This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, M.S.W., J.D., C.S.A.C. served as the CDM TIPs project director. Other CDM TIPs personnel included Jonathan Gilbert, M.A., managing editor, Y-Lang Nguyen, copy/production editor, Raquel Ingraham, M.S., project manager, Mary Smolenski, Ed.D., C.R.N.P., former project director, and MaryLou
Leonard, former project manager. Special thanks go to consulting writers Jeff Allen, Ph.D., A.B.P.P., Janet Dickinson, Ph.D., Debra Guthmann, Ed.D., and Elizabeth Villalobos, M.S.W., for their contributions to this document.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized patient care and treatment decisions.
What Is a TIP?
CSAT Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance use disorders. CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities for substance use disorders as these disorders are increasingly recognized as a major problem.
The TIPs Editorial Advisory Board, a distinguished group of substance use disorder experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance use disorder treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://isis.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance use disorder treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities, is intended to enhance treatment providers' knowledge concerning people who have a physical or cognitive disability in addition to their substance use disorder. Treatment programs for substance use disorders already see many individuals with coexisting disabilities, but many providers fail to accommodate these individuals either because they are unaware of the disability or how accommodations can improve treatment outcomes (even though such accommodations are legally mandated). The first chapter defines and explains the issues involved in treating people with coexisting disabilities. Chapter 2 discusses how to screen for coexisting disabilities and how to adapt substance use disorder screenings for clients who have a disability. Chapter 3 discusses treatment planning and counseling; it also describes how treatment can be modified to meet the particular needs of people with coexisting disabilities. Forming linkages with other service providers is the topic of Chapter 4, and Chapter 5 presents material for program administrators. In Appendix B, there is a comprehensive list of resources. Appendix C discusses the proper language to use when referring to people with disabilities. Alcohol and Drug Programs and the Americans With Disabilities Act, a pamphlet from the Pacific Research and Training Alliance, is reproduced in Appendix D.
Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
Editorial Advisory Board
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance use disorder treatment field.
Executive Summary and Recommendations
Nearly one-sixth of all Americans have a disability that limits their activity; countless others have disabilities (mostly cognitive in nature) that go unrecognized and undiagnosed. The Americans With Disabilities Act (ADA) was signed into law in 1990 to ensure equal access to all community services and facilities, including substance use disorder treatment facilities both public and private, for all people regardless of any disability they might have. People who are blind, deaf, paraplegic, and who have arthritis, heart disease, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), mental illness, and substance use disorders are among those covered under this legislation.
People with physical and cognitive disabilities are more likely to have a substance use disorder and less likely to get effective treatment for it than those without such a coexisting disability. There are already many people in treatment who have a coexisting cognitive or physical disability. But, as many still go untreated, the number of people with coexisting disabilities entering treatment can only be expected to rise. Treatment programs have a legal and ethical responsibility to make treatment for these clients as effective as possible.
The ADA states that both public and private facilities be equally accessible for all. The law requires the installation of ramps, elevators, proper lighting, and usable doorknobs, and the removal of other physical obstacles, but accessibility means more. Barriers to communications must be removed; discriminatory policies, practices, and procedures eliminated; and attitudes changed in order to not hold a person's disability against him. Accommodating people with coexisting disabilities in treatment for substance use disorders entails such things as adjusting counseling schedules, providing sign language interpreters, suspending "no-medication" rules, and often, overcoming people's fears and ignorance. This TIP presents simple and straightforward guidelines on how to overcome barriers and provide effective treatment to people with coexisting disabilities.
The topic of substance use disorder treatment for people with coexisting disabilities is a broad one. In creating this Treatment Improvement Protocol (TIP), the Consensus Panel focused its attention on the needs of adults in treatment who had a coexisting physical or cognitive disability (including those disabilities also classified as "sensory" in nature). While people who have an affective disability (i.e., mental illness) are mentioned in the TIP, the reader is referred to TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994), for more detailed information concerning the assessment and treatment of these clients.
In order to avoid awkward construction and sexism, this TIP alternates between "he" and "she" for generic examples. Since substance use disorders are considered a disability under the ADA, when people in substance use disorder treatment are referred to in the TIP as having disabilities it is understood that they have "coexisting" disabilities.
The Consensus Panel for this TIP drew upon its considerable experience in both the disability services and substance use disorder treatment fields. Panel members included providers as well as consumers of these services. Because of a lack of substantial research on the particular needs of people with coexisting disabilities in treatment for substance use disorders, the Panel often relied on clinical experience to develop the recommendations provided here. In the summary of recommendations listed below, recommendations that are supported by research literature or legislation (i.e., the ADA) are followed by a (1); clinically based recommendations are marked (2). Citations supporting the former are given in Chapters 1 through 5.
Summary of Recommendations
This TIP is organized into five chapters, the first of which presents an overview of the issues involved in providing substance use disorder treatment for people with coexisting disabilities. It provides important definitions, relevant research findings, and a discussion of barriers to treatment for people with coexisting disabilities. The second chapter presents methods of screening for disabilities and ways in which substance use disorder treatment may need to be modified for people with coexisting disabilities. Chapter 3 discusses treatment planning and counseling, and gives specific recommendations concerning how treatment can be modified to be most effective for people with specific disabilities. Information on forming and maintaining linkages with other service providers is provided in Chapter 4. The final chapter is aimed at program administrators and discusses issues such as staff training, funding mechanisms, marketing, and demonstrating an organizational commitment to working with people who have coexisting disabilities. The recommendations that follow are, however, grouped thematically and not according to the chapters in which they are found.
Making Accommodations To a Program
Screening for Disabilities
Improving Treatment for All Clients
Treatment that is planned and provided on a case-by-case basis will benefit everyone, not just those clients with coexisting disabilities. All people have different functional capacities and limitations, and an evaluation of these, as described and encouraged in this TIP, will help providers focus on individual needs. This TIP explores the treatment needs of people with particular types of disabilities, but the processes of assessment and evaluation it suggests can help all clients gain greater benefit from treatment.
There is a growing belief in the substance use disorder treatment field that treatment is more successful if it can respond to all the needs of an individual, not just the need to stay away from alcohol and drugs. If treatment is to succeed for a client with a coexisting disability, a wide range of services may be required. For this reason, this TIP strongly encourages the use of case management services and service linkages. The TIP also aims to educate people in both the disability services and substance use disorder treatment fields concerning the problems faced by people who have both a substance use disorder and a coexisting disability. A better understanding of the needs of these clients and the services available to them can be gained through reading this TIP.
Chapter1 -- Overview of Treatment Issues
In 1990, it was estimated that 36.1 million people in America (14.5 percent of the population) had a disability that limited their functioning in some manner (LaPlante, 1992). A great number of people with disabilities have struggled for years with barriers to employment, inaccurate and hurtful stereotypes, and inaccessible community services. In order to redress these barriers that affect millions of Americans, President Bush in 1990 signed into law the Americans With Disabilities Act (ADA), the most significant civil rights legislation in two decades. The legislation prohibits discrimination on the basis of disability, including substance use disorders (See Figure 1-1), and guarantees full participation in American society, including access to community services and facilities, for all people with disabilities. It makes provision for many accommodations that may be necessary in substance use disorder treatment, such as the use of large print materials, reading services, attended care, adaptive equipment such as listening devices, and flexible schedules to accommodate different physical needs. Because of this legislation, many people today are more aware of the problems faced by people with physical and cognitive disabilities.
Though the ADA is correcting the situation, many people with disabilities remain stigmatized and shut out. They are also at much higher risk than the rest of the population for substance abuse or dependence. A study of adult males receiving treatment for alcoholism, for instance, revealed that 40 percent had a history indicative of learning disabilities (Rhodes and Jasinski, 1990). Another study indicated that at least one half of persons with a substance use disorder and a coexisting disability are not being identified as such by the systems providing them services (Rehabilitation Research and Training Center on Drugs and Disability [RRTC], 1996).
New York State maintains within their Office of Alcoholism and Substance Abuse Services (OASAS) some of the most comprehensive records in the country on substance use disorder services for persons with disabilities. The OASAS client services statistics for 1997 showed that of 248,679 clients served by licensed facilities in New York, a total of 55,719 (or 22.4 percent of the total clientele) were recorded as having a coexisting physical or mental disability. Of these clients, 58.9 percent had a disability not related to mental illness (e.g., mobility impaired, visually impaired, deaf) (OASAS, 1998). These records were generated by treatment staff personnel who were not necessarily trained in disability assessment or by client self-reports, which suggests that some disabilities (e.g., traumatic brain injury [TBI], learning disability, attention deficit/hyperactivity disorder [AD/HD]) may be greatly under-reported. Given that these "hidden" conditions affect more than half of all special education students, coexisting disabilities may actually affect up to 40 percent of all clients served by substance use disorder treatment programs.
Yet despite the prevalence of substance use disorders among people with disabilities, these individuals are less likely to enter or complete treatment (de Miranda and Cherry, 1989; Kirubakaran et al., 1986; Helwig and Holicky, 1994; Schaschl and Straw, 1989). This is because physical, attitudinal, or communication barriers often limit their treatment options or else render their treatment experiences unsatisfactory.
Fortunately today, substance use disorder treatment providers are better able to face the challenges of accommodating people with coexisting disabilities because they have already had the experience of making treatment modifications for other constituencies. Over the past decades, the substance use disorder treatment field has matured through the challenges of treating populations with specific needs, such as women, adolescents, people from various racial and ethnic minority groups, and gay men and lesbians. The effectiveness of treatment has improved as a result--it has become more developmentally and culturally specific, flexible, and holistic. Rather than placing a person in an established treatment "slot," treatment providers are learning the importance of modifying and adapting services to meet an individual client's needs. Thus, the knowledge and skills necessary to adapt a treatment program to meet the needs of people with coexisting disabilities are a logical extension of existing principles.
Disabilities can be classified as physical, sensory, cognitive, or affective (see Definitions section below). This TIP addresses the problems that may arise when treating people with the first three types; providers treating people with affective impairments (often called dually diagnosed persons) are referred to TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse. This TIP targets substance use disorder treatment providers with little or no experience treating people with physical, cognitive, or sensory disabilities. These providers may be prompted to address disability issues because of the ADA, or perhaps they are treating their first-ever client with deafness, TBI, spinal cord injury, or another disability. This TIP will help them screen, assess, refer, and treat this large and underserved population.
Definitions and Terminology
Physical and cognitive disabilities are very sensitive topics for discussion and providers need to pay attention to the language they use to discuss this issue. Appendix C presents specific guidelines on how to refer to persons with disabilities in a respectful, sensitive manner. As a general rule, one should always put people first, before their disabilities, referring to "persons with disabilities" rather than "disabled people." One should never refer to the disability in place of the person (not "the retarded" but rather "people who are retarded"). Nor should one call a person with a disability a "patient" or "case," unless it is to refer to his relationship with his doctor.
Diseases, disorders, and injuries, whether congenital or acquired, can have various effects on organs and body systems. Conditions (and diseases) such as multiple sclerosis, TBI, spinal cord injury, diabetes, and cerebral palsy can lead to impairments, such as impaired cognitive ability, paralysis, blindness, or muscular dysfunction. These impairments in turn cause disabilities, which limit an individual's ability to function in various areas of life, such as learning, reading, and mobility. While diseases, impairments, and disabilities are distinct categories, they are often used interchangeably; to ensure clarity, they are defined in Figure 1-2.
The field of disability services has developed its own terminology to discuss physical and cognitive disabilities, and many substance use disorder treatment providers will not be familiar with these terms. The terms used throughout the TIP (and in the field of disability services) are defined below.
The World Health Organization (WHO) has devised a method for the classification of impairments and disabilities (World Health Organization, 1980). This complex system has been simplified here into four main categories:
Figure 1-3 categorizes various disabilities according to these four classifications; however, some conditions may be more difficult to categorize and some individuals may experience multiple conditions.
Functional Capacities and Limitations
People may have the same disability without having the same functional capacities and limitations. It is, however, their capacities and limitations that will determine what accommodations should be made to the treatment plan. Treatment providers should look at each individual when determining the level and type of service needed rather than prescribing an approach or course of treatment based on the disability diagnosis. For example, one person with TBI may require a period of specialized services because of problems with attention span, unconstructive behaviors, or medical needs. Someone else with TBI may be stable enough to be integrated with nondisabled persons with minimal accommodation.
Though this TIP addresses accommodations and adjustments by disability, functional limitations are actually what will drive program modifications. There are seven categories of functional capacity and limitation that can impinge on a person's treatment. They are listed below with some of the specific functions that fall under each category.
Disabilities and Chemical Dependency
Data from the Robert Wood Johnson Foundation indicate that about 10 percent of the population have a substance use disorder (Robert Wood Johnson Foundation, 1994). Yet studies have consistently found that 20 percent or more of all persons qualifying for State vocational rehabilitation services exhibit symptoms qualifying them for a diagnosis of substance abuse or substance dependence (Moore and Li, 1994; Schwab and DiNitto, 1993; RRTC, 1996). In the 1996 RRTC study, the disabilities represented included those most prevalent within State vocational rehabilitation (VR) systems: mental illness, various orthopedic impairments, deafness/hearing impairments, blindness/visual impairments, learning disability, mental retardation, TBI, and chemical dependency. In a subsequent analysis, persons with the primary disability of chemical dependency were omitted from the sample. Yet the remaining VR consumers with other disabilities reported patterns of illicit drug use that were more frequent and heavier for every drug compared with a general population sample matched for age and geographic distribution (RRTC, 1996).
In 1988, the Wisconsin Department of Health and Social Services conducted a statewide study of alcohol use by people with disabilities (Buss and Cramer, 1989). It asked 3,216 consumers of VR or independent living services (people who had disabilities such as orthopedic impairments [including spinal cord injury and amputation], vision impairments, loss of hearing, arthritis, cerebral palsy, polio, brain trauma, heart disease, and multiple sclerosis) to report their use of alcohol. Alcohol use patterns were based on typologies established by Cahalan (Cahalan et al., 1969). The study found that respondents with a disability were more likely to be "heavy" or "moderate" drinkers (35 percent and 25 percent, respectively) than the general population. While heavy or moderate drinkers are not considered dependent, this heavy alcohol use puts them at higher risk for injury and other health consequences, as well as future risk of dependence. The results of this study suggest that people with disabilities may use alcohol at least as much if not more than the general population.
Not all people with disabilities are equally likely to have substance use disorders. Certain types of disabilities seem to have more impact than others on substance use behavior. For instance, research suggests that the rate of substance abuse among people with mental illness may be twice as high as that of the general population, and over 50 percent of young people with mental illness report some kind of substance use (Kelley and Benshoff, 1997; Kessler and Klein, 1995; Regier et al., 1990; Brown et al., 1989). Substance use is often the major contributing factor to both spinal cord and traumatic brain injuries, and people living with the aftereffects of such trauma often continue to have substance use disorders (Heinemann et al., 1988; Sparadeo and Gill, 1989; Corrigan et al., 1995).
