The Register Report, Spring 2009 National Register Graduate Student Corner Disability and Accessibility: Ethical Implications by: Stacy L. Weber, MS, CRC Return to Table of Contents

Disability is a prevalent human condition that results in unique needs which require distinctive regulations and specialized therapeutic care. The disability rights movement resulted in a conceptualization as the result of social and environmental responses to individual impairment. The Americans with Disabilities Act of 1990 (ADA) has upheld this position and created a framework from which psychologists must operate in relation to service provision. Ethical issues in psychology arise in areas such as funding, accommodations for clients, research practices, and training of psychologists. These ethical issues must be navigated carefully using the American Psychological Association Code of Ethics and the ADA in order to provide appropriate, nondiscriminatory services to people with disabilities.

Disability and Accessibility: Ethical Implications for the Clinical Psychologist

More than 22% of Americans have disabilities, accounting for more than 54 million people (Centers for Disease Control, 2001). Currently persons with disabilities are one of the fastest growing minority groups in the United States, and they require mental health services as often as people without disabilities (Kemp & Mallinckrodt, 1996). Individuals with disabilities often seek therapy for the same issues that cause non-disabled individuals to seek therapy (Pelletier, Rogers, & Dellario, 1985). Thus psychologists should be ready to encounter and provide services to people with disabilities in whatever venue they practice (Leigh, Powers, Vash, & Nettles, 2004).

Principle E of the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (2002) states that psychologists must be aware of and respect individual differences, including disabilities. With this in mind, psychologists need to be cognizant of issues such as attitudinal barriers, lack of training, funding issues, physical accessibility, and other aspects of psychological service provision because they all carry unique implications for the ethical practice of psychology with persons with disabilities (Pledger, 2003).

Defining Disability

Historically, persons with disabilities have been associated as a marginalized group with a unique culture (Gill, Kewman, & Brannon, 2003). A new disability paradigm recently emerged as the result of disability rights legislation, the independent living movement, and the growing popular emphasis on positive psychology and cultural competence (Nagi, 1991). This new paradigm seeks to address disability within a social context in which a disability is actually the result of social confines that restrict an individual with a physical or mental impairment (Gill et al., 2003). Proponents of the new paradigm argue that disability is a common and universal human experience that can be either aggravated or mitigated through dynamic social, cultural, and environmental interactions (Nagi, 1991). The Americans with Disabilities Act of 1990 ([ADA] §2[a][7]) recognized people with disabilities as a unique minority group and provided legal affirmation of the social basis of disability, while guaranteeing equal rights and access to services for these individuals.

Psychology’s Historical View of Disability

Within psychology, the concept of disability is viewed through a medical model, also known as the old paradigm (Pledger, 2003). In this paradigm disability is depicted as an impairment of the person, and the goal of therapy is to minimize the implications of the person’s disability with regard to societal standards and reduce the visibility of the impairment (Wright, 1960). Psychology has a tradition of defining disability in terms of abnormalities or special deviations from the norm (Olkin & Pledger, 2003). This tradition has cultivated a conceptualization of disability that is taught in relation to what can go wrong with a person, leading to a focus on individual deficits instead of assets (Finkelstein, 1998). The medical model system also drives the reimbursement system in the United States, and requires a psychologist to provide a reimbursable diagnosis to qualify for payment (Gill et al., 2003). This certainly limits the ability of psychology to fully adopt the new paradigm model of disability.

As people with disabilities fight against social exclusion and discrimination, they have called on psychologists to adopt the new paradigm and challenge the sociopolitical foundations of their disadvantaged status (Olkin, 1999). Psychologists have done much to unseat the historically dominant views of biological inequality for other minority groups such as women, African Americans, and gay, lesbian, and bisexual groups (Jenkins & Ramsey, 1991). The APA, for example, has initiated multiple advocacy efforts to address social issues of minority groups (Gill et al., 2003). By viewing disability within the context of the new paradigm, psychologists will find numerous opportunities to reframe the way they define problems related to disability (Gill et al., 2003).

Barriers to Treatment

In order for psychologists to adopt the new paradigm view of disability and move forward in providing equal care and treatment to people with disabilities, it is important to systematically scrutinize the barriers that exist for people with disabilities in relation to psychological treatment (Leigh et al., 2004). Also, it is crucial for psychologists to assess their own attitudes, biases, and beliefs that may serve to maintain unequal treatment or ineffective practices.

