Chapter 4 --Treatment Planning and the Community: Linkages and Case Management

Because persons with disabilities often have multiple life problems, they may require services ranging from vocational training to medical care to assisted living. It is not unusual for services to be duplicated or ineffective when a case manager is not utilized, and so a substance use disorder treatment provider may have to either case manage these services or find another organization that can do so. A case manager can be a strong advocate for a person with a disability and help her locate appropriate and accessible services.

Treatment Improvement Protocol (TIP) 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT, 1998), suggests three different models for establishing linkages to provide for interagency case management. These include

  • The single agency
  • The informal partnership
  • The formal consortium

In the single agency model, relationships with other agencies are established as needed to meet the needs of particular clients, with a single case manager retaining full control over the case. Often, this model is used to meet acute needs in a system where no partnerships have been established. While this model has the advantage of providing a single point of contact for the client, it may limit the array of services available and may require considerable time on the part of the treatment provider to establish a connection and reach a suitable arrangement.

In an informal partnership, staff members from several agencies collaborate as a temporary team to provide multiple services for clients, advising and consulting one another and exchanging information. No contractual mechanism is used in informal partnerships, which are readily constructed on a case-by-case basis. Such partnerships make more services available for the client and improve service coordination. However, breakdowns in service coordination are possible, and different problem orientations may lead to conflict among members.

A formal consortium links three or more providers through a formal, written contract. Agencies work together on an ongoing basis and are accountable to the consortium, usually with one agency taking the lead to ensure coordination. Case managers may be supported through resources pooled from members of the consortium or by the lead agency. Among the advantages of this approach are more opportunities for coordinating care, less duplication of services, and strengthened service integration. Disadvantages are that multiple agency participation may raise costs and consortia take more time to organize and to respond to problems.

Providers must determine the type of organizational structure that will best meet the linkage goals they have identified. Considerations include the number of people with disabilities served, the regularity with which clients with coexisting conditions are served, the types of disabilities represented, the service providers most frequently accessed, financial considerations, and geographical and political factors within the community.

Providers must be prepared to act as advocates for their clients when services and supports that are normally readily available and effective prove inaccessible for the client. There may be physical barriers to access in other facilities, such as stairs and no ramp, inaccessible parking, or an elevator that is frequently nonfunctional. Other barriers may arise from policies or procedures that should be modified to take the client's disability into account; for example, the reliance on prescription medication may initially bar the client from 12-Step programs or halfway houses that require participants to be "drug free." Materials supplied by linkage agencies may be in inaccessible formats; for example, an agency might ask a client to pay for a set of resource materials in Braille or closed captioning on videotaped materials for people who are deaf or hard of hearing. To act as the client's advocate in such circumstances may require linkages with agencies that are familiar with the requirements of the Americans With Disabilities Act (ADA), other Federal legislation, and applicable State and local disability laws and regulations. With a stronger understanding of the ADA, agencies and their field workers can become much more confident and effective advocates for their clients. In addition, agencies should establish working relationships with legal services, law school legal clinics, civil rights pro bono offices, and attorneys in order to provide clients with needed legal assistance. There are many types of creative pro bono legal services available on a local, State, and national level for both the agency as an organization and the client as an individual.

While establishing additional linkages may seem an almost insurmountable barrier to overtaxed treatment agencies, they are essential to increase the effectiveness of substance use disorder treatment and recovery services for people with disabilities. A recent 3-year study of people with disabilities treated by the Anixter Center in Chicago demonstrated that even individuals with severe and multiple disabilities are successful in treatment and maintain sobriety if provided with modified treatment and case management services (Research Development Associates, 1997). Because many disabilities go undetected, successful outcomes for the treatment center may increase as providers build these linkages and use them to enhance their expertise and experience in identifying and accommodating disabilities. Furthermore, the techniques that enable providers to better accommodate people with disabilities can be readily applied to help them meet the varying needs of all clients with greater effectiveness and insight.

Building Linkages for Treatment Programs

Why Linkages Are Necessary

The following are among the most frequently cited goals that motivate providers to establish linkages. The specific goals that resonate most with the provider will drive the linkage model chosen, the specific partners who participate, the activities engaged in by the collaborative team, and the means of formalizing and maintaining the relationship.

To improve an individual's prognosis for recovery. As stated in Chapter 1, research suggests that, for persons with disabilities in particular, issues such as lack of employment and social isolation contribute strongly to substance use. Linkages can address some of these problems, even when a client is unable to work on them in treatment. For example, most individuals who are deaf would benefit from a strong aftercare plan that connects them with an aftercare counselor in their community. Three factors that contribute to long-term sobriety following treatment for individuals who are deaf and hard of hearing are (1) employment, (2) having a friend or family member that they can talk to about sobriety, and (3) the availability of self-help groups such as Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) (Guthmann, 1996). Linkages can help ensure that these additional services are available.

To ensure compliance with legal mandates. Legal mandates such as the ADA require treatment programs to be accessible for people with disabilities. Programs that are not accessible face the possibility of a class action suit from people with disabilities. Disability advocacy groups or consultants often have expertise to share on how to meet legal requirements. For example, one organization may review the policies and procedures, physical facilities, and communication strategies of another, identifying areas that may be in violation and suggesting means of coming into compliance.

To increase teamwork among providers in addressing advocacy issues. People with disabilities who have substance use disorders are subject to double discrimination and may face seemingly insurmountable barriers to treatment. Many are not able to speak effectively to their own needs. In such cases, the treatment provider can help identify appropriate resources and enhance the client's capacity for self-advocacy. Both at the client and community level, it is critical that members of the substance use disorder and disability treatment communities support one another in promoting advocacy for their clients.

To improve coordination of services. A person with a coexisting disability may be eligible for services from several agencies, which might provide similar, duplicate, or conflicting services concurrently. Services provided in a fragmentary way typically prove far less effective than those coordinated thoughtfully. By establishing a working relationship with disability resources--both on a case-specific basis and through ongoing coordination mechanisms such as task forces--the treatment provider can better serve the client. Interagency collaborations also tend to formalize case management services and ensure that these services continue in spite of staff turnover.

To access or leverage scarce financial resources effectively. Some people with disabilities are eligible for a range of services and funding from a variety of agencies, such as State vocational rehabilitation (VR) services, Centers for Independent Living (CILs), community mental health services, Department of Veterans' Affairs, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), workers' compensation, physical rehabilitation, public transportation, public assistance, and managed care capitation programs for members of designated "risk pools." In order to ensure that people benefit from these services, treatment providers need to have linkages that will enable them to identify what may be available for their clients and how to access available services and funding.

An increased familiarity with disability-related resources in the community will also greatly help eliminate unnecessary expenditures for inappropriate accommodations or out-of-state services. For example, New York (a State that has obtained a Medicaid waiver) had to address the needs of persons with traumatic brain injuries (TBI), a small group that required extensive nursing home care. After providers refused to serve these high-cost clients, the State referred them to out-of-state providers at $750 to $1,000 per day, for a total cost of $100 million yearly. A significant percentage of these persons also had substance use disorders. A provider aware of the problem, as well as alternative treatment options, pointed out how the cost of treatment could be reduced. The State obtained a home/community-based medical services waiver to allow individuals to receive services within the community. Substance use disorder services were reimbursed more generously than ordinarily allowed under Medicaid, and the total costs of providing care were greatly reduced. (See Chapter 5 for more information on funding treatment for people with disabilities.)

To identify appropriate accommodations and procedural modifications. Disability resource agencies can often help providers better understand the nature of people's impairments and identify strategies available to increase their functionality. To varying extents, people may effectively provide information on their own disabilities and the accommodations that have worked for them in the past. Some, however, may be newly disabled; may have had little opportunity to make informed decisions; or may be poorly motivated, due to low self-esteem or discouragement, to seek accommodations. Community linkages can help the provider determine whether or not a disability accommodation is needed. An example is a patient with a spinal cord injury who entered a treatment program that only allowed 10-minute breaks. The patient's bladder program sometimes took 30 minutes. When she explained the problem, it was viewed as treatment resistance and she had to leave the program (a clear violation of the ADA). Had treatment staff consulted a disability organization familiar with spinal cord injury, it would have recognized her legitimate need for accommodation.

Disability resource groups can help identify communication strategies or equipment that may be practical in a particular instance. They can also help treatment providers develop equitable policies and procedures, and materials in accessible formats for people with disabilities participating in treatment. Other benefits can accrue from such linkages (see Figure 4-1 for examples). Consultation should always occur early in the treatment to avoid the unfairness of last-minute adjustments. For example, a visually impaired person who needs materials in large print format should not fall behind while waiting for a resource or assignment others received the previous day.

Identifying Needed Linkages

It is helpful for people with disabilities if treatment programs take the time to analyze their current client base and determine the types of linkages and models that are most needed. Through formal surveys or informal meetings useful information can be gained, such as

  • Number of people served with disabilities
  • Types of disabilities people in treatment have had and the number of people with each disability
  • Examples of disability-related barriers encountered and how they have been addressed
  • Current retention and completion rates for people with disabilities
  • Linkages used to address disability-specific problems, and their effectiveness
  • Gaps in linkages that still need to be addressed

This information can be used to determine the areas in which disability-specific expertise or resources are required to more fully address people's needs.

Of course, if an initial assessment reveals the agency is not treating significant numbers of people with disabilities, the program should try to determine whether people are deterred by barriers that may not be apparent to the agency. The treatment agency should determine

  • The number of its clients who might be expected to have disabilities on the basis of national or State incidence data and whether the actual number of clients with disabilities is lower than expected
  • How it has publicized its services in the disability community, and how it might better serve people with disabilities through differently placed or more accessible outreach materials, or through direct contacts with disability advocacy and resource agencies
  • Whether the agency is physically inaccessible or perceived as inaccessible
  • Whether the agency's admission policies and procedures deter people with disabilities
  • Whether the current assessment process is adequate to detect hidden disabilities that would commonly be missed
  • Having this information will make it easier for programs to identify their needs and present them to other organizations and agencies.

Locating Collaborative Partners

Most communities can help locate agencies to assist providers who want to treat people with disabilities effectively, and every State has a State Independent Living Council that can also provide information. Public health departments, the United Way, and county governments frequently produce directories of social, welfare, health, housing, vocational, and other services offered in the community. Sometimes they produce an automated directory. An excellent way to locate disability-related advocacy groups is to contact the State agency for vocational rehabilitation. Each office is mandated to have an ongoing consumer connection and should be able to assist in locating locally active service or advocacy agencies. Some of the agencies that may provide assistance to substance use disorder treatment programs seeking to work with persons with disabilities are listed in Figure 4-2.

