Infusing Disability in Counseling Curricula: Counseling Practice and Relationships

Section E of the Council for Accreditation of Counseling and Related Programs (CACREP) Standards (2024), which is a part of Section 3 (Foundational Counseling Curriculum), refers to Counseling Practice and Relationships. Section E contains 21 unique components encompassing foundational knowledge in counseling theory, case conceptualization, therapeutic relationship competence, and counseling microskills, among others. Section E and its encompassed components are infused into the counseling curriculum in master’s-level counselor education and preparation programs and required across the different specialty areas accredited by CACREP (e.g., School Counseling, Clinical Rehabilitation Counseling; Barrio et al., 2016). As an example, CACREP (2024) Standard E.1. covers: “Theories and models of counseling including relevance to clients from diverse cultural backgrounds” (p. 14). Therapeutic relationships, active listening skills, and theoretical foundations of counseling are all crucial elements of counselor preparation and not only reflect an accreditation requirement, but also an ethical requirement of counselors to “use techniques/procedures/modalities that are grounded in theory and/or have an empirical scientific foundation” (American Counseling Association (ACA), 2014, p. 10).

Although there is some counseling literature that addresses the unique considerations of forging relationships or applying counseling theories to persons from diverse populations, and specifically persons with disabilities, the precise means for doing so is incumbent upon counseling programs and counselor education faculty. Despite CACREP standards requiring education and training in counseling practices and relationships, counselors-in-training often report that disability-related content is not present in their programs (Sprong et al., 2018) and counselors in the field often report feeling as though they lack the skills necessary for working with persons with disabilities (Bang et al., 2021; Rivas & Hill, 2023). Therefore, counselor educators are encouraged to take steps to intentionally and thoughtfully incorporate and infuse disability-related content throughout the counseling program curriculum to better prepare students for providing services to persons with disabilities.

Importance of Counseling Practice and Relationships to the Overall Profession of Counseling

The therapeutic relationship is broadly defined as “the feelings and attitudes that therapist and client have toward one another and the manner in which these are expressed” (Gelso, 2011, p. 5). The therapeutic relationship is comprised of “the bond between the therapist and client as well as the agreement about the tasks and goals of therapy” (Duncan et al., 2010, p. 68). Research consistently demonstrates that the therapeutic relationship between a counselor and their client is the primary driver of counseling outcomes (Horvath et al., 2011). The ability to forge effective, healing relationships with clients requires an understanding of the application of counseling theory to practice, as well as proficiency in listening and interviewing skills. Therefore, counseling students need to develop skills in goal setting and counseling techniques, as well as the dispositional and technical skills needed for developing healing relationships with persons with disabilities.

The goals and tasks of counseling, as well as the nature of the therapeutic relationship between a counselor and client, are determined by a counselor’s theoretical orientation and their ability to effectively demonstrate active listening skills. A theory of counseling practice is “an organized set of assumptions that provides a framework for (a) generating hypotheses about what change processes will further therapeutic goals, (b) formulating specific tasks to facilitate desired change processes, and (c) evaluating progress toward the goals of therapy” (Truscott, 2015, p. 7). Microskills are the specific communication skills that comprise counseling interactions in counseling relationships and serve as the ‘how’ when it comes to incorporating theory into practice (Martin, 1999). The basic empathic listening skills are questioning, observation, encouraging, paraphrasing, summarizing, and reflecting feelings. Empathic listening skills are foundational in the development of healing, therapeutic relationships and fostering a climate for therapeutic change.

The practice of counseling as a helping profession does not readily lend itself to rote application of specific training and instead embodies a degree of complexity that requires the utilization of judgment on the part of the professional counselor (McAuliffe & Eriksen, 2011). Counselor education and preparation aims to prepare counselors in training for what Schön (1991) describes as professional work, or the ability to use judgment and considered action in ambiguous situations. Counselors-in-training benefit most from training and preparation that fosters the development of clinical judgment in an effort to promote greater intentionality and flexibility in their work. McAuliffe and Eriksen (2011) described counselor preparation as intending to help counseling learners develop a way of knowing the promotes a tolerance for ambiguity as well as the ability to be “culturally relativistic” (p. 3). The ability to cope with and respond to ambiguous situations in the context of counseling is critical in effectively serving and helping all clients they may encounter. In the context of Section E, this means that counselor educators can benefit from being equipped to prepare counseling learners to be more than merely technicians, or those who can apply techniques. Instead, counselor educators might consider preparing students to apply theory, listening skills, and techniques in a manner that is internally congruent such that it can be spontaneous, creative, and responsive in counseling interactions (McAuliffe & Eriksen, 2011). It is important for counselor educators to prepare students to utilize judgment, flexibility, and cultural relativism specifically when working with persons with disabilities.

