Dana Cea (she/they) (00:00)

Executive function shows up differently for every person, even two people with the very same, it's never exactly the same, but the very same disability are gonna have very different experiences related to executive function. So another misconception that I think a lot of folks have around accommodations is that they're one size fit all,

So accommodations-wise, helping with executive functioning, we're first gonna figure out what's going on for the client, where's this showing up at work, at school, at home, how's it showing up for them specifically? So what sort of barriers does it create?

And then we have the opportunity as rehab counselors to get really creative in finding accommodations that will meet their needs.

Sheela (00:41)

Welcome to Not on the List, where we have conversations with professionals about executive function, support, and the things we don't talk about for those of us with never-ending lists. I'm Sheila Ivlev, and today we're talking to

Dana Sia, a rehabilitation counselor and clinical mental health counselor in North Carolina at Panacea Mental Wellness and also a continuing education developer. This conversation is for education and not medical advice.

So welcome, Dana. I think it's awesome that you are a rehabilitation counselor because I'm an occupational therapist. So I'd love to hear about your work. You do a lot of things and just what brought you to it.

Dana Cea (she/they) (01:22)

I heard some of your other episodes and thought like surely you've run across some rehab counselors because we end up in the same spaces with similar clients. So I thought maybe our work had overlapped before. Yeah. I think a big

For rehab counselors, a big focus is on disabilities. And in our programs, I think one of the misconceptions about rehab counselors is that we only focus on like mental health or developmental disabilities when really we look at all disabilities, any type.

So that's for me a big focus, but also an education piece on what I do. That I do focus on a variety of disabilities, chronic illnesses that clients might be bringing. And of course, with my license, I can also work from the mental health side. But I think it offers those of us who are rehab counselors a more holistic view of a person and their life, which I'm sure you as an OT also experience. So yeah, just excited to talk.

Some

more about what rehab counselors do and the opportunities for the collaboration between different professionals.

Sheela (02:27)

Yeah, thank you. I'm curious where you started first. Did you start as a mental health counselor and then a rehab counselor,

Dana Cea (she/they) (02:34)

So my program, my master's program that I went into, it was kind of like a dual enrollment type of situation where when we graduated, we were both eligible to become rehab counselors and licensed mental health counselors in our state.

And then in my PhD program,

very similarly it was like a dual focus. So even though I graduated with a degree rehabilitation counseling and administration, it's now kind of considered that like counselor education and supervisor PhD program. So again, it was dual. There's a lot of overlap in both of those programs.

Sheela (03:12)

So can you tell us more about what rehabilitation counseling is? maybe even kind of contrast when you're wearing the hat of a mental health therapist and a rehab counselor, what that difference might be.

Dana Cea (she/they) (03:25)

I think one of the ways that people view rehab counselors is solely as vocational rehabilitation counselors, which is primarily what the program was developed for, was so that we would have vocational rehabilitation services, which are funded both at the state and the federal level. And counselors help clients, again, with a wide variety of disabilities who want to maybe go back into work. Maybe they've been out of work, or

Maybe they need to change the type of work they're doing because either they've acquired a disability or their disability has changed.

Rehab counselors can help students at any age, all the way from elementary, middle school, high school, as well as into college, universities, and trade schools as well. so there's a lot of different education opportunities that rehab counselors will look at that maybe clients don't consider.

And that also means that rehab counselors can work in the private sector as well. So they can work in academia as like disability support services or related to workers' comp claims, in a hospital, independent living. There's a lot of ways that rehab counselors can apply the skills that we've learned in our master's program.

Sheela (04:39)

So thinking about people re-entering work or the support that you provide with students all across the age span, I would think that executive function support would be huge. And so you're working with people likely with physical disabilities as well as cognitive and mental health is a big piece as well. So I'm curious,

how you've seen the work that you do support people's executive function.

Dana Cea (she/they) (05:03)

Well, because

executive function shows up differently for every person, even two people with the very same, it's never exactly the same, but the very same disability are gonna have very different experiences related to executive function. So another misconception that I think a lot of folks have around accommodations is that they're one size fit all, or that it's gonna be like time and a half for everyone.

And that's just not gonna work. Honestly, some folks with executive function difficulties might need less time. Maybe extended time actually makes things worse. So accommodations-wise, helping with executive functioning, we're first gonna figure out what's going on for the client, where's this showing up at work, at school, at home, how's it showing up for them specifically? So what sort of barriers does it create?

And then we have the opportunity as rehab counselors to get really creative in finding accommodations that will meet their needs.