Both disability and chemical dependency service providers report increases in substance use disorders among people with disabilities. For example, State directors of alcohol and drug departments and directors of State VR agencies reported increases in coexisting disability and substance use disorders among recent referrals to their programs. Directors of both agencies predicted that these numbers would continue rising in the future (RRTC, 1996). Since many people with disabilities are not currently receiving the treatment for substance use disorders they require, the number of people with disabilities seeking treatment can only be expected to grow.
Life Problems Contribute to Substance Use Disorders
People with disabilities are more likely to use substances in part because they experience unemployment, lack of recreational options, social isolation, homelessness, and victimization or physical abuse more frequently than the general population (Susser et al., 1991; Vash, 1981; DeLoach and Greer, 1981; Marshak and Seligman, 1993). If they also have substance use disorders, such problems are further exacerbated.
Many adults with disabilities are underemployed or unemployed. Some 30 percent live below the poverty line, a rate approximately 20 percent higher than that for people without disabilities (LaPlante et al., 1997). People with disabilities at all income levels generally spend a large proportion of their income to meet their disability-related needs. Like others who have been isolated or unemployed over a long period of time, some people with disabilities lack the social skills and familiarity with workplaces needed to succeed in a job.
For many reasons, people with disabilities may rely on a smaller social network. They may be isolated because of their families' efforts to protect them, the physical difficulty of getting out to social settings, lack of opportunities to practice social skills, lack of physical stamina, trouble finding activities and negotiating transportation, poverty, and nondisabled people's discomfort with people with disabilities. An altered body image can make those with a recent disability onset (e.g., people using a wheelchair for the first time) reluctant to socialize. Additionally, physical limitations make some people fear violence or exploitation. People with disabilities are at greater risk of being victims of sexual abuse and domestic or other violence (Glover et al., 1995; Varley, 1984). They are more likely to be victimized because they are perceived as unable to protect themselves. Depression and low self-esteem associated with their disabilities can also play a role in some individuals' victimization, and in turn their substance use.
Isolation and functional limitations leave many people with disabilities with few recreational options, yet they often have much unstructured time on their hands. For example, people who are blind or have a visual impairment may face increased isolation, excess free time, and underemployment (Motet-Grigoras and Schuckit, 1989; Nelipovich and Buss, 1989). Some people may perceive bars or other places where alcohol is consumed as the only social gathering places open to them and drinking or drug use the only possible means of recreating or gaining social support (Greer, 1986).
Panel members report that employed assistants and caregivers for people with disabilities may often abuse their clients, steal from them, or otherwise exploit them. The caregiver for a substance-using client with a disability may purchase alcohol or drugs for the client or tolerate the client's self-destructive behavior.
Each of these life problems increases the individual's risk of substance use disorder, makes treatment more complex, and heightens the possibility of relapse. Coordination with an agency providing case management services for people with disabilities should be a priority if those services are not provided by the substance use disorder treatment program. People with both a substance use disorder and a coexisting disability may need assistance and individualized accommodations to
Programs face procedural and other obstacles when they attempt to rectify such problems. For example, clients may be declared ineligible for some VR programs until they have remained sober for 6 months or more (even though such a requirement is counter-productive and can act to maintain a vicious cycle between a lack of vocational skills and substance use disorders). Some VR counselors resist working with people with substance use disorders, believing them too "difficult" and destined to fail. Furthermore, by the time a person with a disability attempts to access treatment, the level of her substance use disorder may be rather severe because of societal enabling, systems that do not identify early substance use and abuse, and the tendency among human service agencies to focus on disability rather than chemical dependency issues.
Obvious Versus Hidden Disabilities
Identifying hidden disabilities is the key to successful substance use disorder treatment. A patient who repeatedly fails at treatment may not understand what he is told, or may not be able to read or remember materials. Many people who have disabilities (e.g., people with multiple sclerosis, seizure disorders, cardiac problems) look healthy much of the time, but these conditions often cause significant fatigue or limitations on walking, driving, or other physical activities. Treatment staff members may not accept or believe a client has a disability based on what they see, regardless of what the client says. In some cases, people may have had a lifelong investment in hiding their cognitive disabilities and will not volunteer or admit to their conditions.
Disabilities can also be hidden from clients themselves. A substance use disorder treatment program may be where a person first discovers she has diabetes, a learning disability, or a hearing loss. Even if a client knows he has a disability, he may not be aware of accommodations that could help him function better.
Whether they recognize it or not, treatment providers are already delivering services to a variety of people with disabilities. Some of these may be the same people who drop out of treatment, who do not seem to make progress, or who seem unmotivated. Such clients can be particularly frustrating for treatment providers; however, if functional limitations are recognized and treatment is modified accordingly, the program is likely to see better results.
The counselor must be especially sensitive when working with people who are not aware of or wish others to remain unaware of their disability. Chapter 2 elaborates some of the ways in which treatment staff can screen for cognitive disabilities that may not be readily apparent.
Hidden cognitive disabilities
Physical and sensory disabilities are generally more apparent than cognitive disabilities. Several studies have indicated that many people requiring chemical dependency treatment have cognitive, personality, or other conditions that affect their ability to learn or benefit from treatment (Corrigan, 1995; Brown et al., 1989; Rourke and Loberg, 1996). Provider experience bears out the fact that a number of persons present to the treatment setting with undiagnosed or misdiagnosed cognitive impairments. Treatment providers should look out for these potential hidden disabilities, because they may not have been documented by previous health care professionals, may not be fully appreciated by the client, or may have been misinterpreted in the past as "poor motivation" on the part of the client.
The majority of individuals with mental retardation is in the mild to borderline range (IQ up to 83) and can function well in many treatment situations with minimal adaptations. However, people with mental retardation and other cognitive disabilities may have very good social and communication skills and yet still have serious problems with memory, decisionmaking, planning, or learning comprehension. Some highly functioning individuals go to great lengths to keep their disabilities a secret, even presenting with noncompliant or negative behavior to deflect attention from their areas of functional limitation.
Hidden physical disabilities
One cannot ascertain the nature of someone's limitations based on obvious physical impairments. A person who speaks slowly due to cerebral palsy may be able to read and process information quite well. On the other hand, someone who uses a wheelchair may in fact face a more serious impairment in an unrelated learning disability that dramatically limits his ability to read. Some persons with physical disabilities may have had to deal with so many disappointments that they have seriously lowered their own expectations of what they can do; in these situations, these individuals' physical disabilities may be less of an impediment to recovery than their lowered expectations.
Recognizing Barriers to Treatment
In spite of two recent Federal laws (the 1992 Amendments to the Rehabilitation Act of 1973 and the Americans With Disabilities Act of 1990), substance use disorder treatment programs continue to provide inadequate services for people with disabilities. Although this difficulty is most visible in inpatient or residential programs, statewide legal proceedings on behalf of people with disabilities have been initiated regarding access to outpatient settings as well. According to the ADA, programs must remove or compensate for physical or architectural barriers to existing facilities when accommodation is readily achievable, meaning "easily accomplishable and able to be carried out without much difficulty or expense" (P.L. 101-336 -301). Providers should examine their programs and modify them to eliminate four fundamental groups of barriers to treatment for people with disabilities: (1) attitudinal barriers; (2) discriminatory policies, practices, and procedures; (3) communications barriers; and (4) architectural barriers. (For a more detailed explanation of what accommodations must be made, and answers to other, more specific, questions concerning ADA compliance and the best ways to overcome these barriers, see Appendix D).
Attitudes about "disability" influence the ways nondisabled people react to people with disabilities, which can affect the latter's treatment outcomes. The stereotypes and expectations of others also influence the ways people think about their own disabilities.
Perceptions, stereotypes, or beliefs held by providers can hinder their ability to treat a person with a disability. Following are some examples of commonly held beliefs that can pose barriers to treatment:
Staff members who hold such beliefs about people with disabilities may screen out those who would be well served by their programs or deny a client an appropriate accommodation for her disability. On the other hand, these staff members may unwittingly enable clients to use their disabilities to avoid treatment. (For examples of inappropriate responses, see Figure 3-1 on Denial, Enabling, and Accommodation.)
Staff training is key to overcoming attitudinal barriers. For more information on staff training, see Chapter 5 for the discussion of Provider Knowledge of People with Disabilities. To learn the appropriate terms to use in referring to people with disabilities see Appendix C: How to Refer to People With Disabilities.
Discriminatory Policies, Practices, and Procedures
Programs can inadvertently discriminate when their policies, practices, or procedures present barriers to the treatment of people with coexisting disabilities. For example, a program may establish a discriminatory policy such as the following:
Examples of discriminatory practices include the following:
The ADA sets forth many requirements to protect people with disabilities from administrative barriers. Programs should periodically review their existing policies, practices, and procedures and adopt new ones as needed in order to avoid discrimination. Rules and treatment plans can be specifically tailored to meet the needs of each person, and consequently the specific treatment requirements will vary for some people. An individualized treatment approach permits more latitude in assigning different types of chores or homework to individuals and in using different techniques or learning modalities (e.g., allowing a client who has great difficulty speaking in a group setting to turn in an oral report on audiocassette). Also, when all clients receive individualized treatment there will be less friction when one client is permitted to do an assignment differently.
Barriers to Communication
These barriers exist when a program's communications with people with coexisting disabilities are less accessible than its communications with others. To eliminate communications barriers, programs should have available a wide range of auxiliary aids and services.
Communications with people with physical disabilities
Persons with slow speech, significant respiratory problems, or other limitations in expression have a great deal of difficulty expressing their thoughts fully. Consequently, treatment staff has less information to guide its therapeutic actions. Ironically, this occurs most often with clients who need to be better understood by their counselors in order to progress in treatment. A counselor or clinician is confounding the potential success of treatment by not allowing clients who have delays in speech or cognition sufficient time to fully express their thoughts.
Speech impairments can result from a stroke or from a condition such as cerebral palsy. Auxiliary aids for individuals with speech impairments include telecommunication devices for the deaf (TDDs), computer terminals, speech synthesizers, and communication boards.
Communications with people with sensory disabilities
A person who is deaf and blind may require the use of a sign language interpreter trained in the use of tactile communication. People who are blind or visually impaired use a wide range of communication techniques, and one should not assume that all people who are blind are Braille-literate. Providers should find out from the blind person her primary communication method and provide materials in that medium. The provider should be able to supply materials in Braille, large print, and audiocassette. Local, State, or private agencies for the blind can either transcribe or help arrange transcription of printed material into these media.
Inadequate communications are the major barrier to treatment for people who are deaf and hard of hearing. Without accommodation, people who are deaf, whether they use sign language or not, will experience barriers to communication that significantly reduce their ability to benefit from a treatment program and to receive services equivalent to those hearing clients receive. Various auxiliary services and devices can help a person who is deaf communicate with program personnel.
An individual who is deaf can experience his first barrier when he calls a program to apply for admission. A treatment program should have a TDD (also referred to as a TTY), which enables people to type and send messages over the telephone network. If a treatment program has a TDD, people who are deaf can call the program directly.
Once the individual who is deaf has been admitted to the program, someone will have to translate the spoken communication that comprises most of the program. Clients who are deaf and use sign language will need sign language interpreters in order to have access to communication. Individuals whose first language is American Sign Language (ASL) know written English as a second language, and may have the same difficulties with it that other nonnative speakers have. Interpreters should be available at all times so that clients who are deaf can fully participate in the program; if there are no staff who use sign language then one or more outside interpreters will need to be hired.
Treatment programs can contact their State commission for the deaf and hard of hearing or the agency in their State that focuses on deaf and hard of hearing service provision. Most States also have a chapter of the Registry on Interpreters for the Deaf (RID), the professional association for sign language interpreters, to help people obtain the services of a qualified interpreter. As a general rule, an interpreter who is certified by the RID is considered qualified. However, in some States there is a screening system to determine if interpreters who have not yet received certification from the RID are able to provide quality interpreting services. In these States, a person who passes the evaluation, or receives a certain rating, may be qualified. The provider should speak with the organization overseeing the evaluation system to ensure that this is the case.
It is important for treatment providers to understand the parameters within which interpreters work. If an assignment (e.g., interpreting for a detoxification program) is 2 hours or less, an interpreter will usually take the assignment alone. He will probably need a break at some point during the 2 hours, however. Interpreting is taxing, and an interpreter's effectiveness diminishes over time. Well-placed breaks or hiring two interpreters will greatly reduce such fatigue and reduced performance.
Treatment programs may have deaf clients who do not use sign language. In this case, a program may need to get an oral interpreter (who mouths the words that people are saying) or Computer Assisted Realtime Transcription (CART) services. A CART reporter types everything that is said into a computer system, which a deaf person then reads on a monitor or laptop screen. Some individuals who are deaf or hard of hearing may request an assistive listening device to amplify sound. The client who is deaf can provide advice to the program and should be provided the type of device he asks for. The State agency for people who are deaf or the State VR agency should know where to obtain these devices.
Communications with people with cognitive disabilities
Programs must be prepared to adapt basic treatment modalities for individuals with impaired communication (receptive and expressive), reading, or writing skills. The use of picture books, comic books, illustrated "flash cards," art therapy techniques, and audio and videotapes may help resolve some of these communication barriers.
Individuals with TBI may have decreased comprehension of both written and oral information, or may have difficulties speaking. In other cases, these abilities may be intact but social cognition is impaired, leaving those people functionally communicative and literate, but without the requisite judgment and social interaction skills to communicate meaningfully or appropriately with clinicians and peers.
People with aphasia lose the ability to convey and comprehend oral or written information. These individuals may be able to think clearly but may not be able to form their thoughts into coherent sentences without a struggle. In some cases, this condition can vary from day to day, causing counselors to suspect willful noncompliance or a mental/emotional problem unrelated to language comprehension.
Cognitive disabilities may limit people's understanding of basic concepts of treatment. Individuals with developmental disabilities may not have acquired abstract thought skills, and dealing with abstract concepts such as admitting their powerlessness over alcohol can be daunting. Those with learning disabilities may have trouble processing and using abstract information. Many will have limited vocabularies. And many individuals with a variety of disabilities--not necessarily cognitive ones--have poor educational achievement due to negative school experiences. Bad experiences in school are also predictors of later substance use disorders (Jessor and Jessor, 1977).
Physical barriers include the absence of elevators or ramps, narrow hallways, poor lighting, wall telephones too high for people in wheelchairs, deep pile carpets that interfere with wheelchairs or crutches, conventional doorknobs that impede access to people with limited manual dexterity, or even a lack of transportation from the property's boundaries (where public transportation may drop off a person) to the facility's entrance. Programs should consider other types of modifications as well in order to make their buildings safer for all participants.
A person who is blind or visually impaired can typically move safely within an environment once it becomes familiar. The treatment provider should early on give clients who are blind a complete orientation to the facility. Signage to accommodate people who are blind and visually impaired is widely available and includes signs and elevator settings that are properly color contrasted or have raised Braille words and numbers. In addition, loose rugs, wall-mounted fire extinguishers, and lighting that is too bright or too dim can create mobility problems for individuals who are visually impaired.