Positionality Statement

Six of the seven researchers are employed in academia or are working toward doctoral degrees in Rehabilitation Counselor Education. One contributor is a licensed clinical mental health counselor providing counseling services to persons with disabilities in a community-based, outpatient private practice. All researchers are fully or provisionally licensed as professional counselors (e.g. LCMHC, LPC, ACMHC, CSW), with four of the seven also being certified rehabilitation counselors (CRC). Four of the seven researchers identify as persons with chronic illness and/or disability (CID). The writing team acknowledged (a) their clinical and educational orientation towards disability-affirming practices, (b) personal values steeped in the rehabilitation philosophy, and (c) a prioritization of ethical and nonjudgmentally accepting service provision for persons with disabilities. Appendix A contains more detailed information regarding each contributor.

Relevance of Disability to Counseling Practice and Relationships

There are more than 61 million persons with disabilities in the United States (Okoro et al., 2018) and 32.9% of persons with disabilities report experiencing frequent mental distress (Cree et al., 2020). Among the barriers to mental health care, persons with disabilities are more likely than persons without disabilities to live in poverty, be unemployed, and report less access to health care (Cree et al., 2020). Further, persons with disabilities have multilayered identities, or identities that are comprised at the intersection of multiple aspects of the self, such as sexual, gender, spiritual, career, and other domains of identity (Öksüz & Brubaker, 2020). Addressing all aspects of identity for a person with a disability in a holistic manner increases the complexity in providing care for them (Öksüz & Brubaker, 2020). Despite the prominent needs of persons with disabilities and the barriers to counseling services they experience, research has consistently demonstrated that counselor education programs do not adequately prepare students to work with persons with disabilities (Feather & Carlson, 2019). To effectively serve persons with disabilities, counselors need awareness, knowledge, and skills specific to persons with disabilities.

Counselors are ethically and professionally obligated to understand how disability can shape and influence a client’s lived experience, identity, and worldview. However, disability is often treated as a clinical category or diagnostic label, rather than as a social and cultural experience. Framing disability as a clinical category or diagnostic label leads to missed opportunities in building therapeutic relationships that are truly inclusive, validating, and responsive. The lack of disability representation in counseling textbooks and clinical training fosters a narrow and often pathologizing view of disability—one that reinforces the medical model and fails to recognize the social, political, and identity-based aspects of disabled clients’ lives (Dunn & Andrews, 2015; Goodley, 2017).

The field of counseling can benefit from critically examining how it has historically framed disability within deficit-based models. Drawing from the Independent Living Philosophy, disability should be thought of as a lived experience to be understood, honored, and centered in practice, not a problem to be solved. When counselors recognize disability as a cultural identity, one that includes pride, resistance, and community, the therapeutic relationship transforms. Counselors become allies, not fixers. They create spaces where clients are not expected to mask or overcome their disabilities but rather integrate them as part of their wholeness (A. J. Forber-Pratt & Zape, 2017).

This reframing requires counselors to actively dismantle internalized and systemic ableism, beginning with how they view competence, autonomy, and resilience. For example, a counselor might unconsciously measure therapeutic progress through a lens of “independence” without acknowledging the ways in which interdependence—a key value in disability communities—is a strength, not a limitation (Garland-Thomson, 2002; Kittay, 1999). Interdependence is based on the universal need for assistance, not limited to persons with disabilities, and the societal and intrapersonal benefit of engaging in mutually caring relationships with others. By emphasizing goals of independence, rather than interdependence, counselors reinforce ableist norms around productivity, communication, and emotional regulation. By contrast, a disability-affirmative counselor validates assistive technology, alternative communication styles, and non-traditional life paths as equally meaningful, effective, and healing (Goering, 2015; Olkin, 2002).

