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Models of disability: implications for the counseling profession.

Disability is a natural part of human existence and is growing more common as a larger proportion of the U.S. population experiences some type of disability (Americans With Disabilities Act [ADA], 1990; Bowe, 1980; Employment and Disability Institute, 1996; Pope & Tarlov, 1991; Trieschmann, 1987; U.S. Department of Education, Special Education and Rehabilitation Services, National Institute on Disability and Rehabilitation Research, 2000). Due to medical advances and technology, wider availability of health insurance, and a generally higher standard of living that provides more services and support, people who would have died in the past now survive with a disability. In the same way that the viewpoints, experiences, and history of various ethnic/linguistic/cultural groups have been incorporated into the broader American culture, people with disabilities wish to have their social context and experiences become a valued and acknowledged part of American life. These contributions will strengthen and enrich the lives of those who do not experience disability (Akabas, 2000). In the past, clients with disabilities were served primarily by rehabilitation counselors, probably because of the misconception that the client's disability was the sole or, at minimum, the most important concern. However, because disability is both a common and a natural fact of life and because all individuals, including people with disabilities, have multiple identities, roles, functions, and environments, clients with disabilities require the services of counselors in all specialty areas: aging and adult development; gay, lesbian, bisexual, and transsexual issues; multicultural concerns; community mental health; school counseling; group counseling; marriage and family counseling; career counseling; and spiritual, ethical, and religious values.

To meet minimum standards of practice, therefore, counselors will be required to become proficient in disability issues (Hayes, 2001; Hulnick & Hulnick, 1989). Indeed, Humes, Szymanski, and Hohenshil (1989) suggested that counselors have not facilitated the personal growth and development of their clients with disabilities: "The literature includes many testimonies of persons with disabilities ... who have achieved successful careers despite roadblocks they perceived to have been imposed by counselors" (p. 145). However, in spite of this need, which continues to grow, very few university counseling programs provide adequate training about disability issues (Kemp & Mallinckrodt, 1996; Olkin, 1999; Pledger, 2003).

This lack of training and the resulting failure to provide services may be due to the powerful influence of models of disability, because these models determine in which academic disciplines the experience of disability is studied and taught. Thomas (2004) made the point that only rehabilitation counselors are trained in disability issues. A growing interest in models of disability has emerged in recent years, led by a variety of counseling practitioners, educators, and policy makers (Bickenbach, Somnath, Badley, & Ustun, 1999; Humes et al., 1989; Melia, Pledger, & Wilson, 2003; Olkin & Pledger, 2003; J. F. Smart, 2001, 2004; Tate & Pledger, 2003). Examining these changing models can assist the counseling profession, and individual practitioners, to reorient service provision. Counselor educators and counseling practitioners, regardless of specialty, theoretical orientation, or professional setting, should recognize that disability is never entirely a personal, subjective, and idiosyncratic experience, nor is disability a completely objective, standardized, and universal experience.

The conceptualization of disability as an attribute located solely within an individual is changing to a paradigm in which disability is thought to be an interaction among the individual, the disability, and the environment (both social and physical; Dembo, 1982; Higgins, 1992). Typically, the disability is not the single defining characteristic of the individual; rather the disability is one of several important parts of the individual's self-identity. When counselors dismiss or ignore the disability, a critical part of the client's self-identity must remain unexplored. On the other hand, counselors may tend to overemphasize the salience of the disability and automatically assume that the disability is the "presenting problem" or the cause and source of all the client's concerns. Indeed, the "roadblocks" referred to by Humes et al. (1989) may be due to a lack of understanding, training, and experience with disability issues. Many individuals with disabilities view their disability as a valued part of their self-identity, see positive aspects in the disability, and would choose not to eliminate the disability if they had this option. In contrast, few counselors conceptualize the client's disability as a source of self-actualization.

In this article, we draw both theoretical and practice implications, which may assist practitioners and educators in gaining a clearer understanding of counseling clients who have disabilities, from four broad models of disability. Intended as a broad overview of the major models and an introductory discussion of ways in which these models can affect the profession of counseling, we present several different ways of conceptualizing the experience of disability. The four broad models discussed here are (a) the Biomedical Model, (b) the Functional Model, (c) the Environmental Model, and (d) the Sociopolitical Model. In this article, the Functional Model and the Environmental Model are presented together because both are interactive models, or stated differently, these two models define disability as an interaction between the individual and his or her environment and functions. Furthermore, it is these two models, the Functional and Environmental models, that are most closely related to the practice of counseling. The Sociopolitical Model is considered separately because it is the newest of the models, and more important, this model conceptualizes people with disabilities as belonging to a minority group of individuals who have not yet received their full civil rights.

The Biomedical Model

The Biomedical Model of disability has a long history, is the most well-known to the general public, and carries with it the power and prestige of the well-established medical profession. This model, rooted in the scientific method and the benefactor of a long tradition, has had dominance in shaping the understanding of disability. The strength of the Biomedical Model lies in its strong explanatory power, which far exceeds the explanatory power of other models. Moreover, this model defines disability in the language of medicine, lending scientific credibility to the idea that disabilities are wholly an individual experience. Due to this "individualization," "privatization," and "medicalization" of disability, the Biomedical Model has remained silent on issues of social justice. Indeed, this model is not considered to be an interactional model because the definition, the "problem," and the treatment of the disability are all considered to lie within the individual with the disability. In addition, interprofessional collaboration is rarely implemented when the disability is medicalized.