When barriers cannot readily be removed, a program must find alternate methods to make its services available. A program that offers counseling in an upstairs room must offer counseling downstairs when needed, if it is not able to add a ramp or elevator. If an onsite adjustment cannot be made, an outpatient program must find an alternate site where it can deliver the same level of care it provides at its nonaccessible site. A residential program may find it necessary to make an appropriate referral as a temporary solution, while it takes the steps necessary to change its facilities for future clients.
Mainstreaming Versus Specialized Services
In general, it is beneficial and feasible to integrate people with disabilities into already existing community-based services used by other individuals recovering from substance use disorders (a process known as mainstreaming). However, there are a number of exceptions to this rule. In instances where a legitimate, documented reason exists, specialized services may be necessary.
People who are deaf and identify with Deaf Culture will usually prefer specialized treatment programs (see below). In addition, clients who have severe psychiatric disorders will benefit from specialized services that understand their medication and behavioral issues. People with mental retardation may find it easier to understand and participate in discussions that involve others with similar disabilities. They do not have to channel all their energy into "passing as normal" and are less ashamed to ask questions. Some clinicians find that even people with mild and borderline mental retardation, and with limited or no reading abilities, prefer to be placed with other nonreaders. Other disability conditions that may warrant some stand-alone services include TBI, spinal cord injury, or severe or multiple disabilities.
In some situations, however, grouping people with similar disabilities may be counterproductive. For example, persons who are grouped by disability may try to ignore the larger treatment population, or they may be at widely dissimilar stages of acceptance or adaptation to their disabilities. Depending on the personalities of the individuals involved, one person may keep another from going forward in treatment. While grouping generally can produce positive outcomes, it is an adaptation that should be monitored once established.
Ideally, stand-alone services should be offered to an individual with a coexisting disability in concert with other community supports, thereby increasing the depth of the recovery plan and making the transition to sober community living more logistically possible. Such community supports could be attending an outpatient chemical dependency program in an area of the town where the client lives, becoming enrolled in vocational rehabilitation, attending support group meetings for head injury, or enrolling in a community college developmental English program.
Deaf and Hard of Hearing
Many members of the Deaf Community benefit from specialized services, which generally are better equipped to handle specific cultural, language, and communications issues that may arise. People who are deaf or hard of hearing and use sign language tend to identify themselves as part of a deaf community. Many will prefer to be served by programs that specifically address their needs and whose staff is fluent in sign language. Unlike many other people with disabilities, people who are deaf often do not identify with a medical model of disability and instead embrace a cultural model that emphasizes their abilities within the Deaf Community and their own language and values.
Most people who are deaf seeking substance use disorder treatment prefer segregated programs to mainstreamed programs. This allows clients who are deaf to participate in a group with deaf peers and a counselor who is fluent in sign language. Direct communication will facilitate greater participation by clients who are deaf than communication through an interpreter. Such a group provides an environment of peers who share similar life experiences and a common language, generally considered important for the recovery process.
Yet having a group that is all deaf is not realistic for most programs. It is more likely that, on occasion, there will be only one client who is deaf in a program, and the rest of the clients will be able to hear. In this case, the program will need to hire one or more sign language interpreters to facilitate comprehensive communication among the client who is deaf, hearing clients, and hearing staff. In some instances, the program may want to refer the person to a specialized program serving people who are deaf and hard of hearing. If a sign language interpreter is not available, the leader of the group may try to communicate with the person through pencil and paper, trying to explain some of the issues. Without the presence of the interpreter, however, the individual who is deaf will miss much of the information shared during a therapeutic group.
Some individuals who are late-deafened or hard of hearing do not use sign language, did not grow up with other people who are deaf, and do not identify with Deaf Culture. This population is actually larger than the population who uses sign language (Minnesota Chemical Dependency Treatment Program for Deaf and Hard of Hearing Individuals, 1996). These individuals will generally prefer to be served by programs for the general population alongside clients who can hear. The types of accommodations they need will differ from what is needed to effectively treat clients who identify with Deaf Culture. These accommodations will usually consist of the use of devices either to amplify sound or to print what individuals in the program are saying. These people have grown up using English as a primary language and do not have the second language issues that are common to individuals who are deaf whose primary language is ASL.
Working With People With Disabilities
A significant number of the people currently seeking treatment for substance use disorders also have a physical, cognitive, sensory, or affective disability. Many others are or believe they are unable to access the treatment they desperately need, often because of the double stigma of having a substance use disorder and a coexisting disability. This TIP provides simple, practical guidelines to help treatment professionals provide services for people with coexisting disabilities, thereby improving the quality of treatment for a large number of persons whose needs are not being met. The TIP is organized to allow treatment providers to find information pertinent to clients who may have a particular disability. Even though these categories of disabilities are often artificial distinctions, this system of organization gives treatment professionals a baseline from which to modify treatment on a case-by-case basis for their clients with coexisting disabilities.
The TIP also aims to educate providers about the needs common to most (if not all) people with disabilities and the legal, ethical, and practical reasons to accommodate this significant client population. Information is provided concerning screening for the physical and cognitive disabilities of those seeking treatment (in Chapter 2), how treatment can be modified to work better for people with disabilities (in Chapter 3), establishing linkages with other types of agencies and programs (in Chapter 4), modifications to the program that might need to take place at the administrative level (in Chapter 5), and ADA compliance (see Appendix D).
Many treatment providers have been reluctant to take on clients with disabilities because they assume difficulties that may not exist. The less one understands disabilities and their corresponding functional limitations, the more daunting accommodation appears. A useful parallel is the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the 1980s, when many health care workers were afraid to treat patients with human immunodeficiency virus (HIV) and AIDS (a population also covered by the ADA). In that case, education and hands-on experience with AIDS patients countered the widespread apprehension better than anything else. Similarly, more information such as that provided in this TIP and the inclusion of clients with disabilities in treatment programs will help reduce barriers to treatment discussed above.
The process of education will help treatment providers discover that people with disabilities are more like than unlike other clients, and that they have already been treating people with disabilities without knowing it. The presence of people with disabilities in a treatment group can benefit all clients. Appropriate accommodation of a person with a disability fosters cooperation at the same time it enriches group diversity. By better serving people with identified disabilities, the treatment provider will improve care for a great many other clients as well, as providers learn to tailor treatment to each client's individual needs.
Chapter 2 -- Screening Issues
Physical, sensory, and cognitive disabilities affect far more clients than many treatment providers realize. Because so many people in treatment programs for substance use disorders have coexisting disabilities, the Consensus Panel recommends that every new client be screened for disabilities. In the screening process, each client's level of ability in various areas of functioning should be evaluated. The screening described here is not and should not be seen as an additional task to be performed only with people who have an obvious physical or cognitive disability.
Persons with disabilities also may require modifications in the way treatment personnel perform screening and assessment for substance use disorders. As with any stage of treatment, providers will need to make accommodations for people with disabilities in their screening procedures. Because both these forms of screening will occur at roughly the same time, both will be discussed below.
It is important that providers be sensitive to the feelings as well as the needs of people with disabilities from their first contact onward. Providers who have never worked with someone with an obvious disability may feel awkward, unsure of what to say, or what help to offer. Sensitivity and openness will help ease this discomfort, as will the following guidelines.
In planning and providing treatment to people with disabilities, the importance of asking questions cannot be overemphasized. "Disability etiquette" involves maintaining an awareness of intrusion into an individual's personal space. Asking before rendering any service is a basic principle. "May I help?" should be followed by "How may I help?" For example, if a person is struggling to put a wheelchair into a car, it is important to first ask if help is needed and then to ask how the wheelchair should be placed in the car so that the person can later remove the wheelchair unassisted.
Some providers may feel embarrassed to ask certain questions or may worry about giving offense, even when the answers are critical to the treatment planning process. It may be helpful to preface such questions by requesting permission to ask them. "May I ask you about..." or "It would help me to know more about..." are ways of beginning to ask more direct questions. It is, however, important for staff members to be able to be honest and acknowledge that they may not know the appropriate way to ask a question.
Although resources regarding disability etiquette are available from organizations such as Easter Seals and the American Foundation for the Blind, it is always best to ask each person what he wants, thus ensuring that cultural, gender, and personal preferences are met. (See Appendix C for information on how to refer to people with disabilities.)
People With Sensory Disabilities
The majority of people who are blind use a cane; fewer use guide dogs. Either way, people who are blind or visually impaired will require assistance in orienting themselves to a new environment. Treatment providers should try to describe or guide a person through a new environment. Instead of stepping back and allowing the person to fumble, the counselor should offer "sighted guide" assistance, during which the person who is blind holds the sighted person's arm just above the elbow and they walk in tandem. Pulling a person by his arm is not appropriate.
People who are blind live in a more touch-oriented world than the sighted population. It is acceptable for the counselor to put the blind person's hand on the back of the chair she is to use. A service animal, however, should not be distracted from its job; the animal should not be touched or petted, nor should one even ask permission to do so.
Word use is important. The counselor must use more descriptive and detailed language and strive to avoid phases like "over there" or "like this." There is no need to avoid words like "see" and "look"--they are part of everyone's daily language.
Finally, more than 80 percent of people considered "blind" have some residual vision. This remaining vision is typically light- or glare-sensitive. It is helpful to ask if the lighting in the current environment is uncomfortable. Figure 3-6 in the next chapter presents these and other suggestions for working with people who are blind in the form of an easy-to-follow list of suggestions.
Communication is the key issue when dealing with individuals who are deaf and hard of hearing. Regardless of the model of communication used by the person who is deaf or hard of hearing, the visual aspect of communication will be important. Therefore, it is important to look directly at the person when communicating so he can see facial expressions and has the option of lip-reading. When interviewing a person who is deaf with an interpreter, it is still important to look directly at the client. Speak directly to him just as if there was no interpreter present.
People With Physical Disabilities
Persons with disabilities that limit their mobility can encounter situations like sidewalks without curb cuts or front doors that cannot be opened from a wheelchair. They are understandably annoyed if they are stymied by these barriers and then hear those responsible for the facility explain, "We hardly ever get someone with a wheelchair here." Providers should not assume that someone in a wheelchair is unusually resistant to treatment just because she expresses anger at not being able to enter the facility through the same entrance or use the same restroom as other clients.
People who use wheelchairs often come to regard the chair as an extension of themselves, and touching the chair may be offensive to them. Never take control of the wheelchair or touch any other adaptive equipment without permission.
Screening for Disabilities
Treatment providers are not expected to become experts in disabilities or to diagnose disabilities themselves. However, functional limitations and symptoms of disability are likely to become apparent as clients with disabilities participate in treatment, and a provider should recognize certain signs and symptoms.
It is the level of abilities and of the functioning of the individual--not the simple determination of whether a disability exists--that must be assessed if screening is to lead to an effective treatment plan. In situations where a diagnosis of disability is needed (e.g., to qualify for special services), treatment providers should refer the client to a disabilities services professional. State vocational rehabilitation (VR) programs may be a good source for referral.
Functional limitations associated with a disability, whether apparent or not, can undermine treatment if they are not recognized and addressed. For example, a person's lack of progress in treatment may be mistakenly attributed to a lack of motivation, when in reality a functional limitation, such as an inability to read, is impeding her ability to understand or participate in treatment. Such an individual may seem indifferent to achieving her treatment goals, when she is actually having difficulty processing or retaining information.
Treatment providers should be careful not to make determinations about a person's disability when they are not qualified to do so. Initial screening is encouraged, but an expert on the particular disability should conduct any further assessment. Of course if a client is being referred from a disabilities expert, staff should ask for a full evaluation that includes specific client strengths and weaknesses.
Through the screening process, the provider can begin to understand the circumstances in a client's life that are likely to have a bearing on treatment. All such circumstances, whether or not they are disabilities, should be incorporated into the treatment plan.
Questions relating to disabilities can and should be incorporated as seamlessly as possible into a comprehensive screen, rather than treated as an altogether separate subject. After discussion of the substance use disorder, the interviewer can bring up visibly obvious impairments, such as those requiring the use of a wheelchair or cane. The questions can be framed by the program's desire to respond to individual needs: "Do you need any accommodations to participate in this program?" This question should be posed to everyone, not only to those the interviewer thinks have a disability.
The possibility of hidden impairments can be explored subtly during the conversation. For example, during a routine medical history, a question about past hospitalizations can elicit information about a previous brain or head injury, thus alerting the interviewer to the possibility of traumatic brain injury (TBI). Similarly, a client's answers to routine questions about past and current medications may point to the possibility of cognitive or affective impairments (see Case Study below). A client's referrals from other service providers such as VR services can also offer insights into less obvious impairments.
Setting always influences the screening process; this is especially true when testing or interviewing for disabilities. An individual's problems with mobility, for example, may make it necessary for the interviewer to travel to his home, where there may be distractions of children or other family members. However, a person might not be willing to speak openly in front of other family members, even if they already know about her disabilities. Wherever the interview takes place, it is important to create a sense of privacy in talking with the client.
Figure 2-1 presents a basic screening instrument for identifying impairments and functional limitations that can be handed to a client preceding an interview. The text can be used verbatim (with the instructions given at the top of the figure) as a form all clients would receive before a screening and assessment session. In the answers to questions such as these, the interviewer should be looking for things such as the history and symptoms of diseases or disorders that can provide clues to impairments and disabilities. If the questions and discussions based on the screen indicate an impairment, the client should be referred to a disabilities expert for a more in-depth screening.
Figure 2-2 presents the questions from Figure 2-1 in the manner they might be asked during a spoken (or signed) interview, with the numbers of the relevant questions provided in parentheses. This figure also provides further questions that might be asked and ideas for how the information gained in the interview could be used in followup treatment planning. Throughout the screening interview, it is important for the screener to pay attention to the individual's affect and behavior in order to pick up on possible cognitive or affective impairments. Screening for psychiatric disorders is discussed in TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994).
Screening for sensory disabilities
A treatment provider need not conduct an assessment of hearing loss when working with people who are deaf or hard of hearing. The provider should, however, note the individual's apparent adjustment to the hearing loss and psychosocial factors related to it. This information could be used in determining the type of program to which to refer the client (a mainstreamed program or an all-deaf program) and could be useful to the treatment provider in developing a treatment plan. Clinicians who conduct screenings should consult with a professional who is experienced in working with people who are deaf and can assist the clinician in developing an appropriate referral to treatment.
Background information to consider when screening an individual who is deaf or hard of hearing includes the following:
If a client uses sign language as her primary mode of communication, attended a residential school for the deaf, or socializes primarily with people who are deaf, it is likely that an all-deaf program is most appropriate for him. On the other hand, if she does not use sign language, grew up attending public schools without support services, and has no deaf peers, a mainstreamed program may better meet her needs.
Screening for cognitive and affective disabilities
Some cognitive impairments, while not readily apparent, may be revealed by subtle behavioral cues. For instance, difficulty in attending to the questions being asked or fidgeting and restlessness during the interview may indicate an attention disorder.
Memory problems, such as those resulting from TBI, may also be hard to detect initially. A person might be quite conversationally skilled and appear to be comprehending a vast amount of new information but might not retain the information even until the following day. Given the significance of retaining treatment information, memory difficulties need to be detected early so that a more in-depth assessment can be conducted and treatment recommendations can be made.
