This document discusses ethical issues related to providing psychological services to people with disabilities. It begins by noting that about 20% of the US population lives with one or more disabilities. The document then outlines some key ethical considerations and competencies needed to work with people with disabilities, including knowledge of disability models and related developmental, medical, and sociopolitical issues. It emphasizes that competence requires not only knowledge and skills, but also self-reflective attitudes to confront one's own biases. The document presents two case examples to illustrate these ethical issues in practice and invites commentaries from experts to further address related questions.

1. FOCUS ON ETHICS
Jeffrey E. Barnett, Editor
Perspectives on Ethical Practice With People Who Have Disabilities
Jennifer A. Erickson Cornish, Kimberly A. Gorgens,
and Samantha Pelican Monson
University of Denver
Rhoda Olkin
California School of Professional Psychology
Barbara J. Palombi
Grand Valley State University
Arnold V. Abels
University of Missouri—Kansas City
An estimated 49.7 million people in the United States live with one or more disabilities, representing
nearly 20% of the 257.2 million individuals ages 5 and older in the civilian population (U.S. Census
Bureau, 2003). Most psychologists are likely to have the opportunity to work with clients who have
disabilities (R. Olkin, 2002) and need the competencies to provide ethical services to this growing
proportion of the population. What constitutes ethical practice with people with disabilities? First, the
ethical issues involved in providing services for people with disabilities are outlined, and 2 vignettes and
a number of questions for practitioners and educators are presented. Then, 3 invited experts provide
commentaries that address these issues, raise additional questions, and provide important resources.
Keywords: ethics, disabilities, competencies, clinical practice
Toward Ethical Practice With People Who Have
Disabilities
Jennifer A. Erickson Cornish, Kimberly A. Gorgens, and
Samantha Pelican Monson
An estimated 49.7 million people in the United States live with
one or more disabilities, representing nearly 20% of the 257.2
million individuals ages 5 and older in the civilian population
(U.S. Census Bureau, 2003). Epidemiologists estimate that the
number will continue to increase as baby boomers age and as
obesity and other secondary health risks increase among younger
persons (Alley & Chang, 2007). The U.S. Social Security Admin-
istration (2006) reported that almost 3 in 10 of today’s 20-year-
olds will become disabled before age 67. In addition to being
personally affected, clients may experience disability as a care-
giver, a parent, or a child of someone with a disability. Thus, most
JENNIFER A. ERICKSON CORNISH received her PhD in clinical psychology from
the California School of Professional Psychology, Los Angeles. She is the
director of clinical training at the University of Denver Graduate School of
Professional Psychology. Her areas of professional interest include supervision
and training, ethics, multiculturalism, and group therapy.
KIMBERLY A. GORGENS received her PhD from Southern Illinois University
at Carbondale and completed a postdoctoral fellowship in rehabilitation
psychology. She has a full-time appointment to the University of Denver’s
Graduate School of Professional Psychology and a special appointment to
the University of Colorado at Denver Health Sciences Center. In addition
to teaching, research, and clinical supervision, she provides community
outreach around issues of disability recognition and access.
SAMANTHA PELICAN MONSON received her MA in clinical psychology from
the University of Denver and is currently a PsyD student at the same
institution. Her predoctoral internship is at the University of Colorado at
Denver and Health Sciences Center. Her areas of professional interest
include integrated primary care, health psychology, and physician–patient
communication.
RHODA OLKIN received her doctorate from the University of California,
Santa Barbara. She is a distinguished professor at the California School of
Professional Psychology at Alliant International University, San Francisco,
and the executive director of the Institute on Disability and Health Psy-
chology. Her interests include disability and deafness, physician-assisted
suicide, online teaching, and doctoral-level training.
BARBARA J. PALOMBI received her PhD in counseling psychology from
Michigan State University. She is the director of the Counseling and Career
Development Center at Grand Valley State University. Her areas of pro-
fessional interest include students with personality disorders, campus well-
ness, and issues related to disability.
ARNOLD V. ABELS earned his PhD in counseling psychology from the
University of Missouri—Kansas City. He serves as the associate director/
training director at the University of Missouri—Kansas City’s Counseling
Center. His professional interests include disability issues, multicultural-
ism, and training and supervision.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jen-
nifer A. Erickson Cornish, University of Denver Graduate School of
Professional Psychology, 2460 South Vine Street, Denver, CO 80208.
E-mail: jcornish@du.edu
Professional Psychology: Research and Practice, 2008, Vol. 39, No. 5, 488–497
Copyright 2008 by the American Psychological Association 0735-7028/08/$12.00 DOI: 10.1037/a0013092
488
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2. psychologists are likely to have the opportunity to work with
clients who have disabilities (Olkin, 2002) and/or those affected
secondarily and therefore need the competencies to provide ethical
and effective services to this growing proportion of our population.
For the purposes of this article, disability may be considered an
evolving concept including “physical, mental, intellectual or sen-
sory impairments that, in the face of various negative attitudes or
physical obstacles, may prevent those persons from participating
fully in society” (United Nations Enable, 2006, Defining Disability
section, para. 1). Among the general American public, 9.3 million
people have a sensory disability involving sight or hearing, 21.2
million people have a condition limiting basic physical activities,
such as walking or climbing stairs (National Center for Health
Statistics, 2007; U.S. Census Bureau, 2003), and 12.4 million
people have a physical or mental condition causing difficulty in
learning, remembering, or concentrating (U.S. Census Bureau,
2003). Additionally, more than 26% of Americans ages 18 and
older meet the diagnostic criteria for mental illness each year
(Kessler, Chiu, Demler, & Walters, 2005).
What constitutes ethical practice with these populations? What
knowledge, skills, and attitudes are necessary for competently
treating persons with disabilities? How can educators and trainers
best prepare psychology students to work ethically and compe-
tently in this area? Should graduate programs be required to
include disability issues as part of the core curriculum? What about
internships and postdoctoral programs? Should separate ethical
guidelines be written specifically for disability issues?
