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Discrimination on the other side of the desk: Impact of disability and minority status on the conduct of psychotherapy

October 20, 2009
by Terry L. Stawar, Ed.D.
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With the exception of some people who used wheelchairs for locomotion or were in recovery, I haven’t worked with many therapists who have had disabilities that I knew about.

We recently had a job applicant who was blind and I was wondering if any readers have had any experience employing psychotherapists that are blind or visually impaired. What sort of accommodations did you make, if any, and was there ever any reaction from patients?

I have generally assumed that vision was not necessarily a bona fide occupational qualification requirement for a therapist position, although since a lot of information is communicated non-verbally, I wonder if this has been investigated or legally determined.

Many years ago, when I was back in training as a school psychologist, one of our classmates had been severely burned as a youngster and, despite reconstructive surgery, still showed significant disfigurement from scarring. I wondered at the time how this might effect her ability to conduct psychological testing with school children. Was it fair to the kids to have this distraction, and, equally, was it fair for her to be excluded from her chosen profession?

Even more controversial, perhaps, is when, in a government-funded setting, a patient or client wants to change therapists because of a therapist’s age, gender, race, sexual preference, or disability. How is this to be decided and what issues and whose rights should take precedence?

It gets really convoluted when there are cases with more than one disability present, like when the person with the emotional support dog came into our transitional employment bookstore and plopped the dog in front of a disabled worker, who had health problems and severe allergies to dogs. In this case of dueling disabilities, who was discriminating against whom?

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I have a trainee about to start my course in Online Therapy who has severe CP, and therefore cannot use voice for communicating with her clients. She relies entirely on text which she types using one hand movement per character at a time. I am in awe of her. Another trainee uses Dragonspeak because of his severe dyslexia.

Over at the Online Therapy Institute (www.onlinetherapyinstitute.com) we also maintain active discussions, with many members having very different experiences of disabilities both themselves and for their clients. In fact, a lot of therapists come into online therapy because of a disability - I did, albeit a temporary one.

The International Society for Mental Health Online (www.ISMHO.org) has developed Suggested Principles for the Online Provision of Mental Health Services (http://www.ismho.org/suggestions.asp), and maintains active discussions about the impact of technology in the fields of psychology around the globe.

I'd also like to share that several disabled psychologists were extremely influential in my professional training, and have maintained meaningful professional careers, despite their disability status.

" have worked with and trained therapists in wheelchairs, with CP, MS, Crohn's, disfigurement, mental impairments or who are blind and, what is more, who are profoundly deaf - the last being a surprise to many hearing therapists who assumed that functioning ears were an essential part of their job. It turns out they are not.
I do not have experimental data but excellent anecdotal evidence (and personal experience) shows that not only can hearing and deaf clients benefit greatly from any skilled therapist, there can be distinct advantages. My profoundly deaf trainee, now a clinical supervisor, initially also assumed himself that his work would be restricted to the deaf community itself. But hearing clients also reported remarkable benefits from forging a positive, effective (and affective) relationship despite what initially seemed to be a barrier. Deafness did not stop him accurately perceiving emotion, so he could do the work and being highly skilled, did it well. Not all hearing clients chose to work with him, however, not unexpectedly. Anything about me might put clients off and I guess I have to accept that.
Summaries of the outcomes research show, it is the relationship that heals (as Irvine Yalom puts it) and where ever one can be made, therapy can happen, it seems. The background work to Solution Focussed Therapy (Miller, Duncan and Hubble - see also Escape From Babel, Towards a Unifying Language for Therapy, Norton) found convincingly (to me) that no matter what theory of therapy is used, the relationship quality accounted for around 40% of the change. Techniques and theory accounted for relativley little. Others (eg Bohart) have also found that clients make therapy work in their way in any case - often in ways their therapists don't imagine and regardless of the theory being applied. So if a relationship can be forged - whether through email or any other means (even via a sign language interpreter or reliant on lip-reading!) - it seems we can make progress.
Personally, I do think it has to be acceptable to the client to work with any therapist - on any ground, including what are usually thought unacceptable prejudices - but that therapists must be themselves and work within, and with, whatever reaction they receive, whether on the grounds of race, ability, class or anything else. IMHO clients must be able to choose someone they are comfortable with but therapists retain the right to practice as themselves.
re Evidence for online therapy, there are certainly increasing numbers of studies in support - cf proceedings of the 1st emental health summit, Amsterdam, Oct 2009 http://www.ementalhealthsummit.com/ for example.

I shared this with a friend that is visually impaired and here is his comment.
My degree was in mental health counseling, and although I did not become licensed and practice professionally, as a rehab counselor with a vision impairment counseling is still involved, and I do know of therapists with vision impairments. There are other ways of capturing the visual aspects of the client such as how they are dressed, grooming, posture, expressions, etc. Much of this can be noticed by the tone of someones voice, the pauses they have, and sounds they make noticing fidgeting, or anxiety, or other expressions. If clarification is needed the counselor can directly ask the client what they are feeling at this moment, or at the outset state that some more verbal communication will be necessary in responses (can't see a nod of the head in agreement or disagreement for example). Also, after the client leaves the counselor can briefly ask the secretary for some visual feedback of the client's appearance. As far as taking notes or doing assessments, there is adaptive software and equipment that can allow the counselor to perform the majority of their job independently. Also, while some information may be missed visually, I believe that in some ways the client can feel more comfortable and at ease with someone that has a vision impairment because they are not being judged visually. They may open up and have rapport more easily. As far as who chooses services, I believe the choice is in the client, and they can either choose a counselor or not choose a counselor based on their vision, or other disability such as the facial disfigurement as was mentioned, or by other reasons such as gender say for someone that may have experienced abuse, or someone that is direct or more passive, or I would hope in most situations the counseling philosophy and technique.

Besides the question of having a counselor with a vision impairment, I have heard of situations where a counselor refused to counsel a client that has a vision impairment, and this I believe is often because of the counselor's discomfort or belief that they are not trained to assist people having this disability. This is plain wrong and discriminatory, and says a lot about the counseling programs. There should be accommodations offered as in any public service. Obviously if the disability is not noticeable, and accommodations are needed it is up to the individual to disclose about their disability and need for accommodations. Usually just being upfront about it in discussion will help both the client and counselor feel at ease and come to some approaches that will work best, and this may vary with each person as people with vision impairments as with any disability have many variations and accommodations are very individualized.

I hope this is helpful, as it is meant to have positive feedback. If the person wants to contact me they can at 348-2730.

Sincerely,
Dan O'Connor, M.Ed., CRC
Senior Rehabilitation Specialist

Yes- recent studies have shown that the efficacy of online therapy is as good as face-to-face.
We try to bookmark the latest research-
http://delicious.com/OnlineTherapyInstitute/research

Also, Azy Barak, PhD Univ of Haifa, Isreal who also conducted a meta-analysis of all of the research to date has compiled a comprehensive bibliography of peer reviewed articles, qualiftative and quantitative studies on the topic. http://construct.haifa.ac.il/~azy/refthrp.htm

How do you know? Is there any comparable outcome data?

I have been conducting online therapy for over 10 years and most of my work is conducted via chat or email. The lack of paralinguistic and/or visual cues is not necessarily an impediment in conducting psychotherapy.

Terry Stawar

President/CEO (LifeSpring, Inc.)

Terry Stawar

@tstawar

planetterry.wordpress.com

Terry L. Stawar, EdD, is President and CEO of LifeSpring Health Systems, a community behavioral...