Title: LGBTQ Module
1Disability and PsychologyA Multicultural View
- Linda R. Mona, Ph.D., Long Beach
- Phillip Keck, M.A., Mountain Home (Intern)
- Jae Yeon Jeong, Ph.D., Richmond
- and the
- Multicultural and Diversity Committee (2014-2015)
- VA Psychology Training Council (VAPTC)
- Contact persons
- Daryl Fujii, Ph.D., Honolulu (Daryl.Fujii_at_va.gov)
- Linda R. Mona, Ph.D., Long Beach
(Linda.Mona_at_va.gov)
2Multicultural Diversity Committee
Committee 2014-2015 Daryl Fujii Ph.D., Honolulu
(Co-Chair) Linda Mona, Ph.D., Long Beach
(Co-Chair) Joseph Fineman, Ph.D., Miami
VA Angelic Chaison Ph.D., Houston Marci Flores,
Ph.D., Psychology Fellow, Long Beach Jamylah
Jackson Ph.D., North Texas Jae Yeon Jeong, Ph.D.,
Richmond Philip Keck, Psychology Intern, VAMC at
Mountain Home Jennifer Peraza, Ph.D.,
Psychology Fellow, Albuquerque Katherine Ramos,
Psychology Intern, Durham Rex Swanda, Ph.D.
Albuquerque Sam Wan Ph.D., San Francisco
3Module Objective
- The purpose of this module is to define
disability as a multicultural experience and
review the conceptual and empirical literature
relevant to providing comprehensive clinical care
to Veterans with disabilities -
4Agenda
- Social, political and historical context
- Definition of terms
- Health and mental health disparities
- Clinical implications (APA Guidelines)
- General considerations
- Exercises
- Questions
- References and resources
5Social, Political Historical Context
6Social context The disability rights movement
- Parallels to the Civil Rights Movement
- Role of Advocacy
- Gang of Nineteen
- Disability Rights Movement
- Museum of Disability
7Americans with Disabilities Act (ADA)
- Federal statue designed to prevent discrimination
and to promote equal opportunities for people
with disabilities - Provides civil rights protection for people with
disabilities in the areas of - Employment
- Public services
- Public and private transportation
- telecommunication services
8How Does the ADA Affect Psychologists?
- Private clinical practice
- Academic settings
- Health Care facility settings
- Employment settings
- Goal in all settings is to establish
- Reasonable accommodations to promote full
inclusion for patients, students, and employees
9Disability Culture
- Acceptance of human variation
- Matter-of-fact orientation using assistance
- Tolerance for unpredictable and living with
uncertainty - Disability humor
- Skills in managing multiple problems
- A sophisticated future orientation
- A carefully focused capacity for closure in
interpersonal communication - A flexible adaptive approach to tasks
10Attitudes Toward People with Disabilities (PWDs)
- Asch (1946)
- Intelligent, skillful, industrious, warm,
determined practical cautious - Intelligent, skillful, industrious, cold,
determined practical cautious - Olkin (1999) described disability as a central
characteristic, adding that when other
attributes are unknown (e.g., when first meeting)
its role is profound in impression formation (p.
55).
11Disability and the Veteran
- Since 2001, more than 1.7 million have served in
the wars in Iraq and Afghanistan (OIF/OEF) - More Veterans with polytrauma or who have two or
more substantial injuries that results in
functional impairment and disability (VA, 2013) - Returning Veteran population Working or seeking
employment, enrolled in college classes, have
school-aged children, may have a combination of
emotional physical health concerns, may
experience difficulty performing social roles,
some may seek VA compensation to support
household. - Kraal et al. (2015).
12Definition of Terms
13Definition of Disability
- ADA (1990) definition of disability
- Physical or mental impairment
- Limits one or more major activities
- Has a record history of an impairment
- Regarded as having an impairment
14Disability A political minority
- The idea that PWD are a political minority and
not sick, is right and brilliant and perfect.
