Appendix C -- How To Refer to People With Disabilities

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Congenital disability. A disability that has existed since birth but is not necessarily hereditary. The term birth defect is inappropriate.
  6. 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.
  7. 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.
  8. Disfigurement. Physical changes caused by burn, trauma, disease, or congenital problems.
  9. 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 unacceptable terms.
  10. 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 for her.
  11. 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.
  12. Mental disability. The Federal Rehabilitation Act (Section 504) lists four categories under mental disability: psychiatric disability, retardation, learning disability, or cognitive impairment.
  13. 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.
  14. 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.
  15. 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 legal accuracy.
  16. 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.
  17. 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 society.
  18. 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.
  19. 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.
  20. 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.
  21. Stroke. An interruption of blood to brain. Hemiplegia (paralysis on one side) may result. Stroke survivor is preferred over stroke victim.
  22. 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 Project

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 Written

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 result.
  • 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 provisions.

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 testing permitted?".)

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 opportunity.
  • 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:

  1. Attitudinal barriers
  2. Discriminatory policies, practices, and procedures
  3. Communication barriers
  4. 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 other videos.

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 and staff.

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 With Disabilities?

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:

  1. 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.
  2. 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.
  3. Actively seek qualified persons with disabilities when searching for advisory board members.
  4. Actively seek qualified persons with disabilities when hiring new staff members.
  5. Develop prevention and treatment services that target specific populations of persons with disabilities. Some possibilities include the following:
    1. Providing some initial information or counseling services in disability-specific settings.
      EXAMPLE 1: Arrange to give a talk or facilitate a rap group on alcohol and drug issues at an independent living center or a rehabilitation hospital.
      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.
    2. 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 site.

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 Awake program.

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 costs.

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 consideration.

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 program.

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 cocaine users.

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 other applicants.

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 Mental Health.12

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 the client.

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, and dressing.15

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 these expenses.

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 Facility?

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 Communications Barriers

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 disabilities.

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 Provide?

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 writing.

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 financial burden.

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 offered."23

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 Services?

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, or Visitors?

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 other clients.

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 text format.
  • 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 Other Materials

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 disabilities.

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 Accessible?

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 interpreter services.
  • 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 audiocassette.
  • 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 24.)

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 the state.

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 fountains.

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 removal project.

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 publication.

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 use wheelchairs.

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:

  1. Installing ramps;
  2. Making curb cuts in sidewalks and entrances;
  3. Repositioning shelves;
  4. Rearranging tables, chairs, vending machines, display racks, and other furniture;
  5. Repositioning telephones;
  6. Adding raised markings on elevator control buttons;
  7. Installing flashing alarm lights;
  8. Widening doors;
  9. Installing offset hinges to widen doorways;
  10. Eliminating a turnstile or providing an alternative accessible path;
  11. Installing accessible door hardware;
  12. Rearranging toilet partitions to increase maneuvering space;
  13. Insulating lavatory pipes under sinks to prevent burns;
  14. Installing a raised toilet seat;
  15. Installing a full-length bathroom mirror;
  16. Repositioning the paper towel dispenser in a bathroom;
  17. Creating designated accessible parking spaces;
  18. Installing an accessible paper cup dispenser at an existing inaccessible water fountain;
  19. Removing high pile, low density carpeting; or
  20. 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 Achievable?

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 facilities."

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 with disabilities.

The next priority is for measures that provide access to those areas of ... [the facility] where services are made available to the public [clients]....

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] lowering telephones.35

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 Buildings?

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 Accessible Space?

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 public accommodation.44

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

Final Remarks

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

General Policies

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) ____________________ (title).

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 our clients.

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 people.

Providing accommodations

__________________ (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.

Risk identification

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.

Communication Access

General policy

_________________ (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 financial burden.

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.

Interpreter services

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 community.

We have the goal of allocating funds in our budget for providing interpreter services when they are needed.

Written materials

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 ______________ (location).
  • Roll-call is taken and the sign-out book is checked to account for each resident/participant.
  • 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.

Extracurricular Activities

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.

Grievance Procedures

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 possible resolutions.

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" above.

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, 9.

9 Ibid.

10 From "Illegal use of drugs," The Americans With Disabilities Act Title III Technical Assistance Manual, III-3.9000, 18.

11 Ibid.

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, 24.

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, III-4.2300, 23.

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, III-4.3300, 26-27.

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, 27

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, III-4.3420, 27.

27 Ibid, 34.

28 From "Removal of barriers--General," The Americans With Disabilities Act Title III Technical Assistance Manual, III-4100, 28-29.

29 Ibid.

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, 29.

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, 34.