Disability as a Multicultural Issue
Persons with disabilities are a large and growing minority group
in the United States, second only to combined ethnic groups at
34% (U.S. Census Bureau, 2003). Many people with disabilities
also have membership in other underrepresented groups. Rates of
reported disabilities are highest in Black, American Indian, and
Alaska Native groups. Although the disability rate is 16.2% for
non-Hispanic Whites of working age (between ages 16 and 64), it
is 26.4% for Blacks and 27.0% for American Indians and Alaska
Natives. Among people ages 65 and older, the rates for these
groups are 40.4%, 52.8%, and 57.6%, respectively (U.S. Census
Bureau, 2003). Persons with disabilities are also overrepresented
among the lower socioeconomic strata. According to the 2000
Census, 8.7 million people (17.6%) with disabilities are poor
(defined as $8,794 annual income per individual). Further, 1 in 4
children with disabilities are reported to live in poverty. Other data
indicate that persons with disabilities also have a greater risk of
abuse and exploitation (Sobsey & Doe, 1991) and may be sub-
jected to hate crimes in the same way that other groups are targeted
(McMahon, West, Lewis, Armstrong, & Conway, 2004).
In addition to the common experience of oppression and dis-
crimination resulting from their legally classified impairments,
persons with disabilities may share common values, customs, and
concerns (American Psychological Association [APA] Task Force
on Diversity Issues at the Precollege and Undergraduate Levels of
Education in Psychology, 1998). These groups, and subgroups
within them, represent unique cultures. For example, the Deaf
community advocates for the inclusion of deafness in conceptions
of multiculturalism (Williams & Abeles, 2004).
A 2002 APA president’s column called disability issues “a
challenge for you, me and all psychologists concerned about
including all those with any disability within the caring human
community” (Zimbardo, 2002, p. 5). It is essential to provide
ethical treatment to persons with disabilities, minimize barriers to
care, and train future psychologists in these endeavors.
Ethical Perspectives
The “Ethical Principles of Psychologists and Code of Conduct”
(APA, 2002) mentions those with disabilities in Principle E (Re-
spect for People’s Rights and Dignity) as part of a list of groups
who may be subject to societal prejudice. This constitutes APA’s
definition of diversity issues to be addressed by psychologists in
all their roles. In addition, APA guidelines on the use of nonhandi-
capping language in APA journals have been published (APA
Committee on Disability Issues in Psychology, 1992), and persons
with disabilities are considered in APA guidelines related to other
oppressed groups (e.g., “Guidelines on Multicultural Education,
Training, Research, Practice, and Organizational Change for Psy-
chologists”; APA, 2003). Yet, unlike other target groups (e.g.,
racial/ethnic minorities, sexual minorities, and women), there are
no separate ethical standards to guide the practitioner on the
psychological treatment of persons with disabilities. Perhaps it is
time for APA to consider publishing such standards.
Clearly, multiculturalism itself may be regarded as an ethical
movement (e.g., Fowers & Davidov, 2006). Whether considered
from a principles-based approach (APA, 2002) or from a philo-
sophical perspective, such as virtue ethics (Fowers & Davidov,
2006), the ethical psychological treatment of clients must include
an “openness to the other” (Fowers & Davidov, 2006, p. 581). Yet,
it may be particularly challenging for many psychologists to truly
celebrate or embrace the differences inherent among people with
disabilities. In addition to the difficult work involved in consider-
ing the privilege of being temporarily able-bodied, many psychol-
ogists may find it extremely uncomfortable to consider their own
physical, mental, intellectual, and sensory vulnerabilities and, thus,
may tend to compartmentalize disabilities or relegate their study to
specialty fields, such as rehabilitation psychology (Daughtry,
2007; Yuker, 1988). In fact, it may even be difficult for practitio-
ners to recognize mental illness itself as a disability because of the
frequency with which they encounter it. Although psychologists
receive training on mental illness, they may not be aware of the
sociopolitical implications of mental illness as a disability. Even
for psychologists who live with a disability themselves, compe-
tence must not be assumed.
Ethical Practitioners
Ethical practice is inextricably linked with competency. Com-
petence “refers to the professional’s overall suitability for the
profession, reflecting his or her knowledge, skills, and attitudes
and their integration” (Rubin et al., 2007, p. 453). Section 2 of the
APA’s (2002) ethics code relates specifically to competencies and
includes a statement indicating that because “an understanding of
factors associated with . . . disability . . . is essential for effective
implementation of their services . . . psychologists have or obtain
the training, experience, consultation, or supervision necessary”
(pp. 1063–1064) to ensure competent care.
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3. Ethical practitioners have a basic knowledge of the Americans
With Disabilities Act of 1990, as well as information on office and
Web accessibility (Pope & Vasquez, 2005) and obstacles to care,
including physical barriers and the cognitive and affective biases
of practitioners themselves (Pope, 2005). Knowledge of disability
models, such as moral, medical, grief, minority, wellness, and
social (e.g., Olkin,1999; Prilleltensky & Prilleltensky, 2003; Wen-
dell, 1997), is important. In addition, ethical practitioners seeking
to work competently with individuals with disabilities are familiar
with developmental issues, including dating, sex, pregnancy, and
childbirth among people living with disabilities (e.g., Ashe & Fine,
1997) and, of course, with medical considerations of specific
conditions. Further, it is crucial to develop an understanding of
multiple minority statuses (e.g., Sue & Sue, 2003) as illustrated by
a woman of color with a disability.
