Guidelines for Assessment of and Intervention with Persons with Disabilities

Approximately one in five Americans or roughly 50 million Americans are currently living with a disability (U.S. Department of Education, 2007). Individuals with disabilities and their advocates have worked for more than 40 years to eliminate attitudinal and physical barriers, to be fully included in all aspects of society, and to secure the freedom to choose their own futures (Jaeger & Bowman, 2005; Priestley, 2001; Switzer, 2008). Their efforts facilitated the passage of the Americans with Disabilities Act (ADA) of 1990. Nonetheless, many people with disabilities continue to encounter both blatant and subtle discrimination in employment, housing, education, recreation, childrearing, health care, and mental health services (e.g., Banks & Kaschak, 2003; Kirschbaum & Olkin, 2002; Raphael, 2006; Schriner, 2001; Smart, 2001; Stapleton, Burkhauser, & Houtenville, 2004; Waldrop & Stern, 2003; Woodcock, Rohan, & Campbell, 2007).

Although many persons who have disabilities have experienced discrimination, each individual reacts differently to those experiences. Moreover, each person assigns a unique meaning to disability, depending on the nature of impairment, the quality of social support and life demands (Olkin, 1999b; Olkin & Taliaferro, 2005; Vash & Crewe, 2004). Above and beyond their disability experiences, persons with disabilities have their own life experiences and, like everyone else, their own personal characteristics, histories, and life contexts.

To work effectively with people who have disabilities, psychologists need to become familiar with how disability influences a client’s psychological well being and functioning. Psychologists should also become aware of how their own attitudes, reactions, conceptions of disability, and possible biases may affect their professional relationships with clients who have disabilities. Further, it is important for psychologists to learn the best “barrier-free” psychological practices for clients with disabilities, including provision of reasonable accommodations, and appropriate integration of disability-related issues into assessment and intervention.

Unfortunately, while psychologists receive extensive training in treating mental health disorders, they rarely receive adequate education or training in disability issues (Leigh, Corbett, Gutman, & Morere, 1996; Olkin & Pledger, 2003; Rubino, 2001; Strike, Skovholt, & Hummel, 2004). Few graduate psychology training programs offer disability coursework (Olkin, 2000; Olkin & Pledger, 2003). This paucity of training is a major barrier to providing effective services to clients with disabilities (Leigh, Powers, Vash, & Nettles, 2004; Olkin, 2002). Limited training and experience may leave many psychologists unprepared to provide clients with disabilities with professionally and ethically sound services, including provision of assessments and interventions.

The goal of these Guidelines for Assessment of and Intervention with Persons with Disabilities is to help psychologists conceptualize and implement more effective, fair and ethical psychological assessments and interventions with persons with disabilities. The Guidelines provide suggestions on ways psychologists can make their practices more accessible and disability-sensitive, and how they might enhance their working relationships with clients with disabilities. Additionally, the Guidelines provide information on how psychologists can obtain more education, training and experience with disability-related matters.

The Task Force hopes that the Guidelines will increase discussion, training and awareness about disability across the profession. Such interest might contribute to needed research on disability-related issues in assessments and interventions. In particular, we encourage the development and use of empirically informed treatments and assessments for clients with disabilities (Olkin & Taliaferro, 2005).

The Task Force based the Guidelines on core values in the Ethical Principles of Psychologists and Code of Conduct (APA, 2002; Smart, 2001; Szymanski & Trueba, 1994) with specific reference to Principle D: Justice and Principle E (Respect for People’s Rights and Dignity). The core values include respect for human dignity, recognition that individuals with disabilities have the right to self determination, participation in society, equitable access to the benefits of psychological services, recognition that people with disabilities are diverse and have unique individual characteristics, and recognition that disability is not solely a biological characteristic, but is also a result of the individual’s interaction with the environment.

Disability is a broad concept that encompasses a wide range of impairments, functional limitations, and barriers to participation in community life (World Health Organization, 2001). The Task Force recognizes that psychologists have a firm grasp on treating impairments that arise from issues of emotional disturbance and mental health disability. Accordingly, although our Guidelines apply to persons with all types of disabilities, including mental health, we emphasize issues of disability arising from the impairments which are less known to psychologists, such as mobility, sensory, communication, and neurological impairments. We also focus on environmental factors that influence all disabilities and accommodations that mitigate them.