Sources of Technical Assistance

Treatment providers need not be experts in all aspects of disability. There are a number of agencies available to provide specific information and assistance in these areas. The following key agencies are resources for general technical assistance on disability issues and can frequently provide referrals to linkage partners. Complete contact information for many of them is provided in Appendix B.

  • CILs--These nonprofit organizations are under the control of people with different types of disabilities. They are nonresidential and provide advocacy, information, independent living skills training, and peer counseling, among other services, for people with disabilities. CILs vary in terms of the scope of services they provide, number of staff and their areas of expertise, consumer groups served, and advocacy activities. However, all share the goal of empowering people with disabilities to achieve the most independent lives possible. Many CIL staff will need training in identification and assessment of substance use disorders in order to function as effective partners. It is important to note that the term "Independent Living Center" (ILC) is also used by nonaffiliated centers that may provide different services, such as live-in facilities.
  • Disability Advocacy and Service Groups--A wide range of advocacy and service groups are organized to serve persons who have specific disabilities or share a certain type of impairment. Their missions may be to provide training, consulting services, technical assistance, or resource material. Programs that begin working with a person who has a disability they have not yet encountered should consider contacting an appropriate advocacy and service group to ask for information, to explore linkage possibilities, or to locate specialized services.
  • Vocational Rehabilitation Centers--Each State has an agency focused on providing vocational training and rehabilitation services to people with disabilities with the goal of placing these individuals into competitive employment. There are field offices located throughout each State and qualified professionals to work in an advocacy and case management role.
  • Rehabilitation Research and Training Centers (RRTCs)--The National Institute on Disability and Rehabilitation Research (NIDRR) funds over 40 RRTCs devoted to specific disabilities or disability-related issues. Different RRTCs focus on topics such as spinal cord injury, traumatic brain injury, mental illness and long term employment, managed care, family issues, deafness, aging, or Native Americans with disabilities. (Appendix B lists contact information for NIDRR and selected RRTCs).
  • Disability Business Technical Assistance Centers (DBTACS)--NIDRR has funded a network of 10 regional DBTACs. These centers provide information, training, and technical assistance to businesses and agencies covered by the ADA and to people with disabilities who have rights under the ADA. They are often well connected with disability resources and agencies within their region and can assist with referrals. In addition, they distribute a variety of resources pertinent to ADA compliance at cost or free of charge.

Building, Formalizing, and Maintaining Linkages

Once an agency identifies its needs and locates a potential partner, it can begin to lay the foundation for what may become a lasting relationship. Areas for collaboration can be identified and tested on an informal basis prior to confirming the linkage in binding agreements. For example, a relationship might be developed in stages such as the following:

  1. The treatment center administrator or program manager reviews the needs of clients with disabilities, based on screening results at intake or referral information.
  2. The program designated surveys community resources and agencies that provide services for people with disabilities and contacts personnel in these agencies to establish linkages.
  3. The contacted agency assists in formulating treatment and recovery goals for the person with a coexisting disability. For example, a client and his counselor might attend an orientation session at a local CIL to determine what services are offered that he could use during aftercare.
  4. During a period of informal information and service exchange, administrators determine whether cross-training activities for their respective staff members might be beneficial.
  5. Other disability service providers are invited to participate in cross-training. For example, a resource fair of disability service organizations might be attended by treatment provider staff, or a representative of the treatment agency could give a briefing on substance use issues to staff members at a local halfway house.
  6. If training or awareness activities are beneficial, and if services provided appear useful to the client, more formal ties with the disability service provider may be initiated to better serve future clients.

One organization that has effectively established strong community links is the Pima Prevention Partnership; it is described in Figure 4-3.

Formalized linkage agreements

Once relationships have shown themselves to be beneficial, they can be formalized through a written service agreement that outlines the duties and responsibilities of both parties. This type of document can articulate why and how the programs should work together, highlighting the benefits each party should expect to derive from the relationship. Listed below are some examples of areas that might be addressed in such an agreement.

Substance use disorder treatment programs can provide

  • Training and consultation on effective substance use disorder screening methods
  • A referral resource for services agencies
  • Training and consultation on the dynamics of substance use disorders and its intersection with other disorders and conditions
  • Training on how to provide relapse prevention plans that also address disability concerns
  • Case-specific consultation for people with substance use disorders

The disability resource agency can provide

  • Assistance in modifying policies and procedures to avoid inadvertent discrimination
  • Assistance with increasing accessibility for persons with disabilities
  • Training for counselors to help them individualize treatment plans
  • Access to specific programs, such as specialized employment programs offered through vocational rehabilitation agencies
  • Support for people with disabilities in recovery who live in group homes or halfway houses

All agencies can

  • Communicate at stated intervals to ensure consistency in coordinating treatment plans for mutual clients
  • Conduct case consultations
  • Conduct on-the-job training and cross training for staff

Of course, a formal agreement is no guarantee of a flourishing and productive relationship. Attention can be given to maintaining the established relationship through shared activities, such as the exchange of speakers, pursuit of joint funding opportunities, cross-training, and periodic meetings.

Linkages in Case Finding And Pretreatment

Case finding generates the flow of clients into treatment, often through formal liaisons with referral sources. Most individuals are referred to substance use disorder treatment by other agencies. A treatment program may use formal agreements with referral sources to create close partnerships and ensure that effective referrals are made so that clients do not fall through the cracks. For example, a treatment program might develop a contract with a hospital to do onsite evaluation of potential clients, whether they are visitors to the emergency room with mild head injuries or individuals who are newly disabled being discharged after acute care. Although many communities have informal referral networks created by individuals who know each other, partnerships are most effective if sought and maintained at the organizational level. (Several common referral sources and their functions are described in Figure 4-4.)

To make appropriate referrals, referring agencies should have a basic knowledge about the approach and procedures used by the treatment program, including admission criteria. In particular, for people with disabilities, they should know that the program is accessible and prepared to treat people with the disability in question. In order to ensure that different agencies have the requisite knowledge, it may be necessary to establish a formal training linkage that would involve staff cross-training.

A referral is effective only if the potential client contacts the treatment program. Ensuring that the contact occurs may be a task of the referring agency, the treatment program, or the client, depending in large part on the client's functional level and support network. In planning all treatment activities for clients with disabilities, it is critical to accurately assess their ability to be proactive and undertake activities on their own behalf. Some individuals with disabilities may become unnecessarily dependent on others. Others may insist on undertaking all activities, even ones that may prove to be beyond their capacity. For some clients, the referring agency need provide only a contact person's name and telephone number and then carry out a routine telephone followup. For others, a staff member from the referring agency may have to accompany the client to the treatment program and remain with the client through the initial phase of treatment. However the first contact is undertaken, the manner in which it is achieved should be regarded as a critical first step toward treatment, and it should not be left to chance.

In developing partnerships with referring agencies, the treatment program should ensure, through interagency agreements, that mechanisms are in place for exchanging client information. The referral process is two-way, however, and the treatment program can also help clients with disabilities by connecting them with other services commonly available through programs for people with disabilities. To do this, programs need to maintain a resource directory of places to make referrals.

Linkages in Primary Treatment

Primary treatment is the period when a client is most actively engaged with the provider in treatment. During this period, many people with disabilities face challenges that may be addressed more effectively through well-chosen linkages. Whether the linkage is accessed through one-time arrangements or is incorporated into a collaborative treatment plan will depend on the treatment agency's policies and the extent of the client's needs.

Many people with disabilities will also have specific needs (such as the use of adaptive equipment) with which the treatment provider may not be familiar. Informed resources, such as disability advocacy groups, can help educate providers about these needs.

When treating clients with disabilities, counselors should be prepared to encounter additional complexities in some routine case management tasks as well as some new tasks and concerns. Because failure to recognize and address disability-related issues can seriously undermine treatment, the Panel recommends that early referrals to linkage agencies be made and that those services be provided concurrent with, rather than following, treatment. For example, because employment is likely to be a particularly challenging issue, realistic employment goals should be established early in the treatment process with the assistance of a vocational rehabilitation agency.

Numerous factors determine the type and level of adjustments required. Among the most obvious are the nature and severity of the disability, the length of time the individual has had the disability, the resources the individual has accessed to help him with the disability, the personal characteristics and skills of the client, his living situation, and his support systems. Linkages to other services may help to address and alleviate many of these problems. The following sections (and Figure 4-5) present some of the most common problems and the ways in which linkages can be used to help solve them.

Addressing Discrimination

As the client's advocate, the treatment provider may need to address discrimination specific to the individual's physical or mental disability, in addition to the discrimination that may occur due to a substance use disorder. The treatment provider should be able to determine if a discriminatory barrier has prevented a client from accessing a requisite service. When discrimination is encountered, the individual may need assistance from disability resource groups to develop and exercise self-advocacy skills. In some cases, intervention by the provider may also be required to ensure accessibility. Linkages in this area are extremely important because the treatment provider is unlikely to know how to advise or assist a client if the client experiences discrimination from another agency.

Linkage strategies

  • Disability Business Technical Assistance Centers, Federal enforcement agencies, statewide protection and advocacy groups, Legal Aid and other community-based legal services, CILs, and many disability advocacy groups may be able to provide clarification of legal requirements and documentation.
  • Disability service groups can also help the client develop and exercise self-advocacy skills.

Disabilities Contribute to Substance Use Disorders

Disability-related issues can contribute to a substance use disorders and often must be addressed as part of the treatment process. For example, in the case of a recently acquired disability or one that is not readily apparent to the client, a client may need peer counseling or psychological counseling in the midst of treatment to help him deal with unresolved disability issues. The disability may have had a profound effect on the quality of peer relationships, job access, sexual function, and other areas--all of which may be relevant to recovery. The isolation, poverty, excess leisure, and low self-esteem that may accompany a severe disability may also have been factors in the development of the abuse pattern.

Linkage strategies

  • CILs and community mental health centers may offer peer group and individual counseling, as well as an extensive array of information on disabilities.
  • National or local organizations that work with people who have specific disabilities, such as the National Multiple Sclerosis Society, may also offer information or counseling services for people with disabilities.
  • Individuals with recently acquired disabilities may need a mentor to help them learn to maximize mobility and access needed services.
  • Some people with disabilities may benefit from self-advocacy skills and assertiveness training to enable them to be proactive and secure the resources they need. This training may be available through CILs, vocational rehabilitation agencies, and community mental health centers.
  • Provider staff may be unfamiliar with nuances of behavior and concerns for people with disabilities. They may benefit from training provided by a collaborative partner with expertise in disability issues, such as a disability service group or CIL, in order to recognize and address these issues effectively in treatment.