In addition to the general skills needed for assessment and
intervention, specific skills may include an understanding of
common therapeutic mistakes with this population (e.g.,
Pardeck, 2001). For instance, how many psychologists routinely
ask about disabilities during a standard intake, particularly
given that many disabilities are invisible? Consultation and
referral skills are also essential. As the “Guidelines on Multi-
cultural Education, Training, Research, Practice, and Organiza-
tional Change for Psychologists” (APA, 2003) recommend,
practitioners need access to interdisciplinary resources (with
client permission and informed consent) for multicultural pop-
ulations. When a psychologist has not yet developed compe-
tency to treat people with disabilities, appropriate referral skills
are necessary. Finally, advocacy skills and knowledge of
disability-related social justice issues are beneficial. Persons
with disabilities live within a challenging sociopolitical context.
Psychologists have the potential to influence disability policies
that may have an impact on training, treatment, and research
issues relevant to this population (Pledger, 2003). Knowledge
and skills are necessary but not sufficient to address these
complex systemic concerns.
Attitudes desirable for competent practitioners include em-
pathy and compassion balanced with appropriately high expec-
tations. Again, such values and attitudes may be particularly
difficult for psychologists to develop if they are unwilling to
confront their own frailties. Nevertheless, ethical practitioners
must possess a willingness to engage in self-reflection. First,
sufficient insight into their own limitations is needed to accu-
rately determine whether they are competent to provide services
to persons with disabilities. Leigh, Powers, Vash, and Nettles
(2004) surveyed 481 psychologists about issues related to the
provision of psychological services to clients with disabilities.
They found that significantly more respondents without disabil-
ities, as compared with the 37% with disabilities, felt that they
did not require additional resources when treating clients with
disabilities. “While this finding can be interpreted to mean that
these respondents view themselves as providing appropriate
support, it also suggests that a number of non-disabled psychol-
ogists may not be aware of their need for training and support”
(Leigh et al., 2004, p. 53). Second, the professional must
“examine his or her view of clients with disabilities and identify
and question prejudicial assumptions” (Sue & Sue, 2008, p.
490). This may be especially pertinent to practicing psycholo-
gists, as well as those who train psychologists, in order to avoid
unwittingly conveying undesirable attitudes or using language
that could be inappropriate or even insulting to clients or
students. Being an ethical practitioner requires recognition of
deficiency areas and biases, so they can be addressed. Failure to
do so may result in perpetuating attitudinal barriers built on
ignorance, false beliefs, and prejudice.
Case Examples
To illustrate our ideas concerning disability as an ethical issue,
we present several case examples. The commenting authors have
been invited to respond to these vignettes, as well as to answer the
questions we posed earlier. In this way, we hope to apply ethics to
actual practice with clients living with disabilities.
Too Close for Comfort
A 60-year-old psychologist who has just begun to experience
early symptoms of macular degeneration has for several years
treated a client with a severe visual impairment that has resulted in
the client’s permanent disability status. The client is highly moti-
vated and engaged in psychotherapy focused on alleviating depres-
sion. Because the psychologist is known for his expertise treating
depression, he has taken pride in his competent work with this
client. The client has recently mentioned significant financial
difficulties associated with his limited disability insurance and has
noticed the lack of Braille guides on the elevators outside the
office. Although a sliding scale spot has just opened on his
caseload, the psychologist doesn’t offer it to the client, and he
questions the utility of the Braille guides when the client seems to
be “getting around just fine with his cane.” His office partner
wonders whether the therapeutic relationship has been disrupted
since the psychologist’s visual problems started.
Complex Competencies
A psychology trainee completing a trauma rotation is assessing
an undergraduate client in a wheelchair who has asked for untimed
testing as an accommodation for the posttraumatic stress disorder
that followed the car accident that caused his injury. The trainee
overhears her supervisor referring to “that handicapped
wheelchair-bound client” to the receptionist. The trainee worries
that her client may have overheard the same comment, and she
wonders if her supervisor’s competence in trauma will overcome a
perceived lack of competence in disability issues. Yet, she hesi-
tates to raise the issue with her supervisor because of worries about
her upcoming evaluation.
Future Considerations
Although individuals with disabilities are specifically named as
a minority group that APA-accredited training programs must
include in their curricula (Olkin & Pledger, 2003), “most graduates
of counseling programs do not possess competencies to provide
services to clients with disabilities” (Smart & Smart, 2006, p. 36).
In fact, the number of academic classes on disability actually
decreased from 1989 to 1999 (Olkin, 2002). Unless graduate
programs include disability as a regular part of the core curricu-
lum, psychologists must individually obtain the necessary educa-
tion and training to offer ethical services to persons with disabil-
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4. ities. Attending disability awareness training, seeking professional
consultation on issues pertinent to individuals with disabilities,
accessing relevant publications, locating appropriate referral
sources, and obtaining specialized clinical supervision from a
competent practitioner can increase familiarity with disability is-
sues (Kemp & Mallinckrodt, 1996). Disability simulation (e.g., not
saying any words containing the letter e to approximate expressive
language disorders) and attending talks given by individuals with
disabilities have been shown to increase levels of empathy for
individuals with disabilities (Wurst & Wolford, 1994). Certainly,
the APA Committee on Disability Issues in Psychology should
also be consulted whenever possible.
Until disability boards the “diversity train” (Olkin, 2002, p.
127), the field of psychology will not have attained its goal of
becoming a truly multicultural profession. In this “Focus on Eth-
ics” section, we seek to outline the challenges faced by psychol-
ogists, educators, and the profession when working to address the
special needs of a population living with disabilities. We raise
important issues for the field, and three experts respond to these
issues and add their own unique perspectives in invited commen-
taries. This section thus encourages psychology’s overdue com-
mitment to developing and enhancing ethical treatment for persons
with disabilities.
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5. Commentaries
Social Warrior or Unwitting Bigot?
