Chapter 3 Self-Direction, Empowerment and Informed Choice: Implications for the Practice of Rehabilitation Counseling Overview For the rehabilitation counselor practicing in the public vocational rehabilitation (VR) program, the issue of enabling and ensuring consumer choice is a critical one. Focus on consumer participation and decision-making in the consumer-counselor relationship is the key to defining choice and fostering empowerment (Rehab Brief, 1994). The counselor not only has the responsibility of turning over the control of the consumer’s rehabilitation plan to the consumer, but also that of assessing the consumer’s needs and desires with respect to readiness and capacity to self-direct. The charge is to enable the consumer, through the provision of counseling and other services, resources and supports, to develop the readiness and capacity for choice and self-direction. At the same time, the potential for conflict exists. The counselor functions within a complex bureaucratic system and has the responsibility of providing responsible and ethical clinical and case management services. While typically these responsibilities are not in conflict with consumer empowerment, there may be occasions when, in the counselor’s professional opinion, the consumer’s choices depart from what may be indicated analytically, resulting in a professional, administrative and possibly ethical dilemma. Therefore, while fully agreeing with the value and importance of choice and self-direction, the counselor may find him or herself in a complicated and precarious position. The public VR program’s consumer base has changed. Individuals without significant disabilities can frequently receive effective services from a variety of sources: the one-stop system, private rehabilitation service or insurance companies. The public VR program is frequently the last resort for many individuals. People do not come to the door of the VR program from a position of power. Many are frightened and are dealing with multiple and complex issues that may require extensive support. Being empowered is not the first thing on the minds of many individuals. The focus of this chapter is on the specific charge of the VR counselor in the public VR program to promote empowerment for the rehabilitation service consumer. The IRI Primary Study Group (PSG) will present an overview of the need from the rehabilitation counseling perspective, a review of the roles and functions of the rehabilitation counselor, a discussion of the potential barriers to empowerment from the counseling perspective, providing a discussion of a consumer-directed model of rehabilitation counseling that promotes consumer choice and direction of the VR process. The PSG will provide a discussion of specific rehabilitation counseling actions and strategies that enhance and enable choice. Being a good VR counselor does not automatically mean you empower the individuals on your caseload. Empowerment does not naturally flow out of good counseling skills. It requires great skill on the counselor’s part to create a relationship where empowerment can develop. It demands that counselors always analyze how to use their abilities to help consumers successfully take control. But what if individuals being served are not interested in being empowered and would prefer to be directed? Haven’t many consumers learned how to be “good clients,” intuitively knowing that good clients frequently get more? What if they have limited cognitive ability to understand the consequences of the decisions they make? What does the counselor do then? These situations represent a portion of every caseload in the country. They represent predicaments counselors face every day. The delivery of rehabilitation services through the public VR program is a highly individualized process. While regulations exist at Federal, State and local levels, the professional VR counselor is the conduit by which services are provided to rehabilitation consumers. It is largely the relationship between the consumer and counselor that will determine whether the consumer’s experience with the public VR agency meets his or her needs. Moreover, there is tremendous diversity among the cultures, values, interests and abilities of individuals seeking services, the disabilities and the impact of these disabilities, supports and resources available. The intercorrelations among these important factors demand that each interaction between rehabilitation consumer and counselor be unique, and present both opportunity and challenge for both parties. The IRI PSG believes that the essence of empowerment takes place at the level of the consumer-counselor relationship, where the unique roles of the two individuals are defined not by power or title, but by areas of expertise and experience. The counselor is experienced in rehabilitation services and delivery, and the consumer, experienced and invested in the pursuit of his or her unique interests and dreams as well as his or her service needs and how those needs should be met. Furthermore, the PSG sees empowerment as inherent in every individual, and seeks to assure that this attribute is maximized through the VR experience. Empowerment therefore is not something that counselors “do” to a consumer. It is an overriding principle or context by which the relationship between consumer and counselor is defined. Accountability for empowerment resides jointly with the counselor and consumer. Finally, the PSG wishes to recognize and acknowledge that counselors often face the realities of large caseloads, fiscal constraints and administrative or system requirements. The strategies recommended in this chapter reflect the authors’ findings with respect to counselor actions that, based upon an extensive review of the issues, we believe optimally promote empowerment. We recognize the possibility exists that for some counselors, in some situations, constraints may preclude optimal empowerment-oriented action. Nonetheless, we strongly encourage counselors to be ever mindful of the value of and need for empowerment, and to seek out the flexibility and resources necessary to effectively promote empowerment through each and every interaction with the VR consumer. Role and Functions of the Rehabilitation Counselor The role and functions of the professional rehabilitation counselor have been debated over the years. Most current thinking reflects a multifaceted role where the VR counselor is a skilled professional with clinical counseling skills and case management skills who coordinates the efforts of a multidisciplinary program designed to meet the needs of persons with severe disabilities (Rubin & Roessler, 2001). The Commission on Rehabilitation Counselor Certification (2001) scope of practice statement defines rehabilitation counseling as a systematic process that assists persons with physical, mental, developmental, cognitive and emotional disabilities to achieve their personal, career and independent living goals in the most integrated setting possible, through the application of the counseling process. The counseling process involves communication, goal setting and beneficial growth or change through self-advocacy, psychological, vocational, social and behavioral interventions. Unfortunately, the scope of practice statement does not emphasize, nor does it reflect, techniques for promoting self-direction and choice among the recipients of VR counseling services. Much of the recent study of the role and functions of the rehabilitation counselor has focused on defining competencies, responding to demand for specialization (either in disability-specific areas or in skill areas), and sensitivity to cultural differences that might impact the counseling and VR process. Unfortunately, little has