Rehabilitation Counseling

Rehabilitation counseling is a process that is designed to assist people with disabilities in accomplishing their goals and in achieving independence and full participation in all aspects of community life. Rehabilitation counseling is also a recognized counseling profession, with a long history and established professional credentialing procedures. It is variously conceptualized as a specialty within counseling, as a specialty within rehabilitation, and as a separate profession.

The historical roots of rehabilitation counseling date back to the early 1900s. During World War I, many military personnel returned home with disabilities, and rehabilitation programs were established to assist them in returning to productive civilian roles. The Soldier Rehabilitation Act (Public Law 65-178) was enacted in 1918. Simultaneously, efforts were under way in several different states to assist workers who had been injured in industrial accidents in returning to work, the roots of contemporary worker’s compensation programs. Finally, the Smith-Fess Act of 1920 (Public Law 66-236) established a vocational rehabilitation program for civilians with disabilities. All of these initiatives evolved into the extensive network of government, private-nonprofit, and private-for-profit agencies and programs to assist people with disabilities. Rehabilitation counseling plays a central role within these agencies and programs, providing assessment, counseling, and coordination of rehabilitation services.

Rehabilitation Counseling Definition

As is true with other professions and specialties, a variety of definitions of rehabilitation counseling have been advanced by individual scholars and practitioners and by professional organizations. An official definition of rehabilitation counseling is provided by the Commission on Rehabilitation Counselor Certification (CRCC), the national credentialing body for rehabilitation counselors, in their “scope of practice statement”:

Rehabilitation counseling is a systematic process which 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.

This official definition emphasizes that rehabilitation counseling focuses specifically on the needs of people with all different types of disabilities; that counseling is central to the process; and that integrated settings are emphasized in the pursuit of career and independent living goals.

Rehabilitation and Disability

Rehabilitation

Rehabilitation counseling is a part of the broader overall rehabilitation process. Medical dictionaries define rehabilitation as restoration or return to function following illness or injury. Rehabilitation is further defined as a process to facilitate independence and a return to full participation in life activities following the occurrence of disability, including employment as a core life activity. This definition is clearly encompassed within the official CRCC definition of rehabilitation counseling. When injury or illness occurs, acute care interventions are pursued to treat, manage, and stabilize the resulting medical condition. However, long-term consequences of illnesses and injuries, including disabilities, will sometimes remain after all available treatments have been pursued, and rehabilitation interventions may then be required to facilitate maximum function, full participation in life activities, and high quality of life. In addition to those disabilities that occur later in life, some occur at birth or during the early developmental years. In these cases, the same principles of assisting individuals in achieving independence, full participation, and quality of life apply. A variety of professions participate in rehabilitation programming, including physical, occupational, speech and language, and recreation therapy, rehabilitation psychology, social work, and rehabilitation counseling.

To illustrate the rehabilitation process, a spinal cord injury may occur through a variety of events, such as a motor vehicle crash, a fall, a diving accident, or a gunshot wound, resulting in paralysis below the level of the injury. An individual who sustains a spinal cord injury will often be taken to a trauma center and will initially be treated through medical interventions to manage the acute condition and any complications that may result, and also to limit long-term adverse consequences. After the medical condition is stabilized, the individual will often be transferred to a rehabilitation unit within the hospital, where a variety of disciplines will assist the individual in recovering function and dealing with the limitations that will remain in the long term. The individual will learn new ways to perform tasks, for example, moving from place to place using a wheelchair, driving a car through the use of hand controls, and performing basic living tasks, such as eating and grooming. Many aspects of the life of the individual, as well as the lives of family and friends, will be affected. For example, the individual may no longer be able to work in the same occupation that had been a primary source of family income and personal identity. In some instances, it may be possible to help an employer identify accommodations that will make it possible for the individual to again perform the job. In other instances, the individual may need assistance in making new plans for the future. Every aspect of life may be affected, and rehabilitation professionals can participate in assisting the individual in recovering function, identifying and implementing accommodations, planning for the future, and maximizing independence and quality of life.

Rehabilitation services are provided in a variety of agencies and programs, and rehabilitation counseling is a part of the programming in many of these settings. Government programs providing rehabilitation services include agencies at the federal level (e.g., the Department of Veterans Affairs, where rehabilitation counseling is practiced in both the Veterans Benefits Administration, which coordinates disability and rehabilitation benefits, and in the Veterans Health Administration, which includes the Veterans Industries/ Compensated Work Therapy Program that provides rehabilitation services to veterans with disabilities); the state level (the State-Federal Vocational Rehabilitation agencies, which exist in all states and jurisdictions in the United States, along with separate agencies for people with blindness and low vision in a number of states); and the county and city levels (e.g., local government agencies providing rehabilitation and long-term support services for people with developmental disabilities and with severe and persistent mental illness).

