Rehabilitation Psychology 2016, Vol. 61, No. 1, 54 – 64

© 2016 American Psychological Association 0090-5550/16/$12.00 http://dx.doi.org/10.1037/rep0000078

Teaching the Foundational Principles of Rehabilitation Psychology William Stiers

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Johns Hopkins University School of Medicine Objective: Wright (1983) described 20 “value-laden beliefs and principles” that form the foundational principles of rehabilitation psychology, and the education and training of rehabilitation psychologists necessitates that they acquire the specialty-specific knowledge and attitudes/values related to these principles. This article addresses 2 questions about how these principles can be taught in rehabilitation psychology training: (a) What are the core theories and evidence supporting these foundational principles, and what should be the content of a “core curriculum” for teaching these?; and (b) What is known about the most effective methods for teaching these foundational principles, including questions of how to teach values? Method: The foundational principles were grouped into 3 categories: individual psychological processes, social psychological processes, and values related to social integration. A literature review was conducted in these 3 categories, and the results are summarized and discussed. Results: A core curriculum is discussed for teaching about disability-specific individual psychological processes, social psychological processes, and values related to social integration, including methods to reduce group prejudice and promote values relevant to the foundational principles. Specific suggestions for training program content and methods are provided. Conclusions: It is hoped that effective teaching of Wright’s (1983) value-laden beliefs and principles will help rehabilitation psychology trainers and trainees focus on the key knowledge and attitude-value competencies that are to be acquired in training.

Impact and Implications This article reviews the existing literature relevant to teaching the foundational principles of rehabilitation psychology, both in terms of teaching content and teaching methods. It provides information regarding concepts and practices that can be used to effectively teach Wright’s (1983) value-laden beliefs and principles, and to help rehabilitation psychology trainers and trainees focus on the key knowledge and attitude-value competencies that are to be acquired in training.

Keywords: rehabilitation psychology, psychology, training, teaching, foundational principles

Stiers et al. (2012) published the results of a national consensus conference on guidelines for training in this specialty. Cox, Cox, and Caplan (2013) described the specialty competencies of rehabilitation psychology in detail, and Stiers et al. (2015) proposed structured observations for measuring competencies. All of these focus extensively on the importance of the person-task-environment whole in considering disability. Today, training in rehabilitation psychology is based upon a disability-specific body of theory and research, and focuses on knowledge, skill, and value acquisition for assessment, intervention, and consultation regarding the biological, psychological, social, cultural, environmental, and policy aspects of disability and rehabilitation. This training occurs through directed readings, in formal teaching such as didactics and seminars, in interdisciplinary forums such as team patient-care meetings and case conferences, and in patient-care observation and practice with associated individual and group supervision. The focus of this article is on Wright’s “value-laden beliefs and principles” (Wright, 1983, pp. x-xxvi) that form the foundational principles of rehabilitation psychology. The education and training of rehabilitation psychologists necessitates that they acquire not only specialized knowledge and skills/abilities as described above, but also the attitudes-values that form this foundations of the specialty. This article groups Wright’s foundational principles into

Introduction The concepts and practices of education and training in rehabilitation psychology have developed over the past 50 years. Wright (1959) and others discussed that the preparation of psychologists for work in rehabilitation requires incorporation of rehabilitation-specific didactic and experiential training (Cox, Cox, & Caplan, 2013; Dunn & Elliott, 2005; Gold, Meltzer, & Sherr, 1982; Shontz & Wright, 1980). Elliott and Gramling (1990) emphasized the importance of developing guidelines for specialized training in the assessment and treatment of persons experiencing chronic injury and illness and their families, as well as specialized training in consulting with rehabilitation teams and other professionals and agencies. Patterson and Hanson (1995) published the first formal guidelines for postdoctoral training in rehabilitation psychology. Hibbard and Cox (2010) described the competencies required for board certification in this specialty.

Correspondence concerning this article should be addressed to William Stiers, PhD, ABPP (RP), Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Suite 406 – POB, 5601 Loch Raven Boulevard, Baltimore, MD 21239. E-mail: wstiers1@ jhmi.edu 54

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three categories: individual psychological processes, social psychological processes, and values related to social integration (see Table 1). This article addresses two questions about how these three types of foundational principles can be taught in rehabilitation psychology training: 1.

What are the core theories and evidence supporting these foundational principles, and what should be the content of a “core curriculum” for teaching these to psychology professionals?

2.

What is known about the most effective methods for teaching these foundational principles to psychology professionals, including questions of how to teach values?