been written about the specific competencies that lead to empowerment and self-direction for the rehabilitation consumer. Schaller & De La Garza (1999) stress developing a counseling relationship with consumers that will encourage increased consumer participation in the VR process. Roessler and Rubin (1998) see involving the client in the problem solving relevant to independent living and vocational planning. They view VR counseling as action-oriented and goal-directed, focusing upon making vocational choices and determining avenues for achieving goals as important. They stipulate that the rehabilitation counselor represents the key person in the VR process and that it is the rehabilitation counselor’s responsibility to involve the consumer in the planning process (Rubin & Roessler, 2001). Given the challenge of empowering rehabilitation consumers to direct the rehabilitation process, continued refinement of the roles and functions of the rehabilitation counselor would seem to be a critical need for the profession of rehabilitation counseling. There must be continuing emphasis on increased consumer participation and involvement in all rehabilitation programs at all levels of operation (Seelman & Sweeney, 1995). Rehabilitation Counseling within a Consumer-Directed Model of Empowerment Many attempts have been made to define empowerment and choice as they relate to the public VR program. Fawcett, et al, (1994) defined it as the process of gaining some control over events, outcomes and resources of importance to an individual. Gutierrez (1990) viewed empowerment as the process of increasing interpersonal power so that individuals can take action to improve their life situations. Ozer & Bandura (1990) posed that empowerment is self-efficacy, which is defined in terms of one’s ability to perform particular tasks and gain control over a situation. In order to identify an approach to VR counseling that promotes consumer direction and control, counselors are required to make a conceptual shift from an orientation that emphasizes the role of the professional as the decision maker to an approach that insures that the authority and power lie with the consumer. Kosciulek (1999) proposes a consumer-directed theory of empowerment as a model for guiding the development and evaluation of VR services. He defines consumer-direction as a philosophy and orientation whereby informed consumers have control over the policies and practices that directly affect their lives. As an underlying assumption of this theory, Kosciulek posed that consumer directed rehabilitation programming is based on the presumption that consumers with disabilities are the experts on their service needs, how those needs are met, and the effectiveness of services addressing these needs. For consumers who enter the public VR program with clearly defined goals and an understanding of their service needs for attaining these goals, the role of the rehabilitation counselor is clear. The counselor draws upon a fund of knowledge, resources awareness and counseling skills to facilitate the consumer’s plan (Bishop, 1999). It is when the consumer, for any number of possible reasons, is unclear about goals, needs or resources and/or is unable to self-direct that the counselor must implement a different approach. In addition to resulting in a successful employment outcome and, even more important, in a consumer-directed model, this approach should provide the encouragement, services and supports that will result in empowering the consumer through enhanced knowledge and skills to be self-directed. The Role of the Rehabilitation Counselor in Addressing Empowerment Individuals seeking services from the public VR program encounter barriers that may interfere with empowerment and may ultimately result in an inability or limited ability to exercise informed choice in planning and directing their own programs of rehabilitation. These barriers are varied and may impact the consumer of VR services through such factors as limited knowledge, skill and resources; through the attitudes of professionals and other individuals with whom they live, learn and work; and through disability-specific and psychological factors they encounter. Not every individual with a disability encounters barriers of the same type and magnitude. Each individual and his or her situation differ. The PSG believes that an understanding of the possible roadblocks to empowerment encountered by consumers is critical to enable the counselor to ensure empowerment in the rehabilitation process. A more detailed description of potential obstacles has been included in Chapter 1 of this document. In providing services to the consumer, including those enabling the consumer to make choices and direct the program of rehabilitation, the VR counselor needs to assess the degree to which the consumer is empowered and/or the consumer’s interest in and capacity to become empowered. This can be done through the counseling relationship and facilitated through the use of surveys or questionnaires developed to assess empowerment in VR consumers. Examples include the Personal Opinions Questionnaire (Bolton & Brookings, 1996) or the Making Decisions Scale (Sciarappa & Rogers, 1991). Barriers that might interfere need to be identified for each individual, and the necessary services and supports should be provided as part of the consumer’s Individualized Plan for Employment (IPE) to assist the consumer in reaching the goal of empowerment. This goal should be viewed with the same level of importance as attaining an employment outcome, to assure not only that empowerment is a part of VR service delivery, but that, ultimately, empowerment is an outcome of the consumer’s experience with the public VR program. Practical Actions and Suggestions for Counselors to Promote Choice The remainder of this chapter will focus upon the strategies and recommendations for the practice of consumer-directed rehabilitation counseling. The VR system has traditionally placed power and control in the hands of the professional rehabilitation counselor. Prior to the emphasis on empowerment and consumer control, professionals tended to have the final say in the decisions that we now recognize could and should be the decision of the consumer. To empower consumers, VR counselors should use the counseling and guidance relationship to clearly define the parameters of the process from the start and help consumers map out how they will take control at each step in the process. This involves rather complex dialogue with consumers, if necessary, helping them to understand how to direct their rehabilitation. Part of this process is helping consumers think about who else they would like to have involved, what that involvement would look like and how to ask for it. It could be as simple as helping consumers develop questions to ask themselves and a variety of people in their life. The following are sample questions that might be useful: What type of support will help me succeed? What type of work environment am I most suited for? What do I view as my strengths, skills and talent? What am I willing to do towards my plan? Where do I want to be a year from now? What accomplishment am I most proud of? What concerns and issues do I have about working? What are the things I need to think about before taking a job? What information about me should be shared with an employer or service provider, and what shouldn’t? The following are recommended counselor actions that enhance consumer choice and self-direction through the VR counseling process. These recommendations are organized to correspond with the timeline of the VR process (e.g., referral – assessment – eligibility – planning – service delivery – placement – follow-up); however, we realize