Seeking Employment

A key area of concern for many people with disabilities is employment. It has been estimated that 60 to 70 percent of people with disabilities are either underemployed or unemployed (Taylor et al., 1986; LaPlante et al., 1997). Lack of employment may be a factor in substance use; conversely, addressing and overcoming barriers to employment, with the aid of collaborative partners, may greatly enhance the prospect for recovery and should be addressed as a component of treatment planning. For people with disabilities who have never worked, the lack of work skills and an employment history will be an added difficulty in securing employment.

Planning for full employment will be more challenging; in some cases it may even be an unrealistic goal. In some cases, the treatment plan may call for part-time work, volunteer work, or other activities that will enable the individual to experience achievement and appreciation. However, given appropriate accommodations and an imaginative approach to the job search process, many more people are employable than might at first be apparent.

Providers should be aware that successful sobriety and employment might mean the loss of medical or other benefits that are perceived as essential for survival. Providers should also recognize that there is an ongoing national debate about the appropriate public assistance policies for people with disabilities.

Linkage strategies

  • State vocational rehabilitation agencies can provide coaching on resume preparation and interview skills; they may also provide job training and purchase tools.
  • CILs can provide help in developing job skills and finding employment.
  • Employers with specialized hiring programs are excellent contacts. Employers who are able to hire large numbers of persons with disabilities, such as Goodwill Industries, may also be able to suggest other agencies.
  • Local or State commissions may exist that address employment issues for persons with disabilities.
  • The Job Accommodation Network provides free advice on accommodations for particular tasks (see Appendix B).

Common Needs of People With Disabilities in Primary Treatment

Clients with disabilities may have distinct needs that impact treatment and will need to be addressed through case management. Ideally, these issues should be considered by a multidisciplinary collaborative team, including a disability advocate, working together to address the client's needs. Figure 4-5 briefly identifies needs or issues that may arise, their possible impact on treatment, and resources that might assist the case manager in addressing these concerns.

Linkages in Aftercare

Because of the many situational factors that may facilitate or impede recovery, careful planning for aftercare is required and little can be taken for granted. Examples of key differences in aftercare likely to apply to many persons with disabilities follow:

  • Ongoing and more frequent monitoring may be required, sometimes using different communication channels.
  • Friends, family, and advocates are often especially material to the recovery of a person with a coexisting disability because of a higher degree of reliance on their care and support.
  • The circle of people involved with recovery may be larger; for example, the support of attendants, residential facility staff, or home health care providers may be critical.
  • Modifications to "typical" aftercare plans are likely to be required. Provisions for transportation and communication aides may be necessary.
  • Service coordination and case management responsibilities are more prominent and time consuming than for clients without disabilities.
  • The transition counselor for the referring program may need to brief outpatient program staff on the client's needs, functional limitations and capabilities, and suggest accommodations or modifications to usual procedures.

Using Linkages to Address Common Challenges

Developing interagency linkages

Accomplishing linkages to other agencies cannot be taken for granted, and additional steps may be required. Ballew and Mink (1996) identify five "tasks" related to linking that should be addressed prior to client contact with the resource agency (see Figure 4-6).

For people with disabilities it is important that the treatment provider not send the client to another agency for care without first checking to ensure that the client will be able to access the services. For example, in the process of rehearsing the plan described above, the provider may find that a lack of ramps, poor facilities for battery maintenance for wheelchairs, or inaccessibility to public transportation may be significant barriers for the client.

Specific problem-solving steps will vary from client to client; for some, it may be important to ensure that someone accompanies the client to the first meeting. For others, a simple drawing of the route showing bus stop and ramp locations may sufficiently alleviate anxiety to enable the individual to make the connection without further assistance.

Linkage strategies

  • Disability advocacy agencies may be able to suggest effective communication and memorization strategies.
  • Alcoholics Anonymous intergroup offices should be able to identify meetings that are able to accommodate people with disabilities; however, all meetings should be visited first to ensure that this information is correct. Some local meetings may be willing to provide a guide or "buddy" to help the client attend and participate in meetings.
  • It may be helpful or necessary for someone to take the client to a service agency. For example, this type of assistance may benefit persons whose cognitive impairments make it difficult to follow directions, and persons with mobility impairments whose concerns about accessibility may otherwise prevent their acting on the referral. This role may be taken by a designated anchor: a family member, friend, disability service advocate, church member, parole or probation officer, peer or mentor, attendant, health care worker, vocational rehabilitation staff member, caseworker, or volunteer.

Persons with disabilities on medication

The need for medication required because of a disability may mean that a client is not viewed as "clean." A client with a mental disability may rely on prescription drugs to stabilize mood and reduce the negative impact of the disorder; a client with a physical disability may depend on pain medication; and a client with epilepsy may use dilantin, a barbiturate-like drug, to control seizures. Some 12-Step programs may view such medications as a "crutch." Some halfway houses may also have policies that would deny admittance to people who are using these, or similar, medications (even though such policies are in conflict with the ADA).

A client's physician may inadvertently be enabling a client's substance use. A physician who is sincerely trying to help his patient might prescribe pain medication for a chronic physical disability rather than investigating alternate means of managing the pain. Other prescription medications can become drugs of abuse. For more information on the abuse of prescription and over-the-counter medications see TIP 26, Substance Abuse Among Older Adults (CSAT, 1998).

Linkage strategies

  • Negotiate with "downstream" providers to ensure that services are available to people regardless of their medication use.
  • Contact the American Society of Addiction Medicine to obtain the names of physicians knowledgeable about addictions; facilitate a consultation with the client's physician.
  • Arrange for the treatment agency's staff physician to write a note to the private physician on followup planning and suggest a meeting.
  • Work with health maintenance organizations to develop physician protocols that provide guidance on the distinction between enabling substance use and appropriate pain management.

Family and caregivers

Family and caregivers may be barriers to treatment rather than sources of support. For any number of reasons (e.g., to make life easier for themselves, to maintain current patterns of relationship) family members may contribute to the individual's continued substance use. In some cases, they may do so with the best of intentions. Because they feel sorry for the person who is disabled they may even encourage substance use as a way for their family member to feel better about herself (Schaschl and Straw, 1989). The family and other caregivers may also be overprotective of the individual and undermine the potential for a greater degree of independence. On the other hand, they may be weary from the strain of providing care and appear indifferent to the recovery process. For these reasons, family and caregivers should be included in treatment planning whenever possible.

Linkage strategies

  • Family counseling services, provided through a community mental health agency, may help family/caregivers to function as effective "anchors."
  • Families should be included in reentry planning through releases from the client.
  • Recommend literature to families that addresses enabling behavior in general and for people with disabilities in particular. Disability resource agencies may be able to provide helpful literature.
  • For some families federal money for respite care may be available.
  • Information on respite care or respite services may be available through the State Unit for Developmental Disabilities, the United Way, and the Social Service Clearinghouse.

Isolation of client

Some people have experienced isolation because of their disabilities, and may have a relatively limited social circle. If isolation was a contributing factor in the development of addictive behavior, the return to relative isolation after the intensity of treatment is of even greater concern. Because the self-care and preparation required to leave home are time consuming and may produce anxiety, people with disabilities may have more difficulty going out to engage in social contacts. Clients who perceive options for social contact as limited may have particular difficulty refusing alcohol from friends who visit and assume that alcohol will be shared.

Linkage strategies

  • Practical steps should be taken to connect the client with an accessible sobriety group or recovery community. It will be helpful to have someone available to accompany a client at first, or have him begin participating in these programs several weeks before he is discharged.
  • For people whose interaction skills are limited, training in social skills or peer counseling may be helpful. Training may be available through CILs, community mental health centers, university disability student services, vocational rehabilitation programs, and programs for mental retardation and developmental disabilities.
  • Establish connections with peer role models, especially those with disabilities, through 12-Step groups and disability advocacy/service groups.
  • Some disability organizations, such as CILs, HIV agencies, American Council of the Blind Service Centers, and Department of Veterans' Affairs offices, offer support groups and social activities.
  • Various community groups may sponsor substance-free picnics and parties.

Limitations of disability

A disability may limit the leisure activities available to a client. For those with moderate to severe disabilities, the nature of the disability may require special attention for identifying suitable leisure activities. Outside organizations can be extremely useful in finding or establishing such activities.

Linkage strategies

  • If disability groups with whom the client is affiliated use alcohol as an integral part of social functions, the provider may offer awareness education (formally or informally) to encourage the provision of nonalcoholic alternatives. Many disability-related, community organizations would be willing to develop substance-free activities if they were aware of the difficulties faced by people with disabilities leaving treatment and trying to maintain sobriety.
  • Providers should facilitate contact with local parks and recreation departments. Under the ADA, public parks and recreation are not permitted to exclude people with disabilities from events for which they are "otherwise qualified" or levy surcharges when they participate.
  • Many groups offer challenging outdoor or sports activities specifically adapted for people with disabilities. Providers can contact groups such as the Blind Outdoor Leisure Development (BOLD), Wheelchair Olympics, and Wilderness International.
  • The National Library Services for the Blind and Physically Handicapped can provide materials on recreational activities (see Appendix B). State and local libraries for the blind and physically disabled will also have resources available.

Uncertain client-employer relationship

Clients who are employed may wish to avoid involving their employer in a recovery plan for fear of jeopardizing employment. In some instances, the employer's policies may threaten

recovery. While these are common client concerns, people with disabilities often have more difficulty securing employment, and thoughtful management of the return to employment may be especially important.

Linkage strategies

  • DBTACs, local disability law centers, Equal Employment Opportunity Commission, and civil rights commissions or offices may provide legal counsel or information concerning employment issues.
  • Encourage the client to use Employee Assistance Programs if they are available.
  • Consider meeting with the employer to facilitate understanding of recovery needs (such as providing an alternative to alcohol at work-related events).

Longer monitoring period needed

More frequent monitoring over a longer period of time than is common may be required for people with disabilities. Creative strategies may be needed to ensure that monitoring occurs with sufficient frequency to identify relapse triggers in spite of funding limitations. For example, e-mail or automated telephone calls have been used to facilitate monitoring that requires less time than direct or face-to-face contact.