So for some folks, maybe they need a break every so often.

How do we build that into somebody's schedule? Or maybe they need to get up and move around. Okay. How can we build that in? Does it mean they need to leave the workspace or the school space? Or does it mean they can stay there and just move in the area? maybe they need the ability to record like a course or to record a meeting or something like that. So the list goes on. You know, we could spend our whole time today talking about different types of accommodations for executive functioning.

I think the main takeaway is that it's not going to be the same for everyone and that we really need to make it unique to the person who's in front of us.

Sheela (06:37)

Yeah, I agree. as an occupational therapist, we do. and so it sounds like very similarly, you're working with a person, understanding their like context and situation, how they do things, what's helpful, what's not helpful, before you make any recommendations for accommodations. I know there are a lot of amazing resources out there, like Ask Jan.

is one job accommodations network. And a lot of workplaces might have generic accommodations. And sometimes people look up based on their diagnosis what they can ask for. But it does have to be really personalized to work. So I think that's absolutely amazing. Can you talk through, the accommodations process? Do people come to you specifically looking for accommodations for work and school?

Dana Cea (she/they) (07:19)

Yes, so I provide accommodations assessments where first I look at what is the current functioning. So what's going on for the client based on their disability? How is this impacting them? Where are they looking for accommodations? Is it work or is it school? then we talk about what has worked in the past. Is there a way to implement that again? Or what hasn't worked? You know, is that time and a half not working? Okay, then what can we change it to?

something else. And I think a big part of rehab counselors is probably similar to what you do as OT, is seeing the client do the thing. So often rehab counselors will go to a workspace or go to this classroom.

and see what's going on for the client. what is the environment like and how could they improve things by physically being there and seeing the situation. Because I'm mostly telehealth, I don't always get the opportunity to go in person with them.

So what I might do with a client instead is say, okay, take me through a typical day. Like what do you do when you first get to work and where does it go from there? And so we can break apart piece by piece, even if I'm not physically there, and figure out where the stuck points are and then what accommodations might be helpful.

Sheela (08:34)

I think that is really great where you're doing that work together. It's collaborative. there are again a lot of resources and tools available to support, especially with executive function. It's very popular now. There are lot of people making and selling things. people might think, okay, this is gonna work for me, or even a professional might recommend this works for you, but until

you do it together and see what's working and what doesn't. if somebody's like, I think I need this. And when we're doing the task together and then we're able to find actually this adjustment helps, or maybe it's not as simple as, this particular thing, like you said, extra time. that can actually sometimes add some extra anxiety to people, some extra pressure or

if you're taking tests or working in maybe a quiet environment. That can help some people, but for some people that can be isolating and much harder. and so just kind of curious with your experience of the kind of one size fits all for this diagnosis versus any experiences of where you found that you've discovered very

particular ways that have been supportive for people just by seeing them do it or walking through their system.

Dana Cea (she/they) (09:43)

Many clients are already know what would be helpful. You know, I say, like, what do you think would be helpful? And they can list off a whole thing of this. I wear headphones, or I need a quiet office, or you know, for some folks, like the working from home is better. And for other folks, they need to go into an office. And that's a big difference between my spouse and I. I love being at home. Like if I had to go back into an office now, I'd I it would be really, really hard. Whereas

When we've talked about them, like what's an opportunity to work at home, they don't want that. That doesn't work. They need to go into an office. So each person that I've talked to typically comes in and says, I already know these things will help me. And then I also try to come in with some examples of what I have seen work for clients who are in their situation. So many of them have actually been students in universities. And because I have worked in a university, I've been involved.

In the disability support services from both ends, both as a client and as a counselor, I have a little bit more insight into how universities typically work and what maybe hasn't been thought of for an accommodation because again, here's time and a half for a test. Okay, that might not be helpful for them. Maybe they just need a clock. They just need to be able to see like how much longer they have. So each person, I think, is gonna come in with

some examples.

But I also try to bolster that with do you think this also would be helpful? Because I would rather be as thorough as possible on the requesting side than to three months from now have them come back and say something's still missing. I'd rather get that approval ahead of time.

Sheela (11:21)

I know it's not the same for everybody because it depends on their school, it depends on their workplace, but what is that approval process like for the average person? are you writing up an accommodation letter? And do you have to justify certain things in order for it to be accepted? And are there sometimes hurdles that you hit that you have to work through?