that the actions promoting empowerment extend from the initial contact with the consumer through follow-up. Assure that consumers have real choices and are in control of decisions in all phases of their rehabilitation. The VR counselor should strive to be an advisor, consultant and mentor. To accomplish this requires a shift of power from “the system” and counselor to the consumer. It is critical that the counselor understand the consumer perspective. The counselor and consumer need to discuss and mutually agree upon the amount of control, responsibility and risk the consumer is willing and able to accept. Each of these factors, from the consumer’s perspective, brings an array of choices and decisions. Furthermore, empowerment is a maturation process that occurs over time. Counselors go through a maturation process of learning how to assist consumers to take control, as well as learning to provide the necessary support without falling into a directive role. Many consumers may feel safer when the counselor takes the control. Because of past experiences, consumers may be more accustomed to working with professionals who automatically assume control in the counseling relationship, at least initially, until their comfort level with their surroundings and demands increase. Unfortunately, some professionals may be unwilling or unprepared to relinquish control. It is a delicate balancing act to provide the appropriate amount of counseling, support, information and direction without overwhelming the consumer or taking control. This is particularly difficult when the counselor is faced with high caseloads or inflexible system or administrative requirements. The counselor must believe that consumers desire and value empowerment, and that they want the control and will ultimately take the responsibility. Moreover, if the consumer has not assumed control, it is the VR counselor’s job to assist him/her in determining how to go about the process of accepting control and responsibility. Address administrative constraints to empowerment. When VR counselors focus on empowering individuals seeking employment, they must find a way to shift the emphasis from meeting the needs/requirements of the VR agency to those of the individual who is seeking employment. Counselors participate in changing service delivery in a manner that will emphasize empowerment and support the individual’s efforts to take a lead role in decision-making related to his or her VR programming. While the essence of this shift occurs in the counselor-consumer relationship, it must be supported by the VR supervisor and administrator to assure that the “system” complements and supports the self-direction goal of the consumer-counselor partnership. Specific recommendations to address system based barriers to choice and self-direction are found in other sections of this IRI document. Define roles, responsibilities and expectations explicitly. Again, empowerment requires a partnership between the VR counselor and the consumer. The counselor’s role is to provide guidance and facilitate the VR process with knowledge of the rehabilitation system, an understanding of empowerment, information regarding resources and current labor market trends. While the counselor ultimately approves the IPE, making decisions is the responsibility of the consumer. Following are some important tips for counselors to build an empowering relationship: • Define your role as a consultant/mentor and the consumer’s role as director. • Take whatever time is necessary to define the responsibilities associated with each partner’s role. • Discuss the expectations that the consumer has of the partnership. • Discuss your own expectations of the partnership. • Explain and encourage the individual’s rights as a consumer of VR services, including the right (and responsibility) of choice. • State your expertise and experience clearly and honestly, and explain how this expertise might be used by the consumer in the pursuit of his or her goals. • Give examples of how you and the consumer might work effectively together. • Negotiate responsibilities and expectations. • Recognize that your opinions, biases and prior experiences as a counselor may not be shared by the consumer. • Respect the opinions, values and experiences of the consumer. Understand your feelings about consumer control and self-direction. Attitudes that may stem from biases that VR consumers are either ill equipped or unable to make decisions for themselves can also be a formidable barrier. The powerlessness and lack of self-direction felt by people with disabilities are more frequently related to the attitudes and practices of caregivers, service providers, funding agencies, social institutions and society in general, rather than to any limitations or impairments resulting from the disability itself (Parent, 1993). Even professionals who believe they are working in the best interest of the consumer may be impeding personal choice and empowerment. Szymanski & Trueba (1994) postulated that difficulties faced by persons with disabilities are not the result of functional impairments related to disability but rather are the result of “castification” processes embedded in social institutions (medical model) and reinforced by well meaning professionals. An assessment of attitude (counselor, consumer, consumer representative) and its impact must take place, and remedies applied if issues arise that negatively impact a person exercising choice. Care must be taken to assure that VR counselors not make decisions for the client based on their own perceptions or prejudices about what consumers can or cannot achieve. For example, a counselor’s perception that a consumer could not achieve a particular vocational objective might preclude the necessary assessments to adequately evaluate the individual’s actual functional level. Such biases may deprive the individual of available opportunities and a realistic assessment of a level of functioning that might be improved with training, accommodations, assistive technology or other types of supports/learning. The consumer’s VR plan and final outcome must address the individual’s interests and choice of employment, not the counselor’s limitations. Since attitude is such an important factor in empowerment and choice, self-evaluation of attitude by the counselor is very important. The counselor should examine his or her own thoughts, experiences and feelings about placing the consumer in control. The counselor should address any concerns he or she may have about empowering the consumer and the conceptual shift from professional expert (in control) to consultant who facilitates control by the consumer. VR counselors must be willing to challenge their preconceived notions and expand their professional expertise. If issues arise through counselor self-exploration activities, these should be addressed through supervision or other interventions or remedies to insure that the counselor’s attitude does not interfere with consumer choice and direction. One action that may be beneficial in addressing biases that might conflict with empowerment of VR consumers is to participate in experiences and develop relationships with individuals with disabilities that are outside the context of the VR relationship. Participation with individuals with disabilities in everyday activities such as recreation or community action neutralizes the power differential and promotes a more accurate understanding of disability and disability culture, thereby providing the counselor with a more realistic perspective on the experience of disability and the value and importance of empowerment for consumers. Address disability related obstacles to empowerment. In some cases, manifestations of or impairments