Attitudes Towards Disability

People with disabilities experience discrimination in many areas of their lives; housing, employment, education, leisure, and health care utilization are frequent venues of discrimination against people with disabilities (Mackelprang & Salsgiver, 1999). Society continues to view disability as a negative individual difference that is associated with disapproval and discomfort (Leigh et al., 2004). Unfortunately, psychologists are not immune to this attitude. Research suggests that studies performed by psychologists who provide therapy to persons with disabilities reinforce negative attitudes about the psychological well-being, productivity, or capacity for intimacy of persons with disabilities (Asch & Rousso, 1995). Research is beginning to emphasize a more positive view of disability, but this research has not yet become prominent in clinical settings (Mackelprang & Salsgiver, 1999). Psychologists’ attitudes of disability are dependent on the acceptableness of the disability in the eyes of the public. Regardless of their functional impact, more visible disabilities are viewed more negatively by the public and psychologists (Olkin & Howson, 1994).

Psychologists’ Lack of Training on Disability

Many psychologists are familiar with disability only within the realm of rehabilitation psychology, and they do not believe that they need to be trained or adept in working with persons with disabilities in general practice. This misconception is salient in psychology literature related to disability, which most often focuses on disability-related adjustment and does not address the most common psychological problems that people with disabilities experience, which are the same as the non-disabled population (Olkin & Pledger, 2003). However, growing evidence indicates that most people with disabilities are seen for psychotherapy and assessment outside the realm of rehabilitation psychology (Olkin & Pledger, 2003). Psychologists will undoubtedly encounter many persons with various disabilities and levels of functioning throughout their careers. The number of clients with disabilities seen in non-rehabilitation settings will invariably continue to increase as community integration and independence increases as the result of the disability rights movement (Olkin & Pledger, 2003). It is important to increase awareness of disability issues in psychologists prior to the commencement of their clinical careers.

Clinical psychologists are mandated by the APA Ethics Code to practice within the realm of their competence (APA, 2002). Specifically, the APA requires psychologists to display diversity awareness and cultural competence of the populations they serve in order to comply with the ethical standard 2.01(a)(b) of the APA Ethics Code (APA, 2002; Olkin & Pledger, 2003). Also, APA accreditation guidelines, specifically domain D, emphasize the need for diversity training for psychology graduate programs to maintain accreditation (APA, 1995). Most often this is interpreted as ethnic and racial competence and, less commonly, gender and sexuality (Bluestone, Stokes, & Kuba, 1996). People with disabilities, as a cultural group, are often overlooked in clinical psychology graduate programs, even though the APA specifically includes disability competence in its Ethics Code (Davis, 1995; Olkin & Pledger, 2003; APA, 2002).

Disability courses are virtually nonexistent in clinical psychology programs. A study by Bluestone et al. (1996) found that disability was the least covered topic in psychology training out of seven diversity issues. Other studies confirmed that disability issues receive little, if any, attention in graduate level psychology curricula (Kemp & Mallinckrodt, 1996; Olkin, 2000). Strikingly, passage of the ADA in 1990 did little to increase disability inclusion in psychology curricula. Prior to the ADA, the modal number of APA-accredited clinical and counseling psychology graduate programs that required even one disability-related course was zero; yet, nine years after the adoption of the ADA, the modal number that required a disability course was still zero. Moreover, in 1999, the percentage of programs that even offered one elective course on disability was 11% and had actually decreased from a decade before. Most of the disability courses offered were structured on the medical model of disability; only 7 out of 210 psychology programs had a class based on the new paradigm of disability (Olkin & Pledger, 2003).

Though it is obvious that training on disability competence is lacking, one may wonder whether practitioners feel that their knowledge of disability issues is subpar. Results of a survey performed by Alisson et al. (1994) regarding competence to provide services to persons with disabilities indicate that there is a low level of perceived ability to provide services to individuals with physical disabilities among recent graduates from counseling and clinical psychology programs. However, these participants were still providing services to individuals with disabilities regardless of their perceived level of competence (Alisson et al., 1994). Also, a survey conducted by Leigh et al. (2004) indicates that 96% of psychologists without disabilities endorsed professional experience working with people with disabilities as an important predictor of success. More than 80% of psychologists with disabilities also indicated professional experience, as well as personal experience, with disabilities as important to success. Similarly, disability training was considered an important factor of success by 75% of non-disabled psychologists and 66% of psychologists with disabilities. Interestingly, 35% of non-disabled psychologists feel their disability competence is sufficient and resist advice and additional support when working with a client with a disability (Leigh et al., 2004). Ethical standard 2.01(c) indicates that professionals planning to treat or research populations of individuals they are unfamiliar with are obligated to gain competence in this population through formal education, training, supervision, or consultation (APA, 2002). Yet, there appears to be a disconnect between psychologists’ training and competence on disability issues and the level of services offered to individuals with disabilities. Considering that most psychologists receive no formal training in disability issues and they often perceive themselves as lacking competence in this arena, the number of psychologists resisting advice and support is astonishingly high. continue

 

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