Rhoda Olkin
Erickson Cornish, Gorgens, and Monson have provided a ratio-
nale for better education and training related to clinical work with
clients with disabilities. They stated that “being an ethical practi-
tioner requires recognition of deficiency areas and biases, so they
can be addressed” (p. 490). Otherwise, psychologists, educators
and trainers can “unwittingly” convey undesirable attitudes or use
“language that could be inappropriate or even insulting to clients
or students” (p. 490). I agree, but I wonder who is going to provide
the disability-competent training, supervision, or consultation? In
their first case example, will the office partner have the knowledge
and skills to help his office mate? In the second case example, can
the trainee address the issues of disability sensitivity and compe-
tence with the supervisor? Where is the professional well trained in
disability to whom she can turn?
What if we don’t know what we don’t know about disability?
What if we believe that we are competent to teach disability as part
of diversity courses? What if we talk about disability in our various
classes without knowing that our words, deeds, beliefs, and actions
are unwittingly conveying undesirable attitudes?
In this commentary, I echo the idea from Erickson Cornish,
Gorgens, and Monson that educators bear a responsibility for
serious introspection, and I offer some questions to guide that
introspection. I invite readers to use these questions for small
group discussions as well as individual reflection. There are no
right or wrong answers, but there are answers that are more
consistent with a social justice philosophy and with the disability
rights movement over the past 4 decades (cf. Mackelprang &
Salsgiver, 1999; Olkin, 1999; Olkin & Pledger, 2003).
Attitudes
Questions
1. Do I believe that a blind student is capable of being
a psychotherapist? Do I have fears about the stu-
dent’s safety in difficult field placements? Am I
willing to send my lecture notes to the student at
least 48 hr in advance of each class? What accom-
modations are reasonable for this student in assess-
ment class and preliminary exams? Do I believe
that this student must do everything other students
have to do?
2. The bathroom in my office building is not wheel-
chair accessible. Am I willing to spend time talking
to the landlord and pursuing the issue until it is
resolved? How much of an advocate am I willing
to be, and when would I give up? Do I think it is a
better solution to refer this client to another psy-
chotherapist?
3. When I look at my student who uses an electric
wheelchair, what do I see/think/feel? Can I admit
to and process my own feelings about vulnerabil-
ity, morbidity, and mortality? Do I expect less of
the student because he or she has so much to cope
with, or do I expect more because he or she must
have overcome many barriers to get here?
4. What accommodations am I personally willing to
make for a student with a visual impairment, for a
student with a learning disability related to writing,
or for a student who experiences fatigue? Are the
principles and rationales I’m following the same in
each of these instances?
5. A Deaf student writes incomprehensible prose.
How do I feel about oral testing in place of written
tests? How might the dissertation be handled so
that it isn’t a major stumbling block on the road to
a doctorate? Am I okay with the idea of all the
practicum placements being ones that serve deaf
clients? Will I learn a few words of sign language
so that we can do some basic communication?
6. Do I think that disability is just another niche issue
and that if we start talking about disability, we then
open the floodgates to talking about every specialty
issue? Where does it end?
Discussion
Some of these questions get at the visceral and unconscious
reactions to disability and whether one feels able to be honest
about them and manage them. Additionally, they ask about basic
beliefs concerning the capabilities of students and trainees with
disabilities and about their appropriateness for the field. Reason-
able accommodations in classes are legally mandated (Americans
With Disabilities Act of 1990; Bruyere & O’Keeffe, 2004; Reha-
bilitation Act of 1973), but their implementation rests with the
instructor, who can be busy, can forget, or may not think it is his
or her job. These questions also assess whether psychotherapists
view their role as one that includes activism for social justice and,
therefore, whether they believe the roles of educator, trainer, and
supervisor should include preparing students for this task (Banks,
2003; Nabors & Pettee, 2003; Olkin, in press).
Knowledge
Questions
1. When I teach classes on the social bases of behavior,
or assessment, or clinical skills, or diversity, how do
I incorporate issues of disability into the curriculum?
Do I see it as my responsibility to become more
knowledgeable, or do I rely on guest speakers?
2. Do I know the various ways of conceptualizing
disability? Do I understand why knowing about
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6. models of disability is important? Do I know how
to change how I talk to clients on the basis of
whether they believe in the moral model, the med-
ical model, or the social model (Olkin, 1999)?
3. Do I know what issues are more likely to be
relevant for clients with disabilities? If pain, fa-
tigue, weakness, and uncertainty are disability-
relevant issues, do I know how to train my students
to ask about and work with these issues?
4. How can I think about helping in a disability-
sensitive way? How should a room be arranged to
be more disability friendly? What basic accommo-
dations should a psychotherapy office incorporate
into its practice?
5. How does disability identity interface with the per-
son’s other characteristics, such as ethnicity, gen-
der, sexual orientation, religion, age, sociodemo-
graphic background? Do I understand the
economic issues affecting the population of per-
sons with disabilities?
6. What accommodations are appropriate in testing a
person with a disability? How do I balance the
standardization inherent in testing with the need for
individualization and accommodation for a person
with a disability? What norms do I use?
Discussion
Models of disability, helping clients manage pain and fatigue,
making accommodations in assessment and in treatment, and un-
derstanding multiple minority identities are essential parts of the
knowledge base. Positive attitudes alone are insufficient in light of
the many specific areas of knowledge needed for competence with
clients with disabilities.
Skills
Questions
1. If the client doesn’t raise the topic of his or her
obvious disability, should I? How do I phrase this
question? What language is derogatory, and what
language is respectful?
2. I want to help my students understand disability
and not just in an intellectual way. What exercises
or tasks can I assign that are culturally sensitive
and appropriate?
3. My Deaf student just used a derogatory sign for
gay male. How do I talk with the student about
this?
4. Whenever the topic of disability comes up in class,
no one says much. How do I facilitate the dia-
logue?
5. How do I tell a student that she can’t miss more
than two classes, even if she has a medical condi-
tion? Is this reasonable? How do I decide, and who
do I consult?
6. My student with a disability says that his place-
ment supervisor is being discriminatory. How do I
follow up on this? What is considered discrimina-
tory in this context? Is it OK for the supervisor to
ask personal questions about the student’s disabil-
ity?