The Task Force conducted an extensive literature search of psychological, medical, rehabilitation, vocational and educational databases, searching in the areas of professional relationship and communication issues, attitudes, biases and assessment and treatment of persons with disabilities across the developmental trajectory. The literature reviews were broad in scope, covering quantitative and qualitative traditions tied to various specialty areas in disability research (e.g., clinical rehabilitation, neuropsychology, education, psychometrics, counseling and vocational rehabilitation). Much of the identified literature was theoretical and professional, focusing on specific disabling conditions rather than generic disability. The Task Force used the results of those reviews in developing these guidelines.

This document offers guidance on how psychologists assess and treat people with disabilities in their professional capacity. Guidelines are not standards. Standards are generally mandatory and may have an enforcement mechanism. Guidelines are intended to facilitate the profession’s continued systematic development and to ensure that psychologists maintain a high level of professional practice. Guidelines are not exhaustive and may not apply to every professional and clinical situation. They are not definitive and do not take precedence over a psychologist’s well-informed judgment. Applicable federal and state statutes also supersede these Guidelines.

These Guidelines are intended for psychologists who work in various settings with clients who have disabilities. Settings may include outpatient therapy; educational, religious, or correctional facilities; businesses and employment settings; insurance, compensation and legal contexts, and hospital, rehabilitation and community service settings. They are meant to facilitate a psychologist’s work with clients who have disabilities, not to restrict or exclude any psychologist from serving clients with disabilities or to require specialized certification for this work. The Guidelines also recognize that psychologists who specialize in working with clients who have disabilities may seek more extensive disability training consistent with specialized practice.

There are many methods and ways for psychologists to gain expertise and/or training in working with individuals who have disabilities. The Guidelines do not prescribe following specific training methods, but instead offer recommendations on those areas of knowledge and clinical skills considered applicable to this work.

Guidelines for the Practice of Parenting Coordination

These guidelines are designed to address the developing area of practice known as parenting coordination. In response to the recognition by family courts and substantial evidence in the empirical and clinical literature that divorce does not end patterns of high parental conflict for some families (Garrity & Baris, 1994; Hetherington, 1999; Johnston, 1994; Maccoby & Mnookin, 1992; Wallerstein & Kelly, 1980), parenting coordination interventions began to be developed more than two decades ago. In the past decade, parenting coordination work has expanded across states and jurisdictions (Kirkland, 2008; Kirkland & Sullivan, 2008).

The course of the divorce process is commonly one of heightened anger and conflict, anxiety, diminished communication, and sadness or depression for one or both partners. These negative emotions are often accelerated by the separation and the adversarial nature of the divorce process. Although the majority of parents significantly diminish their anger and conflict in the first two to three years following divorce, between 8% and 15% continue to engage in conflict in the years following divorce, with little reduction in intensity of their feelings (Deutsch & Pruett, 2009; Hetherington, 1999; Hetherington & Kelly, 2002; Johnston, Roseby, & Kuehnle, 2009; Kelly, 2000, 2003; Maccoby & Mnookin, 1992; Wallerstein & Kelly, 1980).

Generally, this relatively small group of parents is not able to settle their child-related disputes in custody mediation, through lawyer-assisted negotiations, or on their own. They turn to litigation in the years following separation and divorce to settle these disputes and utilize disproportionate resources and time of the courts. They are more likely to have significant psychological problems, which may interfere with their parenting, and they more often expose their children to intense conflict and intimate partner violence, also commonly referred to as domestic violence (Johnston et al., 2009). As the negative impacts of continued high conflict on children became well established in the empirical and clinical literature (Clarke-Stewart & Brentano, 2006; Deutsch & Pruett, 2009; Emery, 1999; Grych, 2005; Hetherington, 1999; Johnston et al., 2009), family court judges, divorce intervention researchers, and psychologists practicing in the divorce and family area explored alternative interventions that would diminish the use of the adversarial process to resolve child-related disputes and deal effectively with these parents to reduce the conflict to which children were exposed (e.g., Cookston, Braver, Griffin, deLuse ́, & Miles, 2007; Cowan, Cowan, Pruett, & Pruett, 2007; Emery, Kitzman, & Waldron, 1999; Henry, Fieldstone, & Bohac, 2009; Johnston, 2000; Kelly, 2002, 2004; Pruett & Barker, 2009; Pruett & Johnston, 2004; Sandler, Miles, Cookston, & Braver, 2008; Wolchik, Sandler, Winslow, & Smith-Daniels, 2005).