Dana Cea (she/they) (11:45)

Yes, to all of those. So many universities and workplaces actually have some sort of form that they want us to fill out. So often I am either filling out that form directly or I'm creating a letter that fits the mold of what they're asking for.

So having that dual role as like a rehab counselor and a licensed clinical mental health counselor, sometimes what can kind of be a conflict, internal conflict for us as counselors, is in the mental health side, I think what we've done is moved away from the medical model. We focus more so on the strengths of our clients. And as a rehab counselor, I actually first need to focus on what are the deficits, what are the limitations, what are the obstacles, because that's

the .

proof that we need for that school or workplace to take the client's disability seriously. We have to explain why do they need these accommodations. And sometimes why do we need these accommodations specifically?

So that can be a really a point of conflict for a lot of counselors when we want to be very strength spaced with clients, but if we are requesting accommodations, we really need to focus on the gaps. And it's not about like a personality flaw of the client or like them not being able to just do the thing. It is really a gap in the environment that they're in that's not meeting their needs.

Sheela (13:08)

I think that's so important that you brought up that distinction because, a lot of mental health practice people focus on the strengths. as occupational therapists, we do the same. But when I'm doing forms for insurance or disability and accommodations, all those systems are deficit based And so I always make sure that I let people know that.

there's no room in these forms for all of the strengths that you carry, all of the things that you've had to overcome, all of the things that you're great at, because it can feel a little discouraging to read that this person can't do this, that list of all the deficits really is the best way to put it. it's a pretty negative framing, but that's what gets approved in these systems.

Dana Cea (she/they) (13:50)

Exactly. Yeah. They want to know what the diagnoses are, what the history is, how the diagnoses were made, what treatments are being given. And that's another place for us to be very careful when we talk about the treatments. Sometimes there are drawbacks to treatments. And so we need to also incorporate that into our requests and let the school or the workplace know, hey, yeah, they're being treated. And here are some potential drawbacks of.

the medication or the therapy or whatever service it might be. I think it's also important and

that makes a little bit more, we can bring that conflict into more of something a a positive for us as we have counselors being able to notice the overlap between the mental and the physical implications of a diagnosis. So even if it's like a limb difference, for example, that is going to have an effect on someone's mental health. So can we note both like that whole person in those forms that we're submitting or the letters that we're submitting?

And we also look at accommodations that have been used in the past. I know I've talked about that already, but talking about which worked and which didn't. And I think that's really important to stress to the school or the workplace to say, hey, this has already been tried. And it either did or didn't work. If it didn't work, we're replacing it with these options. If it did work, look, we already have a history showing that it has worked. So that is a bit of.

The strengths that we can bring in. but the last bit that I would just kind of note with anyone who's filling out a form like this is to consider the client if they had absolutely no supports, like it at their worst, if there was a symptom flare up, what would that be like for that client so that you can write that letter or that form from that perspective? Because we know there's the potential for that, so we want the workplace or school

to know what the potential.

potential is what could happen in the future.

Sheela (15:46)

That makes sense. So you're writing those accommodations for the moments when they need the most support if their capacity is fluctuating.

Dana Cea (she/they) (15:55)

Exactly, because our executive functioning is gonna change like day to day, sometimes hour to hour. And so we need to be able to encompass a person's from every angle of their executive functioning when they're at their best and when it's at its worst, so that we can cover all that. Maybe they don't need to stand up and move around all the time, but when they do, they need to have that accommodation ready so that they can take up their workplace or school on that, just as one example.

Sheela (16:22)

And and that is something that's really important for people to note that, executive function isn't a constant. And so it can fluctuate from day to day, from hour to hour, depending on how you've slept. there are just so many different things to consider that can affect executive function. So I'm curious if you're open to share

your own experiences of how that might show up for you. and, if you want to share any general things that you've seen with clients.

Dana Cea (she/they) (16:52)

I think for me and my executive functioning, it does vary every day. And more so now in the last couple of years than it did before because of some chronic illnesses that I was diagnosed with. I already had, you know, some executive functioning fluctuations, but

Within the last couple of years, I've had to really relearn what accommodations I need, whether those are organic and things I build into my day to day or things that I actually need to request from other people. we're all like

sharing in that executive functioning experience, knowing that it's not something that's a steady line, that it changes over time, with lots of factors to your point that can influence that. And with clients, the same is true. And that's why I try to get a full picture of like what is most difficult related to your executive functioning. When does that happen? Are there any signs that that's going to happen? Like what can we do to bolster you to maybe prevent that from happening?

But that's just

not always the case. We can't predict everything.