Linkage strategies

  • Use a Community Health Rap, a line that enables the health professional to record answers to questions and make them available to others.
  • Set up telephone support groups that enable people to access a telephone conference in lieu of a face-to-face meeting.
  • Automated periodic telephone contact can be used to detect and prevent relapse; a telephone reminder system may be particularly useful for patients with memory impairments (Alemi et al., 1992).

Community Partnerships

Too often, the needs of people with disabilities who have substance use disorders are either not met at all or met inadequately. Many systemic factors can contribute to poor or nonexistent treatment. Because of these systemic barriers to treatment, many believe, as does Rebecca Sager Ashery, that case management must involve active community advocacy and systems intervention in order to be truly effective (Ashery, 1992). The activities of such a coalition could, she suggests, include

  • Documentation of gaps in services
  • Documentation of service duplication
  • Examination of eligibility criteria
  • Formation of a comprehensive referral network with formalized mechanisms of referral
  • Development of communication channels between agencies
  • Ability to merge services where needed
  • Ability to address gaps in services
  • Political advocacy for more resources and/or making changes in the service system
  • Data collection and evaluation
  • Quality assurance of programs

Substance use disorder treatment providers and disability service providers can and have worked together to meet one or more of these goals. For those seeking systemic change, a key step has been collecting data that demonstrate unmet needs. For example, data derived through screening people for disabilities may be useful in advocating for increased funding, particularly when several providers are able to offer similar data. Disability organizations may also be able to provide data on the prevalence of certain disabilities within a given area, adding specificity to estimates of unmet needs. Such data can be used to justify new risk pools and create functional carve-outs that benefit persons with disabilities who have substance use disorders. By sharing these data with decision-makers in managed care or public health policy, coalitions can help create an awareness of needs that may lead to enhanced resources.

Providers concerned with community advocacy may either start a task force from scratch or convince an existing task force to work to improve access to substance use disorder treatment for people with disabilities. Those who should be represented on such task forces will vary according to community characteristics and task force goals. Common participants include representatives of treatment programs, rehabilitation services, disability advocacy or service organizations, mental health agencies, volunteer organizations, funders, community leaders, and consumers of disability and substance use disorder treatment services.

Many providers have chosen to work through existing coalitions. Fortunately, in the arena of substance abuse prevention, many local coalitions exist throughout the United States whose mission is to reduce substance abuse in a community. (See Figure 4-7 for a few examples from the State of California.) These coalitions may be funded by local, State, or Federal sources or by private foundations. Many of these organizations have board members who are concerned about the prevalence of substance use in their community. However, members of these organizations are often unaware of the degree to which people with disabilities are affected by substance use disorders. Treatment providers who are able to demonstrate need and suggest specific activities that would benefit the community may persuade these already funded community coalitions to assist in making changes that will benefit people with coexisting disabilities.

Treatment providers interested in approaching existing coalitions may want to consider adapting the following step-by-step strategy:

  1. Identify a local, countywide, or statewide effort whose mission it is to help reduce substance use (Mothers Against Drunk Driving, Governor's Alliances, federally funded community partnerships and coalitions, boards of large prevention and treatment agencies).
  2. Develop and present (ideally in concert with a disability services provider) the issues of people with coexisting disorders.
  3. Gain commitment to provide further education and training, including the development of a short-term action plan that includes constituency.
  4. Evaluate how effective the partnership is in helping people with disabilities.
  5. Publicize and reward the efforts of the coalition or partnership with public acknowledgment.

Chapter 5 -- Administrative Tasks

While it is important for substance abuse counselors to understand the emotional and practical needs of individuals who are living with coexisting disabilities, program administrators also play an important role in their treatment, by ensuring that staff are properly trained and by modifying components of programs as needed. Substance use disorder treatment programs should take definite steps to improve treatment for persons with coexisting disabilities and be in compliance with accrediting agencies and regulations. Programs need to demonstrate an organizational commitment to assist those with disabilities; apply specific measures to eliminate barriers (either physical or procedural) to treatment; and develop treatment plans that take into account the particular needs and problems of people with coexisting disabilities.

There are definite legal and ethical motivations to modify programs to accommodate people with coexisting disabilities. Certainly, the Americans With Disabilities Act (ADA) is one motivator for this type of outreach (see Chapter 1 and Appendix D for more information on the legal ramifications of the ADA), but there are others (see Figure 5-1). The inclusion of people with coexisting disabilities will increase the diversity of a program and prove an enriching experience for all those involved. Expanding treatment to include people with coexisting disabilities presents a real opportunity to ask program funding sources for additional money, since there will be new people to be served who may be insurance or Medicaid reimbursable. Agencies should not, however, seek to serve clients with disabilities simply because they represent increased funding; this could lead to the provision of substandard services.

Additional services for people with coexisting disabilities should have a positive impact on substance use disorder treatment outcomes. For example, a program with a small percentage of individuals with traumatic brain injury (TBI) who are not completing treatment would likely show an improvement in overall treatment outcomes if they received appropriate services for their disability. Programs serving individuals with cognitive disabilities may find greater success rates if abstract concepts are simplified, and if reading and writing tasks are tailored to the cognitive level of the individuals.

Provider Knowledge of People With Disabilities

Substance use disorder treatment programs must become aware of their legal obligations and teach their staff some basic information about people with disabilities. Staff should understand, in particular, the factors that can affect a person's understanding of her coexisting disability, the many related problems that often accompany a disability, and the emotional responses someone might have to her own disability. Staff can learn about the needs of people with disabilities in several ways:

  • Read this TIP and the resources cited in its bibliography.
  • Train staff that substance use disorders are a disability and about the limitations imposed by the disabling characteristics of substance abuse and dependency.
  • Participate in training that addresses the impact of physical, cognitive, sensory, and affective disabilities and the impact of a coexisting substance use disorder. Teach how those dual diagnoses affect significant others and family.
  • Train staff concerning barriers to treatment for people with coexisting disabilities and how best to remove them. Such training should include, among other things, daily living skills strategies, information on the use of assistive devices, and ways to manage the living environment.
  • Bring in outside providers with specialty in treating substance use disorders and disabilities to do in-service trainings. It may be helpful to use people with disabilities as trainers. Doing so will give the staff an opportunity to learn how to interact with people with disabilities and overcome their own prejudices and fears.
  • Form resource networks with groups that focus on the needs of people with disabilities such as vocational rehabilitation programs, Centers for Independent Living (CILs), physical and occupational therapy providers, advocacy organizations, and developmental services. These organizations can be a source of staff training. (See Chapter 4, Treatment Planning and the Community: Linkages and Case Management, for more information on establishing linkages.)
  • Train staff how to work with interpreters, how to use the Telephone Relay Service and Telecommunication Devices for the Deaf (TDDs). Staff should know how to access necessary people and devices. Telephone companies rent TDDs at a very low monthly rate, and some service centers located in a variety of states loan out equipment such as television decoders, visual alarm systems, and TDDs.
  • Teach staff the proper etiquette to use with people who have physical and cognitive disabilities.
  • Be sensitive to people with coexisting disabilities and consult them about their needs. Staff can learn a great deal from talking to them. While staff may feel it is impolite to inquire about a person's disability, consulting the person is necessary to provide appropriate accommodation. If a provider won't talk to a client about his disability, the client may get the idea that it is too shameful to discuss it.

For people with coexisting disabilities, as for any particular population, the higher the cultural competence of the program and staff in understanding the needs of this population, the higher the likelihood that they will be engaged and maintained in treatment. Persons with coexisting disabilities should be able to talk about their disabilities with program staff and feel understood and accepted. However, they should not have to feel that they must educate treatment providers about how to meet their needs.

Organizational Factors

A program demonstrates its commitment to working with people with coexisting disabilities from the top down. While there may be no substitute for a counselor's understanding of her clients, the counselor needs the support of her treatment program if she is to effectively apply that knowledge. It is the program that must demonstrate commitment if it is to attract persons with coexisting disabilities, and it is the program that is responsible, in the long run, for training its counselors to work with people with coexisting disabilities, and not the counselor who is responsible for educating the program.

Organizational Commitment

Policies and procedures

To ensure full organizational support for treating people with coexisting disabilities, the Consensus Panel recommends that a treatment program develop a policy statement that articulates the program's willingness to accommodate any individual with a disability who chooses to attend the program. Title III of the ADA requires that programs prepare a plan stating how they would serve a person with a disability. Therefore, the policies and procedures manual should be reviewed and revised to describe how the program would make an accommodation. Questions to address in the manual include: What is the process for asking for an accommodation and for assessing whether the program can make it? Who is responsible for instituting the process (asking for the accommodation)? Who decides whether the program can make the accommodation or whether it would impose an undue burden? What procedures should be followed when a person must be referred elsewhere for services?

A program's basic values and philosophy are reflected in its approach to a person whose impairment presents a challenge to the "standard" treatment plan. Treatment providers understand the anxiety most people experience when they make the first step toward getting help for an addiction, as well as the small window of opportunity that may exist to provide treatment. In response, many programs have developed formal or informal "open-door policies"; people who appear at such facilities without an appointment are seen, if only briefly, to arrange further care. An open-door policy means that no one is turned away or denied services. Instead, all people seeking treatment are assessed and a decision is made whether or not the program can meet the needs of the potential client.

However, many treatment providers' clinical experience has made them aware that treatment that is inappropriate for a person's current needs or situation may actually be harmful. For example, inappropriate treatment may use up a person's insurance resources while providing little or no gains in return. The sense of "failure" resulting from such unhelpful treatment may establish a precedent that the individual will use to justify avoiding treatment in the future. Indeed, the patient placement criteria of the American Society of Addiction Medicine, which are being used to define publicly funded care in several States, stipulate that if a program cannot provide a client with the necessary level of care, the program should not treat that client; instead an appropriate referral should be made (American Society of Addiction Medicine, 1996). (See Chapter 4 for more information on the importance of linkages in referring individuals for treatment.) In developing a policy statement about the program's commitment to serve people with coexisting disabilities, administrators and staff should consider these issues.

Board membership

In making a commitment to treat persons from any particular population, one question that often arises is whether a member or members of that group will be appointed to the board of directors. The level of representation on the board (i.e., whether one or several members from a group are appointed) should, and sometimes does, reflect the proportion of that group in the treatment population. Many have argued that board membership of people with disabilities (or the lack of it) is a measure of the strength of a program's commitment, and that having several people with disabilities at this high administrative level will have a strong "cascade" effect on the program as a whole.