Therapeutic presence and the ability to “meet the client where they are” must be contextualized within disability experience. Students and practitioners alike can benefit from learning to ask, “How does this theory or technique honor the lived reality of disabled clients?” and “Am I upholding client dignity, or am I inadvertently replicating systems of exclusion?” These are not just clinical questions; they are justice questions (Annamma et al., 2013). To build more equitable counseling relationships, it is essential to center disability in conversations about power, identity, and access. Teaching students to explore how relationship-building might shift when working with a client who uses an Augmentative and Alternative Communication (AAC) device, who navigates the world from a wheelchair, or who has experienced medical trauma, for instance, helps future clinicians move beyond intellectual understanding into relational competency. Moreover, this approach fosters the cultural humility and critical reflection needed to support disabled clients in their pursuit of autonomy, belonging, and self-defined growth (Chapin et al., 2018; Zhu et al., 2021).

For counselor educators, there are three critical considerations in infusing disability into counseling practice and relationships, specifically counseling practice and relationships:

• Critical Consideration #1: Persons with disabilities comprise one of the largest non-majority populations in the United States, may require a variety of counseling services, and report higher levels of psychological distress. Students, therefore, can benefit from being prepared to respond to the complex needs of a population they are highly likely to encounter.

• Critical Consideration #2: There are multiple models of disability, and each model of disability provides a different definition of disability, defines the needs of persons with disabilities, and the location of the “problem” of disability. Awareness of different models of disability can better prepare students to provide intentional counseling services for persons with disabilities.

• Critical Consideration #3: Counselors and counseling learners report feeling underprepared relative to skills needed in working with persons with disabilities and there is a need to more purposefully and intentionally infuse disability competencies into courses covering counseling theories and counseling skills.

Infusing Disability Into Counseling Practice and Relationships

Persons with disabilities often report that the chief difficulties they face are not with their disability, but with the public attitudes, perceptions, and accommodations of their disability (Wang et al., 2021). Such a concept, known as the social model of disability, is often foreign to students in counselor education programs in the absence of specific instruction. In fact, outside of psychiatric disability and psychopathology, theories of counseling overall do not directly account for a person’s disability experience. Instead, persons with disabilities are most often subjected to healthcare providers operating from the medical model of disability—one in which the disability is something to be treated or cured in an effort to mitigate functional limitations (Goering, 2015). Thus, counseling practice that relies on specific goal-setting practices intent on bringing a person more in line with “normal” functioning tends to minimize or discount a person’s disability, thus perpetuating ableist practice.

Fortunately, by infusing disability into instruction on counseling theory, practice, and relationships, counselor preparation programs have an opportunity to build understanding of the disability experience. Informing students of the definitions and categories of disability (e.g., sensory, psychiatric, cognitive, motor, chronic illness, developmental) while encouraging them to consider how counseling theory may be applied to their work with persons with disabilities brings counseling more in line with a social justice approach to disability. It also encourages students to look beyond the surface of a counseling theory to explore how it can be applied to their work with one of the most overlooked marginalized populations we serve.

Lecture Content

When discussing disability from a counseling lens, it is imperative that the counselor is aware of factors related to disability from a holistic perspective. This can be done by understanding the importance of disability identity from a cultural viewpoint. People with disabilities have a shared history, identity expression, and pride regarding the overcoming of discrimination and other challenges in their past (Collins et al., 2015; A. Forber-Pratt, 2018; Vega et al., 2018).

Historically, people with disabilities have been subjected to counseling methods that stigmatize the individual by focusing on the functional limitations of the disability. The medical model sees the disability and associated behaviors as the problem to be solved. Coming from an anti-ableist outlook, the social model of disability was formed. This model views the person with a disability as inherently equal, with societal barriers and discrimination limiting function. It considers disability as one aspect of a person’s identity, much like race/ethnicity, culture, or gender (Lawson & Beckett, 2020).