A person's problem-solving and reasoning abilities may be impaired by head trauma and substance use. While this functional limitation can greatly affect decision making in high-risk situations, it might not emerge as problematic while the client is responding to questions about his personal background in a well-rehearsed fashion. For this reason, it may be important for the clinician to informally assess reasoning and problem solving with more novel questioning or a brief screening tool that does not solely target the individual's personal social history. One way to screen self-care and problem-solving capacities informally is by asking a person to complete some simple activities such as writing a check or performing a practical math problem.
Substance use disorders may elicit behaviors that could be mistaken for mental health concerns. For example, many substance-using clients display paranoid behaviors that may take time to dissipate even after detoxification. Looking at these cues as potential signals, rather than drawing conclusions from them, will help the interviewer avoid making false presumptions.
Interviewers also need to be aware that substance use disorders can obscure a disability. The use of cocaine and crack can mask clinical depression, and some individuals with severe, chronic depression may self-medicate with crack or cocaine. Upon admission to a substance use disorder treatment facility, these individuals appear appropriate in affect. However, after detoxification, they plunge into a deep, intractable depression, requiring psychiatric intervention and medication. Individuals with mental retardation or developmental disabilities often use marijuana or alcohol to mask their disability--it is difficult to discern a drunk or high person with developmental disabilities from a drunk or high person without such disabilities.
Conversing with an individual with a cognitive disability about her disability can provide other information relevant to treatment. For example, asking someone how he became cognitively disabled may reveal a history of physical abuse, accidents, or illnesses resulting in head injuries in childhood. Asking how old someone was when she first realized she had a disability and what that felt like can reveal suicidal ideation in childhood and untreated pain over the disability, problems that may contribute to a substance use disorder in later life.
From Screening to Treatment
One of the challenges substance use disorder treatment programs face in providing services to people with disabilities is determining what the program can offer these clients to best meet their needs. The screening process can help to identify those areas where linkages with other services and agencies are needed. Changes to the program and its facilities may also be needed.
The aim of the initial screening for disability-related considerations is not a diagnosis, but rather a pragmatic exploration of the potential barriers to treatment that may arise from a disability and its associated functional limitations. Individuals entering chemical dependency treatment do not always benefit from learning new, potentially stigmatizing terms that apply to them, but they may benefit from modifications to the treatment process. Which is not to say that staff and clients should avoid talking about disabilities, but that it is more important to focus on necessary modifications to treatment than on a specific label. Additionally, treatment personnel are unlikely to be qualified to make disability diagnoses; however, in a practical sense, they are likely to be more skilled than they realize in adjusting treatment approaches based on the needs of their clients.
Questions used to screen for the presence of disabilities can be asked verbally, or the client can fill out the written survey provided in Figure 2-1 before an interview begins. After the screening it may be useful to draw up a profile of the client that presents the person's strengths and needs, along with recommendations to address those needs. This profile can be drawn up as a chart listing the seven areas of functional limitations described in Chapter 1. Each of the seven areas of functional limitation used in this screening (self-care, mobility, communications, learning, problem solving, social skills, and executive functions) presents specific considerations that may be identified in the screening interview. In the example below, questions from Figure 2-1 are applied in an actual interview; an accompanying profile, for a person with TBI, is depicted in Figure 2-3. A discussion of how the information gathered can be applied in treatment planning follows.
"John," a 26-year-old white male, was referred from a local criminal justice agency after an arrest for driving under the influence (DUI). A high-school graduate, he lived with his mother and had held a series of entry-level jobs, none for more than 8 months. He had no obvious disabilities and stated that he is at the program because he "got into trouble." The screening questions presented below reflect a portion of a lengthier interview; John's answers to the questions will assist providers in planning his treatment program.
Q: Do you feel you have a disability, or has anyone ever told you that you have one?
A: No, nothing like that.
Q: Have you ever had to stay in a hospital overnight, or gone to an emergency room for any reason?
A: I've had some falls, and once I broke my arm. I went to the emergency room. But I never had to stay overnight.
Q: Have you ever seen a doctor for a long period of time, more frequently than just one visit or for routine check-ups?
A: Yes when I was in grade school.
Q: What was going on for you that you needed to see the doctor so often?
A: I'm not sure. I think I was overactive. I was on some kind of medicine.
Q: Do you know what kind of medication it was?
A: It was "rid-lin" [Ritalin] or something like that.
Q: Were you ever diagnosed with a learning disorder?
A: I don't think so.
Q: Were you ever in special education classes in school or did you receive any kind of tutoring?
A: I had some tutoring for math.
Q: Have you ever been given a hearing test?
A: Yeah. When I was in school they did hearing tests. I always passed them with flying colors. I don't have any hearing problems.
Q: Do you ever have to ask people to repeat what they're saying? Or has anyone ever complained to you that you don't listen?
A: Yeah, well my boss at work always says that I don't listen. And my teachers at school used to tell my mother that I don't hear what people are saying to me.
Q: Did you ever need to wear glasses?
Q: When was the last time that your eyes were checked?
A: Oh, about 2 years ago. I was having some problems at work because they have really bright lights in the building. That would give me a headache sometimes. The eye doctor said that my eyes looked good. I guess I just don't like bright lights.
Q: Have you ever been hit on the head or had any blows to the head?
A: Now that you mention it, there was this one time in high school after football practice. Some of us were fooling around and I got into a fight. I don't know what happened. But I had to get some stitches and I had a headache for a few days.
Q: Did you lose consciousness?
A: I don't know. I guess there were some things I don't remember that people told me about later.
Q: What's the first thing you remember after the fight?
A: Riding in the ambulance.
Q: What did they do at the hospital?
A: I got some stitches in my forehead and they kept me around for a while to keep an eye on me.
Q: Did you notice any changes in your abilities since then?
A: No, not really.
Q: Have you had problems with bad or frequent headaches since the fight?
A: I guess sometimes I have headaches.
Q: Have you ever talked to a doctor about them?
A: No, not really.
[This is a problem that may need to be followed up with a physician visit. If neuropsychological testing was never done after the accident, it should be performed now if funds are available.]
Q: Have you ever received benefits of any kind? Like from a government agency?
Q: Let's talk about your work history for a while. How many jobs have you had in the past three years?
A: Oh, about four or five.
Q: What was the longest job that you held?
A: Last year I worked for 8 months as a grocer's assistant. I quit because the boss was getting on my case. I don't think he liked me very much.
Q: Why do you think that?
A: Well, he would yell at me or tell me that I didn't do my job right. I should have been given a better job there, but he would say that I couldn't figure out how to do the job I had. He said I was forgetful.
Q: Do you think that you are forgetful?
A: Yeah, I guess so. I just sometimes forget things at work. There's too much to remember all at once.
Q: How were you taught your job?
A: Well, I followed this guy around and did what he told me to.
Q: Did that work? Do you feel that you learned the job?
A: It was OK when we worked together. Then they gave me a big list of stuff and I was supposed to just follow the list, but it didn't make sense.
Q: Were you able to read the list OK?
A: I guess some of it I didn't understand.
Q: Were you able to ask someone to explain the tasks required?
A: No, I just kind of figured it out. I don't like to ask a lot of questions. People don't always understand what I'm asking about anyway.
Q: Do you ever have trouble controlling your anger?
A: Maybe when I'm drinking.
Q: Do you ever feel anxious or on edge?
A: Sometimes. When I'm bored.
Q: How about feeling depressed? Or really happy for no reason?
Q: Is English your first language? Did you speak any other language when you were growing up?
A: No, I only speak English.
Q: Tell me about your reading habits. What kind of stuff do you like to read? How often do you read?
A: I don't really like to read. I mostly read the comics. Stuff like that. [The screener suspects a reading problem from this answer. Later on in the interview the client is asked to read a simple sentence from a Release of Information form, and he labors over it in a halting manner.]
Q: Do you ever have trouble paying attention or concentrating on things?
A: With things I like, I don't have a problem, no.
Q: What kinds of things interest you and hold your attention?
A: Sports and TV shows I like--mostly comedies.
[In the last portion of the interview, the screener has noticed that the client has been preoccupied; he keeps looking out the window, and the interviewer has had to repeat some questions.]
The results of this screening interview and how they pertain to the identification of areas in which John may have impairments and disabilities are presented in Figure 2-3. The interview with John and the accompanying profile may raise as many questions as they answer. However, after the interview the major issues become clearer, and the next steps are more evident. John may have had one or more sources of compromise to his mental abilities. Regardless of the source, at this point the screening has raised questions about his reading, learning ability, problem-solving ability, and social skills. Additionally, executive functions as they relate to vocational capability need to be further evaluated. There are two questions the treatment provider should consider at this point:
The extent to which John's needs will affect participation depends on the program. His reading problems will only limit participation if written materials are a pivotal part of the program. Attention problems will be more of a difficulty in group treatment, extended sessions, or treatment that occurs at the end of the day. His possible difficulties with awareness and problem solving will be more limiting if the treatment program requires higher levels of insight and abstraction, particularly if there are not opportunities for individualized attention to assist with understanding and recognition. Finally, limitations in social skills may limit participation in a residential program or other treatment that involves significant peer interaction.
If the nature of the treatment program is such that John's needs will limit his participation, then more aggressive steps to seek additional information and assistance may be necessary. For instance, consultation with a rehabilitation psychologist might be called for to help ascertain John's optimal learning style and ways in which problem-solving abilities and social skills can be mediated. On the other hand, if there appear to be few ways in which John's participation in the program will be hindered by his functional limitations, then treatment might be initiated with the intention that if problems emerge additional information or consultation will be sought.
The Consensus Panel recommends an "open door" policy that states that all clients are entitled to an assessment if they are presenting with a chemical dependency problem, regardless of what other problems they may appear to have. If the proper course of treatment is not available at the facility, it is still possible to perform an assessment for substance use disorders and refer the client for treatment elsewhere.
Some treatment programs allow only 1 hour for the intake interview. Persons with certain physical or cognitive disabilities may require a longer interview, and rest periods may need to be scheduled. Flexibility should be built into interview scheduling. Some residential or inpatient treatment programs have found it effective to schedule an interview over 2 hours, before and after lunch. Facilities with in-house meal programs can offer the person a meal ticket when the intake is scheduled, which may provide an additional incentive to stay to complete the interview. In other programs, the interviewer can encourage the individual to bring a bagged lunch. For some people, the informality of a shared lunch may encourage the disclosure of issues that might not come up in a formal interview session.
Admissions procedures for people with sensory disabilities
While treatment providers should try to use qualified sign language interpreters for communicating with people who are deaf or hard of hearing, there may be times when the program is not prepared for such a client. If a person who is deaf or hard of hearing shows up unannounced at the treatment center's door, the program will need to cope as best it can. If no one at the agency knows sign language and there is no interpreter available to come in, paper and pencil is probably the best way to communicate to the person that she cannot be helped today.
Due to the wide range of reading abilities among people who are deaf, paper and pencil should never be utilized to gather detailed screening information. Written English forms and questionnaires should be interpreted into sign language for these clients. Some programs use a videotape in ASL, or with captioning to ensure understanding. The client who is deaf may have questions after watching the video, so an interpreter should be available to interpret any questions and the answers from the counselor.
If there are forms to be completed, people who are blind must have the option to complete them in the medium of their choice (Braille, large print, audiocassette, or sighted assistance). Admission to substance use disorder treatment can be a stressful process that will be made more uncomfortable by forced adherence to an uncomfortable modality. Individuals who are both deaf and blind will need to have a tactile interpreter to translate for them during the admissions process and afterward.
Admissions procedures for people with cognitive disabilities
A program should examine its written forms, from intake and screening forms to treatment plans, to determine whether they adequately address the needs of people who are cognitively impaired. Intake forms should either be simple enough for a cognitively impaired person to understand or else someone should be available to assist the client in completing them.
It may prove useful for clients with cognitive disabilities if the informed consent form has a clause that allows the program to go to a collateral source, such as a family member or significant other, for information. (However, it should be kept in mind that information obtained from these sources may not be reliable, and that they may not have an accurate perception of a person's functional abilities.) It is a good idea to get background information from as many sources as possible, but to interview the person alone if possible. Having others present often distorts the quality of the interview.
Admissions procedures for people with physical disabilities
Persons with disabilities that affect their fine or gross motor skills may not be able to fill out self-report questionnaires because the boxes are too small; large print forms can assist persons with mobility limitations as well as some individuals with visual impairments. Computers can also be used to respond to questionnaires, as keyboards are sometimes less cumbersome than writing by hand (Moore and Siegal, 1989).
A supportive, nonconfrontational intake interview is critical to engaging the client. Often, it is the pivotal meeting during which a client makes a short-term commitment to "check out" treatment. Depending on the treatment program, various approaches are used to help a client admit that he needs help in overcoming addiction. The Consensus Panel recommends that intake interviews of persons with coexisting disabilities be conducted by the most qualified staff members--those who have been specifically trained to understand their needs. The interviewer must have the skills to ask difficult questions in ways that are not offensive and maintain a good rapport with the client. Most important, such an interviewer will be more likely to detect subtle or hidden disabilities not previously identified that may make a significant difference in treatment outcome. If the intake interviewer does not have expertise or knowledge about disabilities and she knows that the individual being interviewed for admission has a particular disability, a professional who is knowledgeable about that disability should be included in the intake interview.
One of the first tasks of the interviewer is to reduce the anxiety of the client, which may be high. Many intake interviewers begin an interview by asking a very open and friendly question. Questions such as "What led you here?" or "What happened to bring you here today?" are usually nonthreatening. It is recommended that this type of question be asked initially rather than a question about the person's disability. Even when a person has an obvious disability, an initial question about it is inappropriate. However, an individual with a disability may also be very sensitive to others being uncomfortable and unwilling to talk about his disability. Thus the interviewer must judge whether it will make the client more comfortable to introduce questions about the disability during the introductory or the intermediate stage. The interviewer must remember the focus is the person, not her disability.
Intake interviews for people with cognitive disabilities
As in any interview with someone who has a cognitive disability, it is important to find the optimal setting, one that has a minimal number of distractions. The interviewer should allow for breaks in the interview and be sensitive to the client's attention span and restlessness.
Questions for people with TBI should be structured to provide concrete landmarks (e.g., "What were you doing 3 weeks before your automobile accident?"). Working backward in time while using specific events will assist the client to structure his responses. For any person who is cognitively impaired, keep questions concrete and avoid abstract concepts.
For people with cognitive impairments, it is important to remember to ask simple questions; to repeat questions; and to ask the client to repeat back, in her own words, what's been said. The counselor may need to periodically check whether the person is understanding what is being asked. If the question is not understood it will need to be repeated in a different manner. However, it is important to not talk to people with cognitive disabilities below their own level of communication or as if they were children. They will be highly insulted, and will probably not come back.
Along those same lines, the interviewer should give specific examples to illustrate words or phrases which may be too abstract or sophisticated, such as "abstinent" or "withdrawal symptoms." Such rephrasing is appropriate for a wide range of clients--not only the cognitively disabled but also clients from different cultural backgrounds.
