Substance Use Disorder Treatment For People With Physical and Cognitive Disabilities Treatment Improvement Protocol (TIP) Series 29
[Figures]
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.
Blindness
Deafness
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.
Do you have a disability or have you ever been told that you have a disability?
___ Yes ___ No
Are you currently under the care of a doctor or other medical care professional?
___ Yes ___ No
Do you take medications?
___ Yes ___ No
Do you have difficulty hearing in group settings (e.g., theaters, classrooms, family dinners)?
___ Yes ___ No
Do you frequently need people to repeat what they have said to you?
___ Yes ___ No
Have people complained that you don't hear or don't listen to them?
___ Yes ___ No
Do you wear glasses or contact lenses?
___ Yes ___ No
Do you have difficulty seeing things that are far away or very close?
___ Yes ___ No
Do you have frequent eye pain or headaches?
___ Yes ___ No
Have you ever hit your head and lost consciousness?
___ Yes ___ No
Have you ever received health or disability benefits?
___ Yes ___ No
Have you ever been unemployed for a long period of time?
___ Yes ___ No
Have you ever been fired from a job, asked to leave a job, or passed over for a promotion?
___ Yes ___ No
Did you ever have special classes or tutoring in school?
___ Yes ___ No
In a school or work setting, do you like to learn or learn best 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
Have you had problems or difficulty with any of the following?
___ Getting your point across to others
___ Sitting still
___ Focusing on the task at hand for more than several minutes at a time
___ Understanding the point that others are making to you or what others are saying to you
___ Communicating your feelings or thoughts to others
Have you ever had problems with or been bothered by any of the following?
___ Controlling anger
___ Remembering things
___ Following instructions (verbal, written, or demonstrated)
___ Concentrating
___ Becoming tired easily
___ Getting along with others
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
Self-Care
Eating
OK
Grooming
Well groomed
Bathing
OK
Dressing
OK
Bowel and bladder management
OK
Mobility
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
Communication
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
Learning
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
Problem-Solving
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
An agency has this rule: All clients must attend an Alcoholics Anonymous (AA) meeting every night. A young person with TBI protests that he does not want to attend AA meetings because the meetings are filled with old people who don't understand him and don't think he should be taking medication for pain. Denial response: There are no exceptions to the rule. Everybody must attend AA every night. Enabling response: It's OK, you don't have to go if they don't understand your problem. Accommodation: We'll help you find support at the existing meeting, or a different meeting or support group that can better recognize and accept your legitimate medication needs.
A treatment program has three discussion groups during daytime hours. A person with multiple sclerosis asks to be excused from the third discussion group because of fatigue. Denial response: I'm sorry you're tired, but everyone has to attend all three meetings. Enabling response: If it's a problem, you don't have to 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?
A person with a visual disability is being coached by the treatment program in her job search. All the positions she finds either have schedules that require her to miss her AA meetings, or are in locations inaccessible by the public transportation she requires. She argues that she should not have to attend AA. Denial response: You're just making excuses. Figure out how to make it work. Enabling response: You're right. This is too much of a problem. Give up the AA meetings, or the work. Accommodation: We'll help you arrange to ride to work with a coworker, so that you have transportation to and from your job. Or else, we'll help you find work with a flexible schedule.
An unemployed person who is alcoholic with time on his hands and little social support is turned away from a State-run VR program because he has not yet maintained sobriety for 6 months. He is outraged but decides there is nothing he can do. Denial response: You'll just have to figure it out and get a job on your own. Enabling response: This is a terrible situation, but I guess you'll have to wait until January. Accommodation: We'll work with you to plan a course of prevocational activities that you can begin doing now. Then you can file an appeal with the State concerning the denial of services; we'll help negotiate with the vocational rehabilitation program for flexibility. (The program should work to get the system to admit persons who are compliant with treatment recommendations, even if they have not yet met the requirement in terms of months of sobriety. In this way the client can begin getting involved in productive activities. Agreeing with the client that nothing can be done encourages his sense of victimization.)
A client with an alcohol use disorder who is deafand 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).
Accommodations:
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.
Accommodations:
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 ensurehe 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.
Accommodations:
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
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?).
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.
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.
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 preventionpartnership 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
Enhancing client's commitment to following through with contacting the resource
Carefully planning the client's initial contact with the other agency
Analyzing the potential obstacles that might hinder successful contact
Modeling and rehearsing the implementation
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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