Appendix C -- How To Refer to People
The terms in the following list are the preferred words used to portray
people with disabilities in a positive manner. This list is adapted from
Guidelines for Reporting and Writing about People with Disabilities
from the Research and Training Center on Independent Living (Research
and Training Center on Independent Living, 1996). With a few modifications
the text is the same as in the Guidelines.
- AIDS. Acquired immunodeficiency syndrome, an infectious disease
resulting in the loss of the body's immune system to ward off infections.
The disease is caused by the human immunodeficiency virus (HIV). A person
can test positive for HIV without displaying the symptoms of any illnesses,
which usually develop up to 10 years later. Preferred: people living
with HIV, people with AIDS, or living with AIDS.
- Adventitious disability. A disability acquired after birth.
The time of onset of a disability may result in or be affected by a
substance use disorder.
- Blind. A condition in which a person has a loss of vision for
ordinary life purposes. Visually impaired is the generic term
used by some individuals to refer to all degrees of vision loss. Use
boy who is blind, girl who is visually impaired, or man
who has low vision.
- Brain injury. A condition where there is long-term or temporary
disruption in brain function resulting from injury to the brain. Difficulties
with the cognitive, physical, emotional, or social functioning may occur.
Use person with a brain injury, woman who has sustained brain injury,
or boy with an acquired brain injury. It is also referred
to as traumatic brain injury.
- Congenital disability. A disability that has existed since
birth but is not necessarily hereditary. The term birth defect is inappropriate.
- Deaf. A profound degree of hearing loss that prevents understanding
speech aurally. Hard of hearing refers to mild and moderate hearing
loss that may or may not be corrected with amplification. The Deaf Community
is a group of people with shared experiences and values, for whom American
Sign Language is often a first language and the language of choice.
- Developmental disability. Any mental or physical disability
starting before the age of 22 and continuing indefinitely. It limits
one or more major life activities such as self-care, language, learning,
mobility, self-direction, independent living, and economic self-sufficiency.
This category includes individuals with mental retardation, cerebral
palsy, autism, epilepsy (and other seizure disorders), sensory impairments,
congenital disabilities, traumatic injuries, and conditions caused by
disease (polio, muscular dystrophy, etc.), and it may be the result
of multiple disabilities. People often use this terminology to refer
to a person with mental retardation.
- Disfigurement. Physical changes caused by burn, trauma, disease,
or congenital problems.
- Down Syndrome. A chromosome disorder which usually causes a
delay in physical, intellectual, and language development and often
results in mental retardation. Mongol or mongoloid are
- Handicap. A condition or barrier imposed by society, the environment,
or by one's own self. Handicap is synonymous with barrier
and not a synonym for disability. Some individuals prefer inaccessible
or not accessible to describe social and environmental barriers.
Handicap can be used when citing laws and situations, but should not
be used to describe a disability. Do not refer to people with disabilities
as the handicapped or handicapped people. Say, the
building is not accessible for a wheelchair-user. The stairs are a handicap
- Learning disability. A permanent condition that affects the
way individuals with average or above-average intelligence take in,
retain, and express information. Some groups prefer specific learning
disability, because it emphasizes that only certain learning processes
are affected. Do not say slow learner, retarded, etc.
Use person with a learning disability.
- Mental disability. The Federal Rehabilitation Act (Section
504) lists four categories under mental disability: psychiatric disability,
retardation, learning disability, or cognitive impairment.
- Mental retardation. Substantial intellectual delay which requires
environmental or personal supports to live independently. Mental retardation
is manifested by below average intellectual functioning in two or more
life areas (work, education, daily living, etc.) and is present before
the age of 18. Preferred: people with mental retardation. Mental
retardation is commonly referred to as a developmental disability.
- Nondisabled. Appropriate term for people without disabilities.
Normal, able-bodied, healthy, or whole are inappropriate
because they imply that people who are disabled are not these things.
- Psychiatric disability. Acceptable terms are people with
psychiatric disabilities, psychiatric illnesses, emotional disorders,
or mental disabilities. The following terms are pejorative:
crazy, maniac, lunatic, demented and psycho. Psychotic,
schizophrenic, neurotic, and other specific terms should be used
only in proper context and should be checked carefully for medical and
- Seizure. An involuntary muscular contraction, a brief impairment
or loss of consciousness, etc., resulting from a neurological condition
such as epilepsy or from an acquired brain injury. Rather than epileptic,
use girl with epilepsy or boy with a seizure disorder.
The term convulsion should be used only for seizures involving
contractions of the entire body. Fit is a pejorative term.
- Small/short stature. Adults under 4'10". Use persons of
small (or short) stature. Do not refer to people as dwarfs or
midgets. Dwarfism is an accepted medical term, but it
should not be used as general terminology. Some groups prefer little
people. However, that implies a less than full, adult status in
- Spastic. A muscle with sudden abnormal and involuntary spasm.
It is not an appropriate term for describing someone with cerebral palsy
or a neurological disorder. Muscles are spastic, not people.
- Speech disorder. A condition in which a person has limited
or difficult speech patterns. Use child who has a speech disorder.
For a person with no verbal speech capability, use woman without
speech. Do not use mute or dumb.
- Spinal cord injury. A condition in which there has been permanent
damage to the spinal cord. Quadriplegia denotes substantial or
total loss of function in all four extremities. Paraplegia refers
to substantial or total loss of function in the lower part of the body
only. Say man with paraplegia, woman who is paralyzed, or
person with a physical disability.
- Stroke. An interruption of blood to brain. Hemiplegia (paralysis
on one side) may result. Stroke survivor is preferred over
- Substance dependence. Patterns of use that result in significant
impairment in at least three life areas (family, employment, health,
etc.) over any 12-month period. Substance dependence is generally characterized
by impaired control over consumption, preoccupation with the substance,
and denial of impairment in life areas. Substance dependence may include
physiological dependence (tolerance, withdrawal). Although such terms
as alcoholic and addict are medically acceptable, they
may be pejorative to some individuals. Acceptable terms are people
who are substance dependent or people who are alcohol dependent.
Individuals who are substance dependent and currently abstaining from
substances are considered to be in recovery.
Appendix D -- Alcohol and Drug Programs and
The Americans With Disabilities Act
by Bill Bruckman, Victoria Thornton Bruckner, and Christine Calabrese
This appendix reproduces in full the compliance guide published by Pacific
Research and Training Alliance and has been reprinted with the permission
of the authors and publisher.
The Alcohol, Drug, and Disability Technical Assistance
Pacific Research and Training Alliance's Alcohol and Drug and Disability
Technical Assistance Project is one of ten projects funded by the California
Department of Alcohol and Drug Programs (ADP) for underserved populations.
The Project provides assistance statewide to programs and communities
that will have long lasting impact and permanently improve the quality
of alcohol and other drug services available to individuals with disabilities.
Pacific Research and Training Alliance (PRTA) was founded in 1990. PRTA
promotes community-driven approaches to eliminate social barriers so that
every person has the opportunity to participate fully in society. Other
PRTA Projects include the Lesbian, Gay, Bisexual, and Transgender Technical
Assistance Project, also funded by California ADP, and Living Out Loud,
a substance abuse prevention project for at-risk girls, funded by the
federal Center on Substance Abuse Prevention.
440 Grand Avenue, Suite 401, Oakland, CA 94610-5085Voice:
(510) 465-0547 * TDD (510) 465-2888 * FAX (510) 465-0505_ Copyright
1996, Pacific Research and Training Alliance
This document is largely based upon the United States Department of
Justice ADA Technical Assistance Manual, a compliance guide for generic
public accommodations. Other public documents quoted in this publication
are the U.S. Department of Justice ADA Handbook and ADA Title III Fact
Sheet. Publications developed by the Resource Center on Substance Abuse
Prevention and Disability in Washington, D.C., are also quoted herein.
Individuals who contributed to the development of this publication include
Nancy Ferreyra of Pacific Research and Training Alliance, David Abramson
of the Alameda County Department of Behavioral Care Alcohol and Drug Division,
and Guy Thomas of the Berkeley Center for Independent Living.
The requirements of the ADA are subject to various and possibly contradictory
interpretations. The editors, therefore, used their reasonable professional
efforts and judgments to interpret the Act and official U.S. Department
of Justice technical assistance documents as they apply to alcohol and
drug programs. The contents of this publication are presented with no
warranty either expressed or implied, and Pacific Research and Training
Alliance and the editors assume no legal responsibility for the information
contained herein. Neither is liability assumed for the outcome of decisions,
contracts, commitments or obligations made on the basis of this publication.
All alcohol and drug program names used in this document are fictitious--any
resemblance to actual alcohol and drug program names is purely coincidental.
Who This Publication Is For and Why It Has Been
This guide is written for owners, administrators, and staff of private
alcohol and drug treatment programs. Private alcohol and drug treatment
programs are any programs which are not directly operated by government
agencies (i.e. ADP, county or city governments). They include both non-profit
and for-profit programs. They also include programs that contract and
receive funds from ADP or local governments.
The purpose of this manual is to help you understand the process of coming
into compliance with The Americans With Disabilities Act so that your
program can become accessible to persons with disabilities.
What Is the ADA?
The Americans With Disabilities Act of 1990 is the first federal law
initiated and championed by persons with disabilities. Unlike prior laws
and regulations, the ADA puts the onus of accommodation on society rather
than the individual with a disability.
The ADA guarantees equal opportunity for individuals with disabilities
in public and private sector services and in employment. It is a comprehensive
anti-discrimination law which extends to virtually all sectors of society
and every aspect of daily living. The ADA is a federal civil rights act
which provides the same basic civil rights protections to persons with
disabilities as afforded all other Americans.
The ADA is organized into five titles.
- Title I: Employment--Employers with 15 or more employees must
ensure that their employment practices do not discriminate against qualified
people with disabilities. (In California, this applies to employers
who have 5 or more employees.) Title I provides protection for job applicants
and employees during all phases of employment, including the application
process, interviewing, hiring, employment itself, and discharge from
employment. Employers must also reasonably accommodate the disabilities
of qualified applicants and employees, unless an undue hardship would
- Title II: State and local government services--Requires that
public programs and services be made accessible to persons with disabilities.
Mandates nondiscrimination on the basis of disability in policy, practice
and procedure. Prescribes a self-evaluation process, and requires that
architectural and communications barriers be removed to the extent required
to provide full access to program services.
- Title III: Public accommodations--Title III requires places
of public accommodation to be accessible to, and usable by, people with
disabilities. Places of public accommodation are all private businesses
and privately owned and operated programs that offer goods and services
to the general public. Title III entities must not discriminate by excluding
people with disabilities, treating them separately, or requiring them
to participate in separate programs. Reasonable modifications must be
made to policies, practices, and procedures so that people with disabilities
may participate. Auxiliary aids and services that ensure effective communication
with people with disabilities must also be provided so long as they
do not create an undue burden or fundamentally alter the services that
the program offers.
- New construction must be barrier free. In existing buildings, architectural
barriers to disability access must be removed when it is readily achievable.
"Readily achievable" means "easily accomplishable and able to be carried
out without much difficulty or expense." Programs must review possible
readily achievable barrier removal on an ongoing basis, typically annually
or with each new program budget.
- Title IV: Telecommunications--Title IV has mandated the establishment
of a national network of telecommunication relay services that is accessible
to people who have hearing and speech disabilities. It also requires
captioning of all federally funded television public service announcements.
- Title V: Nonretaliation, and other provisions--Title V explicitly
prohibits retaliation against people exercising their rights under the
ADA. It sets forth specific responsibilities for the adoption of enforcement
regulations by federal agencies. It also includes a number of miscellaneous
The ADA includes a set of architectural standards called the Americans
With Disabilities Act Accessibility Guidelines (ADAAG). All Title
II and Title III entities must comply with ADAAG requirements for new
construction and alteration building projects. In California, public and
private building projects must also comply with state accessibility regulations
(Title 24). Title 24 has recently been revised to incorporate specifications
found in the ADAAG. The Equal Employment Opportunity Commission and the
U.S. Department of Justice have been designated as the lead ADA enforcement
agencies. The Architectural and Transportation Barriers Compliance Board
develops accessibility guidelines (architectural standards) for enforcement
of the Act.
Who Is an Individual With a Disability?
The ADA has established the following definition of disability:
An individual with a disability is a person who has a physical or
mental impairment that substantially limits one or more "major life activities,"
has a record of such an impairment, or is regarded as having such an impairment.1
Major life activities are essential functions such as personal care tasks,
manual tasks, walking, seeing, hearing, speaking, breathing, thinking,
learning, and working.
In 1990, 43 million persons living in the United States were counted
as eligible for protection under the ADA.2
Still more Americans will become either temporarily or permanently disabled
during their lifetimes and will claim their rights under the Act. It has
been estimated that today, nearly 17 percent of the populace of California
has a disability as defined by the ADA.
Of special importance to privately operated drug treatment programs is
the following excerpt from the Department of Justice ADA Title III
Technical Assistance Manual:
Title III prohibits discrimination against drug addicts based solely
on the fact that they previously illegally used controlled substances.
Protected individuals include persons who have successfully completed
a supervised drug rehabilitation program or have otherwise been rehabilitated
successfully and who are not engaging in current illegal use of drugs.
Additionally, discrimination is prohibited against an individual who is
currently participating in a supervised rehabilitation program and is
not engaging in current illegal use of drugs. Finally, a person who is
erroneously regarded as engaging in current illegal use of drugs is protected.3
It should be noted, however, that drug testing is permitted under Title
III and that individuals who engage in the illegal use of drugs are not
protected by the ADA when an action is taken on the basis of their current
illegal use of drugs. (See sections titled, "Can we refuse services to
individuals currently engaging in illegal use of drugs?" and "Is drug
What Does the ADA Require of Privately Operated
Alcohol and Drug Programs?
Alcohol and drug programs operated by private agencies (whether or not
they receive Federal, State, or local funding) are considered places of
public accommodation under the ADA and are therefore subject to Title
III requirements. The remainder of this manual discusses the requirements
of Title III of the ADA in detail so that providers can gain understanding
of how to comply with Title III.
The Civil Rights Division of the U.S. Department of Justice has provided
the following overview of the responsibilities of Title III entities.
Under the ADA, a privately operated alcohol or drug program must:
- Provide services to people with disabilities in an integrated setting,
unless separate or different measures are necessary to ensure equal
- Eliminate unnecessary eligibility standards or rules that deny individuals
with disabilities an equal opportunity to enjoy the activities, benefits,
and services of alcohol and drug programs.
- Make reasonable modifications in policies, practices, and procedures
that deny equal access to individuals with disabilities, unless a fundamental
alteration in the nature of the program would result.
- Furnish auxiliary aids when necessary to ensure effective communication,
unless an undue burden or fundamental alteration would result.
- Remove architectural and structural communication barriers in existing
facilities where readily achievable.
