Proceedings of a conference on vocational rehabilitation counselor specialization: cause and effects [Apr. 30, 1965]

VOCATIONAL REHABILITATION COUNSELOR SPECIALIZATION:
Cause and Effect
Georgia Division of Vocational Rehabilitation

Proceedings of a Conference on Vocational Rehabilitation Counselor Specialization:
Cause and Effects
Edited by William M. Holbert, Ph.D. Georgia Division of Vocational Rehabilitation
Atlanta, Georgia April 29-30, 1965
A Conference Sponsored by the Georgia Division of Vocational Rehabilitation and Supported by the Vocational Rehabilitation Administration of the U.S. Department of Health, Education, and Welfare

TABLE OF CONTENTS

Page

Conferees__ _

2

Foreword__ _

5

Vocational Rehabilitation Counselor Specialization-

Its Past and Present___________

7

Specialization in Rehabilitation Counseling

- -- -- 11

Comments __

- ----- 21

Consolidated Group Report___

24

Skills and Personality Required to Effectively

Counsel the Emotionally IlL______

28

Comments_________ _

38

Consolidated Group Report__ ____

42

Skills and Personality Required to Effectively

Counsel the Mentally Retarded

44

Comments ___ _

57

Consolidated Group Report_______ _

62

Skills and Personality Required to Effectively Counsel the Blind

63

C o m m e n t s _____ _

---- ---- 74

Consolidated Group Report

78

Summation

79

CONFEREES
JoHN T. AcREE, Counselor for the Blind, Division of Vocational Rehabilitation, Augusta, Georgia.
HENRY 0. ADAMS, Consultant for the Mentally Retarded, Division of Vocational Rehabilitation, Albany, Georgia.
AsA BARNARD, Specialist for Psychiatric Cases, Division of Vocational Rehabilitation, Atlanta, Georgia.
MARY K. BAUMAN, Co-director, Personnel Research Center, Philadelphia, Pennsylvania.
R. E. BAXTER, Coordinator, A. P. Jarrell Pre-Vocational Center, Division of Vocational Rehabilitation, Atlanta, Georgia.
E. K. BELL, District Supervisor, Division of Vocational Rehabilitation, Savannah, Georgia.
H. A. BRIGHT, Project Supervisor, Gracewood State School and Hospital, Division of Vocational Rehabilitation, Gracewood, Georgia.
P. D. BusH, District Supervisor, Division of Vocational Rehabilitation, Gainesville, Georgia.
DR. RIVES CHALMERS, Chief Psychiatric Consultant, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
E. J. CLAXTON, Counselor for the Blind, Division of Vocational Rehabilitation, Athens, Georgia.
W. P. CRIBB, Counselor for the Emotionally Ill, Milledgeville State Hospital, Yarbrough Rehabilitation Center, Division of Vocational Rehabilitation, Milledgeville, Georgia.
W. A. CRUMP, Supervisor of Program for the Mentally Retarded and Handicapped Young Offenders, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
LEWIS M. DAVIS, Consultant for the Mentally Retarded, Division of Vocational Rehabilitation, Savannah, Georgia.
OTis C. DYER, Supervisor of Case Standards Program, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
J. N. EDWARDS, Supervisor, Guidance, Training, and Placement, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
W. L. FLANAGAN, Counselor for the Blind, Division of Vocational Rehabilitation, Macon, Georgia.
W. B. GAINES, Supervisor of Services for the Blind, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
LEON C. HALL, Supervisor of Business Enterprises, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
H. J. HARPE, Specialist for Psychiatric Cases, Talmadge Memorial Hospital, Division of Vocational Rehabilitation, Augusta, Georgia.
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DR. JASPER HARVEY, Chairman, Special Education, University of Alabama, University, Alabama.
DR. LESTON L. HAVENS, Associate Clinical Professor of Psychiatry, Harvard Medical School, and Chief Psychiatric Consultant, Massachusetts Rehabilitation Commission, Boston, Massachusetts.
J. L. HISE, Assistant Director in Charge of General Services and Program Section, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
DR. WILLIAM M. HoLBERT, Assistant Director in Charge of Special Disabilities, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
DR. A. P. JARRELL, Assistant Superintendent, Vocational Rehabilitation Services, State Office Building, Atlanta, Georgia.
LEE JoNES, Superintendent, Georgia Academy for the Blind, Macon, Georgia.
E. E. KENNEDY, District Supervisor, Division of Vocational Rehabilitation, Macon, Georgia.
JoHN W. LEWIS, Counselor, Disability Determination Unit, Division of Vocational Rehabilitation, Atlanta, Georgia.
ToMMY M. McCOLLUM, Assistant Supervisor of Services for the Blind, Division of Vocational Rehabilitation, State Office Building, Atlanta, Georgia.
SHELTON W. McLELLAND, Associate Regional Representative, Vocational Rehabilitation Administration, Atlanta, Georgia.
GEORGE MAu, Counselor for the Blind, Division of Vocational Rehabilitation, Atlanta, Georgia.
JAMES H. MILLER, Specialist for Psychiatric Cases, Milledgeville State Hospital, Yarbrough Rehabilitation Center, Division of Vocational Rehabilitation, Milledgeville, Georgia.
GEORGE L. NuNNALLY, Counselor for Business Enterprises, Division of Vocational Rehabilitation, Athens, Georgia.
C. H. PARKER, Counselor for the Blind, Division of Vocational Rehabilitation, Savannah, Georgia.
DR. C. H. PATTERSON, Professor of Educational Psychology, University of Illinois, Urbana, Illinois.
W. C. PETTY, Supervisor, Program for the Emotionally Ill, Milledgeville State Hospital, Yarbrough Rehabilitation Center, Division of Vocational Rehabilitation, Milledgeville, Georgia.
FRED L. SPARKS, JR., Superintendent, Georgia School for the Deaf, Cave Spring, Georgia.
W. L. TOMLINSON, Specialist for Psychiatric Cases in Charge of Rehabilitation Residences, Division of Vocational Rehabilitation, Atlanta, Georgia.
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R. WATT, JR., District Supervisor, Division of Vocational Rehabilitation, Albany, Georgia.
J. H. WHITWORTH, Coordinator, Evaluation Center for the Deaf, Georgia School for the Deaf, Division of Vocational Rehabilitation, Cave Spring, Georgia.
F. E. WYNN, District Supervisor, Division of Vocational Rehabilitation, Atlanta, Georgia.
LEONARD B. YoUNG, Assistant Program Supervisor, Program for the Mentally Retarded, Division of Vocational Rehabilitation, Atlanta, Georgia.
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Dr. A. P. Jarrell is Assistant State Superintendent of Schools in Charge of R ehabilitation Services. He is a board member of numerous committees relating to rehabilitation work, including program development, mental health, and hospital advisory council. He has written numerous articles relating to rehabilitation. R ecipient in 1960 of the H. B. Cummings Award, NRA, Region IV, for distinguished services to the handicapped. In October 1962 received the NRA President's Award for outstanding achievem ents for the physically handicapped. President, National Rehabilitation Association, 1964- present, served as director and on the executive committee of NRA . R ecipient of 1965 "Goodwill to th e Handicapped" Award.
FOREWORD
It is probably trite to say we are living in an age of specialization. The medical profession has frequently been the butt of jokes about the neurologist specializing on the right cerebral lobe or the orthopedist specializing on the grand toe of the left foot. Since the passage of the Vocational Rehabilitation legislation in 1943 which extended rehabilitation services to the mentally and emotionally handicapped there has been a detectable trend toward specialization becoming more intensified as more specific and complete services are made available to such disability categories as the mentally ill and the mentally retarded. Another possible explanation for this trend toward counselor specialization is that it tends to accompany professionalization. The emphasis of NRA on "counseling" and its growing status as a professional entity has resulted in the establishment of the National Rehabilitation Counseling Association.
Much of the Vocational Rehabilitation literature regarding this project is focused on the need of specialties as a possible effective approach to the myriad of problems confronting various individuals. Some of the specialization has been on the basis of function, such as placement specialists and evaluators, and to some extent based on specialized problems within disability category, such as the mentally retarded and mentally ill.
Most if not all of the participants of this conference indicated that specialization within Vocational Rehabilitation agencies is inevitable. We are aware of the benefits that specialization is bringing to the human race and more particularly to Western civilization. The complexity and diversity of human achievement has been in no small part due to our capacity for 'specialization on the one hand, and our coordination of specialists on the other. If we accept the fact that through specialization our handicapped citizens will receive more effective service, then we must accept the responsibility of directing and controlling this technique
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m such a manner that it fulfills and liberates the individual and the group.
Nothing seems to come to us in unmixed blessings. There are many hazards inherent in the practice of specialization which we must keep in mind if we are to experience the maximum benefits from it. All specialization occurs within a larger framework of the total organization. Our capacity to use specialization will have meaning and purpose only as it is related to the total framework within which it is practiced.
Vocational Rehabilitation agencies must in the future be prepared to offer services to the more severely disabled in all disability categories including the mentally ill and mentally retarded. In tooling up for such programs we must base our decisions on accurate data. I believe that this conference has resulted in our knowing much more about the process of specialization.
DR. A. P. JARRELL Assistant Superintendent Vocational Rehabilitation Services
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VOCATIONAL REHABILITATION COUNSELOR SPECIALIZATION-ITS DEVELOPMENT PAST AND PRESENT
SHELTON W. McLELLAND VRA Associate Regional Representative
It seems to me that this subject in any state Vocational Rehabilitation program is both significant and very timely. I think that in our efforts to serve and rehabilitate increased numbers of disabled people, we must constantly seek solutions to problems of administration and organization. This two-day conference should uncover and hopefully document the best approach to providing quality services to more disabled people.
There is a trend as all of you know towards specialization and has been for some time, and I suspect that we will see an even greater one in the future. I am sure we will gain some insight here and hopefully some direction from our experts who have given a good bit of thought to the subject. Also those of you who are working in the various specialties already, will have contributions.
Occasionally a program lacks effectiveness because staff members differ widely in their philosophy of rehabilitation, and sometimes we fail to even try to resolve or to learn to live with these differences. I do not believe this is the situation in Georgia. I think all you are trying to get are the facts on which to make some decisions or on which to base some recommendations.
As we all know, there are some very basic characteristics which counselors must have whether they are specialists or whether they are generalists. One certainly is intelligence. I am sure we would all agree that a certain amount of intelligence is necessary, because if he does not have this, he is not going to be successful in any situation; also, maturity, judgment, interest in helping people and many, many other things which I am sure we are going to discuss while we are here today and tomorrow.
My first experience with specialization in rehabilitation dates back some twenty or more years. It was in connection with my responsibility for working with the blind, not just counselor specialization, but even specialization within the program for the blind, in the area of placement. For many years blind people have been set apart somewhat as a group having special problems, and some felt then and perhaps still do that these special problems could best be dealt with by assigning a counselor to work with them on a full-time basis. Some of you old timers will recall that Public Law 113 passed by Congress in 1943 made some special provisions for the rehabilitation of the blind-the vending stand program, for example - and a great deal of progress has been made since then. State Vocational Rehabilitation agencies in this region at
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that time started assigning counselors to work with this special disability group. However, I am sure some agencies started prior to 1943. You will recall, also, that Public Law 113 gave authority for the rehabilitation of the mentally ill and mentally retarded, but very little was done by state Vocational Rehabilitation agencies. Almost no progress was made until within the last few years. But I suspect that if state agencies had become involved at that time, and there are a number of reasons why they did not, we would have seen specialization developing then with the mentally disabled. As you will recall, we had no psychologists, psychiatrists, or social workers to help us. At least we had very few, and we knew we could not do the job without assistance of these professional people.
In the past ten years under Public Law 565 which was passed in 1954, as all of you know, state Vocational Rehabilitation agencies have done a number of things. They have developed new concepts in rehabilitation and taken an active part in increasing rehabilitation resources that are so necessary if we are going to make progress in rehabilitating people who have severe problems. I think this is true in practically every state and certainly in Georgia.
This whole philosophy and concept of vocational rehabilitation is being adopted by many agencies and organizations. It has affected the philosophy of those who work in welfare programs, public health, and many others. It is being used in alleviating problems that are associated with mental health, mental retardation, juvenile delinquency, and the school dropout problem. More recently this philosophy has become an important component of the current attack on poverty, although rehabilitation has always been engaged in this effort. Last year some 75 or 80 percent of cases closed rehabilitated by Vocational Rehabilitation agencies had little or no income at the time of acceptance. Rehabilitation agencies have been engaged in this attack on poverty from the beginning.
One of the important characteristics of our rehabilitation program is its vitality and willingness to grow and experiment. State agencies, however, have kept much of the traditional approach to rehabilitation because it was good and met the existing need, but the traditional approach now is accompanied by a whole host of new ideas, methods, and techniques, and we are indeed grateful for these. For example, one of the most significant developments is the establishment and use of rehabilitation facilities and workshops. Since the passage of Public Law 565, forty-five states have spent over 23 million dollars to enlarge or modernize 360 facilities and workshops under Section 2 and 3 of the Act. Some of these facilities are operated by state Vocational Rehabilitation agencies, some by other public agencies, but a large number are being operated under private auspices and their services made available to state Vocational Rehabilitation agency clients. These facilities and workshops vary
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greatly. Some are comprehensive centers, specialized facilities for the mentally retarded, centers for the deaf, speech and hearing centers, optical aids clinics, half-way houses, and rehabilitation workshops. All of these facilities and workshops are looking for counselors with special training to work with the disabled people that they are set up to serve and in some instances in a highly specialized way.
An important development also is the growth of cooperative programs with other public agencies. One of the most significant of these, and one of the most recent, is the joint undertaking that state agencies have with the special education programs in public school systems. This seems to serve the purpose of bridging the gap between school and employment and prevents the waste of human talent. Services are being made available to young people who can find no acceptance in the working world because they have no skill to offer and what is more, they have a disability or disabilities-they are deaf, hard of hearing, have emotional problems, or are mentally retarded. Here we have another area of counselor specialization, but one cannot find trained people, so we find those who have an interest in this kind of work and hope to provide the necessary training that it takes to help them do an acceptable job.
Such cooperative programs usually involve curriculum revision, comprehensive evaluation, personal adjustment, pre-vocational services, intensive counseling, the development of on-the-job opportunities, work adjustment, and placement. Vocational Rehabilitation agencies in this region have found that the best way to provide these special services is to assign staff on a full-time basis to work in one or more of these specialties.
Another cooperative endeavor which reflects how rehabilitation is extending its services can be found in state institutions for the mentally ill and the mentally retarded. A few states are also pioneering, such as Georgia, in developing rehabilitation facilities and programs for young offenders in federal and state penal institutions. Staff assigned to such programs needs to have special training to do a thorough job.
A number of rehabilitation agencies have cooperative projects with the state welfare departments to rehabilitate people who are drawing public assistance. More than twenty states are conducting demonstration projects for the rehabilitation of this group. Here, again, counselors are usually considered specialists in such situations.
Many new patterns of services are coming into use through specialized placement counselors, mobility instructors for the blind, work adjustment counselors, etc. Increasingly, state agencies are employing personnel to work in special situations and through in-service training, preparing them for their assignment.
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All of these developments are making substantial changes in the kind of personnel that state agencies are employing and training. We know that all of our professional knowledge is growing very, very rapidly-education, psychology, medicine, social work, and rehabilitation -and it is very difficult indeed, if not impossible, for any professional person to keep up in his own field, let alone fields that are allied or related to his. The situation could likely be improved, if we could get more and better coordination, or a pooling of this knowledge which is being accumulated. Our professions have been subdivided almost to an absurd degree in an effort to obtain more knowledge and keep up with the expansion that is taking place within the profession. Psychology, for example; even in so young a profession, the American Psychological Association now has twenty or more specialty areas or divisions-a difference in techniques, interests, language, perhaps are the reasons for so many divisions.
I am not criticizing subdividing or specialization because I think that it has paid off in so many ways. As a result, we have a vast storehouse of information, but in many instances this knowledge is unassembled and not in as usable form as it might be, and maybe in this meeting we can get some help in learning how to pull from this vast storehouse of knowledge to make it applicable to our particular situation whether we be evaluator, vocational counselor or rehabilitation counselor, placement officer, or specialist in working with the blind, the deaf, mentally ill, or mentally retarded. As I said in the beginning, maybe we can find and document the best approach. Certainly, this is what we hope to accomplish.
There are many pros and cons, and I hope all of them will be discussed while we are here. You have the experts to provide the information, and you should be able to develop guidelines for further expanding the Vocational Rehabilitation program in Georgia.
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Dr. Patterson heads th e rehabilitation counselor training program at the University of Illinois, where he is professor of education. Former president of APGA's American Rehabilitation Counseling Association and a m ember of the A m erican Psychological Association's Division 22, he is chairman of th e N RA literary awards committee. Dr. Patterson has written over 50 articles and five books.
SPECIALIZATION IN REHABILITATION COUNSELING
We live in an age of specialization. It appears that we have not reached the end of specialization; the development of new specialties seems to be continuing in all areas of our lives. In the face of increasing specialization, each of us becomes a layman in more and more aspects of life and knowledge, with increased feelings of inadequacy accompanying increased respect for experts.
The extent of specialization may be seen if one examines the faculty list of any of our large universities. We find an increasing number of departments, resulting from the splitting off of developing specialties. These differentiations show up in professional titles. Titles _are much more numerous than departments, so that there are specialists within departments. In a department of agronomy, for example, we have not only professors of agronomy, but professors of biometry, plant genetics, plant physiology, plant breeding, plant pathology, pedology, soil microbiology, soil physics, soil fertility, soil minerology, soil chemistry, and crop production. I have learned that in some universities there are finer distinctions, such as between professors of small plant agronomy and large plant agronomy. Similar lists could be developed for many other departments. And there are many specialties which are not indicated by titles, such as the English professor who is a specialist on a particular writer, such as Chaucer, who spends all his time and teaching on this one author. The specialist is the expert who knows more and more about less and less.
There are differing reactions to specialization. It is not eagerly or even willingy accepted by everyone. There are those who resist it. Sometimes they are department heads who object to the breaking up of a large department. But there are also individuals who do not wish to confine themselves to a narrow area. I have for a long time tried to resist becoming narrowly specialized, and giving up interests in various aspects of psychology or even the behavioral sciences. My career has not been
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one of concentration on a narrow area. I began with an undergraduate major in sociology, with an interest in social psychology. Circumstances at the time of my graduation in the depression led to my taking a position as a psychologist in a child development research institute. So I became a child psychologist. The war led me into clinical psychology with adults, so that I bypassed adolescent psychology. Following the war I moved to counseling psychology, and as a specialization within that field, rehabilitation counseling or rehabilitation psychology. My title, however, is professor of educational psychology. So I have been many kinds of a psychologist, even, perhaps in the eyes of some, an abnormal psychologist. But specialization has been catching up with me. I no longer am able to read Psychological Abstracts from cover to cover to keep up with the various fields of psychology. There is probably no psychologist who does so. There may no longer be such a person as a general psychologist. Even the instructor who teaches only the introductory course in psychology is a specialist in teaching the first course in psychology. The American Psychological Association now has 25 divisions and more may be on the way. The generalist doesn't get anywhere. Job requirements are becoming more specific. The way to achieve recognition is to select a narrow area for research and writing, and become an expert in this narrow field.
To anyone who becomes aware of what is happening in science and the professions, it becomes clear that the question is not one of whether we should have specialization. Specialization is inevitable. Knowledge increases at a geometrical rate. It is impossible for any one person to acquire, retain, and continue to absorb the knowledge existing and being produced in any of the areas which have been traditionally designated as the sciences, let alone to be able to integrate the sciences. Frances Bacon, it is said, knew about all that was to be known in his day. Today this is beyond the capabilities of a single mind. We are facing problems regarding the storage of information, and are turning to machines to help us. A whole new specialty of information storage and retrieval is being developed consisting of people who know no subject matter in the traditional or classical sense, but who know how to store and retrieve subject matter information.
What the ultimate outcome of this situation will be I do not know. I am pessimistic about the capacity of machines to hold the information which is being developed. To be sure, much of it, it may be contended, is not very useful or important, and shouldn't be published or retained. But the machine cannot determine this. It takes the judgment of people to select and prepare information for the machine. Nor is the machine likely to be able to analyze and integrate the information to lead to generalizations or theories.
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But specialization is inevitable, whatever its ultimate outcomes. Our problem is one of utilizing its advantages while minimizing its disadvantages. This involves the determination of the rate of specialization, to avoid overspecialization, or specialization for which we are not ready, or which is not warranted by the state of our knowledge. In some cases specialization may provide more advantages than disadvantages, but may be too costly or expensive to develop and adopt.
Professional specialization is only economically feasible when the population is large enough to support it, that is, when there are enough clients in the areas of specialization to occupy the time of the specialists. A small town obviously cannot support a group of specialists. In the field of rehabilitation, we have reached the point where specialization is economically feasible in many geographical areas and in regard to a number of disability areas.
Rehabilitation itself is of course a specialty in the general area of medical, social and psychological services. In the medical field, physiatry or physical medicine is a recent specialty. In the field of counseling, rehabilitation counseling at a professional level is a recent development within the field of counseling.
Specialization is inevitable, then. It is also a natural development in a situation where there are large numbers of clients who form clearly definable subgroups, or where complex professional functions can be easily or logically subdivided. Thus we have specialties in medicine related to differences among patients, such as age, and differences in the nature of the disease or disorder. There are also specialties in terms of functions, such as surgery, radiology, anesthesiology, etc. In rehabilitation counseling we are seeing the beginnings of both these kinds of specialization. In terms of function, there is the beginning of specialization in the function of placement. Specialization has proceeded further in terms of kinds of clients, or disability areas. This specialization has to a great extent, developed naturally. That is, counselors have, for one reason or another, become interested in clients with a particular disability. Such counselors begin to become sensitive to special problems related to the disability, and special needs of the clients. They become more knowledgeable about the disability, more aware of the individual differences which exist among those having the same disability. They learn more about the disability, and about ways of working toward the rehabilitation of such clients. They become experts in the area. Other counselors consult them about their clients having the same disability. Or they refer some of the more difficult clients to the expert. Eventually the expertness is recognized by assigning most if not all cases with the particular disability to the counselor who is recognized as an expert. In short, he has become a specialist. This process indicates one of the
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advantages from the point of view of the counselor. It is an advantage which has not been sufficiently recognized. Specialization allows the individual to find and engage in an occupation or profession which may be more closely suited to his interests, aptitudes and abilities, and personality than would be possible without specialization. It allows for the exercise of his unique characteristics and pattern of traits. It thus makes possible a greater degree of satisfaction in his work.
The other side of this advantage to the individual is an advantage to society and to clients. Specialization capitalizes upon individual differences, and makes possible the maximum use of the talents and abilities of the individual for the good of society. The individual who is more satisfied with his job does a better job. The individual who is utilizing his special talents is a better professional or practitioner. The specialist, therefore, renders better service not only because he is better trained or prepared to do so, but because he is better fitted to do so in terms of his interests, aptitudes and abilities.
The advantages of specialization seem to be recognized, even by those who resist specialization. Counselors who are opposed to the development of specialization in counseling would strongly resist being limited to the services of a general practitioner if they were seriously ill, or for their own clients. They want the services of specialists where they seem to be indicated.
Thus, specialization is not only inevitable, but it is desirable. There are, however, problems, or disadvantages, which accompany specialization. Whether all of these are necessary or inevitable is a question. Some of them probably are not inevitable, but can be avoided.
The major disadvantage associated with specialization is the breaking of the individual into parts. The client may be seen and dealt with as a problem, as a disease, or as a disability rather than as a total person. Now it is true that specialization requires concentration upon a part or aspect of the whole person. This is necessary, and specialization would not be possible without it. To an extent, this is a price we must pay for specialization. But this concentration upon a part or aspect of an individual need not mean the complete neglect of other aspects, or of the individual as a whole. In fact, the specialist must view the disease or disability as a part of a whole if he is to understand or treat it adequately.
In counseling, there is danger in a problem orientation to clients. The counselor who focuses upon a particular problem, be it educational, vocational, social, marital or what not, is not able to deal adequately with the client. This has been the problem with traditional vocational counseling, which has isolated the vocational aspects of life from the rest of life. Vocational problems were dealt with apart from feelings. aspirations, motives, and other emotions, and were attacked in a logical manner
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by providing information and attempting to reason with the client. Many counselors, and I suspect among them many rehabilitation counselors, still use this approach with clients. But fortunately it is being recognized that vocational development is a part of the individual's total development, and that vocational or occupational choices involve, as do all choices, feelings and emotions. Thus the vocational counselor, if he is to function adequately, must be more than one who knows tests and measurements, and occupational information and opportunities. He must be able to recognize, understand, and deal with therapeutically, affect and feelings. The vocational counselor must be a psychological counselor, in other words.
It may appear that I am saying that there is no place for specialization in counseling. To an extent this is the case. There is no specialization of function. All counselors have the same function, that is, to deal with psychological problems of clients. Counselors may specialize in clients with certain kinds of problems, but they are all psychological problems, or else the client would be seeing a lawyer, engineer, doctor, or another professional person.
Thus counseling is counseling is counseling. It is fundamentally the same regardless of the particular problem or the kind of client. Nevertheless, there are some differences related to particular kinds of clients. These differences do not relate so much to the counseling relationship as to the ability of the counselor to develop and continue an appropriate relationship with the client on the basis of understanding the client, and his problems and needs.
