“I have always thought it would be a blessing if each person could be blind and deaf for a few days during their early adult life. Darkness would make them appreciate sight; silence would teach them the joys of sound.” — Helen Keller, author and educator

“At some point, we have to stop and say, ‘There’s Marlee,’ not, ‘There’s the deaf actress.’”  — Marlee Matlin, actress

The first meeting of the new group will begin soon, and you are busy getting the room ready. You are an experienced counselor who has led many group therapy sessions and support groups, so you know that the beginning phase of each new group can be stressful and challenging for everyone involved. As each new person enters the room, he or she may be tense, not knowing what to expect or who will be there. It will be your job, as the skilled and professional facilitator/counselor, to create a safe and welcoming environment for all.

But if an individual who uses a wheelchair for mobility arrives, will that person feel welcome? The entry doors to the building may already comply with the required width specifications for wheelchair access as called for by the Architectural Barriers Act of 1968, but will the process and mood of the group be welcoming to a person with a disability? If eye contact is a key method of group cohesion and emotional impact, how can the group function if one of the participants has low vision or is blind? If shared comments and verbal confirmation are important elements in counseling, will the group feel inclusive for an individual who has hearing loss, uses a hearing aid or is deaf?

Vocational rehabilitation counseling

The field of vocational rehabilitation counseling essentially began as a result of the thousands of soldiers returning home after World War I with missing limbs and broken spirits. The treatment of all varieties of disabilities, as well as the medical and social implications of society’s reaction to disabilities, is at the core of the training that rehabilitation counselors receive while pursuing their master’s-level degree and professional certification.

According to research conducted by the National Center on Birth Defects and Developmental Disabilities’ Division of Human Development and Disability, approximately 20 percent of U.S. adults report having a disability. As categorized by the Employment and Disability Institute’s Disability Statistics website (disabilitystatistics.org), this can include hearing, visual, cognitive, ambulatory, self-care or independent living disabilities. Section 504 of the Rehabilitation Act of 1973 (with amendments passed in 1978), the Americans with Disabilities Act (ADA) of 1990 and the ADA Amendments Act of 2008 also address areas of emotional, mental and behavioral disabilities.

As a vocational rehabilitation counselor for a state agency, I work with individuals with a wide variety of physical, cognitive, psychological and emotional disabilities. My agency’s services focus on helping clients in their efforts to achieve meaningful employment and independence. Therefore, it is already assumed that the individuals who come to this agency for services may have one or more types of disability. In most situations, arrangements already have been made for the various types of accommodations or adaptations that may be needed for all clients to have full access to available services. For clients who are deaf, arrangements can be made to provide American Sign Language (ASL) interpreters when needed. Clients with low vision can view documents on a specialized closed-circuit TV system that magnifies printed material. For individuals who are blind, computer programs are available that can read aloud the printed words on the computer screen. Other programs can turn spoken words into printed words on the computer using speech-to-text software.

However, according to the updated provisions of both the ADA and the Architectural Barriers Act, the need for accessible facilities now extends to all businesses, services and facilities that are open to the general public. Inclusion means that all individuals can and should be able to participate in all the activities of society, including movie theaters, live theatrical event venues, amusement parks, public swimming pools, shopping malls and even support groups.

In 1998, the Association for Specialists in Group Work, a division of the American Counseling Association, published Principles for Diversity-Competent Group Workers. The principles state, in part, that “Diversity-competent group workers exhibit an understanding of how race, ethnicity, culture, gender, sexual identity, different abilities, SES [socioeconomic status], and other immutable personal characteristics may affect … the appropriateness or inappropriateness of the various types of and theoretical approaches to group work.”