- Provide ... alternative ... [means of delivering services] when removal
of barriers is not readily achievable.
- Provide equivalent transportation services and purchase accessible
vehicles in certain circumstances. [If the program provides transportation
to its clients, equivalent accessible transportation for clients with
disabilities must be provided.]
- Maintain accessible features of facilities and equipment.
- Design and construct new facilities and, when undertaking alterations,
alter existing facilities in accordance with the Americans With Disabilities
Act Accessibility Guidelines issued by the Architectural and Transportation
Barriers Compliance Board and incorporated in the final Department of
Justice Title III regulation.4
Four Steps Toward ADA Compliance:
Privately operated alcohol and drug programs must take action to overcome
four fundamental groups of barriers in order to comply with ADA requirements
and provide people with disabilities an equal opportunity to benefit from
services. They are as follows:
- Attitudinal barriers
- Discriminatory policies, practices, and procedures
- Communication barriers
- Architectural barriers
The remainder of this booklet will elaborate upon actions to take to
facilitate the removal of these four groups of barriers.
Step One: Changing Attitudes That Prevent Access
to Alcohol and Drug Programs for Persons With Disabilities
An attitudinal barrier to substance abuse intervention and treatment
can be defined as a way of thinking or feeling that results in limiting
the potential of people with disabilities to function independently within
society and to be "treatable" and recognized as wanting help with their
substance abuse problems.5
How Important Is Disability Related Training for
Alcohol and Drug Staff?
There are many unique issues in the provision of alcohol and drug rehabilitation
services to persons with disabilities.
In order to make ADA compliance efforts truly successful, alcohol and
drug program staff must have the skills and the willingness to respond
to the needs of clients with disabilities. Staff training is key to overcoming
attitudinal barriers that prevent people with disabilities from receiving
equally effective alcohol and drug treatment services.
Disability-awareness training should include efforts to ensure that staff
members: 1) overcome their fears and stereotyping of people with disabilities;
2) learn the rights of people with disabilities and the responsibilities
of alcohol and drug programs under the ADA; and 3) develop skills and
resources to provide equally effective services to people with disabilities.
People with disabilities who are familiar with the ADA and alcohol and
drug programs can provide the best initial training for alcohol and drug
program staff. Pacific Research and Training Alliance (PRTA) is one organization
that provides such specialized services. Your local independent living
center should also be an excellent resource for meeting persons with disabilities
who can provide pertinent training and technical assistance. Ongoing training
of new staff can include the use of videos. "J.R.'s Story" is a video
that elaborates on many of the unique issues faced by a client with a
disability who eventually seeks chemical dependency treatment. Contact
PRTA regarding training services, for a list of independent living centers
in California, and for information on how to borrow or purchase this and
Negative myths about disability tend to lessen opportunities for people
with and without disabilities to have social contact with each other.
It is crucial that providers who attend disability awareness training
have the opportunity to meet and ask questions of people with a wide variety
of disabilities, especially people with disabilities who are in recovery.
Panel discussions often provide the best opportunity for this dialogue
and serve as a possible springboard for further contact and cooperation.
High quality disability awareness training should be led by facilitators
who have the skills to create an environment in which people feel free
to discuss the fears that they have and the stereotypes that they still
may hold. Pacific Research and Training Alliance can supply an appropriately
trained consultant with extensive experience in delivering disability
awareness training to audiences of alcohol and other drug (AOD) providers
In addition, fact sheets about issues related to substance use and abuse
by people with various disabilities are available from the Resource Center
for Substance Abuse Prevention and Disability in Washington, D.C. These
fact sheets compare myths and facts about people with many types of disabilities
and discuss strategies for overcoming attitudinal barriers that prevent
people with disabilities from accessing AOD services. They also discuss
some of the typical reasonable accommodations for many disabilities. Pacific
Research and Training Alliance (PRTA) can furnish information about how
to order these fact sheets. PRTA has also developed many other educational
materials and curricula on the subject of disability and chemical dependency.
All of these written materials are an invaluable addition to any disability
awareness training. They include many references and resources for further
reading that is important for both program administrators and staff.
How Serious Is the Problem of AOD Abuse Among People
Persons with disabilities currently seek alcohol and drug services in
small numbers, yet they are at a higher risk for alcohol and drug addiction.
Studies have shown that alcohol and drug abuse rates for people with disabilities
may range from 15 to 30 percent of all persons with disabilities; rates
for people with certain disabilities such as spinal cord and head injury
exceed 50 percent.6
People without disabilities commonly do not think of people with disabilities
as having chemical dependency problems. However, these problems are widespread,
and if ignored, they worsen.
There are many reasons why people with disabilities do not avail themselves
of alcohol and drug treatment services. These range from individual difficulties
such as lack of social skills or chronic pain to societal problems such
as lack of targeted outreach, lack of transportation, and inaccessible
facilities. Many of these problems can be resolved during the alcohol
and drug program's initial ADA compliance effort. Other issues can be
addressed by working closely with each individual with a disability and
with disability advocacy organizations.
Do We Have To Comply With the ADA Even If We Have
Never Served a Person Who Is Disabled?
The intention of the ADA is to bring people with disabilities into the
mainstream of American society. The ADA requires that individual agencies
make their programs accessible and it is the clear responsibility of alcohol
and drug programs to seek out clients with disabilities.
The following actions have proved effective in creating a client base
of people with disabilities:
- Institute an ongoing campaign to publicize your program to people
with disabilities. Send disability-specific program information to local
advocacy agencies for persons with disabilities, including the Department
of Rehabilitation, campus disabled student services offices, independent
living centers, and rehabilitation hospitals and clinics.
Also include advocacy groups for parents of children with disabilities,
and advocacy organizations for people with specific disabilities, such
as arthritis, cerebral palsy, multiple sclerosis, muscular dystrophy,
and vision and hearing disabilities. Don't forget your local mental
health association, and local veterans and seniors groups. Your local
United Way may be able to help you to locate these organizations. Wherever
possible, develop outreach materials in formats which are accessible
to people with disabilities, such as in large print, on audiocassette,
or on computer disk. Also arrange for any outreach videos to be captioned
for people with hearing impairments.
- Establish links with organizations in your community that provide
advocacy and services to people with disabilities, such as independent
living centers. Invite their representatives to speak at staff meetings
and send your staff to speak at their events.
- Actively seek qualified persons with disabilities when searching for
advisory board members.
- Actively seek qualified persons with disabilities when hiring new
- Develop prevention and treatment services that target specific populations
of persons with disabilities. Some possibilities include the following:
- Providing some initial information or counseling services in disability-specific
EXAMPLE 1: Arrange to give a talk or facilitate a rap group
on alcohol and drug issues at an independent living center or a
EXAMPLE 2: Offer drop-in peer counseling on alcohol and drug
issues at an accessible community center. Air radio public service
announcements about this service and send written announcements
about this peer counseling to independent living centers and other
disability advocacy groups.
- Working with local Alcoholics Anonymous and Narcotics Anonymous
groups to make meetings accessible.
EXAMPLE 1: Help locate resources to fund sign language interpreting
at a local AA meeting.
EXAMPLE 2: Assist a local NA group to find an accessible meeting
Step Two: Revising Policies, Practices, and Procedures
To Ensure Access
Access for people with disabilities is often thought of in terms of physical
access to the built environment. Most people understand the need for ramps,
curb cuts, and parking spaces for people with disabilities. What many
do not consider are the nonphysical barriers to people with disabilities--policies,
practices, and procedures that discriminate or tend to discriminate on
the basis of disability. We can't see these "administrative barriers"
but they have as much impact on people with disabilities as physical ones.
The ADA sets forth a substantial number of requirements to protect people
with disabilities from administrative barriers. It is necessary for alcohol
and drug programs to review existing policies, practices, and procedures
and adopt new ones in order to avoid discrimination and ensure compliance
with ADA Title III requirements. The administrative review should be performed
by the program director or another individual who is thoroughly familiar
with the program and has the authority to effect policy changes.
The following section is intended to answer questions that you may have
about specific policies, practices, and procedures relevant to alcohol
and drug program operation.
Admitting People With Disabilities Into Your Program
Discriminating against people with disabilities often occurs during first
contact. Therefore, an important first step is to review admissions policies,
practices, and procedures. Drug and alcohol program admissions includes
recruitment, referral, screening, and intake of clients with disabilities--everything
that occurs prior to receipt of services or participation in the program.
May We Refuse To Admit People With Disabilities?
Programs may not refuse to admit people solely based upon disability.
Blanket policies, practices, and procedures that prohibit the participation
of people with disabilities are discriminatory.
May We Decide To Restrict the Participation of People
With Certain Disabilities?
No. Alcohol and drug programs should not presume that an individual or
class of individuals with a disability can or cannot participate in any
aspect of a program. An important step in ensuring nondiscrimination on
the basis of disability is to establish procedures by which each individual
is evaluated based upon his or her unique needs and abilities.
Even if architectural or communications barriers seemingly prevent program
access for people with certain disabilities, the program must give each
individual with a disability an opportunity to determine for him- or herself
whether he or she can function within the program's constraints.
EXAMPLE: A program, named Awake, has no funds to hire staff with
special training in communicating with people who have had strokes. The
program cannot, however, refuse to admit people with severe speech impairments
caused by a stroke based upon this constraint. An individual with a severe
speech impairment caused by a stroke must be apprised of the program's
limitations, and other programs seemingly more suited to his or her needs
may be suggested, but the individual can still opt to participate in the
Can We Limit the Number or Proportion of People
With Disabilities Admitted to Our Program?
No. Quotas are prohibited under the ADA.
EXAMPLE: A program cannot limit the number of deaf persons that it
serves in a given year based upon the desire to limit sign language interpreting
If architectural, financial, or other constraints limit the number of
people with disabilities that a program can serve at any given time, the
program must make every effort to ensure that individuals with disabilities
are provided with other options for services such as a referral to a comparable
program. The individual with a disability should be apprised of all
options and his or her preference for placement must be given primary
EXAMPLE: A residential recovery program has only one wheelchair-accessible
bedroom that is currently occupied. A person who uses a wheelchair but
can walk short distances may opt to enter the program immediately even
though the wheelchair-accessible bedroom is not available. A person who
is quadriplegic may, however, require a referral to an alternate accessible
What If a Person's Disability Makes Him or Her Unable
To Meet Our Eligibility Requirements?
Alcohol and drug programs may require that people with disabilities meet
essential eligibility criteria in order to participate in programs and
services, and they may refuse services to individuals with disabilities
who cannot meet these admission requirements. Programs must, however,
demonstrate that these requirements are essential and that no person
with a disability is unnecessarily excluded or limited from participation
in programs and services.
Essential requirements are those requirements that are fundamental to
the nature of a program or activity.
EXAMPLE 1: A program cannot require that clients present a valid
driver's license in order to receive services because the ability to drive
is not essential to alcohol and drug recovery. Other forms of identification,
such as a social security card or birth certificate, should be accepted
in lieu of a driver's license.EXAMPLE 2: A methadone maintenance
program is approached by a blind woman who is a crack cocaine user. The
woman has no history of using heroin or other opiates. The program may
deny her its services because they are specifically designed for heroin
users. The program should refer her to other treatment services for crack
The Department of Justice does not consider it discriminatory for a program
with a specialty in a particular area to refer an individual with a disability
to a different program if:
- The individual is seeking a service or treatment outside the referring
program's area of expertise; and
- The program would make a similar referral for an individual who does
not have a disability.7 For
example, a private agency provides recovery meetings for Latino immigrants.
A person who uses a wheelchair but is not a Latino immigrant asks to
attend the meetings. The agency may refer the individual to another
agency that provides accessible meetings.
May We Require Further Information or Documentation
From Persons With Certain Disabilities?
Programs cannot require that people with certain disabilities provide
information not required of other applicants. Eligibility for participation
may not be determined based upon disability unless the program or service
is specifically designated for people with disabilities.
EXAMPLE: A program cannot require that an applicant with HIV provide
medical records or disclose health information that is not required of
What Is "Illegal Use of Drugs"?
According to the Department of Justice, "illegal use of drugs means the
use of one or more drugs, the possession or distribution of which is unlawful
under the Controlled Substances Act. It does not include use of controlled
substances pursuant to a valid prescription or other uses that are authorized
by the Controlled Substances Act or other federal law. Alcohol is not
a controlled substance, but alcoholism is a disability."8
What Is "Current Use"?
The Department of Justice defines current use as "the illegal use of
controlled substances that occurred recently enough to justify a reasonable
belief that a person's drug use is current or that continuing use is a
real and ongoing problem. Therefore, a private entity should review carefully
all the facts surrounding its belief that an individual is currently taking
illegal drugs to ensure that its belief is a reasonable one."9
Can We Refuse Services to Individuals Currently
Engaging in Illegal Use of Drugs?
The Department of Justice offers the following guidance in regard to
the illegal use of drugs by those seeking drug rehabilitation services:
Drug addiction is an impairment under the ADA. A public accommodation
generally, however, may base a decision to withhold services or benefits
in most cases on the fact that an addict is engaged in the current and
illegal use of drugs.Although individuals currently using illegal
drugs are not protected from discrimination, the ADA does prohibit denial
of health services, or services provided in connection with drug rehabilitation,
to an individual on the basis of current illegal use of drugs, if the
individual is otherwise entitled to such services.Because abstention
from the [illegal] use of drugs is an essential condition for participation
in some drug rehabilitation programs, and may be a necessary requirement
in inpatient or residential settings, a drug rehabilitation or treatment
program may deny participation to individuals who use drugs [illegally]
while they are in the program.10EXAMPLE:
It would be inappropriate for a crack cocaine detoxification program to
refuse to admit an individual because she is illegally using crack cocaine.
A residential alcohol and drug treatment program may, however, expel an
individual for illegal use of drugs in its treatment center.
Is Drug Testing Permitted Under the ADA?
Yes. The Department of Justice has indicated that, "public accommodations
may utilize reasonable policies or procedures, including but not limited
to drug testing, designed to ensure that an individual who formerly engaged
in the illegal use of drugs is not now engaging in current illegal use
of drugs."11 It is important
not to discriminate against those who appropriately use medications. Sometimes
individuals who are appropriately using prescription medications will
test positive, even if they have not been using drugs illegally, because
the drug test is not sensitive enough to discriminate between different
types of drugs.
Can We Refuse to Serve an Individual Whose Disability
Poses a Direct Threat to the Health and Safety of Others?
One of the rare instances when a program may deny participation in activities
to a person based upon disability is when the individual's disability
legitimately presents a direct threat to the health or safety of others
that cannot be eliminated or reduced to an acceptable level by reasonable
changes to policies, practices, or procedures or by the provision of auxiliary
aids and services. The program must establish that the perceived threat
is real and not based upon preconceptions or unwarranted fears about the
individual's disability. Assessments must consider both the particular
activity and the actual abilities and disabilities of the individual.