It seems therefore, that by the very nature of counseling, the individual must be dealt with as a whole, if counseling is actually to occur. While a so-called client may be dealt with piecemeal, as by providing certain material services, such as a prosthesis, if counseling is to occur then he must be dealt with as a whole individual. If counseling is to be successful, then the counselor must understand the client, as a unique individual. Specialization with a particular kind of client enables the counselor to know the problems and needs of such clients, to recognize individual differences among them rather than lumping them together as a homogeneous group. He is then better able to understand and thus to help such clients.
Specialization in rehabilitation counseling is thus in terms of developing a knowledge and understanding of clients possessing specific disabilities, as a basis for working more effectively with such clients. It does not involve the utilization of any new, unique or highly specialized techniques of counseling, although it may include the use of specialized resources, facilities or personnel for their rehabilitation.
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There are certain practical problems of specialization which are usually raised. One of these is related to the concern for the individual as a person. The use of specialists usually involves referral, and referral means that the client must work with a greater number of individuals. There are those who contend that it is undesirable for the client to have to relate to many different persons. But life is a process of relating to different people. It is not the matter of referral which is bad; it is the way in which the referral is made, the way in which the client is treated by the different people who work with him. Clients don't object to being referred to specialists, if they undestand what is going on. Too often the client is treated as an object rather than an individual, and is shuffled back and forth from specialist to specialist. It is not the use of specialists which creates the difficulty, but the way in which they are used. There is a procedure of referral which has developed which assumes that the client doesn't need to know what is happening to him, that he wouldn't understand anyway, and that he shouldn't know the nature or results of special examinations or studies. The difficulty lies in the acceptance of these assumptions and their influences on referral, rather than anything inherent in referral and the use of specialists.
Thus, it should not be a problem for a counselor who first comes in contact with a client who has a disability which is dealt with by a special counselor to make a referral to that counselor. Rather than impairing the attitude toward the and relationship of the client with the agency, it should lead to a better attitude and relationship, since the client will appreciate being provided the services of a specialist. Perhaps some of this referral from one counselor to another might be reduced by centralized case finding, eligibility determination, and assignment of clients to the appropriate counselor.
There is of course a problem in providing specialized counseling services in rural or sparsely settled areas. The question might be raised as to whether such clients are denied specialized medical services. I do not believe they are, though there may be a tendency to less readily obtain such specialized services. Usually it is accepted that the client can travel to the specialist. However, where counseling is concerned, the reverse seems to be the practice, that is, the counselor goes to the client. It may be questioned whether this is the best practice, both in terms of efficiency in the use of the counselor's time and the professional nature of the counseling relationship. This is not to deny the value, in some cases. of a visit to the client's home, or the inclusion of his family in any plans. But why cannot the client travel to the counselor? A regional office arrangement, which was the organization of the Veterans Administration, would permit having specialized counselors serving a geographical area, perhaps around a fairly populous city or town.
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These problems with regard to specialized counselors do' not seem insurmountable, once it is recognized as desirable to' use them. They do not exist, or course, where the counselor is part of the staff of an institution which serves clients with a particular disability.
I will turn now to another area which perhaps constitutes the most difficult problem at present. This is the matter of adequate preparation for functioning as a specialized counselor. I think it would be safe to say that none of the counselors now functioning as specialists have had any special preparation for their work as part of a regular counselor education program. Any specialized preparation they have had has been obtained in special workshops or short courses. This is because there are rio long term rehabilitation counselor education programs which are preparing specialists; all the rehabilitation counselor education programs of which I know are preparing general counselors~
Now if it takes two academic years to prepare a general counselor, it must take longer to prepare a special counselor. Remember that the basic fundamentals of counseling are the same, regardless of the client, whether he is disabled or not, or what the nature of his disability. Therefore, it is not reasonable or possible as one counselor has suggested,1 to concentrate upon training for work with a specific disability and to accomplish this in the same period of time. The specialist requires additional preparation beyond that of the general counselor. He needs it if he is to function any more adequately with a specific disability group than a general counselor. And it should be primarily on the basis of special skill derived from special training that differential pay i:<~ justified. To be sure, it is possible to learn from experience, or through on-job training. But this cannot continue to be an adequate basis for a profession. Where and how, then, is the counselor to obtain such specialized training?
It is, of course, possible for a student to obtain some bac~groui:ld in a special disability area during his general preparation in rehabilitation counseling. All students get some exposure, in lectures and reading, to the nature and problems of the major disability areas. In addition, a student can probably make a special study of an area as .a project or
term paper. Then in the field training, placement maybe in an agency
or institution specializing in. a specific disability. In my own program all students read my book, "Counseling the Emotionally Disturbed," in the seminar on rehabilitation counseling. This is a text on the vocational rehabilitation of the psychiatrically disabled, but it is used to illustrate the vocational rehabilitation counseling process in general. In addition, students who are interested in working in this area can arrange to take their field training at the Chicago State Hospital, which has~been
--
1Harper, R. B., Professional Dilemma? NRCA News, 1965, 7 (2), 3.
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designated as a training hospital in rehabilitation counseling by the State Department of Mental Health. Or they may take their field training in a Mental Health Center, working with outpatient clients. Such students are then employable as rehabilitation counselors in the State Department of Mental Health in a hospital or mental health clinic. Several of my former students are presently employed in such positions.
Similarly, students may take their training in an institution for the mentally retarded, the deaf, or the blind. However, such institutions, in Illinois at least, do not have rehabilitation programs with competent staffs of rehabilitation counselors to supervise the student.
In addition, the general training program in rehabilitation counseling does not provide sufficient background in a specialized field to prepare specialized counselors. It would be undesirable, in my opinion, to attempt specialization in the regular program. This would result in inadequate preparation in the basic or generic field of rehabilitation counseling. It would result in inadequate preparation in counseling if courses dealing with special disabilities were to crowd out basic courses in psychology and counseling. There would be the danger that rehabilitation counseling would become separated from the basic field of counseling and become splintered into a group of specialties, with the special counselors being inadequately grounded in counseling.
This danger of divorcing rehabilitation counseling from the basic profession of counseling is a real one, even at the present time when there are no specialized programs. There are those who see rehabilitation counseling as a unique profession, separated from the rest of counseling. This, to me, appears to be one of the dangers of having a National Rehabilitation Counseling Association which is a part of the National Rehabilitation Association but not associated in any way with the general counseling profession.
The point of view taken by many of us in counselor education is that the preparation of rehabilitation counselors involves basic preparation in counseling, with students in rehabilitation taking many of their courses with school counselors and those preparing for work with other institutions or agencies, such as the state employment service. This is the position of the American Personnel and Guidance Association, which has prepared a statement on the preparation of counselors which applies to all counselors in all settings2 This statement is to be supplemented by statements applying to the preparation of counselors for specific settings, such as rehabilitation. The period for this basic preparation is two academic years.
It is thus necessary that specialized counselors be well grounded in
2American Personnel and Guidance Association. The Counselor: Professional Preparation and Role. A Statement of Policy. Personnel Guidance J., 1964, 42, 536-541.
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counseling. The danger of splitting specialists off from the basic profession must be avoided. The basic science of counseling, which is psychology, must be a part of the preparation of all counselors, specialists as well as generalists.
It is apparent, therefore, that specialized training must be in addition to the present two years of graduate preparation for rehabilitation counselors. It is possible that if undergraduate programs could be planned better, there might be some room for more specialization than at present in the two year program, although I doubt that much could be done.
The line which such preparation could take is illustrated by what I believe is the only program for the preparation of specialists which currently exists. This is the program for the preparation of counselors in the area of the deaf, located at the University of Illinois and supported by a VRA grant. This program prepares not only rehabilitation counselors, but teachers of the deaf, specialists in speech and hearing to work with the deaf, and researchers, college teachers and administrators. Our concern here is only with the preparation of counselors for the deaf.
This is the first year of the program and currently there is one student in rehabilitation counseling enrolled. This student, a graduate of the two year program, with several years of experience in working with the deaf and hard of hearing following his general training, is taking an additional year of work which includes such courses as Psycho-Social Educational Aspects of Deafness, Communication Problems of the Deaf, Introduction to Hearing Disorders, Aural Rehabilitation, Audiometry and the Use of Hearing Aids, Psychology of Speech and Hearing Disorders, Seminar in Hearing Disorders, and Advanced Audiology. Field work is provided for students who have had no experience in rehabilitation.
There is a. problem of providing stipends for students to take specialized work beyond the two years to which VRA stipends are limited. The program for the preparation of specialists in the area of the deaf is classified by VRA as a different program than the preparation of rehabilitation counselors, so that students who have had a VRA stipend for two years in rehabilitation counseling are eligible for further support. Some similar provision would be necessary for programs preparing specialists in other areas, unless the current VRA amendments are approved by Congress, which would extend the period for which a student may receive support from two to four years.
The addition of a year or more for the preparation of specialists to the current two years required for the preparation of general counselors has implications for salary levels. It is only reasonable to expect that additional specialized preparation will require a higher salary scale.
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In summary, we may say, with some confidence, that specialization is inevitable, in rehabilitation counseling as in all other professional fields. It is, of course, possible that specialization can proceed too rapidly; that is, before there is sufficient knowledge and skill which warrants specialists and programs for preparing specialists. It is also probable that specialization may be warranted in only a few disability areas, which present special problems, such as the blind, the deaf and hard of hearing, the mentally retarded, and the emotionally disturbed.
If specialization is inevitable, then we should prepare for it by considering the nature of the special preparation which is desirable. It is contended that such special preparation must be built upon the present two year programs for the preparation of rehabilitation counselors. Specialists are still counselors, and cannot skip over the basic preparation necessary to become counselors. Such preparation should consist of specialized study of the nature of a particular desirability, and the needs and problems of clients with such a disability, so that the counselor will better understand his clients and be better able to assist them in their rehabilitation.
Specialization seems to be becoming generally accepted. Programs for the preparation of specialists do not now exist, however. We must move forward from the workshop and short-term study programs for the preparation of specialists, and begin to develop regular academic programs as extensions of our current two year programs for the preparation of general rehabilitation counselors.
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COMMENTS
(Dr. Patterson's Presentation) R. WATT, JR.
Supervisor-General Program
Somebody said that there is nothing constant except change. Some philosopher said, "Do not be the first to take on the new and do not be the last to lay aside the old." I think that is what we are doing in Georgia and that we should continue to do so.
This particular predicament, or experience, which we are going through in regard to specialization has caused me some concern for a long time. Again, I think we have to roll with the punches, take care of things that come along with time, but the word counseling-! am not yet sure that I know what is meant by counseling. Many of the counselors who come into our program have to learn the simple fundamentals of handling physical restoration cases from which we get most of our numbers. We take this young chap who is quite eager and for the first few months he thinks he knows a great deal, but in about a year and a half or two years he learns that he does not. We supervisors teach him the fundamentals of practical counseling.
Let us take a young counselor (and the experienced one, too) and see if he counsels in this instance. Our client may be an illiterate farmer, laborer, or pulp laborer. The counselor visits the home and checks with the employer. Will this i:nan be hired back? At his office or in the man's home, he obtains the necessary information on the forms and fills out the medical form. He tells the client, "Take this and go to the doctor. The doctor will fill this out and mail it back to me. You go back home and wait till you hear from me ot the doctor. When the doctor tells you to go to the hospital, you go and take this letter with you. Do not go until you are told to go, and then will you please come back and see me once every month for three months and then once every three months until your case is closed?".
That is about all you do for him. He follows instructions, is rehabilitated, and goes back to work. Is that counseling? I think it is a form of counseling--direct, but effective.
Many people come to us who have lost limbs, arms or legs, and by the way what causes the most amputations? Farm implements and farm machinery cause more now than any other particular category. You tell this person who has .lost a limb that he must learn to live with it. He is taken to an amputee clinic where he is evaluated. He is then given some gait training, goes back to his home community, and you place him, or he is already placed. Is that counseling?
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Dr. Cummings, former Vocational Rehabilitation Administration Regional Representative for Region IV, has a favorite story that I have heard him tell many times. I have been in similar situations and some of you older counselors have also. A man was referred as having a cardiac condition who worked in a cotton mill. The company doctor referred the case, stating, "He is going to lose his job unless something is done. If you had a sedentary job, he could do that kind of work." The counselor went to the cotton mill and was referred to the card room where fifteen people were working. Fourteen of them were sitting down, lifting strings once in a while, sometimes not doing anything for an hour or two. One person had to go on a trot, pick up the finished product, and carry it to the conveyor belt. He was the only person trotting.
The counselor asked the foreman to point out the person who had the heart condition. Out of the fifteen people, he was the man who had to trot and run, aggravating his heart condition. This counselor spoke to the foreman and said, "Sir, I believe that if this man had one of the jobs of the other fourteen workers the company doctor would keep him, he could do the work, and live a long time." The foreman thought, "Why didn't I think of that?"
At the coffee break, the foreman gathered the workers together and explained the situation. He said, "We think that the company doctor will keep this man if some of you will exchange jobs with him. Who will volunteer to exchange jobs with this man to keep him working and supporting his family?" My faith in humanity was restored a great deal when every one stepped forward and said, "We will swap jobs with this man." The foreman said, "Okay, you go ahead and I will work this out."
Several weeks passed and the counselor went back by the factory and a program had been worked out whereby every person exchanged for one month his job with the man who had the heart condition. This man was sitting down working on a job which he could hold with his disability. I know one counselor who did this and did not get any credit for the case because he did not have time to work it up. Was this counseling? I think it was.
The complaint that comes to me from the regular counselors is partially this. They have said to me, "Counselors who work with one disability are considered specialists, and I want you to know that I think I am a specialist. I have to be a specialist in many different categories."
/ One day a long time ago while a counselor, I wrote down the people that I met. I started out in the City of Albany and for you who do not know, this is a town of about 65,000 people-a bustling town with many facilities. Albany has two big military installations, about twenty motels and hotels, some fine churches, and actually one of the biggest Y.M.C.A.'s in Georgia with olympic facilities.
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The first person I contacted was the minister of the First Baptist Church who had referred a janitor to me for a hernia repair. I went in and talked with this minister about rehabilitation and what we could do for this man. Then, to the bank to discuss with the president one of his tellers who was emotionally disturbed, explaining the program and what we could do. From there I went to at least three doctors and discussed several cases and visited the hospital contacting whatevefCifents were there. Next I discussed rehabilitation with an illiterate, syphilitic individual in the slum section of town. You cannot talk down your nose to these people, you have to some way get on the same level to talk with them. I went from there to a widow's home who was scared to death. She had lost her husband recently and there were five children to support. She had to have a hysterectomy and I discussed what we could possibly do, visited the Welfare Department and worked out some support for the children while we were rehabilitating her, then went back and told her what had been done. Finally, I went to the home of an employer checking on a referral that had been made to me of a domestic servant. She was not in her home, but the neighbor gave me the address where she was working. I drove to the address, talked with the landlady to determine whether she would take this maid back, obtained the necessary information, and~
My favorite peeve with psychologists and psychiatrists is that they will not give you a direct answer when asked a question. They answer in very technical terms and finally say, "It may or may not be so." Dr. Patterson did not use it may or it may not a single time.
I found only two or three things I would like to check on. I believe Dr. Patterson said there were no schools teaching specialized training. Could not Gallaudet in Washington, D. C., be classified as a training school for the deaf?
I would like to have further information on the two-year program for general counselors in Illinois which Dr. Patterson mentioned. Is a Bachelor's degree plus two years of specialized training in the general counseling field required or do you require a Master's degree? What about the program at the University of Georgia? Are we training specialists in mental retardation there?
Dr. Patterson said, "Whether we like it or not, specialization is inevitable". He mentioned the specialized fields that people are getting into now. We are in the day of specialization in all fields. It is going to cause a little trouble, but let's do it in rehabilitation.
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GROUP RESPONSES TO DR. PATTERSON'S PRESENTATION
Following Dr. Patterson's presentation, the conferees apportioned themselves into four discussion groups for a review of the speech, and also for a closer look at specialization in general. Dr. Patterson's speech dealt primarily with specialization and its development. Much of the discussion that followed was left with his imprint and with the group members' own preconceptions about specialists for the mentally ill even though their goal was to use the presentation only as a base for discussion of the general topic. Some time was utilized in open discussion of interests, achievements, gripes, and problems, but the groups hurriedly settled down to exploring some of the major considerations of counselor specialization. ~ Specialization got its start because of observable unmet needs. It appeared that where a peculiar problem of an industry or a group of people existed, special knowledge and talents were required to resolve them. Without proper attention and interest, the problem or gap remained. In the Vocational Rehabilitation Agency, specialization tended to develop when we became more acutely aware that certain types of clients were not being adequately served, and in some cases, were not being. served at al~It was recognized that specialization was on the increase in industry, in education, and in medical practice. Why not Vocational Rehabilitation?
There appeared to be a very small proportion of the blind, the mentally retarded, and the mentally ill being offered rehabilitation services. To bridge this widening gap, counselors were selected to specialize with those particular groups of clients. As it was improbable that experienced counselors with special training could be hired, most agencies simply went about the not-so-easy task of identifying men who possessed an interest in working with the special groups and who had the other personality characteristics believed desirable for effectively working not only with the special client, but also with the community, center, or hospital teams who would also be involved with the impaired person.
Thus, the Agency gave recognition that needy clients were going unserved and that there was some basis for this unfortunate gap. In the case of the mentally ill, prejudices existed, of course, but the absence of vocational rehabilitation services here could not be entirely the result of intolerance or prejudgment. The element of time was important, too, but even more crucial was the need for general preparation in serving the emotionally disturbed client. These clients were not being served because they were different, because the counselor was not prepared
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to assist them, and because the community felt little or no responsibility for their rehabilitation and future.
Concurrent with the Agency's self-objectification were pressures developing from without; that is, other agencies, prospective clients, and other interested persons encouraged Vocational Rehabilitation to work with them. Furthermore, special demonstrations and research projects, partially supported by the Vocational Rehabilitation Administration, gave inspiration, support, and guidance to specialty programs, and some rehabilitation specialists originated from this source.
Findings (or feelings) concerning specialization were referred to generally as advantages and disadvantages. It appeared that the discussion groups commenced coming to grips with the issue by stating the pros and cons of specialization. The first fact brought out was that there were discrepancies or discrimination in the area of salary administration. It was brought out that some "specialists" receive more pay than others, for example, counselors for the blind were the first so-called specialty group established in the state, but none of those counselors receives additional pay as do the specialists working with the mentally ill and the mentally retarded. On the other hand, it was revealed that only about one-half of the other specialists actually received more pay than the general rehabilitation counselors. Therefore, there appeared to be a morale problem because the general counselor thought all specialists were paid better than he, the counselor for the blind thought himself to be the only specialist not receiving specialist pay, and the other specialists, such as those working with the emotionally disturbed clients and the mentally retarded clients, had no clear understandin2; as to why the man in the next office received specialist pay and yet he did not.
It was admitted that specialization was economically unsound and unfeasible in some sparsely populated rural areas. This implied that the general counselor would continue serving everybody living in or returning to his geographical area. Would this counselor be a special sort of person? If not, effective work by him would possibly contradict previously made statements concerning the need for a person with special knowledge, talent, and training to work with the special disabilities.
The problem of communication was discussed as some felt that specialization and its ramifications contributed to the gap in counselor inter-relationships. It was suggested that both counselors and specialists frequently experienced misunderstandings and frustrations in trying to coordinate services and get the job done. It was mentioned, for instance, that the hospital counselor (and the treatment team) probably did not understand why the field counselor did not make the desired early contact with the recently discharged patient, for example, the field counselor was concerned with itineraries, pre-arranged appointments, and
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so forth and could not drop everything and implement the continuation of services recommended by the hospital treatment team.
There was mention that the counselor overly concerned with "production" would meet frustration if he should enter the specialty field. The following discussion dealt with the unusual problems experienced in working with the specialty groups, giving recognition that the service rendered was primarily counseling, guidance, and selective job placement rather than a purchase of services. There was further mention, although slight, that the special counselor may need less difficult cases to work with from time to time to give him some relief. The specialists present, however, saw little merit in this proposal, as they tended to see all clients as challenges, but in varying degrees of complexity.
Rehabilitation services have been expanded in all phases of the general program, but with more intensity in the specialty areas. As an example, rehabilitants with psychiatric diagnoses constituted 8 percent of all closures in 1964 as opposed to 2 percent in 1954. Encouragement and stimulation by the specialty programs have assisted the Agency in rendering more and better services not only to the specialty groups, but to all handicapped individuals. It appeared further that specialization while making services available to specialty groups, would also allow the general rehabilitation counselor to continue being the Agency work horse by meeting and bettering production quotas each year.
Specialization and smaller case loads seemingly allowed more counselor (specialist) time with clients (and treatment teams), and thus provided a climate for concentration of effort which is believed required for effective work with many of the severely disabled.
It appeared that, partially as a result of specialization, case finding was simplified in certain sections of the state. There, the specialist has been recognized as the rehabilitation expert and the substantial service he has rendered and the professional image he has presented have served to reassure the individual client and the community that they are being adequately served. Case finding has been simplified where communities have been oriented and familiarized with the specialists serving specific disability groups, such as the blind, mentally retarded, and emotionally disturbed. It was felt that specific and direct referrals would be facilitated further.
The concept of specialization is rapidly gaining acceptance in private industry, in government work, in professional services, in education, and in many other areas of employment. Peculiar problems of the industry or services have been recognized as needing special attention, for example, there may be a need for mechanical or human engineering to resolve a particular problem or there may be a need to hire a specially trained man to handle a very special type job or problem.
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Specialization, per se, does not seem to be as important or crucial as does its manner of use. In Vocational Rehabilitation, for instance, the so-called specialist was considered no more likely to neglect the client as a "total individual" than the field counselor who has traditionally focused his attention on the physical ailment and the task of getting the impaired man back to work.
It was recommended that the state continue to develop specialty services, at least until the time that all counselors are prepared to work at the specialist level of functioning. The preference for specialization has been enhanced by the opinion of professional persons in the medical field who believe that the average rehabilitation counselor (across the United States) lacks the interest and capacity for serving severely impaired persons, such as chronic state hospital cases.
There was discussion about different levels of rehabilitation counselors with recommendations that these men be recognized by the Agency on the basis of their training and capacities rather than by their identification with a particular disability group. It was also recommended, however, that when a disability group was recognized as needing special attention or specially trained counselors, that the staff serving them be treated on an equal basis with other specialists.
It was requested that specialists (or counselors) for Milledgeville State Hospital cases be located in each district (as is now done in Atlanta) in order to facilitate the movement of these patients into the communities and also to familiarize the local counselors with psychiatric cases from the State Hospital, and to work with them as needed.
In addition to the above recommendations, there was a request for further defining of individual roles. In discussing the problem of communication between general counselors and specialists, and between others in the Agency, it was recommended that the Agency take additional steps toward clearly defining chains of command between all staff members. It was also recommended that there be a closer tie within the ranks of specialty groups and between the specialty groups and the field counselors.
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j j j j j j j j j j j j j j j j j j j j j j j j j

