focus on the presenting problem. There is clear evidence to support the mental health counseling needs of individuals with disabilities in the areas of social, relationship, vocational, and overall life satisfaction (Jans & Stoddard, 1999; Kemp & Mallin ckrodt, 1996; National Organization on Disability, 2000; Olkin & Howson, 1994). A s people with disabilities enjoy greater involvement in the community, they are likely to seek mental health services independent of their disabilities (Hayes & Po tter, 1995, p. 25). While it is not imperative that LMHCs be experts on the specific dynamics of each type of disability, it is important the clinician have an awareness of disability issues and be able to differentiate between problems related to or caused by a disability and presenti ng problems unrelated to th e individual's disability. Models of Disability To best understand the dynam ics of disabi lity and this minority population, the LMHC should have an understanding of th e historical models of disabili ty and how they may influence attitudes, environment, and the individual. Curre nt literature reflects th e numerous models of disability that have develop in recent years (Harris, 2000; Pledger, 2003; Smart, 2001; Smart & Smart, 2006; Tate & Pledger, 2003). However, it is generally accepted that all models have origins in one of three primar y models: moral, medical, and so cial. A fourth group of more contemporary models will also be discussed. The moral model of disability is perhaps the ol dest model and is clearly the least prevalent in current literature. It is ar guably derived from religious doctrin e and associates disability with sin and shame (Kaplan, 2006). The moral model explai ns disability as an act of God in reaction to a sin of an individual or a family (Gill, Blanck, Schartz, Klein, & Searcy, 2003). Even in modern times, there are cultures th at still view disability as shameful and individuals with disabilities are ostracized This model has been associated w ith shame on the entire family with
33 a member with a disability. Families have hidde n away the disabled family member, keeping them out of school and excluded from any chan ce at having a meaningful role in society (Kaplan, 2006, para5). Although this model is not pr evalent in most modern cultures, it serves as a powerful reminder of a possible origin of di scriminatory, negative and biased views of disability. The medical model of disabil ity became popular in the 19th century as physicians gained prominence in society. The medical model is deri ved from scientific origins, specifically the medical arena. It is the most familiar model to the general population and is supported by the power and prestige of the medical and scientific communities. The strength of this model is in its strong explanatory power, which far exceeds other models (Kahn, 1984). According to this model, issues associated with the disabling condition are considered to be within the individual. Social factor s play little to no role at all in the disabling condition. The individual with the disability assumes a sick or patient ro le within this model. This can be problematic for the individual with the disability, especially those who do not view their impairment as a primary problem. While professionals may view people with disabilities as patients, people with disabilities often accept their disabilities and move away from the patient role to resume life roles of worker, student and parent within the community (Seelman, 2004, The Medical Model, Professional Training sect., para. 3). Nagi (1969) described this model as placing individuals with disabilities into stigmatizing categories that promoted non-disabled individuals to label them as their disability. For example, the indivi dual with a visual impairment would be labeled as the blind guy. Smart and Smart (2006) examined four aspects (pathologizing, objectification, categorization, & individualization) of the medical model that exemplify the shortcomings of this
34 view. Pathologizing refers to the underlying as sumption that there is a pathology present within the individual with the disabilit y. This can lead to the belief that individuals with disabilities have something wrong with them. Disability th erefore is considered a flaw or deficit. Undoubtedly, this premise could be at the root of biased and discriminatory viewpoints. Objectification, which is intertwine d with pathologizing, refers to th e premise that disabilities are objective conditions that exist in and of themselves. Objectification makes it possible to lose focus on the person because attention is focused on the supposed pathology. It also can be interpreted as unbiased or fair because of the assumed objectivity under which the disability is being viewed or treated. Categor ization, as discussed in the prev ious paragraph, refers to the labeling of individuals with disa bilities. Although this behavior is apparent in the general population, it is also prevalent in medical settings (i.e. the quadrip legic in exam room two, or the bi-polar client). This cate gorization according to disability type has had many pervasive, institutional, and systematic consequences, some of which have resulted in inferior services or a lack of services from the c ounseling professions (Smart & Smart, 2006, p. 31). The fourth aspect, individualization, is a central theme in th e medical model and places the disability within the individual, with little or no consideration of societal or envir onmental influences. This view relieves society of a ny responsibilities. The lack of consideration of environmental or societal influences within the medical model is an important factor when dealing with mental and psychiatric disabilities. Stefan (2001) notes that the medical models lack of environmenta l consideration and its focus exclusively on the individual can make it inappropriate for treatment of individuals with me ntal health conditions, which are very responsive to context and environment.
35 The social model of disability is based upon th e premise that individu als are not disabled because of their impairment. Rather, they are di sabled due to societal or environmental factors (Given, 2005). Therefore, this m odel views disability as a social construct. This disability paradigm maintains that disabili ty is a product of th e intersection of indi vidual characteristics (e.g. conditions or impairments, functional status or personal and socioeconomic qualities) and characteristics of the natural, built, cultural, and social environments (U.S. Department of Education, Office of Special Edu cation and Rehabilitative Services, NIDRR, 2000, p. 2). This model makes a clear distinction between an impa irment and a disability. The social model supports the notion that an indivi dual with an impairment does not equal an individual with a disability. The latter is determined by social and environmental factors. Researchers have expanded upon ba rriers defined in the social model to include not only environmental, societal and structural limitati ons but also political and attitudinal barriers (Brandt & Pope, 1997; Tate & Pledger, 2003). Ba rriers in education, heal thcare, transportation, housing, employment, communication, and public f acilities as well as negative images and representations of disability in the media are the driving force behind the existence of disability. The social model supports the premise that if you remove the barriers, you eliminate the disability. The World Health Organization's publication of the ICF International Classification of Functioning, Disability, and Health (2000) furthered the argument fo r a model of disability with an emphasis on social factors. A person's func tioning and disability is conceived as a dynamic interaction between health conditions (diseases, di sorders, injuries, trauma s, etc.) and contextual factors (World Health Organi zation, 2001, p. 8). The ICF defines contextual factors as both personal and environmental. Environmental factors interact with all the co mponents of disability
36 and pertain to the impact of the physical, so cial and attitudinal world (World Health Organization, 2001). The ICF explains the social model of disabili ty as one where the makeup of disability is within society, not the person. Disability is not an attribute of an i ndividual, but rather a complex collection of conditions, many of which are created by the social environment. Hence the management of the problem requires social ac tion, and it is the collec tive responsibility of society at large to make the environmental modi fications necessary for the full participation of people with disabilities in all areas of social life (World Health Organization, 2001, p. 20). The basic premise of the social model is more closely related to the theoretical assumption and practice orientations of mo st LMHCs (Smart & Smart, 2006). By following this line of thought, the LMHC is more capable of viewing a client with a di sability as a complete person within the context of his/her environment. It allows the LMHC to see beyond the disability which may or may not be the presenting problem. Th is is not to say that the social model has no limitations and should be unquestio nably adopted by all LMHCs. It should be noted that many researchers and individuals with disabilities see the social model as just redefining the problem (Smart, 2001; Swain & French, 2000; Tate & Pledger, 2003). It is argued that the social model still frames the impairment and/or disability as something negative. T he non-tragic view of disability, however, is not about the problem, but about disability as a positive personal and collective identity, and disabled people leadi ng fulfilled and satisfying lives (Swain & French, 2001, p. 571). It should also be noted that th e ICF proposes a hybrid model of disability that combines the social model with the medical model. As mentioned, the medical model views disability as an individual phenomenon, within the person, cause d by some disabling condition or trauma. The
37 combined social and medical approach, referre d to by the ICF as a biopsychosocial model, attempts to integrate two different models to create a new model that considers medical, individual, and social perspectives. Like the ICF model, new hybrid or modified models are emerging and gaining acceptance by researchers and individuals with disabilities. The sociopolitical model, also referred to as the minority model, attempts to explain and describe mo re of the day-to-day life of individuals with disabilities (Hahn, 1988; Smart & Smart, 2006). This model focuses more on the damaging effects of prejudice and discrimi nation rather than medical impairm ents or functional limitations. This model rejects the inferior and dependant definition of disability. This model also resists medical categorization by diagnos is and explains that such an occurrence actually may be the source of discrimination and prejudic e. It is an interactional mode l that views disability not as a personal tragedy but as a public concern. Similar to the sociopolitical or minority model is the affirmative model of disability. It is essentially a non-tragic view of disability a nd impairment which encompasses positive social identities, both individual and collective, for disabled people grounded in the benefits and life style and life experience of being impaired and disabled (Swain & French, 2000, p. 569). The affirmative model does not focus so much on the pr oblem of disability or impairment but instead on the positive experiences and identity of individu als with disabilities from being impaired and disabled. And although the affirmative model in some respects builds upon or extends the social or minority models, it also addresses some shor tcomings of those paradigms. For example, issues such as pain and chronic illness may not be applicable to the social model. Crow (1996) explains that conditions such as chronic pain or chronic illness may be so debilitating that restrictions in the environment or outside world become irrelevant and that the impairment may
38 remain even when social or environmental barrier s no longer exist. Other researchers extend this debate. Pain and chronic illness are neither im pairments nor restricted to the experiences of disabled people. Non-disabled people experience both pain and chronic illness. Indeed, in the pursuit of physical fitness, pain can be actively pursued by non-disabled people: no gain without pain (Swain & French, 2000, p. 572). The new models and paradigms clearly view disability and impairments in a different light; one focused less on dysfunction and tragedy. Unde rstanding the conceptual ization of disability is an important element within the LMHCs unders tanding of this minority population. Smart and Smart (2006) summarize this premise: Typically, the disability is not the single defini ng characteristic of the individual; rather the disability is one of several important part s of the individuals se lf-identity. When counselors dismiss or ignore the disability, a crit ical part of the clients self-identity must remain unexplored. On the other hand, couns elors may tend to overemphasize the salience of the disability and automatically assume that the disability is the presenting problem or the cause and source of all the clients concer ns. Indeed, the roadblocks may be due to a lack of understanding, training, and experience with disabi lity issues. Many individuals with disabilities view their disability as a valu ed part of their self-identity, see positive aspects in the disabilit y, and would not choose to eliminate the disability if they had this option. In contrast, few counselors conceptualize the clients disability as a source for selfactualization. (pp. 29-30) Knowledge of the various models, paradigms and conceptualizations of disability can further the LMHCs ability to build empathy a nd rapport, effectively diagnose and treat, and create trust and understanding within the counseling relationship. Psychosocial Adjustment to Disability An understanding of how individuals adjust to disability can be another powerful tool within the LMHCs repertoire. Early clinical theori es pointed to the severity of the disability as the primary factor in adjustment (Shontz, 1989). More contemporary research has refuted this idea. Rather, the relationship between psychol ogical adjustment and physical disability is complex, multidimensional, and moderated by other variables, such as gender, socioeconomic
39 status, and availability of social supp orts (Cook, 2004, p. 332). The importance of understanding psychosocial adjustment to disabi lity is paramount. Psychosocial adjustment problems have been associated with extensive costs in terms of long-term community welfare and health service utiliza tion (Kendall & Buys, 1998). Vash (1981) explained that, because the adju stment to disability is an individualized experience, people with similar di sabilities or circumstances may deal with the adjustment in different ways. There are also numerous factors that may influence the process of psychosocial adjustment for each individual (Atkins, Lynch, & Pullo, 1982). These factors include (but are not limited to) the severity of the disability, the age or stage of life at which the disability is acquired, the visibility of the disability, th e gender of the indivi dual, the individuals spiritual/cultural beliefs, and the physical pain involved in the disability. There are many theories in existence that attempt to explain psychosocial adaptation to disability. Perhaps the most popular methods for describing psychosocial adaptation to disability are based on stage theories. Typically, these models portray adjustment evolving through a sequential series of stages and culminating when an individual has achieved a working acceptance or adjustment (Garske & Turpin, 1 998). Livneh (1991, 2001) developed a variation of the stage theory that placed the individual with a disability in an active role. Referred to as the unified model of psychosocial adaptation to disability, Livneh described this model as a process through which the individual slowly appro aches an optimal state of person/environment congruence (Livneh, 1991). Stage 1 of the unified model is initial imp act. This is described as the individuals response to the onset of a sudden disability or ps ychological trauma. This stage consists of two components: shock and anger. During the shock phase, the individual may be confused,
40 disoriented, or emotionally withdrawn. As the shock wears off and awareness increases, anxiety may set in. This anxiety occurs when one realizes the magnitude of the event. The anxiety may cause the individual to overreact, beco me irritable, or feel helpless. The second stage is known as defense mobili zation. This stage also has two phases: bargaining and denial. Both bargaining and deni al are considered defense mechanisms, and in most instances are an appropr iate part of overa ll adjustment (Marshak & Seligman, 1993). Bargaining involves deals that ar e offered up to God or any other entity or person that might be able to take away or reduce the impact of the disability. While bargaining is usually shortlived, denial can last much longer. Once no bargains are found, the individual may try to forget or erase the disability and everything rela ted to it. The individual may seem upbeat or optimistic. While this mentality may seem unrealis tic, it serves a valuable purpose in that it can insulate or protect the individual from his/her painful reality. Stage three is known as initi al realization. Common them es of this stage include mourning, reactive depression, and internalized anger. The i ndividual may become withdrawn, detached, and may try to avoid so cial interactions. The defens e mechanisms of withdrawal and avoidance are necessary in order for the pe rson to concentrate on the disability and its consequences without becoming distracted by the social and physical environments surrounding him/her (Garske & Turpin, 1998, p. 35) It is impor tant to note that while there is value in withdrawal and avoidance, internalized anger does not have a useful purpose and in no way insulates the individual from the painful adjustme nt he or she must make. This internalized anger may lead to long-term depression (Marsh ak & Seligman, 1993). In turn, this depression may lead to the individual seek ing the services of an LMHC.