Sheela (17:50)

I think that's so important. and I liked how you framed it. You know, when we think of accommodations, we're thinking that it's a formal letter or a form that you have to submit to a certain department at a university or HR, for example, at work, but you can have accommodations in your own life and you can ask your partner, your friends, people in your life to meet you where you are and let them know what your needs are.

in that moment. we didn't talk that much about the mental health counseling piece? are those things that you also support people in practice with figuring out the other parts of their life beyond the accommodations and the things that they have to navigate in the world?

Dana Cea (she/they) (18:27)

Absolutely. Yeah. I work with individuals and I also work with couples and figuring out what are their executive functioning needs, both as an individual or within a relationship. So whether that other person in the relationship is there or not, talking about what their needs are, how to ask for them to your point. If they didn't get what they needed, then what do we need to change? What kind of approach would be better in the future? But also like what can they do for themselves? And this is something I have.

have

to ask myself quite often,

Maybe I need a medicine bottle that's easier to open. Can I request that from the pharmacy for myself? Or if I know that something is really heavy, then do I maybe make sure it's easier to reach rather than like under the counter? or if I have like a variety of ways to access the computer so that at different times I can be in a different place, a different environment. So there are things that we can do individually to put into place, but also there's a lot that we end up

Asking with others, can you help me with this or can we change this? And then the reverse is true. So I also work with parents and caregivers who are helping others with their executive functioning and their disabilities or chronic illnesses. And that's you know, I'm seeing this from all sides of the conversation. Every single person, whether you have a diagnosis or not, is going to have some sort of executive functioning difficulty at some point or another. So it's figuring out what you can do for yourself.

How can you ask for what you need from others? And then how can you support others while not necessarily like pulling yourself down in the process?

Sheela (20:03)

I'm a family caregiver. I've been one since I was 15. So it's been a very long time. And you know, for a lot of people, they're unpaid, unofficial roles as well. And so they take up time from work and your own self-care. And it sounds like you teach those clients how to support the person, but also how to take

care of themselves, probably realistically knowing that they don't have time and that, their mental, cognitive, and physical loads are also being tested. And so their executive function is something that's being impacted by the responsibilities and again, often lack of like time and support resources for themselves. Is that what you see?

Dana Cea (she/they) (20:46)

Absolutely. Just that feeling of overwhelm, feeling of not having enough time, not having enough energy. And I had a supervisor who told me, you know, when working with clients, ask them what's the smallest thing you can do? And sometimes depending upon how they answer, it might be like, can we break that even smaller and really start with the smallest thing possible? So to your point, like how do you take time for yourself? Well, if you don't have an hour to go do something, do you have five minutes? Do

you have

Have just one minute where you could step away and do something for yourself. If that's walk outside, if that's read a book or an article, and just start as small as possible. It doesn't have to be every day. Can you do it once a month or once a week and start just really, really small, really easily achievable? Nothing is super easy, but something that's maybe more achievable than what's going on right now to help break through some of the overwhelm or the feeling like you have to do it all.

Sheela (21:42)

I think that is very important and realistic. I use that same lens, one from lived experience, and also just recognizing a lot of the generic advice out there can be expensive and time consuming. and not everybody has that. So, you know, when you're focusing on function and really looking at what people are doing, their environment, the context, what they have control over. Sometimes it is

A very modified version that's realistic for the person to be able to do. I would love to ask you about your own experiences because this is something that we talked about before recording this episode, is that you share a lot of identities with the people that you serve. I'm imagining that.

you're making accommodations for yourself probably in the work that you're doing as well. And your own lived experience probably helps inform the support that you're providing to others.

Dana Cea (she/they) (22:32)

Yeah, I do you know being telehealth, working from home is my own accommodation. Could I get an office? Could I see clients in person? I could and I have. but right now for me, working from home and being online is the best. I get to set my own schedule. I make sure that I have time in between activities, whether that's a client or a training, and I can take rest if I need it. I might not need it. I might be able to sit down and knock out some administrative work.