Dr. L. L. Havens is A ssociate Clinical Professor of Psychiatry, Harvard Medical School. He also heads the Psychiatric R ehabilitation Internship Program, Massachusetts Mental Health Center, Harvard M edical School, and is Chief Psychiatric Consultant, Massachusetts R ehabilitation Commission. He is the author of numerous publications on various aspects of human behavior.
SKILLS AND PERSONALITY REQUIRED TO EFFECTIVELY COUNSEL THE EMOTIONALLY ILL
The problem of specialization is one that touches almost every facet of rehabilitation, from the question of salaries to issues of administration, from the type of cases selected to geographical problems of distribution and referral. I am going to concentrate primarily on the psychiatric aspects of specialization, but at the end I shall take the liberty of listing what I think are the principal difficulties of specialization, especially those which bear on psychiatric work. You should regard any remarks that I make with great skepticism, since medicine has a frightful record with this same problem of specialization. Perhaps you can teach medicine how to live with the enormous increase in types of cases and specific knowledge and not "splinter" your profession into forms that actually interfere with certain aspects of the best practice.
I suggest to you that there are four features of counseling that are crucial in the selection of vocational rehabilitation counselors for psychiatric work. Only the first two are special to psychiatric work and are required in order to be effective in psychiatric rehabilitation. The first and by far the most important is the capacity to like the group of clients to be psychiatrically rehabilitated. The second is the capacity to be objective about the facts of human nature. This is almost as important. The third is the capacity to be interested in doing something about the facts of human nature. Finally is the ability to get things through congress. Every man's mind is a congress, and your capacity to maneuver things through people's motivations and objections is part of your capacity as a counselor, psychiatrist, or any other of the helping professions.
The most important qualification in my experience of selecting people for mental disability work is that they like the clients. You may say, "People will not go into the work unless they have some liking for that type of client", but we know this is not the entire story. The question of pay raises, opportunities for advancement, and a whole complex of
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features affect the appointment of people to work. I will suggest a little later some ways to test for the features I am describing.
The greatest difficulty that stands in the way of helping mentally disabled people is the fact that they are often very difficult to like. Stated another way, the greatest difficulty that stands in the way of helping psychiatric patients is our own personal reaction to them. This is what throws dust in the eyes of the clients, the office, the supervisors, the counselors, everybody. It is for the most part a fact that mentally disabled persons set up within us certain attitudes of repugnance, disgust, hostility, despair, anxiety, or the like.
Let me illustrate this to you by listing the types of cases which in any sturdy and fruitful practice of mental disability work you must encounter every day. One of the first things I tell each new group of medical students whom I teach at the Harvard Medical School is that they must get used to their own reactions to mentally sick people, and they should remember that if a patient has been hospitalized in a mental hospital it is primarily because no one in the community can stand him, and no one else can help him. The same thing is true of general hospitals. The major reason you go to a general hospital is that people do not like to see all the blood and pain around, including yourself, of course. The blood and pain of psychiatric patients lie not in the red stuff that comes out from a wound or broken leg; they lie in the emotional responses, reactions, and ideas of people in contact with each other. And anxiety, depression, and sadness are no more popu1ar than blood and pain.
The following is a list of seven types of difficult people. All of us fall, to some measure, into one or two of these groups. The first, and one of the most difficult groups of patients with whom psychiatrists, counselors, social workers, and psychologists have to deal are hostile and argumentative people. There is little need to tell you that in the presence of argumentative people the normal human reaction is to argue back, and that it is seldom a usefu1 reaction. Half the wisdom in the world consists of listening to argumentative people and not arguing back, but the temptation to argue back is almost irresistible, especially in the presence of the most argumentative people in the human race who are called, for purposes of medical convenience, paranoid people.
Second, there are many people in the world who want to suffer and fail. They want to suffer and fail just as desperately as most of you, I hope, want to succeed, and they may be just as adept, or more adept. at failing than many of you are at succeeding. The temptation every counselor or psychiatrist faces in dealing with a person who wants to fail is secretly to agree with him. The temptation in dealing with the depressed person, who characteristically wants to fail, is to stop the world and let him off. He persuades us that he is right and we may, quite inadvertently, stop the world and one way or another, let him off.
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The third group are people we might call the 'mentally deaf'.* These people on tests of audiometry and other scientific devices can hear everything that you say to them, but when you talk about anything they consider unimportant or too important, they hear nothing. Some of us are deaf to our wives at five or six o'clock in the evening; so that we know the phenomenon. Some of us are deaf to certain kinds of people, but there are people who are specialized in not hearing what the world says to them and many of them wander into your offices. The temptation is to pretend that they hear you when they do not, to pretend that they understood what you suggested, the plan you have outlined, or the vocational course you have indicated. Indeed, the only thing they may have heard is the continuous internal ticking of their own feelings and ideas, and you may not have penetrated to them at all. The amount of patience they require makes it easy to forget their deafness, a temptation to which many of us fall victim every day.
The fourth, and this is a very large group of people we must take care of, are the passive and dependent. It is a popular group to talk about presently in view of the effort to do something about povertystricken people of whom a large number are passive and dependent. The temptation the counselor should resist here is the "all or nothing" alternative. (I mention these temptations because counselors who fall into them too easily are people who need either to learn more about pathological behavior or not to do this kind of work.) At one moment you throw up your hands and say you will not do another thing for this person because you are sick and tired of beating your efforts against the wall of his passivity and dependence, while the day after you realize, or feel you realize, that you must now do everything for him, if only to get the case off your hands. There are many people in life who are specialized in taking your most devoted efforts and giving them a third degree turn which points right at a large hole in their vocational futures into which they, under your careful direction, stumble and fall. The passive and dependent often have this gift.
The fifth type of person none of us likes. I suppose there is only one group of people in the world we like less than the group I am about to mention, and these are the people who have perversions of one type or the other. I shall not talk about perverse people because I do not think many of us are ready to deal with them. I will instead talk about another very unpleasant group of people who come to the attention of psychiatric counselors-people who lie. Lying is an interesting subject from many angles. Everybody lies, but the lying that everybody does is called white lying. This lying is done in the service of social convenience, peace of mind, or one or another of the virtues that more or
*I am indebted for this term to Christopher W. Havens.
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less inhabit the world between the ethical and the non-ethical. However, there are people who lie more seriously than that. In addition, there are people who lie and do not even know they are lying because they live in such a completely imaginary world. It is extremely difficult for most of us to accept the fact that the tendency to lie may be just as much a disease as tuberculosis, and just as dangerous in many cases.
The normal human response to discovering that somebody is a dyed-in-the-wool inventor and incorrigible liar is to dislike the person enough to throw him out of whatever office he is in. Few of us are saints and self-sacrificial enough to put up with just anything, and I am giving you this list not to urge that you add a lot of liars to your case loads-you probably have too many there already-but because I want to give you the range of human despicableness and difficulty, the reception of which has to be one test of whether a person really wants to do psychiatric rehabilitation.
The next group is usually more fun. They beguile us; in fact, they often beguile us into just as much trouble as the first-rate liars. The sixth group is the grandiose and megalomaniac, the persons for whom life is an external promise. They are always prepared to sell you a new plan, vastly outside their ability, but a plan that they are devoted to; and any restriction on that plan is automatically a sign that you do not understand them, do not like them, and are not prepared to go to the death for them.
These are some of the most difficult people in the world, because as with the passive and dependent, we can fall into one of two quite different but equally unfortunate traps. Very often they beguile us and we pursue their visions. When we find out that their visions are just visions and delusions, we then turn around and, as with the dependent people, want to do nothing for them. You should be aware of the very natural and intense personal reaction that we all feel to disappointing grandiose patients' expectations and your sense of being let down and thrown off by the discovery that they cannot do what you may have hoped. The alternative trap is to be too skeptical and negative from the very start; so that you lose touch with the grandiose person's needs. You must walk a fine line between skepticism and support.
The seventh and last group is called technically in psychiatry, hysteria. This is one of the conditions that makes our life worth living, constantly enlivens the excitement of the office, and gives us all a respite from serious work. It is not for a moment to be neglected, forgotten, or thrown out, but contains a special kind of peril. Everything you do for the typically hysterical client becomes a question not of whether he or she is vocationally ready, or the plan realistic, or training a real need, but whether you love them. Do you like them? Do you respond to them?
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Do they excite you? Many of these people are very attractive, and they are easily loved. As the plan develops and you fall in with it (these clients are usually women and, of course, the majority of people in the Vocational Rehabilitation Office are men) you feel a sense of excitement and anticipation before every interview. Beware. You will begin to realize that what counts for you now is the affection of this person, not the vocational objective so much, but the visit which is fun, or the person's response to you, which is even more fun. You can forget everything because of these clients, including the remainder of your cases. One's case load may fall slowly apart when these people who have a genius for making others attentive and even loving appear in the Vocational Rehabilitation world.
I mention these different types of difficult people because one principal test that you have to bring to bear in deciding whether you have someone who can specialize in mental disability work is the person's capacity to like these particular individuals enough to work with them. Counseling and psychotherapy come together around what we can term the paradox of objectivity and intimacy. If you are to counsel someone, you must be friendly with them, but to be effective you must also be objective. It is especially difficult to be both objective and friendly when you are dealing with dependent, hostile, megalomaniac, or depressed people. When you are trying to be objective, you must stand back, be a little unfriendly, a little cool. If people are very sensitive, they will sense that you have stepped back and they may be very annoyed with you for not being on their side all the time.
At the same time, if you are friendly with someone, you cannot be too objective-you have to see it from their side. In psychiatric counseling and psychotherapy, there is no place you can stand. You cannot be just objective or just friendly; you have to be moving all the time back and forth between these two points. If you stay objective, they will think you are a "cold fish" and go to somebody else. If you stay friendly, you will not get anything done.
Many of you are old hands at this. You have been doing it without thinking for as long as you have been in this business. It is a crucial part of psychiatric rehabilitation.
The third point requires only a sentence or two. To do psychiatric counseling, you must want to do something about the problems the clients bring. It is not enough to like the clients, it is not enough to understand them, you have to want to do something for them. You must have what we call in medicine a "therapeutic urge". In my experience with rehabilitation people, they have a very strong "therapeutic urge". In fact, if there is any sin they have, it is they sometimes possess too strong a "therapeutic urge". They often do things for the client that perhaps the client would be better off doing for himself.
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The final point under this heading I want to discuss is something I prefer to call the capacity to get things "through congress". I call it that because we have now in the Presidency of the United States a man who has the largest ability to accomplish this of anyone who has ever had his job. Whether or not you like what he gets through congress, I am sure that most of you have admired his extraordinary ability to take a mass of people and by the most incredible manipulations produce the results that he wants.
A counselor must get certain things through his client's congress. He has the same job that Johnson has; he has the same kind of things inside the head of one person that the President finds inside the congress -a number of conflicting aspirations, skills, a complexity of different motives, interests, ideas, and memories. Many of you are past masters at this and can size up someone in terms of the specific movements, remarks, and urgings that will get a reasonable plan through the congress of that client's mind.
One of the saddest things about this whole work is that very often we find people in the agencies and medical schools who have an extraordinary ability to operate in what is called office politics. They can get their own causes triumphantly through the congress of the office, promotion boards, or the governing bodies-the politics of institutions. I have often said to myself, "Oh, if that particular individual would use his skills for the advancement of patients, clients, or students which he uses in such marvelous measure for his own self advancement, he would be one of the most helpful people in the United States". Sometimes you must make a decision as to whether that zeal and skill in getting ahead can be turned equally to the client's promotion. These are old things with you and they are certainly not specific to psychiatric rehabilitation. But the first two are-the capacity to like a certain class of difficult people, and second, to understand that class of difficult people.
The best way to find out if someone likes the clients enough to work with them is to ask the counselor to discuss his case load. If he cannot remember anything about them, if he can only remember the most unfriendly things about them, or if you can read on his face the distaste that he feels for these particular types of cases, you will know fairly well what kind of people he really just does not like. There is one peril here. Many people, if they like you enough, will tell you the most dreadful things about their psychiatric cases as a sort of unburdening or catharsis. This does not mean that they do not like the cases; it simply means they are "letting off steam" in your presence, and that is different.
Secondly, to find out whether the counselor understands the cases, again you want him to talk about his case load. The prime question should be: How do you think this client is sick? Of course, you do not
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want a "highfalutin" answer in psychoanalytic or other terms, but you should get a feeling at the end of the discussion whether this client comes through to the counselor as a human being. Would you, for example, recognize him from the counselor's word picture? Some of you undoubtedly have an ability to describe certain persons in two or three sentences-to rough them in like an artist-in a manner that would make them recognizable anywhere. Give the counselor a chance to see
if he knows the types of subjects he is dealing with, because if he does
not he will be lost. If you asked him what kinds of cases were on his physical disability case load and he got the orthopedic clients mixed up with the blind or deaf clients, you would be very seriously concerned as to whether he was ready for that kind of work. The same kind of decision is less easy with psychiatric cases, but it can be made.
Thirdly, when you are trying to find out if the counselor wants to do anything about his clients, ask him about the future of his cases. If he tells you they do not have any future, and if he tells you that about enough of his cases, you will know that he is basically discouraged, disappointed, and perhaps not interested in this group of people. You might be surprised at the number of counselors who really feel that way about mentally ill people, even though many of the mentally ill clients have sounder features than many of the physically disabled cases. If, on the other hand, you get an impression that the counselor is determined to see some way out for this particular person, you are obviously dealing with a lively "therapeutic urge".
Finally, you should ask the counselor to describe his plans for the psychiatric cases. Here the difficulties of being a vocational counselor come out plainly. The Vocational Rehabilitation Counselor has a job which is in many ways more difficult than a psychiatrist's job. You must inhabit not only the medical and the psychiatric worlds, but the legal, administrative, and a dozen other worlds. This comes down hard on planning. And the counselor cannot make just a vocational plan for his clients-it has to include at least a notice of the social problems and treatment problems as well. It is extremely difficult to trust your judgment on this last ability because some of the most effective people I have met in vocational counseling cannot tell you what they are doing. They are inarticulate. Of these four tests for judging people's potentiality for psychiatric rehabilitation, this is the one that I would trust the least, because not all practical people are articulate people.
In the material Bill Holbert sent me, he asked that I give some thought to the following questions: Should the specialists serve only in areas of their specialty, or should they serve in other areas also? What qualifications should an individual have before being considered as a specialist? What type or types of training should be provided for the specialist and how can specialized skills gained in training best be dis-
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seminated to unspecialized counselors? How can we continue to improve coordination and communication between specialties to insure one unit of Vocational Rehabilitation rather than splintered units? I shall make some remarks about each of these.
Obviously, the counselor should be trained in the basic work of the Agency first. Can university or college training, or Master's program provide sufficient information about the operation of the particular state agencies to obviate the need for some general agency training? I am not speaking simply of a six-week orientation course. My judgment is that before a person becomes a specialist, he should spend one or two years as a general counselor in an agency. That is, he must be a competent general counselor first, at least competent to the point of knowing the work of the agency.
Are we going to mean by specialty counseling restricted counseling, or are we going to make specialty counseling the sign of a special level of expertise? We could divide counseling from the beginning and say that the counselor is going to do psychiatric work, or work with the blind. On the other hand, we could say we think the counselor has developed certain special skills and has a special interest; therefore, should be promoted into specialty work or consultation. These are different things and no one, fortunately, can make rules for all the agencies. My own feeling is that we would be better off with the second of the two alternatives; that is, starting from a pool of general counselors and working up to specialty designations. This would get around the very terrible problem of differences in financial rewards between sections of the agency. It might also help to avoid the unfortunate situation which has developed in medicine where it is difficult for the patient to find a doctor interested in a variety of the patient's complaints.
In my opinion, the general counselor should remain with us, handling perhaps the easier types of cases, but grounded in a wide experience. This is a debatable point because it may be that a general counselor needs to be more specialized, better trained, more effective, and better paid than any specialist. By the way, make sure that the specialist counselors actually handle the toughest cases, and not just the attractive ones!
Thirdly, there is the question of training. When we began to train counselors for mental disability work in Massachusetts, we started, as some of you know, with a tutorial program; that is, we sent counselors in groups of one or two to psychiatrists to discuss their case material once a week for an average of nine months. Most of the counselors in the Massachusetts Rehabilitation Commission were rotated through this program. There was discussion of case material in the presence of psychiatrists without didactic teaching. My theory in advocating this was that the main problem the counselor had at the beginning of the
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work was his fear of psychiatrists and of emotionally ill clients. I thought that the bestway to do something about this fear was to get psychiatrists and counselors together, see that the two did not bite each other most of the time, and discuss case materials.
We have been criticized in a number of ways for this. Many have felt that it was not structured enough. I was very worried because I did not think psychiatrists were the right people to do this teaching and that they could not help but turn the counselors into psychotherapists -to mold the counselor in the psychiatrist's image.
We have entered a second phase of the Massachusetts program in which certain counselors selected from the general case load counselor group-selected partly from the observations made in these tutorial sessions, and partly on other bases-were made mental disability supervisors. They have been given a four-month course (two hours a week) of didactic psychiatry taught from a textbook. It will be their job in the future to orient new counselors to psychiatric work. As a general principle, it is sound for the teaching within a specialty to be done by the specialists who are in the agency and not brought over from another profession. For example, the development of social work in this country has been seriously distorted, in my opinion, because social workers let psychiatrists take too much responsibility for their education for too long. You would be wise to keep hold of your training as much as possible when you have people you think can really do it.
Let me express another personal opinion, if I may. The Federal government has often been mistaken in promoting training on the basis of one, two, three day, or even a week or two-week institutes. In my opinion, these are seldom a useful form of education, particularly in psychiatric work. Much more prolonged, even if occasional, contacts between teaching people and students is a sounder way to develop programs of in-service training. I would put little dependence on brief institutes, visiting speakers like myself, and much more on relationships that are established over longer periods of time. Many of you are teachers and have strong links with your own educational theories and backgrounds; therefore, I probably do not need to emphasize this point.
Teach psychiatric counseling around case material. Do not teach it from books exclusively. A man can only afford to read a psychiatric book after he has done a good deal of case work. Nothing in psychiatric books is as good as exposure to psychiatric material. You know people whose minds are frozen by certain concepts they learned too early in their educations. They can talk about Oedipus complexes, reaction formation, and the like without ever getting to the material itself. Books are fine if you are sophisticated enough in psychiatry to use them, but the first experience must be around case material.
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The more specialization of counselors we have, the more we must worry about a psychiatric problem within the counselor group itself, and that problem is jealousy. The more specialization, the more separate groups within the agency, the more our energies will be given up to hating how much the other person has. It takes a very strong spirit to resist the enormous human capacity for envy. It is one of the great engines of life, this envy, and we must be careful as we specialize (and we are going to specialize whether we like it or not) that we do not release too much this engine of envy.
I have heard each time I have been in Atlanta that one of your most difficult problems is the question of the transfer of cases between general and specialty counselors. This is a problem everyone has. Continuity of relationship is one of the first principles of adequate care of mentally sick people, especially of the type of severe mental illnesses that you find in the state hospitals. We have to work out ways to provide enough continuity so that patients, often very shy patients who have difficulty forming relationships, do not have to form too many too soon after they leave the hospitals.
These are some of our problems and a little advice. One last piece of the latter: Keep track of your experiences and circulate what you learn. We are just beginning, especially in psychiatric rehabilitation, and cal) all profit from each other's experiences.
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COMMENTS
(Dr. Havens' Presentation)
AsA BARNARD
Specialist-Program for Mentally Ill
The thing that impresses me most about Dr. Havens' speech was his saying that it takes just a little something extra to work effectively with mental clients. I wonder just how many of us here are really buying this. Does it really take a specialist to be effective with clients who are mentally disabled? What are we talking about when we say specialist? Are we talking about counselors with special case loads? Are we talking of the counselors with super talents? Are we talking of counselors with limited talents? A person who works on an assembly line and does nothing but run up a nut or a bolt is a specialist, you understand. Are we talking about counselors with specialized training? Are we talking about an administrative tool to get a job done? Are we talking about pioneers who fear not to venture into a new and difficult field? I think these are some of the things that we might want to consider in our group discussions.
Dr. Havens' first major point is that to be effective with mental clients there must be a liking for people. We must like the hostile, the failures, the mentally deaf, people who will not listen, the passive, the dependent, the grandiose, and the love-testers. We must like all of these people. How many of us can really tolerate such a wide range of pathology? Here, again, I think that we are favoring his point that it takes a specialist to be effective with mental clients.
Another main point is "the disability". I felt he was emphasizing that the counselor must understand disability, whereas Dr. Patterson emphasizes counselor must understand the person. Maybe the generic counselor, the generalist, will recognize the person and will do something for the person, whereas the specialist might be too disability oriented and run away from the person in chase of the problem of disability only.
I would like to digress here for a moment and talk about our Milledgeville State Hospital Program whereby we have had a special project for three years, attempting to bring the very hard-core cases out of this hospital and re-establishing these persons into local communities. Here is a good example of just what specialization can do as opposed to the generalized counseling in an attempt to do the same job. Part of the project was designed to demonstrate this very thing. We were hoping to have some specific figures for you since all of us are accustomed to talking in terms of closure 12's and this kind of yardstick to measure effectiveness. The exact figures were not available, but let's say this: the
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cases that were followed through completely by the specialist-even though there was a transfer from the specialist inside the hospital to the specialist outside the hospital-resulted in about 75% success in rehabilitation. The figure for the regular caseload counselors for the same kind of cases under similar circumstances was just a little bit better than 50%. So, you can see right here a point for specialization.
Dr. Havens' total speech sold specialization so much that maybe no further mention should be made of this. Let me talk about a few of the viewpoints from the counselor's level. He talked in Harvard terms; let me talk in Atlanta counselor terms. In working effectively with clients who are mentally disabled, one of the very difficult things is establishing an effective counseling relationship. The paranoid; how difficult it is to put behind your own tolerances, your own prejudices, your own attitudes that would keep you from working with these hostile people and actually establishing a relationship with them that would permit you to assist the client. At the other extreme is another kind of client, the schizophrenic, who probably has never had any kind of successful relationship. You, as counselor, are the first one that will actually permit a close relationship to be formed, but there's the danger that it becomes too close, too intense, which could get into dangerous proportions.
Also, clients who are mentally disabled are really sensitive people. They have out the super antennas. If the counselor fills out the R-4 form at the same time he is attempting to interview a client, this individual might feel rejected. It takes good training and a great amount of attention that only a specialist can provide to develop an effective way of establishing counseling relationships with mental clients.
