Psychosocial Aspects of Disability and Chronic Illness | Comprehensive Case Management Certification

Welcome to Case Management Toolbox podcast, sponsored in part by All CEU's Continuing Education. I'm your host, Dr. Donnelly Snipes. Case management CEUs are available for these podcasts@allce.com slide that's allceus.com casemanagement. I'd like to welcome everybody to today's presentation on the psychosocial aspects of disability. I am Dr. Donnelly Snipes. Today we're going to define disability, review the phases of disability adjustment, explore the concept of disability identity, identify aspects of disabilities that increase stigma, explore the five A's of intervention, and using ecological theory, explore the psychosocial impact of the disability on the individual and family. So we've got a lot to cover. Disability is anti mental health, addictive or physical health issue that restricts or alters a person's regular or desired activities. So that's a broad range. We're not just talking about physical disabilities. We're not necessarily just talking about severe and persistent mental illness. We can be talking about addiction, hiv, paraplegia, deafness, visual impairment, down syndrome, schizophrenia, autism, muscular dystrophy, Crohn's disease, and the list goes on. Most of us in our practice are working with people who have disabilities, one or more disabilities, and it's important to recognize that and, or one or more chronic conditions. And I want to make sure that we incorporate chronic illness and chronic conditions in addition to disability when we're thinking about this. So if you're working with somebody who has fibromyalgia or Crohn's disease, or rheumatoid arthritis, or, you know, again, the list goes on. Those people may not always have their access or ability to engage in desired activities restricted or impaired in some way, but sometimes they might, if they're having a flare up, they may not be able to engage in certain things. Many people experience more than four stages of adjustment. A lot of times when we talk about adjustment to disability, we talk about the stages of grief, you know, denial, anger, bargaining, depression, acceptance, yada, yada. But a lot of people experience multiple stages. Shock is the first one, depending on the disability. And I also want you to consider that when you're working with people, you know, you may be working with a parent who just found out that their child has a disability. Now, a fetus or an infant or a 2 year old isn't going to react with shock to the disability. That's kind of the way they've always been, it's the way they're always going to be. It's just, it is, but the parent may react with shock. So you may be dealing with the emotional reactions of the caregiver. Anxiety about what this means, you know, is the disease or condition or issue going to progress? Is it going to get worse? How is it going to impact the person? How is it going to impact me if I'm not the person with a disability? There can be denial that the problem exists. You may see people starting to go to multiple physicians just trying to get somebody to go, oh, no, that wasn't the right diagnosis. Once people get through those stages or phases, people often go into a state of mourning or depression. Mourning, it's a grieving process where they have acknowledged the loss of basically perfect health, if you want to put it that way, or perfect mental health. They're grieving what they thought they had or the loss of something they thought they had. This can lead to a sense of depression. Remembering that with depression there's often a sense of hopelessness and helplessness. We want to help people in their adjustment to disability develop hope and self empowerment. Recognizing that for depression, for example, it can be episodic, but the intensity of the depression can be altered to some degree. There are some things that can be altered. If you're diagnosed with schizophrenia, yes, that is not something that we would typically choose. However, there are a lot of medications and treatments out there that are available to help people manage their symptoms so they can go on to lead a higher quality of life. We want to help people embrace the reality and confront their fears about the situation. Because a lot of times when people are diagnosed with some sort of disability, their mind goes to worst case scenario. Withdrawal from other people is not uncommon. With some disabilities, especially during this depressive phase, they're trying to adjust to their new normal and figure out what that means and what that means for them. There can be internalized anger about the fact that their body is working against them or their mind is not doing what they want it to do. They can be very frustrated and irritable and upset at the people in the world who don't have this particular condition, which can result in some externalized aggression. A lot of times it comes out as you just don't understand, okay, you know, we want to be there for people and help them eventually develop a social support system system of people who do understand. Can I understand exactly what it's like to have fibromyalgia? No, I don't have it. I can't say that I've been there. I can empathize as much as possible, but I Can't say that I've been there. And I can reflect upon how frustrating that must be to deal with that pain day in and day out. Acknowledgement is the next phase that people go through. Once they get angry, then they get to this phase where they acknowledge, okay, this is really happening and there's nothing I can do about it. Then they move to acceptance. All right, it's really happening, there's nothing I can do about it. Alright, let's figure out how I can make the best of it. And that moves you into the adjustment phase where people start figuring out what