When I started to understand that were treated
and dissed just like any other minority,
everything clicked. - Billy Golfus
15(No Transcript)
16A Strengths-based Model of Disability
- Ableism - The unique form of discrimination
experienced by PWDs based on their disabilities.
The expression favors people without disabilities
and maintains that disability in and of itself is
a negative concept, state, and experience. - In essence, the goal should not be to fix the
person with a disability, but rather to repair
the broken systems that perpetuate unjust
treatment - A shift from individual pathology to social
oppression
(Keller Galgay, 2010, p. 242) (Olkin, 1999, p.
28).
17WHO-ICF Model
18Health Disparities
19Disparities in Disability Overview
- Historically, the public health field has used
various approaches to understand and address
preventable disparities between those with and
without disability - Traditional approach prevention of disability
- Contemporary approach individuals with
disability regarded as a minority group
experiencing preventable and inequitable health
outcomes - Emerging approach broader, holistic approach,
where disability is viewed as one of many health
determinants (e.g., ICF Model)
20Disparities in Disability Overview
- Future directions should involve
- Increased advocacy
- Understanding role of the environment
- Emphasis on health promotion
- Community-based participatory work
21Model of Disparities in Disability
- Numerous factors contribute to disparities
between those with and without disabilities - Genetic predispositions
- Environmental conditions
- Social circumstances
- Behavioral patterns
- Medical care access
22Health Disparities Disability
- 14-28 of veterans have a documented
service-connected disability - Poorer preventive health behaviors among people
with disabilities vs. those without - Increased risk factors for poor health (e.g.,
more smoking prevalence, less physical activity)
among people with disabilities vs. those without
disabilities - People with disabilities less likely to receive
mental health treatment compared to those without
disabilities
23Intersection with Race/Ethnicity
- 2004-2006 Behavioral Risk Factor Surveillance
System - Adults with disabilities less likely to report
excellent or very good health (27 vs. 60)
and more likely to report fair or poor health
(40 vs. 10) vs. those without disability. - Reporting fair or poor health among adults
with a disability is most common for Hispanics
and American Indian/Alaska Natives (55.2
50.5) and least common among Asians (24.9).
24Social Ramifications
- Access to care issues negatively impact the
ability of a PWD to fully engage in significant
social roles and activities such as maintaining a
household, independent living, employment, social
functioning. - Within the disability population, there are
higher rates of unemployment, underemployment and
poverty. - Individuals are more likely to rely on
government-funded health care (Medicare,
Medicaid) - For women, health care rights such as
reproductive health may be neglected - National Council on
Disability
25Clinical Implications Assessment,
Conceptualization, Treatment
26Guidelines for Assessment of and Intervention
with Persons with Disabilities
- APA Guidelines Provide
- (1) Guidance on how psychologists assess and
treat people with disabilities in their
professional capacity. - (2) Foundational information to facilitate
working with people with disabilities in a
variety of contexts, including assessment,
intervention, diversity, education, training, and
research.
27Guidelines for Assessment of and Intervention
with Persons with Disabilities
- Themes of guidelines include
- Learning about various disability paradigms and
their clinical implications - Examining ones personal belief system regarding
disability - Recognizing how providers attitudes and
knowledge about disability concerns may be
relevant to assessment and treatment and seek
consultation or make appropriate referrals when
indicated - Understanding how the nature of a persons
disability affects their individual development
across the lifespan
28Guidelines for Assessment of and Intervention
with Persons with Disabilities
- Themes of guidelines include
- Empowering family members to advocate for
themselves and their loved ones, as well being
integral to the overall treatment plan - Utilizing psychological measures appropriate and
non-stigmatizing to persons with disabilities - Considering the sexual and reproductive rights of
persons with disabilities - Supporting individual choice and freedom for
persons with disabilities - Maintaining a disability friendly therapeutic
environment
29Disability Assessment
- Clinical interview
- MSE
- Appearance factors
- Accessibility of instruments
- Adherence to standardized administrations can
lead to false conclusions - Standardized norms
- Implications for diagnoses
30Case Conceptualization
- Include personal views of disability
- Consider models of disability
- Think about both the social and medical domains
of the clients life - Treat case as you would any other cultural group
- Think about cultural influences on the client
- The presenting clinical issue is not always
related to disability
31Disability Identity Development
- Stage 1 Passive Awareness
- Stage 2 Realization
- Stage 3 Acceptance
Gibson (2006). Disability and clinical
competency An introduction. The California
Psychologist, 39, pp 6-10.