36 Ibid, 34-35.

37 From "Alternatives to barrier removal--General," The Americans With Disabilities Act Title III Technical Assistance Manual, III-4.5100, 38.

38 Ibid.

39 Ibid.

40 From "Priorities for barrier removal," The Americans With Disabilities Act Title III Technical Assistance Manual, III-4.4500, 34.

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, 31.

43 Ibid.

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, 17.

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 Coexisting Disability

Figure 1-1
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

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 or functions.**
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.**
Functional capacities: The ability or degree of ability possessed by the individual to meet or perform the behaviors, tasks, and roles expected in a social environment.***
Functional limitations: 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

Figure 1-3
Disability Chart
Category Disability
Physical Spina bifida
Spinal cord injury
Chronic fatigue syndrome
Carpal tunnel
Cognitive Learning disability
Traumatic brain injury
Affective Depression
Bipolar disorder
Eating disorder
Posttraumatic stress disorder
Sensory Blindness
Visual impairment
Hard of hearing

Figure 2-1: Educational and Health Survey

Figure 2-1
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.
  1. Do you have a disability or have you ever been told that you have a disability?
    ___ Yes ___ No
  2. Are you currently under the care of a doctor or other medical care professional?
    ___ Yes ___ No
  3. Do you take medications?
    ___ Yes ___ No
  4. Do you have difficulty hearing in group settings (e.g., theaters, classrooms, family dinners)?
    ___ Yes ___ No
  5. Do you frequently need people to repeat what they have said to you?
    ___ Yes ___ No
  6. Have people complained that you don't hear or don't listen to them?
    ___ Yes ___ No
  7. Do you wear glasses or contact lenses?
    ___ Yes ___ No
  8. Do you have difficulty seeing things that are far away or very close?
    ___ Yes ___ No
  9. Do you have frequent eye pain or headaches?
    ___ Yes ___ No
  10. Have you ever hit your head and lost consciousness?
    ___ Yes ___ No
  11. Have you ever received health or disability benefits?
    ___ Yes ___ No
  12. Have you ever been unemployed for a long period of time?
    ___ Yes ___ No
  13. Have you ever been fired from a job, asked to leave a job, or passed over for a promotion?
    ___ Yes ___ No
  14. Did you ever have special classes or tutoring in school?
    ___ Yes ___ No
  15. 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
  16. 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
  17. Have you ever had problems with or been bothered by any of the following?
    ___ Controlling anger
    ___ Remembering things
    ___ Following instructions (verbal, written, or demonstrated)
    ___ Concentrating
    ___ Becoming tired easily
    ___ Getting along with others
  18. Have you ever had problems or 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 rate
    ___ Pounding in chest
    ___ Heart burn or stomach pain
    ___ Uncontrolled feelings of happiness or euphoria

Figure 2-2: Impairment and Functional Limitation Screen

Figure 2-2
Impairment and Functional Limitation Screen
Questions Further Questions Followup Treatment
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. Provide medication 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? (4-6) 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. Administer hearing 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) Further investigate 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. Obtain results 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. Request records. 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 program. Obtain 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. 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 effectively. 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. Use relaxation 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? (18) 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. Obtain medical 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"

Figure 2-3
Profile of "John"
Functional Area Strengths Needs Recommended Followup
Eating OK    
Grooming Well groomed    
Bathing OK    
Dressing OK    
Bowel and bladder management OK    
Positioning OK    
Walking, with or without assistive devices (e.g., walker, cane) OK    
Use of wheelchair No    
Use of stairs OK    
Ability to operate motor vehicles   License suspended 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 site
Reading   Apparent reading problem Request school 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
Writing     Writing skills need to be determined, but requirements are minimal in program
Speaking Well-spoken    
Listening     Listening ability may be limited by attention problems
Attention   Attention problems Ritalin use in childhood may indicate the need for a referral to a psychiatrist for further evaluation
Comprehension Comprehension appears to be good    
Retention and Application     May need formal assessment of retention and application abilities
Awareness and recognition of problem   Statement that reason for being in treatment is he "got into trouble" may indicate lack of awareness of problem (DUI)  
Identification of alternatives     Screen problem-solving skills and anticipate possible consequences of various alternatives; then decide on optimal alternative
Social Skills
Understanding of social mores and values Statement that he "got into trouble" indicates awareness of social values    
Impulse control   DUI and story of fight indicate impulse control problem; although they may be drinking-related Further evaluation called for since substance use can cause a lack of impulse control
Intimacy     Explore relationships
Conversational skills Conversational skills consistent with age, etc.    
Empathy; ability to identify with others     Need to further explore
Executive Functions
  • 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

