Professional Psychology: Research and Practice © 2010 American Psychological Association

2010, Vol. 41, No. 5, 442– 448 0735-7028/10/$12.00 DOI: 10.1037/a0020864

Disability and Psychotherapy Practice: Cultural Competence and

Practical Tips
Laura K. Artman and Jeffrey A. Daniels
West Virginia University

Persons with disabilities constitute the largest minority population within the United States, yet only
recently has psychology entered the dialogue of treatment issues for this population beyond the
traditional medical model. In this article the authors provide an overview of considerations for psychol-
ogists who work with clients presenting with disabilities. Specifically, we address conceptual models of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

disability and considerations for cultural competence for working with persons with disabilities. Within
This document is copyrighted by the American Psychological Association or one of its allied publishers.

the cultural competence discussion, we include critical awareness and knowledge, skills development,
and practice/applications; such as accessibility, consent forms and other handouts, the psychotherapy
milieu, testing accommodations, and the importance of resources, which are provided in the Appendix.

Keywords: disability, multiculturalism, accessibility, advocacy, accommodations

Multiculturalism has become a powerful force within psychol-
ogy. With its emphasis on historically under-represented popula-
tions, multiculturalism calls for shifting the focus from White,
middle-class clients and research participants to include people
from ethnic and sexual minority groups, as well as people who
hold various spiritual/religious views (Gilson & DePoy, 2000).
One population that has received less attention within the multi-
cultural literature is people with disabilities (PWDs) (Olkin, 2002).
People with disabilities “. . . have long-term physical, mental, in-
tellectual or sensory impairments which in interaction with various
barriers may hinder their full and effective participation in society
on an equal basis with others” (United Nations Enable, 2006,
Defining Disability section). PWDs are the largest minority group
in the United States, comprising ⬃50 million people, or 15% of the
population (Cornish et al., 2008; Longmore, 2009; Mpofu &
Conyers, 2004; Olkin, 2002).
Despite the popularity of multiculturalism in the field of psy-
chology, most of the disability-related literature in psychology
focuses on psychosocial adjustment to disability, rather than strat-
egies for better serving this population. There are, however, nota-
This article was published Online First September 6, 2010.
LAURA K. ARTMAN received her MS in Rehabilitation Counseling from
West Virginia University. She is currently a PhD candidate in Counseling
Psychology at West Virginia University in Morgantown. Her areas of
professional interest include traumatic brain injury, spinal cord injury,
neuro-rehabilitation, and the legal aspects of disability and employment.
JEFFREY A. DANIELS received his PhD in counseling psychology from the
University of Nebraska–Lincoln. He is currently an associate professor in
the Department of Counseling, Rehabilitation Counseling and Counseling
Psychology at West Virginia University in Morgantown. His interests
relate to averted school violence and global hostage-taking.
LAURA K. ARTMAN was affiliated with the Job Accomodation Network as
a graduate assistant and a human factors consultant from August 2003 to
May 2010.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Laura
K. Artman, P.O. Box 446, Halifax, PA 17032. E-mail: laura.artman@
gmail.com
ble exceptions, including but not limited to: Cornish et al. (2008)
proposed ethical guidelines for working with PWDs, Olkin (1999,
2002) provided comprehensive information on various therapeutic
and cultural issues related to PWDs, and Olkin and Pledger (2003)
specifically addressed integrating disability in psychology. Be-
cause PWDs constitute a large population with whom psycholo-
gists will come into contact, it is critical that multicultural per-
spectives of disability be incorporated into theory, research, and
practice.
In this manuscript, a brief discussion of psychology and con-
ceptual models of disability will be offered. Reasons for the
disconnection between the psychological literature and the tenets
of the disability rights movement will be provided, followed by a
brief overview of the current state of disability issues in psycho-
logical practice. The remainder of the manuscript aims to integrate
the existing literature on psychological practice with PWDs, and
create suggestions for practice, practical tips for accommodations
in psychotherapy, and information and resources for both psychol-
ogist and client advocacy. While information on working with
children with disabilities and families is another critical area of
psychologists’ competency, in the interest of limited space and
depth of material, the authors are primarily focusing on adult
clients with disabilities.
