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LGBTQ Module

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Disability and Psychology: A Multicultural View Linda R. Mona, Ph.D., Long Beach Phillip Keck, M.A., Mountain Home (Intern) Jae Yeon Jeong, Ph.D., Richmond – PowerPoint PPT presentation

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Title: LGBTQ Module


1
Disability and Psychology A 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)

2
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
3
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

5
Social, Political Historical Context
6
Social context The disability rights movement
  • Parallels to the Civil Rights Movement
  • Role of Advocacy
  • Gang of Nineteen
  • Disability Rights Movement
  • Museum of Disability

7
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

8
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

9
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).

11
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).

12
Definition of Terms
13
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

14
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

15
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16
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).
17
WHO-ICF Model
  • WHO-ICF overview

18
Health Disparities
19
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)


20
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



22
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).

24
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
26
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.

27
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

28
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

29
Disability Assessment
  • Clinical interview
  • MSE
  • Appearance factors
  • Accessibility of instruments
  • Adherence to standardized administrations can
    lead to false conclusions
  • Standardized norms
  • Implications for diagnoses

30
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

31
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.
32
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)

33
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

34
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.
35
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

37
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)
39
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

44
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

47
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.

48
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)

49
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?

52
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)

53
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!

54
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!

56
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

63
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).
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