The PsychInfo literature database was searched without time restrictions using the terms (and their variants) “attribution,” “appraisal,” “coping,” “positive psychology,” “resiliency,” “simulation,” and “values.” Dunn’s (2015) book The Social Psychology of Disability was read to identify similar relevant literature. Each

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source located was then read to identify additional relevant citations. Sixty-nine manuscripts and book chapters were located, and 46 were included in the article. This article reviews the existing literature relevant to the foundational principles, including disability-specific individual psychological processes, social psychological processes, and values related to social integration. It also reviews the existing literature relevant to teaching methods for the foundational principles, including methods for reducing group prejudice and promoting values related to the foundational principles. In each section, it identifies the important literature and provides a brief summary of key points for teaching, and lists specific suggestions for teaching methods.

Core Curriculum for the Foundational Principles What are the core theories and evidence supporting these foundational principles, and what should be the content of a “core curriculum” for teaching these to psychology professionals? The core curriculum should include disability-specific individual psychological processes, social psychological processes, and values related

Table 1 Wright’s (1983) Foundational Principles Grouped Into Three Categories Disability-specific individual psychological processes

Disability-specific social psychological processes

4. The assets of the person must receive considerable attention in the rehabilitation effort.

2. The severity of a handicap can be increase or diminished by environmental conditions.

5. The significance of a disability is affected by the person’s feelings about the self and his or her situation. 8. Because each person has unique characteristics and each situation its own properties, variability is required in rehabilitation.

3. Issues of coping and adjusting to a disability cannot be validly considered without examining reality problems in the social and physical environment. 7. The client is seen not as an isolated individual but as a part of a larger group that includes other people, often the family.

9. Predictor variables, based on group outcomes in rehabilitation, should be applied with caution to the individual case.

11. Interdisciplinary and interagency collaboration and coordination of services are essential.

10. All phases of rehabilitation have psychological aspects.

12. Self-help organizations are important allies in the rehabilitation effort.

13. In addition to the special problems of particular groups, rehabilitation clients commonly share certain problems by virtue of their disadvantaged and devalued position.

Disability-specific values related to social integration 1. Every individual needs respect and encouragement; the presence of a disability, no matter how severe, does not alter these fundamental rights. 6. The active participation of the client in the planning and execution of the rehabilitation program is to be sought out a fully as possible. 14. It is essential that society as a whole continuously and persistently strives to provide the basic means toward the fulfillment of the lives of all its inhabitants, including those with disabilities. 15. Involvement of the client with the general life of the community is a fundamental principle guiding decisions concerning living arrangements and the use of resources. 16. People experiencing disability, like all citizens, are entitled to participate in and contribute to the general life of the community. 17. Provision must be made for the effective dissemination of information concerning legislation and community offerings of potential benefit to persons with disabilities. 19. Persons with disabilities should be called upon to serve as co-planners, co-evaluators, and consultants to others, including professional persons.

Note. This Table does not include two principles: 18. Basic research can profitably be guided by the questions of usefulness in ameliorating problems, a vital consideration in rehabilitation fields, including psychology; and 20. Continuing review of the contributions of psychologists and others in rehabilitation within a framework of guiding principles that are themselves subject to review is an essential part of the self-correcting effort of science and the professions.

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to social integration. This section provides a brief summary of the relevant literature that can assist with developing this teaching content and provides specific suggestions for training programs.