The Department of Justice gives the following guidance for direct threat
assessment: The individual assessment must be based on reasonable judgment
that relies on current medical evidence, or on the best available objective
evidence, to determine
- The nature, duration, and severity of the risk
- The probability that a potential injury will actually occur
- Whether reasonable modifications of policies, practices, or procedures
will mitigate or eliminate the risk
Such an inquiry is essential to protect individuals with disabilities
from discrimination based on prejudice, stereotypes, or unfounded fear,
while giving appropriate weight to legitimate concerns, such as the need
to avoid exposing others to significant health and safety risks. Making
this assessment will not usually require the services of a physician.
Sources for medical knowledge include public health authorities, such
as the U.S. Public Health Service, the Centers for Disease Control, and
the National Institutes of Health, including the National Institute of
EXAMPLE 1: A program may not refuse to admit an individual because
he or she is infected with HIV. HIV is not a direct threat to the health
and safety of other program participants because it cannot be transmitted
through casual contact.EXAMPLE 2: A program may refuse to admit
an individual with a contagious form of tuberculosis if the program finds
that it cannot reasonably provide other clients adequate protection from
the disease.EXAMPLE 3: A man with a traumatic brain injury who
is often loud and aggressive may not be denied admission to a program
because of staff or participants' fears that he may exhibit violent behavior.
However, if he recently placed others at risk during a violent outburst,
the program may place behavioral limits on his admission or participation
in specific activities, as long as those limits are the same as those
expected of other applicants or participants.
When Can We Ask About Disability?
Inquiries regarding disability made prior to acceptance into an alcohol
or drug program are generally unnecessary and should not be made. Once
a person has been accepted into the program, necessary inquiries can be
made regarding special accommodations that an individual may need. Application
forms, consent forms, and other documents where such inquiries are made
should be reviewed and revised accordingly.
EXAMPLE 1: A residential perinatal program should not require that
a woman fill out an application form that asks about additional medical
conditions until she has been admitted to the program.EXAMPLE
2: A residential recovery program for persons who are HIV-positive may
inquire as to the history of a person's alcoholism and ask for an HIV-positive
test result prior to admission because having both disabilities is a prerequisite
for participation.EXAMPLE 3: During an intake interview, program
staff cannot ask applicants questions about how they acquired their disabilities
or why they use mobility aids such as wheelchairs.
What Questions Can We Ask About Disability?
Necessary inquiries about disability are questions asked in order to
provide services, not deny them. This includes questions asked to provide
program modifications, auxiliary aids and services, health care, or emergency
services to the client; questions asked to assess the client's conformance
with legitimate health and safety requirements, and questions asked for
some other essential purpose. Unnecessary inquiries about disability include
questions asked to screen out the participation of people with disabilities,
to satisfy one's curiosity, or to discriminate in the provision of treatment,
health care, emergency services, etc. They are in direct violation of
the ADA. Alcohol and drug programs should adopt policies and procedures
to ensure that written and verbal inquiries about disability are limited
to necessary ones.
While alcohol and drug programs cannot require that clients disclose
information about disability, they may give clients an opportunity to
voluntarily provide information about disability. This is especially true
if the intention is to use information about disability in order to accommodate
Is Information About a Client's Disability Confidential?
Yes. Programs should have a written policy and procedure in place to
ensure that records pertaining to a client's disability are kept confidential
and not used in a discriminatory fashion.
To What Extent Must We Modify Our Policies, Practices
or Procedures for Individuals With Disabilities?
The ADA requires that privately operated alcohol and drug programs make
reasonable modifications to policies, practices, or procedures when required
to ensure equal opportunity and avoid discrimination against people with
disabilities. Reasonable modification means any modification that does
not fundamentally alter the nature of the services provided. In this way,
the burden of accommodation is placed upon the program, not the client.
Clients should, however, be consulted as to the modifications they need
to successfully participate in the program.
EXAMPLE 1: A residential social model treatment program which has
a "drug-free" policy for its residents must modify that policy to allow
for the appropriate use of prescribed medications in order to avoid discriminating
against a qualified applicant who has to inject himself daily with insulin
because he has diabetes. The program would also have to allow a qualified
applicant with epilepsy to take appropriately prescribed antiseizure medications
according to her doctor's instructions.The barbiturate Phenobarbital
has occasionally been prescribed to control seizures. If an applicant
took Phenobarbital as prescribed, the program could not refuse
to admit her for this reason. Program administrators and staff might appropriately
accommodate her by modifying the program's drugfree policy and
establishing additional security procedures so that her medication would
not be misused or fall into the hands of other participants.EXAMPLE
2: A methadone treatment facility requires that clients pass a urine screening
just prior to receipt of medication. Clients must urinate in the presence
of program staff to ensure the validity of the test. It would not be reasonable
for the program to waive the drug screening requirement for a person with
a disability even if that person's disability prevented him from providing
urine samples on demand. Alternative methods of screening would need to
be provided as a reasonable accommodation.
When Is It Appropriate To Place Persons With Disabilities
in Separate Programs Designed Especially for Them?
The primary emphasis of alcohol and drug service providers in serving
persons with disabilities must be integration into regular programs. However,
the ADA does not prohibit the establishment of target programs to serve
communities of persons with disabilities, such as a residential treatment
facility for persons who are deaf.
Nevertheless, individuals with disabilities cannot be excluded from regular
programs or required to accept special services or benefits simply because
special or target programs are available.13
EXAMPLE: A county has established a special residential facility
for persons with traumatic brain injuries and alcohol or drug addictions.
The county may offer this separate program in order to meet the unique
cognitive and environmental needs of persons with traumatic brain injuries
in recovery. The county cannot, however, require that persons with traumatic
brain injuries participate in this special program or refuse to admit
them to regular programs because of their disability.
Can Persons With Disabilities Refuse Special Services
and Choose Instead To Participate in Regular Programs?
Yes. Persons with disabilities are entitled to participate in regular
programs whether or not alcohol and drug program personnel believe that
they can benefit from regular services. The existence of special programs
does not relieve alcohol and drug programs of their obligation to provide
reasonable modifications and auxiliary aids and services to individuals
choosing to participate in the regular program.14
EXAMPLE: A residential facility called Transitions is located in
a rural setting and residents perform farm labor as part of the treatment
program. A wheelchair user named Joe applies to Transitions. Program staff
advise him that a rigorous physical routine is a fundamental part of the
Transitions program. They suggest an alternate program that offers special
services for persons with mobility disabilities.Joe chooses to
join the Transitions program despite the availability of a special program
suited to his disability. He believes that he can negotiate the terrain
of the Transitions facility and do some of the required physical labor
with limited program modifications.Transitions may limit the
extent of modifications provided to Joe because of the availability of
an appropriate separate program, but they cannot refuse to admit Joe.
Transitions must still reasonably accommodate Joe, including providing
transportation for Joe if transportation is provided for other clients,
but they need not make extraordinary modifications, such as the purchase
of costly specialized farming equipment. They may also modify Joe's chore
schedule, with input from Joe regarding which chores he is able to perform.
Is Our Program Required To Cover the Cost of Personal
Equipment and Attendant Services?
While a public accommodation is required to provide auxiliary aids for
effective communications (such as telecommunications devices for deaf
persons) and reasonable personal assistance to persons with disabilities
(such as help with filling out an application form), it is not required
to provide equipment or services of a personal nature such as wheelchairs,
prescription eyeglasses, hearing aids, or assistance in eating, toileting,
Can We Charge People With Disabilities for the Extra
Costs of Providing Services to Them?
No. ADA compliance measures may result in an additional cost for serving
clients with disabilities. Alcohol and drug programs may raise the fee
for all clients but they may not place a surcharge on particular individuals
with disabilities or groups of individuals with disabilities to cover
EXAMPLES: A methadone program is located on the second floor of an
older four-story building that does not have an elevator. Because the
director has determined that providing physical access to the program
for those unable to climb stairs would not be readily achievable, she
has chosen to provide home services as a readily achievable alternative
to barrier removal. A medical technician will visit clients' homes to
perform urine tests and give injections, and counselors will provide services
to clients by phone. The program may not charge individuals who receive
home care for the additional cost of providing services to them.16
Can We Prohibit Smoking?
Yes. The Department of Justice has indicated that public accommodations
such as alcohol and drug programs "may prohibit smoking, or may impose
restrictions on smoking, at their facilities."17
Must We Allow the Use of Service Animals in Our
Yes. Alcohol and drug programs must allow a service animal (such as a
guide, hearing or companion dog) to accompany a person with a disability
for all services except when doing so would fundamentally alter the particular
activity or jeopardize the safe operation of the program. (See section
titled "Limitations and Alternatives" below.)
It is the responsibility of the animal's owner to feed, walk, and care
for the service animal in any other way.
EXAMPLE: An individual who is blind wishes to be accompanied by his
guide dog to an alcohol and drug program orientation session. The alcohol
and drug program must permit the guide dog to accompany its owner in all
areas of the facility open to other clients, and may not insist that the
dog be separated from him at any time. Furthermore, the client may not
be charged a deposit as a condition for permitting the service animal
into the program's facility.18
The ADA Protects People With Disabilities and Their
Allies From Retaliation or Coercion
Alcohol and drug programs may not take any retaliatory action against
persons who exercise their rights under the ADA or individuals who assist
others in exercising their rights. This prohibits the suspension or termination
of employees for advising persons with disabilities of their right to
reasonable modifications and auxiliary aids and services in the program.19
Step Three: Understanding Is Everything--Overcoming
The ADA requires alcohol and drug programs to ensure that communications
with people with disabilities are as effective as communications with
others. Communications conducted by alcohol and drug programs include
outreach, education, prevention efforts, intake interviews, group meetings,
counseling sessions, telephone and mail communications, and provision
of medical services. Communication barrier removal is especially important
for people who are deaf or have hearing, speech, visual, and learning
What Are Auxiliary Aids and Services?
In many cases, ensuring effective communication entails the provision
of auxiliary aids and services--a wide range of practices and equipment
that allow people with disabilities to communicate and access information.
The type of auxiliary aid or service necessary to ensure effective communication
will vary in accordance with the nature and duration of the communication
and the individual person's preference and ability to use a particular
aid or service.20 The Department
of Justice gives the following examples of auxiliary aids and services:
Auxiliary aids and services for individuals who are deaf or hard
of hearing include qualified interpreters, notetakers, computer-aided
transcription services, written materials, telephone handset amplifiers,
assistive listening systems, telephones compatible with hearing aids,
closed caption decoders, open and closed captioning, telecommunications
devices for deaf persons (TDDs), videotext displays, and exchange of written
notes.Examples for individuals with vision impairments include
qualified readers, taped texts, audio recordings, Brailled materials,
large print materials, and assistance in locating items.Examples
for individuals with speech impairments include TDDs, computer terminals,
speech synthesizers, and communication boards.21
What Range of Auxiliary Aids and Services Must We
Public accommodations such as alcohol and drug programs should be prepared
to provide the widest variety of auxiliary aids and services possible
to people with disabilities. The ADA suggests that individuals with disabilities
be given the opportunity to request the auxiliary aids and services of
their choice and that primary consideration be given to the choice expressed
by the individual.
It is important to consult with the individual to determine the most
appropriate auxiliary aid or service, because the individual with a disability
is most familiar with his or her disability and is in the best position
to determine what type of aid or service will be effective. For example,
some individuals who were deaf at birth or who lost their hearing before
acquiring language use sign language as their primary form of communication.
They may be uncomfortable or not proficient with written English. This
makes use of a notepad an ineffective method of communication with them.
Some individuals who lose their hearing later in life, however, may not
be skilled in sign language and can communicate most effectively through
The Department of Justice states that, while consultation is strongly
encouraged, the final decision as to what measures to take to ensure effective
communication rests in the hands of the alcohol and drug program, provided
that the method chosen results in effective communication.22
When Must We Provide Auxiliary Aids and Services?
If needed to ensure effective communication, auxiliary aids and services
must be provided at all phases of a client's participation in an AOD program.
This would include application, intake, counseling, group meetings and
all social activities. It would extend to followup contact after the client
has left the program, if this service is usually provided.
Limitations and Alternatives (Claiming Fundamental
Alteration Or Undue Burden)
The ADA does not require privately operated alcohol and drug programs
to provide any auxiliary aids and services that would fundamentally alter
the nature of the programs and services they offer or result in an undue
What Is a Fundamental Alteration?
A fundamental alteration as defined by the Department of Justice is "a
modification that is so significant that it alters the essential nature
of the goods, services, facilities, privileges, advantages, or accommodations
What Is an Undue Burden?
Undue burden is defined as "significant difficulty or expense." The Department
of Justice advises programs to consider the following factors in determining
whether an action would result in an undue burden:
- The nature and cost of the action;
- The overall financial resources of the site or sites involved; the
number of persons employed at the site; the effect on expenses and resources;
legitimate safety requirements necessary for safe operation, including
crime prevention measures; or any other impact of the action on the
operation of the site;
- The geographic separateness, and the administrative or fiscal relationship
of the site or sites in question to any parent corporation or entity;
- If applicable, the overall financial resources of any parent corporation
or entity; the overall size of the parent corporation or entity with
respect to the number of its employees; the number, type, and location
of its facilities; and
- If applicable, the type of operation or operations of any parent corporation
or entity, including the composition, structure, and functions of the
workforce of the parent corporation or entity.24
Any program that cannot provide an accommodation because of fundamental
alteration or undue burden concerns should make every effort to provide
an equally effective alternative accommodation. The program should carefully
document the entire process and be prepared to substantiate their claim
of fundamental alteration or undue burden in a court of law.
EXAMPLE: An individual who is deaf requests that a sign language
interpreter be provided at all times while he is participating in a day
treatment program. The program operates on a small budget and cannot afford
to hire an interpreter for frequent and extended periods of time. The
program has tried and failed to find volunteer interpreters. The program
determines that it would be an undue financial burden to provide professional
interpreting services for all aspects of services but resolves to provide
an interpreter for weekly counseling sessions and all group meetings.
Furthermore, the program welcomes the client to bring a friend or relative
to interpret for him at other times and makes a computer terminal available
for typed communications between the deaf client and program staff.
Who Is Qualified To Provide Sign-Language Interpreting
A program must ensure that any interpreter it hires or otherwise provides
is qualified. There are a number of sign languages used. (The most common
methods of communication are American Sign Language and signed English.)
Individuals who use one form of sign language may not communicate effectively
through an interpreter who uses a different one. A qualified interpreter
is an interpreter who is able to sign to the individual who is deaf what
is being said by the hearing person and who can voice to the hearing person
what is being signed by the individual who is deaf. This communication
must be conveyed effectively, accurately, and impartially through the
use of any necessary specialized vocabulary, and in the type of sign language
the deaf person uses.25
How Do We Make Telephone Communications Accessible?