When a client with a disability engages in the counseling process, it can mean they are struggling with multiple aspects of their disability. The client may be looking to adjust to a recently acquired disability or one that has existed for a lifetime. Once a client with these concerns arrives, there is a tendency in counseling to immediately provide skill-based techniques as a quick solution to troubles a client may be experiencing. For instance, counselors may feel compelled to teach clients with disabilities skills for coping with distress, rather than utilizing their counseling microskills to explore in greater depth the complex interplay between disability, identity, and the client’s environment. Listening to clients with disabilities and demonstrating deep empathic understanding accompanied by nonjudgmental acceptance can promote self-understanding, healing connection, and a source of empowerment.

Quick solutions can often reinforce negative belief systems and do little to explore the meaning-making that persons with disabilities have engaged in regarding their disability experience. They can also preclude understanding, on the part of the counselor, regarding the cultural identity either formed or in the process of being formed by the client. These techniques can also reinforce negative messaging on how a client should think and act through comparison with non-disabled peers (Ahuvia & Schleider, 2023). One way to combat this counseling tendency is to use theoretical explanations of client behavior that incorporate the lived experience of persons with disability. Often this can be achieved in counseling settings through meaning-making regarding disability experience through the utilization of summarizations, paraphrasing, and questions. This demonstrates respect for the client’s struggles, achievements, and cultural identity as a person with a disability. For instance, a client might describe feeling ‘undesirable’ as a result of a physical disability, which may lead some clinicians to want to promote more positive thinking or simply reassure the client. Instead, counselors can simply reflect to clients, “So because of your disability, you are undesirable to others,” in an effort to demonstrate deep empathic understanding of a client’s lived experience with disability, with the belief that this level of support and understanding will promote healing.

Counselor educators can infuse the experience of disability into their instruction regarding counseling theories. For example, when teaching a counseling theory such as Person Centered, counselor educators might utilize examples of adjustment to disability when describing the concept of congruence. A client with a disability might experience incongruence when who they believe they should or are expected to be is not who they feel they are, such as when persons with disabilities feel they can no longer be as productive as they are supposed to be. When teaching about pragmatic theories such as Cognitive Behavior Therapy (CBT), counselor educators can use examples of core and intermediate beliefs such as, “I’m not enough” and “Because of my disability, I am not enough,” to highlight the meaning-making persons with disabilities may engage in relative to cognitive theory.

Classroom/Online Discussion

The Golden Questions

Instruction in cultural humility tends to be rooted in the client’s and counselor’s worldview (Zhu et al., 2021). Likewise, a student’s understanding and resonance with a particular counseling theory tends to be rooted in two key questions: “Why do people suffer?” and “How do people change?” Allowing students to individually reflect on these questions, process them as a group, and then consider how they apply to counseling theory, offers instructors an opportunity to encourage consideration for the disability experience. For example, “If people suffer because of X, why do people with disabilities suffer and how do they change?”

Grading Considerations. Because the goal of these questions is to explore the student’s worldview in order to identify potential alignment with a counseling theory, discussion and grading should focus on developing student self-awareness, assessing their willingness to openly explore their internal belief systems, and beginning the process of integrating their values with those of the field at large. Students should be encouraged to use language that is familiar to them, while refraining from using language that is overly clinical or pathologizing in exploring these questions. This approach promotes a more authentic self-exploration that can help identify implicit biases students may hold regarding persons with disabilities, while supporting students as they begin the process of integrating their personal identity with an emerging professional identity.

Counseling Relationships with Persons with Disabilities

One of the key considerations in counseling is building and nurturing the counseling relationship. Yet, many students have limited interaction with persons with disabilities, particularly those with intellectual or developmental disabilities. Prompting students to consider how their relationship building efforts, rooted in counseling theory, would shift given a particular disability offers them a chance to examine ways in which they may need to adapt their approach. You may even consider asking students ways they would adapt their approach when:

• Conducting an intake with an adolescent with Down’s syndrome

• Meeting with a graduate student with a fluency disorder

• Consulting with a person with autism who has expressed acute suicidality

Grading Considerations. When evaluating student ability to incorporate disability considerations into their counseling skills, instructors should emphasize a student’s understanding of the core conditions of counseling relationships and how they may be experienced by persons with various disabilities and psychosocial considerations. For instance, students should utilize their counseling theory to conceptualize the nature of distress experienced by a graduate student with a fluency disorder, how the therapeutic relationship might be experienced by a person with a fluency disorder, and what psychosocial variables associated with fluency disorders might influence the counseling process.