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Individual Psychological Processes Importance of psychosocial assets. Assets refer to those personal qualities (self-concept, sense of humor, or self-discipline), abilities (professional, intellectual, social, physical, or knowledge), social support, and financial means available to an individual through their personal or relational resources. Dunn (2015) notes that assets can refer to real assets, attainable assets (e.g., education), and imagined assets (e.g., goals, hopes). There are two specific types of psychosocial assets that are important for rehabilitation psychologists to think about: positive psychology and a focus on strengths. Positive psychology. Seligman and Csikszentmihalyi (2000) described three elements of positive psychology—positive personality, positive experience, and positive communities and institutions—that are “what makes life worth living” (Keyes, Fredrickson, & Park, 2012, p. 110). Slavin, Schindler, Chibnall, Fendell, and Shoss (2012) proposed a model of well-being or flourishing that arises from successful pursuit of five goals: Positive emotions, Engagement, Relationships, Meaning, and Achievement. These five pursuits comprise the PERMA model that provides a sense of coherence or comprehension of the world and one’s place in it, a sense of purpose or goal directedness, and a perception that one’s life matters and is somehow significant. Duckworth, Steen, and Seligman (2005) distinguished three domains of happiness: pleasure (positive emotions about the past, present, and future), engagement (using positive individual traits), and meaning (belonging to and serving positive institutions). Aspinwall and Tedeschi (2010) described how positive affect, life meaningfulness, knowledge or skill mastery, personal growth, forgiveness, gratitude, hope, optimism, and spirituality provide a sense of coherence, comprehensibility, and manageability, a feeling of optimism and expectancy for positive outcomes, and the potential for benefit-finding and posttraumatic growth arising from adversity. Hart and Sasso (2011) discussed positive psychology as involving character strengths and positive personality traits, subjective sense of fulfillment and satisfaction, fulfillment of capacities and actualization of potential, and adaptive functioning/behavior (positive coping under conditions of stress or hardship). These positive psychology characteristics, involving both positive internal states and characteristics as well as positive relationships and interactions with others, are significant psychosocial assets for dealing with adversity. Psychologists working with individuals experiencing disability should be able to recognize and support these assets, as well as help individuals develop and enhance them. Suggestions for training programs. Readings • Aspinwall and Tedeschi (2010) • Duckworth, Steen, and Seligman (2005) • Hart and Sasso (2011)

Discussion • What are the shared and distinct domains of positive psychology described by the authors in the texts above? • How are these positive psychology domains affected by individual factors and by environmental factors (physical, social, economic, and policy environments)? What individual and environmental factors can increase or decrease these positive psychology domains? • Considering disability as a person-task-environment interaction, how does the presence of disability affect these positive psychology domains as compared to the absence of disability? Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on positive psychology as a psychosocial asset (a case in which this was a focus or could have been a focus) Considerations for Trainers • Some positive psychology domains may be seen as virtues, and thus, can lead to thinking that individuals who are virtuous have these positive qualities, and individuals who do not have them are less than virtuous. The discussion can be guided to make explicit any underlying assumptions and beliefs about this. Focus on strengths. A focus on strengths is critical for optimal human development and successful management of adversity. Dunn (2015) stated “A focus on the development of human strengths and assets is integral to psychosocial well-being” (p. 108). Dunn (2015) recommends that individuals conduct an Inventory of Strengths to help identify and develop personal assets such as: wisdom and knowledge (curiosity, love of learning), courage (integrity, persistence), humanity (love, social intelligence), justice (fairness, leadership), temperance (forgiveness, modesty), and transcendence (gratitude, hope), and that this focus on strengths can help with coping and flourishing. A focus on strengths, involving both personal characteristics and attributes, can provide an important buffer against despair, and direct attention and efforts toward utilizing these strengths in an adaptive fashion to deal with adversity. Psychologists working with individuals experiencing disability should be able to facilitate a focus on these assets, as well as help individuals develop and enhance them. Suggestions for training programs. Assignment • Ask each trainee to conduct a personal Inventory of Strengths (using Dunn, 2015, Table 7.1, p. 109). For each trainee, what assets are well developed and what assets need to be better developed (including real, attainable, and imagined/future assets)? Discussion • Discuss the personal Inventory of Strengths. • How can a focus on strengths be affected by acquiring a disability (defining disability as a person-taskenvironment interaction)?

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Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on strengths as a psychosocial asset (a case in which this was a focus or could have been a focus)

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Considerations for Trainers • Strengths need not be heroic or powerful, but can also be playful or caring. It is important to promote discussion of the broad range of strengths. Promoting adjustment. Adjustment involves modifying behavior (including thoughts, feelings, and actions) to achieve desired goals when necessary to accommodate to changed circumstances. These processes are often discussed in the psychological literature under the terms adaptation and coping. Adaptation. Acquiring a disability may destabilize previous established physical, emotional, cognitive, and social equilibriums, and challenge individuals to establish new equilibriums in response to these changed circumstances. As Dunn (2015) describes: “Adaptation . . . involves . . . the individual [viewing] disability . . . as a nondevaluing outcome” (p. 29). What helps with adaptation? Dunn (2015) describes the following: resilience and endurance, self-regulation skills, accepting change, emphasis on assets, positive self-esteem and social skills, positive connections with others, and environmental resources. The explicit consideration of these factors can help to focus attention and effort on ways to promote adaptation. For example, social support provides tangible and intangible aid, buffers against distress, and encourages positive health behaviors, and the degree to which individuals feel embedded within a stable social structure is a key component of quality of life and of health outcomes. Therefore, explicit consideration of how to increase social integration can improve adaptation. Similarly, explicit consideration can be given on ways to increase other capabilities such as self-control and problem-focused coping. Suggestions for training programs.