32Disability Identity Continuum
- More vulnerable to Disability part of
self-identity, - the effects of stigma, more likely to have
friends - prejudice, and discrimination and partners
with disability, seek therapist with
disability - Not Disabled but Identifies
Feels a part of Disability - Disabled No Identity As PWD
the Disability Rights - As a PWD Community Activist
-
- Gibson (2006)
33Treatment Philosophy Disability Affirmative
Treatment (DAT)
- Seven guiding principles for beginning treatment
- Establish a framework for therapy
- Consider using a systemic model (disability is a
family affair) - Acknowledge biculturalism and consider
disability and non-disability life domains - Think first of disability as a social construct
- Therapists might need additional skills
- Go beyond deficit reduction approach and aim to
reduce negative symptoms optimize well-being - Need to show and not just tell
- Demonstrate your ability to work with people with
disabilities and diverse populations
34DAT Treatment Goals
- Help patients understand their model or
perspectives about disability - Explore ways in which power has affected patient
- Aim towards increasing Empowerment
- Explore personal values
- Have values shifted since disability has been
acquired? If so, how? - Assist with containing spread effects
- Discuss disability as a characteristic not a
possession - Encourage patients to be forward thinking
- Focus on helping patients develop a strong
support network
Olkin, R. (1999). The personal, professional and
political When clients have disabilities. Women
and Therapy, 22, 87-103.
35Skills Disability-Affirmative Therapy
- Flexibility
- To work within different models and understand
systemic issues (must incorporate economic,
legal, and political considerations) - Coordinating with other services
- Generate MULTIPLE hypotheses
- Culture blindness vs. hyperawareness
- Rule of 5, rule of 2
- Utilizing time resources outside of session
36Common Clinical Topics
- Financial concerns
- Independence vs. Dependence
- Sexual health and expression
- Fertility and reproduction
- Personal assistance/Care-giving
- Employment and education
- Frustration over negative societal attitudes
- Social isolation
37Cultural Competence Disability
- Conceptualize people with disabilities using the
minority model (Artman Daniels, 2010) - People with disabilities are similar to other
minority groups - Shared history of discrimination, oppression and
intolerance - People with disabilities are also different than
other cultural groups - Issues related to accessibility
- Medical symptoms related to their disability
38PWD vs. Other Minority Groups
- Proximity is not the same as integration
- Isolation within family
- Open enrollment
- Fault
- Less well-organized and visible subculture
- High risk (substance abuse gt25)
- Body as reflection of self
- Subservience
- Disclosure (similar to LGBT)
- Prescription of affect
(Olkin, 1999)
39Microaggression in PWD
- The results of the study revealed an initial
taxonomy of eight microaggression domains that
included - Denial of Identity (denial of personal identity,
and denial of experience) IN COMMON - Second-class Citizenship IN COMMON
- Desexualization PARTIAL OVERLAP
- Spread Effect PARTIAL OVERLAP
- Denial of Privacy UNIQUE
- Helplessness UNIQUE
- Secondary Gain UNIQUE
- Patronization - UNIQUE
(Keller Galgay, 2010)
40Supplemental material Microaggressions chart
41Supplemental material Microaggressions chart
42Research on Cultural Adaptations of
Evidence-Based Practice
- Specific phobia with Asian Americans (Pan, Huey,
Hernandez, 2011 Huey Pan, 2006) - Relevance to disability psychoeducation,
addressing acculturation, demonstrate awareness
of cultural values - Mexican American parent management training for
children who exhibit behavioral problems
(Domenech Rodriguez, 2008) - Relevance to disability culture appropriate
language, demonstrate awareness of cultural
values
43Research on Cultural Adaptations of
Evidence-Based Practice