Underlying the Biomedical Model is the assumption that pathology is present, and, in addition, disabilities are objective conditions that exist in and of themselves. This "objectification" process opens the door to the possibility of dehumanizing the person because attention is focused on the supposed pathology (Albrecht, 1992; Longmore, 1995). Bickenbach (1993) described this definition of disability as deviance:</p>

<pre> The most commonly held belief about [this model of] disablement

is that it involves a defect, deficiency, dysfunction, abnormality,

failing, or medical "problem" that is located in an individual.

We think it is so obvious as to be beyond serious dispute that disablement is a characteristic of a defective person, someone who is functionally limited or anatomically abnormal, diseased, or pathoanatomical, someone who is neither whole nor healthy, fit nor flourishing, someone who is biologically inferior or subnormal. The essence of disablement, in this view, is that there are things wrong with people with disabilities. (p. 61) </pre> <p>It is interesting that Bickenbach considered the Biomedical Model to have roots in the religious model of disability, in which biological wholeness was viewed as virtue and righteousness. The combination of religion and science in the Biomedical Model has had a formidable influence.

Furthermore, there is a clear-cut normative aspect to the Biomedical Model in that the disability is considered to be biological inferiority, malfunction, pathology, and deviance when compared with (or normed on) individuals without disabilities (McCarthy, 1993). Thus, the individual with a disability, regardless of personal qualities and assets, understands that he or she belongs to a devalued group. Frequently when clients with an identified disability seek professional services, such as counseling, they understand that, in the view of others, a life with a disability is worth less investment (McCarthy, 2003). Joanne Wilson, the commissioner for the Rehabilitation Services Administration from 2002 to 2005, is blind. She summarized the devaluation and the normative aspect of having a disability when she stated, "It's not quite respectable to have a disability" (Wilson, 2003). Furthermore, many individuals with disabilities may see no value in trying to integrate into a society that automatically discounts and pathologizes them. Taken to its extreme, the normative aspect of this model views a perfect world as a world without disabilities, and the possibility exists of providing the medical profession the mandate with which to eliminate disabilities and the people who experience them (Singer, 2000).

The Biomedical Model places people with disabilities in stigmatizing categories, therefore allowing the "general public" to view them as their category--"the blind," "quads" (individuals with quadriplegia), or "the mentally ill" (Nagi, 1969). Regardless of the category, categorized people are viewed as their category and not as individuals. Schur (1971) described the effects of categorization:</p> <pre> Others respond to devalued persons in terms of their membership in the stigma-laden category. Individual qualities and actions become secondary.... Individuals of devalued categories are treated as being ... substitutable for each other.... Stigmatized persons, then, are little valued as persons. Classificatory status tends to displace alternative

criteria of personal worth.... Others may claim license--implicitly, if not explicitly--to treat stigmatized individuals in exploitative and degrading ways. (pp. 30-31) </pre> <p>This categorization according to disability type has had many pervasive, institutional, and systematic consequences, some of which have resulted in inferior services or a lack of services from the counseling professions. In addition, this categorization has fragmented people with disabilities from their own community and robbed them of a collective history (Hahn, 1985, 1988, 1993). Categorization has also successfully taught society to focus on the disability category rather than the universal problems and challenges faced by people with all types of disabilities. Because of the strength and prestige of the Biomedical Model, both the general public and individuals with disabilities have come to see people with disabilities as categories.

In the Biomedical Model, the disability exists totally within the individual, and, accordingly, the individual responsible for the "problem" should also be totally responsible for the solution (Kiesler, 1999). This view, therefore, has the authority to relieve society of any responsibility to accord civil rights to individuals with disabilities. After all, the disability is the individual's flaw and tragedy. A disability is thought to be bad luck, but it is the individual's bad luck. Society often communicates to people with disabilities: "This is how the world is. Take it or leave it." Not only does the Biomedical Model legitimatize prejudice and discrimination, but to the general public, its treatment of people with disabilities often does not appear to be prejudicial and stigmatizing. For example, when individuals with disabilities are not integrated into the workplace, schools, and other social institutions, their absence is usually not noticed. After all, according to this attribution theory, individuals with disabilities are thought to be responsible for their stigmatization. Clinicians have attempted to include environmental issues in their classification/diagnostic systems; however, the degree of prejudice and discrimination experienced or the lack of accommodations is typically not considered when medical professionals determine the level of severity of the disability or render a percentage of impairment.

In the traditional view of the Biomedical Model, both the cause of the disability and the solution and treatment rest with the individual. Liachowitz (1988) described an additional responsibility placed on individuals with disabilities: "Recent medical textbooks go further and construe disability as a variable dependent upon characteristics of motivation and adaptability as well as the limiting residue of disease and injury" (p. 12). Individuals concerned with the rights of people with disabilities derisively refer to this as the "Try Harder" syndrome. One hundred years ago, people with disabilities were often given moral and religious education in an attempt to "rehabilitate" them (Byrom, 2004).