Psychology and Conceptual Models of Disability
There are several reasons why psychology has not reflected the
social model and has not widely regarded disability studies as part
of the multicultural canon. First, psychology is heavily based on
the medical model. The medical model characterizes PWDs
in terms of deficits, loss, and functional limitations because of
some type of mental or physical impairment. From the perspective
of this model, PWDs must adapt to an environment that does not
meet their needs. Their situation is viewed as unfortunate and
incurable, and they are viewed as permanently handicapped and
relegated to abnormal status (Gilson & DePoy, 2000; Gross &
Hahn, 2004; Olkin, 1999; Phemister, 2001; Winance, 2007).
Therefore, it is frequently assumed that grief and depression are an

442
 DISABILITY AND PSYCHOTHERAPY PRACTICE
inevitable aspect of living with a disability. Interventions tend to
focus mostly on intrapsychic issues related to coping and adjust-
ment to disability (Longmore, 1985; Olkin, 2002; Olkin & Pledger,
2003; Olkin & Taliaferro, 2006). We do not recommend a whole-
sale rejection of literature on adjustment and coping, because these
are a facet of psychological work with PWDs; however, adjust-
ment literature does not define the entirety of work with PWDs, or
even a substantial amount of it. In addition, Olkin (2002) points
out that this model has been beneficial in some ways. Medical
conceptualization of disability has contributed to interventions and
symptom management that have greatly improved the quality of
life of PWDs. Assistive technology and adaptive equipment have
also improved quality of life and fuller participation in society
(Olkin, 2002).
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In contrast to the medical model, the social model, which
focuses on power, resources, and unequal access, came about in
the 1960s and 1970s. The subsequent deinstitutionalization and
independent living movements were spearheaded primarily by
people with more severe disabilities, who experienced consider-
able restrictions in personal freedoms and basic rights. They chose
not to identify as patients, or even clients, but as consumers, which
implied a sense of agency and active decision-making about their
lives. They demanded self-determination with living arrange-
ments, relationships, and employment. They also advocated for
less reliance on institutions via self and peer help, assistive tech-
nology, and the removal of environmental barriers (both physical
and attitudinal) that blocked their access to public life (Longmore,
2009; Middleton, Rollins, & Harley, 1999). Disability-rights ac-
tivists have also used the construct of multiculturalism to provide
themselves with a group identity and sense of belonging, thus
creating pride instead of shame (Gilson & DePoy, 2000). PWDs
constitute a community that identifies as an oppressed group onto
which nondisabled people have projected their embarrassment,
hostility, and existential anxiety (Gross & Hahn, 2004). Further-
more, as a culture, PWDs share a common history and an outrage
at oppression, placing the discourse within the context of civil
rights (Gilson & DePoy, 2000; Olkin, 1999; Phemister, 2001).
Like other minority groups, some PWDs have their own slang to
refer to the dominant culture, such as TABs, an acronym meaning
Temporarily Able Bodied (Longmore, 1985; Olkin, 1999). Only
recently has psychology begun to address disability within the
social model (Cornish et al., 2008; Olkin, 1999; Olkin, 2002; Olkin
& Pledger, 2003).
Second, discussion of disability in any fashion is generally
relegated to the specialization of rehabilitation psychology, even
though other psychologists will come into contact with PWDs
(Olkin, 2002; Olkin & Pledger, 2003). Overall, PWDs receive less
attention than other minority groups in psychology training. Edu-
cation and training for work with PWDs is rare at the undergrad-
uate or graduate level in clinical, counseling, or school psychol-
ogy. The exception to this would be education about learning
disabilities, mental retardation, and developmental disabilities in
children (Olkin, 2002; Olkin & Pledger, 2003).
Third, PWDs are not well represented among psychologists; less
than 2% of American Psychological Association (APA) members
identify as PWDs (Olkin, 2002; Olkin & Pledger, 2003). Most
research on this minority group is conducted by members outside
of the group. The key stakeholders (PWDs) are rarely directing, or
significantly included in, research that is about them. The acces-
443
sibility of the research is a common barrier; Web sites and flyers
announcing the research may not be accessible to those who are
unable to read or have low/no vision. PWDs may be screened out
of studies for participation. The site where the research is taking
place may not be accessible. In addition, accommodations for
participating in the research, as well as accommodations and
modifications of the research materials, are frequently not consid-
ered. Granted, there may be legitimate concerns about how ac-
commodations may affect research protocol, standardization, or
resulting data. Since psychology is based on the medical model,
the research may not take the social model or minority issues into
account as a theoretical underpinning to scientific inquiry. In
addition, funding can be inconsistent and study topics are fre-
quently prioritized by funding sources (Olkin & Pledger, 2003;
Olkin & Taliaferro, 2006).