this means and how they can live their highest quality of life based on this new situation. Disability identity is the beneficial self belief that people with disabilities hold regarding their disabilities as well as any ties they possess to members of the disability community. Think of it sort of as a cultural thing. Some types of disabilities or however you want to label them are. You can think of it as cultural, if you will. And it's helpful to spend time with other people who have similar disabilities. People who are blind, people who are deaf, people who are. They can provide each other a lot of social support as well as helping people, you know, kind of learn the ropes. If you are a person, maybe you had a traumatic head injury and now, you know, did something to your optic nerve and now you are going to be permanently blind. You know, there's going to be a lot of adjustment there. But by associating with people who are also visually impaired, the person can start getting a leg up, if you will, on, okay, this is how it goes. They basically have a battle buddy, if you want to look at it that way. So it's really important to encourage association with people who may have the same or similar disabilities. People with invisible disabilities often have low disability identity. Invisible disabilities can be things like fibromyalgia or depression, or even addiction, where you can't just look at a person on the street and go, that person has whatever. So they often don't hold beneficial beliefs regarding this disability. They see it as a hindrance completely. And oftentimes they aren't as attached to to other people with similar issues as they are, which can be a problem. They found that disability identity is negatively correlated with mood disorders, which means as disability identity goes down, mood disorders go up, they go in the opposite direction. Even for people with depression and schizophrenia, we want to encourage them. People with invisible disabilities, we want to encourage them to think about their self beliefs regarding their disability. For example, if they have schizophrenia, for example, a person with schizophrenia has a mental health diagnosis. That doesn't make them any less loving. That doesn't mean, you know, if they like to work out, maybe they do that. That doesn't mean that they're not sleeping smart anymore. Encouraging them those beneficial self beliefs, that the schizophrenia is just one part of who I am. We want to help them start developing those self beliefs and we also want to help them again start engaging with other people whose schizophrenia is well controlled so they can develop hope and they can develop an awareness of what services and resources are out there and different treatments that may be coming available. Identity development is a fundamentally social process and identities are formed through mirroring, modeling and recognition through available identity resources. Which means you're going to figure out what it means to have schizophrenia or depression or fibromyalgia by seeing what it means to other people, by seeing what types of lives they can live. If you've got great models that are showing that they are living great quality of life despite having this particular issue, then that is going to help develop a positive identity. So it's imperative that when we're working with people with disabilities that we're aware of the developmental process and the different factors that will help them move to this level of acceptance and adjustment and growth. Key themes in disability identity development Communal attachment The person gets to the point where they're not only doing it begrudgingly, but they're enjoying affiliating with other people that have disabilities. They affirm their disability, which means and the best way I can explain this is living in the and they say yes, I've got this condition, whatever it may be, and I'm an awesome person and I am going to live my highest quality of life. I'm not going to let this stop me. It may mean I have to do things a little differently. They have a sense of self worth and feel equal to people without disabilities. They don't devalue themselves because they are because they have a some sort of condition. They have a sense of pride of their identity despite recognizing that disabled is often often viewed as a devalued quality. Instead of seeing themselves as, you know, disabled, kind of like something on a scratch and dent self, they have scratch and dent shelf. They have pride in who they are and the fact that of what they've accomplished, including living and thriving with their disability, they see their disability or their condition as sometimes as an obstacle that they have overcome, other times as an asset that demonstrates how strong and how much perseverance they have. Discrimination in identity development People become aware of prejudicial behavior in daily life. People with HIV are regularly discriminated against. I know they're not supposed to be, but they are. People with addictions are often discriminated against. People who have, you know, visible disabilities often experience some discrimination. It's important for them to recognize that this is just part of life and not saying that it's okay, you know, we'll get to advocacy and all that stuff later, but recognizing that it exists. So they don't feel like, well, this feels weird. I'm not sure validate the discrimination may be there and they find personal meaning or significance in this disability and they make sense of it. The whole why is this happening to me? Or how can I use this basically to be stronger, to grow. All of those things go into identity development. And if you're working with somebody with a recently acquired disability, these are things that you may have to work through with them. If you're working