Others may feel that such mandates for board membership tie the hands of administrators and may not be the best way to ensure that the needs of all people with disabilities are met. For example, an individual appointed to the board who is blind may be effective in raising issues about persons who are visually impaired but not about persons with learning disabilities. As an alternative, some organizations form an advisory group or a task force made up of individuals who have different disabilities and chaired by a board member. However, some advocates may argue that task forces do not always produce real change. To be effective, an advisory group must have the ability to act upon its findings.

When a program makes a commitment to serve people with coexisting disabilities, board membership of people with disabilities may be implemented immediately or considered a goal to be reached as the program begins to serve a greater number of people from these groups. A program should try to obtain regular input from the community it seeks to serve, and creating a permanent task force or an advisory committee is an ideal way to address this need. But board members or advisory committees may have an important advocacy function without being experts on implementation, and programs will still need to obtain technical or consulting services related to specific disability issues.

Hiring persons with disabilities

Another sign of organizational commitment is to hire people with disabilities to work in the treatment program. Hiring people with disabilities also benefits other staff members, who can learn from these coworkers. Having such staff members can help sensitize others to issues, help differentiate between enabling responses and appropriate accommodations for people with coexisting disabilities, and provide encouraging role models for them. A person with a disability should not be assumed to be an expert on every type of disability and all disability issues, however. The extent of familiarity an individual will have with legal issues and the functional implications of disabilities will also vary according to that individual's background.

While it may not always be easy to find qualified staff who have disabilities it is worthwhile to actively seek such personnel. If a person with a coexisting disability is not available to serve as a counselor, a person with a disability (perhaps a former client) can still serve a function as a "client advocate" and act as a liaison between administration and clients.

Monitoring the program's efforts

The program must make a commitment to continually reexamine its effectiveness for people with coexisting disabilities. As knowledge concerning the treatment of people with coexisting disabilities grows, it is expected that further changes to the program will need to be made. The main question to consider is, "Are we doing what is necessary to meet the needs of clients?" Such inquiry can take place formally, using quality assurance methods and consumer satisfaction surveys, and informally, using an anonymous suggestion box or by routinely asking clients whether their needs are being met.

One useful strategy is to routinely set aside a specific time at staff meetings to ask staff members for evidence that goals are being met, or not being met. For example, during a meeting at a therapeutic community, it might be asked whether the residents have been adequately apprised of the needs of a person with a disability who is scheduled to enter the community. Have they been given the opportunity to discuss how those needs might differ from other residents' needs? Has the incoming person been assigned to a "buddy" for peer support if that is the policy? Has the buddy received training or information in order to be sufficiently prepared? What specific steps are being taken to accommodate the new person's needs? For example, have certain household tasks been modified so that they can be performed by the new resident?

Staff Training

One concept that has remained largely unchanged in the treatment field is the importance of the bond that forms between a client and a counselor or group leader when the client feels understood and accepted. Without such bonds, it is difficult for a person to summon the commitment and courage needed to undertake recovery. In order for this understanding to develop the counselors must have knowledge of the particular needs of their clients. Staff training is essential to ensure this communication and understanding.

All program staff should be trained to understand functional limitations and capacities, the wide variety of conditions that lead to them, and the barriers that treatment-as-usual may present for persons with specific disabilities. Without this training, true organizational change cannot occur. Training modules using didactic and experiential methods have been designed for staff at all levels, including managers, program and clinical directors, clinical staff, and support staff. One approach is to provide a "disability awareness experience" in which staff role play and take on a specific disability for a period of time during which they have to do what is expected of the clients. In this manner they experience first-hand the problems, issues, and barriers a person with a disability might face, and can gain a better understanding of what it is like to have a decreased or altered level of functioning. At all levels of the program, training should strongly encourage and reward staff members who find creative ways to adapt treatment procedures for people with coexisting disabilities. A variety of disability organizations in the community can assist the program with training by providing materials and speakers. (For more information, see Appendix B, Resources for Information About People With Coexisting Disabilities.)

As with all groups who have been isolated and stigmatized, stereotypes and myths about people with disabilities abound, and fears may distort staff members' perceptions. A good training program will begin by eradicating such myths and replacing them with knowledge, skills, and a welcoming attitude. Staff should be encouraged to express their fears and to examine their beliefs. (See Figure 5-2 for some questions staff may wish to consider when examining their disability-related beliefs.) This initial training for all staff should be followed with more specific and specialized training focusing on different disabilities, the functional limitations associated with those disabilities, and possible treatment modifications and accommodations. Sometimes a brief staff training to address the needs of an individual slated to begin treatment helps bring an immediacy to the situation, which is beneficial.

Considering how pervasive some coexisting disabilities are within treatment populations, staff training in this area should also be ongoing and involve staff sharing their experiences in working with people with disabilities. In addition, with training, staff will become increasingly aware of the hidden disabilities of clients with whom they are already working. The program will benefit from this clearer clinical picture of the treatment population, and improved treatment outcomes can result.

Training of support staff is also important since these staff members are often a person's first contact with the program. A potential client's initial conversation with a receptionist or other support staff often forms her perception of the program. The success or failure of these interactions often determines whether or not the intake interview occurs at all. A warm and friendly reception is important for any person taking the difficult step of seeking substance use disorder treatment, especially for someone with a disability worried that he will not be accommodated. The message from the first contact should be upbeat, proactive, and geared toward allaying the person's anxiety and creating an initial bond. Receptionists and other support staff should receive special training to prepare them to respond knowledgeably and sensitively to people with coexisting disabilities; they should have the necessary practical skills, such as the ability to use a TDD or other common assistive devices, and a knowledge of basic disability etiquette.

Funding Mechanisms

Treatment for substance use disorders can often involve multiple funding streams, and treatment for people with coexisting disabilities may add new complexities, as well as opportunities, to the process of securing funding. Services may acquire funding from a variety of sources, including

  • Block grants from Federal agencies
  • Medicaid, which includes options that allow for nonmedical services (e.g., the Medicaid rehabilitation option)
  • Medicare and Supplemental Security Income for people with disabilities
  • Migrant health funds
  • Private organizations, such as United Way
  • Veterans services
  • Developmental services
  • Local tax dollars
  • Private foundations

To provide sufficient funding for the longer and more complex supports that may be required for a person with a coexisting disability, blended funding is highly recommended. When several agencies have a mandate to provide care, as is the case for many people with coexisting disabilities, each may have access to funds for case management. Alone, no one agency may have enough funds to address the demanding case management issues that could arise in treating persons with multiple or severe disabilities. However, blending funding may enable the coordinating team to create a pool of funds sufficient to fund a single case manager at an acceptable level.

Programs might consider collaborating with rehabilitation and other providers to share resources. For example, a substance use disorder treatment program might carry educational and treatment services into a vocational rehabilitation site. Carry-in services reduce the overall cost of separate programs and may, in certain cases, allow for third-party payment for both providers. In these cases, there is not a blending of funding, but rather a sharing of costs and a potential for mutual billing. (See Chapter 4 of this TIP for more information on the establishment of linkages that could be used to create blended funding.)

With low-incidence populations such as individuals who are deaf or hard of hearing, it may be more cost effective for States to use regional programs where fluently signing staff and interpreters for nonfluent staff are readily available. In some of the more rural States, there may not be enough individuals requiring treatment at any given time to have a separate, statewide program. But even in a well-populated State like New Jersey there has been a call for the use of out-of-state services (see Figure 5-3).

Funding Under Managed Care

For people with coexisting disabilities, managed care policies can pose a serious barrier to getting the level of treatment they require. Examples of managed care policies or limitations that could adversely affect clients include

  • Lack of access to Health Maintenance Organizations (HMOs)
  • Being placed on a waiting list by public HMOs
  • Loss of funding due to capitation policies when treatment is required over long time
  • Restrictions on needed ancillary medical or physical care
  • Not being allowed to use accessible treatment options

Poor self-advocacy skills, often coupled with low self-esteem, may impair a person's ability to "push" the system in order to get the care she needs. A case manager may have to either find strategies to overcome the adverse effect the managed care provider's policies have on the client or seek to change those policies through direct communication with the managed care agency. Managed care agencies should be held responsible for the effect of their policies on client outcomes.

For example, some managed care treatment programs use capitation to identify and contain costs for particular disability groups. Due to decreased stamina or other disability issues, some individuals benefit more from a program of lower intensity but longer duration. Preliminary research data indicate that some clients with disabilities may require more extended treatment--from several months to over a year longer--but with no more than standard outpatient intensity (Hser et al., 1988; Drake et al., 1996). For this reason, the treatment provider may find it necessary to document the client's unmet needs and negotiate managed care waivers or special plans to improve chances for a positive outcome.

By documenting and communicating the accommodation needs of people with coexisting disabilities, providers can sometimes persuade state officials to make systemic changes that will benefit these clients, increasing positive outcomes and thereby benefiting their communities as well. For example, in New York State, where everyone applying for public assistance is screened for substance use disorders, 18 million dollars are set aside annually for treatment. Such functional "carve outs" can also be used to address the need people with coexisting disabilities often have for extensive and extended case management services to facilitate their recovery. Treatment providers should have a thorough knowledge of the rights of people with disabilities in order to recognize when managed care policies are discriminatory and not in compliance with the ADA.

Marketing the Program

It is not enough for a program to simply be ready to serve the Disability Community. Rather, the program should be proactive in making the Disability Community aware of its services, to ensure that disability organizations will support referrals to the program. It is hoped that any program that makes a commitment to treat people with coexisting disabilities will be in contact from the outset with a variety of disability organizations in the community. Staff members should be available to present their agency and its willingness to provide services for people with disabilities at the meetings of disability organizations, thereby providing a personal contact for referring staff. Of course, the best advertisements for a program are people with successful treatment outcomes.


Outreach materials should assure potential clients that an agency is able to provide accessible, appropriate substance use disorder treatment for people with coexisting disabilities. In addition to stating that accommodations and alternative communication strategies can be provided as needed, providers may wish to assure people with disabilities that they are welcome by including the universal accessibility symbol on their literature.