Another social issue that receives limited attention is that of
demographic variables– ethnicity, gender, socioeconomic status,
sexual minority status, and how these intersect with disability. For
example, racial discrimination can influence access to appropriate
health care, work, and assistive technology. Chronic illness and
disability are more common among people of color (Cornish et al.,
2008; Livneh & Antonak, 2005). People of lower socioeconomic
status may have substantial trouble affording health care, health
insurance, transit, and necessary assistive technology as well.
Sexism can interact with disability for both men and women,
especially if a person’s disability affects her or his ability to adopt
the culturally accepted roles for men and women. People who
identify as lesbian, gay, bisexual, or transsexual also face addi-
tional challenges, because there are even fewer legislative protec-
tions for members of these groups (Balcazar, Suarez-Balcazar,
Taylor-Ritzler, & Keys, 2009; Cornish et al., 2008; Elliot,
Uswatte, Lewis, & Palmatier, 2000; Hershenson, 2000; Livneh &
Antonak, 2005; Mpofu & Conyers, 2004).
Because of these aforementioned factors, there are no evidence
based practices (EBPs) for clients with disabilities. Ethical guide-
lines for practice are still in development (Cornish et al., 2008;
Olkin & Taliaferro, 2006). Perhaps, because of this invisibility of
PWDs in psychology research, training, and practice, many psy-
chologists do not know they need additional training to work with
PWDs (Olkin & Taliaferro, 2006). However, competence to work
with a specific group is a critical component of ethical practice
with that group (Cornish et al., 2008). To complicate matters,
PWDs are a heterogeneous group, and it is not clear whether they
have more needs for psychotherapy than the general population. It
is known that PWDs experience fewer options for employment,
housing, leisure and recreation activities, and social outlets be-
cause of stigma, discrimination, and inaccessibility of facilities;
therefore, the case can be made that they have unique needs in
psychotherapy, such as information, resources, and advocacy skills
(Olkin & Taliaferro, 2006).
What are the implications for psychologists? While supervised
training is often the gold standard for competency, this may be
hard to come by since basic training is lacking. Olkin (2002)
summarizes it as such: “Most able-bodied psychotherapists are
doing cross-cultural counseling with clients with disabilities with-
out requisite training” (p. 132). This substantially increases the risk
of poor therapeutic outcomes, attrition, and resistance to psycho-
logical treatment in this population (Olkin, 2002). Psychologists
are not helpless in these circumstances, and there are some ways to
 444 ARTMAN AND DANIELS
start building a more disability-competent practice. The remainder
of this manuscript focuses on helpful guidance on cultural com-
petence with PWDs.
Cultural Competence With PWDs
Because PWDs are a minority group, it may be helpful to
conceptualize them within a minority-group model. PWDs are
similar to other minority groups, in that they share a history of
subjugation, intolerance, and discrimination. In addition, they have
been defined through the lens of the majority group, and therefore
historically denied self-definition. They have been underrepre-
sented in positions of power, and have been forced to emulate and
adopt the values of the majority group. Like other social move-
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ments, the disability-rights and independent living movements
have fought these circumstances. Similar to sexual minorities,
PWDs may have been in a family of people who did not have their
minority status, or in neighborhoods where they had common
peers. Support from family and friends in the home may vary
(Olkin, 2002).
However, PWDs have their own unique characteristics that set
them apart from other minority groups. Therefore, they may not fit
neatly within other multicultural frameworks, and comparisons
may risk forcing them to fit or oversimplification of their circum-
stances (Olkin, 2002). For example, there are no longer restrooms
or separate water fountains for people of color, but there are still
designated restrooms, entrances/exits, parking spaces, and other
separate conveniences for PWDs. This creates a conundrum of
sorts; while these are critical for building accessibility and inclu-
sion, some disability-rights advocates call for making all entrances
accessible, rather than setting aside separate entrances (Olkin,
1999, 2002). In addition, PWDs experience symptoms related to
their conditions that may require additional medical maintenance
compared to other minority groups, as well as assistive technology,
personal assistance services, and other items that cost money;
sometimes a substantial amount (Olkin, 2002). Therefore, while
conceptualizing PWDs within a multicultural framework is useful,
it is also important for psychotherapists to realize both the simi-
larities and the differences to other cultural groups. Balcazar et al.