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Coping. Coping is often discussed as begin comprised of three types: problem-focused coping and practical problem solving to lessen the effect of the problem, emotion-focused coping and self-management to lessen the effects of the stress response, and appraisal-focused coping to alter the cognitive perception of the stressor (Groomes & Leahy, 2002). Hope is identified as a key component in coping. Synder and colleagues (Snyder, 1993; Snyder Cheavens, & Sympson, 1997; Snyder et al., 1991; Snyder, 2000; Snyder, Ilardi, Michael, & Cheavens, 2000; Snyder, Rand, & Sigmon, 2002) propose that hope consists of three basic aspects: identified and attainable goals, belief in possible pathways to achieve the goals, and belief in agency (capacity) to achieve the goals. Hope anticipates that the future will be better than the present, and one important component of this is having meaningful, realistic, and flexible goals (Elliott, Uswatte, Lewis, & Palmatier, 2000). Individuals who report higher goal stability are likely to experience less distress and better adjustment following the onset of physical disability than individuals who report higher goal instability. Individuals who report higher goal instability have difficulty setting new and meaningful goals in the face of limitations, demands, and changes. Suggestions for training programs. Readings • Groomes and Leahy (2002) • Snyder, Ilardi, Michael, and Cheavens (2000) • Elliott, Uswatte, Lewis, and Palmatier (2000) Discussion • What are the similarities and differences between hope and denial? • When is hope more adaptive and when is hope less adaptive? • When is denial more adaptive and when is denial less adaptive? • What helps people move from less adaptive to more adaptive?

Discussion • What are the relative roles of emotions, cognition, and behavior in adaptation? • How does one promote adaptation in an individual with significant cognitive limitations? • How does one promote adaptation in an individual with significant emotional disturbance?

Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on the importance of hope in developing flexible goals to promote coping (a case in which this was a focus or could have been a focus)

Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on individual adaptation to disability as a nondevaluing condition, and discuss how resilience, self-regulation, acceptance, assets, selfesteem, social skills, positive relationships, or environmental resources played an important part (a case in which this was a focus or could have been a focus).

Considerations for Trainers • When discussing a case-based application where hope and flexible goals were a problem, help trainees distinguish between difficulties when patients believe goals are not attainable versus pathways are not possible versus their capacity is not adequate, or, alternatively, simply not being ready to accept the necessity of change.

Considerations for Trainers • Adaptation has its own developmental timeline, and that is of the patient, not the staff. Consider concepts of stages of change when discussing this.

Self-perception. Subjective identity is fundamental in how individuals conceptualize themselves, their place in the world, their interactions with others, and their course over time. Identity is enduring but also malleable. McAdams (1993) stated that:

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“[Identity] stories are based on biographical facts, but go considerably beyond the facts as people selectively appropriate aspects of their experience and imaginatively construe both past and future to construct stories that make sense to them and to their audiences, that vivify and integrate life and make it more or less meaningful” (p. 101). People tend to have a self-enhancement bias in their identities—an inclination to hold positive beliefs and feelings about the self (Dunn, 2015). This known as a “better-than-average” effect (Buckingham & Alicke, 2002; Kuyper & Dijkstra, 2009). In one study (Myers, 1980), 100% of high school seniors rated their “ability to get along with others” as being above average—a statistical impossibility. People tend to attribute failure to external causes (e.g., task, context, or circumstances) and tend to attribute success to internal causes (e.g., ability and effort; Sakaki & Murayama, 2013). Dunn (2015, p. 81) described the positive functions of the self-enhancement bias in personal identity. A positive illusion such as seeing yourself as “better off” than real or imagined others allows one to maintain positive views of the self, a sense of control over events, and optimism regarding the future. Suggestions for training programs. Readings • McAdams (1993) • Sakaki and Murayama (2013) Discussion • Discuss the positive and negative effects of the selfenhancement bias. • How can psychologists increase the positive effects and decrease the negative effects of the selfenhancement bias? Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on the importance of an identity narrative (a case in which this was a focus or could have been a focus) Considerations for Trainers • When discussing a case-based application involving an identity narrative, consider whether all identity narratives include a self-enhancement bias, and to what extent this is a positive versus negative aspect