Many private agencies and programs also provide rehabilitation services, both nonprofit and for-profit.

Private-nonprofit programs include independent living centers (ILCs), rehabilitation facilities (e.g., Goodwill Industries), hospitals (e.g., physical medicine and rehabilitation units in university and community hospitals), disability organizations (e.g., state and local offices of the Epilepsy Foundation and United Cerebral Palsy), and a variety of community agencies providing rehabilitation and long-term support for people with disabilities (e.g., mental health, supported employment, and supported living programs). Private-for-profit programs often serve people with work or personal injuries covered by workers’ compensation, automobile, and other insurance polices. These programs are sometimes a part of national and international insurance companies that provide workers’ compensation or long-term disability coverage. Some are freestanding companies and private practices that may operate in one location or in many locations nationwide, and others are disability management programs that are a part of large business and industrial organizations. These programs facilitate the prevention of illness and injury and assist workers who have sustained disabilities in their attempts to return to work.

Disability

Since individuals with disabilities are the focus of the rehabilitation counseling process, it is important to define disability. However, different definitions of disability are advocated by different professional groups, and also by groups representing people with disabilities themselves. In addition, disability is defined by laws and government regulations, often in different and sometimes conflicting ways. These laws can have a dramatic impact on opportunities and protections provided to individuals with disabilities. For example, legal definitions of disability determine whether children are eligible for special education services in elementary and secondary schools; whether college students are eligible for accommodations, such as extended time on examinations and special services to facilitate their education; and whether adults are eligible for vocational rehabilitation services, including financial assistance with education and training in colleges and universities, technical colleges, and other types of training programs. In addition, legal definitions determine eligibility for disability benefits, such as Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits, or for legal protections in employment and housing.

The term disability is sometimes used to refer to a variety of medical or related conditions (e.g., spinal cord injury, brain injury, schizophrenia, epilepsy, cerebral palsy, or diabetes), and impairment is sometimes used as an alternative to the term disability to express this meaning. In contrast, other definitions are based on the functional limitations associated with physical, cognitive, or psychiatric impairments that affect the performance of various tasks or functions (e.g., mobility, communication, self-care, self-direction, interpersonal skills, work tolerance, or work skills) or limit the fulfillment of major roles or life activities (e.g., employment and independent living). Other terms, such as impediment and handicap, are sometimes used as alternatives to disability to express this meaning. For example, for purposes of determining eligibility for SSDI or SSI benefits, disability is defined in terms of medical impairments that result in an inability to work in any “substantial and gainful activity.” In determining eligibility for services provided through the State-Federal Vocational Rehabilitation Program, disability is defined as a physical or mental impairment that results in a substantial impediment to employment. In identifying individuals who are provided legal protection under the Americans with Disabilities Act (ADA) of 1990, disability is defined as an impairment that substantially limits one or more major life activities, such as self-care, performance of manual tasks, walking, seeing, hearing, breathing, sitting, standing, lifting, reaching, learning, and/or working.

The most contemporary definitions recognize the importance of the physical, social, and cultural environment in defining disability. The environment is viewed as a primary source of barriers, stereotypes, and discrimination, which play central roles in the disabling consequences of physical, cognitive, and psychiatric impairments. Such definitions have been incorporated into ecological models of disability and rehabilitation counseling practice, which focus on interactions between individuals and their environments. Consistent with ecological models, rehabilitation counseling is not limited to traditional counseling interventions that focus on the individual. Rather, other types of interventions, such as advocacy, are also included, focusing on environmental factors contributing to disability and the interactions between the individual and environmental factors.

The variety of types of disabilities is extensive, with many different physical, cognitive, and psychiatric conditions, illnesses, and injuries. Examples include sensory disorders (e.g., blindness and low vision, deafness and hearing loss); developmental disabilities (e.g., cognitive disabilities, autism, epilepsy, brain injuries occurring during the developmental years); mental illness (e.g., schizophrenia, affective disorders, personality disorders); substance abuse and addiction disorders; injuries (e.g., spinal cord injuries, traumatic brain injuries, burns, amputations, carpal tunnel syndrome, chronic pain due to low back and other injuries); and a variety of other illnesses and conditions (e.g., stroke, cardiovascular disease, cancer, HIV/AIDS, respiratory disorders, multiple sclerosis, muscular dystrophy, rheumatoid arthritis, diabetes, chronic renal failure).