41 The fourth stage is known as retaliation or re bellion. This stage consists of anger and hostility that has an external focus. The direc tion or target of this hostility may be towards people, objects, or environmental aspects associat ed with the individual's functional limitations. Defense mechanisms such as projection, externali zation, and regression may be used to fight and overcome anything in the external environment that may be perceived as threatening or as an obstacle in the individuals way (Garske & Turpin, 1998). The fifth and final stage in Livnehs unified model is rein tegration. This stage is characterized by acknowledgement, acceptance, and fi nal adjustment. It is described as the gradual integration of the f unctional limitations associated with ones condition into ones self-concept (Antonak & Livne h, 1997, p. 10). Acknowledgement occurs when the individual comes to terms with the permanent nature of hi s/her condition. Acceptan ce and final adjustment occur when the individual finds satisfaction and contentment in living with the disability. The individual no longer utilizes defense mechanisms to cope with his/her situation. This phase is constructed of the individual's emotional acceptance of his/he r functional limitations, his/her behavioral adaptation to the disabi lity, and a social integration as part of a newly perceived life situation (Antonak & Livneh, 1999). Although stage models like Livnehs unified a pproach are popular among researchers and practitioners, they are not without criticism a nd possible limitations. While stage models may adequately represent the genera l progression towards adjustment, they do not sufficiently address the recurrent nature of the psychosocial adaptation pr ocess (Kendall & Buys, 1998). Researchers have argued that linear models do not allow counselors to appreciat e or anticipate the disorder, unpredictability, and complexity of the issues associated with psychosocial adaptation to disability (Rosenthal, 1996). Others criticize the implicit pass ivity of the individual with a
42 disability within the stage mode l (Stewart, 1996). The individual is subjected to waiting for unavoidable stages to occur and may be less like to be an active participant in the rehabilitation process. This may also cause counselors or he alth care providers to wait unnecessarily until one stage is completed before progressing on to th e next. Stage models also normalize responses such as denial and distress, which may lead counselors or health care provid ers to expect, or even encourage, these types of responses (Kendall & Buys, 1998). Some researchers have even opined that stage models of psychosocial adjust ment represent a form of social oppression. Dovey and Graffam (1987) indicated that these models encourage in dividuals with disabilities to accept fewer alternatives and less personal cont rol than individuals in the non-disabled population. Other researchers have noted that social and e nvironmental factors play as much of a role as internal factors in determining an individual's response to disa bility (Charmaz, 1995 & Shontz, 1991). Hahn (1988) explaine d that adjustment to disabil ity is not only an internal process, but also involves social reactions to disability. He argued that social attitudes, political climates, and physical environments could be as im portant as the individual 's internal process of adjustment. An alternate theoretical construct must better take into acc ount the social impacts and implications of being labeled disabled. In order to provide an accurate model, it must go beyond the individual's immediate experience to encompass the various cultural and personal meanings of disability (Olney, Brockelman, Kennedy, & Newsom, 2004, p. 7). Similar to the social model of disability, this social view of adaptation to disa bility considers disability as a product of the environment rather than an aspect of the individua l. Olney et al. (2004, p. 8) discusses the following interrelated phenomena that have ties to the social model of adaptation to disability:
43 (1) An evolving disability policy which increas ingly recognizes the pejorative treatment of individuals with disabilities as a human rights issue rather th an as a result of individual failings (Rehabilitation Act Amendments of 1992); (2) A gradual shift from a medical model of disability with its fo cus on ameliorating the limitations of the individual, to a minority gr oup model that views the disenfranchisement of individuals with disa bilities as evidence of di scrimination (Hahn, 1985); and (3) A rights perspective concerning r easonable accommodations and community integration (Americans with Disabilities Act of 1990). Theories of adjustment are primarily deri ved from an event marking the onset of a disability or impairment. They do not typica lly address life long developmental, physical, cognitive, or learning disabil ities. Individuals who are bor n with disabilities may have experiences quite different than people who acquire disabilities later in life. Also, adjustment for one disability group may be very different than another type of disabi lity group (Mackelprang & Salsgiver, 1999, Olney et al., 2004). These issues are especially important for the LMHC who is treating an individual with a disabi lity. Adjustments to disability can take place at any time or period of an individual's life. Th e majority of literature pertaining to the adjustment to disability ignores the on-going, long-term adjustments that are necessary as one goes through life after disability (Olkin, 1999). In response to the shortcomings of stage models, Kendall and Buys (1998) proposed an alternative approach to c onceptualizing adjustment to disability known as the recurrent model This model views adjustment as an ongoing cycle. In articulating the recurrent model, the authors explain that cognitive theories of psychosocial well-being are based upon schemas, which are fundamental beliefs and assumptions a bout the self, others, and how the environment works (Kendall & Buys, 1998). The recurrent nature of adjustment originates from the fact that new schemas will be developed incrementally and will be revised, modified or completely
44 restructured as the individual consolidates his or her new positi on in life and has opportunities to explore the environment (Kendall & Buys, 1998, p. 18). This modification of schemas is typically guided by three separate themes: (1) the search for meaning in the disability and in post-disability life; (2) the need for a sense of control over the environment, the disability, and ones future; and (3) the effort to protect and enhance ones post-disability life (Ken dall & Buys, 1998). The recurrent pro cess of adjustment may reflect the turbulence and confusion that occurs while indi viduals with disabilities try to find a balance between two extremes. For example, Barnard (1 990) discusses how, in the search for identity, individuals oscillate between schemas dominated by either self-rejection or self-acceptance. Individuals who are able to move through this phase are likely to continue moving through a series of decreasing pendulum swings while th ey establish their new schemas (Kendall & Buys, 1998). These schemas may become more positiv e or negative, largel y influenced by the individuals environment and su rroundings. The speed and quality with which individuals move through the adjustment process is heavily infl uenced by the individual s available resources (Kendall & Terry, 1996). Thus, sufficient resour ces result in more pos itive schemas, more appropriate coping efforts, a nd greater psychosocial well-being (Lazarus, 1993). A systemic, ecological model would focus counselors towards th e identification of environmental as well as personal coping resources which are crucial to adjustment (Kendall & Buys, 1998, p. 21). While it may not be imperative that LMHCs have a thorough and detailed understand of adjustment models, it is important that the practitioner have a basic understanding of the psychosocial adaptation process and the various approaches to this understanding. A lack of awareness of the strengths and limitations of the various models, or strict adherence to only one method, may negatively impact the quality of care provided to individuals with disabilities.
45 As part of adjustment to disability, as well as living with a disabilit y, individuals must face everyday, recurring issues that can impact their overall quality of life. These issues are numerous and vary widely but, for the purposes of this study, they will be categorized into three general areas; practical issu es, health maintenance issu es, and social reactions. Practical Issues of Disability As indicated previously, it is inappropriate to assume that the reason for treatment or presenting problem of an individual with a disability arises out of the disability itself, or is even related to the disab ility. However, the LMHC should be awar e of everyday issues related to the disability that may contribute to, or exacerbate the presenting problem. Within the realm of multicultural counseling, therapists are challenged to understand the complexity of issues that different cultures face and the context within which problems present themselves. It is only reasonable to expect the LMHC treating the indi vidual with a disability to have the same understanding. It is unlikely that a compet ent, ethical therapist would provide marriage counseling without having a workin g knowledge of the dynamics of marriage, family systems, or intimate relationships. Similarly, an LMHC may be ill advised to wo rk with an individual with a disability without unders tanding the practical, everyday issues that comprise the world of the client. Because individuals with disabilities are as varied and unique as non-disabled individuals, it is difficult to identify specific issues that a ll of them face. However, many individuals with disabilities encounter daily dilemm as and struggles that may seem unfamiliar or foreign to nondisabled persons. Research reflects evidence of barriers to full social pa rticipation and the slow rate of progression to an equal opportunity status for individuals with disabilities, even following the implementation of laws such as the ADA (S toddard, Jans, Ripple, & Kraus, 1998). Such evidence points to the persiste nce of an uneven playing field of opportunity for persons with
46 disabilities (Renard, 2001). One example would be the increased percentage of individuals with disabilities categorized in a low socioeconomic status (SES) compared to the general population (Olkin, 1999 & Shapiro, 1994). Pers ons with low SES are at greate r risk for personal adjustment problems and for diminished quality of life a nd sense of well-being (Adler, Boyce, Chesney, Cohen, Folkman, Kahn, & Syme, 1994). Counseling professionals need to be aware of the nature and personal consequences of the voca tional, social, and economic arenas in which individuals with disabilities are situated. Personal and/or intimate relationships are anot her important part of everyday life in which individuals with disabilities expe rience unique situations and circum stances. It has been shown that prejudicial attitudes by non-di sabled persons create or mainta in social distance from persons with disabilities (Abrams, Jackson, & St. Claire, 1990; Olkin & Howson, 1994; Westbrook, Legge, & Pennay, 1993). Compared with non-disabled adults, adults who have disabilities are less likely to be married or coupled, are less so cially active than they would desire, and report significantly lower levels of life satisfaction (Renard, 2001, p. 62). Such issues are often the reasons why individuals, disabled or not, seek treatment with an LMHC. Understanding the source of these issues and the environment within which they exist is crucial in assisting clients in effectively improving their lives. LMHCs should also be aware of the discri mination and prejudice that many individuals with disabilities must face on a daily basis (Bar nes, Mercer, & Shakespeare, 1999; Koch, 2001). The type of disability cannot only determine the environmental barriers but may also be a major factor in determining other peoples attitudes about the disabled person. Gething (1992) found that a visible disability functioned as a central and organizing characteristic around which global impressions were formed. Disabilities, especially those that are visible, are often the impetus
47 behind the spread effect (Wright, 1983, 1988). The spread eff ect is a phenomenon that occurs when multiple assumptions about a person are made on the basis of a single trait. Spread effects tend to be negative and they can lead to a lessening of the whole person (Wright, 1983, 1988). This phenomenon underlies stereotyping. Another daily form of discrimination that is relatively consistent throughout disability types is the misuse of language (Olkin, 1999; Shapiro, 1994). This is especially important because it is an area where LMHCs can easily portray understanding and competence regarding sensitivity and empathy. Yet, they can also easily distance, offend or anger a client by unintentionally using inappropria te language. Many people in the general population label individuals with disabilities ba sed upon the disability itself. A person may be known as the deaf man or the blind lady. It is essential to put the focus on the individual, not the particular functional limitation. It is also common to label succ essful individuals with disabili ties as extraordinary or heroic (Shapiro, 1994). Even though the general popula tion may appreciate over achievers, portraying people with disabilities as supers tars raises false expectations that all people with disabilities should achieve this level (Wes tbrook, Legge, & Pennay, 1993). Disabilities, like individuals, should be dealt with on a case-by-case basis. The disability itself shoul d be dealt with openly and straightforwardly without condescending euphemisms (Oliver, 1996). Terms such as handicap, mental, and physically challenged are consid ered condescending. They also reinforce the idea that disabilities ca nnot be dealt with up front. Some practical issues of disability may be obvious to the general public or to LMHCs. However, in addition to accessibility issues a nd certain forms of discrimination, there are numerous issues that lie below the surface of aw areness and are powerful forces that can shape