(2009) developed a cultural competence model based on an exten-
sive review of the literature. Critical awareness consists of being
aware of personal biases, lack of knowledge/training, and an
understanding of what privilege status one may have. Knowledge
is the interest and investigation into other cultures, and gaining an
understanding of their core values, shared history, and customs.
Skills development describes increasing critical awareness and
knowledge, as well as interacting with clients in an empathic
manner, and being able to weave their cultural values and personal
context into therapeutic interventions. Practice/Application refers
to the implementation of all elements within the constraints of the
organizational context within which the psychotherapist works
(Balcazar et al., 2009). These concepts can be applied to PWDs
(Balcazar et al., 2009). Olkin developed Disability-Affirmative
Therapy (Olkin, 2008) as a template to use with clients with
disabilities in developing a case formulation approach. That for-
mulation should neither over- nor under-inflate the role of disabil-
ity. The models of both Balcazar et al., (2009) and Olkin (2008)
are examples of culturally affirmative therapies with people with
disabilities.
Critical Awareness and Knowledge
Psychotherapists can build their critical awareness and knowl-
edge by paying attention to the language, attributions, and attitudes
they have about PWDs. Most perceptions of disabilities are neg-
ative, and are frequently reflected in language. A major change
enacted by PWDs is the use of person-first language. When
disability status is mentioned first, it becomes primary to the
individual, that is, the person’s main defining characteristic. Race,
gender, personality, preferences, education, hobbies, and interests
become subsumed under the diagnostic label, as though labels
trump the individuality of the person. Person-first language is just
that: saying, for example, person with schizophrenia rather than
schizophrenic. This reminds others of PWDs basic humanity
(Fowler & Wadsworth, 1991; Kaplan, 1994; Longmore, 1985;
Mpofu & Conyers, 2004; Olkin, 2002). PWDs have also combated
other terminology that appears harmless, but is actually an expres-
sion of negativity toward PWDs. People who use wheelchairs is
meant to replace phrases such as confined to a wheelchair or
wheelchair bound, which reflect the perspective of people without
disabilities. In reality, wheelchairs help people with mobility im-
pairments get around, providing them with a great deal of freedom.
This use of negative language serves to perpetuate negative atti-
tudes and assumptions that PWDs are inherently miserable
(Kaplan, 1994; Mpofu & Conyers, 2004; Olkin, 1999). This can
result in inaccurate attributions toward PWDs who are not suffer-
ing or depressed: remarks about being brave, courageous, spunky,
and others (Kelly, Sedlacek, & Scales, 1994; Mpofu & Conyers,
2004; Olkin, 1999).
Exposure to and building relationships with PWDs is also an
invaluable learning tool. Olkin (1999) wisely recommends not
learning about PWDs in hospitals, because it adds to discomfort,
stigma, and the association of disability with medical pathology.
Local Centers for Independent Living (CILs) are a community
resource that can also assist in a fuller understanding of PWDs as
a cultural group. Longmore (2009) provides other resources for
learning about the history of disability, such as books, and journals
that have devoted substantial attention to the topic, and an ency-
clopedic series that provides detailed disability history in the
United States (Longmore, 2009). Olkin’s (1999) book What Psy-
chotherapists Should Know About Disability is an invaluable re-
source in this endeavor as well. It provides comprehensive infor-
mation on history, culture, unique aspects of working with PWDs,
and therapeutic implications for many facets of psychological
practice. Kenneth Pope’s Web site (http://www.kpope.com/) also
provides accessibility and disability information for training and
practice in psychology (Pope, n.d.).