with a parent of a child who has a disability or is anticipated to have a disability when they're born, then these are also things that they're going to need to work through because especially when the person with a disability is a child, the family has to develop a certain level of disability. Identity development, because caring for that child often means that they are not going to have the same lifestyle or same things aren't going to go the same way as they would have gone had the child been born without any disabilities at all. Stigmatizing dimensions I talked about discrimination earlier and recognizing it, well, this is where we can step in with advocacy and we can encourage people to self advocate and families to educate. The source of the responsibility for the condition tends to be more stigmatized if it's seen as self inflicted. It's less stigmatized if it's accidental or congenital. Doesn't mean there's no stigma there. A lot of times people want to blame. And depending on their cultural values, some people may see disability as a punishment for something that you did. Other people may just see it as poor choices. Whatever the case may be. A lot of times instead of saying it is what it is, people want to find a reason for it. And you know, why do bad things happen? Generally the logic is because something bad prompted it, which leads to stigma. Aesthetic is another stigmatizing dimension. And that kind of goes along with apparent and concealable. So I'm going to cover them both together. Does the stigma distress or otherwise upset other people? If you're dealing with somebody who has an addiction, sometimes, you know, they may have. They may be very drawn they may have jaundice, so their eyes are kind of yellow. If you're dealing with somebody who's an amputee or, or in a wheelchair, it doesn't mean that their devices are necessarily going to upset everybody. But the aesthetic component may upset some people. If you're working with people who have maybe they lost an eye and they have a false eye, that can be distracting. For some people, it's just really individualized who is going to be bothered by what. That's not the person's fault. It's important for us to educate everyone about, you know, what's going on. If the stigma is obvious, then if it's visible, then there tends to be more stigma associated with it in some ways because people you know may need additional reasonable accommodations, obvious accommodations, etc. If it's invisible, such as psychological or a mood disorder or chronic pain or diabetes, sometimes there is less stigma associated with it. Other times, people, especially if it's something like fibromyalgia, I see a lot of stigma around that because you have non believers, if you will, who say, well, that doesn't exist. The person is just pill seeking or whatever. But again, the more distracting it is, the more apparent it is, the more likely it is to bring stigma. The disruptiveness of the disability, does it hinder or otherwise prevent social interaction or communication? And this can be because of aesthetics, like we talked about earlier. It can be because of cognition. If the person is not cognitively able to function as they used to be, it could be disruptive and stigmatizing. Or if they have down syndrome or some other disability, it could be considered disruptive because it's harder for people to know how to communicate. Or if their speech is particularly difficult to understand, is it perilous? Can the stigma be seen as contagious or even dangerous to others? People with HIV are often seen as perilous, or hepatitis are often seen as paralyzed perilous. We need to educate how these things are transmitted and how difficult it is to transmit them in casual contact. Addiction is often seen as dangerous or contagious, if you will. People don't want to be around people with addictions, psychosis. Oh, okay, I'm going to go off on my little soapbox here. A lot of times people see those who have psychotic disorders as being dangerous. We don't see them as contagious, but we see them as dangerous. And people with psychotic issues, if they're going to be dangerous, which they rarely are, tend to almost exclusively be dangerous towards themselves, not towards other people. I'M much more worried about danger to, of people who don't have psychosis in terms of their, in terms of their behaviors. And people with autism are sometimes seen as dangerous to others if they in their stimming behaviors engage in, you know, head banging or wall banging or something that seems aggressive to other, other people. Again, most people with autism are not going to hurt someone else. Now if they are touched. A lot of people with autism are very hypersensitive to touch. They may flail, but their intention is not to hurt someone. And course we want to look at is the stigma getting worse or better in terms of helping people develop their identity and feel a sense of hope and empowerment and stuff like that. What is society saying about this stigma? We are becoming well aware now of autism and I'm thrilled that people have a better understanding of it. We are much more educated about HIV than we were before. So the stigma for some of these things is going down, but not necessarily for others. And unfortunately right now there is, there aren't any tools to assess a person's perception of stigma. Now remember, when we're talking about stigma, it is going to be very individualized. My perception of stigma in this area that I live in right now may be very high for a particular disability. And if I have that disability and I go somewhere else like New York City, I may perceive a much lower stigma surrounding that same disability. But even in the same locale, three different people could have three very different reactions to me. One may have no issue with it at