If your program has frequent or extensive telephone communications with
clients and members of the general public, a telecommunications device
for the deaf (TDD) makes telephone communications accessible to individuals
who are deaf, hard-of-hearing, or speech impaired. A TDD allows individuals
to communicate over regular telephone lines through text rather than voice.
Often, a continuous tone or a series of beeps will be heard when an individual
calls from a TDD. This is the signal to place the phone receiver in your
TDD machine and begin text communication. You may consider installing
a separate telephone line for TDD calls to eliminate confusion when receiving
a TDD signal over the regular telephone line. If you do provide a separate
TDD phone line, that number should be listed wherever you advertise the
number for regular telephone service.
In California, individuals who use a TDD may communicate with agencies
without a TDD through a service called the California Relay Service, 1-800-735-2922
(voice) and 1-800-735-2929 (TDD). An operator acts as an intermediary,
reading to the agency staff what the TDD caller is typing and typing to
the TDD caller what the agency staff is saying. Until your program obtains
a TDD, it should use the relay service to call clients who have TDDs.
Program staff should be advised that some individuals will use the relay
service to call even if you have a TDD. These calls should always be accepted.
What About Outgoing Calls by Clients, Patients,
The Department of Justice advises that "TDDs must be provided when customers,
clients, patients, or participants are permitted to make outgoing calls
on more than an incidental convenience basis. For example, TDDs must be
made available on request ... where in-room phone service is provided."26
If calls come to the front desk before they are transferred to clients'
rooms, the front desk should also be equipped with a TDD so that clients
using TDDs in their rooms have the same access to in-house services as
How Do We Make Print, Audiocassette, Videos, and
Other Materials Accessible?
Communication barriers also appear when programs attempt to send outreach
materials to people with disabilities. If advertising, prevention, or
other materials are not available in a format that is appropriate for
a person with a disability, then programs should make that material available
in an appropriate alternative format. Alternative formats include but
are not limited to the following:
- Print materials may be made available to blind or visually impaired
individuals in audiotape, large print, computer disk, Braille or raised
- Print materials may be made available to people with limited upper
body use in computer disk format.
- Videotapes may be made available to deaf or hard-of-hearing individuals
in captioned format (with subtitles).
- Audiotapes may be made available to deaf or hard-of-hearing individuals
in print format.
How Can We Make Advertisements Accessible?
If your program advertises its services, then such advertisements should
be made in a sufficient variety of formats to ensure access to people
with disabilities. For example, radio advertisements are not accessible
to the deaf and newspaper advertisements are not readily accessible to
the blind. Only with a combination of the two would both communities be
reached. In addition, programs should make an effort to contact those
media resources that are frequently used by the disability community.
Designing and Selecting Outreach, Prevention, and
Programs should include the following in all outreach, prevention, and
other materials that they produce:
- A statement of the program's responsibilities under the ADA and its
commitment to provide effective communication to people with disabilities.
- A description of the accommodations and resources that the program
has available for people with disabilities.
No new or existing outreach, prevention, or other material produced
by the program should contain any discriminatory language or representation
of people with disabilities. Programs should also take steps to ensure
that no material produced by others, but distributed by the program,
contains any discriminatory language or representation of people with
It may be an unwieldy task for a program to review each of the materials
that it currently distributes. As an alternative, programs may choose
to establish a procedure by which persons can file a complaint if they
find any material to be discriminatory against people with disabilities.
A complaint review procedure should be established. Remedies may include
discontinuing use of the material or removing the discriminatory portion
of the material.
When selecting or designing new materials, PRTA recommends that programs
should make an effort to find or produce materials that contain positive
representations of people with disabilities. In addition, an appropriate
number of materials should address issues specific to disability. For
example, you may include a video that addresses the issue of deafness
and alcohol use in your video library. PRTA suggests that an "appropriate
number" of materials should address disability-related issues. Since over
15 percent of California's population are people with disabilities we
recommend that at least 15 percent of your program's materials address
the needs of this population.
How Do We Make Open Meetings And Other Public Events
The following are minimum guidelines for holding an accessible meeting
or other public event:
- Make invitations, flyers, and other announcements available in alternative
formats upon request. Conduct outreach to persons with known disabilities
in an appropriate format.
- Include clip-and-return form and phone numbers on announcements that
allow persons with disabilities to contact your program in advance and
request accommodations such as large-print handouts or sign-language
- Hold public events at a wheelchair-accessible location. At a minimum,
these sites should have wheelchair-accessible parking, entrances, paths
of travel, seating, toilet facilities, and public phones.
- If possible, secure a sign language interpreter for the event. Otherwise,
provide notice in your advertisements that a sign language interpreter
will be available if requested 72 hours in advance.
- If possible, make written handout materials readily available in the
following common alternative formats: large print, computer disk, and
- Place refreshments and handout materials in an accessible location.
Step Four: It Doesn't Have To Cost Much!--Physical
Access Can Be Readily Achieved
Under the ADA, privately operated alcohol and drug programs should remove
architectural (or physical) barriers to program areas in existing facilities
where it is readily achievable to do so. Readily achievable is
defined by the Department of Justice as "easily accomplishable and able
to be carried out without much difficulty or expense." New construction
and alteration requirements are much more stringent than the readily achievable
barrier removal standard for existing facilities. When undertaking a new
construction or alteration project, privately operated alcohol and drug
programs in California must comply with the Americans With Disabilities
Act Accessibility Guidelines (ADAAG) and state accessibility regulations
Title III allows that barriers be removed slowly, over time, as it becomes
readily achievable to do so. According to Title III, programs should have
removed all those barriers they readily could by January 26, 1992. Over
time, programs are obligated to take stock of barriers that remain and
to evaluate what resources they have, so that they can determine which
additional barriers can be removed.
Because the California Department of Alcohol and Drug Programs (DADP)
and each county has its own obligations under the ADA and the Rehabilitation
Act of 1973, the state and counties may hold AOD programs they fund to
a higher standard of access than readily achievable. The state and counties
are likely to require that all publicly funded alcohol and drug programs
with 15 or more employees achieve programmatic access. This means
that physical barriers to programs and services must be removed whether
or not it is readily achievable to do so. Agencies with several facilities
may be allowed to make only one facility accessible per this higher standard
if each facility provides essentially the same program (same modality
and target population) and the facilities are located within the same
general geographic area.
Programs with fewer than 15 employees may be required to refer persons
with disabilities to essentially equivalent accessible programs within
their service group. If no such equivalent accessible program is available,
publicly funded programs with fewer than 15 employees will most likely
be required to achieve programmatic access. Your county alcohol and drug
program administrator or DADP ADA coordinator can help you determine what
is currently required of your program.
In addition, PRTA recommends that programs should have a long-term plan
to achieve programmatic access whether or not immediately required by
ADAAG or California Title 24 regulations are often used as the standard
to survey a facility. Once the survey is complete, a program can narrow
the scope of renovation depending upon the level of access immediately
required--readily achievable or programmatic access.
Programs that have not already done so should perform a survey of their
facilities to identify physical barriers to programs and services. The
survey should be performed by a person who is thoroughly familiar with
physical access standards and the operation of alcohol and drug programs.
This is important because the surveyor should be able to identify and
prioritize physical barriers to program access--not just identify ADAAG
or Title 24 violations in general. A surveyor who understands the nature
of a program can suggest cost-efficient solutions and alternatives to
physical barrier removal. The Department of Justice also advises that
this process should include consultation with individuals with disabilities
or organizations representing them. They may provide useful guidance identifying
the most significant barriers to remove and the most efficient means of
removing them. "A serious effort at self-assessment and consultation can
diminish the threat of litigation and save resources by identifying the
most efficient means of providing required access." 27
Depending upon the program, barriers that prevent access to toilet and
shower facilities, bedrooms, meeting areas, dining rooms, counseling offices,
medical offices, and other essential program areas would be considered
programmatic barriers. Programmatic barriers often also include stairs,
narrow doorways, and lack of accessible features such as disabled-accessible
parking spaces, toilet stalls, sinks, showers, pay telephones, and drinking
Certain architectural features such as bathrooms and meeting rooms must
be made accessible. In many cases, however, alternative measures to barrier
removal can narrow the scope of renovation required while providing equivalent
program access for persons with disabilities.
EXAMPLE: A program normally performs intake off-site at an inaccessible
facility. An alternative to a costly renovation project would be to conduct
intake of applicants with disabilities at an alternate accessible location.
This may sound very complicated on paper, but in most cases barrier removal
is a common sense issue. Becoming familiar with the ADA Title III physical
access requirements is an important first step toward undertaking a barrier
The following readily achievable barrier removal guidelines are quoted
directly from the Department of Justice ADA Title III Technical Assistance
Manual unless otherwise specified in the References section of this
What Is an Architectural Barrier?
Architectural barriers are physical elements of a facility that impede
access by people with disabilities. These barriers include more than obvious
impediments such as steps and curbs that prevent access by people who
In many facilities, telephones, drinking fountains, mirrors, and paper
towel dispensers are mounted at a height that makes them inaccessible
to people using wheelchairs. Conventional doorknobs and operating controls
may impede access by people who have limited manual dexterity. Deep-pile
carpeting on floors and unpaved exterior ground surfaces often are a barrier
to access by people who use wheelchairs and people who use other mobility
aids, such as crutches. Impediments caused by the location of temporary
or movable structures, such as furniture, equipment, and display racks,
are also considered architectural barriers.28
What Is a Facility?
The term "facility" includes all or any part of a building, structure,
equipment, vehicle, site (including roads, walks, passageways, and parking
lots), or other real or personal property. Both permanent and temporary
facilities are subject to the barrier removal requirements."29
What Architectural Standards Apply to Alcohol and
Drug Programs in California?
Measures taken to remove barriers should comply with the Department of
Justice's ADA Accessibility Guidelines (ADAAG) and California Accessibility
Regulations (Title 24). Deviations from ADAAG and Title 24 are acceptable
only when full compliance with those requirements is not readily achievable.
In such cases, barrier removal measures may be taken that do not fully
comply with the standards, so long as the measures do not pose a significant
risk to the health or safety of individuals with disabilities or others.30
How Does the Readily Achievable Standard Relate
to the ADA Standards for New Constructions And Alterations?
The ADA establishes different standards for architectural barrier removal
from existing facilities than from facilities undergoing a new construction
or alteration project. In existing facilities, where retrofitting may
be expensive, the requirement to provide access is less stringent than
it is in new construction and alterations, where accessibility can be
incorporated in the initial stages of design and construction, often without
a significant increase in cost.
The readily achievable standard also requires a lesser degree of effort
on the part of alcohol and drug programs than the "undue burden" limitation
on the auxiliary aids requirements of the ADA. In that sense, it can be
characterized as a lower standard.31
Also see section titled "Limitations and alternatives".
What Barriers Are Readily Achievable to Remove?
There is no definitive answer to this question, because determinations
as to which barriers can be removed without much difficulty or expense
must be made on a case-by-case basis.
The Department of Justice's regulation contains a list of 20 examples
of modifications that may be readily achievable:
- Installing ramps;
- Making curb cuts in sidewalks and entrances;
- Repositioning shelves;
- Rearranging tables, chairs, vending machines, display racks, and other
- Repositioning telephones;
- Adding raised markings on elevator control buttons;
- Installing flashing alarm lights;
- Widening doors;
- Installing offset hinges to widen doorways;
- Eliminating a turnstile or providing an alternative accessible path;
- Installing accessible door hardware;
- Rearranging toilet partitions to increase maneuvering space;
- Insulating lavatory pipes under sinks to prevent burns;
- Installing a raised toilet seat;
- Installing a full-length bathroom mirror;
- Repositioning the paper towel dispenser in a bathroom;
- Creating designated accessible parking spaces;
- Installing an accessible paper cup dispenser at an existing inaccessible
- Removing high pile, low density carpeting; or
- Installing vehicle hand controls.
The list is intended to be illustrative. Each of these modifications
will be readily achievable in many instances, but not in all. Whether
or not any of these measures pertain to your program or are readily achievable
is to be determined on a case-by-case basis in light of the particular
circumstances presented and the factors discussed above.32
How Do We Determine When Barrier Removal Is Readily
Determining if barrier removal is readily achievable is necessarily a
case-by-case judgment. Factors to consider include:
- The nature and cost of the action;
- The overall financial resources of the site or sites involved; the
number of persons employed at the site; the effect on expenses and resources;
legitimate safety requirements necessary for safe operation, including
crime prevention measures; or any other impact of the action on the
operation of the site;
- The geographic separateness, and the administrative or fiscal relationship
of the site or sites in question to any parent corporation or entity;
- If applicable, the overall financial resources of any parent corporation
or entity; the overall size of the parent corporation or entity with
respect to the number of its employees; the number type, and location
of its facilities; and
- If applicable, the type of operation or operations of any parent corporation
or entity, including the composition, structure, and functions of the
workforce of the parent corporation or entity.
If the [alcohol and drug program] is a facility that is owned or operated
by a parent entity that conducts operations at many different sites, the
... [alcohol and drug program] must consider the resources of both the
local facility and the parent entity to determine if removal of
a particular barrier is "readily achievable." The administrative and fiscal
relationship between the local facility and the parent entity must also
be considered in evaluating what resources are available for any particular
act of barrier removal.33
Does the ADA Permit an Alcohol And Drug Program
To Consider the Effect of a Modification on the Operation of Its Business?
Yes. The ADA permits consideration of factors other than the initial
cost of the physical removal of a barrier.34
EXAMPLE: A residential drug treatment program with 24 beds that has
only one wheelchair accessible sleeping room is considering making another
sleeping room accessible. After an appropriate access survey and consultation
it is determined that the only way to make the room in question accessible
would be to move the partition between it and an adjacent sleeping room,
which has four beds. However, moving the partition to create accessible
space would mean that the program would lose two of the four beds in the
adjacent room. The effect of the net loss of two beds on the program's
operation can be considered in the process of determining whether moving
the partition would be readily achievable.
What Are the Priorities for Barrier Removal?
The Department [of Justice's] regulation recommends priorities for removing
barriers in existing facilities. Because the resources available for barrier
removal may not be adequate to remove all existing barriers at any given
time, the regulation suggests a way to determine which barriers should
be mitigated or eliminated first. The purpose of these priorities is to
"facilitate long-term ... planning and to maximize the degree of effective
access that will result from any given level of expenditure. These priorities
are not mandatory.... [Programs] are free to exercise discretion in determining
the most effective "mix" of barrier removal measures to undertake in their
The regulation suggests that "... [an alcohol and drug program's] first
priority should be to enable individuals with disabilities to physically
enter its facility." This priority on "getting through the door" recognizes
that providing physical access to a facility from public sidewalks, public
transportation, or parking is generally preferable to any alternative
arrangements in terms of both business efficiency and the dignity of individuals
The next priority is for measures that provide access to those areas
of ... [the facility] where services are made available to the public
The third priority should be providing access to restrooms, if restrooms
are provided for use by clients....