These aspects of the Biomedical Model--the pathologizing, the objectification, the categorization, and the individualization of a disability--are dependent on the diagnosis and classification systems used by the medical professions. Certainly, the diagnostic systems of the medical professions are the most objective, standardized, reliable, and morally neutral assessments compared with those of the other models (American Psychiatric Association, 2000; Peterson, 2002; World Health Organization, 1980, 2001). Medical diagnoses are, however, only as valid as the classification systems used, and further, medical diagnoses can be subjective, impressionistic, value-laden judgments of individuals (Clendinen & Nagourney, 1999; Kirk & Kutchins, 1992; D. W. Smart & Smart, 1997a). L. Eisenberg (1996) stated, "Diagnostic categories and classification schemes are acts of the imagination rather than real things in the world .... We must not mistake this for reality itself" (p. xv), whereas Stone (1984), in a chapter titled "Disability as a Clinical Concept," referred to these systems as "false precision" and stated that medical diagnoses are not the product of "a scientific procedure of unquestionable validity, free from error" (p. 111). Stone concluded by pronouncing the determination of a diagnosis as "an unattainable quest for neutrality" (p. 111). Disability scholars (Albrecht, 1992; Reno, Mashaw, & Gradison, 1997) have posited that all diagnoses are based on the dual concepts of clinical neutrality and clear-cut measures of "normality" and that neither complete clinical neutrality nor absolutely clear-cut measures exist.

The Biomedical Model of disability does not provide a strong basis for the treatment and policy considerations of chronic conditions, which include most disabilities (J. F. Smart, 2005a, 2005b). Because of the long history of the two-outcome paradigm of medicine--total cure or the death of the individual--medical professionals work best with acute injuries rather than chronic, long-term disabilities. Vestiges of this two-outcome paradigm remain in insurance payment policies, which dictate that payments for services--such as counseling--are withdrawn once medical stabilization has been achieved and progress toward a full recovery has terminated. This has a kind of reasonableness, because the business of medical insurance was originally based on the Biomedical Model, with physicians acting as gatekeepers and policy makers.

Furthermore, due to the Biomedical Model's lack of attention to the individual's environment and its focus on the individual, this model is less useful for mental and psychiatric disabilities, which are episodic and very responsive to context and environment (Stefan, 2001). In short, the Biomedical Model is much stronger, in both diagnosis and treatment, when dealing with physical disabilities. This narrow emphasis presents difficulties because the definition of disability is enlarging and evolving beyond that of only physical disabilities to include such impairments as learning disabilities, mental illness, and other disorders.

The Biomedical Model is often conceived to be a model of experts in control (J. F. Smart, 2001, 2004), therefore reducing individuals with disabilities to the role of passive and compliant patients. Because most individuals with disabilities do not possess the expertise, knowledge, education, and experience of physicians, they may not be accorded respect as decision makers. For example, many individuals with disabilities have consistently reported that "doctors always underestimate the quality of my life." Thus, the subordinate, dependent, and inferior status of people with disabilities is reinforced by the power differential inherent in the Biomedical Model. Conrad (2004) described another result of the use of medical experts:</p> <pre> Because of the way the medical profession is organized and the mandate it receives from society, decisions related to medical diagnoses and treatment are virtually controlled by the medical professions.... By defining a problem as medical, it is removed from the public realm where there can be discussion by ordinary people and put on a plane where only medical people can discuss it. (p. 22) </pre> <p>As would be expected, much of the current conceptualization of disability is a reaction against the Biomedical Model (Brant & Pope, 1997; Gill, Kewman, & Brannon, 2003; Pope & Tarlov, 1991; Scotch, 1988). In spite of its shortcomings, no one, including proponents of the other models, suggests totally abandoning the Biomedical Model, nor is any intentional harm on the part of the medical profession implied. Indeed, the medical profession itself is moving away from many of the assumptions of this model. Furthermore, in the final analysis, it is the broader society that has endowed the medical professions and the Biomedical Model of disability with the appearance of reality, science, and objectivity.

Functional and Environmental Models

The Functional and Environmental models are considered together in this article because both are interactional models. In these two models, it makes no sense to discuss the definition of disability, or the ways in which to intervene, without first considering the functions of both the individual and the individual's environment. Therefore, biology becomes less important. Disability is defined in relation to the skills, abilities, and achievements of the individual in addition to biological/organic factors. Thus, these models do recognize the biological factors of a disability. Disadvantages or limitations such as poverty or a lack of education, although social ills, are not considered to be disabilities. Also, although everyone is required to successfully negotiate difficult environments, to undertake demanding functions, and to experience disadvantages, not everyone has a disability.

These two models are considered to be interactive models because the disability (of the individual) interacts with functions and environment (Dembo, 1982; Yanenbaum, 1986; Thomason, Burton, & Hyatt, 1998). Therefore, the definition of disability, the causal attribution, and the solution attribution are not found wholly within the individual (or his or her disability). Instead, adherents of these models of disability recognize the importance of biology but also posit that the environment can cause, contribute to, and exaggerate disability. Furthermore, these models do not view the "problem" of disability as located totally within the individual, suggesting that many of the difficulties of disability are also located outside the individual, specifically within the environment and its functional requirements (Wolfensberger, 1972). If the location of the problem shifts, the onus for the solution of the problem also shifts. By viewing the definition, the cause, and the difficulties of disability as interactional, helping professionals can aim interventions at adapting the environment and functional demands to the needs of the individual with a disability in addition to "rehabilitating" the individual.

