LGBTQ Module

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Disability 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)

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Multicultural 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
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Module 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

4
Agenda

• Social, political and historical context
• Definition of terms
• Health and mental health disparities
• Clinical implications (APA Guidelines)
• General considerations
• Exercises
• Questions
• References and resources

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Social, Political Historical Context
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Social context The disability rights movement

• Parallels to the Civil Rights Movement
• Role of Advocacy
• Gang of Nineteen
• Disability Rights Movement
• Museum of Disability

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Americans 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

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How 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

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Disability 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

10
Attitudes 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).

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Disability 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).

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Definition of Terms
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Definition 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

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Disability 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

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A 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).
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WHO-ICF Model

• WHO-ICF overview

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Health Disparities
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Disparities 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)

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Disparities in Disability Overview

• Future directions should involve
• Increased advocacy
• Understanding role of the environment
• Emphasis on health promotion
• Community-based participatory work

21
Model 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

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Health 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

23
Intersection 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).

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Social 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

25
Clinical Implications Assessment,
Conceptualization, Treatment
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Guidelines 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.

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Guidelines 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

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Guidelines 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

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Disability Assessment

• Clinical interview
• MSE
• Appearance factors
• Accessibility of instruments
• Adherence to standardized administrations can
  lead to false conclusions
• Standardized norms
• Implications for diagnoses

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Case 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

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Disability 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.
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Disability 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)

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Treatment 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

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DAT 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.
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Skills 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

36
Common 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

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Cultural 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

38
PWD 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)
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Microaggression 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)
40
Supplemental material Microaggressions chart
41
Supplemental material Microaggressions chart
42
Research 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

43
Research 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

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Adaptations 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

45
Adaptations 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

46
Adaptations 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

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Clinical 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.

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Treatment 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)

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General Considerations
50
Disability 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.
51
Do 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?

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Asking 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)

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Two 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!

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Recommendations 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.
55
Recommendations 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!

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Exercises
57
Disability 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

58
Supplemental Material Olkin
59
Supplemental Material Olkin
60
Supplemental Material Olkin
61
Disability 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

62
Disability 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

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Questions?
64
References 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.

65
References

• 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.

66
References

• Grant, S. K. (1997). Disability identity
  development An exploratory investigation.
  Dissertation Abstracts International Section B
  The Sciences and Engineering, 57(9-B), 5918.
•  
• Hopps, S., Pépin, M., Boisvert, J. (2003). The
  effectiveness of cognitive-behavioral group
  therapy for loneliness via inter relaychat among
  people with physical disabilities. Psychotherapy
  Theory, Research, Practice, Training, 40, 136-147
•  
• Huey, S., Pan, D. (2006). Culture-responsive
  one-session treatment for Asian Americans A
  pilot study. Psychotherapy Theory, Research,
  Practice, Training, 43, 549-554.

67
References

• Jones, G., et al. (2010). Health risk profile for
  older adults with blindness an application of
  the International Classification of Functioning,
  Disability, and Health framework. Opthalmic
  Epidemiology, 17, 400-410.
•  
• Kraal, A. Z., Waldron-Perrine, B., Pangilinan,
  P.H., Bieliauskas, L.A. (2015). Affect and
  psychiatric symptoms in a Veteran polytrauma
  clinic.
• Rehabilitation Psychology, 60(1), 36-42.
  
• Krahn, G., Campbell, V. (2011). Evolving views
  of disability and public health the roles of
  advocacy and public health. Disability and
  Health Journal, 4, 12-8.
•  
• Mona, L. R., Romesser, J.M., Cameron, R. P.,
  Cardenas, V. (2006). Cognitive behavior therapy
  with persons with disabilities. In P. A. Hays
  G. Y. Iwamasa (Eds.). Culturally responsive
  cognitive-behavior therapy Assessment, practice,
  and supervision, (pp. 199-222). Washington DC
  American Psychological Association.

68
References

• Mona, L.R., Cameron, R.P., Goldwaser, G., Miller,
  A.R., Syme, M.L., Fraley, S.S. (2009). 
  Prescription for pleasure Exploring sex-positive
  approaches for women with spinal cord injury. 
  Topics in Spinal Cord Injury Rehabilitation, 15,
  15-28.
• National Council on Disability (2009). The
  current state of health care for people with
  disabilities. Washington, DC NCD.
•  
• National Institute on Disability and
  Rehabilitation Research. (1999). NIDRR long-range
  plan. Washington, DC Office of Special Education
  and Rehabilitative Services.
•  
• Nicolas, G., Arntz, D.L., Hirsch, B.,
  Schmiedigen, A. (2009). Cultural adaptation of a
  group treatment for African American adolescents.
  Professional Psychology Research and Practice,
  40, 378-384.
•  
• Olkin, R. (1999). The personal, professional and
  political When clients have disabilities. Women
  and Therapy, 22, 87-103.

69
References

• Pan, D., Huey, S. Jr., Hernandez, D. (2011).
  Culturally adapted versus standard exposure
  treatment for phobic Asian Americans Treatment
  efficacy, moderators, and predictors. Cultural
  Diversity, Ethnic Minority Psychology, 17, 11-22.
  
• Reichard, A., et al. (2011). Health disparities
  among adults with physical disabilities or
  cognitive limitations compared to individuals
  with no disabilities in the United States.
  Disability and Health Journal, 4, 59-67.
•  
• World Health Organization. (1980). International
  Classification of Impairments, Disabilities, and
  Handicaps A manual of classification relating to
  the consequences of disease (Geneva, 1980).