The next thing is counseling employers. When a counselor presents to the employer a physically disabled client, immediately he gains the receptivity, even the sympathy, of the employer. But when you present a mental case, the mental client, to the employer, immediately there arises anxiety, fear, doubt, and even rejection on the part of the employer. You then have to be the super salesman. You must be able to convince him, sell him, that it would be good business, a good risk, to accept this particular person. The relationship with this employer does not end at that point. You continue to work with him. You will find him to react almost like a client. He will feed to you his anxieties, doubts, and fears. You must cope with them and counsel the employer much like the client.
There are many instances when these crises happen at a time when professional assistance is not available, such as at night. A counselor handling this kind of disability must develop a high degree of tolerance in order to withstand the extreme anxiety to be able to act with confidence and assurance and this requires specialized experience, specialized training, and specialized capability.
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Most mental clients are rehabilitated through joint efforts of several agencies andjor persons. The successful counselor has learned to work effectively with the other mental health disciplines within the community. These other disciplines have a vocabulary of sophisticated psychiatric terms. They are going to have their own special ways of communicating, and unless you are capable of fitting in with them in their language on their terms, it is rather difficult to get their full cooperation, and this you must have.
Next I would like to mention the termination of counseling relationship. When I was serving the physically disabled, it was an easy thing to terminate such a relationship. All I had to do was get the client to fill out the Georgia Employment Questionnaire form and that was good-bye, but with clients of mental disabilities, this is not the way it is done. You have to prepare the client for this termination and have sufficient strength developed within the client so that he can carry on by himself. To prepare the client is a long and very specialized process. The Employment Questionnaire form alone is certainly not sufficient. The person working with the mental clients must be able to discern when the client is prepared for termination of the counseling relationship. It takes something special to render correct judgment in this matter.
One of the most difficult things regarding selection of mental cases is determining how ill the client is. Among physically disabled you have a person with a leg that is missing, and you know right off how limited this person is because of the missing leg. But there is no such indicator for mental illness. This very fine discrimination of when a person is disabled enough to become eligible and when he is too disabled to be feasible requires a high degree of specialized skill. There are no black lines, they are all gray, and it requires special abilities to recognize them. This is one of the most important areas, most important aspects, of counseling the emotionally disturbed-to be able to select the appropriate cases for services, either inside the hospital or outside the hospital.
Dr. Havens mentioned man's mind as being a congress. I would like to think in terms of a Vocational Rehabilitation Agency as being a congress. Often times the administrative structure does not recognize what you are attempting to do with clients. Also, you do not know how far they will permit you to go in extending services, or just whom they will permit you to serve. You as the counselor, you as the specialist, must be able to define your role and be sure that it fits in with the administrative policy. You must get through the Agency congress so that the administrators accept what you are doing.
In working with mixed caseloads a counselor must be able to change tempo. The physically disabled move at a certain pace and you adjust your work, outlook, and movement to that speed. But mental
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cases move so differently. They progress much, much slower. I do not see how one person working with the physically disabled and who suddenly gets a slow-moving schizophrenic can change pace fast enough. This change of pace, this change of tempo, is just not a practical expectation from one person. This is another reason why I lean toward specialization; that is, assigning counselors to special caseloads.
I agree that training counselors to work with mental clients has been most effective by centering on casework materials. In Atlanta we have found this to be a very effective way. Our Atlanta District now has been working with a psychiatric teacher, a psychiatric consultant, for many months. The approach to the counselor is through the casework materials.
Short-term training may be questionable as to benefits for counselors in working with mentally disabled clients. We have used shortterm training in Georgia. I believe that at one time all the counselors were provided a four-day training program at the Yarbrough Center at Milledgeville. Also, some plans are now under way for a repeat of this program, to begin soon after the new fiscal year. What agency can afford long-term training? What has been the result of the short-term training in Georgia? These might be good points to discuss in our groups.
Concerning the higher salary scale for specialists; people who work with mental clients certainly do earn extra pay.
A question which might be of interest for further group discussion is: What does working exclusively with mental clients do to a counselor? First, we know that it makes for a great deal of wear and tear, and frankly, this is the big concern that I wish to point out. You have a frame of references that changes, shifts from day to day according to your intellect and experience. If you work exclusively with clients who are mentally disabled, does this frame of reference shift so far to one side that one loses a little touch of reality? It might be better to mix in a few cases of other types of disabilities in order to maintian a broader based, more realistic frame of reference.
I would like to refer back to Dr. Patterson's presentation and say that certainly Dr. Havens concurred that a broad, basic generic type of training should come first, and afterwards any specialization should transpire. I do not think we have argued this point. However, in the mentally retarded program in Georgia we have brought new counselors immediately into specialization. I ask you, should this matter be aired in some of our discussion groups? How effective are these brand-new counselors in their special category?
As Dr. Havens said so well, we must understand the mental client, we must avoid the pitfalls and traps into which he can so adeptly lead us.
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GROUP RESPONSES TO DR. HAVENS' PRESENTATION
An initial premise was that one of the causes of counselor specialization in the area of emotional disturbance was the particular type of counseling that was peculiar to the handicapped. It was agreed that special knowledge and experience in dealing with various types of behavior patterns and personality characteristics were necessary. Particularly noted was of skill and ability in being able to recognize "masked behavior". It was brought out that tremendous amount of time beyond the normal time considered for counseling would be required with the emotionally disturbed client. The necessary therapy tone of the counseling with the emotionally disturbed client was also brought out. There was considerable discussion as to the resistance or reluctance of the general counselor in the field to accept the responsibility to learn to work adequately with the emotionally disturbed client. One district supervisor advised that there was no problem in his district and that all of his counselors were doing a more than adequate job and did not feel uncomfortable or threatened at any time by this client having this particular handicap. However, it was brought out additionally by other professional people, including Dr. Havens, that this was the exception rather than the rule, by and large the general counselor in the home town areas was not as comfortable and as efficient with mentally disturbed clients as he should be. There was some question, however, as to how this could be elevated. Again, reflecting the subject that there must need be special counselors in this area.
Emphasis was given to the great need of involving the community in any counseling and rehabilitation attempt the local counselor might make. The concept of rehabilitation residences was approved and supported. The necessity of less pressure for closures and numbers and more opportunity for follow-up and intended supportive counseling was indicated as one of the effects of counselor specialization.
Emphasis should be given to a refinement of the naming of specialty contingencies within these several units, as well. Under this might be a set of criteria to guide in the defining and classifying of these specialty groups. It is recognized that the adaption of this or some acceptable set of policies promotes and stimulates mutual understanding and goodwill. There is the danger that specialty groups might infringe upon the services offered by the Health Department, Crippled Children's Division, and other programs. Perhaps an overall code of ethics should be established for our own functioning, operation, and purposes.
It was noted that one of the effects of counselor specialization is some inevitable breakdown in communication between counselors in conjunction with institutions which transfer emotionally disturbed clients
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through the local area and rural and suburban areas. One of the answers, perhaps, might be the counselors specializing in this area as a consultant and having responsibility within a given geographic area for the local counselors involved. All in all it was felt that some of the causes of counselor specialization in the area of emotional disturbance are:
1. We are moving in a direction of more severely involved clients and this requires the necessary intensive counseling.
2. The special counselor has special knowledge, skills, understandings, and habits before he can adequately deal with this client.
3. Another cause would be that the local counselor does not have the time to adequately counsel the emotionally disturbed client if they comprise a major part of his case load. However, a small percentage of his case load might be made up with these clients and the counselor still function adequately if adequate community resources were available and reliable.
Therefore, the effects of specialized counseling would be better understanding of the client, more adequate counseling, the development of an ability to move into, heretofore, unpried ground and deeper and more severely involved cases.
Another effect would be the lessening of the number and time requirements on counselors who work with the emotionally disturbed. Another effect would be the necessity of additional specialized training in this area. The necessary establishment of exceptionally good lines of communication and procedures so there would not be a breakdown and transfer from special to general counselor of information is another effect.
Above and beyond all is the moral support we must give each other. I would like to conclude on a serious note. Let each of us emphasize understanding and minimize concern for being understood. Emphasize willingness to give of self, rather than receiving. Demonstrate emphatic qualities and subdue our own self-preoccupation.
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Dr. Jasper Harvey is Professor and Chairman, Department of Special Education, University of Alabama. He was Research Associate, United States Department of Education for two years. His publications include articles on education, training, and rehabilitation of the mentally retarded.
SKILLS AND PERSONALITY REQUIRED TO EFFECTIVELY COUNSEL THE RETARDED
Perhaps if I defined the general working term for mental retardation as accepted by the President's Pane1 on Mental Retardation, we'll be using the same frame-of-reference. That definition is: "Mental retardation is a condition, characterized by the faulty development of intelligence, which impairs an individual's ability to learn and to adapt to the demands of society." (I. p.6) In rehabilitation we actually are concerned with ability to adapt. This is the major problem in helping to make retarded individuals placeable in some type of job setting.
To give you some feeling as to how I react to mental retardation and some of the feelings that a teacher, a Rehabilitation Counselor, anyone who works with the retarded, must at least give some thought to, let's consider the model in Figure 1.
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In considering the various sensory modalities which come into play when we work with any individual, and particularly with exceptionalities, this model is one which may be manipulated any way one wishes. For example, if Mrs. Bauman were doing this, she probably would want to put vision at the top, and if Mr. Whitworth were doing it, he would want to put audition, some would give prime consideration to other modalities. This would be the model which we would need to consider rather carefully when working as a counselor or as a teacher with retarded children and youth. At the top is somatesthesis or real "gut" feeling-how you react to people, to individuals, and, of course, very closely related to somatesthesis would be vision and audition because as more directives from the national level-and let's face it, the reason that state rehabilitation agencies are concerned with mental retardation today is that directives have been made-they have said rather specifically, "Work toward rehabilitating or habilitating individuals who are retarded." At this time we're more concerned with the educable retarded, approximately 50 to 70 or 80 intelligence level. It probably will not be more than two to three years until the lower limit will be into the 40's. This is frightening in a way, but it's coming and at that level counselors will be working with visual stigmata such as mongolism. When one first sees the more severely retarded individual and begins to hear their level of speech, or to see their inability to speak intelligibly, there will be some very specific "gut" reactions which can affect the ways in which one goes about effective planning for their habilitation. In institutions, or when making home visitations, "gut" reaction often comes into play because of olfaction-some homes aren't very pleasant. Gustation enters in since frequently the first thing one is offered is a cup of coffee. Our teachers who are in training are told that when they make a home visit, regardless of what is offered them, at least take some of it. In the west we frequently deal with Latin Americans and Indians and one of the greatest affronts is to be offered coffee and to refuse it. It may be in a badly cut can but you still should take some. If you don't you've lost them as a client. My perception doesn't change too much in the southeast because a cup of coffee is hospitality, and if you reject hospitality then you have rejected the client.
Tactile sensation refers to touch. In kinesthesis as a sensory modality, there is a more critical aspect with the blind than any other disability. This modality refers to deep muscle reaction and affects and spills over into orientation in space. For what it's worth, be aware of these "gut" feelings and realize that they are going to be there. In some way, work through your own feelings about mental retardation if you're going to work with retardates so that your reactions don't come between you and your client.
A second broad consideration, let's consider quickly the mimeo-
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graphed data, "Mental Retardation: Its Emotional Impact on Child, Family and Community" (Appendix). This is somewhat psychiatrically oriented as Dr. Adamson is a psychiatrist. Many of you know him through his work at the Woods Schools in Langhorne, Pennsylvania. These data have some real meaning in skills and personality factors that we are considering. Regarding cultural reactions to mental retardation on page 52, there are actually three levels of maturity, both for the community and the parents. The first, the subjective level, second, exploration level and third, objective level. At the subjective level, the social worker and possibly the school will be having to deal with parents while by the time rehabilitation gets them let's hope they're at least at the exploration level-both the community and the parents. Referring to "cause?" on the exploration level, it needs to be pointed out that at the level of knowledge that we have today in three out of four cases of mental retardation one can not specifically describe the etiology or causative factor. Only one of four can be identified as having brain "insult" from a medically diagnostic standpoint and with the others it simply isn't known what the entity may be. At the objective level from the community phase a great deal has been done as a result of President Kennedy's interest. The public law under which special education is operating in training programs, community mental health facilities, and many other aspects is the direct result of that interest. Senator Hill has introduced Senate 1400 to amend Public Law 88-164 while Representative Fogarty of Rhode Island has introduced the companion bill, HR 5850. These will provide more monies for basic diagnostic, training and education programs. A tremendous amount of money is being funneled into these programs, but in the main, they can mean the difference between whether a youth when rehabilitation gets him at fourteen, fifteen or sixteen, can be rehabilitated. I am convinced that vocational rehabilitation for the retarded, or for any other exceptionality, begins with identification of the disability, be the child three weeks or three years of age. In the research that we did in Alabama (RD-842) which considered curriculum, one of the factors that became increasingly clear was that many of the youngsters that came to us really had been "lost" in the rehabilitative sense, years before.
In the figure on page 54 of Appendix, there is an ever widening circle of social awareness and the wider this becomes the easier it's going to be for those of us who are concerned with rehabilitation to do what needs to be done for the retarded. On page 53, the child's reactions to mental retardation, and these too are at difficult levels, I will not go into those, but consider them. On page 55 there is a model for "Long-Term Child-Family-Community Planning Service" and you will note that under "Program," vocational exploration and counseling, vocational rehabilitation has a very specific role. At this time only three
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percent of the mentally retarded are getting some kind of service from vocational rehabilitation. This three percent means in the 1960's approximately this: three percent of five and four tenths million people of all ages who are mentally retarded, then when one considers the families that mental retardation touches very directly this involves an additional twenty million people or approximately ten percent of the total population! One can see why we're beginning to get pressures and I don't perceive those pressures as being lessened.
Now to explore some of the necessary skills and personality factors. I've implied a number of them. Paramount among the skills required to effectively counsel the retarded is a basic understanding of the reasons for vocational failure among that group. In summary, studies seem to indicate that personal adjustment and interpersonal relationships are the critical factors affecting a retarded individual's ultimate vocational success or failure, and not the job itself.
Engle (1952) indicated that the primary cause for failure was that upon leaving school the retardate has no conception of what the working world expects of him. They find it difficult to remain at the same task for eight hours at a time and she suggested that "possibly, the school has failed to give them the necessary training." It should be emphasized, however, that "not all retarded youth will be successful workers-but neither is this true of normal individuals." Engle did an unpublished study in Detroit which concerned 66 male retardates in employment and subsequently dismissed. Employers listed reasons for dismissal as "talked too much, irregular, not punctual, and could not follow instructions." She added "that none of these reasons included the inability to do the work." Engle also listed the workers' reasons for quitting their jobs. Those included "too hard, didn't like the work, too far to go, too dirty, and didn't make enough money."
Cohen (1960) linked social adjustment to vocational failure. He analyzed the vocational failures of 57 mental retardates placed in the community after a period of institutionalization. A summary of Cohen's findings indicates: ( 1) that only in rare instances were the workers unable to meet the skill and strength demands of the job, (2) about one third of the cases were reported as having some difficulty in community adjustment rather than on the job, (3) a major reason cited as the cause for failure was a generally poor attitude with regard to the job, and (4) an appreciable number demonstrated lack of readiness for employment or difficulty in adjusting to employment, as distinguished from lack of job skills. Lack of readiness was indicated in terms such as "immature, lazy, or vulgar."
Cohen's study again indicates that vocational failures of retarded workers seem to be due to difficulty in community adjustment, poor
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work attitudes, lack of readiness for employment, and difficulty in home adjustment.
Peckham (1951 ) , working with a team of ten rehabilitation counselors, examined eighty representative cases of clients and then defined prominent problems that occur immediately following initial job placement of the retarded. Those were reported as follows:
l. Client acceptance by fellow workers. Each counselor indicated that this problem was paramount with all clients. Reports emphasized that ridicule, teasing, and practical joking were severe and ever recurring obstacles confronting the retarded, and this was listed as the most frequent condition for terminating employment.
2. Lack of social and vocational sophistication. A second problem which was common to all reports was the lack of "worldliness" on the part of the mentally handicapped. Five examples were: ( 1) The study indicated that the retarded often displayed a rather naive disregard for punctuality, dress, and general deportment. (2) They also found it difficult to manage the problems of transportation, particularly in urban areas, and where the problem was complicated by circumstances, they generally did not even try to get to work, nor did they phone their employer regarding difficulty. (3) The same was found to be true for such items as sick leave and vacations. Here again, they did not seek the advice of management but simply absented themselves until the time that they deemed it advisable to return. (4) They were unable to converse with management, and to a lesser extent, their fellow employees. The majority preferred that all transactions be conducted for them by the counselor. [Havens' "Passive and Dependent"] (5) It was also reported that in some instances, when clients were on their first jobs, many did not know how to handle such problems as the cafeteria, the time clock, or in one case-the rest room.
3. Lack of initiative and job responsibility. One of the most serious problems reported was the lack of flexibility on the part of these individuals. Upon completion of a unit task, they often would sit and wait for the supervisor to discover that the work was done, rather than making an inquiry on their own about what to do next. In some instances individuals were prone to continue doing an operation that was incorrect rather than to ask for help-they simply produced scrap.
4. Salary dissatisfaction. Another frequent adjustment problem was salaries, as many individuals found it difficult to distinguish that the types of jobs to which they were ordinarily assigned were not as "important" to the employer as were certain other
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jobs, and as a result, had difficulty in understanding the salary differentials. In a number of instances, it was reported that the retarded workers felt they were being victimized, and accordingly quit to look for something better.
5. Budgeting. Herein many clients demonstrated the inability to adequately handle their own paychecks. Money that should have been allocated for such items as laundry, lodging, and board were dissipated on trivialities. These personal difficulties, as expected, often created major job adjustment problems in the period immediately preceding pay day.
6. Thoughtless quitting of the job. It was reported that the retarded workers often quit their jobs without regard for the immediate consequences of unemployment. Job terminations of this type were generally for purely capricious reasons insofar as could be determined. Laziness and irresponsibility were believed to be the essential reasons for this behavior, although it was recognized that hidden casual factors of a different nature might also be basic.
7. Family attitudes. It was reported that status anxiety on the part of the family was a jeopardizing influence on the individual's job adjustment. Herein the parents often found it most difficult to accept the fact that their son or daughter would attempt employment at a level beneath the family dignity. These attitudes, when communicated to the client, were found to be a definite disrupting factor.
With the completion of this listing, Peckham stated: Job difficulty itself was not recognized in any of the studies as being a primary source of job maladjustment except insofar as certain aspects of it have been enumerated in the foregoing. Generally speaking, the complexity of the tasks involved was believed to be otherwise within the mental competence of the group in question. (450)
He later concluded:
One would feel that as youth in school approach the age of employability, their exposure to job and community sophistication might receive increasing attention in the curriculum in order that they might be better prepared to find and hold a job of their own. Practice on actual job internships, supplemented by experience within the classroom in the nature of practice interviews, filling out application blanks, job conduct, and the endless bits of social and vocational "know how" that separates the able from the unable would be an early line attack on a problem that to the individual involved is critical. (452)
In a recent joint publication by the Vocational Rehabilitation Administration and the Council for Exceptional Children concerning
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guidelines for coordinating services for handicapped children, eleven specific points were made. Those were:
1. DVR should work very closely with SPE to make for easy transition from pupil to work force. It is imperative that the two agencies work together.
2. DVR and SPE must anticipate the transition at 15 to 16 from pupil to the work force and plan for skills, knowledges, competencies; that is, the two agencies must work closely together and begin as early as possible with each potential client.
3. Both the school and the Rehabilitation Counselor need to encourage an attitude of optimism, however, don't underestimate or overestimate abilities. Research seems to indicate that too frequently ability is underestimated.
4. Schools, in consultation with DVR, should give work-experiences within the curricular framework (look at school maintenance).
5. SPE and VR should cooperate in finding, motivating, and evaluating youngsters who are so severely involved that they do not come to the attention of the public schools.
6. Procedures for classes should be established for all levels. Too frequently, no evaluation has been made concerning what is being done in SPE at the high school level.
7. The administration of DVR and SPE needs to recognize needs and add sufficient staff to carefully consider, deliberate, and make purposeful planning.
8. Specialized personnel will be needed and they should be oriented to accept "non-traditional" aspects. They also must not get into areas of non-competencies. THIS IS SAYING THAT COUNSELORS AS WELL AS SPECIAL EDUCATION PERSONNEL SHOULD NOT GET INTO AN AREA FOR WHICH THEY ARE UNTRAINED.
9. In-service training must consider objectives, opportunities, and roles for the counselor and for SPE personnel. Roles must be emphasized. A continuing redefining of roles needs to be considered. (TEPS and the new CEC Conference on Continuing Education)
10. Written agreements should spell out who does what-these are extremely important. They designate roles in advance and do much to help eliminate friction.
11. In cooperation, VRA and SPE need to involve any other public or voluntary agencies to provide the most effective kinds of services and other aspects for programming for retarded youth.
IN SUMMARY, THESE ELEVEN POINTS SEEM TO BE SAYING THAT SPECIALIZATION IS A REQUISITE.
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Basic to provision of vocational rehabilitation services for the retarded are the administrative commitments and understandings which will allow an individual counselor sufficient time to work with a client to assist him in working through basic problems which will make him employable. Included within this is the concept that habilitation or vocational rehabilitation for the retarded and thereby counselor effectiveness cannot be evaluated in terms of the number of closures during a fiscal year.
One group of retardates which has turned out to be "unplaceable" by the public school programs has been the intelligence level group 50-65 which frequently has youth with social and physical stigmata. Wirtz, at the Knoxville Conference, indicated that this is the group that most desperately needs the services of Vocational Rehabilitation and in order to provide these services, a specially trained individual seems to be indicated. Wirtz* further suggested that there is a group within the intelligence quotient range 40-60 which could be prime candidates for sheltered workshops provided cooperatively by DVR.
In assessing programs in Region IV, as well as on a national scale, it seems to be entirely too early to say what is good, what is bad, what is right, or what is wrong concerning rehabilitation for the retarded. There does seem to be a trend which indicates that rehabilitation has no desire or intention of "taking over" but that they are desirous of assisting in the development of guidelines for end products of SPE and are concerned with the development of an end product that is placeable within the labor market. There is some continuing questioning about the statements that have been made which indicate that some "disabilities" disappear at adolescence. Probably this refers to the fact that the retarded individual no longer poses a problem to the public school and in some way is placed on welfare or some other public kind of care and "drops out of sight."
Assessment of recent literature and trends seems to indicate that there is a growing need for vocational rehabilitation counselor specialization in the area of the mentally retarded. The specialization does not necessarily mean a "different" kind of program but it does mean that during the rehabilitation counselor training program individuals need to be exposed to the retarded so that they know what it is to work with them as well as understand who they are and what the "package" entails from a rehabilitation aspect.
*Director, Division of Handicapped Children and Youth, U. S. Office of Education.
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APPENDIX