Some interviewers find it useful to ask a client to write a few sentences describing his activities over the past few days or weeks, or to read a sentence from the informed consent form. Some high-functioning individuals may simply never have learned how to read and write, and the interviewer should not make assumptions about a disability based on the lack of this ability.
The interviewer should end the interview by summarizing the information learned. Recognizing a person's difficulties by providing feedback is an important way to let her know that she has been understood. The interviewer should present an overview of the services the program offers that meet the client's individual needs, as well as express the program's willingness to accommodate her disability needs, in hopes of obtaining her commitment to return.
Intake interview with people with sensory disabilities
An intake interview should address the eye condition and blindness adjustment skills of people who are blind or visually impaired. The counselor should know the pathology of the loss of vision (if it was congenital, adventitious, or traumatic), and precisely how much vision remains. Each situation will affect the treatment plan differently.
It is important to know how well a person who is blind can maintain independence. Some considerations are
The counselor must ask direct questions because the person who is blind may be ashamed of his lack of skills and unknowingly lie. For example, do not assume because someone has a white cane that it is used properly. Programs can consult with a local disability service provider who has experience working with people who are blind to find out what are good and/or acceptable levels of ability. Questions such as, "Tell me how often you've used Braille in the last 2 weeks," can then be used to assess each individual's level of ability. If the person who is blind has limited knowledge and skills about blindness, the counselor may need to arrange some form of training. This lack of knowledge and skills could be a factor in the person's substance use.
When interviewing people who are deaf, treatment programs should contact an interpreter referral service in their area to ensure that sign language interpreter services will be available when needed. The interpreter should be a neutral third party hired specifically to interpret for the counselor and the person who is deaf; a family member or friend of the client should not be used as an interpreter. Family and friends often cannot be neutral and unbiased, which is the interpreter's responsibility. Use only qualified interpreters as determined by either a chapter of the Registry of Interpreters for the Deaf or a state interpreter screening organization. Ideally, the interpreter will have had previous experience working in treatment settings or will have at least attended workshops related to addiction treatment settings. However, it is not always possible to obtain an interpreter with this specialized training. In any case, prior to the session, the staff should try to meet with the interpreter to clarify the purpose of the interview and the meaning of the terminology and the questions to be asked.
Intake providers and counselors at any stage of the treatment process should realize that sign language interpreters have varying skill levels. If an interpreter has difficulty interpreting for a particular individual, the counselor should ask questions to determine if the problem lies with the skill level of the interpreter or the cognitive processing or language style of the client who is deaf. This is a critical piece of information for the counselor to have during the intake process so that the counselor does not misdiagnose the client or assign a level of functioning to him that is not correct.
Some of the questions during the intake process may be difficult to interpret into sign language. For example, some assessments include questions to test orientation to reality and cognitive functioning. In order for the interpreter to interpret these questions correctly, she could give away the answers. In these instances, the interpreter will need to discuss the question with the counselor to determine how the question can best be asked to obtain the information needed. Much of the language used in substance use disorder treatment will not be familiar to clients who are deaf and will need to be explained.
Additionally, some individuals who are deaf or hard of hearing may have limited communication skills. They may not have even been exposed to any formal system of sign language. In these cases, an interpreter may not know how to communicate questions to the person who is deaf. The screener can try to use props or pictures to help make the message understood in a different way. It may also help to hire a deaf interpreter to work along with the hearing interpreter. The deaf interpreter would be a native sign language user and thus is likely to have a better understanding of how to communicate with a deaf person who has minimal communication skills. If these methods do not work, it may not be possible to make the screener's questions understood by the client.
Intake interview with people with physical disabilities
When conducting an interview with an individual with a physical disability, make certain that table surfaces are the correct height, and in particular that wheelchairs can fit beneath them. Interviewers should try to place themselves so that they are no higher than the person being interviewed. They should be aware of the pace of the interview, and attempt to gauge when clients are becoming fatigued. In addition, some forms of chronic pain make lengthy interviews excruciating. Periodically inquire how the individual is doing and offer to take breaks in order to make the experience more tolerable.
It is important to consider whether an individual's physical disability may influence his responses in ways which portray him inappropriately. A person with a long-term back injury may, in fact, wish to return to work, but still respond that he doesn't "intend on working in the future." He may neglect to inform the interviewer that working even part-time in the future may jeopardize his disability benefits, including medical services.
Adapting Substance Use Disorder Screening for Persons With Coexisting Disabilities
As stated above, the more information a provider has about a client's disabilities and functional limitations, the more she can tailor treatment to the client. As with any person with a substance use disorder, details about the patterns of abuse and dependence are also critical to effective treatment. This section presents modifications to screening and assessment questions for people with coexisting disabilities.
Drug and Alcohol History
It is important to understand the relation of drug use to an acquired disability. Some people begin using substances in response to an acquired disability; for others their substance use may have caused or contributed to the coexisting disability. Some people may not even be aware that their disability is substance-related. The use of prescription medication in combination with alcohol and the use of other people's prescription medications, are common for some persons with physical disabilities (Moore and Polsgrove, 1991). Consequently, make certain that this aspect of the drug history is well discussed.
Screening people with cognitive disabilities
Rather than asking generally about "abstinence," take a history of use. Ask, "Did you get high today?" or "What about yesterday?" Try to ask concrete questions, perhaps using time markers such as the 4th of July. It may be helpful to ask the person to relate his whole life story; opportunities to ask about substance use will occur during the telling of the story.
A client's understanding of "alcohol" may be different than the interviewer's. Be as specific as possible with clients--rather than asking if they "use alcohol," ask if they like to drink beer, wine, wine coolers, etc. Remember that wine coolers may not be the same as wine to many people. It may help to use props such as different glass or bottle sizes rather than asking how many ounces were consumed.
Do not assume people with cognitive disabilities understand the terminology being used; explain or define it and ask them to repeat back their understanding of the words. Instead of asking if they have had a blackout, describe a situation that would explain what this means. For example, ask, "Have you ever gone to a party and drank and the next thing you know you wake up and can't remember anything from the night before?" (It may also be necessary to ask if this problem ever occurred when the person was sober, or is still happening now, in order to check for dissociated symptoms.)
This history should look at an individual's work record, residential life, educational background, family, employment status, mental health history, and history of past abuse (since many people with disabilities have been victims of physical, emotional, and/or sexual abuse). It is also important that the assessment of a person with a disability gather information about involvement in vocational, physical, or social rehabilitation. The history should determine whether a person has had skills training, where she received it, and how long ago it was completed. The interviewer should determine when the training took place relative to the history of the substance use disorder. If the client was undergoing personal adjustment training and using substances at the same time, it is reasonable to assume that he will need to repeat at least some elements of the adjustment training.
Use of Screening Information
Treatment providers should not feel the need to be experts on all disabilities or disability issues. Instead, providers should view the task of screening for disability symptoms as a benefit for individualizing and developing appropriate treatment goals. Treatment should be more beneficial to clients if their limitations are considered in the development of their treatment goals. This in turn should make the counselor's job less frustrating and difficult. Chapter 3 of this TIP discusses how screening information can be applied in treatment planning and counseling and the alterations that will need to be made for clients with coexisting disabilities.
Chapter 3 -- Treatment Planning and Service Delivery
Considering the prevalence of people with physical, cognitive, and sensory disabilities who require substance use disorder treatment, treatment providers should be better informed about the particular needs of this segment of the treatment population. They should also put that knowledge into practice, which may require changes to the treatment program. Successful treatment for all clients must involve all levels of the treatment staff; changes at the systemic level will be reflected at the organizational level and, most importantly, at the client-counselor level where recovery begins. When such systemic and organizational change does not occur, treatment personnel do not receive adequate support, and they and their clients feel isolated--repeating and maintaining the feelings of isolation that are often at the core of addiction.
In order to make treatment as effective as possible, persons with coexisting disabilities will require specific accommodations. Treatment plans should be revised to accommodate the needs of people with coexisting disabilities, with recognition that not all clients respond equally well to the same types of treatment. If at all possible, treatment plans should be drawn up on a case-by-case basis; doing so will ensure better outcomes for all clients, not just those with disabilities. Understanding how an individual feels about her own disabilities will also enhance treatment.
Understanding Client Attitudes in Treatment
Kubler-Ross identifies five stages in the grieving process: denial, anger, bargaining, depression, and acceptance (Kubler-Ross, 1969). Denial of a substance use disorder is a common client characteristic that must be addressed by treatment professionals. But as they face multiple losses (a loss of physical or cognitive functioning and the loss of a substance upon which they are dependent), some people with coexisting disabilities may experience two types of denial at once: denial of the substance use disorder and of the disability. The presence of a coexisting disability can alter how a person manifests denial of his substance use disorder or can cause his denial to be focused solely on the disability. For a person with a disability, substance use may also be a form of "bargaining." She may think of her substance use as something she is "allowed" to compensate for a disability she must face. Recognizing her problem forces her to cope with all the often painful emotions typically experienced by any person in recovery, in addition to those related to her disability. For most people with severe disabilities, adjustment to this condition is considered a lifelong process (De Loach and Greer, 1981).
Most substance use disorder treatment professionals already have extensive knowledge of the complex ways in which psychological denial and addiction are intertwined, and they have developed methods of working with clients whose denial presents a significant obstacle to treatment. However, for people with disabilities, denial has additional dimensions. Some individuals may have used denial of their disability at various times in their lives as a legitimate coping mechanism to deal with the trauma of an accident or to push themselves toward a goal. Others will want to avoid the stigma and devaluation of being labeled. Other individuals may be cognitively unable to recognize their functional limitations, a problem that may only appear to be denial (see Figure 3-1 for some of the factors that influence a person's understanding of a coexisting disability). An addictions counselor may not have the time or the expertise to keep confronting the denial of the disability; he should make a referral to a peer counselor at a Center for Independent Living (CIL), whose job it is to help disabled individuals come to terms with the limits of their disability. The two counselors can then work as a team.
Risk Avoidance and Risk Taking
Another important issue in treatment planning is the extent to which risk taking and risk avoidance may shape the daily life of a person with a disability. Some individuals with disabilities have been taught or have otherwise come to believe that they should avoid sources of risk (e.g., risk of embarrassment, risk of rejection, risk of failure). Avoidance may become such a favored strategy that it takes on the force of a personality trait, resulting in increased isolation. For example, a person who uses a wheelchair may miss seeing a much-anticipated movie to avoid a situation in which she arrives at a theater and is unable to get in because of a physical barrier. A person with a visual or speech impairment may avoid riding the subway for fear of missing his stop or of having to ask for directions. A person with mental retardation may have been victimized by new "friends" so often that she avoids pursuing friendships. Long-term use of substances may be deeply intertwined with such avoidance strategies. Treatment planning can introduce situations, such as attending a 12-Step meeting or trusting an unknown group member, to which the person's first response may be impulsive anger, or exhibiting avoidance. Early in the treatment planning process, discussions of how a person with a disability uses avoidance strategies in daily life will be beneficial to both him and the treatment provider. The person with a disability should be encouraged and supported to try other strategies.
While some people with disabilities avoid social interactions or situations that involve risks, others take too much risk rather than too little. A client with a coexisting disability, especially if the disability is of traumatic origin such as traumatic brain or spinal cord injury, may be more likely to engage in high-risk behavior for two reasons. First, individuals who sustain injury-related disabilities are often prone to risk taking because of personality and behavioral characteristics, the same characteristics that contributed to their injury. Second, neurological damage can impair judgment and further increase risk taking. People with learning disabilities, especially those with attention deficit/hyperactivity disorder (AD/HD), may also tend to take excessive risks because they too lack sufficient skills or judgment to recognize and avoid risky situations. Obviously, continued risk-taking behavior often places the person in situations where sobriety is challenged.
For treatment to succeed, all clients must understand the particular strengths that they can bring to the recovery process. A strengths-based approach to treatment is especially important for people with disabilities, who may, because they have so frequently been viewed in terms of what they cannot or should not attempt, have learned to define themselves in terms of their limitations and inabilities. Well-intentioned family members and friends may encourage dependence and may even feel threatened when the person with a disability attempts to achieve a measure of independence.
However, people with disabilities must also understand their functional limitations, especially in relation to their risk for relapse. One of the overriding goals of treatment for people with disabilities is that they gain and maintain self-awareness about their functional limitations and capacities, as well as their substance use disorders. A better understanding of one's unique learning needs is an important step toward sobriety. For example, some persons with cognitive disabilities experience a great deal of difficulty learning from written material. This can be a particularly difficult limitation to acknowledge, especially in group settings or a workplace. The client who learns that it is a sign of personal strength to make adjustments and seek accommodation for reading difficulties is not only more empowered to make important decisions relative to sobriety, but also understands the importance, for example, of expanding the repertoire of skills used to compensate for a low reading level.
It is key to the treatment planning process for the treatment provider to learn how well a person understands her disability. Some people will have a clear knowledge of the ways in which they are functionally limited, whereas others may deny having any limitations. Similarly, in the area of individual strengths, some people will have received extensive support from family, friends, and professional caregivers to pursue their interests and develop unique talents, but others may have been overly sheltered or may have experienced repeated failures. A treatment provider should confer with a disability expert on this delicate topic of how to discuss a client's disability with him.
Treatment plans for people with coexisting disabilities should be flexible enough to take into account changes that may occur in a person's condition or new knowledge that may be gained during treatment. By law, providers will need to make accommodations for people with disabilities so that they will have equal access to all components of the treatment program. Many of these accommodations are simple to make and inexpensive, but all will require planning and understanding on the part of providers.
Making Treatment Accommodations
Many substance use disorder treatment providers have addressed the problems faced by individuals with coexisting disabilities, including those who are human immunodeficiency virus (HIV) positive or have acquired immunodeficiency syndrome (AIDS) and individuals with coexisting psychiatric disorders or disabilities from past traumas. However, the treatment field has been slower to address the needs of individuals who have physical and cognitive disabilities. These populations, especially since the advent of the Americans With Disabilities Act (ADA), present a new challenge to the field. Providers may be uncomfortable when first confronted with a person with a physical or cognitive disability. That unease can lead them to err in one of two directions, either by enabling the person to use his disability to avoid treatment or, conversely, by refusing to recognize that a legitimate need for accommodation exists.
The need for understanding
Some people with disabilities present in the treatment setting with issues that require a great deal of therapeutic understanding. Many of these clients begin treatment expecting that their needs will not be understood, and their previous experience has likely reinforced this view. This may lead a client to believe that no one understands her, and that she is therefore entitled to use mood-altering drugs in order to cope with her own situation (Moore, 1991c). In such cases, staff members who demonstrate an understanding of the disability, such as knowing about its onset and course, can show empathy while maintaining realistic expectations for the client's full participation in the treatment program (De Loach and Greer, 1981).
Providers should know the degree to which a disability affects a person's life. For some persons with severe physical limitations, resulting from conditions as diverse as cerebral palsy and spinal cord injury, the task of simply preparing for the day can be exhausting. Some people with disabilities must arise before dawn every day in order to begin the arduous process of dressing, conducting a hygiene program, and meeting transportation that may take hours to take them into town. Obviously in cases like this, treatment staff must consider pacing of assessments and treatment. Rest periods, breaks, and "downtime" become critical components of a successful rehabilitation program.
