Stacy L. Weber, MS, CRC
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).
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]) 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.
Accommodations and Funding
For persons with disabilities, accessibility to health care services has been an ongoing movement that began as the result of the civil rights movement of the 1960’s. The Americans with Disabilities Act (1990), and subsequent revisions, as well as Section 504 of the Rehabilitation Act of 1973, provide a legal basis for the utilization of healthcare services by persons with disabilities without threat of discrimination. Yet many persons with disabilities still do not receive equal care due to their disability because health care providers, on both the organizational and individual provider level, do not provide necessary accommodations for equal service (Mackelprang & Salsgiver, 1999). Often this lack of accommodation is justified by lack of funding (Leigh et al., 2004).
Sixty-two percent of psychologists indicated lack of funding as the number one hindrance to successful service provision (Leigh et al., 2004). The APA Code of Ethics ethical standard 6.04(b) states that a psychologist’s fees must be in accordance with legal standards (APA, 2002). Also, ADA mandates reasonable accommodations must be made to provide appropriate services to individuals with disabilities (ADA, 1990). This suggests that psychologists must adhere to the ADA and provide reasonable accommodations without charging the person with a disability an increased fee for the service.
Accessibility barriers were the second highest ranked issue that hinders service provision in a study by Leigh et al. (2004). More than 59% of respondents indicated accessibility as a significant and common problem in clinical practice with persons with disabilities (Leigh et al., 2004). In the psychology setting, accessibility issues often require accommodations to be made before services can be rendered. Accommodations often include assistive technology, communication devices, sign language interpreters, text telephones, accessible restrooms and therapy offices and ramps for stairs (ADA, 1990; Leigh et al., 2004).
Lack of funding is not considered an appropriate ethical or legal justification for inaccessible services. Legal cases have been litigated in favor of clients with disabilities when defendants, such as psychologists or clinics, have used the “lack of funds” argument (Leigh et al., 2004). Other cases have also upheld that “lack of funds” can only be used as a sufficient reason for denied services in extreme cases where the accommodation would cause undue hardship on the provider (Olmstead v. L.C., 1999).
Ethical Implications of Disability on Clinical Practice
The ADA (1990), in its simplest form, dictates standards of practice for public, state, and government entities that provide services to people with disabilities. Specific titles of the ADA require that state and local governments (Title II) and public accommodations (Title III) must provide people with disabilities the opportunity to participate in programs, services, and activities without unequal treatment. Reasonable modifications to physical settings, policies, and practices must be initiated to include people with disabilities (ADA,1990). This is a particularly important piece of civil rights legislation for individuals with disabilities that must be understood, embraced, and advocated by psychologists and psychology organizations such as the APA (Gill et al., 2003; Pledger, 2003).
The ADA regulations prevent discrimination of people with disabilities and, though not explicitly endorsed in the APA Ethics Code, fit with the general theme of the psychology field (Pledger, 2003). The guiding principles of Justice and Beneficence, as found in the APA Standards of Conduct, direct psychologists to provide the best care to each patient based on that person’s individual needs and to uphold an individual’s autonomy through respect and advocacy (APA, 2002).
Disability legislation, though often viewed with some uncertainty as to the rigidity by which a single provider must ensure it is upheld, provides unique opportunities for psychologists to expand their professional roles into advocacy and policy-making positions, in addition to positions as service providers (Gill et al., 2003).
The ADA requires employers to make reasonable accommodations for employees with physical or mental disabilities that would allow them to perform a job they are otherwise qualified to do. The only time employers are not required to make accommodations is if it results in undue financial hardship for the employer (ADA, 1990). Since litigation is often required to enforce adherence to the ADA (Pollard, 1993; Shapiro, 1993), psychologists often become involved in psychological consultations of appropriate accommodations (Gill et al., 2004).
Psychologists may be asked to participate in determination of reasonable accommodations for people with various psychiatric, cognitive, and intellectual disabilities (Foote, 2000). Often the employer will retain the psychologist’s services, so a psychologist must be aware of possible ethical issues that may arise. For example, while the psychologist may view both the employer and the employee as the client, the third-party (employer) may have certain expectations of psychologist loyalty and reporting of confidential information. Ethical standards 3.05, 3.06, and 3.07, multiple relationships, conflicts of interest, and third-party requests for services, respectively, may all arise in these types of situations, and the APA recommends discussing roles and expectations at the outset of the evaluation and professional relationship (APA, 2002). Similar ethical problems may arise when psychologists are asked to provide expert testimony in discrimination cases (Goodman-Delahunty, 2000) and educational evaluations for students with disabilities as allowed by the Individuals with Disabilities Education Act (1997).