Discussion
Ultimately, it all comes down to what instructors do and how we
do it. Helping students acquire skills related to disability will help
them feel more confident treating clients with disabilities. Instruc-
tors need the skills before they can teach them. Unfortunately, so
few instructors received disability training in graduate school that
we embark on teaching what we are still learning. Openness to the
topic, recognition of the need for training, acknowledgement of the
special skill sets necessary, and desire for ethical and competent
practice with clients with disabilities—these are the factors we
must model genuinely for our students.
Recommendations
Psychotherapists who want to learn more about treatment for
people with disabilities are directed to Mackelprang and Salsgiver
(1999) and Olkin (1999), because both books were written for
professionals who had not received training in this area. Addition-
ally, a video (Olkin, 2005) demonstrates many of the concepts in
those books and comes with an instructor’s manual. The Associ-
ation on Higher Education and Disability (ahead.org) has many
resources for educators re accommodations.
References
Americans With Disabilities Act of 1990, 42 U.S.C.A. § 12101 et seq.
(West 1993).
Banks, M. (2003). Preface. In M. Banks & E. Kaschak (Eds.), Women with
visible and invisible disabilities: Multiple intersections, multiple issues,
multiple therapies (pp. xxi–xxxix). New York: Haworth Press.
Bruyere, S. M., & O’Keeffe, J. (Eds.). (2004). Implications of the Ameri-
cans With Disabilities Act for psychology. Washington, DC: Springer.
Mackelprang, R., & Salsgiver, R. (1999). Disability: A diversity model
approach in human service practice. Belmont, CA: Brooks/Cole.
Nabors, N. A., & Pettee, M. F. (2003). Womanist therapy with African
American women with disabilities. Women & Therapy, 26, 331–341.
Olkin, R. (1999). What psychotherapists should know about disability.
New York: Guilford Press.
Olkin, R. (2005). Disability-affirmative therapy: A beginner’s guide
(Video 460). Hanover, MA: Microtraining and Multicultural Develop-
ment.
Olkin, R. (in press). Disability-affirmative therapy and case formulation: A
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7. template for understanding disability in a clinical context. Counseling &
Human Development.
Olkin, R., & Pledger, C. (2003). Can disability studies and psychology join
hands? American Psychologist, 58, 296–304.
Rehabilitation Act of 1973, Pub. L. No. 93–112.
Focus on Disability: It’s About Time
Barbara J. Palombi
I am pleased to see that Erickson Cornish, Gorgens, and Monson
possess the courage to bring to the forefront the issue of persons
with disabilities not being considered a multicultural group and
this group’s need to be considered from that perspective. Psychol-
ogists in the field of multiculturalism have struggled with the
question of which groups may be considered multicultural (Sue &
Sue, 2003). Some believe that the inclusion of other marginalized
groups takes away from the focus of race (Sue & Sue, 2003),
whereas others view multiculturalism from a model of power and
privilege and therefore consider persons with disabilities a multi-
cultural group (Hays, 2002).
Three major pieces of federal legislation, the Civil Rights Act of
1991, the Rehabilitation Act of 1973, and the Americans With
Disabilities Act of 1990 were passed to guarantee the equal rights
of persons with disabilities in education, employment, health, and
full participation in today’s society (Middleton, Rollins, & Harley,
1999). Because of the need for federal legislation to guarantee the
rights of persons with disabilities, it would seem obvious that
persons with disabilities face many of the same prejudices and
discrimination as other underrepresented groups. Yet, it has taken
almost 2 decades for psychologists to address, as an ethics issue,
the absence of persons with disabilities among groups with mul-
ticultural concerns.
Many psychologists remain unaware of the unique needs and
struggles of persons with disabilities and may be unable to provide
ethical and competent care. According to a study by Olkin (2002),
only 11% of psychology graduate training programs offered at
least one course on disability. Most of these classes focused on
exceptional children, learning disabilities, or mental retardation.
Only 7 out of 210 training programs had a course on the psycho-
social aspects of disability. Instead of the field of psychology
becoming more aware of the ethics issues regarding mental health
care for persons with disabilities and recognizing the need for
education and training, there has been a reduction in the number of
courses focusing on disability offered in psychology training pro-
grams since 1989 (Olkin, 2002).
The lack of awareness concerning multicultural issues may
leave a client with a disability feeling further marginalized and
invalidated. Kemp and Mallinckrodt (1996) stated that it is crucial
for psychologists “to assess for the possible effects of social
stigma, culturally inferior status, pejorative treatment, feelings of
belongingness, discrimination experiences, and power and rela-
tionship issues with individuals who have a disability” (p. 382).
Persons with disabilities live in a culture that values “physical
beauty, work productivity, and financial success” (Kemp &
Mallinckrodt, 1996, p. 382). Psychologists need to have an under-
standing of the complex issues associated with disability in order
to provide effective mental health treatment. Inadequate education
and training leaves psychotherapists vulnerable to making clinical
treatment errors.
As Erickson Cornish, Gorgens, and Monson pointed out, psy-
chotherapists fail to ask clients about issues related to disability,
whether the disability is visible or invisible. In working with
persons with disabilities, psychotherapists need to be aware of the
clinical issues that may arise during the therapeutic process, in-
cluding concerns regarding dependency, questions about the cli-
ent’s capabilities, hesitancy to ask specific questions regarding the
client’s disability, and conflicts regarding personal values (Kemp
& Mallinckrodt, 1996). The following is a case illustrating how the
lack of education and training about mental illness as a disability
hinders effective treatment and exposes psychotherapists to possi-
ble clinical negligence.