all. Another person may be extremely uncomfortable around it and then you can have a third person in the middle. The key is to educate people about what tends to promote stigma so they can dispel it, so they can help others understand, you know, where it comes from and you know, if they need to. Fundamentals of working with people with disabilities Clients must feel empowered to make decisions regarding their own self management. Educational empowerment strategies must be individually tailored. If you're working with somebody who has Crohn's disease, for example, and they have been dealing with it for 10 years already, you're not going to start at the very beginning and you know, explain to them about gluten or whatever, you're going to assess and see where they are, this knowledge continuum, where they are on the needs continuum and start there. Information and support should be, should be consistent with current best practices. And as always, collaborative relationships with patients and supporters is critical to success. And I'll keep saying supporters in there. It's not necessarily just family, it's Supporters, significant others, however you want to put it. But people with disabilities are influenced and influence those in their immediate social support circle. When we're talking about the psychosocial aspects of disability, we've got to consider the impact of the disability on those people and the impact of those people on the person with the disability. The five A's go through these real quick. You want to assess the condition. Where are we at if a person has bipolar disorder? You know, where are we at with this? What type of bipolar disorder do they have? Are they in a depressive episode, a manic episode? If they have fetal alcohol spectrum disorders, that's a spectrum. Or autism, There's a spectrum there. So you want to figure out where the person is on the spectrum to figure out kind of what you're dealing with. Some things can be more severe than others. You want to assess the client and the significant other's understanding of the condition, what caused it, or what do they think caused it, what the prognosis is, what the treatments are, you know, all of those sorts of things. In order to help remove the stigma in their own mind, because some people may feel stigmatized, we want to help dispel that, Assess their current coping strategies and efficacy. How effective are their coping strategies at helping them live their highest quality of life, given the current circumstance and the impact of the condition on the client's overall well being? And the mnemonic I use is pacer. Their physical health, how is this impacting their physical health? If they have schizophrenia, for example, there are a lot of side effects of antipsychotic medications. We want to maybe take a look at that. Sometimes they may have difficulty remembering to eat, and different activities of daily living may be impaired because of the disorder. So we want to assess their physical health. We want to assess their affect. How do they feel emotionally right now, and how is their condition impacting that? Are they depressed? Are they guilt ridden? Are they angry? Or are they feeling empowered and optimistic? What are their cognitions about life in general? Not just. We don't want to just focus on this disability or condition. We want to focus on life. What are their cognitions? Yes, this condition is probably not something they ever wanted, and they're going to have to figure out a way to come to acceptance and adjustment with that. However, we want to look at their cognitions about life in general. What is good, what do they have control over, all that kind of stuff. How does the condition impact the client's environment and economic well being? And I kind of put those two together because a Lot of times they go hand in hand. If it's a physical disability, they may need certain modifications made to their house or to their work environment or which may cost money. So we want to kind of take a look at that and figure out what we need to do again to facilitate their highest quality of life. And how does that impact their economic well being? Sometimes disabilities, especially acquired disabilities, may mean that somebody cannot return to the work that they used to do. Or even congenital disabilities, the person may not have a high earning potential. We want to look at their economic well being because we need to make sure highest quality of life. Think of maslow. They need to have housing, food, medical care, safety, you know, basic needs and meaningful activity every day. Which takes us to relationships and recreation. How does their condition affect their relationships with their significant others and the public in general, you know, people they interact with. And how does it impact their ability to recreate? It may not impact it at all. It may have a huge impact. If they got shot in a drive by shooting and are now paraplegic and they used to love to go water skiing, obviously that's not something that's probably going to be able to happen, at least not in the same way. There may be modifications I don't know about. I'm not a water skier, but we want to look at that. Are there any meaningful things in your life that you used to love to do that you can't do anymore? My grandfather, when his Parkinson's got to a certain point, he used to make miniatures, you know, dollhouse furniture, really fine minute work. I mean, it was beautiful stuff that he did. But when his Parkinson's got to a certain level, he couldn't hold the stuff still anymore in order to make those. And at that point, there were no modifications we could do. But the fact that his main hobby, his main recreation was making those miniatures, he couldn't do that anymore and he fell into a pretty deep depression. We do want to