Skills Development
Olkin (1999) notes that many psychotherapists without disabil-
ities are reluctant to ask questions directly to PWDs who present
for psychotherapy, similar to the hesitance to ask about racial or
ethnic issues when the client is culturally different from the psy-
chotherapist. If a client mentions a disability, it is generally ac-
ceptable to ask about the nature of the disability or condition. If the
client does not broach the subject during the discussion of pre-
senting issues in psychotherapy, the psychotherapist can open
dialog by asking if the client feels her or his disability plays a role
 DISABILITY AND PSYCHOTHERAPY PRACTICE
in the presenting issue, similar to asking about race, religion, or
sexuality playing a role in presenting concerns. Questions that are
intended to satisfy curiosity may be less welcome, such as asking
a client who was born without arms how she or he uses the
restroom. PWDs frequently experience intrusive inquiries by
strangers and the general public. The main message is that it is
important to remember that disability may or may not be central to
the client’s concerns, but it should not be completely ignored
(Olkin, 1999).
Disability etiquette is a common concern, and people without
disabilities can be concerned about social interactions, for exam-
ple, whether or not they should ask if a PWD needs help, or if it’s
acceptable to tell a person who is blind “see you later.” Olkin
(1999) provides guidelines for disability etiquette, as does the
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APAs Office of Disability brochure Enhancing Your Interactions
with People with Disabilities (APA, 1999).
In addition, it may be helpful to investigate to which conceptual
model(s), if any, the client adheres. The goal is not to convert
PWDs from a “wrong” conceptual model to a “right” model. All
have positive and negative attributes, and the key is to accentuate
the positive aspects and reduce the negative influences of disability
conceptualization for each client (Olkin, 2002).
Personal issues may arise within psychologists in the form of
countertransference. The APA Ethical Principles of Psychologists
and Code of Conduct addresses potential conflicts in this vein; it is
imperative that psychologists be aware of their personal reactions
to clients and take appropriate steps should these reactions inter-
fere with the therapeutic process and client welfare (APA, 2002).
Furthermore, the APAs Guidelines on Multicultural Education,
Training, Research, Practice and Organizational Change for Psy-
chologists broadens this concept, stating that psychologists may
“hold attitudes and beliefs that can detrimentally influence their
perceptions of and interactions with individuals who are ethnically
and racially different from themselves” (APA, 2002, p. 17). While
the Guidelines emphasize racial and ethnic diversity, this can be
expanded to working with PWDs; that is, urging psychotherapists
to examine their attitudes that may negatively affect psychological
practice with this group.
Countertransference often takes the form of fear about one’s
own vulnerability. Psychotherapists without disabilities may also
be uncomfortable with physical symptoms (e.g., coughing, drool-
ing, toileting needs, speech impairments) or cosmetic indicators of
disability (e.g., scarring, amputations, or burns). This is particu-
larly poignant when the client’s disability was adventitious; that is,
an accident that occurred simply because of being in the wrong
place at the wrong time. The attributions toward those whose
disability was a result of poor judgment, immoral, or illegal
behavior (sexual promiscuity, drug and alcohol abuse, reckless-
ness) may also color a psychologist’s perceptions of the client. It
may feel safer to blame the victim to distance oneself from the
possibility of sharing that person’s fate: Psychotherapists may use
this to distance themselves emotionally from the client to protect
their own psyches, which interferes with providing empathy. It is
critical that psychotherapists monitor countertransference, and
seek supervision or make referrals when it appears to be a signif-
icant barrier to effective work (Olkin, 1999; Wilton, 2003).
Diagnostically, psychologists also need to consider the effects of
a disability on the results of testing, such as the MMPI-2 (Butcher,
Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) or BDI-2 (Beck
445
& Steer, 1993). Many standard personality and symptom assess-
ments are not normed on PWDs. PWDs may endorse items about
bodily concern, physical illness, fatigue, and other symptoms that
are part of their disability, but not indicative of depression or other
psychological disorders as the test scores may suggest. The appar-
ent preoccupation with bodily functions may be a necessity of the
client’s medical status, and not a sign of hypochondriasis or a
conversion disorder (Livneh & Antonak, 2005; Olkin, 1999; Olkin
& Taliaferro, 2006).