Facilitating a group, whether it is a task group, a psychoeducational group, a support group or a psychotherapy group, is like being the conductor of an orchestra. The facilitator not only must have a firm grasp of the material to be covered, but also must be in charge of the environment in which the meeting takes place, including lighting, sound, temperature and the placement of chairs. In addition, the facilitator is there to “guide” the discussion. Many techniques or methods are employed in this process, just as in any face-to-face therapeutic interaction. Most of these techniques, such as reflecting, clarifying, summarizing or linking, usually depend on the ability to make eye contact and hear what is being said. Any one group session may include some moments of storytelling, talk therapy, counseling, stand-up comedy, improvising, listening, talking and responding.

My background in facilitating groups 

My work with groups predates my entering the field of rehabilitation counseling. This goes all the way back to 1981, when hundreds of job seekers in Dallas would gather in local churches each month for Zig Ziglar’s Interfaith Job Search Support Network. At these events, I was able to speak to large groups about job search methods and assist with the group process. For many years thereafter, I ran similar groups as a volunteer in San Diego for smaller nonprofits.

In the 2000s, the Library of Congress hired me to facilitate groups for its Veterans History Project. This association with the military led to my becoming a group facilitator for the U.S. Navy’s PREVENT substance abuse prevention program. I was assigned to conduct the programs on Navy bases in San Diego and Hawaii, as well as on destroyers and aircraft carriers at sea in the Pacific. The program was a requirement of each sailor’s training program and had to be completed before the sailor was granted shore leave on any overseas deployment. The class discussions had to keep moving forward regardless of whether we were all sitting together in the ship’s eating area (the mess), huddled together in the bowels of the ship in a small room designated as both the “library” and “chapel,” or trying to hold on and hold steady as we braved the cold winds and salty splashes out on the ship’s anchor bay area. Group work in this environment involved not only group facilitation and group therapy methods, but also crowd control and crisis intervention.

Therefore, by the time I began my graduate program in vocational rehabilitation counseling, I felt confident that my many previous years of leading groups had already prepared me to be a skilled group facilitator in this arena. I was soon to learn, however, that my previous group work experiences had not completely taught me the principles or methods of “inclusion for all.”

Group facilitation skills are part of the curriculum in the degree program for rehabilitation counseling. San Diego State University’s Interwork Program, where I was a student, featured many experiential assignments in group therapy. All graduate classes participate in group therapy sessions for two semesters. While mastering the many techniques of group process, a need also existed to provide a fully accessible and interactive experience for all participants.

In the group assignment for my class, there were seven students. As we settled into our circle for our first gathering, one young man was blind, while another young man was deaf. The student who was deaf preferred to communicate with the rest of us by texting on his cell phone. This method did not work for the student who was blind, however. During those two semesters, we were able as a group to develop many adaptations and accommodations that eventually led to a meaningful learning experience for everyone.

During the course of my studies, I was able to participate in three significant internship opportunities. At the San Diego Center for the Blind, the day’s agenda was filled with a series of educational and support groups in which the participants and the facilitator were blind or had significant low vision. Each day around lunchtime, enticing aromas floated out of the adapted kitchen as students learned how to chop vegetables with sharp knives and cook on the stove without harming themselves or those around them. The learning curve was steep. I followed along behind the skilled orientation and mobility instructors as they accompanied clients to crosswalks at busy intersections. There they would discuss how to identify the different beeping sounds emanating from the stoplight that would signal clients when to cross, wait or stop.

At my next internship assignments, I was able to create and lead discussion groups at both Veterans Village of San Diego and Naval Medical Center San Diego. It was necessary in each setting to make adaptations and accommodations for the unique needs of the various participants. For instance, individuals with posttraumatic stress disorder could be unnerved by needing to quickly turn their heads from side to side to take in all of the action. Any sudden movement or loud outburst could be very disturbing for them. Individuals dealing with severe depression could struggle to pay attention to the group’s activities because of the various effects of their medications.

Each of these experiences was invaluable when I graduated and started working for state agencies as a rehabilitation counselor.