look at that. We want to advise and educate the client and significant others about the condition. As much as they need to know, obviously start where they are and about the potential treatment options and service things that are available for them. We need to agree or collaborate to develop a workable plan for the short term, this week, this month, what needs to happen so you can live your highest quality of life depending on the reason that they're there. If they are leaving the crisis stabilization unit after having their first psychotic episode, then how can we help you in this first month? What is our workable plan? But then we Also need to look long term. What is the prognosis for this condition? What sorts of things are you going to need in order to keep this condition stable and continue to live a high quality of life? Rehabilitation counselors are often trained in what we call life care planning. And that's when we look over the course of 10, 15, 50 years about the different services a person will need. We want to assist clients and supports in identifying and accessing services. The person with the disability will probably need services of some sort. It could be medical care, it could be mental health care, medication, whatever it is. But we also want to make sure that their supports are able to access the support that they need. If they are a parent of a child with autism, they need support. If they are a parent of a child with down syndrome, they need support. If they are a, you know, family member of a person who was in a bad car accident and is now a paraplegic, you know, they may need support to because their vision of what was going to be the life of this person may be shook right now. You know, there was a young man in a football game this weekend who developed a brain bleed right after scoring a touchdown or something. His life's going to be altered now. Now, how much we don't know yet. But it's important to recognize that at any point in time, any of us could develop some sort of disability. And how is that going to affect the person? I worked with a went to school with a young man when we were in high school together, and he had always thought that he was going to play pro football and he was good enough to play pro football. You know, he had people scouting him and all kinds of stuff from the time he was a freshman. Turns out in his junior year, they discovered that he had a fracture in, in one of his first three vertebra and he was never allowed to play football again because chances are if he got hit the wrong way and that fractured completely, it would kill him. There was no ifs, ands or buts about that. So all of a sudden, this condition disrupted his view of what his next 20 years was going to be like. We also want to arrange for referrals and follow up as needed. You know, whatever the person needs. Sometimes, especially right after a diagnosis, they're going to be in a little bit of a crisis state. They may need assistance reaching out to or figuring out who to reach out to, interventions. We want to raise the awareness people of their rights and the possibilities and services available to them to enhance their mental and physical health. A lot of times when someone has a disability and it's an acquired disability, they go through that grieving process. There's also a time for some people, even if they have a congenital disability, that they. Until they develop their disability identity, that they may benefit from mental health counseling or support in order to help them embrace that identity, services to help them enhance their physical health, you know, what is it that they need in order to help them live their highest quality of life? What do they need in order to help them engage in social and recreational activities? Some people, like I said, may think, well, now that I've got this condition, I can't do the stuff that I used to do ever again. And that's really depressing. So we want to look at what sort of modifications are available and we need to raise their awareness in order to help them act to eliminate discrimination and recognize what services their protections under the ADA and all that kind of stuff. Now, to the meat and potatoes. Let's talk about psychosocial aspects of the disability. We've talked in general about stigma and, you know, potential mood disorders. Reviewing real quickly Brofenbrenner's ecological model. You have the person at the center and the person interacts with their microsystem that includes their family, their peers, their teachers, their neighbors. Every people they interact with every day. That's considered the microsystem. All of those people impact the person. It's a reciprocal relationship. Likewise, that microsystem and that person interact with the larger mesosystem that can include, you know, their community and their schools themselves. Again, reciprocal. If the school not responsive, then, or if the school has a lot of discrimination or whatever, that is going to negatively impact the individual risk and mitigating factors. There's a lot of them. The good thing is all of these can potentially be mitigating factors too. People's age when they acquire a disability, it can be a risk factor. High school is really hard for all of us or for most of us. So especially during those adolescent years, it can be really difficult. And then something that is acquired later in life can also be difficult. But when people are younger, they tend to have more cognitive flexibility and are cognitively able to adjust a little bit more their health, any concurrent conditions and health behaviors are also a risk or mitigating factor. If they have rheumatoid arthritis, for example, and we can help them prevent getting any other problems, then that's going to mitigate their outcomes. We don't want them to start