Social Psychological Processes Person-environment relation. The fundamental attribution error. Behavior is a function of both internal dispositions and external situations. However, there is a general tendency for people to attribute their own behavior to situational (external) influences, and to attribute others’ behavior to dispositional (internal) influences. The tendency to underestimate the degree to which one’s own behavior is internally caused and to underestimate the degree to which others’ behavior is externally caused has been called the Fundamental Attribution Error (FAE). These causal attributions occur not only for individuals, but also for groups. Causal attributions for acts differ for in-group and out-group members: people tend to make more external attribution

for negative/failure acts of in-group members (performed well but could not help it) and more internal attributions for negative/failure acts of out-group members (lack of ability or effort). The effects of the fundamental attribution error suggest that when persons not experiencing disability perceive persons experiencing disability as “other” (out-group), then persons not experiencing disability may attribute the disability to negative characteristics of the individual rather than to external circumstances. A concern is that persons newly experiencing disability may initially see themselves as now belonging to that other group, and thus, blame themselves for their physical impairments, activity limitations, and role restrictions. Suggestions for training programs. Readings • Beatson and Halloran (2013) Discussion • How can patients come to terms with a disability identity when their nondisabled identity may have included attributions of blame (even if primarily nonconscious) for those experiencing disability? What interventions could help them with this process? Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation where self-blaming attributions were active for a patient. Considerations for Trainers • Many attributions are nonconscious, both for trainees and for patients, and therefore, these discussions are difficult. The belief in a just world. The belief in a just world (BJW) theory states that people often believe that good people have good things happen to them and bad people have bad things happen to them— both get what they deserve (Nudelman and Shiloh (2011). BJW is associated with higher life satisfaction, self-esteem, and adaptive health behaviors, and lower depressive feelings. People with high BJW are more inclined than others to perceive illness causes as fair, and illness causes perceived as most fair were those that are more controllable (e.g., lifestyle-related or risk-related health conditions). However, judging illness causes as fair can have detrimental effects. It means that for some people illness is deserved. It has been amply demonstrated that health care providers’ beliefs that patients are responsible for becoming ill has negative effects on patients’ wellbeing and on the care they receive (Barrowclough & Hooley, 2003; Ladany, Stern, & Inman, 1998; Lobchuk, McClement, McPherson, & Cheang, 2008; Salmon & Hall, 2003; White, Lehman, Hemphill, Mandel, & Lehman, 2006). Suggestions for training programs. Readings • Nudelman and Shiloh (2011) Discussion • What are trainees personal beliefs regarding a just world— do people get what they deserve in health and illness?

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Does this differ for lifestyle-related or risk-related illness/injury (e.g., morbid obesity and lack of physical activity, smoking, not wearing a seatbelt or helmet) versus nonlifestyle/risk illness/injury (e.g., cerebral aneurysm, unforeseen accident)?

Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation that involved a patient with controllable cause of illness (e.g., alcohol-related motor-vehicle crash) • Discuss a particular case involving assessment, intervention, and consultation that involved a patient with uncontrollable cause of illness (e.g., multiple sclerosis) Considerations for Trainers • Believing in a just world is associated with adaptive health behaviors, and so is beneficial for health care providers. And yet believing that patients are responsible for becoming ill has negative effects on patients’ well-being and on the care they receive: • What should health care professionals do when they believe patients are responsible for their illness/injury? • What should health care professionals do when they observe other health care professionals blaming patients for their illness/injury? Disability as defining or “essentializing.” Insider-outsider perspectives. Dunn (2015, pp. 10 –12) describes that observers can highlight disability over all other qualities possessed by the person, and such social categorization can create in-groups and out-groups, which increases the likelihood of prejudice and discrimination. For example, people not experiencing disability commonly think that persons experiencing disability will have a lower quality of life. However, this is not necessarily true. In general, life satisfaction and happiness appear to have unique individual set points, perhaps determined by genetics and relatively fixed personal characteristics, and across time people usually adjust to both positive and negative events so that they return to their original set point of life satisfaction and happiness. Over time, people who incur a spinal cord injury are not uniformly less happy, and people who win the lottery are not uniformly more happy, than their beginning points (Dunn, 2015). For persons experiencing disability the disability is familiar and thus background, while other life events are foreground (need to go to the store, seeing friends for dinner). However, for a naïve observer of a person with a disability, the disability itself is unusual and thus foreground, while the other life contexts are background, leading to thoughts such as “I could never be happy like that.” Suggestions for training programs. Discussion • For an individual experiencing disability, how might their perception of that disability experience change when the disability is newly acquired versus when it has become more familiar?



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For an individual experiencing disability, how might their perception of that disability experience change in relation to the level of diversity acceptance in the surrounding social/cultural community?

Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation where outsider perspectives about disability by patient or family caused difficulties in rehabilitation progress Considerations • Persons experiencing a newly acquired disability may perceive it as foreground, and thus defining or essentializing, while persons for whom the disability experience is familiar may see it as only one of many personal characteristics. • Persons experiencing a newly acquired disability may perceive it from the perspective of a person not experiencing disability, that is, perceive it as an out-group characteristic, while persons for whom the disability experience is familiar may begin to form a disability in-group identity. • The surrounding level of social/cultural diversity acceptance can affect the ability to see disability as background and to form a disability in-group identity Heuristics and associations. A heuristic is a mental shortcut or “rule-of thumb” strategy that allows people to process information and make decisions quickly and efficiently without constantly stopping to think about their next course of action. Heuristics can be helpful. Gillath, Bahns, Ge, and Crandall (2012) found that people were able to correctly judge a stranger’s age, gender, income, political affiliation, emotional, and other important personality traits by looking at the style, cost, and color of the person’s shoes. However, heuristics can also introduce errors. When asking for directions from passers-by, research confederates using wheelchairs elicited more overly simple and repetitive phrases, with speech that was louder and higher-pitched, such as is used with children, than did confederates not using wheelchairs, as if physical disability equates to cognitive disability (Gouvier, Coon, Todd, & Fuller, 1994; Liesener & Mills, 1999). The Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998; Greenwald, Poehlman, Uhlmann, & Banaji, 2009) examines participant response times to stimuli. Participant response times tend to be fastest when the stimuli are paired into nondisabled/good and disabled/bad and participant response times tend to be slowest when the stimuli are paired into disabled/good and nondisabled/bad—the fastest response times indicating the implicit associations that are most common. Suggestions for training programs. Readings • Gillath, Bahns, Ge, and Crandall (2012) • Greenwald, Poehlman, Uhlmann, and Banaji (2009) Assignment • Have each trainee take the Implicit Associations Test (https://implicit.harvard.edu/implicit/takeatest.html)

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Have each trainee write a brief description or list of the biases that were taught in their family of origin (e.g., negative views of persons of certain socioeconomic classes or of certain racial or ethnic groups, of people who are overweight or have certain behaviors, of people with certain religious or political beliefs, of people experiencing disability, etc.)

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Discussion • Discuss the individual lists of biases. • Have individuals anonymously pool their results of the Implicit Association Test and discuss these as a group. Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation regarding biases against a person experiencing disability Considerations • It is very difficult for individuals who consider themselves broad-minded, altruistic, or equalitarian to be aware of their personal negative biases, and yet everyone has such biases of one type or another, having been raised in families/societies/cultures where some types of individuals/societies/cultures were judged negatively. Discussing those biases can be helpful, or even openly acknowledging that biases exist in those striving to be unbiased.

Values Human dignity. Marks (1999) defines disability as “the complex relationship between the environment, body and psyche, which serves to exclude certain people from becoming full participants in interpersonal, social, cultural, economic and political affairs.” This definition succinctly captures the complex and interactive nature of disability as a person-task-environment phenomenon, and makes evident that the simplistic description of disability as a personal characteristic is not only inadequate but also negatively biased. Thus, “a person with a disability” describes a person who is the focus of this phenomenon involving body, psyche, and environment. An alternative phrase, used throughout this article, is “a person experiencing disability.” Wright (1983) states that “Human dignity: Regardless of physical, intellectual, cognitive, or other form of disability, a person is a person, not an object, thereby deserving respect and encouragement.” Suggestions for training programs. Readings • Marks (1999) Discussion • What are the challenges in keeping human dignity in focus when interacting with patients? • When patients act dignified, for example with socially appropriate speech and behavior, then keeping dignity in focus is easy. But what about patients who are abusive or resistive or inappropriate? How does one