Reasonable treatment accommodations
If a client believes that he needs an accommodation, the treatment provider will still need to determine if the request is legitimate or an attempt to manipulate the treatment program. Most substance use disorder treatment providers are aware of client efforts to elicit enabling behavior from them. However, providers' vigilance in avoiding enabling may predispose some of them to reject legitimate requests for accommodation. If there is any doubt on the part of the provider regarding the legitimacy of the person's request, he should consult a "disability expert" in order to make this determination (see Figure 3-2 on how to locate an appropriate expert). Of course, experts in disability services will themselves face uncertainty when trying to determine if an appropriate accommodation is being made or if it is enabling the client to avoid change.
Too much of the wrong type of modification, on the other hand, may unwittingly enable the person to avoid change. For example, whether she recognizes it or not, the provider may react by thinking, "He has it so hard, maybe he should be able to take it easy instead of reading all this material." Or even, perhaps in the case of a person with AIDS or spinal cord injury, "If I were in her shoes, I'd want to drink, too." Such misplaced sympathy is harmful.
Accommodation does not mean giving special preferences--it does mean reducing barriers to equal participation in the program. People with coexisting disabilities are harmed by a provider's complicity in their avoidance of all challenges to chemical dependency.
Figure 3-3 illustrates enabling, denial, and appropriate accommodation in the treatment setting. Making the distinction among denial, enabling, and accommodation is more difficult for persons with coexisting disabilities. Adding to the challenge is the fact that people may not always be able to articulate their disability-related needs. It is important for multidisciplinary teams of providers to discuss and resolve these issues on a case-by-case basis. Increased communication between the substance use disorder treatment and disability services fields will help providers understand the approaches and philosophies needed to treat people with coexisting disabilities. The Panel recommends cross-training between substance use disorder treatment providers and agencies that work with people with disabilities, including vocational rehabilitation (VR), medical, and other professional specialists on specific disabilities, disability service providers, CILs, and disability education and advocacy organizations.
When treatment teams make the effort to accommodate individuals with coexisting disabilities, the quality of care improves for all clients. All clients can get more out of treatment that is individualized and that takes their specific functional capacities and limitations into account.
Extending treatment times
The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals has found that individuals who are deaf and hard of hearing have less access to prevention and intervention programs and less knowledge about addiction and recovery than nondeaf clients who enter treatment. Therefore longer term treatment may be required for them to have a level of knowledge similar to nondeaf clients when they leave treatment (Guthmann et al., 1994).
People who are blind and those with a cognitive disability have similar problems with which to contend. Sighted people gather approximately 80 percent of their information through their vision. Obviously, people who are blind or visually impaired cannot take in as much information through reading or through conversation. Many cognitive disabilities also affect the rate at which people can learn, and so people with these disabilities may also require more treatment time to understand the same amount of information.
Motivational Aspects of Treatment
Counselors should work with all clients to decide what incentives will best motivate them. Motivational strategies in treatment involve a number of approaches, including assisting the client to better understand the intrinsic rewards of a sober lifestyle and the negative consequences of continued use. For people with coexisting disabilities, these rewards and consequences can sometimes be different from those of other individuals.
Considerations for people with physical disabilities
For a person with a spinal cord injury, there are a number of medical concerns associated with the disability that are dramatically exacerbated by substance use. Chronic bladder infections are relatively common for persons with spinal paralysis and other mobility impairments. Alcohol consumption promotes, irritates, and inflames bladder infections, as well as nullifies the effects of antibiotics. Alcohol consumption has been identified as contributing to autonomic hyperreflexia, a nervous system reaction that leads to a rapid and sometimes fatal rise in blood pressure. Some persons with mobility impairments experience difficulties with balance--even small amounts of alcohol or mood-altering drugs can impair balance to the point that falls and other problems are more likely to occur. A fall for a person with a mobility impairment can be more costly and medically debilitating than for someone without such a condition. Anecdotal evidence from physical rehabilitation programs indicates that persons with spinal cord injuries who consume substances to the point of intoxication often experience decubitous ulcers of the skin (pressure sores), a serious medical condition that can take months to heal. Persons with physical impairments are also more likely to be using prescription medication for medical management of their disability. Alcohol and drugs nullify the effects of some drugs while making others potentially lethal. Liver inflammation also occurs more rapidly when alcohol use is potentiated by some prescription drugs.
Considerations for people with cognitive disabilities
People with cognitive disabilities may have difficulty recognizing the negative consequences of their substance use, which does not necessarily mean they are in denial of their problem. Showing some people with mental retardation how substance use affects other aspects of their lives will provide them with strong motivation for continued sobriety (see Figure 3-4).
Alcoholics who have sustained TBI often perceive alcohol as improving their social interaction and comfort level, when it is actually reducing social judgment and insight to an even greater degree than it does with other, nondisabled drinkers. Clients with TBI are at a much higher risk for seizures, in general, and they should be made intensely aware of alcohol's effect in further lowering their seizure threshold. TBI patients are also at least twice as likely as other individuals to sustain additional brain injuries, a risk that rises with alcohol use (Corrigan, 1995). Educating the client about these problems can increase his motivation for abstinence (Langley et al., 1990).
Developing a treatment plan often requires contracting with the individual to identify specific behaviors that indicate that the plan is not working and to determine what consequences will occur when these behaviors become evident. In case problems do arise, a graduated series of appropriate consequences will enable a better response on the part of treatment staff. A program may require outside consultation from a disability expert (see Figure 3-2) to develop an understanding of what consequences are appropriate, and should try to have such an expert as part of the treatment team. An example of how one program, the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals, works with behavioral contracts for people who are deaf is presented in Figure 3-5.
Contracts with people with disabilities may need to be more explicit than those with other people, and the consequences for relapses in particular may need to be individually tailored to what the individual is realistically capable of achieving. Discharging a patient from the treatment program for a single relapse, for example, may be counterproductive for many people with coexisting disabilities, especially considering how difficult all life transitions can be and how limited the options may be for alternative treatment or care. It is possible that dismissing a client with a coexisting disability for a relapse will shut the door to treatment for some time.
Some nondisabled people in treatment may protest the "special treatment" of an individual with a disability, and the counselor should be prepared to address that issue with all clients in the program. The provider should emphasize that program policies, procedures, and practices aim to ensure accessibility and promote success for everyone, and therefore treatment plans need to be individualized. It is helpful to identify early on any needed exceptions to the routines of the treatment program for a person with a disability and to explain that accommodations for persons with disabilities simply give them the help they need to meet shared goals. The exceptions and the rationale for these exceptions should be discussed openly in group meetings so that peers are aware of the exceptions and why they need to be made. The group may participate in some problem solving and have other suggestions that may be helpful. These discussions will allow the person with a disability to work in partnership with his peers as opposed to being seen as the recipient of special favors. However, some people with disabilities may, rightfully, wish to preserve their privacy and not have their disabilities discussed, and clients should be consulted about their feelings before such open discussion proceeds.
As discussed below, when a person with a disability fails to attain a treatment goal, one consideration should be that the treatment accommodations were not sufficient and the treatment plan did not articulate the proper steps for that person to reach that goal. For example, if a nondisabled client fails to complete a written assignment of a Step 1 report for a 12-Step program, he may experience a consequence, such as withdrawal of a leisure activity. A client with a cognitive, sensory, or physical disability, however, might be unable to complete such a report. In this case, however, the program may respond by working with her to develop an accommodation. If the individual agrees to make an audio recording of the report and fails to do so, then consequences follow. Figure 3-6 presents three common treatment tasks with consequences and accommodations for people with disabilities.
Provide Accessible Leisure Activities
Treatment programs often try to encourage people to participate more in leisure activities. However, many treatment programs have difficulty identifying and responding to the needs of people with disabilities. The following sections offer suggestions for making recreation programs as inclusive as possible.
Leisure activities for people with physical disabilities
Many people with disabilities resign themselves to spectatorship because their disabilities often force them to sit on the sidelines. Participating in enjoyable activities with others and having fun without consuming substances is a learned skill that many persons with disabilities don't have an opportunity to practice. It is essential that all clients participate in planning leisure activities, and programs with rigid approaches that exclude clients from such participation should consider changing their policies.
A physical disability can contribute to potential medical problems, such as poor circulation or digestion, obesity, heart disease, or other medical conditions. The often sedentary lifestyle associated with substance use only makes these conditions more pronounced. Exercise and activity can stave off these problems; therefore it is especially important for counselors to find activities that people with disabilities can participate in.
Treatment staff may need help adapting leisure activities so that all people with disabilities can participate. The local Special Olympics Committee is one resource for youth and some adults with developmental disabilities, and can be located through local school systems. The National Association of Therapeutic Recreators assists adolescents and adults in accessing a whole range of activities from which they have traditionally been omitted; their offices can be located through university disability offices or local physical rehabilitation programs. YMCAs, YWCAs, Boys' Clubs, United Way, and CILs also can assist treatment staff in identifying specialized recreational programs that may be of assistance.
Leisure activities for people with sensory disabilities
In the case of individuals who are deaf and prefer to socialize with other people who are deaf, leisure activities with a supportive peer group are difficult to find. The size of the Deaf Community is limited. In any State, however, there will be different clubs and organizations sponsoring activities for community members. Alcoholic beverages are present at many community events, and, if not, people may go to bars after the event. It will be difficult for a person who is deaf to find alcohol-free activities that include other people who are deaf. There may be limited options to form a peer group that is deaf and substance-free. Socializing with hearing peers who do not know sign language but who are sober may not be a realistic alternative, because the person who is deaf could feel extremely isolated. The counselor and client who is deaf need to be creative in developing plans for the client to become involved in leisure and social activities.
Adjust Treatment Goals To Fit the Person
For clients with disabilities, failure to achieve treatment goals may indicate that not enough attention has been paid in the treatment plan to outlining a series of discrete steps to meet the goals, or that the goals themselves need to be adjusted. In setting a goal, the client and the counselor must work closely to understand all the physical and cognitive requirements of meeting a goal. Sometimes it will be necessary to teach someone how to make a new friend before he can be expected to give up the only one he has in order to remain sober.
People with coexisting disabilities face many challenges, barriers, and apparent dead ends, and the skills training and decisionmaking practice necessary to address these issues are often not available in accessible and comprehensible ways. Consequently, treatment goals for these consumers need to be more individualized, expansive, and reflective of the immediate environmental challenges which confront them on a daily basis. Obviously, some of these ancillary, but essential, goals need to be accomplished with the assistance of persons beyond the immediate treatment team.
Adjustments for people with physical disabilities
The treatment plan for a person with a physical disability needs to take into consideration not only the physical limitations the person might have, but also the psychological and social consequences of the disability. Issues that need to be addressed may include impulsivity, social isolation, low self-awareness relative to medical or psychological needs, anger, feelings of hopelessness, or outright panic that life without substances will be unbearable considering the disability. These issues are hardly new to the treatment provider, nor are they unique to persons with disabilities; however, a disability may exaggerate the severity of these conditions or their impact on recovery.
The counselor should work with the client to set up incremental goals, rather than expecting major changes all at once. For example, a person who uses a wheelchair and her counselor may set a goal to attend an Alcoholics Anonymous (AA) meeting at a certain site several times a week. They may then set several interim steps for her to take with the ultimate goal of regular meeting attendance. These may include having her call the site to ensure its accessibility, working with the counselor to arrange reliable transportation, and making a trial run to the site during a less busy time of the day, perhaps with a friend or with the counselor. In the end, the goal may or may not be attained, and more discrete steps may be needed before it is achievable. For example, the transportation may prove to be unreliable on some days, and alternative transportation may need to be arranged or a wheelchair-accessible AA meeting site located.
For another person with a disability, regularly preparing evening meals at home may be a treatment goal, especially if he has been accustomed to eating dinner at a bar. A number of small steps are then successfully negotiated: The person receives cooking skills training from another agency, basic cooking equipment is obtained, and a grocery delivery service is engaged. However, he may then find that he tires easily after standing for even a short period in the kitchen. An energy conservation program may be a necessary additional step before he can fully use his new skills. A disability expert on the treatment team can help the individual create strategies to conserve energy, such as obtaining a high stool to sit on during meal preparation.
Adjustments for people with cognitive disabilities
A similar process of planning small steps to meet a goal should be undertaken for people who have cognitive disabilities. For example, a person with brain injury and alcoholism may set as a goal avoiding drinking on Friday night after picking up her Supplemental Security Income (SSI) check in the afternoon. If she does not drink then several other leisure activities are possible during the weekend, all of which she enjoys and benefits from. She and her counselor may then develop the interim goal of cashing the SSI check at a bank on Friday instead of the liquor store, and plan a structured, sober activity for immediately after the check cashing. The individual could also meet with her case manager for the purpose of budgeting and paying bills. She and the counselor or case manager can discuss how she would like to spend what is left, and if she would like to save for something special. Alternatively, the treatment program may wish to consider forming a relationship with a nearby supermarket to ease the way for its clients to cash checks there. The individual and counselor will then need to establish other steps toward the goal of not drinking on Saturday morning, perhaps through specific exercises in treatment that desensitize or eliminate the environmental cues that prompt her weekend bingeing.
Adjustments for people with sensory disabilities
When developing treatment goals, the counselor needs to consider what is realistic for the client who is blind or deaf. It is important for the counselor to know what resources are available in his area. For example, in all areas of the country except a few metropolitan areas, there are not enough interpreted 12-Step meetings available for a person who is deaf to attend meetings every day. Therefore, 90 meetings in 90 days is an impossible goal for the person who is deaf to achieve. Attending one meeting per week is a more realistic goal. Counselors who are not experienced in working with deaf clients should consult a professional who has that experience to provide guidance during the treatment planning process.
When working with clients who are blind or visually impaired, the counselor must be keenly aware of their blindness adjustment skill level and the availability of the proper adaptive equipment in the environment. Before giving a reading or writing assignment, the provider must make sure the required equipment is available. Additionally, if the blind person is asked to attend 12-Step meetings, transportation must be arranged. Figure 3-7 presents other suggestions of how to interact better with clients who are blind.
Revising and Documenting the Treatment Plan
Because the counselor's knowledge of an individual's strengths and limitations is always growing, no treatment plan should be static. In the case of a person with a coexisting disability, there may be even more reason why revision is necessary and careful documentation is called for. An individual with a disability may need to explore several methods for learning something or fulfilling a goal before an achievable approach to the situation can be identified and implemented.
Frequent revision of the treatment plan is crucial, for instance, when working with clients with TBI because they often show a dramatic recovery curve over the first year to second year following their accidents. Additionally, periods of even relatively short detoxification can dramatically clear cognitive functioning. Given these realities, treatment plans need to be frequently updated to account for these clients' rapidly changing and improving memory, reasoning, and attention abilities. Therapeutic interventions that would not have been appropriate even a few months previous can rapidly become within the client's grasp. However, counselors must keep in mind that these cognitive abilities may improve at different rates. For example, certain language abilities may be recovered early, while memory deficits can continue to plague the client for years after the head trauma. The treatment plan must be flexible enough to accommodate these rapidly changing cognitive abilities.