A graduate student with an excellent academic record sought treat-
ment for anxiety. The client was nearing graduation and expressed
having little confidence about securing full-time employment. After
the initial intake, the psychotherapist agreed with the client’s concep-
tualization of the problem as a lack of confidence. During the course
of treatment, little progress was being made. The psychotherapist was
aware that the client received academic accommodations for a dis-
ability but had not explored the possible ramifications associated with
the disability. With additional supervision, the focus of treatment
changed. The clinician began to ask questions about the client’s
disability. The client shared with the psychotherapist the tremendous
amount of energy required to be academically competitive, which left
little energy available to accomplish other life tasks. The client was
also aware of not fitting the norms of society—physical beauty, work
productivity, and financial success—and had a personal view of being
inferior, unattractive, undesirable, incompetent, and lazy. When in-
formation regarding the financial costs associated with the disability
was explored, the client reported that the medication cost exceeded
$100,000 per year. For the clinician to assume that the client’s major
area of distress was a lack of confidence in entering the employment
market without exploring potential themes related to the client’s
disability was naı¨ve and clinically damaging.
It would be easy to view this case simply as a clinical problem.
Yet, if the client’s issues are viewed from a multicultural perspec-
tive, they reflect the beliefs of the dominant able-bodied culture.
Within the dominant able-bodied culture, it is assumed that every-
one can read, walk, talk, and hear. If not, they are quickly regulated
to the culture of the disabled (Wendell, 1997). It is difficult for
those who are able-bodied to acknowledge that they have the
power and privilege to create a culture that disenfranchises and
marginalizes persons with disabilities and to create social policies
that may continue this oppression. For example, some persons with
disabilities, including this client, depend on social security disabil-
ity for financial support. These benefits permit persons with dis-
abilities to maintain a subsistent standard of living. If persons with
disabilities decide to enter the job market to improve their financial
situation, the additional income is subtracted from their benefits.
Another important component of social security disability is the
accompanying medical benefits. When persons with disabilities
secure full-time employment, they frequently lose their medical
benefits, which deters them from seeking full-time employment.
Yet members of the able-bodied culture may then view persons
with disabilities as helpless, dependent, and incompetent. These
are terms similar to the ones that the client used to describe herself.
The process of psychotherapy needs to include a multicultural
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8. perspective that explores limitations associated with the disability,
the loss of the ability to have possibilities and life experiences
similar to those of other individuals, and feelings of being mar-
ginalized and incapable of fully participating in today’s society.
Psychologists need to educate students and trainees on the
components required for ethical and competent clinical practice
with persons with disabilities. If students and trainees are unaware
of the multicultural issues associated with disability, they may
unknowingly perpetuate the marginalization of persons with dis-
abilities and their invalidation as members of society. Because
persons with disabilities belong to a group with open membership,
psychologists need to address their own fears and anxieties asso-
ciated with disability (Gold, 2002; Olkin, 1999). Without an
awareness of how these anxieties and fears affect treatment of
persons with disabilities, it becomes easy to ignore concerns re-
lated to disability.
To be ethical practitioners, psychologists need to (a) broaden the
definition of multicultural counseling, (b) develop multicultural
models that incorporate the unique cultural experiences of persons
with disabilities, (c) continue to explore their attitudes regarding
disability and those who are disabled, (d) educate the community
about the issues facing persons with disabilities, and (e) infuse the
multicultural concerns of persons with disabilities into clinical
service, supervision and training, consultation, teaching, and re-
search. Multicultural counseling also includes an awareness of
issues related to social justice, public policies, civil rights, and
attitudinal and environmental barriers that may impact the full
participation in society of persons with disabilities. If psycholo-
gists consider themselves to be leaders in providing competent and
ethical mental health services, they must address the needs of all
underrepresented groups and assure that all are acknowledged and
provided with opportunities to empower their lives—including
persons with disabilities.
References
Americans With Disabilities Act of 1990, 42 U.S.C.A. § 12101 et seq.
(West 1993).
Civil Rights Act of 1991, Pub. L. No. 102–166.
Gold, S. (2002). Beyond pity and paternalism: Even progressive persons
committed to social justice are unable to embrace the disability rights
movement. Are we afraid of something? The Other Side, 38(5), 16–21.
Hays, P. A. (2002). Addressing cultural complexities in practice: A frame-
work for clinicians and counselors. Washington DC: American Psycho-
logical Association.
Kemp, N. T., & Mallinckrodt, B. (1996). Impact of professional training on
case conceptualization of clients with a disability. Professional Psychol-
ogy: Research and Practice, 27, 378–385.
Middleton, R. A., Rollins, C. W., & Harley, D. A. (1999). The historical
and political contest of the civil rights of persons with disabilities: A
multicultural perspective for counselors. Journal of Multicultural Coun-
seling and Development, 27(2), 105–114.
Olkin, R. (1999). What psychotherapists should know about disability.
New York: Guilford.
Olkin, R. (2002). Could you hold the door for me? Including disability in
diversity. Cultural Diversity and Ethnic Minority Psychology, 8, 130–
137.
Rehabilitation Act of 1973, Pub. L. No. 93–112.
Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Therapy
and practice (4th ed.). New York: Wiley.
Wendell, S. (1997). Towards a feminist theory of disability. In L. Davis
(Ed.), The disability studies reader (pp. 260–278). New York: Rout-
ledge
Putting Disability Ethics Into Practice
Arnold V. Abels
Erickson Cornish, Gorgens, and Monson provided a thoughtful
exploration of ethical issues relevant to clinical work with people
with disabilities. They articulately enumerated several main as-
pects of ethical practice with this population. These include main-
taining an awareness and appreciation of the prevalence of this
diverse population, recognizing the need for competence and stan-
dards that guide training and psychological treatment of individ-
uals with disabilities, and understanding professional and personal
attitudes, prejudices, and biases toward disability. I build on these
themes to emphasize the great importance of competence, acces-
sibility, etiquette, and treatment when working with clients with all
types of disabilities. Relevant ethics standards, a model for effec-
tive decision making, and specific recommendations for ethical
and competent clinical practice are presented.