- Depression with Haitian American adolescents
using CBT (Nicolas, Arntz, Hirsch, Schmiedigen,
2009) - Relevance to disability meeting with community
and community leaders to understand possible
challenges/barriers
44Adaptations for People with Disabilities
- Hopps, Pepin, Boisvert (2003)
- Focus on Loneliness for people with disabilities
- Adaptation
- Use of internet chat for goal oriented group CBT
- Social Skills for People With Disabilities Manual
- Results Improvement of loneliness, acceptance of
disability, and social difficulties in disability
situations compared to wait-list control
45Adaptations Next Steps
- Artman Daniels (2010) Disability and
psychotherapy practice - Possible adaptations
- Critical awareness and knowledge
- Person first language exposure to PWDs
- Skills development
- Opening dialogue about disability similar to
race, religion, or sexuality disability
etiquette - Practice/applications
- Building accessibility consent
forms/handouts/publications scheduling
appointments testing
46Adaptations Next Steps
- Mona et al. (2006) CBT and people with
disabilities - Possible adaptations
- Education about disability culture
- Education about disability paradigms
- Mona et al. (2009) Third-wave CBT and spinal
cord injury related to positive sexual health - Possible adaptations
- Education about sexuality after SCI
- Utilization of Disability Affirmative Therapy
47Clinical Example
- Chris is a 20-year-old university senior,
majoring in marketing. Diagnosed with muscular
dystrophy, Chris lost the ability to walk in
early childhood and has utilized a wheelchair
since the age of nine. As a member of the
university adaptive soccer team, the client has
established a sense of community during his
college years, as well as a circle of support to
navigate the challenges associated with his
diagnosis. - At the time of intake, Chris reported
experiencing feelings of sadness and worry about
his future that developed over the holiday break.
He endorsed feelings of intense anxiety about
returning home upon graduation and what the
future would hold for his professional
aspirations, the process of reestablishing a
social network, and the difficulties in adjusting
to life at home with his parents and younger
brother, a high school freshman.
48Treatment Consideration
- Identifying where client falls in the disability
identity continuum. - Enlargement of scope
- Intrinsic values recognition
- A focus on positive assets (what one can do,
versus what they cannot) - Researching potential resources in the Charleston
community (i.e., Vocational Rehabilitation,
disability advocacy groups, family therapy)
49General Considerations
50Disability FAQ
- Do not say Some of my best friends are disabled
- Ask person with disability for permission before
giving assistance - Assistants or interpreters may be present in
treatment, so plan accordingly! - OK to say you do not understand when you dont!
- OK to use words like see and walk with people
with visual and mobility impairments - Do not touch assistive devices
- Do not rely on verbal cues in therapy
- Rules can vary!!
Olkin, R. (1999). The personal, professional and
political When clients have disabilities. Women
and Therapy, 22, 87-103.
51Do Not ask!
- Do you mind if I ask you a personal question?
- People with disabilities hear it a lot, and since
when do therapists ask?! - How might you be different without your
disability?
52Asking about disability
- Asking is not rude or intrusive in the
therapeutic context - Providing the different experience
- Not shying from the topic
- Managing eye contact
- You are not necessarily given the benefit of the
doubt (unless you have a disability)
53Two useful questions
- What is the nature of your disability?
- Typically used in disability culture
- Focus on present functioning, not cause
- Are there ways in which your disability is part
of (the presenting problem)? - If disability has not yet been broached
- You can disagree!
- Clinical judgment!