Causal attribution differs also, but it is safe to state that for most individuals, the Biomedical Model's conception of causation is much easier to understand. As we have pointed out, in the Biomedical Model the causes and solutions to the disability are found in the individual, and generally the social solution and the built environment are ignored. In contrast, the Environmental and Functional models of disability posit that society can cause disabilities, exaggerate disabilities, and, in the words of some disability scholars, "make disabilities" (Higgins, 1992). Two examples illustrate these models. Itzak Perlman, the world-famous violinist and a survivor of polio, stated that people with disabilities experience two problems: (a) the physical inaccessibility of the environment and (b) the attitudes of the people without disabilities toward disability and people with disabilities (J. F. Smart, 2004). As difficult as these problems are, it can be seen that neither problem concerns the disability itself (or the individual with the disability). Indeed, one of the results of the ADA has been the increased public awareness that many of the problems and obstacles experienced by people with disabilities are due to their environments. Also, it can be seen that for Perlman's major professional function, playing the violin, his difficulty in walking is not a functional disability. The definition of disability varies with the roles expected of the individual. In addition, it can be seen that both of Perlman's difficulties can be ameliorated.

World War II and the resulting demands for a large number of military personnel changed both the functional and environmental definitions of disability. During World War I and World War II, many men who had been residents of institutions for the long-term care of individuals with mental retardation entered the U.S. military and fought in the wars' battles. Sobsey (1994) told of 13 men from such an institution in Connecticut who, in spite of being labeled as having mental retardation, enlisted to fight in World War II. Four of these men were promoted to higher ranks, and 7 were wounded in action. In spite of their war records, most of these men returned to the institution after the war. Sobsey concluded, "wars and labor shortages have repeatedly redefined who has mental retardation" (p. 132). It can be seen that nothing in the disability or the individual changed, but rather changes in the environment occurred.

These two examples also illustrate the disabling effects of prejudice and discrimination, and therefore in both the Environmental and Functional models, the potential exists for incorporating some degree of societal prejudice and discrimination when attempting to render a rating of the severity of a disability. For example, a young African American man with schizophrenia would probably experience more prejudice and discrimination than a Euro-American man who is blind. Medical ratings of the level of severity of these two disabilities might be relatively equal, but the difficulties experienced are probably much greater for the man with schizophrenia, mostly because of societal attitudes. Schizophrenia is a disability that is considered highly stigmatizing, and blindness is not. Furthermore, other perceived characteristics of the individual who "carries" the disability label (such as racial/cultural/ethnic identification, gender, sexual orientation, or age) intersect with the public perception of the disability.

There is a tendency to think that each individual's environment and functions are exclusively unique to that individual. However, broad, general changes in both environment and function can affect the daily life of an individual with a disability. For example, in a society based on physical labor such as farming or mining, a physical disability presents more difficulties than a cognitive disability, but in a service-, information-, and technology-based economy, a physical disability does not cause as many difficulties as does a cognitive disability. Liachowitz (1988) in her book, Disability as a Social Construct: Legislative Roots, made a compelling argument that literally overnight, the federal government has the capability to define disability and, therefore, to determine who has a disability. Nazi Germany is an extreme but clear-cut illustration of the Environmental Model and its power to shape the response to disability. Because of the political-social environment (Nazism), "Aryan" Germans with disabilities were systematically mass murdered by their government (Friedlander, 1995; Gallagher, 1990).

The causal attributions of these two models are not as sharply defined and as easily understandable as those of the Biomedical Model; certainly one of the strengths of the Biomedical Model is its strong explanatory power. Nonetheless, both the Functional Model and the Environmental Model possess strengths that the Biomedical Model does not. In addition, the bases of the Functional and Environmental models are more closely related to the theoretical assumption and practice orientations of most counselors. Viewing the client as a complete person with skills, abilities, and demands and conceptualizing the client within a context allow the counselor to see the client as more than a disability. If the disability is not the only factor in the equation of disability, then the diagnoses and labels attached to the individual will not acquire as much power to define the individual to himself or herself and to others. It will be more difficult to dehumanize people with disabilities and to think of the person with a disability as "not one of us." Labels and diagnoses, and the professionals who render them, will not be as powerful as they once were.

In contrast to the Biomedical Model, the Environmental and Functional models deal more flexibly with psychiatric disabilities that are</p>

<pre> episodic, highly responsive to context and environment, and exist along a spectrum, which theoretically could be cause for

hope--people with mental disabilities are frequently strong, talented, competent, and capable, and their environments can be structured in a way to support and increase their strengths, talents, competence, and capabilities. (Stefan, 2001, p. 10) </pre> <p>Because an individual's cultural identification defines his or her functions, roles, and environment to a great extent, the Functional and Environmental models provide a better basis from which to understand and respond to the disabilities experienced by individuals who are not White, middleclass, heterosexual, male, or Euro-American (D. W. Smart & Smart, 1997b; J. F. Smart & Smart, 1997). The Functional and Environmental models are also more appropriate for chronic conditions, which most disabilities are. With chronic conditions, after medical stabilization, the treatment focus is on maintaining the highest quality of life, avoiding secondary disabilities and complications, supporting independence, acquiring the appropriate assistive technology, and assisting the individual in negotiating developmental tasks. It can be seen that most of these interventions require functional and environmental adaptations--rather than focusing solely on "rehabilitating" the individual.

In the Functional and Environmental models, it is more difficult to dehumanize individuals with disabilities because of the following factors: (a) Categorization by disability type is less likely; (b) the power differential is reduced when the individual is viewed as a total person and not as a stigmatized, medicalized category; and (c) partial responsibility for the response to the disability devolves upon "society" to provide a physically accessible and nonprejudiced environment.

Perhaps most important, the discomfort, anxiety, defensiveness, and existential angst experienced because of the fear of acquiring a disability are decreased when individuals without disabilities take the opportunity to associate with friends, colleagues, and clients with disabilities. Thus, by viewing the individual as more than the disability and conceptualizing the environment and the functional requirements as major determinants of the difficulties experienced by people with disabilities, the fear of acquiring a disability will be greatly reduced.