The fourth priority is to remove any remaining barriers to using the
... [alcohol and drug program's] facility by, for example, [installing
visual alarms, adding Brailled floor indicators to elevator panels, or]
If We Find Barriers That Should Be Removed, but
It Is Not Readily Achievable To Undertake All of the Modifications Now,
What Should We Do?
The Department [of Justice] recommends that ... [alcohol and drug programs]
develop an implementation plan designed to achieve compliance with the
ADA's barrier removal requirements. Such a plan, if appropriately designed
and diligently executed, could serve as evidence of a good-faith effort
to comply with the ADA's barrier removal requirements.36
What Are "Alternatives to Barrier Removal"?
When a program can demonstrate that the removal of barriers is not readily
achievable, the program must make its services available through alternative
methods, if such methods are readily achievable.
EXAMPLE: A residential program that has its counseling rooms upstairs
determines that it is not readily achievable to provide a ramp or elevator
to these upstairs rooms. However, the program is still required to provide
access to its services, if any readily achievable alternative method of
delivery is available. Therefore, this program would be required to make
counseling available in a downstairs room when needed.
How Can We Determine if an Alternative to Barrier
Removal Is Readily Achievable?
"The factors to consider in determining if an alternative is readily
achievable are the same as those that are considered in determining if
barrier removal is readily achievable."37
If We Provide Services Through Alternative Measures,
Such As Home Visits, May We Charge the Client for His Special Service?
No. "When services are provided to an individual with a disability through
alternative methods because ... [a program's] facility is inaccessible,
... [the program] may not place a surcharge on the individual with a disability
for the costs associated with the alternative methods."38
May We Consider Security Issues When Determining
If an Alternative Is Readily Achievable?
Yes. "Security is a factor that may be considered when ... [an alcohol
and drug program] is determining if an alternative method of delivering
its ... services is readily achievable."39
Must Barriers Be Removed in Areas Used Only by Employees?
No. "The 'readily achievable' obligation to remove barriers in existing
facilities does not extend to areas of a facility that are used exclusively
by employees as work areas."40
However, if one or more employees have disabilities which need to be accommodated
through barrier removal, then barrier removal must be carried out unless
it poses an "undue hardship" to the employer. This "undue hardship" standard
is established by Title I of the ADA.
Are Portable Ramps Permitted?
Yes, but "only when the installation of a permanent ramp is not readily
achievable. In order to promote safety, a portable ramp should have railings
and a firm, stable, nonslip surface. It should also be properly secured."41
Do We Have to Install an Elevator?
The readily achievable standard does not require barrier removal that
would necessitate extensive restructuring or burdensome expense.42
However, the programmatic access standard would require that
program services be moved to an accessible site when needed. Therefore,
small privately operated alcohol and drug programs that have limited budgets
generally would not be required to remove a barrier to physical access
posed by a flight of steps, if removal would require extensive ramping
or an elevator.
Does the ADA Require Barrier Removal in Historic
Yes, if it is readily achievable. However, the ADA takes into account
the national interest in preserving significant historic structures. Barrier
removal would not be considered readily achievable if it would threaten
or destroy the historic significance of a building or facility that is
eligible for listing in the National Register of Historic Places under
the National Historic Preservation Act (16 U.S.C. 470, et seq.), or is
designated as historic under State or local law.
EXAMPLE 1: A residential treatment program is located in a century
old house that was designed by a famous architect and is listed in the
National Registry of Historic Places. An architect familiar with disability
access regulations has determined that ramping the front entrance would
require extensive structural modifications to the front porch. The porch
roof is supported by decorative columns that cannot be moved, and a ramp
cannot fit between them. Therefore, ramping the front entrance would not
be readily achievable. It would be readily achievable, however, to remove
obstacles and broaden a pathway to a side door on the ground level which
is wide enough to permit wheelchair access.EXAMPLE 2: A nonresidential
alcohol and drug counseling center is located in a private building where
city founders signed a charter 150 years ago. The building itself has
no architectural features that are historic. However, it is well known
that the charter was signed there, and a plaque near the front entrance
commemorates this fact. The entrances to this building are each up several
steps. It would be readily achievable to install a ramp or a platform
lift adjacent to the steps at the front entrance if the program had the
resources to do so and if access to the plaque and the plaque's visibility
were not obstructed by the ramp or lift.
If We Move, Do We Have an Obligation To Search for
Privately operated alcohol and drug programs are not required to lease
space that is accessible. However, upon leasing, the barrier removal requirements
for existing facilities apply. In addition, any alterations to the space
must meet the accessibility requirements for alterations.43
Who Has Responsibility for ADA Compliance in Leased
Facilities, the Landlord or the Tenant?
Both the landlord and the tenant are public accommodations and have the
full responsibility for complying with all ADA Title III requirements
applicable to that place of public accommodation. The Title III regulation
permits the landlord and the tenant to allocate responsibility, in the
lease, for complying with particular provisions of the regulation. However,
any allocation made in a lease or other contract is only effective as
between the parties, and both landlord and tenant remain fully liable
for compliance with all provisions of the ADA relating to that place of
Maintaining the Accessible Features Of Your Facility
"Public accommodations [such as privately operated alcohol and drug programs]
must maintain in working order equipment and features of facilities that
are required to provide ready access to individuals with disabilities."
Where [alcohol and drug programs] must provide an accessible route, the
route must remain accessible and not blocked by obstacles such as furniture,
filing cabinets, or potted plants. Similarly, accessible doors must be
unlocked when ... [the facility] is open for business.
EXAMPLE 1: Placing a vending machine on the accessible route to an
accessible restroom would be violation if it obstructed the route.EXAMPLE
2: Placing ornamental plants in an elevator lobby may be a violation if
they block the approach to the elevator call buttons or obstruct access
to the elevator cars.EXAMPLE 3: Using an accessible route for
storage of supplies would also be a violation, if it made the route ...
[too narrow or crowded to be accessible].
BUT: An isolated instance of placement of an object on an accessible
route would not be a violation, if the object is promptly removed.
Although it is recognized that mechanical failures in equipment such
as elevators or automatic doors will occur from time to time, the obligation
to ensure that facilities are readily accessible to and usable by individuals
with disabilities would be violated if repairs are not made promptly or
if improper or inadequate maintenance causes repeated and persistent failures.
Inoperable or "out of service" equipment does not meet the requirements
for providing access.45
People with disabilities need alcohol and drug abuse prevention and treatment
services as much as anyone else in society. In fact, people with disabilities
are at higher risk for alcohol and drug abuse problems than the general
population. Your ADA implementation efforts will help to ensure that people
with disabilities in your community will receive desperately needed alcohol
and drug prevention and treatment services. We hope that this summary
of the US Department of Justice ADA Title III Technical Assistance
Manual, as adapted to meet the needs of alcohol and other drug service
providers, has been of assistance to you. If needed, further technical
assistance is available from PRTA.
Sample Alcohol and Drug Program Policies and Procedures
Statement of nondiscrimination
It is the policy of _________________ (program) to support and comply
with the requirements and principles of the Americans With Disabilities
Act (ADA) and to ensure that, to the maximum extent practicable, persons
with disabilities are afforded equal access to the facilities, programs,
and services of ______________ (program).
______________ (program) has assigned overall responsibility for ensuring
equal opportunity and nondiscrimination in the provision of services and
on-going compliance with the ADA to _______________________ (name) ____________________
The following notice will be included in all contracts we enter into
with other entities to provide services to our program and clients:
Federal law requires that you comply with the Americans With Disabilities
Act and _____________ (program) requires you to adhere to our policy of
nondiscrimination when providing services to _____________ (program) and
Prevention and outreach
The prevention and outreach materials produced by ________________ (program)
will be available in alternative format (such as large print, cassette
tape or computer disk) upon request.
A representative number of the outreach events and prevention/educational
presentations conducted by ________________ (program) will be held in
wheelchair accessible locations. Upon advance request, sign language interpreters
will be available at outreach/educational presentations when feasible.
Recruitment and advertising
All written program advertising materials will be available in alternative
formats upon request. All advertisements will contain a statement that
____________ (program) does not discriminate against people with disabilities.
Whenever possible, information will be circulated to organizations and
agencies that serve people with disabilities.
Benefits and services
_________________ (program) will ensure that persons with disabilities
are provided maximum opportunity to participate in and benefit from all
our programs, services, and activities. Moreover, it is our goal that
such participation will be in an equally effective manner as non-disabled
__________________ (program) will accommodate the known disabilities
of otherwise qualified program applicants and participants. When a prospective
client or program participant identifies having a disability that requires
accommodation, program staff will discuss possible disability accommodations
with that person.
Whenever possible, preference will be given to the disability accommodation
that is the individual's first choice. If that accommodation cannot be
provided, program staff will suggest one or more alternative accommodations
that could be provided to ensure the individual's full participation in
the program. If necessary, staff will seek the assistance of disability
service providers in order to develop effective accommodations.
Program participants will not be excluded from our program because they
take appropriately prescribed medications to maintain their health. Program
staff will arrange for the secure storage of appropriately prescribed
medication. All medications will be locked in _______________. All prescribed
medications will be taken as outlined on the bottle and logged in the
medication record book.
Application forms and intake questions
The criteria for admission into this program shall not exclude or restrict
the participation of people with disabilities. During intake, staff shall
not ask questions about disability, unless this information is
part of medical history taking and medical history taking is required
of all prospective clients. If a prospective client self-identifies as
having a disability, intake staff may ask questions about how to accommodate
the person's disability needs.
When staff or other participants are concerned that a client or prospective
client with a disability may pose a significant risk to others'
health and safety, supervisory staff will conduct an assessment of that
potential risk. This assessment will take into account factual information
about the person's disability and abilities. It will exclude from consideration
stereotypes, hearsay, rumors, and unwarranted fears.
_________________ (program) will ensure equally effective communication
and participation in our services for people with disabilities.
Auxiliary aids and services for people with disabilities (including people
who are deaf or hard of hearing, blind or vision impaired, speech impaired,
learning disabled, and cognitively disabled) will be provided in all phases
of participation in our program. These will be provided unless the Program
Director determines that a specifically requested auxiliary aid or service
would fundamentally alter the nature of our program or result in an undue
The individual with the disability will be provided an opportunity to
request the auxiliary aid or service of their choice. If it is not feasible
for ___________ (program) to provide the requested aid or service, the
Program Director will suggest other effective aids or services which __________
(program) can provide to accommodate the individual's needs.
Telecommunication Device for the Deaf (TDD) (For
programs that have TDDs)
______________________ has a TDD and at least one staff person per shift
is trained in how to use it. Our TDD phone line, if separate, is included
in our local telephone directory and in all our advertising materials.
Program participants will, as needed, have access to and use of this TDD.
California Relay Service
At least one staff person per shift is trained in how to use the California
Relay Service. This person will train other staff in how to use the California
Relay Service if necessary.
Upon being provided with reasonable prior notice of need _____________
(program) will, to the maximum extent feasible, provide interpreters for
program services and/or activities by contacting ________________ in our
We have the goal of allocating funds in our budget for providing interpreter
services when they are needed.
All written program materials distributed to clients will, upon reasonable
prior notice of need, be made available in alternative formats (large
print, cassette tape, Braille, computer disk, modified English).
Emergency Communications and Evacuation
Our fire safety and emergency warning systems are configured and maintained
in compliance with applicable state and local building codes and regulations.
This includes provision of visual alarms and/or bed shakers to alert the
deaf and hard-of-hearing to fire and other emergency situations.
The emergency evacuation procedure is as follows:
- When the fire alarm rings, clients leave the building and assemble
- Roll-call is taken and the sign-out book is checked to account for
- The person on duty will assist any disabled person from the building.
Other residents/participants will assist if necessary.
Emergency drills are carried out on a regular basis.
Information on emergency evacuation procedures will, as appropriate,
be provided to clients verbally, in written form, or in alternative format
as earlier described.
Staff and other residents will receive training from each resident/participant
with a disability in the best way to assist him/her in an evacuation.
The person(s) responsible for coordination training for emergency evacuation
in our program are _____________________________________.
Whenever transportation is provided as a component of program services,
_________________ (program) will provided appropriate accessible transportation
to residents/participants with disabilities.
- _______________________ (a number) of the vehicles we use for transporting
clients are accessible to people who use wheelchairs.
- We have no accessible vehicle but contract with _______________ (name
of service) to provide accessible transportation services when needed.
Whenever extracurricular activities, such as 12-Step meetings and social,
educational and recreational events, are provided or offered as a component
of program services, _________________ (program) will ensure that these
or other equivalent activities are accessible to persons with disabilities.
Completion and Followup
Reasonable modifications will be made to completion and followup procedures
for participants with disabilities. Referrals will include accessible
12-Step meetings, group and family counseling, educational and vocational
services, recreational programs, and other community resources appropriate
for the individual participant.
All participants will be informed of their right to express grievances
through an effective grievance procedure. It may be used by anyone who
wishes to file a complaint alleging discrimination on the basis of disability
in the provision of services, activities, programs or benefits.
The complaint should be made in writing and contain information about
the alleged discrimination such as name, address, phone number of complainant
and location, date, and description of the problem.
Alternative means of filing complaints, such as personal interviews or
tape recording of the complaint, will be made available to persons with
disabilities upon request.
The complaint should be submitted to ________________ (name), _______________
(title) as soon as possible, but no later than 60 calendar days after
the alleged violation.
Within 7 calendar days after receipt of the complaint, ______________
(name/title) will meet with the complainant to discuss the complaint and
Within 7 calendar days after the meeting ___________ (name/title) will
respond in writing, or other format accessible to the complainant and
offer options for resolution.
If the client is not satisfied, he or she may appeal the matter to ___________
(name/title/agency/address/phone) who will adhere to steps "c" and "d"
If the client is still not satisfied, he or she may appeal to the County
ADA Coordinator, ___________ (name/title/agency/address/phone).
1 See "Individuals with disabilities - General." The ADA, Title
III TAM - 2.1000, 8.
2 See The Americans With Disabilities Act Handbook, Equal
Employment Opportunity Commission and U.S. Department of Justice (Washington,
DC: U.S. Government Printing Office, 1991), Preamble, 1.
3 From "Drug addition as an impairment," The Americans With
Disabilities Act Title III Technical Assistance Manual (Washington,
DC: Department of Justice, Civil Rights Division, Office on the Americans
With Disabilities Act), III-2.3000, 9.
4 See The Americans With Disabilities Act Title III Fact Sheet
(Washington, DC: U.S. Department of Justice, Civil Rights Division, Office
on the Americans With Disabilities Act).
5 From Strategizer 9. Coalitions Address Americans With Disabilities,
Resource Center on Substance Abuse Prevention and Disability (Washington,
DC: Community Anti-Drug Coalitions of America), 3-1, 4.
6 See Alcohol and Other Drug Abuse Prevention for Persons
With Disabilities (Washington, DC: Resource Center on Substance Abuse
Prevention and Disability, 1991), 1.