Guiding Principles

Many of the guiding principles, philosophies, and values underlying the practice of rehabilitation counseling are shared by counseling in general, as well as by other helping professions. The belief in the worth and dignity of all people, including people with disabilities, is particularly important. Following from the belief in the worth of all people, rehabilitation counseling practice is dedicated to facilitating full access to opportunities for participation in all aspects of community life and to the pursuit of individually determined goals, consistent with the opportunities available to others in society. Following from the belief in the dignity of all people, rehabilitation counseling attempts to empower people with disabilities in achieving control over their own lives and the opportunities and goals that they choose to pursue. Consistent with this value is an emphasis on informed choice in rehabilitation counseling practice, viewing people with disabilities as equal collaborators in the rehabilitation counseling process and assisting them in obtaining and processing the information that they need to make their own decisions regarding services, interventions, and goals.

Also similar to counseling in general, rehabilitation counseling has a long tradition of going beyond limitations and problems to focus on the strengths of individuals with disabilities and helping them to build on those strengths in overcoming the difficulties that they face in accomplishing their goals and living high-quality lives. In addition, the ecological perspective in rehabilitation counseling advocates a focus not only on the individual but also on environmental contexts, in assessing difficulties brought to rehabilitation counseling and in the planning of goals, services, and interventions.

Another value held in contemporary rehabilitation counseling practice, as specified in the CRCC definition of rehabilitation counseling, is the importance of pursuing “personal, career, and independent living goals in the most integrated settings possible.” Historically, career and independent living goals for people with disabilities, particularly for those with significant cognitive disabilities and severe and persistent mental illness, were often focused on segregated settings. Large numbers of people with disabilities were congregated in large work environments, such as sheltered workshops, and in large living environments, such as skilled nursing facilities, community-based residential facilities, halfway houses, and group homes. Contemporary practice emphasizes the pursuit of employment goals in regular work environments in business and industry, where individuals with disabilities will be integrated with the regular workforce, with necessary supports provided to facilitate success. Similarly, integrated living environments would be exemplified by one or two people with disabilities living in a regular community apartment building or complex, together with nondisabled people, with necessary supports provided.

Rehabilitation Counseling Process

The rehabilitation counseling process is generally consistent with the counseling process in general. The process is collaborative, with rehabilitation counselors and individuals with disabilities jointly assessing and identifying needs; establishing personal, career, and independent living goals; identifying barriers to accomplishing those goals; identifying needed services and interventions to overcome the barriers and accomplish the goals; organizing those services and interventions into a service plan; and implementing and evaluating the progress and success of the plan. Individuals with disabilities often seek rehabilitation counseling at times of change or crisis, such as the onset of a disability, changes in condition or functioning associated with disability, or times of transition (e.g., discharge from a hospital, completion of high school and moving on to adult and community life, struggles with the demands of an education or training program, the illness or death of a caretaker, or termination from a job). At times of crisis, assistance will often be required through rehabilitation counseling in processing those changes and their implications, identifying and accessing community resources, and finding new ways to meet needs, which may precede the establishment and pursuit of personal, career, and independent living goals.

As in counseling in general, in rehabilitation counseling the emphasis is on the counseling relationship and developing a strong working alliance between rehabilitation counselors and individuals with disabilities. As is also true in counseling in general, eclectic approaches to counseling are common, with counselors drawing from a number of different counseling theories and techniques in their practice. Because of the emphasis on facilitating career, independent living, and life decisions, trait-and-factor theories and concepts are often applied. Given their emphasis on helping people build on strengths, cognitive-behavioral theories and practices can be beneficial in guiding people to develop skills for coping with difficulties and become masters of their own destinies to greater degrees.

Given the complexity of needs that is often associated with disabilities, the involvement of many different professionals, programs, and services is often required and, as a result, service coordination and case management are often critical components of the rehabilitation counseling process. In addition, given the common focus on career goals, important components of the process are often job development and placement and the facilitation of independent job-seeking efforts on the part of individuals served.

Some functions and tasks are unique or are emphasized to a greater degree in rehabilitation counseling practice than in counseling in general. Given the prominence of ecological perspectives, and the belief that problems related to disability reside in large part in the physical and social environments in which people with disabilities live and work, advocacy is emphasized. This includes both advocating for people with disabilities and assisting them in their efforts at self-advocacy. Related to advocacy, rehabilitation counselors may be called upon to consult with business, industry, and other organizations in facilitating accessibility and accommodating the needs of people with disabilities, including the identification of assistive technology that may be used. In addition, rehabilitation counselors may be called upon to assist in legal proceedings, such as workers’ compensation, personal injury, and divorce cases, to assess the impact of disability on earning potential so that appropriate compensation can be determined. Similarly, in life care planning, rehabilitation counselors may be called upon to assess the life-long service needs of individuals with disabilities, along with the costs of obtaining those services, in order to determine appropriate insurance settlements following the onset of a disability.