Parenting coordination began gaining recognition in the 1990s as a result of presentations and trainings first offered at conferences, such as those of the Association of Family and Conciliation Courts (AFCC), and by experienced parenting coordinators (PCs). Initially, there were variations in role, source and degree of authority, and practice in different jurisdictions, and different titles were used to describe this innovative intervention model, including special masters, coparenting facilitators, or mediator/arbitrators. In 2003, AFCC appointed an interdisciplinary task force to develop guidelines for parenting coordination to guide mental health professionals, mediators, and lawyers with respect to training, practice, and ethics (AFCC Task Force on Parenting Coordination, 2006).

The complex and hybrid parenting coordination model continues to be refined in professional deliberations about the role, emerging statutes and case law, and court and local rules and regulations governing parenting coordination practice at the local jurisdictional level. These American Psychological Association (APA) “Guidelines for the Practice of Parenting Coordination” are intended to provide a specific framework and direction for psychologists for professional conduct and decision making in the practice of parenting coordination. Although designed for psychologists, many aspects of these guidelines may be relevant to other professionals as well.

The literature reviewed in drafting these guidelines was selected by the members of the APA Task Force for the Development of Parenting Coordination Guidelines to include the most seminal, relevant, and recent publications

Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline

Dementia in its many forms is a leading cause of functional limitation among older adults worldwide and will continue to ascend in global health importance as populations continue to age and effective cures remain elusive (Mathers & Loncar, 2006). Plassman et al. (2007) estimated that over 2.5 million Americans suffered from Alzheimer’s disease (AD) and that nearly 4 million had that and other forms of dementia in 2002. Given expected increases in the size of the older adult population, those numbers are expected to increase strikingly by 2050 (Alzheimer’s Association, 2009).

The following guidelines were developed for psychologists who perform evaluations of dementia and agerelated cognitive change. These guidelines conform to the American Psychological Association’s (APA’s) “Ethical Principles of Psychologists and Code of Conduct” (APA, 2002). The term guidelines refers to statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help facilitate a high level of practice by psychologists. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional situation. They are not definitive, and they are not intended to take precedence over the judgment of psychologists.

Guidelines on this topic were originally developed by an APA Presidential Task Force, approved as policy of APA by the APA Council of Representatives, and published in 1998 (APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia, 1998). Consistent with APA standards, these guidelines were subject to sunset or review in 2008. The Board of Professional Affairs and the Committee on Professional Practice and Standards conducted an initial review and determined that the guidelines should not be sunset and that revision was appropriate. The APA Committee on Aging empanelled a group of experts who reviewed and deemed appropriate the maintenance of these guidelines with appropriate revision and updating. The introduction to the original guidelines remains pertinent today:

Psychologists can play a leading role in the evaluation of the memory complaints and changes in cognitive functioning that frequently occur in the later decades of life. Although some healthy aging persons maintain very high cognitive performance levels throughout life, most older people will experience a decline in certain cognitive abilities. This decline is usually not pathological, but rather parallels a number of common decreases in physiological function that occur in conjunction with normal developmental processes. For some older persons, however, declines go beyond what may be considered normal and are relentlessly progressive, robbing them of their memories, intellect, and eventually their abilities to recognize spouses or children, maintain basic personal hy-giene, or even utter comprehensible speech. These more malignant forms of cognitive deterioration are caused by a variety of neuropathological conditions and dementing diseases.