48 the lives of the individual with a disability. The previous paragraphs have touch on only a few. Yet, even if the practical issues are managed e ffectively, the individuals with disabilities must still face numerous issues that can affect the maintenance and quality of their health and wellbeing. Health Maintenance Issues Individuals with disabilities m ay be no different than persons in the general population when considering the need for ongoing health maintenance and medical care. Having a disability does not necessarily c onstitute the need for frequent medical interventions. However, individuals with disabilities may require speciali zed care or more frequent medical interventions as a result of a condition or func tional limitation. Research has s hown that there is a lack of understanding by health care provi ders regarding the difficulties faced by individuals with disabilities seeking health serv ices (Leigh et al. 2004; Lishner, Richardson, Levine & Patrick, 1996; Livneh & Antonak, 1999). Scheer et al. (2003) noted a lack of disability literacy or understanding by health care providers that could dram atically impact the quality of care given to individuals with disabilities. Dis ability literacy refers to the sp ecific knowledge and skill set that enables health-care providers and administrators to respond more appropriately to the needs of individuals with disabilities. It en compasses a range of general skills such as the ability to listen to, understand, acknowledge, and respond to the variable needs of individuals with disabilities (Scheer et al., 2003, p. 229). A possible myriad of barrier s and dilemmas may be enc ountered, from maintaining personal hygiene to obtaining tr ansportation to medical appointme nts. LMHCs should be aware of the impact that disability can have upon basic activities of daily living (ADLs) such as dressing, attending to personal appearance, and ma naging household chores. The individual with a disability may need to utili ze a personal care assistant to help with ADLs. The LMHC should
49 maintain awareness of the psychological implications of depending upon others to complete ADLs. Even if the individual wi th a disability is completely independent, issues pertaining to sexuality, body temperature regulation, body image, and verbal communication may influence the counseling process (Hayes & Potter, 1995). Th e dynamics of disability have been shown to have considerable impact in the areas of sexual and body esteem (McCabe & Taleporos, 2003), family life (Rogers & Hogan, 2003), and marriage (Copel, 2006). Although it may be impossible for LMHCs to know and understand all the dynamics of so many potential issues, it would seem important that a general knowledge be established and maintained if they are treating members of this population. A common barrier related to health care for individuals with disa bilities is transportation. It has been frequently reported that access to healthcare services for individuals with disabilities is not equal to the general population (DeJ ong, Beatty, Neri, & Hagglund, 2001; Lishner, Richardson, Levine, & Patrick, 1996; Weissman, Stern, Fielding, & Epstein, 1991). Even when public transportation is available it can be insufficient. Clinics or medical providers may not have offices close to public transportation routes Hours of operation for transportation may not be congruent with available appointment times of healthcare providers. Individuals that use wheeled mobility devices, have fatigue and ener gy limitations, or chronic physical pain may find it difficult to utilize public transportation, even if that transportation vehicle is designated for individuals with disabilities. Scheer and colleagues (2003) performed a qualitative study that examined the issue of transportation and medical care fo r individuals with disabilities more closely. Persons who used publicly funded door-to-door para-transit van or taxi services said that appointments often needed to be scheduled a week in advance, a sy stem that is not respons ive to more immediate
50 medical needs. Even with advance scheduling, pa rticipants frequently found the publicly funded services to be undependable, often picking them up too late or not coming at all. Another frustration was that when the tr ansportation service di d come, the drivers did not have the proper equipment to either load or securely attach wheel chairs or scooters to the floor (Scheer et al., 2003, p. 224). Even if the individual is able to obtain transportation or travel independently, their struggles may not be over on ce they reach thei r destination. Office accessibility is another problem encountered by individuals with disabilities seeking health care. Scheer and colleagues (2003) noted that inaccessible medical offices often proved to be an environment barrier. Specific elements of such a barrier included examination and diagnostic equipment, office parking (location, co ndition, topography and curb cuts), office and doorway entries, and restrooms. In fact, some pa rticipants found the experience of trying to get into an inaccessible health-care setting too stressful and physically draining and put their health at risk by delaying or avoiding care (Scheer et al., 2003, p. 224). Not all health maintenance issues create problems or difficulties for individuals with disabilities. Yet, there is su fficient evidence of frequent str uggles encountered by individuals with disabilities seeking health care to questi on the source underlying th ese struggles (Shapiro, 1993). The problem, like the disability itself, may be traced to the society or social environment within which the problem exists This line of thought is cons istent with the aforementioned social model of disability. As LMHCs, it is im portant to understand the wi de variety of reactions and variables that are contained in the social li fe of individuals with disabilities. Social Reactions History has shown that social r eactions to individuals with disa bilities have been negative, aversive, and possibly dam aging (Mackelprang & Salsgiver, 1999). Wolfensberger (1972) found that individuals with disabilitie s were often viewed as deviant and were assigned social role
51 expectations based upon such stereotypes. It has also been shown that individuals with disabilities are objects of pity (Shapiro, 1993). This pity is not only revealed on a person-toperson basis, but on a grander public scale as well. Promoting public pity has been consistently used as an effective fund raiser for human services organizations serving people with disabilities (Mackelprang & Sals giver, 1999, p. 5). Although pity may be used as an effective fund raising tool or manipulated in other seemingly beneficial wa ys, the long-term results can be detrimental. Shapiro (1993) reported the words of Evan Kemp, Jr., a then advisor to President George Bush and a key figure in the disabili ty rights movement. As an individual with a disability, he spoke out regardi ng displays of public pity and the possibly damaging effects. He explained that by arousing the publics fears of the handicap itself, the telethon makes viewers more afraid of handicapped people and emphasized that playing to pity may raise money, but it raises walls of fear between the pub lic and us (Shapiro, 1993, p. 22). Individuals with disabilities continue to experience social discrimination and face significant challenges on many fronts (Kraus et al., 1996; NOD, 1994). The unemployment rate for persons with disabilities is deplorably hi gh, relationship development may be sub-optimal, and public misperception of the individual with disability is commonplace (Renard, 2001, Rosenau, 2000 & Shapiro, 1993). Although unfair, society can alienate individuals with disabilities by its social reactions. Hahn (1988) reported that society viewed persons with disabilities that impacted their mobility as ugl y. Although cruel and perhaps ignorant, this can be particularly important in cultures that define beauty in a narrow and restricted sense. Persons with mobility disabilities are seen as particularly offensive aesth etically, and they create an apprehension of difference a kind of xenophobia of nonaesthetics (Mackelprang & Salsgiver, 1999, p. 92).
52 It is crucial that LMHCs accura tely conceptualize the interpla y of environmental and social factors that affect the clients functioning and overall mental hea lth. Social reactions may play a pivotal role in the presenting probl em or have little to do with th e clients dilemma. Along with knowledge of possible social reac tions, it is also imperative th at the LMHC understand his/her own personal views, biases, valu es and distortions. These can significantly affect the LMHCs ability to provide competent treatment for individuals with disabilities. This is directly related to the issue of countertransf erence. While we can come to underst and that disability is not equated with inferior and different is not negative, as ps ychotherapists we must s till remain vigilant to our deeper reactions (Grzesiak & Hicok, 1994, p. 248). Countertransference Countertransference is a concept with which mo st LMHCs are familiar. The therapists countertransference is of central importance in the treatment of individuals with disabilities (Oliveira et al., 2004, p. 431). It has been defined as a set of attitude s, beliefs needs, conflicts, or feelings unconsciously held, or repressed, by th e counselor that is tr iggered by the client (Padrone, 1994). These attitudes, beliefs, or em otions can be positive or negative. Either way, countertransference can interfere with the LMHCs ability to unde rstand the client and adversely affect the therapeutic technique. Researchers ha ve speculated that countertransference strongly influences formation of therapeutic bonds, accu rate assessment of the clients presenting problem, and treatment planning (K emp and Mallinckrodt, 1996, p. 378). Some researchers have noted the possible difficulties encountered when attempting to effectively deal with countertransference brought about by interactions with individuals with disabilities (Marshak & Seligman, 1993; Leigh et al., 2004; Olkin, 1999b). Because individuals with disabilities are in the minority, counselors may have limited opportunity for selfexamination in this area to experience and beco me familiar with their own feelings and attitudes
53 (Padrone, 1994; Tervo, Palmer, & Redinius, 2004). Yet, issues of mortality, independence, physical vulnerability, and sexuality are all part of the disabili ty experience and can prompt significant emotional reactions. Research has shown that the presence of a di sability can change the course or focus of treatment by a therapist. Kemp and Mallinckrodt (1996) conducted a study in which therapists observed a survivor of sexual abuse who was di sabled and one that was non-disabled. The therapists were subsequently asked to provide case conceptualizations. Findings indicated that the therapists emphasized different treatment st rategies primarily depending upon whether or not the client had a disability. When the client wa s disabled, the therapist was more likely to focus on extraneous issues rather than appropriate themes of treatment. Olkin and Howson (1994) discussed a hierar chy of acceptability of disabilities and emphasized the therapists lack of immunity from discrimination agai nst clients with less acceptable disabilities. Disability forces us to recognize that the wo rld is not just, that lightening can strike anyone, and thus we face our own vulnerabilities. Ther efore, in addition to tolerating affect in our clients, we must tole rate in ourselves the strong emotional reactions generated by disability (Olkin, 1999a, p. 95). As with countertransference generated by sources other than disability, awareness of its presence is critical. It is unrealistic to expect LMHCs to rid themselves from any trace of countertransference. However, it is important to deal with the manifestation by consulting with colleagues, ad dressing his/her own personal unresolved issues, or gaining greater knowledge and understanding of the client or population (e.g., individuals with disabilities) that generate this reaction from the counselor (Corey, 1991; Flanagan & Flanagan, 1999).
54 Legal and Ethical Issues LMHCs are bound to provide com petent services to persons with disabilities from a legal and ethical perspective. In 1990, the U.S. government passed the ADA which extends civil rights protection to persons with disabilities. As a result of the ADA, the responsibility for equality and accessibility transferred from persons with disabilities to employers and providers of public services and accommodations (Strike, 2 000). LMHCs, as providers of a public service, became legally obligated to provide non-discrimina tory and accessible care to individuals with disabilities (Mackelprang & Sals giver, 1999). The ADA provided explicit detail regarding the need for such legislation: historically, society has tended to isolate and segregate indivi duals with disabilities, and, despite some improvements, such forms of discrimination against individuals with disabilities continue to be a serious and pervasive social problem; discrimination against individuals with disabilities pe rsists in such critical areas as employment, housing, public accommodations, education, transportation communication, recreation, institutionalization, health services, voting, and access to public services; unlike individuals who have experienced discrimination on the basis of race, color, sex, national origin, religion, or age, individuals who have experienced discrimination on the basis of disability have often had no legal recourse to redress such discriminati on; individuals with disabilities continually encounter various forms of discrimination, in cluding outright inten tional exclusion, the discriminatory effects of architectural, transportation, and communication barriers, overprotective rules and policies, failure to make modifications to existing facilities and practices, exclusionary qualific ation standards and criteria, segregation, and relegation to lesser services, programs, activ ities, jobs, or other opport unities; census data, national polls, and other studies have documented that people with disabilities, as a group, occupy an inferior status in our society, and are severely disadvantaged socially, vocationally, economically, and educationally; individuals wi th disabilities are a discrete minority who have been faced with restrictions and limita tions, subjected to a history of purposeful unequal treatment, and relegated to a position of political powerle ssness in our society, based on characteristics that ar e beyond the control of such i ndividuals and resulting from stereotypic assumptions not truly indicative of the individual ability of such individuals to participate in, and contribute to society; the continuing existence of unfair and unnecessary discrimination and prejudice denies people with disabilities the opportunity to compete on an equal basis and to pursue thos e opportunities for which our free society is justifiably famous.(ADA, 1990).