Olkin (1999) and Olkin and Taliaferro (2006) also point out
common mistakes psychotherapists make when working with
PWDs. In addition to assuming the disability is central to present-
ing concerns (or ignoring disability entirely), psychotherapists
sometimes fall victim to the spread effect; that is, allowing the
disability to completely define the individual and subsume other
aspects of the person, such as personality, gender, race, sexuality,
religion, age, ethnicity, interests, and employment status, among
others. Another error involves misinterpreting affect; just because
a PWD is depressed does not mean it is a normal part of adjust-
ment, or an inevitability. Anger over lack of accommodations and
discrimination may be justified, rather than labeled as maladjust-
ment. In addition, many psychotherapists may risk holding the
PWD to lower standards of personal achievement, such as in the
areas of academics, employment, intimate relationships, or lead-
ership in the community because of their own negative attributions
about the abilities of PWDs. To help avoid some mistakes, con-
ceptualizing clients within the social model helps remove the
effects of these pathological labels, viewing some of their diffi-
culties in terms of those inherent in being a cultural minority,
rather than being a damaged individual (Olkin, 1999).
Practice/Applications
When confronted with these issues, psychologists may be con-
cerned about how they can implement their knowledge and create
a more accessible practice, as well as improving advocacy skills of
them and their clients with disabilities. The following tips and
guidelines are presented to help psychologists start thinking about
inclusive practice, provide simple action steps, and direct them to
additional resources for further learning. Ideas for accommoda-
tions are based on the first author’s experience as a clinician who
has worked with people with disabilities, and as a Graduate As-
sistant and Human Factors Consultant with the Job Accommoda-
tion Network (JAN). In general, it may be helpful for psycholo-
gists to let all clients know that they wish to make psychotherapy
as accessible and successful as possible, and to let him or her know
if they need any considerations or modifications to improve their
psychotherapy experience. Most importantly, psychologists are
urged to listen to their clients with disabilities, taking their feed-
back and concerns seriously.
Building accessibility. If the clinic in which the psychologist
works is a private facility, then it is covered by Title III of the
Americans with Disabilities Act of 1990 (ADA), and if the clinic
is publicly owned, such as a state or county facility, then it is
covered by Title II of the ADA (Bruyere & O’Keefe, 1994). If the
clinic is in a federally owned facility, then it is covered by Section
504 of the Rehabilitation Act of 1973. The building needs to be
accessible per the accessibility guidelines set forth by the law.
While separate entrances and restroom facilities have been criti-
 446 ARTMAN AND DANIELS
cized by advocates as isolating PWDs, they can be a necessary part
of building access. One action step psychologists can take is to
peruse the facility–are there designated parking spots and usable
ramps (i.e., not too steep such that a wheelchair would tip)? Are
hallways and offices cluttered with boxes, decorations, etc., that
may impede the mobility of a wheelchair user or increase the
navigation difficulty for a person with low or no vision? Are
the restrooms accessible? If part of the facility is questionable, the
United States Access Board provides information on specifications
of the building (see Appendix). If there is a legal question (e.g., the
clinic is located in the historic district and there are strict regula-
tions on building modifications, or if a modification is prohibited
by a fire code) the Disability Rights Section of the Civil Rights
Division of the U.S. Department of Justice enforces Titles II and
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III of the ADA, and can provide legal technical assistance in
resolving these questions (see Appendix). Psychologists are also
encouraged to advocate on behalf of PWDs, letting management
and land owners know that part of the facility may not be acces-
sible, or where current accessibility can be improved. Title IV of
the ADA addresses accessibility of telecommunications, which is
enforced by the Federal Communications Commission (FCC).
Does the office have a TTY number, and are receptionists familiar
with the TTY or video relay service for clients who are deaf, hard
of hearing, or have speech impairments? The FCC (see Appendix)
can provide technical assistance and answer questions.
Websites, client recruitment, and flyers. Print ads may not
be accessible to people with reading disorders or low/no vision,
therefore presenting potential limitations to recruiting clients and
research participants. Other formats may be helpful, such as com-
mercials or Web site ads. Web site accessibility is critical for many
PWDs, whether it be related to reading abilities, vision, fine motor
skills for navigating Web sites, or assistive technology used by
PWDs to access computers and the Internet. Comprehensive
guidelines are offered by Loy and Rowan (2009), including the use
of text descriptions for visual material, captioning, allowing for
various types of Web navigation (such as keyboard navigation), in
addition to resources for having a Web site reviewed for accessi-
bility.
Consent forms, handouts, and publications. PWDs may
need alternative formats, and these can be fairly simple to provide.
