Chapter 2
Common Themes

Sheri Bauman and Amanda Easton1

In this chapter we focus on themes that are common in groups specifically for persons with disabilities. Understanding why these issues are important, and being informed about these topics, will help the counselor facilitate more productive interactions and growth among members.

Although we mentioned the social or minority model of disability in the Introduction, it is relevant to this chapter as well and bears some amplification. We also review disability identity and culture because of its general significance and as a backdrop for the more specific topical issues. Because many groups for persons with disabilities have a goal of assisting clients to adjust to life with the disability, we provide an overview of a model of adaptation to disability so that the counselor can conceptualize the members' progress within a well-known framework. Then we turn to specific topics of social relationships and dating, sexuality, overprotection, abuse, substance abuse, maintaining health, and accessibility issues.

Models of Disability

Historically, disability has been viewed through several lenses, and there are lingering remnants of those views today (Olkin, 1999). The moral view of disability suggests that disability is either a punishment for or evidence of moral failure or sin. When this view prevails, those with disabilities are shunned and shamed. The flip side of the moral view, however, paints disability as a marker of a model family: "God only gives children with disabilities to those who are up to the challenge." In addition, some cultures have viewed disability as evidence of extraordinary powers (e.g., ability to foresee the future).

A later theoretical development was the medical model (Olkin, 1999), which focused on the defective bodily or mental systems. This perspective focused on the individual, who was seen as abnormal or pathological. The goal of treatment was to repair the defective systems to the extent possible while also learning to adapt to the condition and to the inhospitable environment.

A contemporary perspective is the minority or social model, which situates the problem in the environment, emphasizing that problems occur when the environment does not accommodate persons with disabilities and holds negative attitudes toward those persons (Olkin, 1999). These environmental obstacles and the attitudinal barriers presented by some nondisabled persons are the focus of this perspective. Only since the passage of the Rehabilitation Act of 1973, and the later development and implementation of the associated regulations, has the minority model become a prominent perspective. The persistence of negative stereotypes of persons with intellectual disabilities (IDs) is such that they have been excluded from full participation in many important activities (e.g., meaningful work, independent living; Special Olympics, 2003). As a result, the Special Olympics organization emphasizes the importance of advocacy and self-advocacy for this population.

The World Health Organization's (2011) global report on disability pointed out that the medical model and the social model are not mutually exclusive. In fact, this organization espouses a biopsychosocial model-which considers the interaction of the health condition, categorized as impairments (physical conditions), activity limitations (difficulty or inability to conduct basic activities such as walking or eating), and participation restrictions (problems with access or discrimination), and contextual factors in the environment (in both the person and the environment)-as the most useful model.

Cultural Views

These perspectives on disability are expressed in different cultures to a greater or lesser degree. We discuss the cultural implications in Chapter 4. There are cultures in which the moral or medical models are the dominant view, and for Americans whose parents or native community still subscribe to ancestral cultural beliefs, their growth and development can be marked by incidents in which those attitudes are influential. For example, Grace Tsao (2000) described her childhood experiences as a female Asian American with a disability. She recalls a time when she protested that she was not allowed to attend certain significant events in the cultural community; the reason she was given by her parents was that if she were to attend, the elders would look down upon the family because her disability would be evidence of their misdeeds.

Although the role of environmental factors in disability is now widely known and generally accepted, negative attitudes and misinformation about disabilities persist in many settings. That means that clients who come to a group probably have experienced overt discrimination and microaggressions that lead to frustration in many areas of life. For example, TS, a woman with cerebral palsy, reveals that strangers have voiced surprise to see her in a bar where many young adults congregate, have asked personal questions about her sexual functioning that they would never ask an able-bodied person, and have assumed that her boyfriend must also have a disability (surely an able-bodied man would not find her attractive), along with numerous other insults.

Although we have a law that requires businesses to be accessible to persons with disabilities (the ADA), many businesses meet the letter of the law by providing some sort of access, but those entrances may be "around the back," so that those accommodations separate and demean persons with disabilities. For example, there is a local pizza and beer establishment that has bar-height tables and stools for seating. Although the eatery does have a separate, albeit inconvenient, entrance that accommodates a wheelchair, the table they have available to a person using a wheelchair is at standard table height, meaning that the person in the wheelchair would be below the other members of her party.

The skilled and sensitive facilitator must recognize that these experiences are hurtful and common, and group members may need to talk about them in a safe and supportive climate in which they believe they will be understood, regardless of the focus or theme of the group. Because these themes are the canvas on which other issues are projected, it is important to allow these issues to be explored and not to treat them as distractions or story-telling behaviors that need to be cut off.

TS attended a group at her university with other students with cerebral palsy, facilitated by a counselor who had both cerebral palsy and an SCI. This counselor brought the additional perspective of someone who had to adjust to a disability at a later point in life. Although all members had cerebral palsy, they differed on many other factors: how they were treated by their families and culture, how salient the disability was to their identity, and in the types and severity of their symptoms. For TS, her disability does not define her, but it does affect her life. She found this group to be valuable because she was accepted easily and found people who could relate to her experience as a new college student with a disability.

Counselors should encourage self-advocacy and should be well-informed about mechanisms that clients can use on their own behalf. For example, ADA complaints can be filed online at http://www.ada.gov/filing_complaint.htm.

A Model of Adaptation

As with other processes that are associated with common experiences (e.g., grief and loss, response to natural disaster), there is a model of adaptation to disability that helps the clinician conceptualize the experience of clients in a group. We emphasize that models never apply universally, and individuals are often not linear in their progression. Stages occur in a different order than the theory describes, or recur, or individuals get stuck at a given stage. However, understanding the tasks involved will enhance the group facilitator's ability to manage the varied responses that are likely to emerge in the group setting. That is, the responses to the same circumstance are likely to vary among group members because they are different people in different stages of adaptation, and the facilitator should be prepared to point that out. It might even be appropriate to do a mini psychoeducational piece about the stages to illuminate the dynamic in the group.

Although more than one model has been proposed, we summarize the one developed by Hanoch Livneh (1986). This model applies to disabilities that are acquired rather than congenital, although even those who were born with a disability may experience some of the same reactions as they develop and mature and realize how their disability affects them.

The first stage, initial impact, occurs when someone has a sudden physical trauma (e.g., amputation, SCI) or an unexpected diagnosis of a serious life-threatening disease (e.g., cancer, Huntington's chorea, amyotrophic lateral sclerosis). During this stage, many persons experience a state of shock, during which their responses are numb and detached. Their thinking may be disoriented by the situation, and their energies may turn inward rather than toward others. As the shock dissipates (at different rates for different clients), people are likely to experience intense anxiety and demonstrate thinking disturbances, and they may display many symptoms of intense anxiety or panic.

The next stage is defense mobilization, in which people utilize psychological defense mechanisms to protect themselves...