7 From "Specialties," The Americans With Disabilities Act
Title III Technical Assistance Manual (Washington, DC: U.S. Department
of Justice, Civil Rights Division, Office on the Americans With Disabilities
Act), III-4.2200, 22-23.
8 From "Drug addiction as an impairment," The Americans With
Disabilities Act Title III Technical Assistance Manual, III-2.3000, 9.
From "Drug addition as an impairment," The ADA Title III TAM, III-2.3000,
10 From "Illegal use of drugs," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-3.9000, 18.
12 From "Direct threat," The Americans With Disabilities Act
Title III Technical Assistance Manual, III-3.8000, 17-18.
13 See "Separate benefit/integrated setting," The Americans
With Disabilities Act Title III Technical Assistance Manual, III-3.4000,
14, and III-3.4200, 14.
14 See "Separate benefit/integrated setting" and "Modifications
in the regular program," The Americans With Disabilities Act Title III
Technical Assistance Manual, III-3.4000 and III 3.4300, 14-15.
15 See "Personal services and devices," The Americans With
Disabilities Act Title III Technical Assistance Manual, III 4.2600,
16 See "Surcharges," The Americans With Disabilities Act Title
III Technical Assistance Manual, III-4.1400, 22.
17 From "Smoking," The Americans With Disabilities Act Title
III Technical Assistance Manual, III-3.10000, 18.
18 An analogous situation is described in "Service animals,"
The Americans With Disabilities Act Title III Technical Assistance Manual,
19 See "Retaliation or coercion," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-3.6000, 16.
20 See "Effective communications," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-4.3200, 25.
21 From "Examples of auxiliary aids and services," quoted from
The Americans With Disabilities Act Title III Technical Assistance Manual,
22 See "Effective communications," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-4.3200, 26.
23 From "Limitations and alternatives," The Americans With
Disabilities Act Title III Technical Assistance Manual, III-4.3600,
24 From Ibid, 28.
25 See "Effective communications," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-4.3200, 26.
26 From "Outgoing calls by customers, clients, patients, or participants,"
The Americans With Disabilities Act Title III Technical Assistance Manual,
27 Ibid, 34.
28 From "Removal of barriers--General," The Americans With
Disabilities Act Title III Technical Assistance Manual, III-4100, 28-29.
30 See "Standards to apply," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-4.4300, 32.
31 See "Readily achievable barrier removal," The Americans
With Disabilities Title III Technical Assistance Manual, III-4.4200,
32 Ibid, 30-31.
33 Ibid, 29-30.
34 Ibid, 32.
35 See "Priorities for barrier removal," The Americans With
Disabilities Act Title III Technical Assistance Manual, III-4.4500,
36 Ibid, 34-35.
37 From "Alternatives to barrier removal--General," The Americans
With Disabilities Act Title III Technical Assistance Manual, III-4.5100,
40 From "Priorities for barrier removal," The Americans With
Disabilities Act Title III Technical Assistance Manual, III-4.4500,
41 From "Standards to apply," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-4.4300, 33.
42 See "Readily achievable barrier removal," The Americans
With Disabilities Act Title III Technical Assistance Manual, III-4.4200,
44 From "Public accommodations," The Americans With Disabilities
Act Title III Technical Assistance Manual, III-1.2000, 3.
45 From "Maintenance of accessible features," The Americans
With Disabilities Act Title III Technical Assistance Manual, III-3.7000,
Appendix E -- Resource Panel
- Peter J. Cohen, M.D., J.D.
- Special Expert
- Medications Development Division
- National Institute on Drug Abuse
- National Institutes of Health
- Bethesda, Maryland
- George Kanuck
- Office of Policy Coordination and Planning
- Center for Substance Abuse Treatment
- Rockville, Maryland
- Peter Mazzella, Jr., M.S.W.
- Program Officer
- Division of Associated Dental and Public Health Professions
- Health Resources and Services Administration
- Department of Health and Human Services
- Rockville, Maryland
- Mary Kay Mullen
- Health Insurance Specialist
- Medicaid Bureau
- Health Care Financial Administration
- Baltimore, Maryland
- Linda Peltz
- Health Insurance Specialist
- Medicaid Bureau
- Office of Long Term Care Services
- Health Care Financing Administration
- Baltimore, Maryland
- Hyden Shen
- Legislative Affairs
- Center for Substance Abuse Prevention
- Rockville, Maryland
Appendix F -- Field Reviewers
- Charles H. Bombardier, Ph.D.
- Assistant Professor
- Department of Rehabilitation Medicine
- University of Washington School of Medicine
- Seattle, Washington
- Janet E. Dickinson, Ph.D.
- Marie H. Katzenbach School for the Deaf
- Trenton, New Jersey
- Janice M. Dyehouse, Ph.D., R.N.
- College of Nursing and Health
- University of Cincinnati
- Cincinnati, Ohio
- Roman Frankel
- Alcohol and Substance Abuse
- New Start, Inc.
- West Bloomfield, Michigan
- Jean F. Golden, R.N., M.L.I.R.
- Executive Director
- National Association on Alcohol, Drugs, and Disability
- Capital Area Center for Independent Living
- Lansing, Michigan
- Debra S. Guthmann, Ed.D.
- Pupil Personnel Services
- California School for the Deaf
- Fremont, California
- J.R. Harding
- Florida State University
- Tallahassee, Florida
- Karen Kelly-Woodall, M.S., M.A.C., N.C.A.C.I.I.
- Criminal Justice Coordinator
- Cork Institute
- Georgia Addiction Technology Transfer Center
- Morehouse School of Medicine
- Atlanta, Georgia
- Shane Koch
- Rehabilitation Doctors
- Abraxas of Ohio
- Shelby, Ohio
- Kathleen B. Masis, M.D.
- Medical Officer for Chemical Dependency
- Office for Healthcare Policy
- Billings Area Indian Health Service
- Public Health Service
- Department of Health and Human Services
- Billings, Montana
- Linda Mazie, M.Ed.
- Alcohol and Drug Abuse Coordinator
- Massachusetts Department of Public Health
- Dedham, Massachusetts
- Lisa Mojer-Torres, J.D.
- Consumer Representative Advocate
- Jersey City, New Jersey
- Jeffrey Nichols, M.D.
- Geriatric Medicine
- Cabrini Center for Nursing and Rehabilitation
- New York, New York
- Anne H. Skinstad, Psy.D.
- Substance Abuse Counseling Program
- Addiction Technology Training Center
- University of Iowa
- Iowa City, Iowa
- Susan Storti, R.N., M.A., C.D.N.S.
- Addiction Technology Transfer Center-New England
- Brown University
- Providence, Rhode Island
- Richard T. Suchinsky, M.D.
- Associate Director, Addictive Disorders
- Department of Veterans Affairs
- Mental Health and Behavioral Sciences Services
- Washington, D.C.
- Elizabeth Villalobos, M.S.W.
- Alcohol and Substance Abuse Coordinator
- Sunmount Developmental Disabilities Services Office
- Plattsburgh, New York
- Robert Walker, M.S.W., L.C.S.W., B.C.D.
- Bluegrass East Comprehensive Care Center
- Lexington, Kentucky
- Hazel Weiss
- Disability Constituant Committee
- Hayward, California
- Eileen Wolkstein, Ph.D.
- Research Scientist
- Rehabilitation Counseling Program
- Department of Health Studies
- School of Education
- New York University
- New York, New York
- D. William Wood, M.P.H, Ph.D.
- School of Public Health
- University of Hawaii
- Honolulu, Hawaii
Figure 1-1: Substance Use Disorders as a
Substance Use Disorders as a Coexisting Disability
|Chemical dependency is called
a disability and covered as such under the provisions of the Americans
With Disabilities Act (ADA). Substance abuse is an illness that frequently
results in serious functional limitations or death when not properly
treated. If an individual has both a substance use disorder and a
physical or cognitive disability, then he is really coping with coexisting
disabilities. However, for the purposes of this Treatment Improvement
Protocol (TIP), the term "disabilities" will refer to physical and
cognitive disabilities and not substance use disorders. When
the TIP refers to a person with a "disability," therefore, it should
be understood that it is a coexisting disability.
Figure 1-2: Some Definitions
|The definitions that
follow explain the terms used in this TIP:
|Disease: An interruption,
cessation, or disorder of body functions, systems, or organs.*
|Impairment: Any loss
or abnormality of psychological, physiological, or anatomical structure
|Disability: Any restriction
or lack (resulting from an impairment) of the ability to perform an
activity in the manner or within the range considered normal for a
human being. A disability is always perceived in the context of certain
societal expectations, and it is only within that context that the
disadvantages accruing from a disability (often called "handicaps")
can be properly evaluated.**
The ability or degree of ability possessed by the individual to meet
or perform the behaviors, tasks, and roles expected in a social environment.***
The inability to perform certain behaviors, fulfill certain tasks,
or meet certain social roles as a consequence of a disability. Those
limitations can be anatomical (e.g., amputation), physiological (e.g.,
diabetes), cognitive (e.g., traumatic brain injury), or affective
(e.g., depression) in origin and nature. They represent substandard
performance on the part of the individual in meeting life activities
and reflect the interaction between the person and the environment.
(A list of the seven areas of functional capacities and limitations
most often assessed follows on page 5.)***
|*Source: Stedman, 1990.
**Source: World Health Organization, 1980.
***Source: Livneh and Male, 1993.
Figure 1-3: Disability Chart
Spinal cord injury
Chronic fatigue syndrome
Traumatic brain injury
Posttraumatic stress disorder
Hard of hearing
Figure 2-1: Educational and Health Survey
Educational and Health Survey
|Please answer the following
questions keeping in mind that we are trying to get to know you better
and to identify areas that may create difficulty for you in treatment
if we don't know about them.
- Do you have a disability or have you ever been told that you
have a disability?
___ Yes ___ No
- Are you currently under the care of a doctor or other medical
___ Yes ___ No
- Do you take medications?
___ Yes ___ No
- Do you have difficulty hearing in group settings (e.g., theaters,
classrooms, family dinners)?
___ Yes ___ No
- Do you frequently need people to repeat what they have said
___ Yes ___ No
- Have people complained that you don't hear or don't listen to
___ Yes ___ No
- Do you wear glasses or contact lenses?
___ Yes ___ No
- Do you have difficulty seeing things that are far away or very
___ Yes ___ No
- Do you have frequent eye pain or headaches?
___ Yes ___ No
- Have you ever hit your head and lost consciousness?
___ Yes ___ No
- Have you ever received health or disability benefits?
___ Yes ___ No
- Have you ever been unemployed for a long period of time?
___ Yes ___ No
- Have you ever been fired from a job, asked to leave a job, or
passed over for a promotion?
___ Yes ___ No
- Did you ever have special classes or tutoring in school?
___ Yes ___ No
- In a school or work setting, do you like to learn or learn best
___ Listening to someone talk
___ Watching someone perform a task
___ Reading on your own
___ Performing tasks yourself
___ Discussing things with another person
___ Discussing things with a group of people
- Have you had problems or difficulty with any of the following?
___ Getting your point across to others
___ Sitting still
___ Focusing on the task at hand for more than several minutes
at a time
___ Understanding the point that others are making to you or what
others are saying to you
___ Communicating your feelings or thoughts to others
- Have you ever had problems with or been bothered by any of the
___ Controlling anger
___ Remembering things
___ Following instructions (verbal, written, or demonstrated)
___ Becoming tired easily
___ Getting along with others
- Have you ever had problems or been bothered by any of the following?
___ Sleep problems
___ Muscle tension or soreness
___ Uncontrolled worry
___ Excessive worry
___ Restlessness (feeling on edge)
___ Mind "going blank"
___ Rapid heart rate
___ Pounding in chest
___ Heart burn or stomach pain
___ Uncontrolled feelings of happiness or euphoria
Figure 2-2: Impairment and Functional Limitation
Impairment and Functional Limitation Screen
|Do you have a disability,
or have you ever been told that you have one? (1)
||It may be useful
to ask what a typical day is like to gain a better understanding of
how these accommodations affect the person's daily life. Ask client
to specifically describe the activities and events of the day. Her
answer may indicate problems in functional areas such as self-care,
learning style, mobility requirements, or reveal her participation
in a work program. If the person uses an assistive device, inquire
how long it has been used.
||Refer to vocational
rehabilitation. Consult with disability professionals.
|Are you currently
under the care of a doctor or other medical care professional? (2)
||Inquire as to how
a condition affects the person's daily life (e.g., what accommodations
and precautions he takes).
||Consult and communicate
with physician. Obtain medical records.
|Are you taking
any medications (prescribed or over-the-counter)? (3)
||If the client takes
medications, does she understand what they are being taken for? What
side effects from medications has she experienced? A recent medication
history should be taken.
education. Use charting or a pill case to organize medications and
ensure proper use. Remind client when she should take medication.
Use timers or pagers to remind client of when to take medication.
Set up appointment for medication check with physician.
|Do you have difficulty
hearing in group settings (e.g., theaters, classrooms, family dinners)?
Do you frequently need people to repeat what they've said to you?
Have people complained that you don't hear or don't listen to them?
||Ask if client has
had his hearing tested recently (or ever). Look for nonverbal signals
that he is having difficulty hearing (e.g., looking at lips instead
of eyes, thinking a long time before answering questions, ignoring
questions, not directly answering questions). Some attempt should
be made to determine if problems are attentional in nature rather
than due to a hearing impairment.
test and language or communication test. Have client sit in front
during classroom type sessions. Place client nearer to the speakers
when movies or tapes are being used. Have sessions with client in
the room with the best acoustics. Meet with client after group sessions
to discuss what occurred as a way to determine whether he heard everything
that was said. Arrange the room so that outside noise is minimal and
so that clients can all see each other. Develop a cueing system to
let client know when he is being spoken to and so client can signal
when he cannot hear. Repeat the points or questions of group members
often. Use an interpreter when appropriate. Use a microphone in a
large group setting. Use other assistive devices like a radio amplification
system. Frequently check in with client to make certain that he is
following what is being said.
|Have you ever hit
your head and lost consciousness? (10)
any occurrences even if the client was not sure whether he sustained
an injury (sometimes issues of inebriation and the loss of consciousness
due to trauma are mixed together). Ask client if he has ever been
in a car accident or a fight. Ask about the length of time unconscious,
the circumstances surrounding the accident, whether alcohol or drugs
were involved, and any changes in functioning dating from the time
of the injury.
of any previous neuropsychological exam. If none has been done, arrange
to have one administered (if funds are available). Consult with a
psychologist about the neuropsychological test results and about possible
accommodations. Administer a short, simple memory test.
|Have you ever received
health or disability benefits? (11)
||Ask client why
she received these benefits and if that influenced her work or search
for a job.