associated with a disability may present a challenge to empowerment. For example, cognitive abilities such as comprehending, organizing and retaining new information, making an appraisal of one’s own competencies, and making vocational choices are considered important and sometimes requisite abilities for empowerment. Likewise, the motivation and energy that are required to take charge over one’s life and rehabilitation may be taxed by some conditions that negatively influence capacity to experience enthusiasm and interest. Other disabilities may negatively impact communications skills or the capacity to make judgments. While individuals with such functional limitations are entitled to empowerment, different strategies may be necessary to promote it. The use of accommodations, assistive technology and supports, more extended periods of service, and involvement of advocates or significant others may be necessary to enable the consumer to be empowered, and therefore need to be a part of the VR program for these persons. For specific suggestions to support individuals with cognitive disabilities in implementing informed choice, see Appendix C, Rehabilitation Services Administration (RSA) Technical Assistance Circular (TAC) 98-01. Provide accurate information in a format that consumers can use. Knowledge of the world around the individual is also important to self-determination and self-direction of a rehabilitation plan. Knowledge of possible options (work, education, independent living, social), available resources and services, laws and funding possibilities are all examples of critical knowledge areas for self-direction in rehabilitation. Individuals must also acquire knowledge of their rights, as well as of the intricate systems they must navigate to obtain necessary services for success. Consumers are much more likely to make decisions that make sense for their lives if they receive information and amass knowledge in a format conducive to their optimal learning style, requiring that the counselor develop an appreciation for how the consumer processes information. Developing an awareness of the consumer’s information processing needs and preferences, and providing the necessary accommodations and supports, while potentially demanding in terms of counselor time and resources, will enable the consumer to be more effectively involved in a reciprocal communication with the counselor. Knowing how consumers process information (understand, analyze and retain) allows counselors to assist the consumer to identify what type and source of information would be most useful to them and reinforces the value and confidence of knowledge about disability, the demands of the world of work, and rehabilitation resources that will lay the foundation for their decisions. In addition to modifying the format, pace and modality of information processing, it may be necessary to provide assistance in structuring and organizing information and planning. Again, RSA-TAC-98-01 (Appendix C) provides guidance and examples to assist VR counselors. Accommodations and supports to address communication of complex information and concepts may be required. Furthermore, the consumer must develop a trust for the veracity of the information provided by the counselor. This trust should develop over time in the counseling relationship. Credibility is established through establishing a relationship with the consumer, not simply through professing an established expertise on a subject. Based upon their experience, counselors may develop and inadvertently convey a professional bias when they provide information about and recommendations for rehabilitation services. Counselors need to acknowledge that they may have biases, and should communicate these to the consumer to enable them to make informed decisions. In many counseling relationships, the consumer may view the VR counselor as a superior in the relationship, and that any information or opinion that they offer may be taken to be the best way to approach a given situation or decision. It is important for the VR counselor to distinguish between the following two aspects of informed choice: providing information and offering opinions. While it is generally assumed that information relates to a body of knowledge or facts associated with an issue and that opinion reflects personal bias, even information may reflect somewhat the rules and traditional responses of the VR program providing services. Thus, the counselor should acknowledge the importance of these considerations in assisting the consumer to make an informed choice. Good advice should be individualized to the consumer’s specific circumstances so that it can be understood and utilized. (See Appendix D, RSA Information Memorandum (IM) 98-03, Advice, Information and Choice.) As professionals, counselors learn that there are practices, procedures, interventions, technologies, etc. that are indicated to address problem areas. We gain this knowledge through experience, research and training. It is important to share the rationale for why a particular practice or intervention is indicated (why it works, why it is indicated, past experiences, advantages and disadvantages) with the consumer. As consultants/experts who are interested in teaching sound consumerism to individuals receiving our services, we should not expect blind faith in the counselor’s recommendations. In addition to ensuring a more informed choice, sharing such knowledge increases the consumer’s base of knowledge and increases motivation to participate in the chosen services. Furthermore, counselors should encourage consumers to obtain information from a wide variety of sources (in addition to the counselor) prior to making a decision. This could include developing a mechanism for providing feedback from other consumers who have previously used the services or resources. The counselor should also offer to assist the consumer in evaluating the pros and cons of information and recommendations. The more the counselor becomes a facilitator in the consumer acquiring reliable knowledge, relevant information and experience, the more empowered the consumer is likely to become. A comprehensive resource on informed choice is available at http://www.rcep7.org/conarch/choice/choice2k.htm This website includes all materials to support choice issued by RSA, final reports from “Choice Projects,” proceedings from the “Choice” national conference and other information that supports empowerment. Consumers may expect VR counselors to identify problems and provide solutions, along with an explanation of the benefits of those solutions. Counselors are trained to be problem solvers and are accustomed to that role. In empowering and enabling self-direction, however, that role changes. Through the established relationship with the consumer, the counselor provides information the consumer has identified as important, and then, if indicated, assists the consumer in analyzing and choosing from an array of solutions. Sometimes when the consumer determines what information would be useful, the solutions that derive are not always as efficient or straightforward as the counselor might chose. However, because it is the consumer’s plan and solution (choice), he or she is more committed to and focused on strengths and invested in effectively attaining the identified outcome of the plan. In this way, empowerment oriented VR counseling promotes and reinforces motivation and sustained effort. Assist in assessing and identifying the skills required for empowerment. In order to effectively direct one’s own rehabilitation, a number of skills and competencies would appear to be important, if not essential. These might include effective written and spoken communication skills, assertion and