But I do have that time there if I needed to like take a quick nap or just sit and rest for a bit away from the computer. So I'm always figuring out new ways for me to kind of use, to your point, my own lived experience and note how I can change what I'm doing day to day to make it a little bit easier for me. And that looks very different from week to week. And it has looked different over the months and the years past as things have changed.

but yeah, I do I share a lot of my identities with clients. I think it can be helpful to find a therapist or rehab counselor who gets it to a certain extent. but at the same time, I also try to really keep in mind that just because we have a lot of identities that overlap or a lot of shared experiences, it doesn't mean that I understand things from the client's perspective one hundred percent all the time. So I have to be very careful not to make assumptions that maybe that break in between activities for me doesn't work.

for a client or I'm queer, I'm in a queer relationship, and maybe that doesn't look exactly the same for a client's relationship. So I have to kind of keep in mind both like what is my lived experience, what are my identities giving me insight into, while also avoiding any assumptions that might be harmful or unhelpful.

Sheela (24:17)

it sounds like you really get to know the person. I think often the term is used person centered. We all try to be person centered, but that shows up differently depending on just what you're viewing, what you're asking, and what you're working on. so I am wondering advice for people that are listening, if they could benefit from a rehab counselor, how do

they find

rehab counselor, how do they ask for a rehab counselor? And if that is something that's hard to do based on their insurance or just where they're geographically located, how can they get that type of support?

Dana Cea (she/they) (24:51)

Nearly every county in the United States is going to have a local vocational rehabilitation office. So you can reach out to that office. You do not need a referral, although you can get one if you want, but you can reach out to the office and see what they provide. Not all voc rehab offices are created the same, and not all counselors have the same insights, experience, or training. So just be aware of that when you reach out to your local office, if that's not a

Good fit, then ask for someone else who is, or maybe try a different office if that's an option for you. If you're looking for someone who's a certified rehabilitation counselor, you can go to the CRCC website and then they have a like a directory or provider search where you can go and try to find someone who's local to your state or local to your area.

Sheela (25:43)

I have also referred some people to the Department of Rehabilitation. I do know that from geographical location to another, for some people it's been helpful and for some people it hasn't been helpful, but that is a free resource available. So curious if you had anything to add to the use of DOR.

Dana Cea (she/they) (26:01)

Yes, it is state and federally funded, although some of that funding has been cut and there are some changes that are happening with that department. so I don't know what that future is gonna look like, but I do know that CRCC and rehab counselors are really working to keep those services and to make sure that counselors have the capacity to help as many clients as possible. So if you have a not great experience.

just know that rehab counselors are going through a very challenging time right now, and the offices are going through a very challenging time. So don't hesitate to ask them for other resources that they might be able to provide you. If you are at a workplace, human resources is a good place to go to ask them maybe for some resources that they have. often, if you work for a larger company, they will have like there's well theory is just one kind of off the top.

top of my head as an organization that they might be paying for already that you can go to for free and use their services. And for your university or college, like if it's community college, there should be some sort of disability supports office that you can go to and talk to them again, whether it's about getting accommodations or having them help you find resources that are in your area.

Sheela (27:16)

Yeah, thank you, Dana. That's really helpful because before people start trying to figure things out and piece them out on their own, you might have resources at your work or school. I I know that employee assistance programs or EAPs are often underutilized at like every single organization. And so starting there is a great way. And then as you mentioned, also county resources. somebody might be able to direct you to what's available that.

might even be covered if you're at work or school.

Sheela (27:42)

So

Dana, I know that you do continuing education as well to support other therapists in being able.

to provide some of the services that you do in their practice. Can you tell us more about what's available and where people can access?

Dana Cea (she/they) (27:57)

I have a variety of trainings on different topics. The key ones are LGBTQ topics specifically to support trans and non-binary clients, especially around documentation and confidentiality concerns. I also have trainings focused on neurodivergence. So a wide variety of angles from neurodivergence, including mixed neurotype relationships. I have a training specific to disability and caregivers.

So it goes over suicide risk for folks with disabilities and caregivers and how to support each of those. And then I also have a chunk of trainings on supervision. And I have one in particular is supervision for supervisees who are neurodivergent, as well as clients and if a supervisor is neurodivergent. So that training covers all three of those. But a lot of what I try to work on is about how do we stay up to date in our

Our field. That's what I'm really interested in. And so I have quite a few on our field and some of the more recent advances.

Sheela (29:00)

That's great. And then you mentioned the accommodation letter requests. A lot of therapists ask for support with that. So that's wonderful to have all these resources so that providers can be more holistic and really meet people's needs and meet them where they are based on their individual identities and experiences.

Sheela (29:17)

So thank you so much, Dana. This was really, really informative. I'm going to make sure that your practice information and all of the resources that were shared, we will have all of those available in the show notes for people to be able to find and look into. And thank you so much for that and we'll catch everybody next time.

Dana Cea (she/they) (29:36)

Awesome, thank you.