Consult with client's case manager or benefits coordinator. Help client
to get assistance that she is entitled to.
|Have you ever been
unemployed for a long period of time? Have you ever been fired from
a job, asked to leave a job, or been passed over for promotion? (12-13)
||Ask if the client
feels unsatisfied with the work he's been able to find. Ask if he's
ever had a job where he didn't understand the tasks he was asked to
perform or felt unable to perform them. Ask how he obtained his most
recent work, and whether he has ever been involved in a vocational
rehabilitation records if applicable. Refer to vocational rehabilitation.
Use self-administered interest inventories. Design assignments and
treatment goals relating to employment and/or vocational rehabilitation.
|Did you ever have
special classes or tutoring in school? (14)
||Ask whether the
person has ever had a past diagnosis of a learning disability. Ask
questions such as, "Is English your first language? Can you read English?
Do you like to read? What do you like to read? How often do you read
and for how long generally?" For a client who is blind, ask, "How
do you read? Audiotapes? Braille? Any other method?" Unless the person
states that she cannot read, find an opportunity--later in the interview,
so that it is not connected with the question--to have her read something
aloud. This should be something brief, such as a sentence in a release
statement or a standardized screening questionnaire for substance
||Use audio- and/or
videotapes. Use murals, art activities, role-playing, etc., instead
of written assignments. Use feelings chart or other picture tools
during session. Take frequent breaks. Confer with client periodically
to find out if she is understanding material. Arrange for extra help/tutoring
from peers or counselor.
|In a school or
work setting, do you like to learn or learn best by listening to someone
talk, watching someone perform a task, reading on your own, performing
tasks yourself, discussing things with another person, discussing
things with a group of people? (15)
||While many clients
will not be able to answer this question very easily, those that can
will be able to provide information that can prove to be very valuable
in developing a treatment plan. Ask for details concerning positive
and negative learning experiences. Find out if any accommodations
have been made in the past in order to help the client learn most
||Attempt to utilize
client's preferred means of learning as much as possible.
|Do you ever have
difficulty sitting still, focusing on a task for more than several
minutes, understanding what people are saying to you, or communicating
your thoughts and feelings to others? (16)
||Anything but an
unqualified "no" should be followed up since it could point to a possible
attention deficit. Ask under what circumstances the person has had
these problems and what kinds of distractions he has had, such as
environmental (noise) or physical (pain). Observe whether he is able
to sit still during the interview. The sensory aspects of understanding
speech need to be addressed separately (see above).
||Take frequent breaks.
Allow client to stand or alternate standing and sitting. Use shorter
sessions. Have an agenda for each session which clients can follow.
Stagger client participation during a session to keep him involved
(for example, every ten minutes after each key point or after each
group member shares). Use cues to let client know when he is getting
off track. Use other refocusing techniques like summarizing what has
happened or using quick response activities ("everyone tell me how
you are feeling right now"). Limit the number of key points per session.
Alternate types of activities throughout the session.
|Do you ever have
problems controlling your anger, remembering things, following instructions
(either verbal, written, or demonstrated), concentrating, becoming
tired easily, or getting along with others? (17)
||Ask about friendships
and relationships with others; find out if the client has problems
with friends, family, or being a "loner." Ask if she is getting tired
or having trouble concentrating during the interview.
techniques. Use memory books. Provide client with a schedule that
is in short increments. Adhere to regular scheduling. Give client
as much notice (and reminders) as possible if schedule will change.
Use written and/or pictorial instructions. Use audio and/or video
instructions. Involve the client in role-playing. Use mock sessions
to prepare client for what will happen. Arrange field trips. Use cues
to keep client on track. Take frequent breaks. Determine client's
most alert times and attempt to schedule key activities during those
times. Begin treatment plan utilizing individual counseling only and
work towards group involvement. Allow client to observe group before
engaging. Include anger management activities in treat-ment plan.
Expect to repeat key points often.
|Have you ever been
bothered by any of the following: depression, anxiety, forgetfulness,
sleep problems, nervousness, muscle tension or soreness, uncontrolled
worry, excessive worry, irritability, restlessness (feeling on edge),
mind "going blank," rapid heart beat, pounding in chest, heartburn
or stomach pain, uncontrolled feelings of happiness, or euphoria?
||Ask the client
if he is in or has ever been in counseling. If he has, ask how often
he visited a mental health professional and what problems were most
often discussed. Find out if the client currently has or has ever
had any suicidal ideation. Ask what his normal sleeping and eating
patterns are, and what a typical day is like. Look to see if he appears
sad or depressed, and if his grooming is adequate.
records or mental health records if possible. Refer for mental health
assessment. Use relaxation techniques. Use recreation therapy. Refer
for a physical therapy or occupational therapy assessment. Refer for
a medication check. Have client keep a journal or log about his symptoms
to see if there is a pattern to them. Use memory book or other memory
techniques. Have client practice memorizing short slogans or phrases.
Figure 2-3: Profile of "John"
Profile of "John"
|Bowel and bladder
|Walking, with or
without assistive devices (e.g., walker, cane)
|Use of wheelchair
|Use of stairs
|Ability to operate
due to DUI
|Use of public transportation
(or other access to transportation)
||Check on the availability
of transportation and the need for explicit directions to treatment
records; records should also indicate whether or not he took special
education classes, received a regular high school diploma, or was
diagnosed with a learning disability
need to be determined, but requirements are minimal in program
may be limited by attention problems
||Ritalin use in
childhood may indicate the need for a referral to a psychiatrist for
to be good
|Retention and Application
||May need formal
assessment of retention and application abilities
|Awareness and recognition
reason for being in treatment is he "got into trouble" may indicate
lack of awareness of problem (DUI)
skills and anticipate possible consequences of various alternatives;
then decide on optimal alternative
social mores and values
he "got into trouble" indicates awareness of social values
||DUI and story of
fight indicate impulse control problem; although they may be drinking-related
called for since substance use can cause a lack of impulse control
skills consistent with age, etc.
to identify with others
||Need to further
- Planning and organization
- Motivation and initiation
- Monitoring and reviewing
- Motivation, decision-making, disinhibition
||Explore basis of
sporadic work history
Figure 3-1: People's Understanding and Acceptance
of a Coexisting Disability
People's Understanding and Acceptance of a Coexisting Disability
|People vary in how well they
understand or accept their own disabilities. Some persons entering
treatment for substance use disorders know what interventions their
disabilities require. Others do not. Some people appreciate and benefit
from accommodations to their disability, whereas others may be reluctant
to acknowledge that some condition limits their functional capacity.
The following are some of the factors that affect a person's willingness
to accept the realities of her disability:
Source: Chart modified from Li and Moore, 1998
- The severity, duration, or specific functional limitations of
- Societal reaction to and expectations of the person with a disability
- The developmental stage at time of the disability's onset
- Access to resources and societal mobility
- A history of risk-taking behaviors prior to the onset of the
- A history of having used substances to cope with a disability
- Recurring and episodic forms of personal grieving due to disability
- The amount of independence resulting from a person's lifestyle
- Age (generally, younger people are more willing to eventually
accept their disability)
- Marital status (married people are more willing to accept disability
than single or unattached)
- Income (the greater someone's income, the more willing he is
to accept disability)
Figure 3-2: Locating Expert Assistance
Locating Expert Assistance
|"Experts" in disability services
can be located several ways, depending on the nature of the client's
disability and the local resources available. Clients who understand
their disability may in fact be the best "experts" on their condition
and specific needs; however, it is not uncommon that persons requiring
treatment for substance use disorders will not understand basic aspects
of their situation or condition. In such cases, immediate family members
or close friends may be important sources of information and guidance.
The treatment team should also consider contacting other sources:
a disability specific service organization (e.g., United Cerebral
Palsy, an organization for the blind or deaf, Association for Retarded
Citizens), social workers, case managers, rehabilitation specialists,
psychologists, nurses, or physicians associated with a social service
agency providing disability services for the individual client in
question (e.g., vocational rehabilitation, family services for people
who are deaf and hard of hearing, the Department of Veterans' Affairs'
physical rehabilitation unit, community case management services),
or other organizations recognized by the disability community (e.g.,
CILs, governors' committees for persons with disabilities, Paralyzed
Veterans Association, local or State consumer coalitions for persons
with disabilities). More information on these and other pertinent
organizations can be found in Appendix B; more on developing linkages
with other agencies can be found in Chapter 4.
Figure 3-3: Responses in a Treatment Setting
Responses in a Treatment Setting
- An agency has this rule: All clients must attend an Alcoholics
Anonymous (AA) meeting every night. A young person with TBI protests
that he does not want to attend AA meetings because the meetings
are filled with old people who don't understand him and don't
think he should be taking medication for pain.
Denial response: There are no exceptions to the rule. Everybody
must attend AA every night.
Enabling response: It's OK, you don't have to go if they
don't understand your problem.
Accommodation: We'll help you find support at the existing
meeting, or a different meeting or support group that can better
recognize and accept your legitimate medication needs.
- A treatment program has three discussion groups during daytime
hours. A person with multiple sclerosis asks to be excused from
the third discussion group because of fatigue.
Denial response: I'm sorry you're tired, but everyone has
to attend all three meetings.
Enabling response: If it's a problem, you don't have to
Accommodation: Why don't you take a rest period in late
afternoon, and attend a third meeting, or alternative treatment
activity, in the evening?
- A person with a visual disability is being coached by the treatment
program in her job search. All the positions she finds either
have schedules that require her to miss her AA meetings, or are
in locations inaccessible by the public transportation she requires.
She argues that she should not have to attend AA.
Denial response: You're just making excuses. Figure out
how to make it work.
Enabling response: You're right. This is too much of a
problem. Give up the AA meetings, or the work.
Accommodation: We'll help you arrange to ride to work with
a coworker, so that you have transportation to and from your job.
Or else, we'll help you find work with a flexible schedule.
- An unemployed person who is alcoholic with time on his hands
and little social support is turned away from a State-run VR program
because he has not yet maintained sobriety for 6 months. He is
outraged but decides there is nothing he can do.
Denial response: You'll just have to figure it out and
get a job on your own.
Enabling response: This is a terrible situation, but I
guess you'll have to wait until January.
Accommodation: We'll work with you to plan a course of
prevocational activities that you can begin doing now. Then you
can file an appeal with the State concerning the denial of services;
we'll help negotiate with the vocational rehabilitation program
for flexibility. (The program should work to get the system to
admit persons who are compliant with treatment recommendations,
even if they have not yet met the requirement in terms of months
of sobriety. In this way the client can begin getting involved
in productive activities. Agreeing with the client that nothing
can be done encourages his sense of victimization.)
- A client with an alcohol use disorder who is deaf and
lives in a remote rural area has few social contacts, and these
are all at the local bowling alley, where her acquaintances tend
to drink alcohol.
Denial response: You're an alcoholic--you just have to
stay away from bars.
Enabling response: You need to get out and socialize. Go,
but try not to drink.
Accommodation: It's possible for you to see your friends
at the bowling alley and not drink alcohol, even if they are.
We'll teach you the skills to socialize in that setting without
drinking alcohol, and teach you to recognize cues that indicate
you are vulnerable to relapse. (By making such an accommodation
the treatment program recognizes the unique challenges this person
faces in attempting to build sources of social support, as well
as the additional responsibility of the program to teach the skills
she will need to function in the settings she is able to identify.
If the program insists that a person avoid all settings where
alcohol is served it has a responsibility to help the person find
other sources of social support and companionship. Simply telling
her to "stay away from bars" denies that isolation is also a threat
to her sobriety.)
Figure 3-4: Development and Coordination
Development and Coordination of Goals
|Fred has mental retardation
and is living in a group home and working with housing program staff
so that he may move with a roommate into one of the program's apartments
in 2 years. Short-term goals developed with housing staff may include
refining meal preparation skills, adhering to a schedule for cleaning
the house, and developing interpersonal skills to solve differences
with housemates. Simultaneously, he will be working daily in a transitional
employment program with the goal of graduating to competitive employment
in a couple of years. Short-term goals developed with job counselors
may include learning proper grooming and punctuality. Fred may seem
to be advancing with little trouble toward the ultimate goals of housing
and vocational independence only to experience repeated and discouraging
setbacks due to monthly episodes of binge drinking. The counselor
should help him understand the concrete cause-and-effect relationship
between staying sober and achieving greater independence, which may
not be clear to him. Treatment goals to reinforce this direct association
should be developed. Treatment plans should identify specific behavioral
goals and a number of different reinforcers for making progress (e.g.,
tokens toward the purchase of his own "Big Book"; homework of reporting
his daily activities and successes to a case manager, counselor, 12-Step
sponsor, or family member; a "sobriety chart" on the counselor's wall
where he can see his progress charted).
Figure 3-5: Behavioral Contracts in a Treatment
Program for People Who Are Deaf
Behavioral Contracts in a Treatment Program for People Who Are Deaf
|The Minnesota Chemical Dependency
Program for Deaf and Hard of Hearing Individuals uses a behavioral
approach with clients that includes education and support designed
to help individuals identify and correct self-defeating behaviors.
Intervention efforts are matched to behaviors of concern. An initial
intervention would typically be a private discussion with the counselor,
which often helps the client recognize and change the behavior. If
the behavior continues or becomes worse, a behavior contract might
be an appropriate second-level intervention.
Behavior contracts may be utilized for incidents such as the violation
of unit rules, arguing about staff directives, failure to complete
work on time, failure to focus on treatment, or focusing on the needs
or issues of other patients (rather than one's own). Behavior contracts
specify the behaviors for which they are given as well as the changes
that are expected.
Another behavior management technique used is the probation contract.
Probation contracts may be used to help a client recognize behaviors
that seriously threaten the success or quality of her treatment experience.
It is used as a followup to a behavior contract if a client does not
respond positively or is openly defiant to the terms of a behavior
contract. Probation contracts also specify expected changes in the
client's behavior and may include an assignment that helps the client
identify and change her behavior. Failure to adhere to the probation
contract may result in the client being asked to leave the program.
Figure 3-6: Sample Contracts for People With
Sample Contracts for People With Disabilities
must write a history of her addiction during the first 3 days of an
||Failure to accomplish
the task will result in a loss of program privileges (e.g., not viewing
the Friday night movie, placing vocational goals or plans on hold,
delaying graduation from treatment).
- Allow more time.
- Allow the use of alternative formats (e.g., someone who is blind,
deaf, or cognitively impaired can dictate or draw aspects of his
- Be specific in assigning a time period for reporting substance
use history (e.g., last year, "since my arrest").
in outpatient treatment must attend all groups.
||Missing a group
will result in automatic discharge.
- Work with the individual to be sure a ride is available. (Transportation
problems can be substantial for some persons with disabilities.)