Frequent consultations with clients
In evaluating and revising a treatment plan treatment providers should get cooperation from the client. Many programs already comply with licensing regulations to review and revise the treatment plan periodically (e.g., weekly or every 30 days). Aside from such formal evaluations, frequent consultations or "reality checks" are essential. All clients should be offered the opportunity to review and revise the goals and objectives of their treatment program on a regular basis. The provider needs to know whether there are barriers in the program or problems with the treatment approach. The provider should make every effort to ensure that such discussions are serious efforts. They should ask questions about specific goals, about how the individual is feeling, and about job or personal situations troubling him. Failure to perform continual evaluations may result in the individual abruptly leaving the program.
The counselor should take every opportunity to learn more about the client. For example, during a group outing, a counselor may take what she considers to be a short walk with a person and observe that he is rapidly tiring and lagging behind. Specific questions about his lack of stamina or level of pain may reveal a more extensive limitation than the counselor originally understood, which may lead to changes in the treatment plan. In conversation during this walk, the person with a disability may bring up other critical psychological issues related to his disability. The client may confide that he avoids the company of others when he is outdoors because many times in the past others have simply abandoned him when he lagged behind, and he has had to find his way back alone. The fear of abandonment and betrayal by friends--perhaps by the counselor and the treatment program--may be a significant issue preventing his deeper involvement in treatment. Discussing this issue, as well as problem solving with the client about how to keep up with others outdoors, (e.g., by use of a scooter), may be highly productive.
To keep treatment on track, it is important that case notes reflect the client's progress or lack of progress toward treatment goals. Accurate, evaluative notes are one way for counselors to stay focused on a client's particular issues, and documentation of all efforts at accommodation is needed to verify ADA compliance. When people relapse, case notes often provide valuable information to explain the relapse. In addition, careful documentation is essential in negotiating with managed care firms to allow extra time for people with disabilities to meet treatment goals.
The treatment plan should document all alterations to the usual treatment procedures that are being made. Careful documentation also allows providers to see what goals have already been met and what procedures are working for the client. For example, a person with mental retardation may not be able to write or share a report on why she is powerless over drugs and alcohol (i.e., Step 1) and may demonstrate little understanding of basic treatment concepts, yet be able to maintain abstinence. In discussions with the person, the counselor may come to understand that her abstinence is mostly attributable to the AA group, which she enjoys attending nightly. If a person who is blind does not complete a reading assignment, this should be documented and investigated. If the assignment was not completed because the facility does not have the proper material and equipment it should also be noted that (1) the patient is not held responsible and (2) he is not fully benefiting from the program.
If an approach does not work, the outcome should still be carefully documented to prevent duplication of effort by other programs in the future. By the same token, details of what is successful for a person should be documented, particularly for persons with cognitive disabilities who may not be able to tell future caregivers which treatments have been effective and why. Careful documentation allows all treatment providers to see the goals of treatment and the accommodations that have been made to meet them.
The Counseling Environment
Making accommodations for counseling begins with a consideration of the physical environment where counseling will take place. People with different disabilities may encounter different obstacles to treatment in their environment. It is best to make accommodations on a case-by-case basis, but some disability-specific factors to consider include the following.
Modifications for people with physical disabilities
The arrangement of furniture can be important--the room should be accessible for all clients, and those who require an assistive device, such as a wheelchair, should have room to maneuver. Counseling rooms should also be near living areas and bathrooms and should be easy to find. Some table tops and desk surfaces should be high enough in the air to be accessible to people in wheelchairs. (Some programs accommodate to these occasional needs by storing wooden blocks that can be placed under tables to elevate them to the proper height.)
Providers of chemical dependency services need to keep in mind that the most important element to ensure physical accessibility for a facility may be the attitude of staff. If they are open and accepting--and willing to be flexible--most physical accommodation issues can be addressed successfully.
Modifications for people with sensory disabilities
Counselors should take into account room arrangement and lighting. It is not readily apparent, but lighting can be very important when there is a person who is deaf in a mainstreamed program. Lighting needs to be sufficient for the person who is deaf to see the interpreter, especially during a movie or video when the lights might be lowered. Blinds or curtains may need to be closed in order to reduce or eliminate glare and enable the person who is deaf to effectively see the interpreter and understand what she is signing. Persons with a visual impairment may also be bothered by the glare from windows and fluorescent lights. The counselor should ask if the client is comfortable with the lighting.
Modifications for people with cognitive disabilities
The presence of visual distracters, such as photos, artwork, and desktop toys, may make it more difficult for someone with AD/HD to concentrate. The glare from windows and fluorescent lights can also be a distraction for people with AD/HD, and the amount of noise should be kept to a minimum. A treatment room away from noisy areas can help such clients gain the focus they need.
There are many accommodations that programs can make to modify individual counseling for people with coexisting disabilities, a number of which cost little or no extra time and money. Counselors must be willing and able to work with all people with disabilities. They should be aware of their own issues concerning disabilities and be able to discuss with other program staff potential issues that may incline them to be especially positive or negative regarding a person with a disability. See the section on staff training in Chapter 5 for more information on how counselors can work through their own feelings about disabilities.
When working with people with coexisting disabilities, some adaptations to counseling may be necessary depending on each individual's capacities and limitations. Some modifications, however, may be helpful for all people with disabilities. For instance, session times should be flexible, so that sessions can be shortened, lengthened, or occur more frequently, depending on the individual treatment plan. For all people with disabilities, the transmission of unconditional positive regard will help the client achieve sobriety as much as anything.
It may be useful to talk about disability issues in individual counseling, especially if the person does not want to talk about them in a group setting. Sometimes an individual's disability and societal attitudes toward it play a large role in substance use. However, there are times when the topic should be avoided.
In addition to structured individual counseling sessions, other opportunities for one-on-one counseling may present themselves during the course of treatment. There is often an opportunity for individual counseling at the end of a group session. The counselor and person in treatment can take 10 minutes together to review what went on in group. More frequent, less formal contacts may benefit the individual as well. Drop-in policies encourage people to stop by and say hello. The opportunity to drop in and announce that they "stayed clean today" helps motivate many people in treatment, as do telephone check-ins.
Sometimes counseling for a client with a disability will not require more time in therapy, but rather more preparation time prior to the actual counseling session. This preparation may include a trip to the library to research a disability, or involve a conversation with an expert.
Modifying counseling for people with physical disabilities
Counselors are trained to observe personal physical boundaries, but the sense of what is proper may need to be modified for some people with disabilities, as counselors may have to assist with adjusting a wheelchair, etc. When the proper course of assistance is not apparent, ask the client for guidance. The relative height of the counselor and the client, when seated and talking, may also be an important consideration when working with someone who has a physical disability. Disproportionately great differences in seated height can hinder communication, especially relative to body language.
If a person with a disability has limited transportation options, conduct individual counseling by telephone, go to the person's house, or meet at a rehabilitation center or other alternative site. Home visits can offer valuable insights into a person's life and ultimately facilitate effective delivery of treatment. The Consensus Panel recommends that providers make home visits if necessary, which may be reimbursable under case management services. Going to the residence of an individual with a disability also provides invaluable information about a client's lifestyle, interests, and immediate environmental challenges.
Modifying counseling for people with cognitive disabilities
Some individuals who have sustained a TBI or have cognitive deficits secondary to a substance use disorder have decreased abstract reasoning abilities and reduced ability to solve problems. However, these areas of deficit may not be apparent because a person can retain his language abilities. Therefore it is important to ask people with TBI to provide specific examples of a general principle; for example, a client can be asked to identify three specific ways drinking or using drugs gets him "in trouble." His responses can be written on a note card to help remind him of the consequences of his drinking. In this way, both the abstract reasoning and memory problems that are common in TBI can be addressed. A number of other suggestions for working with people with TBI are outlined in Figure 3-8.
When working with people with cognitive disabilities, counselors need to know that insight and behavior may not be closely correlated. For example, a person with a cognitive impairment may actually reduce substance use over time even though her responses suggest that she is not yet ready to do so. Likewise, there are persons who can hear information and repeat it back in a counselor's office, but cannot maintain the behavior elsewhere. Counselors must consider both people's insight and their behavior.
Counseling materials should be organized in advance, and the goals of counseling stated clearly up front and repeated often. Memory books can help people with cognitive disabilities keep track of essential information such as names, meeting times, and maps of local areas. The main points of the treatment session can also be chronicled and dated. The counselor should make sure people use these aids. They should watch a client write down his next appointment in his pocket calendar, and, on the telephone, ask him, "Are you writing this on your calendar now?" The conversation should not be ended until the counselor is sure the client has done so.
Most people who are cognitively disabled have trouble transferring knowledge from one situation to another. Thus the consequences of drinking must be gone over and over incident by incident. Counselors can teach clients with TBI and AD/HD, and others with poor impulse control, to hesitate and "think a drink through" before acting. People with severe cognitive impairment may need help developing a repertoire of internal controls, rather than simply responding to external control.
Discussions should be kept concrete. People with mental retardation may not understand abstract concepts such as "powerlessness," "depression," "avoidance," "unmanageability," and "sanity." They may even have trouble with more basic terminology like "sobriety," "abstinence," "relapse," or even "drunk." Regularly review the terminology of the treatment program and any other programs (such as AA) in which the person might be participating. Do not assume people with cognitive disabilities understand the terminology used. The counselor can ask the client to repeat back her understanding of these terms. Use short sentences, and skip elaborate, abstract analogies. Goals should also be phrased in concrete terms.
When working with clients with limited language skills, try using alternative media to communicate ideas. If, for example, the client cannot read and also has short-term memory deficits or auditory processing problems, then a tape recorder will not solve the reading problem. Some people who are nonreaders will do far better with a video (looking and hearing at the same time) than with an audiocassette. Some people will learn better by drawing or making a collage of a concept. For example, a client who has difficulty explaining her understanding of her 12-Step group's first step may find it easier to draw five pictures showing how her life is unmanageable. Individual counseling sessions are an ideal time for the counselor to review such materials as AA's Big Book that a person with a cognitive disability may not be able to read.
Counselors should not assume that insight into drinking behavior will also affect other drug use--for a person with a cognitive disability these behaviors may be very different.
For example, the person may agree not to drink anymore and may understand the consequences of drinking. The same person, however, may continue using marijuana and may not truly understand the dangers associated with that behavior.
Although counselors must not expect too much from people with cognitive disabilities, they should also not expect "too little." Many are just as capable as any other client of having the insights that are important in treatment, such as "when I drink and drug, I get in trouble." (Exceptions include clients with severe memory deficits and some with TBI.) Counselors will have greater success by going slowly and reiterating with each crisis the role that substance use played. Keep asking after each relapse: "What happened and what did you think would happen? How do you feel about what happened? How will you handle the situation differently next time?"
Modifying counseling for people with sensory disabilities
The counselor should ask the client who is deaf or hard of hearing what accommodations he needs. If the client is hard of hearing or deaf and does not use sign language, he may request only to have a counselor whom he can lip-read. For instance, he may not be able to lip-read a counselor with a beard and mustache, but a counselor with no facial hair blocking his mouth may be acceptable. The individual may need an interpreter, an assistive listening device for sound amplification, or Computer Assisted Realtime Transcription (CART). The accommodation requested should be provided.
Regardless of the mode of communication, the counselor should be seated so the deaf or hard of hearing client can look directly at her. When an interpreter is used, the interpreter should be seated next to the counselor in order for the client to see the counselor and the interpreter at the same time. The counselor should speak directly to the deaf client, using first person tense, as if the interpreter was not present. It is very common for hearing counselors (who have usually had little or no experience communicating with a person who is deaf and using an interpreter) to speak to the interpreter (saying "tell him") rather than to the client. There may, however, be instances where the interpreter needs to ask the counselor or the person who is deaf for clarification of something the counselor has said, in order to interpret it appropriately. This sort of interruption is part of the interpretation process. However, the counselor should not try to include the interpreter in the counseling process except to facilitate communication with the client.
Many clinicians worry about confidentiality when using interpreters and fear that the use of interpreters will make it difficult to develop rapport with a client. Treatment programs should realize that sign language interpreters who belong to The Registry of Interpreters for the Deaf (RID), the professional association for sign language interpreters, follow a code of ethics that includes confidentiality of job-related information as one of its tenets. The staff of a treatment program can emphasize the importance of discretion in this situation by informing the interpreter of the strict laws regarding confidentiality in substance use disorder treatment.
Certain programs for the deaf have successfully used alternative media in place of the writing assignments often given to hearing clients. The Clinical Approaches manual developed by the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing contains numerous drawing assignments concerning concepts important for recovery that clients can be given as homework. These activities are particularly useful for clients who are deaf and may not be comfortable with their written English skills or for those with minimal communication skills in sign language.
Both one-to-one and group discussions are more tiring for people who are blind or visually impaired because they lack the benefit of observing facial expression, gestures, and posture. Sighted counselors can help their blind clients by avoiding visual images in conversation that a congenitally blind person will not understand. People who are blind will also require more time for reading assignments. A good print reader may read and comprehend from 600 to 700 words per minute (wpm), while a good Braille reader reads only 100 wpm. "Reading" an audiocassette proceeds at 200 to 250 wpm. These alternative ways of reading take not only more time but more energy as well.
While accommodations may be needed to integrate people with coexisting disabilities into group counseling, it is important to first emphasize what all group members have in common. Counselors can emphasize to the group that, despite a wide variety of individual differences, all members are there for the same reason. Everyone is present because they cannot control their substance use, and they want to stay sober.
Some counseling groups with a single person who has a visible disability may meet on a regular basis, and disability issues are never discussed. For other groups, this topic may emerge quickly. Although it's not possible to state one policy that applies to all situations, there are some common considerations. Group members should be oriented to any special considerations that someone with a disability may require in order to effectively participate. Discussions about an individual's disability can be quite therapeutic and pertinent to the process of recovery, especially if the client has recently acquired the disability or has spent so much time under the influence that he has continuing adjustment problems associated with the disability. Consequently, treatment staff should encourage discussion of disability issues when clients bring them up.
Group members can be trained to assist in making accommodations for peers who have disabilities. It is important, however, to work with nondisabled clients to minimize their enabling of or overcompensation for people with coexisting disabilities. Describe to the group the practical aspects of helping the person with a disability, and ask that person to describe what she expects people around her to do. The concept of asking for help is congruent with many treatment approaches. However, for a person with less awareness or acceptance of her disability, it is important that peers are aware of what is appropriate help to offer.
When working with people with coexisting disabilities in a group counseling setting, counselors may find it useful to alter group participation expectations, limit the time in group, and work with the group to extend the group learning experience outside the confines of the group session. While the actual accommodations used will likely be tailored to each individual, there are some general strategies (discussed below) that have been successful in making group counseling more accessible for individuals with particular types of disabilities.