The Sociopolitical Model

The Sociopolitical Model, also referred to as the Minority Model of Disability (Hahn, 1985, 1988, 1991, 1996, 1997; Kleinfield, 1979), is the most recently developed model and, more important, is a fundamental and radical change from the previous models. The Sociopolitical Model (in contrast to the Biomedical Model and the Environmental and Functional models) has the capability to explain and describe more of the day-to-day life of people with disabilities. Certainly, for most people with disabilities, the prejudice and discrimination found in the broader society are more of an obstacle than are medical impairments or functional limitations.

Madeline Will (cited in Weisgerber, 1991), former assistant secretary for education and head of the Office of Special Education and Rehabilitation Services underscored this:</p> <pre> Most disabled people [sic] ... will tell you that despite what everyone thinks, the disability itself if not what makes everything different. What causes the difficulties are the attitudes society has about being disabled, attitudes that make a disabled person embarrassed, insecure, uncomfortable, dependent. Of course, disabled people [sic] rarely talk about the quality of

life. But it has precious little to do with deformity and a great

deal to do with society's own defects. (p. 6) </pre> <p>In this model, people with disabilities view themselves as members of a U.S. minority group, indeed, some disability rights advocates have described Americans with disabilities as "foreigners in their own country" (Higgins, 1992). The hallmarks of this model include self-definition, self-determination, the elimination (or reduction) of the prejudice and discrimination (sometimes referred to as "handicapism"), rejection of medical diagnoses and categories, and the drive to achieve full equality and civil rights under U.S. law.

The Sociopolitical Model refuses to accept the inferior, dependent, and stigmatizing definition of disability; furthermore, in this model, disability is defined as a social construction in that the limitations and disadvantages experienced by people with disabilities have nothing to do with the disability but are only social constructions and therefore unwarranted. If society constructs disability, society can also deconstruct disability. Stigmatization, prejudice, discrimination, inferiority, and handicapism are not inevitable, natural, or unavoidable consequences of disabilities. Inherent in this definition of disability are three aspects: (a) People with disabilities must define disability; (b) people with disabilities must refuse to allow "experts" or "professionals" to define the disability, determine the outcomes of their lives, or judge the quality of their lives; and (c) people with disabilities refuse the "disabled role" of deviance and pathology. Whereas in the past, professionals defined disabilities and the experiences available to individuals with disabilities, disability rights advocates assert their rights to self-definition and self-determination. It can be seen that much of the Sociopolitical Model seeks to displace the "expert in control" basis of the Biomedical Model.

In the past, the disabled role was determined by people who did not have disabilities and therefore had no experience in managing a disability on a day-to-day basis. Individuals with disabilities were expected to learn the rules of this role; to live the rules; and, most important, to believe in the rules. The rules and expectations of this role, although unwritten, were strongly enforced, and individuals who did not comply with these expectations often experienced severe consequences, including lack of services and social isolation. These rules included the following: always be cheerful; face the disability with courage, optimism, and motivations; manage the disability as well as possible (in the view of others); adhere to medical and rehabilitation regimens; request only those accommodations and assistance that others feel are necessary; make others comfortable with the disability; and keep all aspirations at a reasonable level, or stated differently, do not ask for much. Often, a person with a disability who is perceived to have adopted the disabled role is considered to be a "Tiny Tim" by disability rights advocates.

Adherents of the Sociopolitical Model resist medical categorization by diagnosis and, indeed, view this categorization to be a source of prejudice and discrimination (although they acknowledge that prejudice and discrimination were not the intention of the medical profession). According to the Sociopolitical Model, categorization has resulted in (a) teaching individuals who bear the diagnoses to accept the meanings of these labels as their self-identity, (b) allowing the general public to avoid focusing on the universal problems of people with all types of disabilities, (c) fragmenting the disability community so that it cannot form broad coalitions with which to effect sociopolitical changes, and (d) leading "society" to believe that disability is inferiority and that, therefore, the prejudice and discrimination toward people with disabilities are inevitable consequences of the inferiority.

Thus, the Sociopolitical Model minimizes dependence on an academic discipline or professional area of expertise, and it does not consider causal attribution to be a relevant concern. This model is considered to be an interactional model. Disability, in this model, is not viewed as a personal tragedy but as a public concern.

Many scholars and researchers state that the prejudice and discrimination directed toward people with disabilities have been more pervasive than the prejudice and discrimination directed toward any other group of people, and, further, much of this has been due to the Biomedical Model. In their book, Fleischer and Zames (as cited in McCarthy, 2003) pointed out the tendency to overlook prejudice against persons with disabilities:</p>

<pre> In The Anatomy of Prejudice (1996), Elisabeth Young-Bruehl

analyzes what she believes to be "the four prejudices that have

dominated American life and reflection in the past half-century--anti-Semitism, racism, sexism, and homophobia." No reference is made to disability discrimination. Misrepresented as a health, economic, technical, or safety issue rather than discrimination, prejudice based on disability frequently remains unrecognized. (p. 210) Albrecht (1992) summarized,