The language of inclusion/disability etiquette

Language changes as society changes. As discussed in the May 1995 issue of The Journal for Specialists in Group Work, certain terms and words can have a negative emotional impact. Linguistic studies have shown that the use of such “negative language” can actually validate and support society’s negative attitudinal barriers toward people with disabilities. The trend now is for “person first” language, which aims to eliminate the use of negative and degrading labels that equate a person with his or her disability. Therefore, a person is not “wheelchair bound,” but rather a person who uses a wheelchair. In addition, disability is not synonymous with disease.

In general, when talking with a person who has a visible disability — for example, someone who is using a wheelchair, a cane or a crutch, or who is accompanied by a guide dog — it is acceptable to acknowledge the existence of the disability. However, detailed questions are typically inappropriate. In addition, it is thoughtful and polite to ask whether the person might appreciate assistance and, if so, what type. However, assistance should not be initiated without first asking if it is needed or wanted.

It is most important to note that if another individual is accompanying a person with a visible disability, it is essential to speak directly to the person with the disability. I could write an entire book containing the collected “war stories” I have heard, each following a similar plot. A person who happens to be sitting in a wheelchair is seated at a table in a restaurant. The waitress asks the person’s dining companion for the table’s food order without even looking at the person with the disability. Or a person who is blind walks into a doctor’s office guided by his or her spouse. The nurse asks the spouse what is troubling the person who is blind rather than addressing that individual directly. These scenarios sound like the setup for a joke, but the memories of these events are not funny to the people involved.

Individuals who are blind or have vision loss 

According to the Department of Justice Civil Rights Division, approximately 2.5 million people in the United States report being legally blind. This means that even with corrective lenses, they have less than 20/200 visual acuity or that their total field of vision is 20 degrees or less, regardless of acuity. Many of these individuals have some vision. Despite popular belief, less than 5 percent of those who are blind know how to use Braille.

Specific group strategies:

• When an individual who is blind or has low vision joins the group, introduce yourself and let the person know where you are with a light touch on the arm.
• In conversation, it is acceptable to use words such as blind, visually impaired, seeing, looking and watching. It is also appropriate to use descriptive language, such as references to color, patterns, lightness and darkness. 
• After asking if the person who is blind or has low vision would like to be guided to his or her place in the group, the “sighted guide” technique involves simply offering your elbow, gently placing the person’s hand on your elbow and then allowing the person to follow the motion of your body. Once you reach the chair, it is helpful to gently place the person’s hand on the back of the chair and give specific verbal directions for guidance. For example, “The chair is to your left. It is near your hip.” 
• If an individual is accompanied by a guide dog, arrange some extra room near the person’s feet. In addition, those sitting nearby need to be made aware of the space to prevent stepping on the dog’s feet or tail. Guide dogs are trained to sit or lie down quietly until instructed to get up and move. While the dog is “on duty,” others shouldn’t lean over to pet or talk to the dog or even say the dog’s name. These actions distract the dog from its job of offering direction and guidance. 
• In a room in which multiple group members are blind, it may be necessary to help them share their comments in turn. The best strategy is to have a sighted individual go around the room and touch each participant on the shoulder to indicate it is that person’s turn to talk, or their hands. I observed this technique in practice at the 2011 national convention of the American Council of the Blind, where hundreds of attendees from around the world were blind or had low vision.
• For group introductions, go around the group in order and have each person state his or her name. Individuals who are blind eventually learn to identify a person by his or her voice and location in the room in relation to their own location. In his revealing memoir, Touching the Rock, about the spiritual experience of being blind, professor John Hull writes that, for those who are blind, “[P]eople are not there unless they speak. Many times I have continued a conversation with a sighted friend, only to discover that he is not there. He may have walked away without telling me. He may have nodded or smiled, thinking the conversation was over. From my point of view, he has suddenly vanished. When you are blind, a hand suddenly grabs you. A voice suddenly addresses you. … I am grasped. I am greeted.” He writes that while others can choose whom they want to speak to, “for the blind person, people are in motion, they are temporal, they come and they go.” He goes on to explain, “For me, knowing someone hangs upon knowing the name.”