55 The ADA makes clear the need for equal opportunity and trea tment regarding individuals with disabilities. It is also evident that services provided by health care providers like LMHCs must adhere to the policies and requirements of the ADA. Although compliance by LMHCs may seem straightforward, complications can arise. Counselors may encounter conflicts as they attempt to meet ADA criteria and the ethical codes of their profession. T his state of affairs is especi ally troubling, considering the potentially conflicting ethical requirements that practitioners provide services in a nondiscriminatory manner while working only within the bounds of their competence (i.e., training and expertise). Few generalist pr actitioners have the level of expe rtise in working with disability issues that these ethical impera tives require (Renard, 2001, p. 72). Most LMHCs adhere to a code of ethics pr ovided by the American Counseling Association (ACA). As a parent organization with numerous specialty associations within its fold, ACA and its code of ethics provides guidelines and principl es for all counselors who are members of ACA. As part of the ACA code of ethics, the issues of diversity and disabi lity are addressed and counselors are asked to pursue and maintain an understanding of clie nts diverse cultural backgrounds. Counselors are also required to maintain professional competence and skills pertinent to working with clients from diverse populations (ACA, 1995). Although LMHCs may follow the ethi cal codes of the ACA, a c ode more specific to their profession is provided by AMCHA. The AMCHA code endeavors to provide clear and specific parameters for appropriate conduct and practice by mental health couns elors. This code addresses ethical issues ranging from confidentiality to internet on-line counseling (American Mental Health Counselors Association, 2000). Persons with disabilities are included in this code under the first principle, Welfare of the Consumer. Under the subheading of Diversity, the code
56 requires the following behavior of all counselors. Mental hea lth counselors do not condone or engage in any discrimination based on age, colo r, culture, disability, ethnic group, gender, race, religion, sexual orientation, mar ital status or socioeconomic status (American Mental Health Counselors Association, 2000, Code of Ethics, Welfare of the Cons umer). It should be noted that this is the only instance in which the term disa bility is mentioned in the code. Yet, the code presents persons with disabilities as a unique or distin ct culture with in the general population. The code emphasizes that all counselors shou ld actively attempt to understand the diverse cultural backgrounds of the client s with whom they work (Ameri can Mental Health Counselors Association, 2000, Code of Ethics, Principle 1, sec. E). As part of the principle of Competence, the code furthers this emphasis. Mental he alth counselors recognize the need for continued education and training in the area of cultural diversity and competency. Mental health counselors are open to new procedures and sensit ive to the diversity of varying populations and changes in expectations and values over time (American Mental Health Counselors Association, 2000, Code of Ethics, Principle 7, sec. C). Including persons with disa bilities as part of multicultural issues is an important factor in gaining a greater understanding of this populations need and characteristics. In recent years, issues related to multiculturalism and diversity have become a focal point for many researchers, authors, and clinicians. This is evident by the num ber of publications and data pertaining to multiculturalism and diversity being produced in the field of mental health counseling (Arredondo & Toporek, 2004; Leigh et al., 2004). It also seems evident that LMHCs are receiving more training, exposure, and opportun ity for understanding the various aspects of multiculturalism today than in previous decades (Corey, Corey, & Callahan, 2003). However, it is inappropriate to assume that, because of this persons with disabilitie s are now being provided
57 the types of mental health services afforded to non-disabled clientele. The mere acknowledgement of a minority population does not equate to the understanding of that population. Many researchers have discussed the possibility of biased or inaccurate information being produced or disseminated regarding persons with disabilities (Abrams, Jackson, & St. Claire, 1990; Arredondo & Toporek, 2004; Hahn, 1988; Livneh & Antonak, 1997; Stri ke et al., 2004). It is possible that incorrect assumptions are made by LMHCs when utilizing information about minority populations that is not thorough, substantiated, unbiased, or accurate. Without training or specific education regarding individuals with disabilities, the general public has many misperceptions about disability (Shapiro, 1994). There is no reason to assume that LMHCs do not share these same misperceptions. It has been shown that recently trained counselors report a low level of both confidence and competence in th eir ability to provide effective services to persons with disabi lities (Renard, 2001). Self Awareness/Beliefs/Attitudes Towa rds Individuals with Disabilities One may assume that, because of the traini ng and education in multicultural issues, that LMHCs are more likely to have positive att itudes and beliefs towa rds individuals with disabilities. While this may be true, there is no research or professional da ta to indicate such. Further, attitudes of health professionals toward individuals with disabili ties have been shown to be poor in some studies (Byr on & Dieppe, 2000; Janicki, 1971; Tervo et al., 2004). For the purpose of this study, it is beneficial to take a closer look at the meanings and concepts of selfawareness, belief, and attitude as they relate to individuals with disabilities. Self-awareness regarding disability is a crit ical issue for LMHCs to examine during and prior to working with individua ls with disabilities. Many counselors may not place much importance on this issue because biases and perspectives are not self-evident. However, before
58 LMHCs can work successfully w ith individuals with disabili ties, they must understand how disabilities relate to their own life circumstances. Failure to take a personal inventory regarding attitudes and beliefs on these matters may translate into interactions that serve to interfere with their effectiveness in the counselor's role (Durodoye, Combes, & Bryant, 2004). Historically, our language and media im ages surrounding disability have evoked sympathy, pity, or horror (Treloar, 1999, p. 1). A lthough great strides have been made in our understanding of disability, stil l we may see a person using a wheelchair and inappropriately assume cognitive impairment in addition to physi cal disability. Viewing each individual with a disability as a person-first begins with the LMHCs self-a wareness of personal biases and assumptions about disability. De-labeling our be liefs and perceptions precedes our establishing a therapeutic relationship with a person having disabilities (Taylor & Bogdan, 1993). It is undeniable that every person brings ones own cultural baggage to every relationship. LMHCs entering in to a counseling relationship shoul d be viewed no differently. Ones own cultural experiences create assumpti ons and miscommunications that can lead to expectations of behaviors (Galle, Angelo cci, Lacho, & Lacho, 2005, p. 5). Examining and gaining greater self-awareness of ones beliefs re garding disabilities will se rve as a precursor to changes or adjustments in false or inappropriate belief systems. Gaini ng greater self-awareness and understanding the influence of his/her belie fs upon the LMHCs couns eling relationship is essential in maintaining a positive working re lationship with clients with disabilities. Understanding and modifying self-awareness and belie fs pertaining to disability may also serve as a foundation for a positive at titude towards disability. A standard definition of attitude can be found in the Merriam-Webster dictionary (2003). The text describes attitude as a mental position w ith regard to a fact or state as well as a
59 feeling or emotion towards a f act or state (Merriam-Webster 2003, p. 76). In their book on the measurement of attitudes towards individuals with disabilities, Antonak and Livneh (1988) provide one of the most thorough and specific de finitions of attitude. The authors begin by describing attitude as comprise d of two dimensions. The first dimension is represented on a continuum of abstractness, ranging from concrete to abstract. The second dimension is represented by the extensiveness of the components within the de finition. The au thors explained that attitudes can be conceived as mediators between specific observed environmental stimuli and specific behavioral responses. With regards to abstractness they indicate: as attitudes are judged to be more proximal causes of behavior, th e more affect they will be thought to exert on the ensuing behavior and the more specific the definition will become (Antonak & Livneh, 1988, p. 7). The second dimension of attitude, extensiveness provides the basis fo r conceptualizing the content of attitude. There are three components to the dimension of extensiveness: cognitive, affective, and behavioral. The cognitive com ponent refers to the persons ideas, thoughts, perceptions, beliefs, or opinions about the attitu de referent. It repres ents how the attitude referent is conceptualized. T he cognitive component, viewed as an index of meaning, is ordinarily measured by such instruments as ad jective checklists and by the activity and potency factors of the semantic differential (Antona k & Livneh, 1988, p. 7). The affective component of attitude reflects the feelings behind the at titude or the emotion that fuels the cognitive component of the attitude. This component is typically expressed in terms of good-bad, likedislike, and pro-con. Measurement instruments fo r this component usually include a Likert type scale. The third component of extensiveness is be havioral. This consists of the actual observed or overt reaction to the attitude referent. Th e behavioral component is usually measured by
60 social distance scales and through observations of how the person actually behaves when dealing with the attitude referent. The authors summari ze concepts related to attitude by discussing common themes in the following paragraph: there appears to be a consensus among scholar s and researchers that attitudes have the following elements: (a) attitudes are learned through experience and in teraction with other people, social objects, and environmental events, rather than being innately determined, although the role of heredity or constitutional factors in attitude formation has not been fully investigated; (b) attitudes are complex, mu lti-component, structures; (c) attitudes are relatively stable (even rigid) as evidenced by their resistance to change; (d) attitudes have a specific social object as a referent (e.g., pe ople, situations, events, ideas); (e) attitudes vary in their quantity and quality, posse ssing differing degrees of motivating force (intensity, strength), and direction (toward, against, away from the attitude referent); and (f) attitudes are manifested behaviorally via predisposition to act in a certain way when the individual encounters the attitude referent (Antonak & Livneh, 1988, pp. 9-10). Olkin (1999b) identified numer ous factors that influence or shape persons attitudes towards disability. These factors included (but were not limited to): beliefs about disability, amount of contact with individuals who have disabilities, the nature of the disability, significant others attitudes, educat ion, mass media, local soci al norms, and characteri stics of the individual who has the disability. Beliefs about disability are developed or affected by prior contact with individuals who have di sabilities, significant others attit udes, education, and mass media. Interestingly, Olkin (1999b) indicated that mass media has a major impact where there is a lack of other types of information available or wh en there is limited exposure to the particular disability. This may be of particular importance to LMHCs due to the possible lack of training and education they receive. Information rega rding disability provi ded in curricula and supervised practicum experiences would lead to more positive beli efs about disability on the part of new counselors (Renard, 2001). Contact can have a positive effect in reducing or eliminating stereotypes when the interaction between individuals is positive or mutually rewarding, characterized by cooperative interdependence between persons of equal status (Olkin, 1999b). Yet, there is a perceived power
61 and status differential in most counseling relatio nships that may not conform to the conditions that lead to more positive attit udes via exposure to persons with disabilities (Olkin & Pledger, 2003; Renard, 2001; Smart & Smart, 2006). The local social norms and att itudes of significant others can influence the type of contact that people have with individua ls with disabilities by determining what is appropriate or common. The type, severity, perceived cause, or potential for transmission also influences attitudes. Characteristics such as age, race, sex, and socioeconomi c status of the person with the disability also shape attitude s. Other factors to consider are the individuals perceived intelligence, social skills, attractiveness, and comfort with his/her disability. Although more educated individuals are associated with mo re positive attitudes toward individuals with disabilities, Olkin (1999b) indicated there are no data to support the contention that therapists of any discipline bear attitudes to ward disability that are notab ly different from the general publics (p. 65). Negative attitudes towards individuals with di sabilities typically are founded in a lack of knowledge and the perpetuation of incorrect, often negative, st ereotypes (Hunt & Hunt, 2004). Such negative attitudes can be the foundation fo r discrimination, bias, an d many other barriers and obstacles. As previously mentioned, this hold s true not only for the general public but also for those working in the healthcare arena. Peo ple with disability often identify inappropriate staff attitudes and behaviors as the biggest barrier to accessing health services (Tervo et al., 2004, p. 908). Research has shown that more positive attitudes toward s individuals with disabilities are being reported (Furnham & Thompson, 1994). However, this change may be due to socially desirable answers instead of actual att itude change. The theory of social desirability suggests that people respond favorably to items expressing what is deemed socially proper
62 (Wright, 1983). In other words, attitudes towards persons with disabilities may not have changed significantly, instead, indi viduals may be less willing to convey their true feelings of negativity because they know it is less acceptable now to express pr ejudices and stereotypes in our society (Folie, 2006, p. 44). Many researchers believe that the changing of attitudes is a lofty, long-term goal. Attitudes toward disability are difficult to change. There are hundreds of studies on this issue and overall the results are not encouraging (Olkin, 1999b, p. 72). Although negative attitudes towards individuals with disabili ties are often difficult to change it is not impossible and should be considered a worthwhile endeavor; especi ally when considering the consequences of not changing them (Hunt & Hunt, 2004). Many advocat es and researchers believe that changing attitudes is one of the most important fact ors in improving the overa ll quality of life for individuals with disabilities (Brodwin et al ., 1994; Huitt & Elston, 1991 ; Leigh et al., 2004). Negative attitudes and beliefs abou t disability can be changed via (a) exposure to persons with disabilities, (b) conscious evaluation of stereotypical beliefs in light of actual experience, and (c) the development of a larger database of info rmation about the indivi dual, so that no single characteristic stands out so much that it alone represents the indivi dual (Renard, 2001, p. 69). In order to provide effective and competent se rvices to individuals with disabilities, the LMHC must gain an awareness and understanding of his/her attitudes toward disability and related issues (Boden, 1992; Hunt, Matthews, Milsom, & Lammel, 2006). If training and education of LMHCs is lacking content that woul d afford the clinician the opportunity to gain greater awareness and understand ing of his/her attitudes toward disability, and contact with individuals who have a disabili ty is occurring, the profession as a whole may be perpetuating professional incompetence. Human service practitioners who work with persons with