MENTAL RETARDATION: ITS EMOTIONAL IMPACT ON CHILD, FAMILY AND COMMUNITY

A. CULTURAL REACTIONS TO MENTAL RETARDAT/ON''' (THREE LEVELS OF MATURITY)

I. Subjective Level
THE COMMUNITY STEREOTYPE!

Community Stigma Superstition Social Ostracism
Self-consciousness
Compassion to Repulsion
D. Wang's Study (Equated with delinquency in degree of negative connotation)

Parents
Self Pity
Revenge
Bereavement (Solnit, 1960)
Martyrdom to Abandonment
Acceptance-Rejection Continuum
Worchel-Worchel (Rated more negatively than their normal 'Child on personality traits)

II. Exploration Level
BREAKTHROUGH IN STEREOTYPE!

Who is this child? Where is he? What is family unit? Whose responsibility? How do we assist child and family unit?

Concern for own child Nature of Problem? Cause? Outcome? Our job as parents?

III. Objective Level
TRANSFORMATION THROUGH CONSTRUCTIVE ACTION!

Realistic Action Programs (NARC, Panel on M.R., Legislation)
Conservation of Mental Health in child, family, and community through educational and community services
Widening circle of social awareness and action. (Figure 1).

Interpretation
Discussion Planning
Working through feelings Year by year planning with Community Resources (see Outline Point D.)

'''After Texas Council of Churches Panel William C. Adamson, M.D.
The Woods Schools Langhorne, Pennsylvania

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B. THE CHILD'S REACTIONS TO MENTAL RETARDATION (AT DIFFERENT AGE LEVELS)
I. EARLY EGO DEVELOPMENT IN INFANCY (0- 2 years)
(1) FACTORS INFLUENCING NATURE OF PARENT-CHILD RELATIONSHIP, INTERACTION AND PSYCHOLOGICAL TRANSACTIONS. (a) VISIBLE OR INVISIBLE NATURE OF HANDICAP. (b) DEGREE OF DISABILITY (MULTIPLE CAUSES AND MULTIPLE HANDICAPS- OFTEN LIKE CHRONIC PHYSICAL ILLNESS). (c) PARENTAL FANTASIES ABOUT WHAT CHILD OUGHT TO BE; PARENTAL LEVELS OF EXPECTATIONS. (d) CHILD'S CAPACITY TO SATISFY OR FRUSTRATE PARENTS' EGO NEEDS AND ROLE STRIVINGS. (e) RELATIONSHIP TO OTHER ADEQUATE SIBLINGS. (Graliker, 1962; Farber, 1959). (f) CULTURAL FACTORS: RURAL OR URBAN; ENVIRONMENT, RELIGION AND ECONOMIC STATUS.
(2) DISTURBANCES IN PSYCHOLOGICAL DEVELOPMENT (EPIGENESIS OF EGO AS DESCRIBED BY Erikson, 1950, 1964 and S. Rappaport, 1960). (a) IN PRIMARY SELF-ORGANIZING EGO FUNCTIONS (e.g., MOTILITY, PERCEPTION, MEMORY AND LEARNING PATTERNS). (b) IN "PHASE SPECIFIC" DEVELOPMENTAL TASKS WHICH SHOULD BE SOLVED IN A CULTURAL MATRIX OVER AN AGE-APPROPRIATE PERIOD OF TIME (Erikson, 1950, 1964).
(3) FOCAL POINTS OF FRICTION, FEAR, FIXATION, FRUSTRATION, FAILURE AND FAMILY STRESS (normal contexts intensified).
II. SIGNS OF EGO INSUFFICIENCY IN CHILDHOOD INSUFFICIENCY vs. DEFECT ATYPICAL EMOTIONAL DEVELOPMENT vs. "AUTISM"
III. SIGNS OF EGO INSUFFICIENCY IN ADOLESCENCE SYNDROME OF PROLONGED EMOTIONAL DEPENDENCY, DECREASED MENTAL ABILITY TO DEAL EFFECTIVELY WITH LIFE ADJUSTMENT, EGO CONSTRICTION WITH DELAY IN PSYCHOSEXUAL AND PSYCHOSOCIAL MATURATION AND IMPACT OF TEENAGE REALITY ON TEENAGER AND PARENTS (Adamson, Hersh and Creasy, 1960).
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C. FAMILY REACTION TO SUBNORMAL CHILD'S INSUFFICIENT EGO
(1) UNFAMILIAR AND INCOMPLETE FAMILY RELATIONSHIP TRANSACTIONS
(2) FAMILY RELATED PROBLEMS vs. MOTHER-CHILD PROBLEM
(3) ROLE INSUFFICIENCY AND ROLE TENSION
(4) EFFECTS OF POTENTIAL FOR FAMILY FULFILLMENT
(5) IMPORTANCE OF EARLY, SKILLFUL PARENTAL COUNSELING OVER A PERIOD OF TIME (Carswell, 1958, and Hersh, 1961).

WIDENING CIRCLE OF SOCIAL AWARENESS AND ACTION
EDUCATE PUBLIC

DEMONSTRATE ACTION PROGRAMS (SERVICE-TRAINING-RESEARCH)
(

LEGISLATE FUNDS
(TRI-LEVEL)

INTEGRATE TEAM EFFORT IN SKILLFUL
SERVICE
~EDUCATE TEAM MEMBERS

APPROPRIATE SALARIES
(FOR TREATMENT TEAM)
--~

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D. LONG-TERM CHILD-FAMILY- COMMUNITY PLANNING SERVICE MODEL

PROGRAM
Early Identification Parental Interpretation Active Parental Counseling (Individual - Group)

FACILITIES
Child Guidance Clinic Mental Retardation Clinic Diagnostic and Evaluation Clinics Hos.,;tals anct Laboratories Well Baby Clinics

Family Physician and Pediatrician Public Health Nurse Service Day Care Center Opportunity Center Special Class Program

Family Physician and Pediatrician Local Departments of Health Community Agency
Public Schools Private Schools

Summer Residential Experiences for Patients and Families (2 weeks)

Community Agency Private Schools

Follow-up Surveys Annually or at Critical Age Levels

Child Guidance Clinics or other Facilities Listed Above

Active Total Treatment Program as necessary

Child Guidance Clinic Residential Schools and Treatment Centers Private practicing clinicians (psychologist, psychiatrists, and social workers)

Vocational Exploration and Counseling

Department of Vocational Rehabilitation Facilities

Long-term Socialization Vocational Habilitation

Own Home plus (Community Club) (Sheltered Workshop)
(Job Placement and Counseling)

Public Residential Schools (State)