developing multiple problems. If they have for Example, clinical depression. Then they start developing alcoholism and obesity and then diabetes. You know, now we've started to add onto the. Onto the pile of things that the person's going to have to contend with. Helping them maintain their health is going to be a big factor. When you're working with people with schizophrenia, the same thing is true. People with schizophrenia tend to smoke a lot more than people without schizophrenia. And I can't tell you what the exact percentage is right now, but that's one of those things you might want to look at in a prevention. From a prevention standpoint, we want to look at their mental health. If they are overall optimistic and empowered and all that stuff that we want people to be, great, that's going to be a mitigating factor. They're going to probably be more resilient to dealing with this adversity. If they have depression, anxiety, or a psychotic disorder, then that may complicate the picture a little bit. We do want to make sure that we are addressing mental health issues as they relate to the condition, but also in general, because they can have depression or grief or something else that's completely unrelated to the disability or chronic condition. But that mood issue is probably going to negatively affect their quality of life and their ability to cope with their disability. Their cognitive functioning. Higher cognitive functioning is obviously preferable that we want to look at, but if they have lower cognitive functioning, we just need to be aware of what that means in terms of the interventions that we apply. What's this person going to need to live their highest quality of life? What's this person going to need in order to understand what's going on? Just because somebody has lower cognitive functioning doesn't mean they can't understand what's going on with them. You just have to break it down in a way they. They can wrap their head around. Socioeconomic status is a mitigating factor or can be a risk factor. Higher socioeconomic status people tend to have access to better medical care, better interventions, and are less stressed if they have problems with employment, which takes us to employment. People who are employed tend to have a higher socioeconomic status. Not always, but they also tend to have better access to health insurance. Employment gives them a sense of meaningful activity every day, which is good. It gives them a sense of independence, like it does for all of us. Employment can definitely be a mitigating factor as long as they are receiving any necessary, reasonable accommodations. We don't want employment to be overwhelming and draining and exacerbating. Whatever the problem is. You can go to the Jan Network and can't remember what that stands for right now, but it gives you reasonable accommodations for just about any disability. And I think I have the link at the end of the PowerPoint, but we'll get there. Education about the condition, but education in general can also be a mitigating factor. When people have a breadth of education, then they are able, you know, maybe they can't do this thing over here anymore, but they can do something else. When they understand what's going on with their disability, then they are able to better wrap their heads around what's going on. And thank you, Pat. Jan. Go figure stands for job accommodation Network. Perception of disability and their disability identity. We really want to work with them to understand what that means and reflect on the fact that their disability is part of who they are and they can choose how much they want to embrace it or compartmentalize it and help them develop their disability identity. I've told you before, people who are deaf often wholly embrace the deaf community and they don't see being deaf as a deficit. They see it as part of who they are and they feel very honored to be part of the deaf community. Each person's perception is going to be different. We just need to help people come to their own understanding. The duration of the disability is also a mitigating factor. If it's been there all their lives, then there's going to be an adjustment period. But it may not be as shocking, so to speak, as somebody who just recently developed this disability. You have soldiers coming back from Afghanistan who've lost a limb or who have experienced traumatic brain injury. You have people who get in car accidents or whatever the case may be, and right after that diagnosis occurs, there's going to be a lot of impact in their life. As soon as you get that diagnosis, you know, it's like, okay, all these things that I used to be able to do, I can't do or can't do in the same way anymore. And that's not only going to impact the person, but also going to impact their microsystem, so to speak. Cultural values can be a mitigating factor. If the culture is very family centric or supportive of one another. But sometimes it can be a risk factor. If the culture views, for example, mental health illness or mental illness as a punishment or as something that is shameful, then it can significantly negatively impact people's moods and self acceptance and disability, identity development, etc. And their perception of social support. And the word perception is really important here because people may have all the support in the world, but they don't feel supported. We want to help them feel supported and we need to ask them, what is it that you need and how can we best facilitate that for you so they feel supported without feeling like they're a burden. Cognitive constructs we want to address really important in preventing negative psychosocial impacts. Help them embrace courage versus mental defeat. If they embrace the notion of the courage to rise to this challenge, that is going to be a lot more