There are many facets of an outreach program that can be modified to accommodate the needs of people with coexisting disabilities:

  • Tailor marketing materials, including signage, messages, brochures, and yellow pages advertisements to people with disabilities. Have all such materials state that accommodation is available.
  • If the treatment program is committed to serving persons who are deaf or hard of hearing, have a dedicated line for a TDD, and have that TDD number printed on all outreach materials.
  • Create and use mailing lists of organizations that work with people with disabilities.
  • Conduct specialized presentations and cross-training to organizations that serve people with disabilities.
  • Offer substance use disorder training for the Disability Community at large.
  • Adapt conference exhibits to show the program's accessibility for people with disabilities.
  • Recruit people with disabilities to the board of directors and staff positions.
  • Establish service agreements (e.g., agreements with organizations to provide a learning styles inventory for people with cognitive impairments).
  • Link with particular disability groups for their expertise and to create training opportunities for the treatment staff.
  • Encourage organizations that represent people with disabilities to conduct outreach to a variety of cultural and ethnic communities.

Substance use disorder treatment providers can establish a relationship with a colleague or more experienced clinician who is familiar with the Disability Community to assist in outreach planning. This individual can help interpret unfamiliar terminology for the treatment provider. Since neither party is an expert in the other's field, there is an excellent opportunity for an equitable relationship in which each party learns from the other. Centers for Independent Living are required, for example, to provide information, referral, and advocacy services. However, there are currently no existing mentorship programs or recognition of this need by national organizations. In addition to mentorship, providers can form or participate in an existing network that is disability-specific.

In making an effort to connect with other fields, programs must consider why other providers would want to collaborate. A key motivating factor for other groups of providers is the ADA, because they must also accommodate persons with substance use disorders. What is important is that linkages begin to be developed; it will, of course, take time for these relationships to be perfected.

Considering the high incidence of substance use disorders among people with disabilities, it is extremely important for substance use disorder treatment providers to be aware of this population's needs. Every treatment provider should expect to have clients for whom they will need to make accommodations, but many of these accommodations will not require extensive or expensive changes. Perhaps even more importantly, making accommodations and adapting treatment for people based on their functional limitations should improve treatment outcomes overall and should enable the program to provide better services to all clients. Better outcomes and improved services should result in more referrals and more satisfied customers.

[Back Matter]

Appendix A -- Bibliography

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Patient Placement Criteria for the Treatment of Substance Related Disorders, 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, 1996.

Anthenelli, R.M., and Schuckit, M.A.

Genetics. In: Lowinson, J.H.; Ruiz, P.; and Millman, R.B., eds. Substance Abuse: A Comprehensive Textbook. Baltimore: Williams & Wilkins, 1992. pp. 39-50.

Ashery, R.S.

Case management community advocacy for substance abuse clients. In: Ashery, R.S., ed. Progress and Issues in Case Management. National Institute on Drug Abuse Research Monograph, Number 127. DHHS Pub. No. ADM 92-1946. Rockville, MD: National Institute on Drug Abuse, 1992. pp. 383-394.

Ballew, J.R., and Mink, G.

Case Management in Social Work: Developing the Professional Skills Needed for Work With Multiproblem Clients. Springfield, IL: Charles C. Thomas, 1996.

Barco, P.; Crosson, B.; Bolesta, M., Werts, D.; and Stout, R.

Training awareness and compensation in postacute rehabilitation. In: Kreutzer, J.S., and Wehman, P.H., eds. Cognitive Rehabilitation for Persons With Traumatic Brain Injury: A Functional Approach. Baltimore: P.H. Brookes, 1991. pp. 129-146.

Betts, H.B., and Richmond, J.B.

Disability in America Report. Washington, DC: Institute of Medicine, Centers for Disease Control, and the National Council on Disability, 1991.

Blackwell, L.R.

Going beyond the anger. In: Garretson, M.D., ed. Deafness 1993-2013: A Deaf American Monograph. Vol. 43. Silver Spring, MD: National Association of the Deaf, 1993. pp. 11-14.

Brown, V.B.; Ridgely, M.S.; Pepper, B.; Levine, I.S.; and Ryzlewicz, H.

The dual crisis: Mental illness and substance abuse: Present and future directions. American Psychologist 44(3):565-569, 1989.

Bruckman, B.; Bruckner, V.T.; and Calabrese, C.

Alcohol and Drug Programs and the Americans With Disabilities Act: A Compliance Guide for Privately-Operated Programs. Oakland, CA: Pacific Research and Training Alliance, 1997.

Burgdorf, R.L.

Equal access to public accommodations. In: West, J., ed. The Americans With Disabilities Act. New York: Milbank Memorial Fund, 1991. pp. 183-213.

Buss, A., and Cramer, C.

Incidence of Alcohol Use by People With Disabilities: A Wisconsin Survey of People With Disability. Madison, WI: Office of Persons with Disabilities, 1989.

Cahalan, D.; Cisin, I.H.; and Crossley, H.M.

American Drinking Practices: A National Study of Drinking Behavior and Attitudes. New Haven, CT: College University Press, 1969.

Center for Substance Abuse Treatment.

Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series, Number 9. DHHS Pub. No. (SMA) 94-2078. Washington, DC: U.S. Government Printing Office, 1994.

Center for Substance Abuse Treatment.

Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series, Number 26. DHHS Pub. No. (SMA) 98-3179. Washington, DC: U.S. Government Printing Office, 1998.

Center for Substance Abuse Treatment.

Comprehensive Case Management for Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, Number 27. DHHS Pub. No. (SMA) 98-3222. Washington, DC: U.S. Government Printing Office, 1998.

Corrigan, J.D.

Substance abuse as a mediating factor in outcome from traumatic brain injury. Archives of Physical Medicine and Rehabilitation 76:302-309, 1995.

Corrigan, J.D.; Rust, E.; and Lamb-Hart, G.L.

The nature and extent of substance abuse problems in persons with traumatic brain injury. Journal of Head Trauma Rehabilitation 10(3):29-46, 1995.

DeLoach, C., and Greer, B.G.

Adjustment to Severe Physical Disability: A Metamorphosis. New York: McGraw Hill, 1981.

de Miranda, J., and Cherry, L.

California responds: Changing treatment systems through advocacy for the disabled. Alcohol, Health and Research World 13(2):154-157, 1989.

de Miranda, J.; Kiley, D.; and Gambina, H.

Inform Yourself: Alcohol, Drugs, and Spinal Cord Injury. A Resource Guide for Persons With Spinal Cord Injury and Their Families. San Mateo, CA: Novation, 1992.

Dick, J.E.

"Signing for a high: A study of alcohol and drug use by deaf and hard of hearing adolescents." Ph.D. dissertation, Rutgers University, New Brunswick, 1996.

Drake, R.E.; Mueser, K.T.; Clark, R.E.; and Wallach, M.A.

The course, treatment, and outcome of substance disorder in persons with severe mental illness. American Journal of Orthopsychiatry 66(1): 42-51, 1996.

Drubach, D.A.; Kelly, M.P.; Winslow, M.M.; and Flynn, J.P.G.

Substance abuse as a factor in the causality, severity, and recurrence of traumatic brain injury. Maryland Medical Journal 42(10): 989-993, 1993.

Elmquist, D.L.; Morgan, D.P.; and Bolds, P.K.

Alcohol and other drug use among adolescents with disabilities. International Journal of the Addictions 27(12):1475-1483, 1992.Ford, J.A., and Moore, D.

Substance Abuse Resources and Disability Issues Training Manual. Dayton, OH: Wright State University School of Medicine, 1992.Freeman, A.C.; Ferreyra, N.; and Calabrese, C.

Fostering Recovery for Women with Disabilities: Eliminating Barriers to Substance Abuse Programs. Meeting the Needs of Women with Disabilities: A Blueprint for Change. Oakland, CA: Berkeley Planning Associates, 1997.Frieden, A. L.

Substance abuse and disability: The role of the independent living center. Journal of Applied Rehabilitation Counseling 21(3):33-36, 1990.

Galanter, M., and Kleber, H.

Textbook of Substance Abuse Treatment. Washington, DC: American Psychiatric Press, 1994.

Glover, N.; Janikowski, T.P.; and Benshoff, J.J.

The incidence of incest histories among clients receiving substance abuse treatment. Journal of Counseling and Development 73:475-480, 1995.

Greenwood, W.

Alcoholism: A complicating factor in the rehabilitation of disabled individuals. Journal of Rehabilitation 50(4):51-52, 72, 1984.

Greer, B.G.

Substance abuse among people with disabilities: A problem of too much accessibility. Journal of Rehabilitation 14(1):34-37, 1986.

Guthmann, D.

"An analysis of variables that impact treatment outcomes of chemically dependent deaf and hard of hearing individuals." Ph.D. dissertation, University of Minnesota, Minneapolis, 1996.

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Interactive video for bilingual ASL/English instruction of deaf. American Annals of the Deaf July:209-213, 1989.

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Substance use and receipt of treatment by persons with long-term spinal cord injuries. Archives of Physical Medicine and Rehabilitation 72:482-487, 1991.
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Treatment of alcohol abuse in persons with recent spinal cord injuries. Alcohol Health and Research World 13(2):110-117, 1989.

Heinemann, A.W.; Keen, M.; Donohue, R.; and Schnoll, S.

Alcohol use by persons with recent spinal cord injury. Archives of Physical Medicine and Rehabilitation 69:619-624, 1988.

Helwig, A.A., and Holicky, R..

Substance abuse in persons with disabilities: Treatment considerations. Journal of Counseling and Development 72(2),:227-33, 1994.

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Drug use patterns and risk factors of adolescents with physical disabilities. International Journal of the Addictions 30:1243-1270, 1995.

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Alcohol and drug use among young persons with traumatic brain injury. Journal of Learning Disabilities 29(6):64-51, 1996.

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Functional limitations: A review of their characteristics and vocational impact. Journal of Rehabilitation 59(4):44-50, 1993.

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Minnesota Chemical Dependency Treatment Program for Deaf and Hard of Hearing Individuals.

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"Substance Abuse and persons with disabilities: A significant public health problem." Paper presented at the American Public Health Association. Westin Peachtree Plaza Hotel, Atlanta, GA, November 13, 1991c.

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Alcohol and other substance use/abuse among people with disabilities. Journal of Social Behavior and Personality 2(5):369-382, 1994.

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Substance use among rehabilitation consumers for vocational rehabilitation services. Journal of Rehabilitation 38(2):124-133, 1994.