Private Residential Schools

Group Boarding Home plus above

Foster Home Program plus above

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BIBLIOGRAPHY
I. Chart Book: Mental Retardation, A National Plan for A National Problem. Published for The President's Panel on Mental Retardation, Washington: U.S. Government Printing Office, p6.
II. Cohen, Julius. "An Analysis of Vocational Failures of Mentally Retardates Placed In The Community After A Period Of Institutionalization," American Journal of Mental Deficiency (November, 1960), 371-75.
III. Engle, Anna. "Employment of The Mentally Retarded," American Journal of Mental Deficiency (October, 1952), 243-67.
IV. Peckham, Ralf. "Problems in Job Adjustment Of The Mentally Retarded," American Journal of Mental Deficiency (October, 1951), 448-53.
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COMMENTS
(Dr. Harvey's Presentation) W. A. CRUMP
Supervisor- Program for Mentally Retarded
Dr. Harvey has brought us some excellent guidance in terms of understanding our situation, in terms of understanding the mentally retarded, and the characteristics and skills of personnel needed to work with the mentally retarded. I will not attempt to add to what Dr. Patterson, and others have said concerning special skills needed in special areas because it would be redundant.
I would like to comment only briefly on some of the points that I think I can relate to what Dr. Harvey has brought out this morning. One of these has to do with the research findings with reference to serving the mentally retarded - the characteristics of this particular group. He pointed out the lack of acceptance by fellow workers, the lack of social adjustment, and the inability to be on time consistently. It appears that these traits, which appear to be prevalent in this particular disability group, point up more and more the need for long-term cooperative service between Vocational Rehabilitation and other agencies, especially the schools in pre-vocational training.
Dr. Harvey made it quite clear that individuals who work with mentally retarded have to have "guts." I think it takes guts to be a Vocational Rehabilitation Counselor in the first place.
The trend of thought seems to be that the skills and personality required to effectively counsel the mentally retarded are basically the same as those necessary in counseling the emotionally disturbed and the severely physically handicapped. The difference, in my opinion, is the degree, the approach, and the content of this counseling. As you know, the mentally retarded as a group have two or more disabilities in addition to mental retardation. However, counseling is the major vocational rehabilitation service needed by the mentally retarded. The counselor who counsels the mentally retarded must be able to accept infinitesimal progress at infrequent intervals over a long period of time and delay the rewards. I found it quite a contrast in working with the physically handicapped in a general caseload as compared with working with the mentally retarded. I did not get the immediate reward in seeing mentally retarded clients placed on jobs and earning their way in life. And so I think this is a factor not only in choosing people to work with mentally retarded, but also in assisting general counselors as they work with adult mentally retarded.
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In an effort to apply the concepts to the Georgia scene, I would like to pick up on the general theme of the conference, Counselor Specialization: Cause and Effects. As you know, the mentally retarded became eligible for Vocational Rehabilitation services back in 1943. Fourteen years later in 1957, the Georgia Agency rehabilitated seven mentally retarded individuals in the state.
At any rate, one cause of specialization with the mentally retarded was the small number of people with this disability who were receiving vocational rehabilitation services.
A second cause had to do with the parent movement. During the 1950's parent groups became more vocal. They began to exert an increasing amount of pressure for vocational rehabilitation services to people at both the state and the local level.
A third cause for specialization with this particular disability group had to do with a decision made by the Department of Education back in 1951. They decided to set up in the public schools special classes for the mentally retarded. By 1961 this program had moved several people on through the elementary setting and had referred to Vocational Rehabilitation 223 pupils who were sixteen years of age and above. Out of this number only 24 were rehabilitated; therefore, teacher criticism of the agency and the counselors became another motivating factor.
Mr. McLelland mentioned Public Law 565 which became effective in 1954. This law permitted agencies to expand, extend, and improve services to handicapped people. Although this law did not require specialization, a project had to be written up and submitted to the Regional Office for approval. We had the climate - the public was ready for services to be provided the retarded. The funds were available through Congress. There was a need within the Agency to provide these services, and it was determined by Dr. Jarrell that the quickest and most effective way to provide vocational rehabilitation services to a large group of the mentally retarded would be to specialize. Specialization had become a pattern in other disabilities even before that time. But as you know, programs are built when the public is ready, when the funds are available, and when you can get the staff. The timing seemed to be right with reference to developing a program for the mentally retarded.
In 1961 the Division developed a Research and Demonstration Project to assist publi~; schools in the establishment of secondary programs for the mentally retarded. We heard Dr. Harvey talk about the inadequacies of the pupils coming out of some special education classes that had been studied, and this had been the experience of our general counselors, as well as those who were specializing in work with the mentally retarded. We were in no position to criticize special education, but at the same time these individuals were being referred to the Agency so we felt we had some responsibility to at least give special education
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the benefit of our thinking and our experience and see if we could work together. In 1961 we did begin this Research and Demonstration Project which set up three positions at one pay grade above the counselor level. I think it would be well for us to review the duties of the personnel in this particular project hurriedly at this time.
This specialist, or consultant as we call him, had the following dutie~. He will provide school officials with assistance in the following areas: establishment of secondary programs for the mentally retarded, evaluation and enrichment of curriculum, expansion and orientation of local advisory committees to constitute resource committees, selection of pupils for secondary program, development of work-school programs. The second part of his work: he will provide Vocational Rehabilitation Counselors with assistance in the following areas: vocational evaluation of adolescent mentally retarded pupils in secondary schools, stimulation of community interest in the rehabilitation of the mentally retarded, development of work study programs, expand vocational rehabilitation training opportunities, expand on-the-job training opportunities, work with local Vocational Rehabilitation Counselors in developing feasible vocational rehabilitation plans for adolescent mentally retarded pupils. Another duty was to develop on-the-job training programs, formal vocational training programs, and job placement programs for the mentally retarded in his assigned geographical area.
Obviously; you do not place an inexperienced counselor in a position which has these responsibilities, nor do you select or secure the services of an experienced successful counselor and ask him to sell his home, move across the state, and go into a new frontier without providing him some incentive in addition. to his basie interest in helping people. This is part of the justification for the specialist position that seems .to have been a concern in our Agency. This is not the only position that has been a concern hi the Agency, but it's one of them. The position being established at one pay grade above the counselor required certain qualifications in addition to those required of a counselor. I would like to review with you briefly the Merit System specification sheet on the specialist position. With reference to training, "graduation from a college or university of recognized standing, including or supplemented by ten quarter hours or one hundred and twenty clock hours training pertaining to the specialty in which assigned." With reference to experience, "three years of full-time paid employment in vocational rehabilitation counseling or closely related fields." This is one more year than is required of a general counselor, plus, six'-months full.,time paid employment in rehabilitation, evaluation, or treatment of the handicapped in the category to which he is assigned: These requirements are maintained currently.
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When a counselor was assigned to work full time at Gracewood State School and Hospital, he had no choice but to specialize because the retarded constitute the only patients who are in this particular institution.
When we developed the A. P. Jarrell Pre-Vocational Center for the mentally retarded, the personnel assigned to that facility had no choice either because only the mentally retarded were referred to that facility.
Last year Vocational Rehabilitation signed an agreement with special education to provide services of a Vocational Rehabilitation Ad:justment Counselor for handicapped pupil-clients who are in the secondary school program. This commitment made three changes within the Agency: ( 1) It divided the counseling load on the basis of function, rather than on the basis of a specific disability. For example, this particuiar counselor works with the mentally retarded from the time he is referred at approximately age fourteen or fifteen on through his four or five years of experiences in the secondary school. During this time he receives pre-vocational training on and off campus, counseling and guidance, all the way on through to job placement and follow up. As soon as this phase of the program is working satisfactorily, the Vocational Adjustment Center will initiate a similar program with the emotionally disturbed in cooperation with the Agency's program for the emotionally disturbed. This program has guidance from both state and district supervisors.
(2) This agreement made another change in the Agency, it increased the Agency's budget by almost a million dollars. We didn't resist this change at all. Some of the funds came in handy actually for case service this year because we were able to utilize certified teachers' salaries to secure Federal funds to match these as State funds and bring in additional funds to the Agency for rehabilitation purposes.
(3) Another change that this commitment made was that it placed the Vocational Rehabilitation Adjustment Counselor under the administrative supervision of the District Supervisor and tied this position to the local level as well as to the over-all State program.
The Vocational Rehabilitation Adjustment Counselor has three types of supervision. One is technical supervision from the State level through the cooperative rehabilitation program. He receives administrative supervision from the District Supervisor and case work supervision from the Case Work Supervisor.
This program anticipates ten specialists as maximum, one for each of the congressional districts of the state. The specialists or consultants for the retarded provide technical supervision to the Adjustment Counselors in each of the areas where they serve.
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This organization was designed on purpose because we felt that it is important for a program that is tied together at the state level between special education and rehabilitation to have some relationship all the way down. At the same time we felt it critical that the District Supervisor and the Case Work Supervisor tie in with this position and provide supervision at the local level.
There has been additional specialization. For example, we have at Gracewood a Project Supervisor, a Vocational Rehabilitation Specialist, a Counselor, an Evaluator, and a Cottage Life Supervisor. At the A P. Jarrell Pre-Vocational Center we have a Vocational Rehabilitation Specialist, a Counselor, a Personal-Social Adjustment Evaluator, an Evaluator for the various units there including the service station, cafeteria, activities of daily living unit, and the general shop.
Specialization has been a natural trend in providing services to the mentally retarded. I prefer to think of specialization as an efficient and economical way to make available to clients who have special needs the particular and specific service they need by people who are trained to provide this specific service. Specialization permits a more economical use of the available man power, and should be considered on the basis of the function, as well as pay grades.
Dr. Harvey referred to the publication "Coordinating Services for Handicapped Children," by Esco Obermann, and enumerated some guidelines for cooperation between agencies. Let us apply these guidelines to our Agency by paraphrasing a quote from page twenty, "The Process of Coordination." "Beginnings in coordinating vocational rehabilitation units are usually made by persons of initiative and conviction who initiate conversations that later lead to extended dialogue involving many people and units and this dialogue can be expected to culminate in action."
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GROUP RESPONSES TO DR. HARVEY'S PRESENTATION
The groups were essentially in agreement with the material presented on specific qualities desired of rehabilitation personnel working with the retarded. A list of considerations discussed by the groups is as follows:
1. Need for university training in the field of mental retardation. 2. Need for emphasis of appropriate evaluation. Cultural depriva-
tion often "colors" test results. 3. Need to realize that familial and environmental expectations can
hamper the rehabilitation process and must be considered in counseling. 4. Need for early identification and delineation of the differences in functional, mental, educational, or cultural retardation. Programs must be adapted accordingly. 5. Often the Welfare Department can give a mentally retarded client more money and economic security than he would have if he returned to work. 6. Often the retardate lacks an acceptable pattern of living, selfimage, and self-confidence.
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Mrs . Mary K. Bauman is Co-Director of the Personnel Research Center in Philadelphia. Pennsylvania Governor William Scranton appointed her to a six-year term orz the State Board of Vocational Rehabilitation in 1962, and she is immediate past president of the Pennsylvania R ehabilitation Association. She has published many articles regarding evaluation and services to the blind.
SKILLS AND PERSONALITY REQUIRED TO EFFECTIVELY COUNSEL THE BLIND
As I approached this assignment, I realized that I would have speaking to you before me on the program three people who would be very able to describe the characteristics that a good counselor should have and they certainly have very ably done so. I, therefore, planned to emphasize the knowledge that I felt a counselor needed specifically to work with blind people. I must admit that I may be to some extent speaking to what Dr. Harvey called the third level of reality. That is, what it ought to be; nevertheless, if we do not think of what it ought to be, we are never going to get there, so let me just share with you my feelings about this.
In the first place, I feel that anyone who counsels blind people needs a good understanding of the structure of the eye. This is not really difficult to get, but it is frequently not present in ordinary education. He needs a knowledge of the diseases of the eye and, especially, of their implications. I am thinking of such things as the knowledge that glaucoma, for example, suffers by pressures upon people. The counselor needs to know that when he is working with an individual who suffers from glaucoma, it is undesirable to place him in a situation where he probably will be frequently under pressure. Let's say, a job that is perhaps just a little too difficult for him. He can do it, but he will always be pushing himself to do it. This is not likely to have a good effect upon the glaucoma itself - on the eye itself. If he wishes to preserve this individual's vision he ought to be not too frequently under pressure.
He ought to know that the implications of certain kinds of eye difficulties will inevitably become worse and that this individual should gradually prepare to live with less and less vision. I do not mean that he needs to make a great issue of this with the client (perhaps in some cases you do, in the client insists upon being unrealistic) but that he himself, as a counselor, should think of the client's getting into a job
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that might still be done if the individual were to have further loss of vision. These kinds of implications of diagnosis are an important part of what the counselor needs to know, because they will affect what the client is going to be able to do a year, two years, five years, or ten years from now, and therefore, it ought to affect where he is heading immediately.
I think that the counselor of blind people needs a considerable knowledge of at least certain other medical problems. All counselors need to know all about each client, of course, but there are certain medical problems that particularly relate to blindness. Diabetes, perhaps immediately suggests itself to even those of you who are not specialists in working with blind people. Diabetes frequently does have a relationship to blindness, but also to other kinds of findings; for example, the loss of tactual skills and tactual discrimination is not always, but frequently, present in the diabetic, and therefore placing this individual in a job which requires rather fine tactual discrimination is questionable. He may be able to do it now, you may test him and find that he can do it now, but you ought to know that perhaps five years from now he just will not be able to feel the differences between those things and perhaps there will be a period during which this tactual discrimination is being lost when the client will not fully understand what is happening to him. He will not fully understand why he is making errors in his job and he may have great frustration, even great emotion. He may try to hide this, not knowing that it is simply something he cannot control; and those around him may also not understand. They will say, "You're stupid. You don't have your mind on your work," when this is not it at all. It is usually up to the counselor to understand this special quality which may come into the picture. It does not always appear, and that makes it all the more confounding, but it does appear sometimes and we must be prepared for it.
I think we need to know the implications of some of the social diseases that are tied in at times with blindness. This is less frequently a cause than it used to be, but generalized central nervous system damage can be progressive in some of these cases and can affect behavior, other than that obviously related to vision.
One of the fields that we often do not realize we ought to know about is prematurity. Now, fortunately, the retrolental fibroplasia which was bringing so many blind children into our field of concern has been pretty much stopped. If it occurs now, it is a most unusual circumstance, but as Vocational Counselors you are only beginning or you have only begun in the last five or seven years, to work with this big group of retrolental fibroplasia children. Many of them are still in school. They will be coming into your concern as counselors and will be with you for many years in the future. While the Vocational Rehabilitation Coun-
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selors may not have needed to know very much about the retrolental fibroplasia children in the 40's when they were still in school and their problems were being met by the school system, now he needs to have some understanding of this. And when I say prematurity, I am talking about a very broadly defined area. Actually, in studies of premature children, the definition is by the birth weight of the child, not by the length of gestation. Any child of roughly five and one-half pounds or less birth weight is regarded as severely premature. The five and onehalf to eight pound birth weight child is in a fringe area. For some studies this is also included as a premature child, for some studies not. Many studies of prematurity do not include the children over five and one-half pounds in birth weight; therefore, you really need to know, if you are trying to evaluate whether you are working with a premature child, not whether he was born at nine months of gestation, but what the weight was.
This will often come into the picture when you have twins because, of course, the twin is a lighter child at birth. So, if you are working with an adult whose birth weight was less than five and one-half pounds, but he was a twin, there is much more chance that he does not have the other damaging characteristics of prematurity than if he was a single birth of this birth weight. Probably none of you has ever thought of asking what was the birth weight of the individual you were working with, but it can have a lot to do with what you had probably better think about as possible characteristics in this individual because the chances of more generalized damage are much greater in the less than five and one-half pound single birth child. This is especially true in the case of a boy because apparently light weight girls are more likely to be otherwise normal than are light weight boys.
I am just giving you a sampling of the kinds of things you really ought to know about prematurity if you are going to be able to assess the total situation for a blind child and be aware of the fact that there may be other subtle evidences of brain damage in this case. We have obvious brain damage in one form when we have blindness, but there may be other effects, so I might add that you need to know a good bit about brain damaged children and their characteristics as they grow up into brain damaged adults. This is an area in which not very much is known, but one can develop a wisdom in interpreting rather vague signals and in accepting the fact that they may be organic, and therefore, should be treated differently than if they are functional. You might often think this sort of thing is simply a lack of motivation, a lack of interest, the child didn't want to learn this, or the family did not encourage learning it. You have to draw a terribly thin line of differentiation. I do not mean that a counselor ought to be able to make that differentiation, but
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he should know that he must try to get someone to make it if there is enough wisdom on a medical basis.
The problems of partial blindness are very odd problems at times because the partiality may be such that the individual sees nothing when he looks straight at it, but can see rather well around the edges. Think of the frustration of this; as soon as you look at what you see, you do not see it any more. If you can understand how frustrating that one thing is, you will understand some of these people better. There are those who have very constricted fields; they can see at almost a pinpoint as well as any of you, but nothing around it. There are those who have variations literally from day to day, not with a calendar, but with their bodily conditions. There are those who can see in one kind of light and not in another, those who can see nothing in bright sunlight, for example, and those who can see nothing at night. It is important to understand all of these variations, that simply saying a person is partially sighted does not mean that these people are all alike. It means that they have all the ways of being different that anybody has. They are different in intelligence, they are different in energy, they are different in general health, and they are also different on a tremendously complicated scale of visual difficulty. To appreciate the fact that vision may still be changing and to appreciate the prognosis is a matter of a great deal of knowledge.
Another complicating factor which frequently appears in certain kinds of blindness is deafness, and I regard this as one of the most difficult counseling problems that could be assigned. No one has mentioned the deaf-blind as being an area of specialty and probably you just do not have enough to have someone who has specialized in this, but from my point of view it is a major area of specialty in the fact that you must know how to communicate, you must know how to use what skills remain, and remember the tremendous skills that can remain.
One always mentions Helen Keller when speaking of what can remain in a blind and deaf person, but actually Helen Keller is not unique. She is just the grande dame of a group of remarkable people who demonstrate marked superiority and much ability despite the double communication problem.
The counselor not only needs knowledge, understanding, and some sense of the prediction in these areas, but he also needs to know where he can get treatment for these problems. For example, what are the sources of optical aids, and which clients should be encouraged to go to the optical aids clinic? In some cases you will needlessly raise hopes by encouraging the individual to go; in other cases you will sadly fail to give him what would be very usable vision, even though it might only be with heavy lenses. To fail to give this might markedly change the vocational opportunities for this person.
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The counselor needs to know a great deal about psychology, not psychology in general which has already been listed as one of the things that all counselors need to know, but he needs to know enough about the testing of blind people to work with the psychologist. I put it this way because, although your situation may be more fortunate in Georgia, in general I have found that the counselor often has to find a psychologist to serve him with blind clients and then pretty much teach that psychologist what to do in testing a blind client. I do not mean that the counselor would literally teach him how to use the test, but put him in touch with sources of information. Psychologists are not commonly trained to test blind people, and it is not a field in which you can readily adapt anything except an interest inventory, perhaps, or the verbal scale of the Wechsler. Quite frequently this is the only relevant skill the psychologist has when he first is asked to work with blind people. The counselor has to be a leader, he has to have some feeling for what information he should be able to get from a psychologist, and know where to refer a psychologist for guidance in testing blind clients.
In addition, the counselor needs to know something of the psychological emotional reactions to blindness. I must speak briefly of these because I could spend all my time talking about them if I were to go into any detail. I think, above all, he needs to appreciate what we refer to in the adventitiously blind adult as the "mourning" period. There is a period of time in which that individual learns to accept himself as a blind person. Now, you have this in other disabilities; for example, there is a "mourning" period when there is a loss of a limb. I work with general rehabilitation clients a great deal of the time and I know very well that you go through exactly the same thing with any major loss.
You need to be there, patiently ready to help when he is ready to move forward; but you will gain nothing and may indeed do some damage if you insist, if you put social pressures, if you try to make him feel ashamed of not moving forward toward rehabilitation before he has gotten through this period. You also need to understand these qualities of dependency that Dr. Havens and Dr. Harvey have talked to you about. You need to understand a lack of feeling of worth which is often an immediate reaction to loss of vision in the male adult who has been supporting his family, and who with the on-set of blindness loses his job. His wife goes out and gets a job, perhaps, to keep this family on a reasonably even keel economically. He has completely lost his sense of his role as the bread-winner and the masculine force in this family and there is tremendous potential for at least a temporary emotional reaction to which you need to apply all the skills that Dr. Havens discussed yesterday. You have to meet this terrible feeling of being different, of being worthless, of being just on the shelf.