63 disabilities and their fam ilies are often forced to face their own attitudes and values about the meaning of disability an d their feelings about those who have disabilities. Professional selfawareness of our attitudes about disability is the first critical component of professional practice (Mackelprang & Salsgiver, 1999, p. 14). LMHCs Level of Knowledge Regarding Disability From a more practical standpoint, the question may be asked: How much do LMHCs really need to know about disability issues? As pr eviously mentioned, ther e are professions that specialize in the area of disabili ty (e.g.; rehabilitation psychol ogists, rehabilitation counselors) that can also provide mental health counseli ng services. Certainly, these professions are alternatives for individuals with disabilities seeking mental health counseling and may be the most appropriate choices; especially if the presenti ng problem is directly rela ted to the disability. Yet, it is nave to believe that generalist c ounselors will treat only those within the general population, exclusive of minorities. Although it is the case that some clients with disabilities, particularly those with recent ons et of disability such as trau matic brain injury, spinal cord injury, or stroke, may be trea ted primarily by rehabilitation ps ychologists, most clients with disabilities who seek evaluation or psychotherapy are seen outsid e the sphere of rehabilitation psychology (Olkin & Pledger, 2003, p. 296). Not unlike working in collaboration with other pr oviders such as psychi atrists, psychiatric nurse practitioners, and physiatris ts, it is useful for the LMHC to have a general working knowledge of the dynamics and/or conditions of the client in which these other providers specialize. For example, while LMHCs do not typically specialize in psychotropic medication management, most have a general working knowle dge of antidepressants and other psychotropic medications. The LMHC may utilize a specialist in disability as a consultant or collaborate with one during the course of care. Moreover, the LMHC should understand how disability can effect
64 diagnosis, course of treatment and treatment outcome (Olkin, 1999). When the presenting problem arises out of disabil ity or requires in-depth knowledg e and expertise pertaining to a specific disability, it may be appropriate for the LMHC to refer out to a rehabilitation counselor (or similar professional) for mental health care. Nonetheless, MHCs ofte n can provide valuable service to those with disabil ities and need not automatically refer these clients to other specialists. When MHCs have partic ipated in short-term training a bout disability issues, they can differentiate needs arising from the disability from those that are likely to arise from the natural course of life itself (Hayes & Potter, 1995, p. 18). LMHCs Level of Skill Regarding Disability Although an LMHC m ay possess awareness and k nowledge regarding disability issues, it is also imperative that the clinician possess adequate skills when working with this population. Studies regarding mental health professionals sk ills and behaviors when working with clients with disabilities have shown mixe d findings. Researchers examined counselors skill in the use of unbiased language and noted no main effect was found for the polit ical correctness of language (Arokiasamy, Strohmer, Guice, Angelo cci, & Hoppe, 1994). Kemp and Mallinckrodt (1996) examined case conceptualiz ation skills and found that portraying a client as disabled distracted counselors from the theme of sexual ab use. Strike and colleagues noted that mental health professionals may affect clients with di sabilities less by the language they use and more by their conceptualizatio n of cases. Similar variations ma y be found across other skills and behaviors. (Strik e et al, 2004, p. 322). As mentioned in previous pages, most counselor training programs, with the exception of specialties such as rehabilitation counseli ng or rehabilitation psychology, do not provide adequate (if any) traini ng or coursework on disability rela ted issues. (Smart & Smart, 2006). Content analysis of popular textbooks in counsel or education programs revealed a lack of
65 disability topics or worse, biased presentations of persons with disabilities (Rosenau, 2000). Therefore, it may be unreasonable to expect LM HCs to possess adequate counseling skills when working with individuals with disabilities. Howe ver, this should not lead one to assume that LMHCs are incapable of tr eating this population. Bu t even if the clients presenting problem is not related to his or her disabili ty, it is still possible that the di sability will be a factor in the counseling process. Understanding the advantages of specific th eoretical approaches when treating this population can be a crucial element in the provisi on of services. For example, some researchers note that person-centered counsel ing with its lack of assumpti ons about how people respond to disability is seen by some to be the least intrusiv e counseling approach, when compared with psychodynamic and behavioral approaches (Reev e, 2000, p. 671). In addition to choosing a theoretical approach, other issues such as building and maintaining coun selor/client rapport and understanding non-verbal communications and cu es may present unique challenges for the LMHC when treating this population. Summary This chapter has presen ted a review of the relevant literature pertaining to LMHCs treatment with individuals with disabilities. De mographics of individuals with disabilities were examined and showed this group to be the larges t minority population; one that is continues to grow. The profession of mental health couns eling was reviewed and was also found to be growing; not only in numbers of practitioners, but in exposure and access to diverse client populations. However, an analysis of literature pertaining to counselor training and preparation showed a probable lack of educa tion and instruction provided to LMHCs in the area of disability. An examination of literature regarding mental health counse ling needs of individuals with disabilities showed clear evidence of such needs in the areas of social, relationship, vocational,
66 and overall life satisfaction. An in-depth look at disability was provided by examining models of psychosocial adjustment, practical issues, health maintenance issues, and social reactions. More specific to the counseling profe ssion was the literature reviewed on countertransference and legal/ethical issues. Finally, an analysis of the literature pert aining to attitudes, knowledge and skills regarding individuals with disabilities wa s provided with a focus on how these constructs apply to LMHCs. In chapter 3, the aforementioned information is utilized as a foundation for this authors research. Specific methods that were used to conduct this study ar e described along with information regarding the instruments and techniques utilized in gathering data.
67 CHAPTER 3 METHODOLOGY This chapter describes the m ethodology of the study. Topics in this chapter include information regarding the study design, procedures of the study, instrument ation, and statistical analysis. The intent of this study is to examine the amount of contact LMHCs have with individuals with disabilities, and to descri be LMHCs Self-Awareness/Beliefs/Attitudes, perceived Knowledge, and perceived Skills when treating individuals with disabilities. Furthermore, the predictive value of the amount of contact upon LMHCs perceived Knowledge and Skills and the predictive value of LMHCs Self-Awareness/Beliefs/Attitudes toward disability upon their perceived K nowledge and Skills is examined. Study Design This study utilized two separate instrument s that were designed to evaluate LMHCs amount of contact, Self-Awareness/Beliefs/A ttitudes, Knowledge and Skills regarding individuals with disabilities. A five-item questionnaire was also us ed to gather demographic data of LMHC participants. The dependent variables are 1) LMHCs self-perceived levels of Knowledge regarding disability 2) LMHCs self-perceived levels of Skills when working with an individual with a disability The independent variables are 1) the amount of contact by the LMHC with individuals with disabilities 2) the Self-Awareness/Beliefs/Attit udes reported by LMHCs pertaining to individuals with disabilities An email was sent to a convenience sample (N=1235) of LMHCs within the state of Florida requesting their particip ation in the study (Appendix A). The email provided a link to a
68 web-based survey site that contained two inst ruments and a demographic questionnaire. There were numerous reasons for utilizing email and the internet for the dissemi nation and collection of research data. Studies have shown that this method can increase accuracy of data entry, produce a more timely collection of partic ipant responses, and reduce costs sp ecific to surv ey replication (Thomas, Rogers, & Maclean, 2003). Furthermor e, it provided a more convenient method of participation for the LMHC and allo wed this researcher the ability to track response rates as they occur. Electronic surveys are becoming increasingly common, and research comparing electronic vs. postal su rveys is starting to confirm that elec tronic survey content results may be no different than postal content results, yet prov ide strong advantages of speedy distribution and response cycles (Andrews, Nonnecke, & Preece, 2003, p. 186). The initial email to the sample population incl uded an informed consent letter (Appendix B), described the purpose of the study and re quested participation by the LMHC The parameters of confidentiality, the voluntary nature of the st udy, and response returns were explained. The completion of the instruments an d the demographic questionnaire were estimated to take approximately ten minutes. A second em ail was sent approximat ely one week following the initial email to those that di d not respond to the first. Collec tion of data lasted approximately two weeks. Selection of Participants A convenience sam ple of individuals (N=1235) was surveyed from a population consisting of active LMHCs in the state of Florida (N=6692). Participants included the entire list of email addresses maintained by Floridas Department of Health, Division of Medical Quality Assurance. The email addresses were voluntari ly provided to the state by LMHCs during the initial or renewal licensure application process. Because it was impossible to accurately predict the number of responses or rate of attrition, a nd due to the possibility that many of the email
69 addresses on the list were no l onger current or in use, the enti re email list (N=1235) was used. Research indicates that online surveys can yield av erage response return rate s that vary from 3% to over 50% (MacElroy, 2000). A power analysis was conducted in the GPower statistical program (Cohen, 1977). Results indicated that with a medium e ffect size of 0.15, Alpha = 0.05, power = 0.90 and 2 predictors, a sample size of approximately N = 123 participants was needed. Participants that left items blank or did not complete any porti on of the study were excluded from the final analysis of the data. Instruments Contact with Disabled Person Scale To m easure the amount of contact the LMHC have with individuals with disabilities, Yuker & Hurleys (1987) Contact with Disabled Persons Scale (CDP) was used (Appendix C). The CDP was created to provide a reliable and valid measure of an individuals prior contact with people with disabilities. The original ve rsion of the CDP was modi fied to utilize personfirst language. The scale contains 20 items and uses a five-point Likert-type scale to measure the amount of contact a person has ha d with individuals with disabilities. Yuker and Hurley (1987) reported that the scale was reliable with a correct ed median split-half reliability coefficient of 0.93 and a median alpha coefficient of 0.92. Th e reliability of the CDP was high, with a Cronbach alpha coefficient of .87. Correlation co efficients ranged from .26 to +0.40, with a median correlation of +0.10. In response to the 20 items on the CDP, partic ipants are asked to indicate the extent of their contact with an individual with a disab ility. Each response should reflect the most appropriate one of five choices (1 = never, 2 = once or twice, 3 = a few times, 4 = often, 5 = very often). Some of the items measure only the amount and type of prior contact while other have an
70 affective component (i.e.; How often have you met an individual with a disability for whom you feel sorry?). Although some items refer to negative contact or in teractions with an individual with a disability (i.e.; How often have you been annoyed or disturbed by th e behavior of a person with a disability?), all items are scored in the sa me manner. The scoring is based upon the extent of contact, not whether the contact is positive or negative (Yuker & Hurley, 1987). Scores on the CDP can range from 20, reflecting no contact at all, to 100, representing maximum contact in all areas. Counseling Clients With Disabilities Survey (CCDS) Three areas of perceived com petence repor ted by study participants were measured utilizing Strikes Counseling Clients With Disabilities Survey (See Appendix D). This instrument is the only existing in strument that measures mental health professiona ls disability competence. The Self-Awareness/Beliefs/Attitudes scale of the CCDS is designed to measure the counselors awareness, beliefs, and attitudes about the impact of being disabled or non-disabled. The perceived Knowledge scale of the CCDS m easures participants factual knowledge about disability that includes exposure to or training about disa bility. The perceived Skills scale of the CCDS measures skills and behavior s that are desirable in mental health practiti oners who treat individuals with disabilities. Th ese items convey effort by the participant to be accessible to the individual with a disability (S trike et al., 2004). Each of the three scales contains 20 items, combined for a total of 60 items. The partic ipants can express a range of agreement to disagreement on a 6-point scale. A total score ranging from 20 to 120 is possible on each scale, with higher scores reflecting great er disability competence. The reliability of the CCDS was tested utiliz ing Cronbachs coefficien t alpha using data from the Strike et al. (2004) study. A hi gh level of internal consistency, Cronbachs = .94, was
71 obtained from the total scale and thus reflected items that were internally consistent. The internal consistencies obtained for each individual scale were as follows: SelfAwareness/Beliefs/Attitudes scale = .67, perceived Knowledge scale = .87, and the perceived Skills scale = .90. Correlations were de termined between the SelfAwareness/Beliefs/Attitudes and percei ved Knowledge scales (.72), SelfAwareness/Beliefs/Attitudes and perceived Skills scales (.69), and perceived Knowledge and perceived Skills scales (.81), with a pos itive relationship appearing among SelfAwareness/Beliefs/Attitudes, Knowledge and Skills. (Strike et al., 2004). Demographic Questionnaire Accom panying the CDP and the CCDS was a five-item questionnaire regarding demographic information of the LMHC particip ant (See Appendix E). Th e questions consisted of 1) gender type; 2) age range ; 3) ethnicity; 4) year s of experience in mental health and; 5) the academic background of the LMHC. The demographic questionnaire was reviewed by an expert panel of mental health and disability professionals. This process involved a review and critique of numerous possible de mographic items. Only items that were free from ambiguity, applicable to the study, and approved by all members of the expert panel were included. As part of the demographic questionnaire, the participants were asked to report the academic training program from which they earned their degr ee. Two of the optional answers included rehabilitation counseling and rehabilitation ps ychology. Because these educational backgrounds would have likely provided extensive training in disability related issues, scores from those individuals would risk skewing the data. Therefore, scores from participants reporting either one of the rehabilitation backgrounds were not included in the analyses of data.
72 CHAPTER 4 RESULTS Results from the current study are described below. First, sam ple characteristics will be reported, followed by measurement reliabilities, and finally results of the analyses addressing each of the three hypotheses. Sample Characteristics The return rate for this study was better than expected with 243, or approxim ately 20% of the sample population (N=1235), responding. Of th e 243 responses, 221 participants completed all three instruments. Twenty-two participants responses were not included in the analyses of the data due to their rehabilitation background. The final sample consisted of 199 licensed mental health counselors practicing in the state of Florida (140 female, 59 male). The sample was primarily Caucasian (78.4%), followed by La tino (10.1%), African American (6.0%), Other (2.5%), Asian/Pacific Islander (2.0%), and American Indian ( 1.0%). The largest group of participants reported their age to be 5060 years old (30.2%), followed by 30-40 years old (27.6%), 40-50 years old (26.1%), 60+ years old (12.1%), and 20-30 years old (4.0%). Participants were asked to report the academic training program from which they earned their degree. Almost half graduated from psychology training programs (47.7%), followed by counselor education (40.7%), social worker s (2.5%), and other (9.0%). Additionally, participants reported their years of experience working in the mental health arena as follows: 30.7% had 10-15 years of experience, followed by 28.1% with 20+ years of experience, 21.1% with 5-10 years of experience, 18.6% with 1520 years of experience, and 1.5% reported 0-5 years of experience. These demographic sample characteristics are illustrated in Table 4-1.