Psychologists are uniquely equipped by training, expertise, and the use of specialized neuropsychological tests to assess changes in memory and cognitive functioning and to distinguish normal changes from early signs of pathology. . . . Neuropsychological evaluation and cognitive testing remain the most effective differential diagnostic methods in discriminating pathophysiological dementia from age-related cognitive decline, cognitive difficulties that are depression related, and other related disorders. Even after reliable biological markers have been discovered, neuropsychological evaluation and cognitive testing will still be necessary to determine the onset of dementia, the functional expression of the disease process, the rate of decline, the functional capacities of the individual, and hopefully, response to therapies. . . .

These guidelines, however, are intended to specify for all clinicians the appropriate cautions and concerns that are specific to the assessment of dementia and age-related cognitive decline. These guidelines are aspirational in intent and are neither mandatory nor exhaustive. . . . The goal of the guidelines is to promote proficiency and expertise in assessing dementia and age-related cognitive decline in clinical practice. They may not be applicable in certain circumstances, such as some experimental or clinical research projects or some forensic evaluations. (APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia, 1998, p. 1298)

Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients

The Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients were adopted by the APA Council of Representatives, February 18-20, 2011 and replace the original Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients adopted by the Council, February 26, 2000, and which expired at the end of 2010. Each of the 21 new guidelines provide an update of the psychological literature supporting them, include a section on "Rationale" and "Application," and expand upon the original guidelines to provide assistance to psychologists in areas such as religion and spirituality, the differentiation of gender identity and sexual orientation, socioeconomic and workplace issues, and the use and dissemination of research on LGB issues. The guidelines are intended to inform the practice of psychologists and to provide information for the education and training of psychologists regarding LGB issues.

Guidelines For Psychological Practice In Health Care Delivery Systems

Psychologists practice in an increasingly diverse range of health care delivery systems (HCDS). This diversification is due to widening recognition of psychology as a health profession (Belar, 2002; Brown, Freeman, Brown, Belar, Hersch, & Hornyak, 2002), of the unique skills of psychologists, and of the value of psychological services for health and wellbeing. It is also due to rapidly evolving systems in which health care is being delivered (American Psychological Association (APA), 2009). At the same time, psychologists’ roles within these settings are expanding, and multidisciplinary collaboration within health care is becoming commonplace. The following guidelines are intended to assist psychologists, other health care providers, administrators in health care delivery systems, and the public to conceptualize the roles and responsibilities of psychologists in these diverse contexts.

These guidelines are informed by the Ethical Principles of Psychologists and Code of Conduct (“APA Ethics Codes”)1 (APA, 2002a, 2010) and the Record Keeping Guidelines (APA, 2007). These guidelines address psychologists’ roles and responsibilities related to service provision and clinical care, including teaching and administrative duties. There are additional obligations related to conducting research in health care delivery systems that will not be included here; guidance in this area can be found in the APA Ethics Code (APA Ethics Code 8.0 through 8.15). In accordance with ethical standards, the practice of psychology in health care delivery systems is based on established scientific and professional knowledge (APA Ethics Code 2.04).

These guidelines may also be used to inform rule making and decision making in health care delivery systems about the roles of psychologists that are commensurate with their training and licensure. Federal and state laws, (including those governing service delivery, payment arrangements and business structures), standards of accrediting bodies (e.g., Joint Commission, 2009), and institutional bylaws are also relevant to these rules and decisions. These guidelines build upon earlier guidelines regarding hospital privileges, credentialing and bylaws specific to hospital settings (APA Board of Professional Affairs, Task Force on Hospital Privileges, 1991) and draw on the issues highlighted in an additional APA document regarding practicing psychology in hospitals from that same time period (APA Practice Organization (APAPO), 1998).