Large print is typically 16 –18 point font. Black letters on a white
background provide high contrast. Font color can be changed from
black to gray to reduce contrast if needed. Conversely, Olkin
(1999) suggests printing black font onto beige or gray paper if
lower contrast is needed. While some people who are blind use the
Braille alphabet, others may prefer to have a recorded version of
publications or consent forms. This can be read into a digital
recorder or tape (enunciating clearly), or read aloud to the client.
Audible format is also helpful for people with reading disorders.
In-house created publications and handouts can be put on a disk so
the client can take the information home where she or he can listen
to it with screen reading software or other assistive technology.
Scheduling appointments. Some PWDs may use public tran-
sit or paratransit, and therefore psychotherapy appointments may
need to be scheduled around transit schedules. Clients with sleep
disorders may prefer appointments that are more consistent with
their sleep/wake cycles and a time of day when they are less
fatigued. In addition, those with temperature sensitivities may not
be able to go out during extreme heat or cold. Psychotherapy can
be scheduled during the warmer or cooler part of the day as
needed. If not clinically or ethically contraindicated, psychother-
apy could be conducted over telephone or Webcam during extreme
seasonal conditions.
Psychotherapy milieu. Proxemics may need to be altered to
accommodate PWDs. Simple solutions include allowing room for
a wheelchair or space to transfer from a wheelchair to an office
chair. People with muscular-skeletal conditions may not be able to
sit for long periods of time, and it may be helpful for the client to
sit differently in a chair, stand, or even lie down for parts of the
psychotherapy or testing session. Lighting can be adjusted to
accommodate a variety of issues. Clients with low vision may need
brighter lighting, while alternatives to flourescent lighting may be
helpful for clients with migraines, light sensitivity, or other needs
related to lighting. Those with temperature sensitivities may need
accommodations; if the thermostat is not under the psychothera-
pist’s control, Olkin (2002) recommends that fans or blankets can
be provided. It may be wise to avoid potpourri and wearing heavy
fragrance, as many people may have allergies, respiratory disor-
ders, and chemical sensitivities that can be irritated by scents and
chemicals.
Clients with cognitive limitations may need additional support
for retaining information from psychotherapy. Providing written
handouts and allowing time for the client to take notes may
facilitate this. Recording information may be helpful as well; if the
psychotherapist and/or client are not comfortable recording an
entire session, then perhaps the few remaining minutes can be
reserved for a brief “recording session” of reminders, key points,
or homework assignments.
Testing. As with psychotherapy, accommodations involving
room lighting, temperature, furniture arrangement, and rest breaks
are considerations to be made for testing PWDs. A common issue
with accommodations in testing is whether or not the accommo-
dations compromise the psychometric properties or standardiza-
tion of the assessments (Olkin & Pledger, 2003). Many neuropsy-
chological tests require fine motor skills, visual inspection, and
other tasks that may not be accessible for the client. Alternative
tests may be used in the protocol based on the skill set of the
individual and the reliability and validity of the alternative test for
the construct in question. Some materials may be read aloud if
needed, or an audio recorded version of the test can be purchased
from the assessment company, which can be done with the MMPI-2,
for example. Large print formats, or Braille may be harder to find and
provide, and sometimes improvisation is the only choice if there are
no available alternative formats, or if there is not time to order an
alternative format. Clinicians are cautioned about making alterations
to tests because there may be ethical/legal risks of copyright violation
and/or invalidating a protocol. Psychologists who have concerns
about accessibility can contact customer service for the assessment in
question. If accessible formats are not available, then urging the
companies to consider modifications is one way to advocate for
PWDs.
Advocacy. In addition to the tips above, psychologists may
want to talk with colleagues about accessibility, perhaps forming
an informal committee or a formal task force within the organiza-
tion to address accessibility issues, and resolve barriers to access.
A local Center for Independent Living would be a valuable asset
on the committee, and can also help pinpoint key areas for im-
proving accessibility and services. Any organization listed in the
 DISABILITY AND PSYCHOTHERAPY PRACTICE
Appendix can be contacted by a psychologist interested in pursu-
ing the resolution of an accessibility or discrimination issue, and
can also be provided to clients if they wish to seek technical
assistance or legal enforcement. In addition, psychologists are
encouraged to educate and share resources with other practitioners
in regard to culture and disability. This can be extended to aca-
demic areas as well; psychologists who teach can add disability
issues and resources in their lectures and course materials. They
can also advocate for increased inclusion of disability issues in the
curriculum, as well as the inclusion of students with disabilities in
graduate programs.