More recent studies suggest that prejudice against impaired persons is more intense than that against other minorities. Bowe (1978) concludes that employer attitudes toward impaired workers are "less favorable than those toward elderly individuals, minority group members, ex-convicts, and student radicals," and Hahn (1983) finds that handicapped persons are victims of great animosity and rejection than many other groups in society. (p. 245) </pre> <p>Proponents of the Sociopolitical Model assert that this prejudice and discrimination against individuals with disabilities is long-standing, systematic, and institutionalized in American life. The ADA (1990) states,</p>

<pre> Individuals with disabilities are a discrete and insular minority who have been faced with restrictions and limitations, subjected to a history of purposeful unequal treatment, and relegated

to a position of political powerlessness in our society, based on characteristics that are beyond the control of such individuals and resulting from stereotypical assumptions not truly indicative of the individual ability of such individuals to participate in and contribute to society. (Seventh Finding) </pre> <p>The ADA (1990) further asserts, "unlike individuals who have experienced discrimination on the basis of race, color, sex, national origin, religion, or age, individuals who have experienced discrimination on the basis of disability have often had no legal recourse to redress such discrimination" (Fourth Finding). Moreover, it is the prejudices, stereotypes, and stigma, and not the disability itself, that are the true handicap and obstacle.

Much like other civil rights movements in the United States and, indeed, building on the history and the methods of the successes of African Americans and the women's movement, the disability rights advocates view the only commonality among people with disabilities as being the prejudice and discrimination they experience. If the occurrence of the disability appears to be unfair and unpredictable, then society's response to disability can nevertheless be equitable, moral, and predictable. A perfect world is not a world without disabilities but a world in which accommodations and services are provided to people with disabilities, and, more important, disability is not viewed as inferiority.

The Power of Models

Lack of Interagency Collaboration

All four broad models answer the question, "What is a disability?" (Berkowitz, 1987). Because each model provides a different answer to this question, the needs of the individual with a disability are also determined differently in each of the models (Bickenbach, 1993). All four models contain a definition of disability that reduces it to a single dimension, thus ignoring and excluding other important aspects. Therefore, all of these models are considered to be reductionistic, unidimensional, and somewhat time bound and culture bound. As a result, these incomplete definitions of disability may impede the type of interagency collaboration that has the potential to provide a range of services to individuals with disabilities. In addition, funding policies (which pay for services) are often based on these unidimensional definitions. Occasionally, the meanings ascribed to the disability experience by professional service providers and funding agencies may remain invisible simply because these meanings are not questioned or challenged.

Despite these basic differences, three of the models of disability lump individuals into categories such as "the blind," "the mentally ill" or "quads" (M. G. Eisenberg, Griggins, & Duval, 1982; Wright, 1991). Furthermore, the simple act of "placing" or "assigning" people to categories robs them of their individuality; to counteract this, counselors can assist clients with disabilities in dealing with the effects of automatic categorization.

These definitions of disability vary with the purposes, values, and needs of the definers. Zola's (1993) article, "Disability Statistics, What We Count and What It Tells Us," provides an excellent introduction to the varying definitions of disability. Zola's title clearly communicates that definitions (and statistics) of disability are a reflection of the values and needs of the defining group, and because of this, none of the models can be entirely value free or morally neutral.

Blaming the Victim

Models ask the questions, "Who is responsible for the disability" and "Who is responsible for the solution?" (Berkowitz & Hill, 1986; Yelin, 1992) Again, each model answers these questions differently. Determining the onset or acquisition of the disability attempts to understand how the disability occurred, or more precisely stated, the etiology of the disability. Often, the search for the etiology or cause of the disability becomes distorted, resulting in implicit or explicit blame, fault, and moral accountability placed on the individual or his or her parents. Nonetheless, for purposes of calculating financial benefits and allocation of services, many disability programs require a clear-cut causal attribution. It is true that regardless of etiology or causal attribution, the treatment of a particular type and severity of disability is almost identical. However, the response of the general population, and hence the personal experience of the person with the disability, is a result of the public's assumptions of causal attribution. For example, an individual who is born with spina bifida is often considered a victim, whereas a person who acquires a spinal cord injury in combat is thought to be a hero, and a person who acquires a spinal cord injury while intoxicated and speeding on a motorcycle, without a helmet, is viewed as a culprit. The attribution of responsibility also determines which professions serve people with disabilities (Albrecht, 1981; Davis, 1997; Reno et al., 1997).

The history of these models can be easily traced simply by looking at the attributions of cause and responsibility in each model and the resulting formulation and implementation of policies and services. Furthermore, these attributions have had a profound effect on the lack of counseling services provided to people with disabilities, simply because the Biomedical Model of disability has dominated. Most important, attribution theory (Heider, 1958) has the power to individualize and privatize the experience of disability by looking for (and seemingly finding) both the cause and the solution for the disability wholly within the individual rather than within the social system. Attribution theories that privatize disability (rather than viewing disability as a public concern) often view the individual as a "patient" or as a "victim," or both.

The models described in this article place varying emphasis on the medical, functional, environmental, and sociopolitical needs and rights of the person with a disability. Three of the models emphasize definitions of disability rather than determining ways in which to intervene. In order for needs to be met, they must be clearly defined (Zola, 1989). For example, in the Biomedical Model, needs are considered to be solely medical; in the Environmental and Functional models, the needs are thought to be those of adapting the environment and functional requirements to fit the requirements of the individual with the disability; and in the Sociopolitical Model, the needs are considered to be full social integration and civil rights. The counseling interventions that flow from each model dictate different responses from the counselor. In order to be even minimally effective, counselors should understand the implications of each model for their manner of practice.