self-advocacy skills, organizational skills, and planning and problem solving abilities. Other skills and competencies include listening and learning skills, negotiation ability, self and system evaluation and monitoring skills. Such skills may not be inherent in the individual but can be developed through training and supports. Training and supports might be provided through the counseling relationship. In some cases, referrals to community-based programs, such as community colleges or rehabilitation providers, might be the best approach. Mentors can also help consumers build new important skills. In order to truly promote consumer empowerment, public VR counselors and agencies may have to develop new resources to address the need for consumers to learn and develop these critical planning and decision making skills. Prepare the consumer for the needs of the VR system. The empowering counselor shares knowledge with the consumer that facilitates effective and efficient access to the VR system. Information regarding eligibility, timing, system parameters and requirements, financial need requirements, services and outcomes should be shared in an open and forthcoming fashion. For example, the counselor might begin by informing the consumer what background information is needed to aid in establishing eligibility and why the information is important and relevant to VR. The counselor might suggest that the individual communicate with medical providers and other professionals she/he has worked with and sign necessary forms in order to obtain information needed for eligibility to bring to the intake interview. In situations where the provider doesn’t feel comfortable releasing information to the individual, the consumer can request that it be sent directly to the VR counselor. This encourages an active “lead role” for consumers. One strategy is to make changes in the way the initial or intake interview is conducted. The individual seeking employment arrives for the interview and either brings needed information or informs the counselor that arrangements have been made to have it sent. During the initial meeting, the counselor might focus on relaying information and asking questions that will not only deal with agency’s requirements and expectations, but also questions that will extend an invitation to the individual to take a lead role in his/her rehabilitation program. The counselor’s assessment might also focus on such areas as the individual’s knowledge of his/her disability, limitations, and what the consumer’s perceived needs are for addressing the impact of the disability. The counselor should discuss expectations, responsibilities and attempt to get an idea of the level of responsibility or role that the individual wishes to assume. It is important that counselors acknowledge that not all individuals seeking employment, their family members, etc. have the same level of awareness, skills and desire for empowerment. In some cases the counselor may discover that the individual knows little about his/her disability and relies on others to make necessary decisions. When encountering such situations, the counselor must develop strategies to assist individuals to move beyond this “learned helplessness” and acquire knowledge and skills that will enable them to move in a direction that both encourages and supports empowerment. The counselor and the individual must discuss what will need to be done and agree on who will be responsible for specific action steps. The counselor might use the initial meeting to assess the individual’s ability to take a lead role in programming. Allow the individual to give her/his assessment of the situation and explain what service she/he is expecting from VR. The second half of the meeting might be used to review information the consumer brought in and sign releases of information so that the counselor can request information that is still needed. A second meeting would be held after the counselor has received needed information and has made an eligibility decision. If the individual is eligible to receive services, the latter part of the second meeting might be used to initiate planning. This would include identifying interests, disability issues and assessing the individual’s understanding of these areas. More information will be revealed about the consumer’s ability and willingness to take a lead role, through the counseling relationship. In this approach, the counselor has changed the approach to service delivery, with the emphasis shifted from focusing on the agency’s requirements to empowering the individual seeking employment and encouraging consumer direction. State an explicit goal of empowerment. It is necessary to establish a mutual agreement between consumer and counselor that one of the expected outcomes of involvement with the public VR agency, in addition to employment, is empowerment. Both parties should agree that the consumer becomes fully self-directed, or at least chooses their own level of self-direction as a goal of the interaction. This goal should be stated and discussed at the outset of service delivery. This practice reinforces the knowledge that services, supports, time and energy will be devoted to the goal of enabling the consumer to be as self-sufficient as possible in decision making, planning and carrying out the rehabilitation program. Utilize the IPE as an empowerment tool. Planning is crucial to empowerment. Within the VR program, the tool for planning is the IPE. This tool enables the consumer and counselor to mutually identify and agree upon a vocational goal, required services, intermediate goals or benchmarks, timelines and responsibilities of involved parties. The mechanism is the counseling and negotiation process that takes place between the consumer and counselor. The pre-planning that takes place prior to establishing the IPE is a valuable means to assess and promote empowerment with the consumer. Orientation to the IPE process from very early in the VR involvement can be a way to stimulate consumer planning, decision making and assuming control. Sharing the IPE requirements and forms with the consumer early in the VR process with the consumer can promote development of a “working plan” that would ultimately evolve into the IPE. Seeing the work between consumer and counselor in the counseling relationship as “pre-planning” can be very conducive to achieving the goals of empowerment. Eliminate or reduce disempowering vocabulary and language. The use of stigmatizing labels, controlling language and professional jargon interfere with the goal of empowerment. Use common, straightforward language when speaking with consumers. Try to avoid or eliminate negative vocabulary such as “non-feasible,” “unrealistic,” “can’t” and “no” from the dialogue with consumers. Use positive, proactive language. Never say never. For example, an assessment should be useful to the consumer and should lead to the development of IPE objectives to attain an employment outcome. The consumer should be offered a copy of the counselor’s assessment. This assessment should be written clearly, using functional terms, in a manner that makes sense to the consumer. The use of jargon and acronyms may interfere with a consumer’s understanding of their interests, aptitudes, skills and supports, and will therefore limit their input when developing the IPE. Assure access to relevant, accessible and empowerment-oriented resources. Rehabilitation resources including the services of a qualified VR counselor, adequate funding for services, accommodations and modifications for disability (including assistive technology), transportation and a support network are examples of what may be necessary to promote empowerment in rehabilitation. Making sure that