Disability in Psychological Research
Research of minority groups brings up many unique ethical situations. Historically, minority groups, especially those with disabilities, were used as research participants without their knowledge, consent, and without any benefit to their population (Goodwin, 2008). The role of persons with disabilities in psychological research has long been that of a subject. Disability research was driven by political and legislative concerns with little, if any, input from the disability community (Olkin & Pledger, 2003). With the emergence of the new paradigm of disability and the increased inclusion of persons with disabilities in determining policy and decision-making regarding appropriate policies and procedures, disability research is asking more questions about the purpose and value of certain types of disability research (Asch, 1984). Questions about the ramifications of research findings on the disability community are now paramount in determining whether certain research avenues are pursued (Goodwin, 2008; Olkin & Pledger, 2003). For too long disability research focused on factors related to the individual with the disability, and the results were subject to the biases held by the psychologists performing the study and were often used to restrict the rights of people with disabilities (Olkin & Pledger, 2003).
Psychologists must consider their purpose for the research and find that the goal parallels the Principles of Beneficence and Nonmaleficence as outlined in the APA Ethics Code (APA, 2002). In accordance with Ethical Standard 9.02(b)(c), psychologists must carefully consider the tests and measures used in research with people with disabilities because many assessment tools do not include individuals with disabilities in the normative samples (APA, 2002; Asch, 1984). Also, assessment measures may be difficult for individuals to complete due to visual, cognitive, or physical impairments that affect the physical capacity for test-taking, written language comprehension, and other variables that may negatively affect the validity of the obtained scores (Asch, 1984).
Finally, psychologists should be especially careful to obtain true informed consent from research participants with disabilities as specified in ethical standard 8.02 (APA, 2002). Efforts must be made to present information regarding the study’s goals, procedures, risks, and benefits in a way that the individuals understand (APA, 2002). This may include offering communication technology or interpreters or writing the consent in language understood by the prospective participant. Though all researchers should attempt this no matter the population they are working with, it is very important to consider the functional limitations of the individual prior to obtaining informed consent and consider the implications of the disability on the person’s capacity to consent to research (APA, 2002; Olkin & Pledger, 2003).
Opportunities for Disability Training
Lack of training and exposure to individuals with disabilities in university settings and clinical practice reinforces the marginalization and invisibility of disability populations (Olkin & Pledger, 2003). But most students and licensed psychologists are not blank slates when it comes to disability exposure. Through personal life experience, the media, or other sources, psychologists have been exposed to all of the myths and stereotypes surrounding disabilities. How do psychologists overcome this negative exposure? Fortunately, even a small amount of training in disability issues may decrease negative biases. A study in which therapists and graduate students were shown a video tape of a counseling session with a woman with or without a wheelchair and asked to focus on case conceptualization and treatment planning found that even a very small amount of training (disability content in another course, one disability related course, or more than one disability specific course) has a positive effect on reducing biases toward disability (Kemp & Mallinckrodt, 1996). This shows that psychologists do not need to participate in large amounts of training to become more attuned to disability issues. Small amounts of training aimed at increasing awareness of disability are sufficient.
Opportunities for Student Training
Much discussion regarding disability training has focused on traditional graduate education as necessary to gain competence in working with persons with disabilities (Asch, 1988; Crewe, 1994). However, students in clinical psychology may also choose to pursue internships or postdoctoral fellowships with either a disability specialization or rotation. Such venues provide experiential learning about working with clients with disabilities. Internships with disability specialization are relatively rare in the United States. A 2003 study found only 81 (out of 618) internships with a disability rotation on the Association of Psychology Postdoctoral and Internship Centers (APPIC) directory (Kemp, Chen, Erickson, & Friesen, 2003). A recent search of the APPIC database showed even more limited opportunities for disability specialty opportunities. Of the 444 APA-accredited internships and postdoctoral fellowships, 61 have a major emphasis in physical disabilities, 66 have a major emphasis in developmental disabilities, and 67 have a major emphasis in learning disabilities. However, upon closer inspection, more than half of the internships included in each section were included in multiple disability categories, so the actual amount of internships with a disability emphasis is overrepresented in the directory (APPIC, 2008). The rehabilitation psychology division of APA provides students with a list of rehabilitation psychology internships with a major focus on disability issues. The current list includes 52 internships and 17 residency programs, most of which are APA-accredited (APA Division 22, 2009). It is important for prospective students to recognize that many of these internships are in medical settings that predominantly subscribe to the medical model of disability and rehabilitation.
Many students who apply to disability-focus internships will have little educational experience related to disabilities, but this does not preclude a student from becoming prepared to work with individuals with disabilities. There are various professional organizations that focus on disability issues. Division 22 of the APA (rehabilitation psychology), Division 33 of the APA (mental retardation and developmental disabilities), and the National Rehabilitation Association allow for student membership and participation and offer annual conferences with student specific topics. Students may also gain invaluable experience through professional and personal experience. Many cities have disability consumer organizations that offer referrals to agencies that frequently work with individuals with disabilities or volunteer opportunities to become involved in the disability community. By taking a proactive step to find practicum sites, volunteer opportunities, or part-time employment, students will become exposed to the issues related to disability and become more adept at successfully working with this population.