Erickson Cornish, Gorgens, and Monson offered two case ex-
amples to illustrate the ethics and clinical issues of relevance to
professional interactions with clients who have disabilities. Pro-
fessional competence is an ethical consideration highlighted in
both scenarios and is of core importance to the provision of
services to people with all types of disabilities. In the first case
example, the psychologist was confronted with the reality of his
own personal disability. The professional needed to consider if and
how his personal experience may have been affecting his profes-
sional work with this client. Potential for issues, such as transfer-
ence and countertransference, existed and needed to be identified,
monitored, and addressed in the therapeutic context (Lee, 1999).
How the psychologist felt about having a personal disability and
his attitudes and values toward individuals with disabilities are
core issues that may have impacted competence (see the APA’s
“Ethical Principles of Psychologists and Code of Conduct,” Stan-
dard 2.06a and b: Personal Problems and Conflicts; APA, 2002). In
the second scenario, the supervising psychologist was identified as
having expertise in the area of posttraumatic stress disorder. Al-
though the client was presenting with that concern, it does not
necessarily mean that the supervising psychologist was competent
to work with the culture of disability and posttraumatic stress
disorder. Clients are more than one aspect of their presenting
concern, and other characteristics, such as sexual orientation, so-
cioeconomic status, ethnicity, gender, and so forth, need to be
weighed in determining the scope and limitation of practice com-
petency (see the APA ethics code, Principle E, Standard 2: Com-
petence, and Standard 7: Education and Training; APA, 2002).
Also embedded in the first scenario was the following question:
Does one need to have a disability to effectively provide services
for someone with a disability? Olkin (1999) effectively explored
some of the assumptions associated with this question. Having a
disability may or may not be a help or a hindrance in the thera-
peutic process. It is important to remember that because a helping
professional possesses a characteristic, such as a disability, this
does not automatically make the professional competent in work-
ing with other individuals with that characteristic. It may also be
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9. important for psychologists to reflect on the reality of our aging
society and the fact that not only will many psychologists be
providing services to individuals with disabilities, but psycholo-
gists may experience one or more disabilities themselves. This
may change not only how one views disability but how one
practices psychology.
The scenario with the visually impaired client also raises the
issue of how important the understanding of disability issues is to
accurate case conceptualization. The depression of this client may
or may not have been caused by his loss of vision. Without proper
training in disability issues, a practitioner might automatically
assume that the two issues were related, something that warrants
exploration but that should not be automatically assumed. Simi-
larly, individuals with disabilities experience the spread phenom-
enon, in which other deficits are attributed to a person because he
or she has a disability (e.g., the belief that a person who is blind
also has intellectual deficits; Sue & Sue, 2003). Training and
exposure to such aspects of disability are essential for a thorough
understanding of disability issues and for the provision of ethical
treatment.
Accessibility issues are present in the first scenario, with the
missing Braille guides on the elevators raising legal and ethical
considerations. Although the client’s feedback had the potential to
be helpful to the psychologist and the entire office building in
becoming compliant with the Americans With Disabilities Act of
1990, it was instead dismissed through what may be perceived as
a compliment to the client’s mobility skills. From a different
perspective, the missing Braille guides may be viewed as discrim-
inatory (see the APA ethics code, Standard 3.01: Unfair Discrim-
ination; APA, 2002). The psychologist exhibited a lack of sensi-
tivity to the client with a visual disability by making assumptions
about the client without asking him about what his unique needs
may have entailed and by not being sensitive to the fact that cane
travel is only one aspect of how this client and possibly other
clients who are blind or visually impaired experience the world.
This client may indeed have needed or wanted the Braille guides
to help him independently identify the office location. For the
client, providing this feedback may have been a manifestation of
empowerment and self-advocacy, which may have been mini-
mized by the psychologist’s response. An open and thankful ex-
pression of gratitude for helping the psychologist to become le-
gally compliant with the Americans With Disabilities Act and
positive reinforcement of the client’s educational and self-
advocacy efforts would have been more therapeutic responses.
Furthermore, the psychologist could have inquired about whether
there were other aspects of his office that were not accessible or
created barriers to people with different types of disabilities.
Financial issues are a particular challenge for individuals with
disabilities (Sue & Sue, 2003) and may also impede accessibility
to clinical services. An understanding and appreciation of this
reality by the psychologist may have afforded exploration of this
issue with the client. The fact that it was not discussed is an ethical
challenge (see the APA ethics code, Standard 6: Records and Fees;
APA, 2002). Exploring the issue would have clarified whether the
client had an economic need and whether hecould have benefited
from some type of assistance by being offered the sliding fee scale.
Such exploration would also have clarified whether this offer of
assistance would have been insulting to the client because he
wanted to pay the full price for services and not receive what he
may have perceived as charity. Other options may have also been
explored, such as meeting less frequently.
Disability etiquette issues exist in Erickson Cornish, Gorgens,
and Monson’s second case example regarding language, with the
psychologist referring to the client as “that handicapped
wheelchair-bound client.” This type of language places emphasis
on the physical limitation and not the person and possibly pro-
motes a sense of pity for the person. The wording may also be
viewed as negative, disrespectful, and lacking in dignity because
the person using the wheelchair is much more than his disability.
Psychologists need an awareness of disability etiquette, such as
using person-first language in their practice with individuals with
disabilities (APA, 1999). The client’s confidentiality was also
jeopardized in this communication because the psychologist not
only spoke to the secretary, but also spoke loudly enough that the
trainee, the client, and others may have heard (see the APA ethics
code, Standard 4: Privacy and Confidentiality; APA, 2002). The
uncertainty of what was heard and who heard it created additional
ethical dilemmas in how one should respond to this situation.
Psychologists should recognize that privacy is important for all
people and that it is particularly important for individuals with
disabilities, whose personal space and privacy may be limited and
infringed upon because of their disability.