consumers have access to vocational training, mentors and jobs is critical. Achieving success in addressing severe disability often hinges on finding the necessary resources in a baffling and overburdened system. From an empowerment philosophy, one of the key roles of the counselor is in resource development. The identified needs of a consumer may not reflect a traditional service typically used by VR. The counselor should utilize his or her skills and knowledge of the service delivery system to identify or stimulate the development of effective resources identified as needs by the consumer. In this regard, the counselor should remain open to alternative, non-traditional and creative goals, options, intervention approaches and plans. While a counselor possesses a significant level of expertise and experience, that expertise and experience may not extend to all possible courses of action for a consumer. A consumer may identify nontraditional goals or resources that may be unfamiliar to the counselor. These choices should be explored. Obviously, caution should be taken to obtain information on the validity of procedures or the viability of nontraditional goals, but such options should not be ruled out simply because the counselor or the agency has no previous experience with them. Encourage and facilitate an ongoing evaluation of the counseling relationship. Since we expect that the value of the counseling relationship lies in a partnership between counselor and consumer, it is important to recognize that this partnership is subject to potential obstacles and barriers. The mutual effort should be regularly monitored jointly by the parties involved to make sure that it continues to meet the expectations and needs of both parties and continues to be effective in accomplishing employment and empowerment goals. Examine with the consumer the process and outcomes of the relationship and be prepared to address areas in need of change. Developing benchmarks or short-term goals as part of the IPE is one way of planning for ongoing assessment of progress. The IPE benchmarks allow consumer and counselor to make periodic evaluations of progress a part of the counseling and planning relationship. Obviously, the counselor and consumer have to commit to making the changes that the ongoing evaluation identifies as needed. The reader is referred to Appendix B for vignettes illustrating alternatives in building an empowering counselor-consumer relationship. Demystify clinical and diagnostic processes. A great deal of effort and importance is placed on the clinical processes surrounding VR. Assessment approaches including intake interviews, obtaining background medical, educational, vocational and psychological information, conducting psychological and neuropsychological evaluation, vocational evaluations and specialty medical examinations are commonplace. Unfortunately, the consumer is too often a passive recipient of these services, has little input beforehand, and receives little useful information (in a manner that he or she can appreciate) afterward. Section 102(d)(2) of the Rehab Act requires that consumers be made active participants in the assessment process. Counselors should share information very pragmatically about what assessment information is necessary, why, and what options are available to obtain this information. For example, if an evaluation such as psychological testing is required, the consumer should be provided the rationale for the need, given choices about how this need would be met, and should be involved in making the decision. Prior to sending an individual to a specialist such as a psychologist for an assessment, involve the consumer in formulating the specific questions that will be posed to the psychologist to address in the assessment. This form of pre-planning facilitates increased control over the assessment process, enhances self-knowledge and increases consumer motivation because the assessment becomes more relevant and meaningful to the specific interests and needs of the individual. Following the assessment, provisions should be made to explain in practical, understandable fashion the results of the assessment and the implications for the consumer’s subsequent planning and decision making. At times, the traditional assessment process may not take into consideration the goals, values, environment and culture of the consumer. The extent to which assessment addresses such issues may have a significant bearing on the degree to which it is meaningful and useful to the consumer. The process of assessment and diagnosis is concrete, rule-based and straightforward. However, in the eyes of the consumer, assessment and diagnosis can take on a mysterious quality, with diagnosis occurring following some unknown, unfamiliar process. In order to promote empowerment of the consumer, the counselor should strive to demystify the process of assessment and diagnosis. Providing concrete information about the purpose and process involved would enable the consumer to better understand the impact of his or her disability. Sharing such “professional” information and resources as the Diagnostic and Statistical Manual (DSM) will assist in enhanced consumerism. The VR counselor must provide opportunities for the consumer to exercise informed choice in decisions related to the provision of assessment services (Rehab Act, Section 102 (d)(2)). Recognize and deal with anxiety, fear of failure and learned helplessness. An individual with a disability may be protected from the opportunity to take risks, and possibly to fail, by well meaning professionals or caregivers. Taking risks and sometimes failing provides valuable knowledge of self and the world around the individual. However, an individual may be fearful of taking on responsibilities due to anxiety about the outcome. Support, reassurance and encouragement are essential components of the counseling process that reduce anxiety and fear and enable, even encourage, consumers to take risks, recover and learn from mistakes and move toward their chosen goals and dreams. Simply offering choices to an individual who is anxious about making decisions or fearful of making a mistake is not effective in enabling and promoting empowerment. It is important to recognize through the counseling relationship how fear and anxiety may manifest and how these factors might limit the individual’s capacity or willingness to choose and self-direct. Addressing the individual’s concerns through counseling techniques such as relaxation, rational restructuring, or through a series of desensitizing experiences may be beneficial. The situation may also require that the individual take his or her time to come to a decision or take an action, or to break up an action into smaller, less threatening steps. Teach and promote sound consumerism. Persons with disabilities need to be informed consumers of services and effective self-advocates. The skills of consumerism and advocacy need to be incorporated into the repertoire of an effective, self-directed recipient of VR services. The counselor may assist the individual in developing problem solving and decision making skills such as those needed to identify and weigh various choices, examine questionable or experimental alternative interventions and self-advocate for needed resources or services. Community and advocacy agencies and organizations such as centers for independent living can serve as resources for individuals with disabilities in developing strong consumer skills. Assess and address the “impact” of disability. Rather than focusing on the diagnosis of a disability or the “symptoms” that may accompany a disability, the counselor should attend to the impact that the disability has on the consumer’s pursuit of