Activities and Assignments

The following activities and assignments require minimal adaptation for asynchronous classrooms. Suggested adaptations are included in each activity but are by no means prescriptive or all-encompassing.

Case Conceptualization

The role of case conceptualization in clinical practice and training is well documented, yet there are few resources that provide a method for teaching students how to engage in the process. Gilboa-Schechtman (2024) suggested that a successful case conceptualization consists of three parts: a dynamic, context-sensitive, yet parsimonious model of the client’s functioning; relevant treatment targets and associated assessment procedures; and a treatment plan including intervention phases and potential obstacles. Such a suggestion naturally includes a client’s disability, as it is part of the individual’s context and functioning.

At Utah State University (USU), the USU Model of Case Conceptualization takes these parts and adds a way for students to consider the client’s functioning through the lens of a singular theoretical orientation (see Appendix B). Throughout courses where instruction requires examination of clinical practice, this model may be utilized to help students consider the client’s and counselor’s experience within a standardized framework. The USU Model does not merely consider the client’s experience through the lens of psychopathology, but it also allows the student to explore the holistic experience of the client through a theoretical lens.

Case conceptualization exercises, where students examine a case study and create a case conceptualization through a chosen theoretical orientation, may begin during counseling theory coursework and continue through internship. This format allows instructors to add the complexity of disability to case studies, while encouraging students to consider the role disability plays in the client’s overall experience, theoretical framework, and treatment planning.

Counseling Skills Transcript and Analysis

Many counselor preparation programs utilize some form of a counseling skills transcript and analysis in which students record a sample exercise and analyze it for the use of individual counseling skills (e.g., questions, encouragers, reflections of feeling). While such assignments allow students to both utilize and analyze their own counseling skills, they rarely incorporate how counseling skills are utilized with persons with disabilities. An assignment where a session with an individual with a disability is recorded, transcribed, and analyzed allows students to evaluate counseling microskills in the context of sessions wherein persons with intellectual disabilities, developmental disabilities, or language or fluency disorders (e.g., stuttering, aphasia, apraxia) are served. Such an assignment should then be processed in an in-person classroom or followed by a written reflection in an asynchronous class. Reflective practice is an important skill for counselors in training to develop as they serve persons with disabilities, as they can help students identify implicit biases they may hold towards persons with disabilities and where those biases might come from.

Research Paper on Evidence-Based Practices

Assignments revolving around the research of evidence-based practices (EBP) are not new. From counseling theory to research methods to mental health assessment, students are frequently required to research an EBP and evaluate it for a variety of considerations. One consideration often overlooked is how a person with a disability accesses the EBP and what accommodation can be made without sacrificing validity. Requiring students to account for a client’s disability experience when conducting research on an EBP also allows students to consider how the particular practice evaluates and considers a person’s disability, while opening the door to future research that may contribute to the overall body of counseling knowledge.

Weekly Reflections

As counselor educators, we frequently emphasize student self-reflection as a part of counselor development. However, to engage in meaningful reflection, most students are expected to acquire new skills that move them from an outcome focus to a willingness to engage in self-reflection when encountering challenging situations (Tobin et al., 2009). Encouraging students to engage in examination of the reciprocal relationship between counseling theory and client experience may naturally account for an individual’s disability if the instructor prompts the student to do so.

Resources

Course Readings

The course readings that instructors select not only inform students by way of driving or supplementing course content, but they also set the tone and focus for courses. By selecting readings, authors, and books that emphasize disability experience and competencies, instructors can provide students with opportunities to integrate disability considerations into their learning, while intentionally emphasizing the importance of considering disability in the counseling process.

Forber-Pratt, A. J., & Zape, M. P. (2017). Disability Identity Development Model: A Proposed Model for Counselors, Psychologists, and Rehabilitation Practitioners

This article presents a model of disability identity development that parallels other cultural identity models often used in counselor education. It helps students consider how disability identity informs self-concept and therapeutic goals.

Goodley, D. (2017). Disability Studies: An Interdisciplinary Introduction (2nd ed.).

This text provides a broad yet accessible overview of disability studies, connecting theoretical foundations to lived experience. Goodley critiques dominant psychological approaches to disability and encourages readers to explore disability as a cultural and political category. Goodley critiques the dominance of the medical model in psychology and education and explores how ableism is embedded in normative constructions of independence, productivity, and health. This is especially helpful for counselor educators seeking to disrupt default pathologizing lenses in theory and practice courses.

