Adaptive Psychiatry: A Framework for Disability-Inclusive Psychiatric Care

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Disability and those living with disabilities are often overlooked by psychiatrists and other clinicians despite their prevalence in medical settings. Disability is often ignored or avoided by clinicians or may be overemphasized at the expense of other characteristics or details. For example, a clinician may not ask a patient about a missing limb that may be the result of a traumatic event or focus so much on the missing limb that they forgo screenings for abuse, substance use, or basic health maintenance. These approaches stem in part from societal norms as well as modern medical education. We are conditioned to not discuss disability out of fear of being rude. In training, we learn to anchor diagnoses and treatments based on buzzwords and develop heuristics. These approaches lead to common pitfalls in patient care.

Understanding ‘Disability’

What do we mean by disability? The US Centers for Disease Control defines disability as any physical or mental impairment that leads to activity limitation and restricted access to activities.¹ Disabilities may be temporary or permanent and may be static or variable over time. Approximately 28% of the United States population has a disability.² People with disabilities (PWDs) are at higher risk for medical and psychiatric comorbidities both related and unrelated to their disability or chronic illness.³

As psychiatric clinicians, we must recognize the mental health challenges faced by PWDs and how to address them. PWDs are more likely to experience mental distress, mental disorders, and suicidal behaviors as compared to individuals without disabilities or chronic illnesses.^4,5 These disparities are often influenced by negative experiences in medical settings. On the flip side, clinicians have expressed feeling that they or their office were ill equipped to treat PWDs, leading to some clinics refusing to see PWDs.⁶ This results in the preservation of the current system where PWDs do not have their needs met, and where clinicians do not learn how to adapt to those needs.

We were inspired to write this piece based on our personal experiences of living with a disability and our goals of providing culturally competent care for the underserved patient population of those who live with a disability. Our experiences as both patients and clinicians grant us a unique perspective to tackle the issue of how PWDs are approached in clinical practice. We do not speak for all living with a disability or chronic illness. Furthermore, we do not intend for the following cases to be all-encompassing for any clinical interaction with a PWD. Rather, we hope that the following may serve as a framework on which clinicians can build their cultural competence.

For Patients With Physical Disabilities

As with any condition, it is important to screen for and keep up to date with a patient’s disability or chronic illness. One way to allow patients the ability to discuss this in their own words in an efficient way is to offer a screener on check-in (Box 1).

Box 1. Sample Intake & Screening for Disability/Chronic Illness in Psychiatric Clinic

Further, ensuring accessibility for PWDs is of paramount importance and requires many considerations (Table 1).

Table 1. Accessibility Do’s & Don’ts

It is also important to note that accessibility starts long before the appointment with the health care professional’s background in clinical education and their comfort with disability and chronic illness. For a more in-depth discussion about accessibility, see the Americans with Disabilities Act (ADA) Accessibility website.

Case 1. A Patient With a Physical Disability

“Dr Brown” is an early-career psychiatrist who works in an outpatient general psychiatry clinic. He has a new evaluation for a patient referred from neurology. The patient, “Ms Olson,” is a woman aged 25 who was born with spastic cerebral palsy (CP). She is being referred for a “depression evaluation.” Consider Table 2 as you read through this case.

Table 2. Screening and Assessment Considerations

Before her appointment, Dr Brown asked his staff to confirm if Ms Olson would need any accommodations. She reported that she wore a brace on her leg but would not need any additional space or accommodations. On the intake screening form (Box 1), Ms Olson described her CP as “something I live with” and “not really affecting” her mental health. For the additional information question, Ms Olson mentioned she believed her CP “impacted her personal life.”

Throughout the interview, Ms Olson said she saw several mental health professionals in the past who “only focused on the CP.” “No one asks about things that matter,” she said. Dr Brown brought up her noted concern about CP impacting her personal life, and Ms Olson disclosed how lower self-esteem had led to increased alcohol consumption and unprotected sex with multiple partners. This led to dysfunction in her life and worsening depression.

Dr Brown recommended psychotherapeutic options and provided counseling regarding her mood and alcohol use, along with sexually transmitted infection (STI) testing and pregnancy testing which came back negative. Over the course of a year, Ms Olson had improvement in her functioning and depression with minimal pharmacological intervention, thus limiting polypharmacy.