Clients who have difficulty advocating for themselves, or are
not sure about what their rights may be, can contact any agency in
the Appendix depending on the specific issue. In addition, skills
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
for self-advocacy can be part of psychotherapy, similar to asser-
tiveness training. Psychologists can role play scenarios and help
PWDs rehearse different strategies, as well as provide resources
for peer assistance, support groups, and advocacy.
Conclusions
Because persons with disabilities constitute the largest minority
population within the United States, psychologists likely will work
with multiple individuals with disabilities. The multicultural
movement within psychology has offered valuable insights and
models for working with racial/ethnic, sexual, and religious/
spiritual minority clients, and has recently addressed consider-
ations for persons with disabilities. In this article we have provided
an overview of issues for psychologists to consider when working
with clients with disabilities, including conceptual models, case
conceptualization, cultural competence issues, and practice appli-
cations. Just as it is necessary for psychologists to obtain educa-
tion, experience and supervision with various ethnic minority
populations to attain competency, we have argued that the same is
required of psychologists to obtain competence in working with
PWDs. Such efforts will serve to increase the quality of psycho-
logical care that clients who present with disabilities will receive.
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Appendix
Resources
General
Kenneth Pope maintains a Web site entitled “Accessibility &
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Disability Information & Resources in Psychology Training &
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Practice,” which can be accessed at http://kpope.com/. It contains
comprehensive information on accessibility and disability-related
laws in ten separately linked sections.
Centers for Independent Living (CILs) are community-based,
consumer-run organizations that provide a variety of services,
resource referrals, and advocacy for PWDs. A local CIL can be
found at http://www.virtualcil.net/cils/.
Housing
Housing is covered under the Fair Housing Act. The U.S.
Department of Housing and Urban Development provides infor-
mation and enforcement at (800) 669-9777 (V), (800) 927-9275
(TTY), or http://www.hud.gov.
ADA-General
General technical assistance on the ADA can be received
through Disability and Business Technical Assistance Centers
(DBTAC) at (800) 949-4232 (V/TTY) or http://www.dbtac
.vcu.edu.
ADA-Employment (Title I)
The Job Accommodation Network (JAN) provides technical
assistance on the Rehabilitation Act of 1973, the ADA, and other
disability laws. Services are toll free and confidential at (800)
526-7234 (V), (800) ADA-WORK (V), (877) 781-9403 (TTY).
JAN can also be contacted through email and online chat at
http://askjan.org.
For legal enforcement and filing complaints against employers
for violations under the ADA, the EEOC can be reached at (800)
669-4000 and http://www.eeoc.gov. For employees in California,
complaints can be filed through the California Department of Fair
Winance, M. (2007). Being normally different? Changes to normalization
processes: From alignment to work on the norm. Disability and Society,
22, 625– 638.
Employment and Housing at http://www.dfeh.ca.gov/DFEH/
default/ or (800) 884-1684(V), (800) 700-2320 (TTY).
ADA-Public Accommodations and Services
(Titles II and III)
Specifications and information per the Americans with Disabil-
ities Act Accessibility Guidelines (ADAAG) can be found at
www.access-board.gov or by contacting (800) 872-2253 (V), (800)
993-2822 (TTY). Links to state guidelines for accessibility can
also be found here.
Legal information and complaint filing can be found at through
the Disability Rights Section of the Civil Rights Division of the
U.S. Department of Justice at (800) 514-0301 (v), (800) 514-0383
(TTY).
ADA-Telecommunications (Title IV)
The Federal Communications Commission (FCC) enforces the
provisions of Title IV. The FCC can be reached at http://
www.fcc.gov/cgb/dro/title4.html or (888) CALL-FCC (V), (888)
TELL-FCC (TTY).
Legal Representation and Advocacy
Protection and Advocacy Agencies provide legal representation
and advocacy to all people with disabilities under all state and
federal disability laws. A list can be found at http://askjan.org/cgi-
win/TypeQuery.exe?560.
Transportation
Questions about transit for people with disabilities can be an-
swered by the Federal Transportation Administration (FTA) Office
of Civil Rights ADA Assistance line at (888) 446-4511 (V),
800-877-8339 (TTY).
Received October 30, 2009
Revision received June 8, 2010
Accepted June 10, 2010 䡲