keep dignity in focus when interacting with those individuals? Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on a patient who was not acting with dignity, and how staff were or were not able to treat that patient with respect for dignity Considerations • Similar to other aspects of appropriate professional behavior and virtuous personal behavior, trainees may have difficulty identifying or disclosing their negative reactions to patients. And yet there are patient behaviors that bring about negative trainee and staff reactions. Social participation. The pursuit of meaningful goals is important for healthy functioning (Elliott, Uswatte, Lewis, & Palmatier, 2000), and most goals require social participation. Indeed, social participation is the strongest factor affecting quality of life (Stiers et al., 2012). Those psychological and social processes that lead to exclusion and marginalization of persons experiencing disability result in decreased social participation. Naidoo (2006) discussed the literature regarding the psychic responses to exclusion, marginalization, or rejection as including compliance, resistance, anger, withdrawal, and despair. A key value competency in the training of rehabilitation psychologists is to “Demonstrate a belief in and emphasis on the human worth of persons experiencing impairment or disability and the importance of their integration into the society at large” (Stiers et al., 2015). Suggestions for training programs. Readings • Naidoo (2006) Discussion • Discuss trainee experiences of personal social inclusion and social exclusion, as well as observing the inclusion or exclusion of others, and how these experiences have affected the trainees, both at the time and during later reflection. Case-Based Applications • Discuss a particular case involving assessment, intervention, and consultation focused on a patient who was experiencing social exclusion, either because of unintentional (physical barriers) or intentional (social rejection) factors Considerations • Some individuals may have experienced profound exclusion or bullying in their personal lives, and caution should be used in determining the appropriate depth for this type of group discussion. The discussion leader may wish to provide this caution explicitly at the beginning of the discussion, and instruct participants to determine their appropriate individual level of participation.

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Teaching Methods for the Foundational Principles What is known about the most effective methods for teaching the Foundational Principles to psychology professionals, including questions of how to teach values? The teaching should include methods to reduce group prejudice and to teach values that are related to the foundational principles in ways that facilitate a personally coherent system for learners. This section provides literature reviews that can assist with developing these teaching methods.

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Reducing Group Prejudice Much of the preceding discussion has described how people experiencing disability are a focus of personal, interpersonal, cultural, and social forces involving psychological functioning, selfidentity, attributions and beliefs, social group membership, attitudes, and values, with the potential for negative judgments and resulting restrictions in social participation. What can help ameliorate these potentially negative effects? Increasing contact with persons experiencing disability. Allport (1954) proposed the “contact hypothesis,” which suggested that prejudice could be reduced by personal interactions between persons of majority and minority groups if those interactions were between persons of equal status in the pursuit of common goals and interests. In essence, working together helps transform outgroup members into in-group members, at least to some extent. However, it is important to note that the contact hypothesis requires that the interactions be between persons of equal status. Training of rehabilitation psychologists who have not experienced disability could reduce their out-group perceptions of persons who have experienced disability by using service learning techniques, wherein trainees work with persons experiencing disability on common goals, such as community improvement projects, educational outreach, or efforts to improve physical or policy access. The use of participatory action research, in which persons experiencing disability participate in program planning and rehabilitation research, could also help reduce psychology trainees’ out-group perceptions of persons experiencing disability. Participatory action research is based on “collective, self-reflective inquiry that researchers and participants undertake” and “pays careful attention to power relationships, advocating for power to be deliberately shared between the researcher and the researched” (Baum, MacDougall, & Smith, 2006, p. 854). Both service learning and participatory action research create contact between persons experiencing and not experiencing disability in a context where both have equal power, and thus can help form a shared ingroup experience. Suggestions for training programs. Readings • Allport (1954) • Mc Menamin, McGrath, Cantillion, and MacFarlane (2014). • Baum, MacDougall, and Smith (2006) Discussion • How can service learning techniques be incorporated in your training program?



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How can participatory action research be incorporated in your training program?

Disability simulations. There have been some recommendations that persons who have not experienced disability may better understand persons experiencing disability through simulations of disability experience, such as reducing or eliminating sight or hearing, confining oneself to a wheelchair, or other such voluntarily imposed functional impairments or activity limitations. There is no evidence that simulation exercises bring about positive attitude change (French, 1992), and there is evidence that negative attitudes can be reinforced instead of reduced (Bruschke, Gartner, & Seiter, 1993). Simulation exercises do not simulate life involving disability, but rather some of the effects of experiencing acute disability. Simulation exercises are limited in that persons who live with disability over time employ familiarity, coping, adaptation, and problem solving so as to effectively manage their situations and experience satisfactions with life. A person who is “blind” for 30 min will be fearful and disoriented. However, someone living as a blind adult after receiving appropriate training is able to navigate in familiar and even unfamiliar situations. In addition, simulation exercises are limited in that they help people experience much about the individual aspects of disability, but little about social, environmental and attitudinal barriers. Painting White people black for an hour or a day does little to help them experience what it is to be Black. Burgstahler and Doe (2004) recommend that disability simulations can be helpful under certain circumstances, and their full description of this can be helpful to read. In summary, they suggest that disability simulations take place only if objectives are clearly stated, allow participants to experience challenges and solutions related to both the individual and the environment, demonstrate the value of universal design, include persons experiencing disability in the planning and delivery of the simulation, and debrief thoroughly emphasizing both person and environment factors. Suggestions for training programs. Readings • Burgstahler and Doe (2004) Discussion • Could the training program benefit from including disability simulation experiences? • If so, what would be the best way to implement these? Considerations • Disability simulation experiences have the potential to reinforce negative attitudes toward persons experiencing disability, and so it is important to follow Burgstahler and Doe’s (2004) recommendations.