goals. This “functional” orientation places the emphasis of services and intervention not on the “damaged” or “deviant” aspects of the individual, but rather on obstacles that stand in the way of goal pursuit. In order to do this, the counselor and consumer identify how the individual’s strengths and weaknesses interact with the demands of the goal and the environment in which he or she has chosen to function. The intervention target then becomes one of ameliorating obstacles that exist outside of and apart from the individual, rather than changing the individual. Consider environmental modifications, accommodations and assistive technology services. Applying interventions that are designed to “correct” the problem, fix or change the individual are obviously not the only approach to addressing obstacles to goal attainment. Approaches targeted to the environment may be more appropriate strategies for addressing obstacles to employment, and these may also be preferred by the consumer. Such interventions promote adoption of disability as a natural phenomenon, inviting attitudinal changes and universal design concepts, as opposed to a medical model orientation that views the deficit as inherent in the individual. Moreover, the use of environmental modifications, accommodations and particularly, assistive technology, has been demonstrated as more effective in addressing the impact of disability. Facilitate peer modeling and mentoring. Peer support is a useful tool in helping consumers obtain and process information. Information that is difficult to hear or process with a professional sometimes becomes easier when spoken from a peer that has experienced a similar situation. Peer support groups can be an extremely effective approach for consumers who are stuck in the rehabilitation planning phase and who seem unable to make a decision. Important elements that peer support groups can provide in empowering consumers are the strength of group dynamics; hearing information from peers; supports for isolated consumers; the opportunity to establish relationships and obtain support; and being in a safe place to express fears and disappointments. Identify natural supports. While each individual’s situation presents unique circumstances and resource possibilities, naturally occurring supports in the community may be more effective, less costly and more likely to promote independence and foster empowerment. Examples of natural supports that might be sought by the individual include resources such as family supports, co-worker supports, use of community resources that are not disability-specific (e.g., YMCA) and the use of volunteers. Individuals should manage their own support services. That means they may require additional training or supports to develop the skills necessary to accomplish this. Model empowered behavior and skills. Modeling can be a very effective tool for the development of self-esteem, independent decision-making and empowerment in the VR process. The stance the counselor chooses to take will directly impact the consumer’s ultimate level of self-direction. In other words, the counselor needs to be aware of how his or her approach to counseling and guidance can either facilitate empowerment or discourage the person from being in control. Consumer control does not mean that the counselor’s expertise is not fully required or utilized. In fact, it requires unique skill on the part of the counselor to structure the process so it is individualized to each consumer and tailored so that information and support are offered in a manner that facilitates choice and self-direction. In order to do this, counselors need to understand the assumptions they hold about VR and the individuals it serves. It is easy to promote choice with someone who has the ability and desire. It becomes more difficult when it is someone who presents greater challenges. In these instances, there is a tendency for the counselor to take control rather than facilitate consumer control. While this may be well intended, it ultimately does not serve the consumer. Assist the consumer to process their experiences over time to gain self-awareness. Use homework activities and exploration as a laboratory for self learning. No one is empowered overnight. Individuals may need time to adjust to expectations, process information and make decisions. Consumers must make their individual decisions based on the information provided not only by their counselors but with the supports, influence and input of other important members of their network of family, neighbors, friends, employers, social workers, and counselors, etc. Assist the consumer in structuring those activities that are most likely to result in an individual gaining information, self-knowledge and confidence. Enable by encouraging, modeling and supporting consumer involvement in rehabilitation and daily living activities “Doing with” is a more effective strategy for promoting self-direction than “doing for,” even though the latter may be more efficient in the short run. Disagreement or conflict is likely to occur from time to time between the counselor’s recommendations and the consumer’s decisions. In these instances, the counselor should allow the consumer to test out his/her plan and benefit from the exploration and self-discovery that occur with action and experience. Through counseling, the counselor can facilitate optimal understanding of experiences in terms of self-awareness and future planning. Advocate for consumer self-direction with others involved with the consumer, including vendors and other providers of services. VR counselors may need to facilitate empowerment through advocacy efforts with family members, employers and other helping or medical professionals. Advocacy in education and training environments may also be required. Expect that vendors or service providers who contract with VR extend the same emphasis on empowerment as the public VR agency. It may be necessary to train and/or give feedback to providers and vendors around empowerment. Raise expectations. The individual with a disability should be encouraged to reach for the optimal outcome from the VR process. Too often, individuals are limited in their choices by the very fact that they have a disability, by the type of functional limitations they experience, and by the services and supports that are traditionally identified and offered for individuals with similar disabilities. Care should be taken not to place limits or boundaries on goals for the individual. Rather, the counselor should stimulate higher self-expectations for the consumers they serve. Raising expectations, rather than assuming more traditional choices or options, increases the success of consumers served by the VR program, and ultimately the success of the program itself. Expect mistakes. It is important that the counselor realize that all decisions made won’t be successful immediately, or perhaps even at all. The counselor must respect the individual’s right to make mistakes and acknowledge that this may require additional time working with the individual. The counselor should also assist in preparing the consumer for possible failures, acknowledging and reinforcing that mistakes are a naturally occurring component of learning. Those who fear moving forward may benefit from reassurance from the counselor that mistakes are not irrevocable. Encourage and support consumer efforts to benefit other individuals. Counselors may create situations that enable consumers to meet other consumers, participate on boards, work groups and consumer organizations. Opportunities may exist for volunteer positions with the Chamber of Commerce and other non-profit organizations. It may be easier for an individual with a disability to