73 Descriptive and Preliminary Analyses Measurement Reliability Reliability s tatistics for the CCDS (SelfAwareness/Beliefs/Attit udes, Knowledge, and Skills) and CDP appear in Table 4-2. Cronbachs alpha for the CCDS total scale score was .94. Alpha values for the three subscales of the CCDS were as follows: SelfAwareness/Beliefs/Attitudes subscale alpha = .60, perceived Knowledge subscale alpha = .86, and perceived Skills subscale alpha = .89. This is co mparable to previous reports by Strike et al., (2004) (.94, .67, .87, and .90, respectively). Because the alpha for the SelfAwareness/Beliefs/Attitudes subscale was belo w acceptable standards (approximately .70) adjustments were made to increase the reliabil ity of this subscale. Experts recommend that researchers revise already devel oped scales by dropping items if re liability coefficients in the study are insufficient (Wilkinson & TFSI, 1999). Ther efore, three items were removed from this subscale (items 10, 14, and 18), which increase d the reliability to .70. Removing item 18 ( Having my mobility temporarily impaired would give me a true picture of living with a mobility disability .) increased the alpha to .66. Removing item 14 ( I enjoy hearing about people who overcame their disabilities .), increased the alpha to .68. Fina lly, the alpha was improved to .70 by removing item 10 ( I believe being non-disabled has cer tain privileges in society. ). No further items were removed because doing so only increa sed the alpha level by small increments (i.e., less than .01 increase). The re vised 17-item Self-Awareness/Belie fs/Attitudes subscale was used for all of the analyses in the current study. Relia bility for the CDP indicated an alpha level of .92 for the overall scale score, which was used in the current study. This is comparable to previous reports by Yuker & Hurleys (1987) (.87).
74 Hypothesis 1 For the first hypothesis ( LMHCs will report between minimum and moderate amounts of contact with individual s with disabilities ), a des criptive analysis wa s conducted to obtain the mean number of contact hours. Re sults indicated that participants reported moderate amounts of contact with individual s with disabilities (M = 63.23, SD = 12.77), with a fairly wide range of scores = 76 (Minimum = 26, Maximum = 100). This was within the predicted direction, but was somewhat on the higher end of the predic tion (moderate rather than minimum). Hypothesis 2 For the second hypothesis ( LMHCs will des cribe themselves as having higher levels of Self-Awareness/Beliefs/Attitudes to ward disability-related issu es than perceived Knowledge and perceived Skills, and will descri be their levels of perceived Knowledge of disability and disability-related issues to be higher than their perceived Skills with perceived Skills rated the lowest of the three variables ), three different paired samples t-tests were conducted at the .05 alpha level to compare the means of the three diff erent variables. Significant differences were found between Self-Awareness/Beliefs /Attitudes and perceived Knowledge (t (174) = -10.79, p < .0001), between Self-Awareness/Beliefs /Attitudes and perceived Skills ( t (174) = -7.23, p < .0001), and perceived Knowledge and perceived Skills ( t (174) = 2.22, p < .0001). The means on these scales in order from greatest to least are: perceived Knowledge ( M = 82.37, SD = 11.96), perceived Skills ( M = 81.01, SD = 13.54), and Self-Awarene ss/Beliefs/Attitudes (M = 75.27, SD = 7.32). As previously indicated, a score betw een 20 and 120 can be obtained on each scale. Higher scores are indicative of gr eater self-reported disability co mpetence. Yet, high or low disability competence cannot be concluded on the basis of a response to an individual scale. Only one other study utilizing the CCDS is curren tly published but scores from this study reflect
75 similar means (Knowledge M = 76, Skills M = 68, and Self-Awareness/Beliefs/Attitudes M = 87) (Strike et al, 2004). The results from the current study were in th e predicted direction for reported levels of perceived Knowledge being higher than reported levels of perceived Skills. However, results were not in the predicted directions for Se lf-Awareness/Beliefs/Attitudes being higher than perceived Knowledge and Skills with Self-Aware ness/Beliefs/Attitudes having the lowest mean of these three variables. Correlational Analyses Pearson Product Mom ent correlations, using a criterion level of .001 (2-tailed), were computed between the two criterion variables (p erceived Knowledge and perceived Skills) and each of the predictor variables (Self-Awareness/Beliefs/Attitudes a nd Contact) in an attempt to confirm that the relationships were in the predicted directions. Participant perceived Knowledge was significantly positively correlated with the perceived Self-Awareness/Beliefs/Attitudes (r = 0.69, P .001) and Contact (r = 0.68, P .010), which were in the predicted directions. Participant pe rceived Skills were also significantly positively correlated with perceived SelfAwareness/Beliefs/Attitudes (r = 0.63, P .001) and contact (r = 0.65, P .001); these were also in the predicted di rections. See Table 4-3 for the correlation matrix. Regression Analyses In order to assess th e capacity of the data to meet the normality assumptions of linear regression, the data was subjected to tests of skewness and kurtosis. Results of these analyses indicated that the assumptions for multivariate normality were met. All skewness and kurtosis
76 estimates for the variables in the current study fe ll within the generally ac cepted values of 1 and Hypothesis 3 For the third hypothesis ( LMHCs who report more frequent contact with individuals with disabilities and have higher Self-A wareness/Beliefs/Attitudes scores will report higher levels of perceived Knowledge and percei ved Skills when working with individuals with disabilities ), two linear regressions were conducted. T he first re gression analysis tested LMHCs amount of contact with individual s with disabilities and their Self -Awareness/Beliefs/Attitudes toward disability as predictors of their perceived Knowledge when working with individuals with disabilities. The scores on the participants amount of contact with individuals with disabilities and Self-Awareness/Beliefs/Attitudes variab les accounted for signi ficant variation in participants perceived Knowledge scores, F (2, 172) = 130.07, p < .001 ( adjusted R = .597). The standardized beta coefficient for the CDP scale ( = 0.426) was in the positive direction and was significant, t (172) = 7.35, p < .001. The standardized beta coefficient for the SelfAwareness/Beliefs/Attitudes subscale ( = 0.453) was also significant and in the positive direction, t (172) = 7.83, p < .001. The direction of effects in dicated that LMHCs that reported higher levels of Self-Awareness /Beliefs/Attitudes and reported hi gher levels of contact with individuals with disabilities, were more likely to re port having higher levels of knowledge about disability. This supported the hypothe sis that these criterion variab les tend towards the direction of higher levels of perceived Knowledge in LMHCs represented by a large effect size, accounting for approximately 60% of the vari ance in LMHCs perceived Knowledge. The second regression analysis tested the degree to which LMHCs amount of contact with individuals with disabilities and their Self-Awareness/Beliefs/Attitudes toward disability predict their perceived Skills when working with indivi duals with disabilities. The scores for the
77 participants amount of contact with i ndividuals with disabilities and SelfAwareness/Beliefs/Attitudes vari ables accounted for significant variation in participants perceived Skills scores, F (2, 172) = 94.81, p < .001 ( adjusted R = .519). The standardized beta coefficient for the Self-Awareness/Beliefs/Attitudes subscale ( = 0.381) was significant and in the positive direction, t (172) = 6.01, p < .001 and the standardized beta coefficient for the CDP ( = 0.439) was also significant and in the positive direction, t (172) = 6.93, p < .001. The direction of effects indica ted that LMHCs that endorsed higher levels of SelfAwareness/Beliefs/Attitudes about the impact of being disabled or nondisabled and reported higher levels of contact with disa bled persons, were more likely to report having higher levels of skills and behaviors that are desi rable in mental health practiti oners who treat individuals with disabilities. This supported the hypothesis that these criterion variables tended towards the direction of higher levels of perceived Skill in LMHCs represented by a large effect size, accounting for approximately 52% of the variance in LMHCs perceived Skills. Summary Three different analyses were conducted to investigate the three hypotheses in the current study concerning the am ount of contact LMHCs have with individuals with disabilities, and the relationships between LMHCs Self-Awareness/Beliefs/Attitudes, perceived Knowledge and perceived Skills in working with individuals with disabilities and their reported levels of contact with individuals with disabilities. The descriptive analysis of Hypothesis 1 variables indicated that LMHCs reported moderate amounts of contact with i ndividuals with disabilities. This was at the higher end of the predicted directions and suggests th at clinicians are inte racting with this p opulation on a regular basis and may possibly be providing mental health treatment as a reason for these interactions. This issue will be examined in more detail in chapter five.
78 For Hypothesis 2, results from three paired sa mple t-tests indicated that LMHCs reported higher levels of perceived Knowledge about disa bility than possessing skills and behaviors that are desirable in mental health practitioners who treat individuals with disabilities, or LMHCs reported Self-Awareness/Beliefs /Attitudes regarding disabili ty. LMHCs also reported possessing higher levels of skills and behaviors that are desirable in mental health practitioners who treat individuals with disabilities than their reported levels of SelfAwareness/Beliefs/Attitudes regarding disability. Lastly, regression analyses for Hypothesis 3 indicated that coun selors with higher levels of Self-Awareness/Beliefs/Attitudes, as well as higher levels of reported contact with individuals with disabilities, had higher levels of perceived Knowledge and Skills. These variables accounted for approximately 60% and 52% of the variance respectively.