Shaping Self-Identities and Daily Lives

One model, the Biomedical Model, provides labels, diagnoses, categories, and theories of causation and responsibility that are derived from seemingly authoritative and prestigious sources. Diagnostic categories, however, can often be distorted to become stereotypes and uninformed assumptions (Clendinen & Nagourney, 1999). Moreover, these stereotypes are continually socially reinforced in the media and in the educational system, eventually becoming an accepted part of the social environment and, consequently, often remain unidentified and unquestioned (Stone, 1984). The individual with a disability may come to accept these diagnoses, and occasionally the stereotypes, as self-identifiers (Goffman, 1963). Often the individual with a disability is required to label himself or herself with a negative diagnosis or other label to be declared eligible for services and benefits. If disability is thought to be an unbearable personal tragedy, the individual (with a disability) is often effectively taught to be both inferior and dependent.

Despite the fact that these models are only representations of reality, and not reality itself, the assumptions, definitions, and history of each model are so persuasive and long-standing that they are often mistaken for fact (Hannah & Midlarsky, 1987). In addition, the personal daily functioning of the individual with a disability is determined, in large part, by assumptions derived from these models. Where the individual lives, how (and if) the individual is educated, the type and quality of professional services offered, and the degree of social integration afforded the individual are all influenced by the model of disability that is implemented.

Determining Which Academic Disciplines Teach About the Disability Experience

The disability experience, despite the large number of individuals with disabilities, remains invisible in most university curricula (Bauman & Drake, 1997; Hogben & Waterman, 1997). Students in counseling training programs, with the exception of rehabilitation counseling (Thomas, 2004), are typically not required to learn about people with disabilities. Simply because disability has been considered solely a biological and medical concern, only medical schools and the allied health professions have offered course work in disability issues. The "medicalization" of the disability experience has effectively kept the history and viewpoints of people with disabilities outside the realm of counseling education and professional training. Models of disability have provided the explanatory rationale for academic disciplines, and therefore most graduates of counseling programs do not possess competencies to provide services to clients with disabilities. Olkin and Pledger (2003) reported that students are trained not to notice the absence of disability issues. In their view, the lack of disability information "in curricula, and among peers and professors--is a powerful statement about the marginalization of people with disabilities" (p. 297). Furthermore, research on disability and people with disabilities, including rigorously designed and executed studies, is often of questionable value because of negative and biased assumptions toward disability. Certainly, any disability-related research study is only as valid as the model of disability upon which it is based. Myerson (1988) provided the following summary:</p> <pre>

The number of investigations that are flawed from inception by prejudicial commonsense assumptions, by theoretical bias, or by methodological error remains high.... These errors are functions, in great part, not of [the researchers'] incompetence in the mechanics of research, but of asking the wrong questions, of incorrect notions of the meaning of disability to those who live with it, and of lack of understanding.... A particular source of error is the narrowly trained clinician who believes that clinical criteria are appropriate measures of problems that arise from systematic social injustice. (pp. 182-183) </pre> <p>Myerson concluded that "like others, to the extent that their thinking incorporates cultural myths, [researchers] become prisoners of plausible but erroneous hypotheses" (p. 183).

Implications for the Counseling Profession

Biology is still a factor in the equation of disability; however, biology does not matter as much as has been previously thought (J. F. Smart, 2005c). For counselors, this assumption has important implications because for the client with a disability, self-identity and the conceptualization of his or her life situation are derived from these basic concepts. In contrast, many professionals may, consciously or unconsciously, ascribe more importance to the biological and physical aspects of the disability than the client does. The individual with a disability certainly does not conceive of his or her life in these four neatly (and artificially) explained models. However, counselors can, albeit unintentionally, reinforce the status quo by unquestioningly accepting the assumptions, including expectations for the client's self-actualization, of these models and their labels and diagnoses. Clients with disabilities, on the other hand, may enter the counseling relationship with the expectation of receiving inaccurate (and often negative) diagnoses and inadequate services, often provided in offices that are inaccessible. Nevertheless, counselors are in a unique position to recognize the interplay of personal characteristics and environmental factors in a developmental context. Furthermore, counselors have long recognized the value of empowerment for all clients. The following is a listing of some implications for the counseling profession.

1. Counselors should engage in an ongoing examination of clients' feelings about the experience of disability and the resulting interaction of the counselor's own identity with that of the client. Taken to the extreme, the counselor may focus more on himself or herself if the disability of the client arouses feelings of existential angst, anxiety, and defensiveness, much of which is a result of the widely held view of the Biomedical Model of disability. If the counselor views disability as a tragic inferiority, then he or she will more likely experience a negative, emotional response to the client with a disability. Countertransference, and other emotional reactions to the disability of the client, may prevent the counselor from fully understanding the client and therefore negatively affect the counseling relationship.

2. Counselors should recognize that most individuals with disabilities do not accept the basic tenets of the Biomedical Model of disability. Rather, they may view the disability as a valued part of their identity; see positive aspects in having the disability; not view the disability as tragic or limiting or being an inferiority; and would not choose to eliminate the disability if they could. At times, it may be necessary to ask the client about his or her identity as a person with a disability. Counselors must recognize that clients with disabilities want respect and not sympathy (Harris, 1992). Indeed, sympathy and lowered expectations may be considered to be stigmatizing and prejudicial; sympathy and lowered expectations toward people with disabilities often result in withholding helpful and honest feedback, reduce the range of opportunities open to the individual, foster dependence, and subtly communicate the message to clients with a disability that standards will be lowered for them because they are not perceived (by the counselor) to be capable.