Professional Aspects of Rehabilitation Counseling

Different points of view have long existed regarding the relation of rehabilitation counseling to other counseling and rehabilitation disciplines. Rehabilitation counseling has been conceptualized as a specialty within counseling, as a specialty within rehabilitation, and as a distinct and separate profession. The different points of view have resulted in multiple professional associations in rehabilitation counseling. Consistent with the view of rehabilitation counseling as a counseling specialty, the American Rehabilitation Counseling Association (ARCA) is a division of the American Counseling Association (ACA), along with other counseling specialties, such as employment, mental health, school, marriage and family, addiction, and offender counseling. Consistent with the view of rehabilitation counseling as a specialty within rehabilitation, the Rehabilitation Counselors and Educators Association (RCEA) is a division of the National Rehabilitation Association (NRA), along with other specialties in vocational evaluation, work adjustment, job placement, and independent living. Consistent with the view of rehabilitation counseling as a separate profession, the National Rehabilitation Counseling Association (NRCA) exists as a separate professional association, with no affiliation with a parent group, and some would consider the rehabilitation specialties represented within NRA to be specialties within rehabilitation counseling per se, focusing on particular rehabilitation counseling functions.

Rehabilitation counseling has been a pioneer in the movement toward the credentialing of practitioners, developing an accreditation mechanism for master’s degree programs in rehabilitation counseling through the Council on Rehabilitation Education (CORE) and a national Certified Rehabilitation Counselor (CRC) credential through CRCC. Both mechanisms were established in the mid-1970s, preceding by a number of years the comparable accrediting processes for general counseling through the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the National Board for Certified Counselors (NBCC).

Rehabilitation counselors are included in the licensing provisions for general counselors in many states, and a few states have separate credentials for rehabilitation counselors and related professionals, including the Licensed Rehabilitation Counselor (LRC) credential in Louisiana and New Jersey and the Qualified Rehabilitation Consultant (QRC) credential in Minnesota. Ethical standards specific to rehabilitation counseling practice were first developed and adopted by NRCA in 1972, which evolved into the current Code of Professional Ethics for Rehabilitation Counselors. The master’s degree is generally considered to be the professional practice degree in rehabilitation counseling. In addition, a smaller number of universities offer programs to prepare rehabilitation counseling professionals at the doctoral degree level. Graduates of doctoral programs often enter academic positions in universities in the training of rehabilitation counselors and related professionals, in addition to positions in research, administration, supervision, and clinical practice, both within and outside of universities.

Knowledge domains specified by CRCC for inclusion in the CRC examination represent an official position regarding the competencies that are important to the practice of rehabilitation counseling. Some of the domains are shared with counseling in general, while others reflect the specialized services provided in rehabilitation settings and the unique needs of people with disabilities. Examples of more rehabilitation-specific knowledge subdomains are indicated in parentheses, following the more general domains in the following listings. Counseling is central to practice, including individual counseling, career counseling and assessment (e.g., interpretation of assessment results for rehabilitation planning, transferable work skills analysis, assistive technology), mental health counseling, and group and family counseling. Other rehabilitation counseling interventions include case and caseload management, job development and placement services (i.e., vocational implications of functional limitations associated with disabilities), and vocational consultation and employer services (i.e., employer practices that affect the employment or return to work of individuals with disabilities, job analysis, job modification, and restructuring techniques).

Domains are also specified regarding the rehabilitation and human services systems, including rehabilitation services and resources (e.g., community resources and services for rehabilitation planning, school to work transition for students with disabilities, and Social Security programs, benefits, and disincentives affecting return to work); foundations, ethics, and professional issues (e.g., ethical standards for rehabilitation counselors and legislation affecting individuals with disabilities); and healthcare and disability systems. Finally, remaining domains relate to knowledge of disabilities and of the people typically served by rehabilitation programs, including the medical, functional, and environmental implications of disabilities and psychosocial and cultural issues.

Among the different counseling interventions, individual counseling is most commonly practiced by rehabilitation counselors but, depending on the specific settings in which rehabilitation counselors practice, group counseling may also be frequently used, along with family counseling. Career counseling is commonly practiced in many rehabilitation settings, because of the central importance of work and career for individuals with disabilities and the impact that disability can have on career direction and employment. In addition, personal issues, coping and adaptation to disability, and consideration of life decisions and plans are often the focus of rehabilitation counseling practice.

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