model behavior and support others than it is to tackle difficult challenges for oneself. These activities may provide valuable learning experiences for the individual that will facilitate increased self-understanding and greater self-direction. Addressing the Empowerment Concerns of Consumers with Significant Cognitive Disabilities Significant cognitive disability may affect the skills and abilities thought to underlie empowerment, such as problem solving, learning and communication. Consumers with cognitive disabilities may need special assistance, support and/or accommodations in becoming empowered in the VR program. The RSA-TAC-98-01 (Appendix C) offers specific guidance for supporting individuals with cognitive disabilities. Frequently, counselors and other professionals working with individuals with cognitive issues start to filter out information for the consumer, take more control and may work around the individual. How many of us have fallen into a pattern of talking to advocates, family members or another professional about the consumer rather than with the consumer? How many of us have sat in meetings with consumers with cognitive issues and seen no one make an effort to include them? Counselors have to take the time and make additional efforts to ensure that consumers with cognitive issues are given the control they can handle and make the choices that are theirs to make. The VR process should be as inclusive as possible, helping consumers include their support network into the process. However, it remains the counselor’s responsibility to assist the consumer in directing the process. Below are some techniques counselors can use when working with consumers who, due to cognitive ability or other issues, find empowerment difficult. Design auditory and video tapes or simple tools to help consumers understand the decisions they will need to make during the rehabilitation process. The tools should help consumers think about: Which decisions they want to make to make independently Which decisions they want to make with assistance Who would they like to be part of the process Which decisions do they feel they would need a lot of support to make and what should that support look like Consumers could take the tape home and replay the information to better understand it, and they could obtain assistance from their family or friends in understanding the information. Counselors can work individually with consumers and the tool or make it part of a group counseling process. The counselor must evaluate and analyze what skills and supports a consumer needs to succeed. Consumers who cannot communicate or have limited communication will require alternative approaches for the counselor to understand how to support and empower them. It may require using a discovery approach. This occurs when the counselor hires a provider to interview the consumer’s friends, family and others and spend time with the consumer in his or her own home and community. The provider then writes a report providing a more holistic picture of the consumer and the support he or she will need. This approach can provide a positive starting point. Vocational assessments are frequently confusing and fear-inducing to consumers with cognitive issues. Too often the process results in telling consumers everything they cannot do rather than what the possibilities might be. The counselor can shape the process to be successful for the consumer by: • Explaining to consumers the assessment approaches available. • Providing consumers with a written or pictorial list of assessments that explain what the different assessments will tell the consumer. • Creating a checklist for consumers on what they need to know from an assessment. • Creating a list of questions with the consumers that they want the assessment to clarify. • Encouraging consumers to ask providers if they can answer these questions when conducting an assessment. The planning process traditionally has occurred between the counselor and the consumer. When working with a consumer with cognitive issues, it can be useful to expand who is involved in the planning. Frequently this can help consumers understand the planning process better and highlight their unique contributions. A commonly used approach is “futures planning.” • The counselor works with the consumer to invite people the consumer wants to be part of the planning process. • The counselor helps the consumer think about what information should and should not be shared in this meeting. • In facilitating the planning meeting, the counselor should always set the stage so that the consumer is in control. One simple way is to always check whether the consumer agrees with what someone said about her/him. • The counselor and consumer can work together to add additional questions to the future planning that will help the planning be more concrete and measurable for the consumer and support team. Ask questions around time; for example, what do you want to be doing a month from now, and what are you willing to do in the next month? This also allows the consumer to set the pace of the plan. • Breaking the individual plan for employment into shorter, measurable steps helps consumers take control and build on their success. This also allows the consumer and support team to correct the direction before failure occurs. • Empowering consumers with cognitive issues may require more hands-on experiences. Choosing a job is difficult for anyone; but to someone with limited exposure to the world of work, it can be baffling. Consumers may need to work with someone just to show them a wide variety of work places. The counselor may need to develop a picture checklist that the consumer could use to track the features she or he liked in the workplace. Counselors and consumers could use this data along with other information to help choose the type of job wanted. The consumer can then direct the community provider to find that type of job. Conclusion The information provided above lays a foundation for a conceptual shift in practice, away from a medical model to one that supports and encourages empowerment through professional rehabilitation counseling, prioritizing consumer choice and rewarding self-direction. An empowerment-oriented model of rehabilitation counseling requires that we examine and change, if necessary, our attitudes and beliefs about disability. It also requires that we change the way we relate with and provide services to consumers. The IRI PSG recognizes the many systemic challenges to empowerment but believes that the interaction between consumer and counselor is critical to enabling empowerment. We encourage VR counselors to adopt new behaviors and practices that are likely to promote positive outcomes, such as those identified in this chapter, as well as to be mindful of new opportunities and strategies for enabling consumers to be empowered through professional rehabilitation counseling. Study Questions T F The powerlessness and lack of self-direction felt by people with disabilities are more frequently related to limitations or impairments resulting from the disability than from the attitudes and practices of caregivers, service providers, funding agencies, social institutions and society in general. T F In order to promote empowerment for VR consumers, the counselor should assess the consumer’s capacity to self-direct. T F For VR consumers with significant cognitive disabilities, empowerment is precluded by judgment and decision making limitations. T F In order to fully empower VR consumers, refinement of the roles and functions of the rehabilitation counselor is necessary. T F Disagreement and conflict between the counselor and client are signs that the counselor has not enabled empowerment in the consumer.