Finally, providers must consider and prepare to justify modifications to group counseling for billing purposes, especially with regard to Medicaid and managed care organizations. In most cases, billing for these services by the half-hour would be acceptable, although the standard unit of service is 1 hour. In some cases, counselors can conduct shorter sessions but bill for the entire session, which is appropriate because additional preparation time is needed for these modified group sessions.
Group counseling for people with sensory disabilities
People who are visually impaired need to orient themselves to the group in a different manner than those who are sighted. They will need to understand the group counseling environment, including the position of all the participants and the format or structure of learning activities such as reading assignments, so that they can prepare for them in advance. Other group members should be aware that they can not use eye contact to communicate with members of the group who are blind, and must rely on different methods. See Figure 3-7 for other suggestions of how to work with clients who are blind or visually impaired.
If a person who is deaf is using an interpreter, group members will need to take turns during discussions. If several people are talking at the same time, which is not uncommon for hearing people, the interpreter will be unable to communicate all the information. Requiring people to raise their hands before speaking is a good method to ensure that only one person is speaking at a time, as is deciding beforehand the order in which people will speak. In a group session the person who is deaf will normally be a few seconds or minutes behind the hearing group members; it will usually take longer to interpret a sentence than it took for the person to speak it. An interpreter must understand the context before interpreting and it may happen that a message will require more signs than words. The counselor should make a point of asking the group members who are deaf for their responses and questions in order to ensure that they are included in the discussion. If a session lasts more than an hour, two interpreters may be necessary, because signing is very fatiguing.
Even if staff members are fluent in sign language, other types of interpreters (i.e., a CART reporter) may be needed. Not all individuals who are deaf are fluent in sign language, and some, such as a person who is deaf and blind, may have very particular communication needs. The issues for the group process are similar in these instances, however. For example, the deaf or hard of hearing individual will get the message through CART slightly later than the hearing clients. The CART reporter will have the same difficulty as the sign language interpreter if hearing group members talk at the same time as one another. The biggest difference is that individuals who are deaf and do not use sign language generally prefer to be included in groups with hearing clients rather than being in all-deaf groups. These individuals have spent most of their lives with hearing peers and do not socialize primarily with other people who are deaf. Their identity is not tied to being deaf and using sign language.
Group counseling for people with cognitive disabilities
Accommodations for persons with cognitive impairments can include the use of visual cues, mixed media, and the repetition of major points. Expressive therapy, or the practice of using movement to express feelings, is also often effective for persons with mental retardation and other cognitive disabilities. Role-playing works well for persons with developmental disabilities--the process of playing a role themselves helps them to internalize it.
The use of verbal and nonverbal cues will help increase participation and learning for people with cognitive disabilities and make the group run more smoothly for all. People with cognitive impairments are often impulsive because they lack normal feedback mechanisms. They do not wish to be impulsive, but lack the ability to regulate this behavior for themselves. Therefore, counselors and peers should try to provide external cueing until the person can internalize it. The counselor and the person with a disability together can design the cues but should keep them simple, such as touching the person's leg and saying a code word (e.g. "interrupting"). If cues are used in a setting where other people will observe them, alert the group to the cue in a matter of fact way as you would alert them to a use of a dog or the space needed for a wheelchair. Cueing can be useful for people with other types of disabilities and for other purposes as well.
For people with AD/HD, it is helpful to establish a maximum length of time, for example, 10 minutes, for presentations. Another modification to group counseling, which is beneficial for those with mental retardation or brain injury (as well as other clients), is to set aside 10 minutes at the end of the session to reinforce what occurred during therapy. Such discussion ensures that content is retained and promotes active rather than passive learning. Some people with cognitive disabilities may have problems with time management and will need to be reminded of group sessions with a phone call or a page.
Accommodations for disabilities can be made when developing goals and awards for successful participation in group counseling. It may be helpful to ask a person what he would like in recognition for accomplishing his goals. Something as simple as a certificate of completion may be an extremely important reward for a person with mental retardation. Utilizing token economies, such as the "medallions" given in a 12-Step program, may be another method.
It may be necessary to make changes to group learning activities in order to accommodate people with cognitive disabilities. The use of alternative media to replace traditional homework assignments involving reading and writing may be required. An individual who has an expressive language disorder may be unfairly judged as uncooperative in expressing feelings and participating in group process. However, given the opportunity to express herself through therapeutic artwork, she may communicate quite a bit.
Mixed media can be incorporated in other ways as well. As a group project, clients could work together to "draw the road to sobriety," depicting the pitfalls they might expect to encounter along the way, or work as a group to construct an image of a "sober city." Clients can create memory books or journals (to capture the content of sessions), or flash cards (of words or pictures) to jog memory for relapse prevention, perhaps presenting people and places to avoid. Clients can also design flash cards containing phrases that are meaningful to them to assist them when they are confronted with a situation that threatens their sobriety.
Counselors should not assume, however, that one person's experience will be understood by another, particularly in the case of a person with a cognitive disability. There may be a great deal of shared experience, but the person with a disability may not understand it unless it is made specific and pertinent to his own life.
Group counseling for people with physical disabilities
As a general modification, it is necessary to accept different types of body positioning for people with physical disabilities--some people may need to stand up or move during a group session, and this activity should not be considered rude. Counselors may have to keep group sessions short or schedule frequent breaks to help people who lack physical stamina and make allowances for increased travel time to meetings for people who use wheelchairs or rely on public transportation. Sometimes individuals with spasticity or other motor problems, such as those associated with quadriplegia, have voluntary or involuntary movements that are sudden and unusual for people not familiar with them. The counselor should ensure that group members are not distracted by these movements and understand that they are a normal manifestation of some disabilities.
Medication Assessment And Management
The counselor should be aware that people with disabilities may be dependent on or inappropriately using prescription medications. Drugs are often perceived as providing comfort and managing the symptoms of a disability even while they are contributing to secondary complications. The routine of taking particular medications may itself provide feelings of control, stability, or safety. Additionally, some physicians prescribe medications in a palliative manner in an attempt to assist with disabilities they cannot cure (e.g., chronic pain, multiple sclerosis); unfortunately, the physician may not get proper feedback from patients regarding the efficacy of a given drug unless a patient is educated and motivated regarding the need to provide such feedback.
The Panel recommends that early in treatment, a medical professional conduct a medical examination and prescription assessment of all clients with coexisting disabilities. The medication assessment should review the consumption of both prescribed and over-the-counter drugs, including herbs and vitamins. The necessity for this review has increased in recent years because managed care has made it increasingly less likely that one physician will be writing or be knowledgeable about all prescriptions provided to a patient.
Learning self-advocacy and assertiveness with physicians and around the issue of health care and medication is important for people with disabilities. Persons with disabilities, like other individuals, may take a passive role during interactions with physicians, consequently receiving incomplete information about medications that are prescribed for them. Clients should also have a basic understanding of medication compliance (e.g., taking a medication regularly and on schedule, rather than just when the condition flares up). An important component of learning to live a sober life is to understand and properly use medications.
Treatment programs that care for people with disabilities have found it helpful to contract with a knowledgeable physician or a licensed pharmacist (Pharm.D.) to conduct medication assessments and review an individual's charts for possible drug interactions. The resulting information and suggestions can then be forwarded to medical authorities associated with the care of this individual. A licensed pharmacist often has a wider knowledge of drugs of many classes than most physicians, who may specialize in treating certain conditions and may only be familiar with a limited number of drugs.
Conditions such as diabetes, leukemia, and AIDS may require the use of medications that are self-injected or administered through a pain pump. Philosophically, self-injecting people may pose a problem for some drug treatment programs, but providers should keep an open mind. Under no circumstances should nonmedical treatment staff advise clients to take or not to take particular medications, vitamins, or herbs. Medication decisions should always be left to specialists. Staff should, though, become more knowledgeable about the purposes and potential side effects of medications taken by people with disabilities. TIP 26, Substance Abuse Among Older Adults (CSAT, 1998), reviews many of the medications used by people with disabilities.
Some people with disabilities experience recurring or chronic pain as a result of a disabling condition. The treatment provider must consider pain management as an important part of the rehabilitation plan. Persons with chronic pain may enter treatment addicted to the medication that they are taking for the pain. In these cases, it is critical that the treatment plan involve a physician for consultation and medication management as well as knowledgeable rehabilitation specialists who understand alternative treatments for chronic pain.
Sobriety may not be attractive or desirable if it is associated with unrelieved pain. The treatment provider should explore with the client what pain management options have been tried in the past, and which alternatives seem to hold promise. The individual should be encouraged to discuss her feeling about pain and how it affects her daily life.
Accommodating chronic pain
There are a number of accommodations that a treatment provider must make for persons with chronic pain. Providers must attempt to determine if the pain is the real reason an individual has been using a substance; if it is, they will need access to a good alternative pain management program (preferably one accredited by the Commission on Accreditation of Rehabilitation Facilities) to help manage withdrawal. The substance use disorder treatment provider should not make these decisions alone, but in consultation with the rest of the treatment team and the client. Confirmation of the medical condition can be obtained with the individual's consent from the medical provider.
In cases of chronic pain it is critical to obtain an accurate pain therapy history for each person. That history should ascertain the amount of medication being taken and determine whether it is within the prescribed limits and whether or not more than one physician has been prescribing medications for the same or similar conditions.
Since most medications for pain management are abusable drugs, programs may need to alter their policies regarding the use of such drugs. In these cases, the client can be given a locked place to store medications on the premises; however, although it may be convenient to ask a person with chronic pain to leave his medication with the treatment staff for dispensing, this may not be legal in a typical, residential substance use disorder treatment program.
Alternative treatments for chronic pain
There are alternatives to the use of analgesic narcotics for chronic pain management that can be considered for people with disabilities who are in treatment for substance use disorders.
Acupuncture is one technique used to manage chronic pain. It is already used in some treatment programs for detoxification and to help relieve symptoms of withdrawal. Some anesthesiology departments now have an acupuncturist on staff, and the technique is gaining broader acceptance. Other alternative treatments for chronic pain include
Many of these therapies have limited or anecdotal support of their efficacy. The treatment provider will need to seek expert advice on their use for any person with chronic pain.
For people with disabilities, providers should begin thinking of aftercare options early on in treatment, as it may be difficult to find the necessary services in the local community. It is important to understand that a person with a disability may require more sustained contact with aftercare resources than usual in order to enhance skill development, fulfill employment goals, or develop alternative social supports. Aftercare plans need to include provisions for counseling or relapse prevention groups, as well as other practical matters such as housing concerns or legal issues. Ideally, one professional within the treatment program or affiliated with some other community agency will be responsible for monitoring aftercare activities. If aftercare services are not reasonably accessible, treatment programs can direct clients to tape or book libraries, Internet sites, or other types of self-directed support activities. Again, the treatment provider should consider that clients with certain disabilities will require more structure and assistance than normal in order for the program to be effective.
Programs will need to make use of linkages in order to facilitate aftercare for people with disabilities (see Chapter 4). For example, a halfway house or other sober living arrangement can help extend support and structure over a longer period of time, which is particularly beneficial for people with disabilities. The ADA requires that halfway houses and sober houses be adaptable for people with disabilities, but in reality that is not always the case. The treatment provider should investigate whether accommodations will be made for a client with a coexisting disability before sending him to an aftercare facility. Even if a person is not going to an aftercare facility, treatment providers should make housing a priority and find out from the community network or other systems serving the person whether there is housing available and if it is appropriate.
Aftercare for People With Cognitive Disabilities
For individuals with cognitive disabilities, providers must systematically address what has been learned in the program and how it will be applicable in the next stage of treatment or aftercare. These clients can be very context-bound in their learning, and providers cannot assume that the lessons learned in treatment will be applied in aftercare.
The use of role-playing to rehearse what will happen at 12-Step-based meetings or in other aftercare settings can be a great help to all clients in treatment, not just those with coexisting disabilities. Someone with a cognitive impairment may find it extremely difficult to understand and complete all 12 Steps, but exposure to even a few of the steps can help her recovery. There are versions of the 12 Steps adapted for persons with brain injury, reading limitations, and mental retardation (although not all 12-Step members or groups agree on these modifications). Other modifications to 12-Step programs may also prove more beneficial to some people with disabilities. For persons with mental retardation, the presence of a facilitator may be very helpful, even though facilitators are not normally a part of 12-Step meetings.
People with disabilities face the same stigma and the same barriers in aftercare as they do in the rest of society. Individuals with mental retardation may be shunned or ignored in 12-Step meetings. They may not understand slogans or concepts or follow what is said in meetings. On the other hand, they may also find groups or individuals who can be very accepting. It may help if counselors find someone in a local 12-Step group willing to help someone with a cognitive disability connect with others in the group.
Perhaps one of the greatest risks for clients with TBI during aftercare is the difficulty of unstructured settings. While they may thrive in highly structured day treatment or residential programs, they might be at high risk for relapse when they must self-structure their environments. After leaving formal treatment, a client with TBI might be unable to avoid high-risk situations, follow treatment recommendations, or find a ride to an AA meeting. The fact that the disability is often not obvious to staff, peers, or family members intensifies this susceptibility to the loss of structure that accompanies treatment discharge. Role-playing and other techniques that enable clients to prepare for upcoming high-risk situations will be very beneficial for people with TBI.
Aftercare for People With Sensory Disabilities
People who are deaf often leave home to attend one of a few inpatient treatment programs across the country and then return to their home States to receive aftercare. There they may find few resources available. Staff members should try to set up a comprehensive aftercare program in the client's home area that would offer education and support from local service providers. Ideally, after an individual has completed primary treatment, she will have access to a variety of aftercare resources, including self-help groups, a relapse prevention group, aftercare therapists fluent in American Sign Language, an interpreter referral center, vocational assistance, halfway houses, sober houses and other sources of assistance and support. Networking with other service providers both locally and nationally is an important activity in aftercare (see Chapter 4 of this TIP for more information on linkages with other programs).
It will be difficult for people who are deaf or hard of hearing to find 12-Step meetings where sign language interpreters are available. Even if they have an interpreter to assist them, many 12-Step terms are foreign to American Sign Language and require very competent signing to translate. If a person who is deaf doesn't know sign language, the situation becomes even more complicated. Professionals who work with people who are deaf have different answers to this problem. Some believe that even if no interpreter is present, a 12-Step meeting is at least a sober environment where the temptation to use may be reduced for some period of time. However, others believe that sitting in a meeting and being unable to communicate with anyone or understand anything that is said is of no use to the individual and can even be harmful. The individual could feel isolated in this situation, become frustrated and angry, and be more apt to use. Meeting attendance is an important issue for the counselor to discuss with a person who is deaf during treatment; the person needs to leave treatment with a realistic plan for how to deal with this issue. The possibility that a client may use her deafness as an excuse for not attending meetings should also be carefully explored.
One common pitfall of aftercare for clients who are blind is low expectations. Too often therapists expect too little from people with disabilities instead of making accurate accommodations to an aftercare plan. For example, if a person is expected to keep a journal but does not have a keyboard or is not Braille literate, he should use audiocassettes. If bibliotherapy is an integral component, the provider should research the availability of the material at the State's regional library for the blind or National Recordings for the Blind.