- Pair up a person with a coexisting disability with a nondisabled
group member who will help ensure he gets to the group
- Substitute another activity if the individual cannot get to
the meeting (e.g., an individual session, a 12-Step meeting, writing
- For persons with memory problems, call and remind them that
a session is occurring or assist them in creating memory books
that include necessary information on group meetings.
must attend 90 Alcoholics Anonymous (AA) meetings in 90 days.
||Failure to attend
will mean that the client is reported as noncompliant to referral
- Pair up the individual with a nondisabled group member who can
accompany her to a meeting. Take extra time to assist someone
in finding a temporary AA sponsor who understands disability issues
or is willing to learn.
- Substitute another activity if the client cannot get to a meeting,
such as requiring attendance at other groups or self-help meetings
(e.g., disability-related groups in a rehabilitation program,
Schizophrenics Anonymous, church groups).
- Have the client report daily by phone to the counselor or AA
Figure 3-7: Accommodating Clients Who Are
Accommodating Clients Who Are Visually Impaired
Improving interactions with an individual with blindness or
- Develop a positive attitude about blindness.
- To guide a person who is blind, let him take your arm. When
encountering steps, curbs or other obstacles, identify them.
- When giving directions, be as clear and specific as possible
including distance and obvious obstacles.
- Speak to the person in a normal tone and speed.
- It's okay to touch a blind person on the arm or shoulder to
- Don't touch or play with a working guide dog.
- Ask the person how much vision she has and what communication
modality she is most comfortable using.
- When leaving a room, say so.
Solutions to access problems
- Keep pathways clear and raise low-hanging signs or lights.
- Use large letter signs and add Braille labels to all signs.
- Keep doors closed or wide open; half open doors are hazardous.
- Have adaptive equipment available so people who are blind can
be full program participants (i.e., talking computer, Brailler,
- Make oral announcements; don't depend on a bulletin board.
- Add raised or Braille lettering to elevator control buttons,
and install entrance indicators at doorways.
- Utilize radio and the newsletters of organizations serving the
blind for announcements and advertising.
- Make optical magnifiers and aids available for people with visual
|Source: Substance Abuse
Resources and Disability Issues, 1995.
Figure 3-8: Suggestions for Providers Working
With Persons With Brain Injury
Suggestions for Providers Working With Persons With Brain Injury
- Try to determine a person's unique learning style.
- Ask how her reading is, how well she writes, or evaluate
- Both ask about and observe a person's attention span; be
attuned to whether attention seems to change in busy versus
- If someone is not able to speak (or speak easily), inquire
as to alternate methods of expression (e.g., writing, gestures).
- Evaluate whether someone is able to comprehend either written
or spoken language (is there a receptive language problem?).
- Help the individual compensate for a unique learning style.
- Modify written material to make it concise and to the point.
- Paraphrase concepts, use concrete examples, incorporate
visual aids, or otherwise present an idea in more than one
- Encourage the individual to take notes or at least write
down key points for later review and recall.
- If the treatment program includes a schedule, make sure
a "pocket version" is kept for easy reference; homework assignments
should be written down as well.
- After group sessions, meet individually to review main points.
- Provide assistance with homework or worksheets; allow the
person more time and take into account reading or writing
- Enlist family, friends, or other service providers to reinforce
- Do not take for granted that something learned in one situation
will be generalized to another.
- Repeat, review, rehearse, repeat, review, rehearse.
- Provide direct feedback regarding inappropriate behaviors.
- Let a person know a behavior is inappropriate; do not assume
he knows and is choosing to do so anyway.
- Provide straightforward feedback about when and where behaviors
- Redirect tangential or excessive speech, including a predetermined
method of signals for use in groups.
- Be cautious concluding that an underlying emotional state is
the basis of an observed behavior.
- Do not presume that noncompliance arises from lack of motivation
or resistance; check it out.
- Be aware that unawareness of deficits can arise as a result
of specific damage to the brain and may not always be due
- Confrontation shuts down thinking and elicits rigidity;
roll with resistance.
- Do not just discharge for noncompliance; follow up and find
out why someone has not showed up or otherwise not followed
|Source: The Ohio Valley
Center for Brain Injury Prevention and Rehabilitation, 1998.
Figure 4-1: Examples of Interagency Collaborations
Examples of Interagency Collaborations
- A treatment provider is provided space at a Center for Independent
Living (CIL) to host a weekly sobriety support group that people
with disabilities can attend during aftercare.
- A treatment provider purchases paratransit services to and from
health care facilities at a negotiated rate so people can receive
appropriate treatment for their disabilities.
- A CIL agrees to provide training to substance use disorder treatment
staff on disability issues. This keeps CIL staff certification
current and sensitizes treatment staff to the issues of people
with coexisting disabilities.
- A disability law center agrees to draft policies related to
ADA compliance for a treatment center on an ongoing, pro bono
basis. This helps the treatment provider stay abreast of ADA-related
Figure 4-2: Potential Community Resources
to Assist With Treatment
Potential Community Resources to Assist With Treatment
Learning Disability (LD)
- Centers for Independent Living
- United Way
- Vocational rehabilitation agencies
- State disability councils
Developmental Disability (DD)
- Local or national Learning Disabilities Association
- Community, school, or university LD program
- Community mental health centers
- Literacy council
Blind or Visual Impairment
- School or community DD program
- Parent organizations
- Goodwill Industries
- Special Olympics
Deaf and Hard of Hearing
- Vocational rehabilitation providers
- Senior citizens' center
- Public library
- Society for the Blind
- Lion's Club
Spinal Cord Injury
- Agencies for the deaf
- Vocational rehabilitation providers
- Senior citizens' centers
- State chapters for the Registry of Interpreters for the Deaf
- Commission for the Deaf and Hard of Hearing (located in numerous
- Hospital rehabilitation programs
- Paralyzed Veterans of America
- Hospital or pain management program
- United Cerebral Palsy
|Developed by D. Moore and J.
A. Ford for the Rehabilitation Research and Training Center on Drugs
and Disability (RRTC).
Figure 4-3: The People With Disabilities
The People With Disabilities Project
|The Pima Prevention Partnership,
a federally funded substance use disorder prevention partnership
in Tucson, Arizona, began including people representing disability
service organizations on its Board of Directors. Board members became
aware of the degree to which people with disabilities used substances
and sought funding to address this issue community-wide. With grants
from the Center for Substance Abuse Treatment (CSAT) and the Center
for Substance Abuse Prevention (CSAP), the Partnership began a 3-year
project to open treatment and prevention services for youth and adults
with disabilities. The Partnership's activities to date have included
- Hosting a training session for the clinical coordinators of
area substance use disorder treatment agencies to help them train
their staffs on how to work with people with disabilities
- Hosting a larger training session for the staff of local substance
use disorder agencies with the assistance of disability providers
(including the local CIL, the Association for the Blind, the Community
Outreach Program for the Deaf, and the Arizona Center for Disability
Law) and a panel of recovering Tucsonians with disabilities who
described the difficulties they encountered going through treatment
without adequate accommodations
- Providing training for disability service providers on how to
identify and refer substance-using clients and how to address
their social and medical needs without enabling their substance
- Developing case management procedures to ensure a coordinated
approach to meeting client needs. Following their procedures,
when a provider identified a client with a disability, the provider
contacted the appropriate disability resource provider; when disability
service providers encountered a consumer with a substance use
disorder they referred the individual to a treatment agency.
|Source: Kressler and
Figure 4-4: Common Sources of Referral for
Clients With Disabilities
Common Sources of Referral for Clients With Disabilities
Agency: Provides training to prepare clients with disabilities
to obtain and maintain competitive or supported employment. Such assistance
may include prevocational training, such as building skills in grooming,
punctuality, and interpersonal relations on the job. Specific training
targets the client's desired job area.
|Criminal Justice System:
Clients with disabilities will be just as likely as other people with
substance use disorders to face legal problems, and many referrals
come from probation or parole officers, the public defender's office,
and the police.
|Hospitals, Physicians, and
Emergency Rooms: Health care providers often encounter substance
use disorders while treating people with disabilities for other medical
conditions, including psychiatric conditions.
|Centers for Independent
Living: These nonresidential, nonprofit organizations run by people
with different disabilities provide advocacy, information, skills
training, and peer counseling for a cross-disability population.
|Schools and Educational
Agencies: Many substance use disorders become noticeable in an
educational environment where a student's performance in different
areas may be closely supervised.
|Welfare Agency: Provides
people with disabilities with access to Federal and State entitlement
programs such as Supplemental Security Income, Social Security Disability
Income, food stamps, general assistance, and Medicaid.
|One Stop Job Shop (Career
Center): Currently being set up in 33 States by the U.S. Department
of Labor. Provides help in writing a résumé, searching
for job openings on the Internet (America's Job Bank lists 750,000
openings by region and job skills), and using a computer.
Agency: Helps people to regain physical functioning after an illness
or accident. These groups will have close contact with a number of
people with disabilities.
|Senior Citizens' Center:
Offers a variety of social and community services to individuals age
65 and older. Services may include counseling and therapy, programming
for persons with Alzheimer's disease, wellness programs, retirement
adjustment programs, and meal delivery to homebound persons.
|Family or Significant Others:
Those closest to an individual are always an important source
of referral for people seeking treatment for substance use disorders.
|Veterans Affairs Program
or Hospital: Serves active and nonactive military personnel and
their families, providing them with medical and behavioral healthcare
including residential treatment.
Figure 4-5: Common Needs, Their Impacts,
and Possible Resources
Common Needs, Their Impacts, and Possible Resources
|Need: Medication management
Impact on Treatment: The medication may cause the client to
be disoriented or show symptoms of illness.
Resources: Pharmacy, physician, nursing staff
Impact on Treatment: The client may be unable to feed or dress
herself, attend to personal hygiene, etc.
Resources: Medical supply houses, nursing programs, attendant
care, CILs, physical rehabilitation programs
|Need: Cognitively accessible
materials (understandable written and verbal materials)
Impact on Treatment: The client may be unable to comprehend
treatment goals and objectives, directions, training materials, or
other important documentation in written form.
Resources: Community mental health agency, Substance Abuse
Resources and Disability Issues (SARDI), National Clearinghouse,
school or college counseling service or disability office
|Need: Equally effective
communication (accessible counseling or training sessions)
Impact on Treatment: The client is not able to participate
fully in counseling sessions, lectures, meetings or training.
Resources: Interpreters, computers, voice enhancement equipment
Impact on Treatment: The client may be unable to arrive at
counseling sessions on time or reach agencies to which she is referred.
Resources: CIL, disability service office of public transit
authority, county disability programs, volunteer assistance through
United Way or other agencies, van pools, disability organizations,
county ombudsman, Retired Senior Volunteer Program (RSVP)
Impact on Recovery: Because there is a shortage of low-cost
housing that is also accessible, many people with disabilities otherwise
capable of independent living may have difficulty locating a stable
living situation. This may result in continued dependence on family
members or caregivers whose attitudes and actions deter recovery.
|Need: Financial management
Impact on Treatment: Clients with cognitive disabilities or
mental retardation may not understand medical bills or benefits, resulting
in a loss of services.
|Resources: CILs, community
case management services
Figure 4-6: Five Linkage Tasks
Five Linkage Tasks
- Enhancing client's commitment to following through with contacting
- Carefully planning the client's initial contact with the other
- Analyzing the potential obstacles that might hinder successful
- Modeling and rehearsing the implementation
- Summarizing for the client what was learned in steps one through
|Source: Ballew and Mink,
1996, pp. 235-236.
Figure 4-7: Examples of Community Coalitions
Examples of Community Coalitions
|The Disability Substance
Abuse Task Force (now the Congress on Chemical Dependence and Disability)--Los
Angeles County, California
- Purpose: To remedy the "unjust exclusion from alcohol
and drug abuse services of people with disabilities" (de Miranda
and Cherry, 1989).
- Representative Accomplishments: All Los Angeles County
alcohol service delivery contracts now include specific language
mandating that each program prepare a plan to increase its accessibility
to people with disabilities. The County also requires all new
treatment service programs to be fully accessible to persons with
|Disabled Access Coordinating
Committee--Orange County, California
- Purpose: To ensure that alcohol treatment programs complied
with Section 504 of the Rehabilitation Act of 1973.
- Representative Accomplishments: The committee conducted
a needs assessment and facilities survey and is currently producing
a series of recommendations to improve accessibility throughout
the alcohol abuse services system.
|Coalition on Disability
and Chemical Disability--San Francisco Bay Area, California
- Purpose: To create a network of agencies that would document
the need for appropriate services for people with disabilities
in the area and to encourage creative coordination, networking,
and cross-training among area alcohol, drug, and disability programs.
- Accomplishments: The coalition held a conference which
included cross-training sessions and county caucuses to encourage
advocacy, sponsored workshops on substance use disorder prevention
among young persons with disabilities, and conducted a needs assessment
to document the prevalence of drug use among persons with disabilities
in the area.
Figure 5-1: Benefits of Modifying Programs
To Accommodate Persons With Disabilities
Benefits of Modifying Programs To Accommodate Persons With Disabilities
- Improved treatment completion rates
- New service population
- Legal compliance insulates program from liability
- Many grants and contracts are contingent upon Americans With
Disabilities Act compliance
- Different funding sources available for a new population base
- Niche area or specialty area for the program
- Communities need to have this service available
- Expand scope of approaches and services to use with all clients
- Broader connection to disability agencies and the Disability
Community provides political benefit
Figure 5-2: Questions for Counselors To Think
Questions for Counselors To Think About
- What books about people with disabilities did I read as a child?
- What view of people with disabilities do I get from the media?
- What scholarly information have I read concerning people with
- What experience have I had with significant others who are disabled?
- Who else from the Disability Community have I had contact with?
- What are my issues, hot spots, fears, and stereotypes concerning
Figure 5-3: Out-of-State Specialized Services
in New Jersey
Out-of-State Specialized Services in New Jersey
|Beginning in the late 1980s,
New Jersey began developing services to meet the needs of persons
who were deaf and hard of hearing and had substance use disorders.
A statewide coordinator was hired by the Single State Agency, and
funding was sought in order to begin developing a continuum of services
for this population. There was a great deal of discussion involving
referring agencies and individuals' families about how to meet the
immediate need for residential treatment, and a decision was made
to approve the Minnesota Chemical Dependency Program for Deaf and
Hard of Hearing Individuals as a New Jersey Medicaid provider. The
reasons for this decision were twofold. First, this was the only hospital-based
residential treatment program designed specifically to meet the needs
of people who are deaf and hard of hearing. Secondly, this high quality
program offered services that were more cost effective than what could
be offered in New Jersey at that time. The daily cost was between
two and three hundred dollars; a "hearing" program in New Jersey utilizing
the services of sign language interpreters throughout the day and
evening (to make the entire program accessible) would have easily
cost twice as much. Additionally, a hearing program with interpreters
would not work as effectively for most people who are deaf as would
a program designed specifically to meet their linguistic and cultural
needs. This cooperative relationship between agencies within one State
and with an out-of-state, disability-specific program resulted in
a more cost effective and higher quality solution.
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