beneficial to them than if they go, well, I've got this now, there's nothing I can do, and they fall into a deep depression. Knowledge. We want to improve their health literacy about the condition, but also, again, about how to prevent other things from happening. We want to prevent them from developing secondary complications or conditions. Health literacy is helpful and health literacy or education about coping skills and coping styles and can also be useful if you've got somebody who has chronic pain and they sometimes they have breakthrough pain or they get frustrated because they just get exhausted so quickly, having so much quicker than they used to, encouraging them to develop coping strategies to deal with that. Garnering a commitment to action is also really important versus hopelessness. Sometimes if people get a diagnosis and they're like, well, all's lost, you know, might as well not even try, but if they can see that certain things they do will enhance their quality of life, then you can, you know, really build up that commitment to action. And this is where that social support and mirroring and development of disability identity really comes into play. Emotional and cognitive transcendence is also important, recognizing that, you know, there are going to be some days where you're depressed, and there are going to be some days when you're not, and there are going to be some days when you have unhelpful thoughts, but there are going to be ways that you can transcend that so you're not ruminating on the disability or what you can't do anymore versus focusing on the pain, ruminating on it, and catastrophizing about, you know, where it's going to go or all the things you don't have anymore. I mean, you can sit there and talk until doomsday about all the things that aren't exactly the way you want them. Any of us can, with or without a disability, but that doesn't get us anywhere. So encouraging people to develop a sense of emotional and cognitive transcendence, accept how they're feeling, accept their thoughts, and then figure out how to improve the next moment. As I mentioned on the last slide, There is a huge impact of people's perceived burdensomeness in terms of the effect on their psychosocial functioning. The effect on their mood, their anxiety, their depression level, their willingness to reach out for support, their willingness to engage in life outside of their house in many cases is significantly impacted by their perception of how burdensome they are on people. If they don't feel like they're a burden, then they're going to be more likely to call somebody and go, hey, I want to go to the mall. Can you come pick me up because I can't drive? Or hey, let's go out to eat. We need to take my vehicle because it's, you know, modified for the wheelchair, whatever the case may be. And then finally, again, for the millionth time, developing that disability identity. So people feel a sense of belonging, they feel a sense of who they are instead of a sense of thwarted belongingness. I can't do that anymore. Like my friend from high school, if he wouldn't have developed a new identity, he would have felt thwarted because he had always envisioned himself as a football player. Now he's a coach, so more power to him. The microsystem remembering. When we're talking about psychosocial impact, disability has an effect on the entire microsystem. We want to examine the community and family response to the person and the person's response to their community and family. Is it a good communication? If the community does not respond well for some reason or the family doesn't respond well, then that is an area where we may need to intervene. You know, Sally comes home and tells her parents that she was just diagnosed with hiv. Or John comes home and, you know, tells his wife that he was just diagnosed with stage three cancer. You know, the family's response, whether they're supportive and helpful and embracing or shocked and grieving and angry, that's going to have a big impact on. On the person, the impact on their lives. Occupational, financial, social, emotional, especially for parents. But even, you know, if the person with a disability is older, if they are the caregivers that they're living with, how does that affect their ability to work? Some people, especially with children with disabilities, one parent may not be able to work. They may have to stay home with the child. Financially, how's it affecting the family that this person has this diagnosis? Socially, how are the friends responding? Do they feel like they've got social support or not? And emotionally, you know, what's going on with the family? How are they adjusting to this news or this turn of events? It's important when we're considering the reaction of the community and the family that there's something called the insider outsider distinction. And in this distinction, the outsider assumes what a disability must be like and frequently concludes that it's not only negative and disruptive to daily living, but but also defining for the individual. You are now a paraplegic, you are now a blind person. And that's not it. Outsiders rarely recognize disability as just one quality among many in a person's life and presume the disability is an ongoing focus and a troubling preoccupation. A lot of people with disabilities, whether they are blind or paraplegic or have fibromyalgia or schizophrenia, you know, that is one part of their life, but it is not an ongoing focus. They don't perseverate on it. It is just part of who they are. Like having brown eyes. I have brown eyes. That's just part of who I am. And it's important for outsiders to understand that children, you know, in school can focus on the assistive devices sometimes and in spite of or instead of focusing on the person who is using the assistive