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Appendix B -- Information Resources

Substance Use Disorder Resources for Persons With Disabilities

The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals

2450 Riverside Avenue
Minneapolis, MN 55454
800-282-DEAF (3323) (voice/TTD)

This program provides inpatient and outpatient substance use disorder treatment services for persons who are deaf or hard of hearing. In addition, the program provides specially developed treatment and prevention materials including a manual of specialized treatment approaches. It provides training about the delivery of substance use disorder services to deaf and hard of hearing persons. The program also receives Federal grant money to provide training opportunities to individuals who work with vocational rehabilitation. The program has a free catalog of materials on substance use disorders that are accessible for individuals who are deaf and hard of hearing.

National Association on Alcohol, Drugs and Disability

2165 Bunker Hill Drive
San Mateo, CA 94402-3801
650-578-8047 (voice/TDD)
650-286-9205 (fax)

The NAADD is a membership organization dedicated to improving prevention and treatment services for people with disabilities. It operates a web site and publishes the newsletter The Report on Alcohol, Drugs and Disability.

New Jersey Coalition on Disabilities and Addiction

c/o Substance Abuse Resources
1806 Highway 35
Oakhurst, NJ 07755
(732) 663-1800 (voice)

National Rehabilitation Hospital

ADA Health Care Facility Access Project
102 Irving Street, NW
Washington, DC 20010-2949
(202) 877-1000 (voice)
(202) 877-1450 (TDD)

Pacific Research and Training Alliance (PRTA)

Alcohol, Drugs and Disability Project
Suite 401
440 Grand Avenue
Oakland, CA 94610-5085
510-465-0547 (voice)
510-465-2888 (TDD)
510-465-0505 (fax)

The PRTA provides technical assistance to all publicly funded substance use disorder programs in California working on disabilities and accessibility. It is working on a statewide project to assist substance abuse prevention, treatment, and recovery service providers in meeting the needs of clients with disabilities. Under this project, the PRTA works with providers from both the disability field and the substance use field. It is also developing a model substance use disorder prevention program for female adolescents with learning or physical disabilities. In addition to the documents PRTA has developed, it has an extensive library of training curricula, articles, research documents, and videotapes. Materials are available to the public.

Pima Prevention Partnership

People with Disabilities Project
Suite 105
300 North Main Street
Tucson, AZ 85701
(520) 623-8871 (voice)
(520) 623-8841 (TDD)
(520) 623-8817 (fax)

Rehabilitation Research and Training Center on Drugs and Disability (RRTC)

Wright State University
School of Medicine
P.O. Box 927
Dayton, Ohio 45401-0927
(513) 259-1384

The RRTC conducts research that focuses on the relationship between substance use disorders and the vocational success of individuals with disabilities. It conducts epidemiological studies, evaluates model systems, and provides training and technical assistance. It is funded by the National Institute of Disability and Rehabilitation Research (NIDRR), the Office of Special Education and Rehabilitative Services (OSERS), and the Department of Education.

SARDI Project: Substance Abuse Resources and Disability Issues

Wright State University
School of Medicine
P.O. Box 927
Dayton, OH 45401
(937) 259-1384 (voice/TTD)
(937) 259-1395 (fax)

The SARDI project provides direct, disability-specific substance use disorder and disability prevention, intervention, and treatment services. SARDI conducts educational training with agency staff to enhance knowledge and awareness of substance use and disability issues. SARDI can provide several resource materials, or refer people to other existing materials. Some of SARDI's resources are listed above in references.

SARDI is also the home of the federally funded Rehabilitation Research and Training Center (RRTC) on Drugs and Disability, funded by NIDRR.

Federal ADA Enforcement Agencies

Architectural and Transportation Barriers Compliance Board: The Access Board

Suite 1000
1331 F Street, NW
Washington, DC 20004-1111
(800) USA-ABLE (voice)
(800) 993-2822 (TTD)
(202) 272-5434 (voice/TTD)
(202) 272-5447 (fax)
(202) 307-5448 (BBS)

An independent Federal agency that developed the ADA Accessibility Guidelines and other architectural accessibility guidelines for the Government, the Access Board enforces UFAS but not ADAAG standards. It provides technical assistance and information on the architectural requirements of the ADA and other access-related legislation, and architectural, communication, and transportation accessibility. The Access Board provides a list of free publications upon request.

Equal Employment Opportunity Commission (EEOC)

1801 L Street, NW
Washington, DC 20507
Complaints and Information
(800) 669-4000 (voice)
(800) 699-6820 (TTD)

Documents/Public Information Center
(800) 669-3362 (voice)
(800) 800-3302 (TTD)
(513) 791-2954 (fax)
(800) 669-4000 (referral to regional offices)

EEOC is responsible for developing and enforcing the ADA employment regulations. It investigates charges of employment discrimination and works to resolve problems through conciliation. The 800 referral number also provides information on discrimination laws in English and Spanish. The EEOC provides free technical assistance publications on request.

Department of Justice (DOJ)

Civil Rights Division
Disability Rights Section
P.O. Box 66738
Washington, DC 20035-6738
(800) 514-0301 (voice)
(202) 514-0301 (voice)
(800) 514-0383 (TTD)
(202) 307-1198 (fax)
(202) 514-6193 (BBS)

Numbers listed are information lines on the ADA and the regulatory process.

The Equal Employment Opportunity Commission and the Department of Justice have jointly produced the Americans With Disabilities Act Handbook. This comprehensive publication provides background, summary, rulemaking history, overview of the regulations, section-by-section analysis of comments and revisions, P.L. 101-336, and annotated regulations of Titles I, II, and III. It includes appendices and related Federal disability laws. One copy is available free upon request from EEOC or DOJ or from the Disability and Business Technical Assistance Centers. Multiple copies can be purchased from:

U.S. Government Printing Office
Superintendent of Documents
Mail Stop: SSOP
Washington, DC 20402-9328
(202) 783-3238 (voice)
(202) 512-1426 (TDD)

Department of Transportation

400 Seventh Street, SW
Washington, DC 20590
Federal Highway Administration:
(202) 366-3764
Federal Transit Administration:

Documents and Questions
(888) 446-4511 (voice)
(202) 366-1656 (voice)
(800) 877-8339 (TTD)
(202) 366-7951 (fax)

Legal Questions
(202) 366-4011 (voice)
(202) 366-3809 (fax)

Complaints and Enforcement
(202) 365-2285 (voice)
(202) 366-0153 (TTD)

The Department of Transportation developed and continues to enforce the regulations to implement the transportation requirements of the ADA. It provides, upon request, information on the Title II and Title III requirements for public and specified private transportation, and publishes the Paratransit Handbook.

Federal Communications Commission (FCC)

Office of Public Affairs
Suite 1000
1919 M Street, NW
Washington, DC 20554

Documents and Questions
(202) 418-0190 (voice)
(202) 418-2555 (TTD)

Legal Questions
(202) 418-2357 (voice)
(202) 418-0484 (TTD)

Complaints and Enforcement
(202) 632-7553 (voice)
(202) 418-0485 (TTD)

FCC developed and continues to enforce the regulations to implement the Title IV telecommunications requirements, such as those requiring relay services. It provides technical assistance and produces publications (available in print only).

Federal and Federally Funded ADA Technical Assistance Agencies

Administration of Developmental Disabilities

370 L'Enfant Promenade, SW
Washington, DC 20447
(202) 690-6590

Clearinghouse on Disability Information

OSERS/U.S. Department of Education
Room 3132, Switzer Building
330 C Street, SW
Washington, DC 20202
(202) 205-5465 (voice)
(202) 732-1252 (fax)

Job Accommodation Network (JAN)

West Virginia University
P.O. Box 6080
Morgantown, WV 26506-6080
ADA Information
(800) ADA-WORK (voice/TDD)

Accommodation Information
(800) 526-7234 (voice/TDD)
(304) 293-5407 (fax)
(800) DIAL-JAN (Computer Bulletin Board System)

A service of the President's Committee on Employment of People with Disabilities, JAN is an international, free consulting service that can provide information about job accommodation for people with disabilities. It helps solve specific job accommodation problems through its toll-free hotline.

Library of Congress National Library Service for the Blind and Physically Handicapped

1291 Taylor Street, NW
Washington, DC 20542
(800) 424-9100

MRI/Penn Research and Training Center on Vocational Rehabilitation And Mental Illness

Matrix Research Institute
University of Pennsylvania Department of Psychiatry
6008 Wayne Avenue
Philadelphia, PA 19144
(215) 438-8200

National Institute on Disability and Rehabilitation Research

U.S. Department of Education
Room 3060
330 C Street, SW
Washington, D.C. 20202
(202) 205-8134

National Institute on Neurological Disorders and Stroke

Building 31, Room 8A06
31 Center Drive, MSC 2540
Bethesda, MD 20892-2540
(301) 496-5751 (voice)
(800) 325-9424 (voice)
(301) 402-2186 (fax)

National Research and Training Center on Psychiatric Disability

University of IllinoisBChicago
Suite 900
104 South Michigan Avenue
Chicago, IL 60603-5901
(312) 422-8180

President's Committee on Employment of People With Disabilities

3rd floor
1331 F Street, NW
Washington, DC 20004-1107
(202) 376-6200 (voice)
(202) 376-6205 (TDD)
(202) 376-6219 (fax)

The President's Committee on Employment of People with Disabilities is a nationwide organization of 600 volunteer members that works to build and maintain a climate of acceptance of people with disabilities in the work force. It can assist in locating State governors' committees and local mayoral committees that address disability issues. It produces technical assistance materials, including videotapes, public service announcements, and fact sheets, and provides information on job accommodation, assistive technology, tax incentives, and other topics. A list of publications can be obtained by calling the above numbers.