79 Table 4-1 Demographic Variables Demographic Variables Frequency (f) Percentage(%) Gender Male 59 29.6 Female 140 70.4 Total 199100.0 Ethnicity African American 12 6.0 American Indian 2 1.0 Asian/Pacific Islander 4 2.0 Caucasian 156 78.4 Latino 20 10.1 Other 5 2.5 Age 20-30 years old 8 4.0 30-40 years old 55 27.6 40-50 years old 52 26.1 50-60 years old 60 30.2 60+ years old 24 12.1 Academic Training Counselor Education 81 40.7 Psychology 95 47.7 Social Work 5 2.5 Other 18 9.0 Years Experience in Clinical Work 0-5 years 3 1.5 5-10 years 42 21.1 10-15 years 61 30.7 15-20 years 37 18.6 20+ years 56 28.1
80 Table 4-2 Paired Samples T-Tests for Know ledge, Skills, and Self-Awareness Subscales 95% Confidence Interval of the Difference Pairs Mean Difference Std. Dev. Std. Error Mean Lower Upper t df Sig (2tailed) KnowledgeSkills 1.29 7.71 .58 .14 2.44 2.22 174 .028 KnowledgeSelfAwareness -7.10 8.70 .66 -8.40 -5.80 -10.79 174 .001 SelfAwarenessSkills -5.81 10.63 .80 -7.39 -4.22 -7.23 174 .001 Table 4-3 Measurement Reliabilities for the CCDS and CDP Scale N Alpha P-Value CCDS Total Scale 175 .94 .001 Self-Awareness 175 .70 .001 Knowledge 175 .86 .001 Skills 175 .89 .001 CDP 198 .92 .001 Table 4-4 Pearson Product Moment Correlations Matrix Measures 1 2 3 4 1. CDP 1 2. Self-Awareness .56** 1 3. Knowledge .68** .69** 1 4. Skills .65** .63** .82** 1
81 CHAPTER 5 DISCUSSION Summary of Findings A sa mple of 199 LMHCs in the state of Flor ida participated in the current study. The sample population was mostly Caucasian, predominately female, with over half of the participants reporting to be more than 30 years of age. Nearly all of the participants graduated from either psychology or counsel or education training programs. Approximately 80% reported having 10 or more years of clinical experience. The findings regarding Research Question #1 ( What is the amount of contact with individuals with disabili ties reported by LMHCs? ) were consistent with Hypothesis #1 (LMHCs will report between minimum and moderate am ounts of contact with individuals with disabilities ). Participants reported moderate amount s of contact (M = 63. 23) with individuals with disabilities. The findings regarding Research Question #2 ( Do LMHCs rate their levels of SelfAwareness/Beliefs/Attitudes, perceived Knowle dge and perceived Skills in different ways? ) revealed some inconsiste ncies with Hypothesis #2 ( LMHCs will have higher levels of SelfAwareness/Beliefs/Attitudes toward disability than perceived Knowledge and perceived Skills, with perceived Skills rated the lowest of the three variables .). Perceived Knowledge had the highest reported average sc ore (M = 82.37), followed by perc eived Skills (M = 81.01), and finally Self-Awareness/Beliefs/Attitudes (M = 75.27). The findings regarding Research Question #3 ( Does the amount of contact LMHCs have with individuals with disabilities and their Self-Awareness/Beliefs/Attitudes toward disability predict their perceived Know ledge and perceived Skills? ) were consistent with Hypothesis #3
82 ( Both amount of contact and Self-Awareness/Beli efs/Attitudes will be predictors of LMHCs perceived Knowledge and perceived Skills .) Research Question #1 Discussion The findings regarding Research Question #1 indicated that L MHCs in Florida have moderate amounts of contact with individuals with disabilities. The average score for the CDP was approximately 63, on a scale of 20-100. This amount of contact is supported by literature that reports the large number of individuals with disabilities in so ciety. Further, researchers have shown that individuals with disa bilities are becoming more mainst reamed and likely to seek the care of generalist counselors. One cannot a ssume, based on this data, that all LMHCs will evaluate or treat individu als with disabilities. The type of c ontact examined in this study is not limited to clinical or treatment interactions. However, the diversity a nd multicultural makeup of the LMHC client population is evident and data from this study s upport the likelihood that individuals with disabilities ar e a component of that population. The implications of this finding suggest that LMHCs are indeed in contact with individuals with disabilities and it is reasonable to assume that at least some of this contact takes place in a clinical setting or during the provision of services. More specific assessments of LMHCs regarding the number of clie nts with disabilities would clarify this issue. However, as previously stated, counselors are ethically bound to provide unbiased, competen t treatment to all clients and it would seem likely that indivi duals with disabilities represen t a portion of that clientele. Research Question #2 Discussion The findings regarding Research Questi on #2 indicated that LMHCs perceived Knowledge had the highest reported average scor e, followed by perceived Skills, and then SelfAwareness/Beliefs/Attitudes. As previously men tioned, the comparatively low score of the SelfAwareness/Beliefs/Attitudes scale was inconsistent with the previous research regarding
83 attitudes towards disability in the study utilizing the CCDS (Strik e et al., 2004). However, data from this current study should not be interpreted in a way that represents LMHCs as having poor or negative attitudes. The CCD S Self-Awareness/Beliefs/Attitude s scale has a scoring range of 20-120, and it is inappropriate to as sume that a score average of approximately 75 reflects a poor or negative attitude. Yet, gi ven that: 1) past research has found positive attitudes towards individuals with disabilities by mental health professionals (C arney & Cobia, 1994; Gordon et al., 1990; Huitt & Elston, 1991), 2) researchers ha ve shown inadequacies in counselor training and education regarding disabi lity knowledge and counseling skills (Rosenau, 2000; Smart & Smart, 2006), and 3) the previous st udy utilizing the CCDS found the SelfAwareness/Beliefs/Attitudes scale to have the highest average scor e of the three scales, it is reasonable to expect findings different from those in this study. A possible reason for the difference in outcome s may be due to the small range of score averages in the three scales. There was approxi mately a 7-point differe nce between the highest average (perceived Knowledge = 82.37) and th e lowest (Self-Awareness/Beliefs/Attitudes = 75.27). This makes the possibility for changes in rank more likely. In the previous study utilizing the CCDS, score averages on the three scales were also similar to one another (SelfAwareness/Beliefs/Attitudes = 88.63, perceive d Knowledge = 80.56, and perceived Skills = 73.41). Sample size for the current study was N=199. For the previous study, sample size was N=108. With smaller sample sizes and similar sc ore averages, the rank or order of the three scales could be more susceptible to change based upon a few individual participant responses. The significance of the findings from Res earch Question #2 in the current study point toward the possibility that LMHCs percei ved Knowledge, perceived Skills, and SelfAwareness/Beliefs/Attitudes regardi ng disability may need improve ment. The scores from the
84 aforementioned CCDS studies support this opini on. In the current study, the highest scale average score was 82.37 out of a possible scor e of 120. This is an overall average of approximately 60%. As will be discussed in mo re detail in the upcoming section regarding limitations of this study, there is no baseline or standard for comparison when utilizing the CCDS. Therefore, one cannot confidently state that LMHCs scores were poor, average, or good in the current study. However, based upon the range of possible scores, it would seem appropriate to state that there is room for improvement in the CCDS scores from the current study. Research Question #3 Discussion Findings from Research Questi on #3 indicated that counselors with higher levels of SelfAwareness/Beliefs/Attitudes, as well as higher leve ls of reported contact with individuals with disabilities, had higher levels of perceived Knowledge and per ceived Skills. However, one should not interpret that merely having more cont act with individuals with disabilities or having a greater self-awareness or more positive attitude s regarding disability necessarily results in greater knowledge or skills when treating this population. Higher levels of contact and SelfAwareness/Beliefs/Attitudes are simply predictors of higher scores on th e perceived Knowledge and perceived Skills scales for this particular study. Implications of these findings could be that as counselors experience more contact with indi viduals with disabilitie s, their understanding of issues specific to this population improve. Fu rther, as LMHCs understanding of issues and dynamics specific to individuals with disabili ties improves, their at titudes and awareness regarding disability are enhanced. However, if these assumptions are true, then such scenarios could equate to a learn-as-you-go type situation. It is reasonable to st ate that much of a counselors growth and education occurs outside of a classroom or training session. Clinical experience is perhaps the greatest teacher of all. Yet, the prepar edness to treat individuals with
85 disabilities has been questioned within the prof essional literature and contact and attitudes are not adequate training modules. Findings from this research question may, however, assist educators in focusing their training of future counselors in the direction of at titudes, beliefs, and self-awareness regarding disability issues. Limitations of the Study The current study did not utilize random sampling to create th e population of pa rticipants. Instead, a convenience sample derived from a list of email addresses of LMHCs maintained by Floridas Department of Health, Division of Medical Quality Assurance was used. The entire list of email addresses (N=1235) was used, which represented approximate ly 20% of the entire population of LMHCs in Florida (N=6692). Fact ors such as a possible low response rate, possible incomplete responses, a nd a required sample size of 123 prevented this researcher from gathering a random sample from the aforementio ned email list. In future research, it is recommended that a random sample from the entire LMHC population in Florida (or elsewhere) be conducted. Another limitation to this study was the limite d reliability and validity data available for the CCDS. Although initia l reliability and validity data was promising, additional data would require continued use of the CCDS. Also, in futu re studies, it is recomm ended that the CCDS be administered along with instruments that mini mize error due to socially desirable responding (Strike et al., 2004). The lack of generalizability represented an additional limitation, as the study was geographically limited to Florida. The resulting data could be skewed when compared to similar data gathered from a nationwide sample. As me ntioned previously, Florid a is in the middle of the spectrum in most disabil ity categories. However, Floridas population of older adults exceeds the national average which may bring about an increase in the percentage of individuals
86 with disabilities (National Organization on Disab ility, 2004). Therefore, one cannot extrapolate data from this study to help determ ine national or global scenarios. A decision not to differentiate among a variety of disability groups or types may also be consider a limitation of this study. While the broad definition of disability used by the author for this study may be appropriate at this exploratory stage of resear ch, more valuable information might be obtained if specific types or categories of disability were examined. For example, future research may include a comparative analys is of visible versus in visible disabilities and how these two types of disabilities a ffect LMHCs competency factors. The definition of contact as it pertains to the CDP limits the applicability of data from this study. The contact as described in the CDP does not differentiate be tween contact in a clinical or counseling setting and other type s of contact such as personal. For example, an LMHC may report frequent contact with and in dividual with a disability that could be a parent or neighbor. That same LMHC may have never had a client with a disability. It would be helpful to have a better understanding of the environment in which contact took place and, mo re specifically, if that contact was betwee n counselor and client. Finally, this author noted the lack of normative data for both the CDP and the CCDS pertaining to the sample populati on. As previously noted, the CCD S has been used in only one previously published study, at which time the sample population consisted of psychiatrists, psychologists, social workers, ca reer counselors, disability speci alists, and other mental health professionals. Although the average scores for the three sub-scales (SelfAwareness/Beliefs/Attitudes, perc eived Knowledge and perceived Skills) were similar to the score in this study, the scoring order of those results differed. In the current study, the SelfAwareness/Beliefs/Attitudes scale had the lowest average while in the previous published study
87 it was the highest. With the lack of additional studies with which to compare, it is difficult to draw conclusions as to which data (if any) may be suspect The same limitation applies regarding the CDP and this study. There is no ba seline or average score with which to compare LMHCs amount of contact. Therefore, it is di fficult, if not impossible, to place a value on all the scores obtained in this study. Recommendations for Future Research In addition to addressing the above-m enti oned limitations, researchers may consider alternative approaches to expl oring questions pertaining to LM HCs interactions with and treatment of individuals w ith disabilities. An examination of the specific types of contact (i.e., clinical, social, etc.) LMHCs have with indivi duals with disabilities would help clarify the frequency and type of interactions that are ta king place between the two groups. This, in turn, may assist researchers in determinin g the need for further training. A closer, and more current examination of the content of educational programs for counselors would be beneficial in determining the amount of pr eparation student s are receiving with regards to providing services to individu als with disabilities. As previously noted, researchers have found that studen ts in counselor training progra ms are not required to learn about individuals with disabilitie s and textbooks used in these programs rarely address disability issues. Further, when disability issues are addressed, they provide biased presentations of persons with disabilities. Pe rforming a more current content analysis of counselor training programs may provide a more accurate understa nding of LMHCs preparedness and training regarding disability issues. A content analysis of continui ng education courses, seminars and post-graduate training would also be worthy research to determine the amount of disability education LMHCs receive. Based upon the findings of this current study, it is apparent that LMHCs have at least moderate
88 contact with individual s with disabilities and could impr ove their awareness, skills, and knowledge regarding disability issues. It woul d therefore seem important to determine the availability of training and edu cation for practicing counselors, a nd whether or not counselors are participating in such training. Researchers may also consider alternative formats of research that do not have the limitations associated with survey research or analogue research. Qua litative research that includes actual counselors and clients with disabi lities in clinical couns eling settings could provide more in-depth information about the co unseling process. For example, such studies could help researchers understa nd how counselors disability-re lated competence affects the counseling process and outcome. Conclusion Individuals with disabilities ar e one of the largest m inority groups in the United States. Based upon a review of the literature, the freque ncy of exposure LMHCs have to this population is largely unknown. However, if su ch interactions are taking place as is suggested in this study, it is necessary to consider the implications of th is contact on both the client and the counselor. There are many issues to be e xplored within the r ealm of these relationships. Counselor competence, ethical considerations, client/couns elor rapport, and accessibi lity issues are only a few of the areas that would warrant further research. However, groundwork must first be established to determine the frequency with whic h LMHCs work with clients with disabilities. One could argue that, even if the frequency of e xposure is miniscule, it matters not whether the contact or provision of services occurs one time or one million. However, if the exposure that LMHCs have to persons with disabilities were significant, then a ppropriate training and continued education in the treatment of this population would cl early be warranted.
89 The findings in this study also indicate that LMHCs may benefit from additional training or education to increase their disability competen cy. Literature supports the theory that LMHCs are not adequately trained in th e area of disability competen cy (Renard, 2001; Rosenau, 2000; Smart & Smart, 2006). This curr ent study supports the po ssibility of inadequate LMHC training while also reporting moderate contact with individuals with disabilities. LMHCs are bound to provide competent services to individuals with disabilities from legal and ethical perspectives. Without specific tr aining or education, the general public has many misperceptions about disability (Shapiro, 1994). It is inapprop riate and perhaps dangerous to assume that LMHCs are drastically different from the general population in that regard. Further research is necessary to ensure that this importa nt client population is be ing served in the manner in which they, and all individuals, disable and non-disabled, deserve.
90 APPENDIX A EMAIL COVER LETTER Dear Counselor, The University of Florida is sponsoring rese arch on licensed m ental health counselors and their interactions with individuals with disabil ities. We ask that you cl ick on the attachment to this email to learn more about the study and how very helpful it will be to us if you would spend a few minutes of your valuable time to complete this brief survey. If you have difficulty opening the attachment, but would like to complete the survey, you may go directly to the survey by clicking on: http://www.surveymonkey.com/s.aspx?sm=gNm0sdHai9rg2INIpsfWqg_3d_3d Your anticipated participa tion is greatly appreciated!