54Recommendations for Clinicians
- Critical awareness and knowledge
- Be mindful of the language, attributions, and
attitudes you have regarding PWDs - Build accessibility
- Accessible environment
- Psychotherapy milieu
- Seating, lighting, delivery of information
- Advocacy
- Educate others and share resources
Artman,L.K., and Daniels, J.A. (2010). Disability
and psychotherapy practice Cultural competence
and practical tips. Professional Psychology
Research and Practice, 41(5), 442-448.
55Recommendations For Mental Health Programs,
Services, Agencies
- Consider physical access (e.g., parking, office
entrance/configuration, ramps, doorways,
restrooms, desks) - Attitudinal access
- Addressing the person rather than the disability
- Asking rather than assuming
- Always address the person rather than the
assistant. - However, treat the assistant with respect too!
56Exercises
57Disability Exercises
- Use Olkins (1999, PP 29-30., Tables 2.1 and 2.2)
to explore the similarities and differences among
people with disabilities and other minority
groups - Ask participants to create three columns One
entitled Disability, a second entitled another
minority group (e.g. person identifying as LGBT
or person of color) and, a third entitled Issue
(e.g., hate crimes, assimilation, mental health
services, inter-marriage) - Have teams of 2-3 people complete columns and
then discuss as a large group
58Supplemental Material Olkin
59Supplemental Material Olkin
60Supplemental Material Olkin
61Disability Exercises
- Interview a person with a disability and explore
psychosocial experiences of this individual. - Use pictures of individuals who have different
disabilities (not/visible) and contrast thoughts,
emotions, attitudes that are elicited. - Write a summary outlining and highlighting
interview results and themes. Prepare comments to
share with your colleagues about your personal
experience with this interview including - Lessons learned
- Discussion themes you expected
- Discussion themes that surprised you
62Disability Exercises
- Attend a disability cultural event (e.g.,
disability pride parade, disability arts
festival, nationwide Abilities Expo trade show) - Write a summary outlining personal reflections.
Then prepare comments to share with your
colleagues about your personal experiences - Lessons learned
- How did you feel while you were in the presence
of people with disabilities - Issues that surprised you
63Questions?
64References Resources
- American Psychological Association. (2011).
Guidelines for assessment of and interventions
with persons with disabilities. Retrieved May 10,
2011 from http//www.apa.org/pi/disability/resour
ces/assessment-disability.pdf -
- Artman,L.K., and Daniels, J.A. (2010). Disability
and psychotherapy practice Cultural competence
and practical tips. Professional Psychology
Research and Practice, 41, 442-448. -
- Centers for Disease Control and Prevention.
(2008). Racial/ethnic disparities in self-rated
health status among adults with and without
disabilities--United States, 2004-2006. Morbidity
and Mortality Weekly Report, 57, 1069-1073.
65References
- Department of Justice (1990). American
Disabilities Act of 1990. Retrieved on September
26, 2011 from http//www.ada.gov/pubs/ada.htm - Domenech Rodríguez, M.M., Baumann, A, Swartz,
A. (2011). Cultural adaptation of an empirically
supported intervention From theory to practice
in a Latino/a community context. American
Journal of Community Psychology. 47(1-2), 170-86 -
- Drum, C., Krahn, G, Culley, C, Hammond L.
(2005). Recognizing and responding to the health
disparities of people with disabilities.
Californian Journal of Health Promotion. 3(3),
29-42. -
- Gibson (2006). Disability and clinical
competency An introduction. The California
Psychologist, 39, pp 6-10. - Gill, C., (1995) A Psychological View of
Disability Culture. Disability Studies Quarterly,
15, 16-19.
66References
- Grant, S. K. (1997). Disability identity
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Dissertation Abstracts International Section B
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- Hopps, S., Pépin, M., Boisvert, J. (2003). The
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people with physical disabilities. Psychotherapy
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- Huey, S., Pan, D. (2006). Culture-responsive
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