Training for Credentialed Psychologists
Many psychologists perceive themselves as competent to serve individuals with most disabilities (Leigh et al., 2004). However, without training and understanding of disability culture and specific needs and barriers related to disability, psychologists may do harm in treating individuals with disabilities. In order to comply with ADA and the APA code of ethics, and to provide the best service to one’s clients, psychologists in all stages of their careers may benefit from further disability training in-services, conferences, or continuing education courses. Where can one receive such training? A recent survey found that 49% of psychologists did not know whether their local or state psychology association offered training on disability service provision (Leigh et al., 2004). Further, training opportunities are not prolific in the United States. One third of respondents stated that their association did not offer such training, while only 18% said that their association did (Leigh et al., 2004).
APA occasionally offers continuing education courses on disability issues; however, they are sparse compared to other minority topics. For 2009 APA currently offers five disability courses throughout the country the topics of which are performing disability independent medical evaluations, disability and substance abuse, psychology and ADA legal issues, and learning disabilities. Five more continuing education courses are offered as home learning options, all of which are related to learning disabilities (APA, n.d.). Opportunities offered by the California Board of Psychology approved continuing education providers provide an even more meager opportunity to learn about disability issues in psychology. In 2009, none of the 56 continuing education seminars offered in California contain disability topics (California Psychological Association, 2009).
There are other venues in which a student or licensed psychologist can learn about disability issues. Division 22 of the APA provides reading lists of current topics in disability psychology and also has links to treatment guidelines for specific disabilities and outcome measures. Division 22 also holds an annual conference that focuses on pertinent current issues in rehabilitation psychology. The conference counts toward continuing education hours for practicing psychologists.
While the resources available from Division 22 are certainly a good place to begin gaining expertise in disability issues, it is important to keep in mind that the field of rehabilitation psychology often emphasizes intra-individual factors of disability as compared to the disability community, which focuses on social factors that influence disability (Olkin & Pledger, 2003). Rehabilitation psychology often concentrates on the medical model of disability whereas the disability studies field adopted the new paradigm view that disability is a social construct. An analysis of the two main journals of each field, Rehabilitation Psychology and Disability Studies, found that over a three year period 81% of the articles published in Rehabilitation Psychology reflect the old paradigm or medical model of disability. Disability Studies predominantly included articles from the new paradigm stance (68%) (Olkin, 2000). Given this continued difference between the perspectives of rehabilitation psychology and disability studies, it is important for psychologists to be aware of differing viewpoints.
One final resource offered by APA on disability is the Disability Issues Office (http://www.apa.org/pi/disability/homepage.html). This website is a collection of links to articles, journals, and legislation about disability issues that affect psychologists. Also, the page offers advice on improving one’s skills in working with persons with disabilities. The Disability Issues Office keeps abreast of current disability research topics as well as congressional activity related to disability rights.
While it is an obligation for psychologists to enlighten themselves about the topics of disability as it pertains to patient care, it need not become an added burden for psychologists to obtain disability related information and training. As long as practitioners are aware of the resources available to them, this education can become an integral part of their service and help meet the therapeutic needs of an underserved population of clients.
Disability is a common human experience that many Americans associate with (Mackelsprang & Salsgiver, 1999; Gill et al., 2003). Individuals with disabilities have recently proposed a new paradigm in which to conceptualize disability that has been acknowledged by the United States Congress in the ADA (ADA, 1990). Individuals with disabilities have called upon the field of psychology to aid in their movement toward equality by advocating for social change and providing nondiscriminatory services (Asch, 1998; Olkin, 1999). Psychologists are beginning to employ the new paradigm view of disability, but there are many barriers they face such as funding issues, negative attitudes and biases, and lack of training on disability issues (Leigh et al., 2004). The ethical standard of care proposed by the APA calls for psychologists to view people with disabilities as a minority group that requires and deserves respect and understanding and equal and competent psychological services (APA, 2002).
Stacy L. Weber is currently a clinical psychology doctoral student at Pacific Graduate School of Psychology in Palo Alto, CA. In her home state, she completed her master’s degree and undergraduate education in Rehabilitation Psychology at the University of Wisconsin-Madison. During her tenure at UW-Madison, Stacy participated as a research analyst for the State of Wisconsin Sentencing Commission, publishing her research results in Sentencing in Wisconsin. In addition, she was employed by the Government of Dane County Juvenile Reception Center, in Madison, Wisconsin as a youth counselor for juvenile offenders. It was through these experiences that Stacy decided to pursue her Doctorate in Clinical Psychology at PGSP. Currently, Ms. Weber continues to actively pursue her interests pertaining to Disability and Accessibility Ethics. She hopes her efforts will improve awareness of accessibility issues for practitioners, legislators and patients alike.
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