Rehabilitation Research and Training Center for Persons Who Are Deaf or Hard of Hearing

University of Arkansas
4601 West Markham Street
Little Rock, AR 72205
(501) 686-9691

Rehabilitation Research and Training Center on Blindness and Low Vision

Mississippi State University
P.O. Drawer 6189
Mississippi State, MS 39762
(601) 325-2001

Rehabilitation Services Administration

U.S. Department of Education
Switzer Building
330 C Street, SW
Washington, D.C. 20202-2500
(202) 205-5482

Research and Training Center on Rehabilitation for Persons With Long-Term Mental Illness

Boston University/Sargent College
Center for Psychiatric Rehabilitation
930 Commonwealth Avenue
Boston, MA 02215
(617) 353-3549

Research and Training Center on Community Integration of Individuals With Traumatic Brain Injury

Mount Sinai School of Medicine
One Gustave L. Levy Place, Box 1240
New York, NY 10029-6574
(212) 241-7917

Research and Training Center on Community Living

University of Minnesota
College of Education and Human Development
Institute on Community Integration
RTC on Residential Services and Community Living
150 Pillsbury Drive, SE
Minneapolis, MN 55455
(612) 624-5005

Research and Training Center on Improving Community-Based Rehabilitation Programs

University of WisconsinBStout
College of Human Development
Stout Vocational Rehabilitation Institute
Menomonie, WI 54751
(715) 232-1219

Research and Training Center on Improving the Functioning of Families Who Have Members With Disabilities

University of Kansas
Beach Center on Families and Disability
3111 Haworth Hall
Lawrence, KS 66045
(913) 864-7600

Research and Training Center on Independent Living for Underserved Populations

University of Kansas
4089 Dole Building
Lawrence, KS 66045
(913) 864-0575

Research and Training Center on Rural Rehabilitation Services

University of Montana
Rural Institute on Disabilities
52 Corbin Hall
Missoula, MT 59812
(406) 243-5467

Other General Disability Resources


P.O. Box 458
Mill Valley, CA 94942
(415) 388-3250

The Accreditation Council

Suite 406
100 West Road
Towson, MD 21204-2331
(410) 583-0060
(410) 583-0063 (fax)

This organization works to promote and measure quality services for people with disabilities and performs accreditation reviews for agencies that work with people with disabilities.

American Association of People With Disabilities

Suite 330
1819 H Street, NW
Washington, DC 20006
(800) 840-8844 (voice)
(202) 457-0473 (fax)

American Association of Retired Persons Disability Initiative

601 E Street, NW
Washington, DC 20049
(800) 424-3410 (voice)

American Medical Rehabilitation Providers Association (AMRPA)

3rd floor
1606 20th Street, NW
Washington, DC 20009
(888) 346-4624
(202) 833-9168 (fax)

Association on Higher Education and Disability

P.O. Box 21192
Columbus, OH 43221-0192
(614) 488-4972 (voice)
(614) 488-1174 (fax)

This organization is comprised of most student disability offices in higher education. It can assist with identifying disability services at nearby community colleges and universities.

Centers for Independent Living (CILs)

Centers for Independent Living is a national network of more than 200 community-based service and advocacy programs run by people with disabilities. If you are unable to find a Center for Independent Living in your phone book, contact any of the following for assistance in locating one near you:

  • Your State vocational rehabilitation agency
  • National Council on Independent Living

Suite 209
1916 Wilson Boulevard
Arlington, VA 22201
(703) 525-3406 (voice)
(703) 525-4153 (TDD)
(703) 525-3409 (fax)

  • Independent Living Research Utilization Center

Suite 100
2323 South Shepherd
Houston, TX 77019
(713) 520-0232 (voice)
(713) 520-5136 (TDD)
(713) 520-5785 (fax)

Consortium for Citizens With Disabilities

Suite 1212
1730 K Street, NW
Washington, DC 20006
(202) 785-3388 (voice)
(202) 467-4179 (fax)

Health Web

Internet Resource
Independent Living for the Handicapped
1301 Belmont Street, NW
Washington, DC 20009
(202) 797-9803

Mainstream, Inc.

Suite 830
3 Bethesda Metro Center
Bethesda, MD 20814
(301) 654-2400 (voice/TDD)
(301) 654-2403 (fax)

National Alliance of the Disabled

1352 Sioux Street
Orange Park, FL 32065

The NAOTD is an online informational and advocacy organization working toward equal rights for people with disabilities.

National Association of Developmental Disabilities Councils

Suite 103
1234 Massachusetts Avenue, NW
Washington, DC 20005
(202) 347-1234 (voice)
(202) 347-4023 (fax)

National Clearinghouse of Rehabilitation Training Materials

816 West 6th Street
Oklahoma State University
5202 Richmond Hill Drive
Stillwater, OK 74078-4080
(800) 223-5219 (voice)
(405) 624-0695 (fax)

This organization is an excellent resource for training materials in disability areas.

National Easter Seal Society

Suite 1800
230 West Monroe Street
Chicago, IL 60606
(312) 726-6200 (voice)
(312) 726-4258 (TDD)
(312) 726-1494 (fax)

This organization provides technical assistance and referral to employers and individuals with disabilities on such topics as assistive technology, vocational training, and rehabilitation.

National Information Center for Children and Youth With Disabilities

8th floor
1875 Connecticut Avenue, NW
Washington, DC 20009
(202) 884-8200
(202) 884-8441 (fax)

National Institute on Life Planning For Persons With Disabilities

Administrative Office
P.O. Box 5093
Twin Falls, ID 833-5093
(208) 735-8556 (voice)
(208) 735-8562 (fax)

National Organization on Disability

Suite 600
910 16th Street, NW
Washington, DC 20006
(202) 293-5960
(202) 293-7999 (fax)

National Rehabilitation Information Center

Suite 935
8455 Colesville Road
Silver Spring, MD 20910
(800) 346-2742
(301) 495-5626 (TTD)
(301) 587-1967 (fax)

Rehabilitation Accreditation Commission

4891 East Grand Road
Tucson, AZ 85712
(520) 325-1044 (voice/TDD)
(520) 318-1129 (fax)

The Rehabilitation Accreditation Commission promotes quality services for people with disabilities by establishing and using standards of quality for such services.

Rehabilitation Institute of Chicago

345 East Superior Street
Chicago, IL 60611
(312) 908-6066 (voice)

Society for the Advancement of Travel for the Handicapped

Suite 610
347 Fifth Avenue
New York, NY 10016
(212) 447-7284

World Institute on Disability

Suite 100
510 16th Street
Oakland, CA 94612-1500
(510) 763-4100 (voice)
(510) 208-9496 (TTD)
(510) 763-4109 (fax)

Disability-Specific Service Resources

American Deafness and Rehabilitation Association (ADARA)

P.O. Box 6956
San Mateo, CA 94403
(650) 372-0620 (voice/TTD)
(650) 372-0661 (fax)

The ADARA is the largest national organization for professionals who work with persons who are deaf and hard of hearing. It provides information and referral, and networking and holds biennial conferences in topics related to substance use disorders, mental health, vocation rehabilitation, job coaching, education, and interpreting.

American Foundation for the Blind

Suite 300
11 Penn Plaza
New York, NY 10001
(800) 232-5463 (voice)
(212) 620-2158 (TDD)
(212) 727-7418 (fax)
(800) 829-0500 (product information)

This organization provides information and referral on adaptive and assistive technology for people who are blind or visually impaired.

American Printing House for the Blind

1839 Frankfurt Avenue
Louisville, KY 40206
(502) 895-2405 (voice)
(502) 899-2274 (fax)
(800) 223-1839 (Customer Service)

This organization provides Braille and large print books (including textbooks), computer voice synthesis hardware and software, computer-related materials on disk, and instructional aids.

Association of Late Deafened Adults, Inc.

Suite 274
10310 Main Street
Fairfax, VA 22030
(404) 289-1596 (TTD)
(404) 284-6862 (fax)

The Arc (formerly Association for Retarded Citizens)

Suite 300
500 East Border Street
Arlington, TX 76010
(817) 261-6003 (voice)
(817) 277-0553 (TDD)
(817) 277-3491 (fax)

The Arc aids the employment of people with mental retardation or developmental disability and publishes resource materials.

Brain Injury Association

105 North Alfred Street
Alexandria, VA 22314
(703) 236-6000 (voice)
(703) 236-6001 (fax)

Children and Adults With ADD

Suite 101
499 Northwest 10th Avenue
Plantation, FL 33317
(800) 233-4050
(954) 587-4599 (fax)

Learning Disabilities Association of America

4156 Library Road
Pittsburgh, PA 15234-1349
(412) 341-1515
(412) 344-0224 (fax)

The Learning Disabilities Association of America is a national, nonprofit, volunteer organization dedicated to enhancing the quality of life for all people with learning disorders and their families. It is an advocacy organization that conducts education, research, and service.

National Association of the Deaf

814 Thayer Avenue
Silver Spring, MD 20910-4500
(301) 587-1788 (voice)
(301) 587-1789 (TTD)
(301) 587-1791 (fax)

The National Association of the Deaf provides information and referral on deafness and accommodations for people who are deaf. It has local chapters in each State.

National Center for Learning Disabilities, Inc.

Suite 1401
381 Park Avenue South
New York, NY 10016
(212) 545-7510
(888) 575-7373

National Information Center on Deafness

Galludet University
800 Florida Avenue, NE
Washington, DC 20002-3695
202-651-5051 (voice)
202-651-5054 (fax)

National Organization for Rare Disorders

P.O. Box 8923
New Fairfield, CT 06812-8923
(203) 246-6518 (voice)
(800) 999-6673 (voice)
(203) 746-6481 (fax)

A disease is considered rare if it affects fewer than 200,000 people in the United States; over 5,000 different disorders fall into this category. The NORD provides information and referrals for people with these lesser known diseases.

National Spinal Cord Injury Hotline

Kernan Hospital
2200 Kernan Drive
Baltimore, MD 21207
(800) 526-3456

Paralyzed Veterans of America

801 18th Street, NW
Washington, D.C. 20006
(202) 872-1300

Rehabilitation Research and Training Center on Severe Traumatic Brain Injury

1314 West Main Street
Richmond, VA 23284-2011
(804) 828-1851 (voice)

Stroke Clubs International

805 12th Street
Galveston, TX 77550
(409) 762-1022

Substance and Alcohol Intervention Services for the Deaf (SAISD)

Rochester Institute of Technology
National Technical Institute for the Deaf
115 Lomb Memorial Drive
Rochester, NY 14623-5608
(716) 475-4978 (voice/TDD)

This center publishes the National Directory of Prevention and Treatment Programs Accessible to the Deaf, a comprehensive directory of substance use disorder programs for people who are deaf. The 1998 edition is available electronically on SAISD's website. Printed copies of the 1995 directory can be obtained through the Rochester Institute of Technology's bookstore at (716) 475-2501.

The University of California Center On Deafness (UCCD)

Suite 10
3333 California Street
San Francisco, CA 94143-1208
(415) 476-4980 (voice)
(415) 476-7600 (TDD)

The UCCD is a research and training center focusing on deafness and mental health. They have a variety of materials, including training videos for substance use disorder treatment providers entitled "Meeting the Challenge: Working with Deaf People in Recovery," and "I Can: Stories of Deaf and Hard of Hearing People in Recovery."

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