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In addition, you need to know sources of evaluation. I have already pointed out that often when you seek psychological help for the first time in a given geographical area you may almost help to teach the psychologist. I think you have to do something of this with many psychiatrists, too, when you turn to them to differentiate between the effect of blindness and what may be a psychiatric problem. We would hope that you would not be referring the person to a psychiatrist unless you believed that there really was something beyond the effect of blindness. As the counselor, you will ordinarily try to deal with simple effects of blindness yourself, but the blind person may also have a real psychiatric problem that needs the attention of the psychiatrist. It has been most discouraging to me, in some of the states where I am a consultant on a long-term basis, to get back reports from psychiatrists which say, "Of course he's this way; he's blind," with no effort to do anything about it, no feeling on the part of the psychiatrist that there may be something that he can do. We have a responsibility, I feel, to the psychiatrist to help him to understand what part of the client's reaction is probably a matter of blindness and what part we hope he will be able to help. I think you will usually get a very good response when you try to work in this way with the psychiatrist.
As a counselor you need to know some of the special problems that can arise in family relationships. The impact upon a family of having a blind child is simply tremendous. We have touched upon this a little bit in the impact of having a mentally deficient child. The impact of having a blind child is equally severe, with feelings of guilt and concern on the part of the family. "What did I do to have a child like this?" They can't help having this reaction. There is a sense of shame, a feeling of being different and inferior because the child is not normal. Inter-personal relationships can sometimes be very disturbed, particularly in the case of a premature child.
I spoke to the mother of a premature child a few months ago. This child is at Overbrook School and it was our feeling that the child needed loving. We were doing all the loving we could within the setting of a residential school, but we felt that this child did not have close relationships at home, so with the brashness that all of us sometimes have, I called the mother in and I gently introduced this concept of, "Could you just love this child a little more?" She broke into tears. I was prepared for defenses, I was prepared for arguments, but she simply wept and said, "Don't you understand, he was premature and for two months he was in an incubator in the hospital after I had gone home from the hospital. Once in a while they would let us go and look at him and I used to think 'when I can get this child in my arms, how wonderful it will be!' For two whole months I waited for this, and then I was allowed to bring him home. In that incubator he had not even had a cover on
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him. He had been in this very controlled area. Hands in gloves had reached in to him, no human being had touched him. They gave him to me. He didn't want to be held, he didn't even want clothes on. He didn't want a cover on, but above all, he didn't want to be held. I was never able to feed him while I was holding him. He would not eat when he was in my arms. He pushed us aside."
What does this do to a family? Also, of course, what does it mean with regard to the child? Maybe some of you have heard of imprinting - the idea that very, very early in the life of any animal it learns to follow what is closest to it. We can imprint a duck on a ball or a box, we can imprint a sheep on a bale of hay by letting it see nothing but the bale of hay for a certain period of its development. Maybe we imprint children on their families and, above all, on their mothers far earlier than we think those children are aware of anything. We are not sure we do, but we certainly are not sure that we do not, and the imprinting period may be passed for the premature child. For some of them at least it may never be possible to relate to their families or to anyone in quite the normal way that a baby who is brought home and loved will relate to a family and to other human beings. When you think that your retrolental fibroplasia young adult is kind of odd, remember these things.
Sometimes it is not the fault of the hospital or prematurity; it is just plain rejection. There is no question about the fact that some children are rejected, so rejected that they are utterly abandoned and left somewhere in a sack because they are blind. Many are rejected without being left in a sack. When it is overt, it is not so difficult to fight, but in many cases it is not overt. It is covered with a pile of overprotection, of verbalized concern without any warmth underneath and people who study the development of children have pretty much concluded that you can do almost anything to a young child if you are warm in the way you do it. It is that lack of warmth that the parents just cannot feel, and do not feel, and you cannot make them feel it, that is in the picture. Perhaps you see its effects years afterward; nevertheless, if you are aware that this may have been in the picture, perhaps you can better understand.
Now, overprotection can be very genuine, a real concern to do for this child all that you can, and overprotection is also likely to be damaging. It certainly can lead to not letting the child have normal opportunity to learn. Dr. Harvey talked about the overprotection in connection with school bussing the mentally deficient child. Well, we overprotect blind children by much more than bussing. Parents very frequently do not want them to get hurt, so they put them in a very small lifespace, as it were. They won't let them go up and down steps. They won't let them have anything around that they could get cut on, or fall on, and by taking almost all the stimuli out of their environment, they also take
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out many of the possibilities of learning at the very early age when children naturally learn by manipulating everything around. A blind child often is given almost nothing to manipulate or he is only given a soft teddy bear or something of this sort on which he cannot hurt himself. Parents need help in this. Someone needs to help them, perhaps not the Vocational Rehabilitation Counselor, but maybe you can have an affect on whomever does work with the families of young blind children. Many families overprotect or may appear to reject the child because they do not know how to meet the problem of having a blind child. It is a big educational problem and it needs to start the day the child is known to be blind, essentially from birth.
There is a great need for knowledge of problems related to education, such as possible effects of early neglect, the fact that the child may come into the school with almost no preparation. This can also have the effect of making him seem naturally retarded. In my opinion, the IQ of a blind child just entering school is meaningless unless you know a lot about the family background. I have seen many IQ's in the 50's and 60's go up to the 70's in a year, to the 80's in another year, and by the end of high school, over 100. I have records of children in the Overbrook School and in the Maryland and Virginia schools whose initial IQ would have warranted the diagnosis of mental retardation, and they are now being gotten ready for college. This great a change can occur, although it does not always occur, of course. Some of those original IQ's are correct, and they are never going to go up very much; but the preparation provided by many homes and communities for the blind child to start school is almost worse, I think, than what we get in the severely proverty stricken group that we are now trying to help through pre-school special efforts.
The attitudes of some teachers toward blind children, particularly in the regular school system, need to be understood. The counselor may have to encourage teachers to give correct grades to blind children, not to say, "Well, this is very good for a blind child," so that the blind child and his family think that he is working at an A or B level, when as a matter of fact, he is barely passing. Teachers need to be encouraged not to pass along children because they are blind and too old to stay in the class. This is no solution. Something has to be done to help the child and the family realistically understand how much progress he is making and to encourage and guide him to make whatever progress he can make. The blind child often is barred from athletics, he is barred from using the lunchroom, he is barred from extracurricular activities. Perhaps a rule is not made against extracurricular activities, but he is sent home on the bus that leaves right at the end of school; therefore, he can never be a part of the clubs and he loses out. This business of integrated
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schools is wonderful if the children are really integrated, but I have seen so many cases where it was a token integration.
The counselor needs to know about readers and how a blind person gets and trains them, because readers have to be trained just as much as anybody else does. This comes in when you are planning for college, particularly. You have to be able to help the blind person who is going on to college to know how to get his work organized, how to get through the difficult courses, the lab courses, etc., where to get material to read, what he should get brailled, how to use a reader, because there are a combination of ways in which to do this. The counselor needs library information, he needs to know about equipment, the "hardware" available for use in various science courses in college.
Then there is, of course, all the knowledge necessary to placement-not merely a good evaluation of this person and the job opportunities, because that is your need for everybody, but very frequently a real selling job with the employer. The educational campaign may include the union or fellow workers if there is no union, so that the blind person will be treated like anybody else when he finally gets to the job. There is a need to know a considerable amount of resource material, not just the professional study, but material in other fields that is, and will soon be, available.
There is a need for the counselor to know about mobility and mobility problems. He certainly needs to know enough to be able to evaluate the client's mobility because the client must be able to get to the job. If he does not get there, he certainly is not going to have a job very long. Whether mobility training should be given by a counselor is a matter of state policy, but certainly the counselor needs to evaluate whether the client is ready to go on his own, and he needs something more than the client's statement. Maybe Pennsylvanians exaggerate more than Georgians, but they always say they can get to the job, and you may find sadly that this is not true. Certainly the counselor needs to know resources for mobility training and for other kinds of pre-vocational training if he feels it is necessary. He needs a tremendous knowledge of resources for blind people, education, recreation. He needs to know what he might be able to get from such a place as the American Foundation for the Blind or the Printing House for the Blind. He needs to know volunteer groups and how to work with them, how to contact the Lions, for example, who is one of the notable volunteer groups. Often women's groups will do reading, church groups will do reading. This kind of thing the counselor needs to be able to mobilize. Very frequently in the process of doing this, he needs to be a good public speaker because one of the best ways to mobilize groups is to go out and talk about blind people and what they need. You can very frequently get many volunteers, at least a few of whom will stick to the
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job and help you all the way through. I am particularly thinking here of blind people who are going to get into some kind of educational setting where they may need various kinds of help.
This means that the counselor of blind people not only needs to know these things, but he needs to care about knowing them. When you get around to the question of personality, it has to be the kind of personality that wants to know these things, that wants to be concerned about these effects, that wants to find himself in such very varied diagnostic and prediction problems as blind people can present.
Above and beyond all that, he needs to believe in the ability of blind people to work. I pause after that because I would not doubt that there are in this room some who do not believe in it. I have practically never talked to any group of this size, even in rehabilitation, where there were not some who did not believe in it. If you do not believe in it, you are certainly not going to be able to bring it to pass. Above all, in something like rehabilitation, I think you have to believe in what you are doing. If you do not really think that a blind person can do the job, you are never going to be able to place him in that job and make it stick. Also, you have to be able to tolerate failure. During the professional study I talked to a very able blind teacher who said to me, "Blind people have as much right to fail as people who can see." The placement person for blind people has to live with this fact, too. I do not mean you should plan failure, but I mean do not avoid somewhat challenging assignments for a blind person in the belief that you cannot let a blind person fail, because a blind person is a whole human being, just as able to grow through the experience of frustration and failure as any of us, and I hope that all of us do at times grow by our mistakes.
The counselor of the blind person must not be too emotional in his reaction to blindness. There is a great tendency to be emotional about blindness. Much has been written about this. You can tie it in with psychoanalysis, Freudian symbolism, or with ancient cultures, if you are interested in this sort of thing. But no matter where it came from, it is true that there is a lot of emotion about blindness. If you feel this emotion to any great degree, you should certainly not be a counselor of blind people.
The counselor of blind people also needs patience because these are often long term rehabilitations. It is not easy to move from the acceptance to the placement status for the blind person. There is a need for patience, a need for persistence, a need for waiting till he is ready if he is a newly blinded person, and just putting in more time than you ordinarily have to with the typical rehabilitation client. Of course, the belief that the counselor of blind persons could not carry as heavy a caseload and could not be expected to make as many placements as
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counselors in other disabilities has been the very big reason for special services.
I would like to add one more thing which is not singular to the counselor of blind people, but which has not been mentioned in just these terms by the other speakers: the need to be by instinct and liking a teacher, because I believe that counselors are teachers. I believe that what we do, we have learned to do; and what we do not do, is also a result of learning. When we have a client who is sitting in a rocking chair quite comfortably, he is sitting there because he learned that was pretty successful behavior, and it will take teaching - teaching of him, teaching of his family, sometimes teaching of his community - to appreciate that he can do other things. To be the counselor of blind people is to be an educator for the blind person, his family, his community, employers, schools, and even for other professional workers whom you must use in order to give your client complete service.
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COMMENTS
(Mrs. Bauman's Presentation) JOHN W. LEWIS
Counselor for OASI Disability Determinations
It is apparent to all who have heard her that Mrs. Bauman brings a weath of experience, a clarity of insight, and a sensitivity of spirit to the problems associated with, and indigenous to the condition of blindness. Such a presentation places her in the front ranks of those who are personally and professionally committed to the removal or mitigation of these problems as they affect the self fulfillment of the individuals involved.
All of our speakers demonstrate the advantages of concentrated effort on a specific problem. Certainly, all of us are aware of the benefits which specialization has brought to the human race and more particularly to Western civilization. Specialization is a fact of all life beyond the monocellular level. It is biologically, sociologically, psychologically, and culturally sound. The complexity and diversity of human achievement have been largely due to our capacity for specialization on the one hand, and our capacity for coordination of specialists on the other. We cannot retard the process, nor can we negate it. It remains for us to accept it as a central truth in our lives which can be used to liberate us for a breadth and depth of experience far beyond anything we have dreamed for ourselves up to this point. Accepting the fact of specialization as a characteristic of life, we must then accept the responsibility of directing and controlling this technique in such a manner that it fulfills and liberates the individual and the group.
Vocational rehabilitation is, of course, no exception to the process as described above. It was found early in our experience that certain disabilities presented problems requiring special attention and understandings. The general counselor found that he had neither the time or the insights to deal with these individualized problems and conditions. This resulted in the specialization which we now know within our agency. Many people within these specialized disabilities have been served who would otherwise have gone unnoticed by the over-worked general counselor.
Nothing seems to come to us in unmixed blessings. There are many hazards inherent in the practice of specialization which we must keep in mind if we are to experience the maximum benefits from specialization. All specialization occurs within a larger framework of the total organism or organization. Our capacity to use the specialization to our best interests will depend upon our understanding of the larger framework within which the specialization occurs. That is to say, our
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specialization will have meaning and purpose only as it is related to the total framework within which it is practiced. For us as rehabilitation counselors, this means that our specialization on a given problem will be effective only as we understand the total personal and interpersonal dynamics in which the specialization takes place. In other words, we cannot rehabilitate an individual whom we do not know and understand.
If one listens to the conversations of his professional peers, it becomes apparent that most, if not all of us, find ourselves oriented to the condition which brought the individual to our attention as a rehabilitation client. Thus we speak of blind people, deaf people, mentally retarded, and the like. It is well for us to concentrate on the specific problem which brings the individual to our attention as rehabilitation counselors; however, if we allow ourselves to become engrossed with the specific problem to the neglect of the total individual response, we are in grave danger of failure both for ourselves and for those whom we would serve.
As we become increasingly specialized as rehabilitation counselors, we tend to see the individual in terms of the condition which brought the individual to our attention. Those of us with professional experience, however, have long since learned that the condition which brought the individual to our attention is far less significant than the response which the individual makes to his handicapping condition. This is a truth about all handicaps including that of blindness. Blindness has no psychological meaning until we see it placed in a given individual setting. The nature of blindness is, of course, physical. The response to blindness is psychological in character and will vary from individual to individual depending upon the background and experience which he or she brings to the condition.
All of us recall the depression days when millionaires lost their fortunes. Some of them jumped out of windows and killed themselves in desperation while others reasoned that if they had made one fortune, then it was reasonable to assume that they could make another. The essential difference was not the condition, but the response which each of them made to the condition of monetary loss.
We are indebted to the psychologists and psychiatrists for much valuable knowledge and insight into the deeper dynamics of our personal and interpersonal lives as we seek to live out our lives on a personal and social basis. All of us have benefited from their contribution but in the process, many of us have tended to become pseudo-psychologists giving a psychological implication to all our actions. We have very nearly reached the point at which a movement of the upper lip has a psychological implication. Blindness, deafness, and other impairments have their psychological meanings and are often the basis for explaining many of the psychological peculiarities noted in the given individual.
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Certainly, there are psychological responses to every physical condition, but this does not mean that the physical condition generated the specific psychological response. We cannot become professional psychologists; but as rehabilitation counselors, we must refine our insights to the point that we are able to distinguish between those problems which are inherent to blindness, and those which are associated with it. Those which are inherent will be dealt with in one manner, and those which are associated with blindness but not intrinsic to it will be managed in an entirely different manner. We cannot properly counsel the individual who is blind until we have achieved this level of analysis. One of the primary things we need to know about the individual is how he responds to a major crisis. The specific condition of blindness or deafness will always remain secondary to this psychological response.
Mrs. Bauman brought out an excellent point which we do not like as rehabilitation people but we must learn to live with it. If democracy means anything at all, it means that every individual insofar as is reasonably possible, should have the opportunity to succeed or fail out of the abundance or paucity of his resources. This is the only way we grow. If we are not willing to face failure and pain as rehabilitation workers, then we are in the wrong business. Certainly we do not want the blind person to fail at every point. On the other hand, we must place the ultimate responsibility for success or failure in the hands of the individual blind person for it is only in this way that the individual is able to discover his assets and liabilities as a productive and creative individual. Both the counselor and client must have the courage and emotional stability to live with failure, but this need not dim our faith in the ultimate capacity of the blind person to achieve a quality of success which is compatible with his total set of aptitudes and abilities. We must believe in the people whom we are serving. Failure to do so constitutes dishonesty to ourselves, the clients we serve, and to society in general who supports us. If we do not believe in our own soap, don't try to sell it. If we do believe in them, then sell the individual with aU our hearts, minds, and souls.
Another factor which Mrs. Bauman brought to our attention in a most forceful manner is what I would call the growth rhythm. Each individual has his or her growth pattern, and it will differ from individual to individual. We as rehabilitation counselors must try to develop the sensitivity to discover this growth pattern for each of the clients we serve. Having discovered the pattern, we must develop the patience to work within the framework of this growth rhythm. Failure to do so will spell defeat for the counselor and the client alike. Often, the only thing we can do is wait and allow the individual to gather his experiences at his tempo, and when the times comes, we are there to provide such service as he may need to restore him to his ultimate self fulfillment.
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In conclusion I would affirm everything which Mrs. Bauman has emphasized to us today. We must believe in these people. We must have the patience to give them the chance to grow and acquire experience in their new condition of blindness. We must not be too fearful of failure for ourselves as rehabilitation counselors or for the blind people whom we serve through the rehabilitation process. Fundamental to all of these, however, is the capacity to analyze our problems ourselves or draw upon those specialists who are competent to do it for us. Whether it is through our own insights or those of others, we must be able to draw the distinction between the problems which are intrinsic to a given physical condition and those problems which are associated with it. Thus we return to our original premise that we can never rehabilitate an individual whom we do not know and understand as a total dynamic entity.
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GROUP RESPONSES TO MRS. BAUMAN'S PRESENTATION
The consensus of opinion was that Mrs. Bauman gave a splendid presentation of the requirements which a counselor or specialist working with the blind needs. There are some twenty requirements or areas in which a specialist working for the blind needs to consider. This is over and above that which is needed by the general counselor.
I think it suffices to say, the general feeling of the groups as they reported was that a person who is working with the blind, as any disability, must have a genuine interest in the whole person. He must have faith that this person can do something and then work with him by coordinating the various agencies who can assist him in getting the job done. As Mrs. Bauman pointed out, you need to know these various agencies, persons, and organizations so you can give assistance.
Our group pointed out that if this business of specialization is to succeed as we all want it to, those of us working in the special disability group must not only exhibit a sincere desire to assist the individual who is handicapped, but assist general counselors and others in the rehabilitation program and offer suggestions to them in rehabilitating people of the same disability because they are working with people who have visual problems and clients who have mental disabilities. We have to exhibit a sincere desire and interest in their problems and use the advantage we have in being able to delve into these problems. We must help them by giving them information that will be needed in assisting the handicapped.
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SUMMATION
COUNSELOR SPECIALIZATION: CAUSE AND EFFECTS
SHELTON W. McLELLAND VRA Associate Regional Representative
The gentlemen who gave the reports presented some very good ideas on what the groups think about the various subjects discussed, and I think they feel that they were of top quality. I want to talk about some of the implications as I have been able to visualize them.
It is not that you in Georgia have not done anything in the area of specialization. You have done a great deal. You have established the relationships with other agencies that Dr. Harvey talked about, particularly with special education, the mental hospital, the institutions for the mentally retarded and the joint financing. We have noticed that vocational rehabilitation agencies are more and more using joint financing to expand their programs. I am speaking of a situation in which another public agency is interested in the rehabilitation of a special group and willing to furnish the state's share of the costs involved.
Someone talked about job specifications and I know you have written these. I noticed that there are some recommendations for certain changes and I believe you are in a better position now to study these suggested changes. You have come a long way in the last two days. If you were looking for facts and information on specialization, you certainly have succeeded. You have been furnished excellent data along with the recommendations. I think now you should take the information and apply it to your own situation and come up with certain basic proposals. These data came from authorities, in my opinion, as outstanding in their field as anyone anywhere.
I am sure that there are some next steps because this meeting was not an end within itself, it was a means toward an end. You have heard the pros and cons, the advantages and disadvantages and the trends from people who were described as being "gold-plated" speakers. I know that the people who planned this conference under no condition meant for it to become an academic exercise, a speech-making contest; rather, they wanted a realistic and practical look at trends toward staff specialization. I think they have all indicated that there are some people who are reluctant to accept it, but that it is inevitable and at the same time desirable in many situations.
We were told that there are some critical factors which must be