For Patients With Hearing Losses

At the Barnes-Jewish Behavioral Health Clinic in Saint Louis, Missouri there is a Deaf Services program that provides culturally competent outpatient mental health care for patients with hearing loss in the region. Our patients’ “hearing loss identities” (similar to the concept of preferred pronouns) primarily include Deaf, deaf, and Hard-of-Hearing (HoH) (Table 3), and they use any combination of signed and/or spoken language, with skilled sign language interpreters present as needed.

Table 3. Common Hearing Loss Preferred Identifiers

When I first meet patients in the Deaf Services clinic, I fill in a SmartPhrase (Box 2) at the top of each of my notes (with consent from the patient), designed to signify to all other providers that (1) the patient has some form of hearing loss and (2) key points on how to best communicate with and accommodate them. In many cases, patients will appreciate being asked such questions, as it signifies a clinician’s awareness, genuine curiosity, and readiness for accommodations.

Box 2. Sample Epic SmartPhrase Used to Document Pertinent History Regarding Patient’s Hearing Loss

Case 2. A Patient With Hearing Loss

“Mike,” a Deaf male aged 31, presents for a routine check-up appointment with “Dr Wilson,” a culturally competent physician. At Mike’s proactive request, an American Sign Language (ASL) interpreter is present; she sits next to Dr Wilson, ensuring that Mike has a clear view of the signed language modality. Dr Wilson begins by establishing a triangular rapport between herself, the interpreter, and the patient, and asks if Mike would benefit from any additional accommodations or if the set-up of the room could be more optimal. Mike appreciates this, and signs “Thank you; actually, it would be nice if you could wear this clear mask I brought, as I speech-read a bit too,” which the interpreter dutifully conveys. (Of note, “speech-reading” is a more accurate and comprehensive way to refer to the colloquial term “lip-reading,” in that speech-reading also considers auditory cues, facial articulations/movements, expressions, and body language.⁷) Dr Wilson happily complies and asks if Mike and the interpreter are ready to begin.

Throughout the appointment, Dr Wilson optimizes visibility by always ensuring she is facing Mike and maintaining eye contact with him rather than the interpreter. She enunciates her words, without raising her voice or speaking slowly, and uses concise, jargon-free language. She pauses between sentences or phrases to allow the interpreter to relay the information. Afterward, Mike is asked to explain what he understood from Dr Wilson, thus ensuring mutual comprehension. Due to her understanding that effective communication can take more time, Dr Wilson remains patient and encourages Mike to speak up if he feels he missed a concept or if he needs adjustments to the environment or communication style. Overall, the interaction is collaborative, respectful, and accommodative to prioritize Mike’s communication needs.

Dr Williams is a psychiatry resident at Washington University School of Medicine/Barnes-Jewish Consortium. Dr Egan is a psychiatry resident at the University of Texas Southwestern Medical Center.

References

1. CDC. Disability and Health Overview. Centers for Disease Control and Prevention. May 2, 2024. Accessed November 6, 2024. https://www.cdc.gov/disability-and-health/about/?CDC_AAref_Val=https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html

2. NIH designates people with disabilities as a population with health disparities. National Institutes of Health (NIH). September 25, 2023. Accessed November 6, 2024. https://www.nih.gov/news-events/news-releases/nih-designates-people-disabilities-population-health-disparities

3. CDC. Disability Impacts All of Us Infographic. Centers for Disease Control and Prevention. Accessed November 6, 2024. https://www.cdc.gov/disability-and-health/articles-documents/disability-impacts-all-of-us-infographic.html?CDC_AAref_Val=https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html

4. Cree RA. Frequent Mental Distress Among Adults, by Disability Status, Disability Type, and Selected Characteristics — United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69. Published September 11, 2020.

5. Marlow NM, Xie Z, Tanner R, Jo A, Kirby AV. Association Between Disability and Suicide-Related Outcomes Among U.S. Adults. American Journal of Preventive Medicine. 2021;61(6):852-862.

6. Lagu T, Haywood C, Reimold K, DeJong C, Walker Sterling R, Iezzoni LI. ‘I Am Not The Doctor For You’: Physicians’ Attitudes About Caring For People With Disabilities. Health Affairs. 2022;41(10):1387-1395.

7. Bernstein LE, Jordan N, Auer ET, Eberhardt SP. Lipreading: A Review of Its Continuing Importance for Speech Recognition With an Acquired Hearing Loss and Possibilities for Effective Training. American Journal of Audiology. 2022;31(2):453-469.

8. Reif S, Mitra M. The complexities of substance use disorder and people with disabilities: Current perspectives. Disability and Health Journal. 2022;15(2, Supplement):101285.