Olkin, R. (2002). Could You Hold the Door for Me? Including Disability in Diversity

Olkin’s article challenges the exclusion of disability from multicultural counseling discussions. It provides practical guidance for clinicians to expand their understanding of diversity to include disability and offers real-world examples of bias in clinical settings.

Oliver, M. (1996). Understanding Disability: From Theory to Practice

As one of the key architects of the social model of disability, Oliver’s work offers a systemic critique of the medical model. His writing helps students and clinicians understand how social barriers, not individual impairments, create disadvantages. It is essential for contextualizing disability within a justice-based counseling framework.

Shakespeare, T. (2013). Disability Rights and Wrongs Revisited (2nd ed.)

This foundational disability studies text offers a direct and nuanced critique of the medical model, examining its historical roots and limitations. Shakespeare contrasts it with the social model and discusses the complexity of integrating impairment and identity. It’s ideal for sparking classroom discussion around which models of disability are embedded in various counseling theories.

Tarvydas, V. M., & Hartley, M. T. (Eds.). (2022). The Professional Practice of Rehabilitation Counseling (3rd ed.)

This updated edition provides a comprehensive look at disability-focused clinical practice through a rehabilitation lens. It explores ethical considerations, counseling theory adaptation, vocational implications, and systemic advocacy making it highly applicable to both foundational and advanced counseling coursework.

Instructor Resources

Theories Overview Handout With Disability Critique (Appendix C)

Multicultural considerations are included in most counseling theory overviews, yet disability is rarely addressed. Adapting and understanding how one’s theory of orientation can support clients with disabilities is vital for all counselors and therapists to engage in equitable and ethical practice (ACA, 2014). Instructors may consider briefly addressing how a theory can be applied to disability specifically when teaching counseling theories to practitioners in training. This can be done by exploring each theory’s strengths from a disability perspective, discussing developmental considerations for specific techniques, and describing strengths-based approaches.

Case Conceptualization Template and Rationale (Appendix B)

The Case Conceptualization Template trains students to develop an in-depth understanding of their theory and apply theoretical constructs in developing an understanding of their client grounded in theory. Students will complete a five-step case conceptualization using one counseling theory, with specific considerations of adjustment to disability concerns: Description of Theory → Behavioral Observations and Theoretical Constructs → Clinical Inferences → Clinical Decision Making → Treatment Plan. Encouraging students to apply counseling theory in understanding client problems, while incorporating themes related to disability adjustment and disability experience can deepen their understanding of and intentionality in serving persons with disability.

Transcript Analysis Form for Counseling Skills (Appendix D)

The “Skills and Competencies” section of transcript analysis assignments have not traditionally included skills and competencies specific to working with clients with disabilities. The Disability-Related Counseling Competencies is a resource that was developed and approved by the American Rehabilitation Counseling Association and the American Counseling Association to provide direction to counselors in relation to providing clinical services to persons with disabilities (Chapin et al., 2018). Instructors may consider guiding students to identify a disability-related counseling competency addressed by a specific counseling skill. For example, in the “Skills and Competencies” section of a transcript analysis assignment a student might include: “A.3 Demonstrate comfort and respectful behavior in interacting with PWDs, by knowing how to: be authentic, use common courtesies, and not pity or patronize” (Chapin et al., 2018, p. 2).

Conclusion

Section E, Counseling Practices and Relationships, of the CACREP (2024) standards includes components related to therapeutic relationships, the incorporation of theory into practice, counseling skills, and evidence-based practices, among others. However, counseling theories, counseling skills, evidence-based practices, and even multicultural considerations have historically overlooked persons with disabilities. Counselors in the field, counseling faculty, and counseling students have indicated feeling unprepared to effectively serve persons with disabilities or include disability in course content. To effectively integrate disability content into coursework covering material from Section E of the CACREP Standards, instructors should consider the historically marginalized status of persons with disabilities and construct learning opportunities that highlight disability experience, while providing students with specific skills needed for case conceptualizing, applying counseling theory, and developing healing, egalitarian relationships with persons with disabilities.