91 APPENDIX B INFORMED CONSENT This is a research study conducted by Grant McDougall, a doctoral candidate from the Department of Rehabilitation Science at the University of Florida. This study examines licensed mental health counselors (LMHCs) and their pe rceived competence when working with clients with disabilities. You have been selected from the total population of LMHCs within Florida. Although this study will assess se veral aspects of LMHCs involvement with individuals with disabilities, no prior training or experience working with this c lient population is required to participate in this study. You are being asked to complete two surveys and a demographic questio nnaire online, at your convenience, through SurveyMonkey.com. The instruments will take approximately 8-10 minutes to complete. Participation in this rese arch project is voluntary. You do not have to answer any questions you do not wish to answer and you are free to withdraw your consent and to discontinue your participation at any time wit hout consequence. You will not be asked to write your name on the research project form s. Your response is anonymous. No personal/professional identifying information or IP addresses will be collected or retained. Potential benefits of participa tion include increasing counselors awareness regard ing disability issues and positively impacting future training and education of counselors in the area of disability studies. There are no kno wn risks or potential harm to the participants in this study. No compensation for participation is provided. The measures will be kept secure and only accessible to Grant Mc Dougall and his faculty supervisor, Linda R. Shaw, Ph.D. Data will be kept confidential to th e extent provided by law and individual data will not be shared. Questions concerning your rights as a research participant can be directed to the UFIRB, Box 112250, University of Florida, Gainesville, FL, 32611-2250. If you have any questions about this study please contact Grant McDougall at firstname.lastname@example.org, or Dr. Linda R. Shaw, Department of Rehabilitation Counseling, (352) 273-6745. By choosing "yes", I provide my informed consent to participate in this study. YES NO
92 APPENDIX C CONTACT WITH DISABLED PERSONS SCALE Contact W ith Persons With Disabilities Scale Please circle the number to the right of each statement indicating your answer to each question. Use a number from 1 to 5 to indicate the following: 1 = never; 2 = once or twice; 3 = a few times; 4 = often; 5 = very often. 1. How often have you had a long talk with a pers on with a disability? 1 2 3 4 5 2. How often have you had a brief c onversation with persons with disabilities? 1 2 3 4 5 3. How often have you eaten a meal with a person with a physical disability? 1 2 3 4 5 4. How often have you contributed money to organizations that help persons 1 2 3 4 5 with disabilities? 5. How often have persons with disabilities discus sed their lives or problems 1 2 3 4 5 with you? 6. How often have you discussed your life or problem s with a person with a 1 2 3 4 5 disability? 7. How often have you tried to help persons with disabilities with their 1 2 3 4 5 problems? 8. How often have persons with disabilities tried to help you with your problems? 1 2 3 4 5 9. How often have you worked with a client, student, or patient with a disability 1 2 3 4 5 on the job? 10. How often have you worked with a co-worker with a disability? 1 2 3 4 5 11. How often has a friend with a disability visited you at your home? 1 2 3 4 5 12. How often have you visited persons with disa bilities in their homes? 1 2 3 4 5 13. How often have you met a person with a disability you like? 1 2 3 4 5 14. How often have you met a person with a disability you dislike? 1 2 3 4 5 15. How often have you met a person with a disability that you admire? 1 2 3 4 5 16. How often have you met a person with a disability for whom you feel sorry? 1 2 3 4 5
93 17. How often have you been annoyed or disturbed by the behavior of a person 1 2 3 4 5 with a disability? 18. How often have you been pleased by the behavi or of a person with a 1 2 3 4 5 disability? 19. How often have you have you had pleasant experi ences interacting with 1 2 3 4 5 persons with disabilities? 20. How often have you have you had unpleasant experi ences interacting with 1 2 3 4 5 persons with disabilities? 21. How often have you had a long talk with a pers on with a disability? 1 2 3 4 5 22. How often have you had a brief c onversation with persons with disabilities? 1 2 3 4 5 23. How often have you eaten a meal with a person with a physical disability? 1 2 3 4 5 24. How often have you contributed money to organizations that help persons 1 2 3 4 5 with disabilities? 25. How often have persons with disabilities discus sed their lives or problems 1 2 3 4 5 with you? 26. How often have you discussed your life or problem s with a person with a 1 2 3 4 5 disability? 27. How often have you tried to help persons with disabilities with their 1 2 3 4 5 problems? 28. How often have persons with disabilities tried to help you with your problems? 1 2 3 4 5 29. How often have you worked with a client, student, or patient with a disability 1 2 3 4 5 on the job? 30. How often have you worked with a co-worker with a disability? 1 2 3 4 5 31. How often has a friend with a disability visited you at your home? 1 2 3 4 5 32. How often have you visited persons with disa bilities in their homes? 1 2 3 4 5 33. How often have you met a person with a disability you like? 1 2 3 4 5 34. How often have you met a person with a disability you dislike? 1 2 3 4 5 35. How often have you met a person with a disability that you admire? 1 2 3 4 5
94 36. How often have you met a person with a disability for whom you feel sorry? 1 2 3 4 5 37. How often have you been annoyed or disturbed by the behavior of a person 1 2 3 4 5 with a disability? 38. How often have you been pleased by the behavi or of a person with a 1 2 3 4 5 disability? 39. How often have you have you had pleasant experi ences interacting with 1 2 3 4 5 persons with disabilities? 40. How often have you have you had unpleasant experi ences interacting with 1 2 3 4 5 persons with disabilities?
95 APPENDIX D COUNSELING CLIENTS WITH DISABILITIES SURVEY Counseling Clients W ith Disabilities Survey Please read each statement carefully and circle the number that bests describes you from Strongly Agree (1) to Strongly Disagr ee (6). Please do not skip items. For the following items, the term disability is defi ned as a physical or mental impairment that substantially limits one or mo re major life activit y (e.g., hearing, seeing, speaking, breathing, walking, thinking/learning, feeli ng/behaving, keeping house, living independently, or working). Strongly Agree AgreeSlightly Agree Slightly Disagree Disagree Strongly Disagree 1. I have respect for people with all types of disabilities. 1 2 3 4 5 6 2. I feel trusted by people with disabilities as much as people without disabilities. 1 2 3 4 5 6 3. If I had a different disability status (disabled or nondisabled) than my clients, it would impair our working relationship. 1 2 3 4 5 6 4. I believe people with disabilities are stigmatized in our society. 1 2 3 4 5 6 5. I have thought about how worldviews are influenced by disability status (disabled or nondisabled). 1 2 3 4 5 6 6. I think most people with disabilities wish they were nondisabled. 1 2 3 4 5 6 7. I think people with disabilities are generally more dependant than people without disabilities. 1 2 3 4 5 6 8. I can identify a wide variety of individual differences among people with the same type of disability. 1 2 3 4 5 6 9. I try to examine my stereotypes about various disabilities. 1 2 3 4 5 6 10. I believe being nondisabled has certain privileges in society. 1 2 3 4 5 6
96 Strongly Agree AgreeSlightly Agree Slightly Disagree Disagree Strongly Disagree 11. I consider people with disabilities to be a minority group. 1 2 3 4 5 6 12. I try to talk with others who have different points of view on disability. 1 2 3 4 5 6 13. It is difficult for me to understand how disability could be a source of pride for people with disabilities. 1 2 3 4 5 6 14. I enjoy hearing about people who overcame their disabilities. 1 2 3 4 5 6 15. I believe disability is essentially a medical problem to be cured. 1 2 3 4 5 6 16. I believe most disability rights activists promote telethons to raise money to cure disabilities. 1 2 3 4 5 6 17. I have participated in events where the majority of people attending had disabilities. 1 2 3 4 5 6 18. Having my mobility temporarily impaired would give me a true picture of living with a mobility disability. 1 2 3 4 5 6 19. I have thought about how a disabling illness or injury would affect my work. 1 2 3 4 5 6 20. I feel satisfied with my level of awareness about disability issues in my work. 1 2 3 4 5 6 21. I understand terms used in the ADA, Americans with Disabilities Act, of 1990 (e.g. reasonable accomodations) 1 2 3 4 5 6 22. I understand terms used in the disability community (e.g., ableism, disability culture). 1 2 3 4 5 6 23. I can state the educational significance of S ection 504 of the Rehabilitation Act of 1973. 1 2 3 4 5 6
97 Strongly Agree AgreeSlightly Agree Slightly Disagree Disagree Strongly Disagree 24. It is unfair to accommodate college students with disabilities by treating them differently than their peers (e.g., extra time). 1 2 3 4 5 6 25. I do not follow current court cases about the legal rights of people with disabilities. 1 2 3 4 5 6 26. I believe that unemployment/ underemployment is common among people with disabilities in the U.S. 1 2 3 4 5 6 27. I feel that people with disabilities are portrayed accurately in the media. 1 2 3 4 5 6 28. I am familiar with the sociopolitical history of people with disabilities (e.g., the disability civil rights movement). 1 2 3 4 5 6 29. I can name famous people known to have disabilities. 1 2 3 4 5 6 30. I can name well-known counseling theorists who have disabilities. 1 2 3 4 5 6 31. In my field, professionals with disabilities are underrepresented. 1 2 3 4 5 6 32. I have learned about disabilities through professional development activities. 1 2 3 4 5 6 33. I have a general knowledge of all the following types of disabilities: learning, psychiatric, vision, hearing and mobility. 1 2 3 4 5 6 34. I am familiar with the distinction between hidden disabilities and readily observable disabilities. 1 2 3 4 5 6 35. I think Englis h is the native language of Americans who are deaf from birth. 1 2 3 4 5 6
98 Strongly Agree AgreeSlightly Agree Slightly Disagree Disagree Strongly Disagree 36. I do not know where the accessible entrances are in my place of employment. 1 2 3 4 5 6 37. If I had a new client who is blind coming to my office, I could give directions without using visual references. 1 2 3 4 5 6 38. I recognize signs/symbols of access that welcome people with disabilities. 1 2 3 4 5 6 39. I am not familiar with adaptive technology (e.g., screen readers, captioning). 1 2 3 4 5 6 40. I feel satisfied with my level of knowledge about disabilities. 1 2 3 4 5 6 41. I am not sure if the terms I use to refer to disabilities are preferred by people with disabilities. 1 2 3 4 5 6 42. I know how to obtain alternate formats of printed material (e.g., Braille, large print). 1 2 3 4 5 6 43. If I had a new client who is hard of hearing, I would know how to modify my verbal and nonverbal behaviors. 1 2 3 4 5 6 44. I am experienced using TTY/TDD or the state Relay Services to communicate with people with hearing/speech disabilities. 1 2 3 4 5 6 45. I am experienced with communicating through a sign language interpreter. 1 2 3 4 5 6 46. In first appointments, I routinely ask clients if they have disabilities/medical conditions. 1 2 3 4 5 6 47. I know how to determine if a DSM-IV diagnosis is a disability. 1 2 3 4 5 6
99 Strongly Agree AgreeSlightly Agree Slightly Disagree Disagree Strongly Disagree 48. I could take a clients disability into account when interpreting the results of assessments instruments. 1 2 3 4 5 6 49. I know how to write letters documenting how disabilities affect clients in their work/academic environments. 1 2 3 4 5 6 50. If I had a new client with a disability, I would hypothesize that adjusting to the disability is a problem. 1 2 3 4 5 6 51. I have learned about disability identity development (e.g., Carol Gills model). 1 2 3 4 5 6 52. I am not aware how disability may interact with human sexuality (e.g., family planning). 1 2 3 4 5 6 53. I would find it hard to deal with strong negative feelings expressed by a client with a disability. 1 2 3 4 5 6 54. I lack confidence with my ability to deal with transference and countertransference about disability. 1 2 3 4 5 6 55. I have advocated in the interests of people with disabilities (e.g., removal of architectural barriers, passage of legislation) 1 2 3 4 5 6 56. I have had opportunities to work effectively with colleagues and/or supervisors who have disabilities. 1 2 3 4 5 6 57. I can readily obtain information/resources about specific disability issues (e.g., disability onset later in life). 1 2 3 4 5 6
100 Strongly Agree AgreeSlightly Agree Slightly Disagree Disagree Strongly Disagree 58. I would have difficulty locating a disability expert to consult with regarding a client with a disability. 1 2 3 4 5 6 59. I know when to refer clients to agencies that specialize in serving people with disabilities. 1 2 3 4 5 6 60. I feel satisfied with my level of skill to work with clients with disabilities. 1 2 3 4 5 6
101 APPENDIX E DEMOGRAPHIC INFORMATION Please choose the item s that best describe you. 1. Gender Female Male 2. Your current age is: 20-30 30-40 40-50 50-60 60+ 3. Ethnicity: African American Black American Indian Asian Pacific Islander Caucasian White Hispanic Latino Other 4. I have ___ many years working in the mental health arena. 0-5 years 5-10 years 10-15 years 15-20 years 20+ years 5. The academic program/training for which I earn ed my above mentioned degree is best described as: counselor education rehabilitation counseling psychology social work rehabilitation psychology other
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117 BIOGRAPHICAL SKETCH Alfred Grant McDougall was born on Decem ber 9, 1967 in Punta Gorda, Florida. The youngest of four children, he was raised in Punta Gorda and Tallahassee, Florida by his mother. He graduated from Godby High School in 1985. He was a professional musician and toured the United States and Canada for two years befo re earning his A.A. at Tallahassee Community College. He went on to earn his B.S. in Communications from Fl orida State University in 1993. He worked in marketing for Eastman Kodak Compa ny for several years before entering into the Department of Rehabilitation Counseling at the University of Florida. He worked as a rehabilitation consultant and earned his M.H.S. in 1997. He became licensed as a mental health counselor and worked as a ps ychotherapist in private pract ice as he entered into the Rehabilitation Science doctoral program. Upon his completion of his Ph.D. program Grant will continue to work as a psychotherapist specializing in c ounseling individuals with disabili ties. He also hopes to teach on the collegiate level. Grant has been married to his wife, Michele McDougall, for 16 years. They have two sons; Sam, age 10 and Drew, age 7.