the prospective employee have what it takes? And does he want to do this type of work? Can he remain objective and friendly? And does he really believe that rehabilitation is possible for the person who is blind, mentally retarded, deaf, or emotionally disturbed? I think a great deal of emphasis was given to these as guides for locating people to help in the vocational rehabilitation program.
Someone suggested that maybe the best way to do is to find people who have experience already as a counselor and try to select candidates for special assignments.
With respect to training, the type of specialists that we have been talking about are not available on the labor market. Our speakers stated this and you knew it before you came here. The challenge is to find people who have certain characteristics and provide the kind of training they need in order to become an individual who is well informed and can work with people in the way that Dr. Havens and others mentioned.
If your clients who have been in an institution should not be referred to regular counselors back in the community because of a strong possibility of a breakdown in relationships, then how should the state agency structure its program so that this possibility can be eliminated? When we talk about specializing to this extent, we are talking about a very expensive program. Many counselors carrying a general caseload can become skilled in handling such a person even though there is the transfer.
We were told that vocational rehabilitation agencies will in the future be working with the more severely retarded, emotionally ill, and blind, and you perhaps have seen this already, and that there are pressures to be dealt with-pressures for numbers, from parent groups, agencies and interested individuals. So our best approach is to have trained counselors and adequate facilities for providing services.
Much has been said about counseling skills that are so necessary to quality and quantity rehabilitation. I want to emphasize that counseling and guidance in depth is absolutely necessary, for working with the kind of people that we have been talking about. In addition, skill in comprehensive evaluation is a must. By comprehensive, we mean psychological, medical, social, and vocational. Personal adjustment services are also involved, work adjustment, vocational training and placement. These are the services that are required and necessary if we are to rehabilitate more of our severely disabled citizens. The skills necessary to do all of these can come through teaching, training, and experience. We can find people who have an interest in our program and do some screening in spite of their interest. Selection then becomes involved and I believe we know much more about the whole process than we did two days ago.
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