3. Counselors should recognize that the disability is simply one part of the individual's identity. As does everyone, the client with a disability has multiple identities and multiple roles. Disability is not the "master status." Furthermore, a deeper and more complete understanding of the client's varied identities, functions, and environments will facilitate the implementation of the Environmental and Functional models of disability in the counseling process. Disability identity also constantly shifts and develops, as do all identities.

4. Counselors know that empowerment refers to the processes and outcomes relating to issues of control, critical awareness, and participation (Perkins & Zimmerman, 1995). For clients with disabilities,</p> <pre>

empowerment values provide a belief system that governs how our clients and we as professionals can work together. Based on this paradigm shift, there are substantial changes to be made to our practice.... Empowerment values include attention toward health, adaptation, and competence, and the enabling environment. As professionals, our goal is to promote our clients' full participation and integration into their communities. The collaboration ... is itself an empowering

process. (Tate, 2001, p. 133) </pre> <p>5. As with any other client, the counselor may occasionally need to guard against imposing his or her values on the client with a disability (Norcross, 2002). Clients with disabilities have, at times, interpreted their counselors' guidance as a type of the "Try Harder Syndrome," or some individuals with disabilities have felt themselves to have been given the negative label by counselors of denying their disability. Often, clients with disabilities are not denying the presence, implications, or permanence of the disability, but rather they are denying the "disabled role" of pathology, inferiority, and deviance. Therefore, these clients may terminate counseling prematurely because they have felt misjudged.

6. The power differential between counselor and client with a disability should be addressed. Often, the power differential is increased when the client has a disability and the counselor does not. If the counselor subscribes to the Biomedical Model, with its strong normative emphasis, this increased power differential may impede the establishment of rapport and trust. Furthermore, this power imbalance in the therapeutic setting may simply reflect the broader world in which the client functions.

7. Counselors should listen to their clients and be willing to hear about experiences of prejudice and discrimination experienced by their clients with disabilities. Learning the basic tenets of the Sociopolitical Model of disability will provide counselors with some introductory understanding of this stigmatization and discrimination, and, accordingly, counselors will be able to set aside some of their preconceived notions concerning the experiences of their clients with disabilities. Counselors should recognize that many clients with disabilities may not seek services at counseling agencies because they understand that often the counselors at these agencies may reinforce the prejudice and discrimination of the broader culture. On the other hand, counselors need to avoid attributing all the client's issues and problems to prejudice and discrimination. Nonetheless, for most people with disabilities, self-identification as a person with a disability does not automatically translate into group consciousness or political action (Scotch, 1988).

8. Counselors should recognize that, for many of them, their professional training may be inadequate to prepare them with the skills and competencies to work with clients with disabilities. Also, some theoretical approaches and counseling practices have their basis in the Biomedical Model and therefore, simply "adapting" these approaches and orientations for clients with disabilities may be at best ineffective and at worst harmful. Stated differently, the little professional training counselors have received may be faulty and ill conceived. Counselors who do not have adequate training must seek opportunities for additional education.

9. Counselors should examine their willingness to broaden their vision about the experience of disability. On one hand, counselors may have strong needs to be knowledgeable, skilled, and helpful, but on the other hand, counselors may view disability as ambiguous and inferior. Students in counseling programs should seek out course work (such as is available in Rehabilitation Counseling programs) and other workshops that focus on disability issues. Certainly, information about a client's identity and feelings about his or her disability must come from that individual, but obtaining a broad knowledge of the topic of disability is imperative. It is not ethical or appropriate to expect clients with disabilities to teach counselors about the world of disability.

10. Both outreach efforts and collaborative learning among counseling professions can be achieved by learning which agencies people with disabilities typically go to for assistance (such as state Vocational Rehabilitation offices) and then establishing professional relationships with these agencies.

11. Professionals, in all aspects of counseling, should intervene at institutional and political levels when appropriate and possible. Although individual counseling and support for clients with disabilities can make a contribution to the larger society, advocating for changes in systems and policies, alerting the public to manifestations of prejudice and discrimination in the media, and advocating for environmental accessibility can also be valuable contributions. Counselors, both as individuals and as part of statewide, regional, or national professional organizations, can create change.

12. Counselors should recognize that it is necessary to clearly articulate the assumptions about models of disability that underlie research studies. Research can be more sharply focused if the basic assumptions and values about people with disabilities are made clear. Articulating these values as they relate to one or more of the four models of disability would help both researchers and consumers of research evaluate the research findings.

In order to provide ethical and effective services to clients with disabilities, counseling professionals in all aspects of the field will be required to examine the ways in which they conceptualize the experience of disability. For some counseling professionals, many of these ideas, derived from the models of disability, may be new and different ways of responding to people with disabilities. For others, these ideas will provide a useful adjunct to the counseling services or the counseling training and education they provide.

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Julie F. Smart, Department of Special Education and Rehabilitation, Utah State University; David W. Smart, Counseling and Career Center, Brigham Young University. Correspondence concerning this article should be addressed to Julie F. Smart, Department of Special Education and Rehabilitation, Utah State University, 2865 Old Main Hill, Logan, UT 84322-2865 (e-mail: jsmart@cc.usu.edu).
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Title Annotation:Practice & Theory; psychological research
Author:Smart, Julie F.; Smart, David W.
Publication:Journal of Counseling and Development
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Date:Jan 1, 2006
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