Teaching Values Related to Social Integration Values are preferences concerned with “right” or “wrong,” and “should” or “should not” (Rokeach, 1973). Glen (1999) defined a value as “an enduring belief that a specific mode of conduct or end-state of existence is personally or socially preferable” to an opposite (p. 8). Values are those ideas, ideals, or beliefs by which individuals or groups guide their behavior.

STIERS

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In classroom teaching, dilemma discussions are more effective than academic courses in promoting the development of moral reasoning related to values (Halstead & Taylor, 2000). Rehabilitation psychology training programs could benefit from explicit dilemma discussions regarding case-problems. Vezeau (2006) discussed that students often have difficulty identifying their values, finding appropriate labels, and describing them, and she proposed some questions to help students identify their values. Glen (1999) also provided important thoughts about values education for health professionals. She discussed that health care professionals need to make decisions about value dilemmas on a regular basis. Thus, values education is essential for the future of interprofessional health care education and practice. Rehabilitation psychology training programs would do well to formally incorporate dilemma discussions specific to issues arising in interprofessional collaboration. Suggestions for training programs. Readings • Halstead and Taylor (2000) • Nunes, Duarte, Santos, and Rego (2015) • Vezeau (2006) Discussion • In what ways is your training program a “just community”? Are there ways in which your training program could improve as a “just community”? • What patient-care professional and intraprofessional dilemmas occur in your practice? How can these be best addressed? Considerations • Students often have difficulty identifying their values, finding appropriate labels, and describing them. Vezeau (2006, p. 7) suggests some questions that my help with this process.

Conclusions This article addresses two questions about how Wright’s (1983) value-laden beliefs and principles can be taught in rehabilitation psychology training: 1.

What are the core theories and evidence supporting these foundational principles, and what should be the content of a “core curriculum” for teaching these to psychology professionals?

2.

What are the most effective methods for teaching these foundational principles to psychology professionals, including questions of how to teach values?

The core curriculum should teach about disability-specific individual psychological processes, social psychological processes, and values related to social integration. The teaching methods should include efforts to reduce group prejudice and to promote values relevant to the foundational principles. This article has reviewed the existing literature in these areas, and provided information that can be helpful in developing teaching content and

methods related to the foundational principles of rehabilitation psychology. Training programs must pay great attention to the nature of the group culture and process when incorporating activities that include reading and activity assignments involving complex personal characteristics and interpersonal interactions, discussions of issues involving individual and social psychological processes, and case-based problem solving involving potent values. Such groups will only result in effective professional development when they are explicitly defined and rigorously guarded as safe and nonthreatening environments, inclusive of individual differences, based on respect and collaboration, and focused on a duty for honest self-reflection to increase understanding of processes and values in patient care. We are aware that the article has not explicitly addressed the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (Adopted August 21, 2002, Effective June 1, 2003, With the 2010 Amendments Adopted February 20, 2010, Effective June 1, 2010). Although the ethical principles are general for all psychologists, they do have specialtyspecific contexts and applications in rehabilitation psychology, for example decision-making capacity in brain injury, choices to forgo treatment in spinal cord injury, or team decision making with persons experiencing profound congenital abnormalities. For the interested reader, there are a number of valuable publications that discuss the specialty-specific application of the general ethical principles in rehabilitation psychology (Donders, 2013; Hanson & Kerkhoff, 2011; Kerkhoff & Hanson, 2013, Hanson & Kerkhoff, 2007). It is hoped that effective teaching of the value-laden beliefs and principles will help rehabilitation psychology trainers and trainees focus on the key knowledge and attitude-value competencies that are to be acquired in training (Stiers et al., 2015). These activities can contribute to psychology workforce development in this important area of health care by improving training practices and increasing the skills of rehabilitation service providers, and thus enhance the health of the underserved population of persons experiencing disability and chronic health conditions.

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Received May 10, 2015 Revision received November 18, 2015 Accepted December 16, 2015 䡲

Teaching the foundational principles of rehabilitation psychology.

Wright (1983) described 20 "value-laden beliefs and principles" that form the foundational principles of rehabilitation psychology, and the education ...
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