devices. This is one of the reasons why we always want to use person centered language or person first language. It's a person with autism, it's a person with schizophrenia, not a schizophrenic or whatever. We want to use that person first language. School and employment is also in that microsystem. How does this disability or condition affect somebody's ability to get a job? What necessary accommodations might they need? And what kind of reception do they get at school or at work? If they are shunned or pitied or there's a variety of different reactions, then that's going to make it difficult for them at work if their colleagues or peers treat them as a human being. Go figure. Treat them as a person who may happen to have a disability, but you don't even need to put that on. Treat them as a person, period, End of sentence. Then it makes it easier for them. And teachers can do a lot of. For helping youth start focusing and realizing that the person is a person first and the disability is just something. Health services, the availability of specialized services and the financial impact of services and medicines can be big for people. Some people have to travel two hours to get to specialized services. That's going to have a significant psychosocial impact. Takes away from time they could spend with friends. It's financially expensive. You know, you see where I'm going In the community, a person's Disability may be impacted by the resources that are available and the attitudes of the community. Their sense of self acceptance may be helped or hindered by what they see in the community. Remember, a lot of disability identity development is from mirroring government agencies can serve to enhance or hurt people's psychosocial development and status or whatever word I'm looking for here. If there's adequate health care in the community, if there's public transportation, if there's adequate housing, or all of those things are going to be important, you know, regardless of the type of disability, we need to make sure that people are getting those basic Maslovian needs met. Otherwise they're going to start developing all kinds of secondary and tertiary problems which is going to negatively impact them psychosocially. We want to look at the mass media. What is the mass media saying about this particular condition? Are there models in the mass media that people can look at? In cultures, a disability often represents a stigma that the person has some quality that is construed as being broadly negative in a given context or cultural setting. When a disability is stigmatizing, it serves as a social marker so that people with disabilities are seen and often treated as distinctly different from people without disabilities. Really important to educate the culture. And even if you can only change the culture in your microsystem, that's one more microsystem that is changing. Specific presenting issues. Depressive symptoms. Anger problems. Harmful habits such as smoking, alcohol, misuse or illicit drugs that may be used to self medicate mood or pain issues. Lack of healthy social support. Poor perceived mental health. Concurrent chronic pain conditions that may impact relationships and sleep. A lot of disabilities have, especially physical disabilities may have physical conditions. You know, people who are visually impaired may have circadian rhythm disorder. We need to be aware of different things that may impact their psychosocial functioning and their mood and their energy and everything else. And some people may have more frequent episodes of intermittent pain. We also know that people who are depressed tend to experience more pain. And high levels of stress can also prompt increased pain. Accommodations. I talked about the JAN network before. We don't have time to go there today. But you can click on the links to identify potential accommodations that people may need. You may not be a vocational counselor, that's fine. You can point clients to this if they need accommodations at home, or not at home, but at work. But you can also look for some of the accommodations. Maybe you have a patient who has chronic back pain and you know, how can you facilitate, what kind of accommodations can you make? So this person can sit through or endure group. You may just want to explore some of the different accommodations that are out there. And like I said, they're out there for just about any disability you could think of. Both visible and invisible disabilities can impact people's physical health, their mood, their affect, their cognitions, their environment and economic well being and their relationships and recreation. The degree to which a disability impacts a person psychosocially depends in large part on their individual characteristics physically, cognitively, emotionally and interpersonally, their community and family response to their disability and just general cultural attitudes. Are there any questions? I got my master's in rehabilitation counseling, so this topic is kind of near and dear to my heart, but remembering, you know, we talked. I kept talking a lot about disabilities, but remembering we were also focusing on people with chronic conditions that it can include fibromyalgia or addiction or bipolar disorder or mental health issues. Alrighty. Well, I was really excited about the different interventions I found. For the brief interventions class that we're doing on Thursday, I said we're going to do 10. Well, I couldn't stop myself. We're doing 13. So lucky you. You get three extra bonus interventions. So with that, I will see you on Thursday. Thank you for listening to Case Management Toolbox podcast. Go to allce.com casemanagement to access the CEU course for this episode. You can also subscribe to Case Management Toolbox Podcast to be notified when new episodes are released.