Figure 3-1
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:
  • The severity, duration, or specific functional limitations of the disability
  • 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 disability
  • A history of having used substances to cope with a disability
  • Recurring and episodic forms of personal grieving due to disability issues
  • The amount of independence resulting from a person's lifestyle and personality
  • 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)
Source: Chart modified from Li and Moore, 1998

Figure 3-2: Locating Expert Assistance

Figure 3-2
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

Figure 3-3
Responses in a Treatment Setting
  1. 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.
  2. 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 go.
    Accommodation: Why don't you take a rest period in late afternoon, and attend a third meeting, or alternative treatment activity, in the evening?
  3. 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.
  4. 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.)
  5. 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 of Goals

Figure 3-4
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

Figure 3-5
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 Disabilities

Figure 3-6
Sample Contracts for People With Disabilities
Task: The individual must write a history of her addiction during the first 3 days of an inpatient program.
Consequence: 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 history).
  • Be specific in assigning a time period for reporting substance use history (e.g., last year, "since my arrest").
Task: The individual in outpatient treatment must attend all groups.
Consequence: 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 session.
  • Substitute another activity if the individual cannot get to the meeting (e.g., an individual session, a 12-Step meeting, writing a report).
  • 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.
Task: The individual must attend 90 Alcoholics Anonymous (AA) meetings in 90 days.
Consequence: Failure to attend will mean that the client is reported as noncompliant to referral sources.
  • 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 sponsor.

Figure 3-7: Accommodating Clients Who Are Visually Impaired

Figure 3-7
Accommodating Clients Who Are Visually Impaired
Improving interactions with an individual with blindness or low vision
  • 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 convey communication.
  • 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, etc.).
  • 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 impairments.
Source: Substance Abuse Resources and Disability Issues, 1995.

Figure 3-8: Suggestions for Providers Working With Persons With Brain Injury

Figure 3-8
Suggestions for Providers Working With Persons With Brain Injury
  1. Try to determine a person's unique learning style.
    • Ask how her reading is, how well she writes, or evaluate via samples.
    • Both ask about and observe a person's attention span; be attuned to whether attention seems to change in busy versus quiet environments.
    • 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?).
  2. 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 way.
    • 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 abilities.
    • Enlist family, friends, or other service providers to reinforce goals.
    • Do not take for granted that something learned in one situation will be generalized to another.
    • Repeat, review, rehearse, repeat, review, rehearse.
  3. 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 are appropriate.
    • Redirect tangential or excessive speech, including a predetermined method of signals for use in groups.
  4. 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 to denial.
    • 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 through.
Source: The Ohio Valley Center for Brain Injury Prevention and Rehabilitation, 1998.

Figure 4-1: Examples of Interagency Collaborations

Figure 4-1
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 requirements.

Figure 4-2: Potential Community Resources to Assist With Treatment

Figure 4-2
Potential Community Resources to Assist With Treatment
All Disabilities
  • Centers for Independent Living
  • United Way
  • Vocational rehabilitation agencies
  • State disability councils
Learning Disability (LD)
  • Local or national Learning Disabilities Association
  • Community, school, or university LD program
  • Community mental health centers
  • Literacy council
Developmental Disability (DD)
  • School or community DD program
  • Parent organizations
  • Goodwill Industries
  • Special Olympics
Blind or Visual Impairment
  • Vocational rehabilitation providers
  • Senior citizens' center
  • Public library
  • Society for the Blind
  • Lion's Club
Deaf and Hard of Hearing
  • 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 states)
Spinal Cord Injury
  • 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 Project

Figure 4-3
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 use
  • 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 Ward, 1997.

Figure 4-4: Common Sources of Referral for Clients With Disabilities

Figure 4-4
Common Sources of Referral for Clients With Disabilities
Vocational Rehabilitation 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.
Physical Rehabilitation 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

Figure 4-5
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
Need: Self-care
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
Need: Transportation
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)
Need: Housing
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.
Resources: CILs
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

Figure 4-6
Five Linkage Tasks
  1. Enhancing client's commitment to following through with contacting the resource
  2. Carefully planning the client's initial contact with the other agency
  3. Analyzing the potential obstacles that might hinder successful contact
  4. Modeling and rehearsing the implementation
  5. Summarizing for the client what was learned in steps one through four
Source: Ballew and Mink, 1996, pp. 235-236.

Figure 4-7: Examples of Community Coalitions

Figure 4-7
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 physical impairments
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

Figure 5-1
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 About

Figure 5-2
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 disabilities?
  • 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 disabilities?

Figure 5-3: Out-of-State Specialized Services in New Jersey

Figure 5-3
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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