Although the script did not provide complete information, the
aspect of making recommendations of reasonable accommodations
was observed. I assume that the trainee was assessing the client to
provide supporting documentation for the requested untimed test-
ing accommodation. The person conducting the assessment needed
to make sure that the instruments being used were valid for this
particular individual and his unique characteristics and needed to
determine whether any modifications to the standard assessment
protocol should have been made. Recommendations should have
been based on the information derived from the testing and should
not have been biased by personal prejudices or sympathy for the
client’s circumstances. The trainee should have explored the ques-
tion of whether untimed testing was an appropriate accommoda-
tion for this situation or whether there were more appropriate
options that should have been recommended or explored (see the
APA ethics code, Standard 9: Assessment; APA, 2002).
Finally, both scenarios pose what I believe to be a frequently
occurring ethics problem in the field of psychology, namely avoid-
ance through silence. In the first vignette, a colleague is described
as questioning whether a therapeutic relationship has been nega-
tively impacted by the psychologist’s visual problems. In the
second case, a trainee failed to confront her supervisor about the
supervisor’s lack of disability etiquette when making comments
about a client. The trainee did not discuss her uncertainties about
the supervisor’s disability competence because of her fears about
how it would impact her evaluation. In the first example, it would
have been most appropriate for the colleague to talk privately with
the psychologist about what transpired with his vision and the
impact of this on therapeutic work with his client (see the APA
ethics code, Standard 1: Resolving Ethical Issues; APA, 2002).
Identifying specific examples of what was observed and exploring
potential methods of addressing these concerns would have been
appropriate steps to take. The clinician would not necessarily have
needed to terminate treatment and transfer the client’s care. With
personal psychotherapy for the clinician, consultation, and/or su-
pervision, treatment could potentially have continued. In the sec-
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10. ond example, the trainee could have considered talking with a
professor or another psychologist in a leadership position (e.g.,
training director, chief psychologist, director) about her observa-
tions and concerns. Understandably, this may have provoked fear
for the trainee; however, placing the welfare of the client first is an
essential ethical principle that ensures that no harm comes to the
client and helps the client receive effective services. In both
vignettes, to say or do nothing could perpetuate ineffective treat-
ment for the clients and allow the psychologists’ professional
incompetence and insensitivity to continue.
Although the vignettes focused on physical disabilities, the
complexity and global relevance of these ethical practices can and
should be relevant to all disabilities, including mental health is-
sues. This has further applicability for professional helpers who are
working with clients who are not disabled but are providing care to
another person with a disability. For example, parents of children
with disabilities are impacted by the child’s disability. The spe-
cialized attention and care that parents must provide may make
them susceptible to stress and depression (Baxter, Cummins, &
Polak, 1995; Hanson & Hanline, 1990)
Erickson Cornish, Gorgens, and Monson have meaningfully
addressed the important question of what constitutes ethical prac-
tice when providing services to individuals with disabilities. Pro-
fessionals are clearly not being adequately trained to provide
services to clients with disabilities given the likelihood that they
will work with this population. Psychologists need to have suffi-
cient competence to provide effective services to individuals with
physical and mental disabilities. Although the APA ethics code
(APA, 2002) clearly applies to psychologists’ work with individ-
uals with disabilities, it may be past time to generate practice
guidelines that enhance psychologists’ work with members of this
group.
References
American Psychological Association. (1999). Enhancing your interactions
with people with disabilities. Retrieved July 2, 2008, from http://
www.apa.org/pi/disability/enhancing.html
American Psychological Association. (2002). Ethical principles of psy-
chologists and code of conduct. American Psychologist, 57, 1060–1073.
Americans With Disabilities Act of 1990, 42 U.S.C.A. § 12101 et seq.
(West 1993).
Baxter, C., Cummins, R., & Polak, S. (1995). A longitudinal study of
parental stress and support: From diagnosis of disability to leaving
school. International Journal of Disability Development and Education,
42, 125–136.
Hanson, M., & Hanline, M. (1990). Parenting a child with a disability: A
longitudinal study of parental stress and adaptation. Journal of Early
Intervention, 14, 234–248.
Lee, W. M. L. (1999). An introduction to multicultural counseling. Phila-
delphia: Taylor & Francis.
Olkin, R. (1999). What psychotherapists should know about disability.
New York: Guilford Press.
Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Theory
and practice (4th ed.). New York: Wiley.
Received December 3, 2007
Revision received June 6, 2008
Accepted June 9, 2008 Ⅲ
Call for Nominations
The Publications and Communications (P&C) Board of the American Psychological Association
has opened nominations for the editorships of Developmental Psychology, Journal of Consulting
and Clinical Psychology, and Psychological Review for the years 2011–2016. Cynthia Garcı´a
Coll, PhD, Annette M. La Greca, PhD, and Keith Rayner, PhD, respectively, are the incumbent
editors.
Candidates should be members of APA and should be available to start receiving manuscripts in
early 2010 to prepare for issues published in 2011. Please note that the P&C Board encourages
participation by members of underrepresented groups in the publication process and would partic-
ularly welcome such nominees. Self-nominations are also encouraged.
Search chairs have been appointed as follows:
● Developmental Psychology, Peter A. Ornstein, PhD, and
Valerie Reyna, PhD
● Journal of Consulting and Clinical Psychology, Norman Abeles, PhD
● Psychological Review, David C. Funder, PhD, and Leah L. Light, PhD
Candidates should be nominated by accessing APA’s EditorQuest site on the Web. Using your
Web browser, go to http://editorquest.apa.org. On the Home menu on the left, find “Guests.” Next,
click on the link “Submit a Nomination,” enter your nominee’s information, and click “Submit.”
Prepared statements of one page or less in support of a nominee can also be submitted by e-mail
to Emnet Tesfaye, P&C Board Search Liaison, at etesfaye@apa.org.
Deadline for accepting nominations is January 10, 2009, when reviews will begin.
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