There are a wide variety of systems for health care delivery, including, but not limited to, primary care and integrative care facilities, tertiary care hospitals, rehabilitation centers, nursing homes, outpatient surgery centers, and substance abuse treatment centers. Similarly, there are a wide variety of patient populations with whom psychologists work within these systems (e.g., pediatric, geriatric, acutely versus chronically ill, those being treated for mental health or medical conditions, those from diverse cultures and socioeconomic groups, etc.) There
are also different entry points for psychologists to deliver professional services for both direct and indirect patient care within health care delivery systems, ranging from being employed by the organization to being independent practitioners with either contractual arrangements or following their patients as they enter a health care delivery system. In all cases, psychologists have special expertise in communication, behavioral issues, patient decision making, human interaction and systems that is relevant to the full spectrum of health and mental health issues and settings; these guidelines apply to that full spectrum. It is recognized that there is rapid growth in the use of technology (in areas such as telehealth) with unique considerations for practice that are beyond the scope of these guidelines. Ethical and legal standards for the practice of psychology pertain to the full range of health care delivery systems, and to every professional psychological role within such systems, unless otherwise specified.

The term “guidelines” refers to statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists. Guidelines differ from “standards” in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help ensure a high level of professional practice by psychologists. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional and clinical situation. They are not definitive and they are not intended to take precedence over the judgment of psychologists.

The following glossary of terms found in these guidelines may be helpful. For the purpose of these guidelines, “psychologists” are considered “health service providers” (APA, 1996), having been duly trained and experienced in the delivery of preventive, assessment, diagnostic and therapeutic intervention services related to the psychological and physical health of consumers, based on: 1) having completed scientific and professional training resulting in a doctoral degree in psychology; 2) having completd an internship and supervised experience in health care settings; and 3) having been licensed as psychologists at the independent practice level.

We use the term “patient” to refer to the child, adolescent, adult, older adult, couple, family, group, organization, community, or other population receiving psychological services in health care delivery systems. However, we recognize that in many situations there are important and valid reasons for using such terms as “client” or “person” in place of “patient” to describe the recipient of services. Finally, we use the term “multidisciplinary” throughout the guidelines but recognize that in some instances psychologists may actually be working in a “transdisciplinary” context where holistic care is being provided that crosses disciplinary boundaries.

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Ethical Principles of Psychologists and Code Of Conduct 2002

The American Psychological Association’s (APA’s) Ethical Principles of Psychologists and Code of Conduct (hereinafter referred to as the Ethics Code) consists of an Introduction, a Preamble, five General Principles (A – E), and specific Ethical Standards. The Introduction discusses the intent, organization, procedural considerations, and scope of application of the Ethics Code. The Preamble and General Principles are aspirational goals to guide psychologists toward the highest ideals of psychology. Although the Preamble and General Principles are not themselves enforceable rules, they should be considered by psychologists in arriving at an ethical course of action. The Ethical Standards set forth enforceable rules for conduct as psychologists. Most of the Ethical Standards are written broadly, in order to apply to psychologists in varied roles, although the application of an Ethical Standard may vary depending on the context. The Ethical Standards are not exhaustive. The fact that a given conduct is not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical.

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Record Keeping Guidelines

Approved as APA policy by the APA Council of Representatives, February 2007.

These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. State and federal laws, as well as the American Psychological Association’s (APA, 2002b) “Ethical Principles of Psychologists and Code of Conduct” (hereafter referred to as the Ethics Code), generally require maintenance of appropriate records of psychological services. The nature and extent of the record will vary depending upon the purpose, setting, and context of the psychological services. Psychologists should be familiar with legal and ethical requirements for record keeping in their specific professional contexts and jurisdictions. These guidelines are not intended to describe these requirements fully or to provide legal advice.

Records benefit both the client1 and the psychologist through documentation of treatment plans, services provided, and client progress. Record keeping documents the psychologist’s planning and implementation of an appropriate course of services, allowing the psychologist to monitor his or her work. Records may be especially important when there are significant periods of time between contacts or when the client seeks services from another professional. Appropriate records can also help protect both the client and the psychologist in the event of legal or ethical proceedings. Adequate records are generally a requirement for third-party reimbursement for psychological services.

The process of keeping records involves consideration of legal requirements, ethical standards, and other external constraints, as well as the demands of the particular professional context. In some situations, one set of considerations may suggest a different course of action than another, and it is up to the psychologist to balance them appropriately. These guidelines are intended to assist psychologists in making such decisions.

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