Individuals who use a wheelchair 

Wheelchair manufacturer BraunAbility released a study published in 2011 that compiled data from various sources, including the U.S. Census Bureau. The numbers show that approximately 3.3 million individuals use wheelchairs for mobility, while an estimated additional 10 million individuals use walking aids such as canes or walkers. Individuals who use wheelchairs are among the most visible members of the disability community.

Specific group strategies:

• For a group setting, chairs can be moved aside to allow room for a person to comfortably maneuver his or her wheelchair within the circle. Allow room for the chairs’ wheels and any attachments. Allow additional room for the participant to navigate the chair around if there will be any movement during the group activity.
• Never lean on a person’s wheelchair. It is an extension of the person’s body and physical space.
• It is OK to ask if the person needs assistance to move from place to place.
• It is acceptable to include action words such as walk, stand or run in conversation.

Individuals who are deaf

Gallaudet University, located in Washington, D.C., is a federally chartered university for the education of those who are deaf and hard of hearing. The Gallaudet Research Institute estimates that anywhere from nine to 22 of every 1,000 people have a severe hearing impairment or are deaf.

Specific group strategies:

• It is usually best to have an ASL interpreter present in the circle. The interpreter should be seated directly across from the person who is deaf. The person who is deaf must pay rapt attention to the actions of the interpreter to catch the meanings of what other group members are saying.
• It is critical that other group members not cause undue distractions because this interrupts the person’s ability to watch the interpreter.
• If directing comments to the individual who is deaf, it is very important, as well as courteous, to direct all eye contact and speech to that person rather than to the interpreter. It is also important that the group leader and other group participants are positioned so that the individual who is deaf can have a clear view of their facial expressions as they talk and react during the brief moments when the individual can look away from the ASL interpreter.
• Participants should speak clearly, without exaggeration, and use a regular speed and tone of voice. The interpreter will follow along and provide all of the interpretations as the group moves at a regular pace.
• A text interpreter, such as a court reporter, can also be seated nearby to type what is being said in real time. This text can be shown on a large screen for the entire room to see. This assistive technology accommodation is used at the Southwest Conference on Disability, held each October in Albuquerque, N.M. Each general session includes an ASL interpreter, who is shown on the large screen at the front of the meeting hall, while another large screen features the typed transcript of what is being said. Participants who are blind can listen on headphones to a description of all activities on the stage during the session.
• The interpreter’s ethical code mandates strict confidentiality.

Communication adaptations

If a participant has speech limitations, it is helpful to simply be patient, maintain eye contact and not interrupt or try to finish the person’s sentences. Many individuals now have access to speech devices such as the one used by British theoretical physicist, cosmologist and author Stephen Hawking. Just be aware that it will take a bit of extra time for individuals with speech limitations to tap out their complete sentences on the keyboard.

The group’s solution 

Our group of seven students gathered together in our circle for the last time. Student F, who is deaf, sat directly across from his ASL interpreter. Student R, who is blind, sat next to the ASL interpreter, directly facing Student F. The rest of us filled in the remaining seats around the circle.

As Student F spoke in sign language about his experiences and memories of the group, the ASL interpreter said aloud what was being signed. He spoke clearly and slowly so that we all could understand what was being communicated. When Student R responded, the ASL interpreter was able to sign to Student F what was being said. This was an inclusive group experience for all.

Knowledge Share articles are adapted from sessions presented at American Counseling Association conferences.

Jo’el Roth is a certified rehabilitation counselor working with the Colorado Division of Vocational Rehabilitation in Denver. She is also the author of a journaling workbook, Life Is a Writing Prompt, which can be found at lulu.com. Contact her at writingprompt@aol.com.

Letters to the editor: ct@counseling.org