Disabilities

Diseases, disorders, and injuries, whether congenital or acquired, can have various effects on organs and body systems. Conditions (and diseases) such as multiple sclerosis, TBI, spinal cord injury, diabetes, and cerebral palsy can lead to impairments, such as impaired cognitive ability, paralysis, blindness, or muscular dysfunction. These impairments in turn cause disabilities, which limit an individual's ability to function in various areas of life, such as learning, reading, and mobility. While diseases, impairments, and disabilities are distinct categories, they are often used interchangeably; to ensure clarity, they are defined in Figure 1-2.

The field of disability services has developed its own terminology to discuss physical and cognitive disabilities, and many substance use disorder treatment providers will not be familiar with these terms. The terms used throughout the TIP (and in the field of disability services) are defined below.

The World Health Organization (WHO) has devised a method for the classification of impairments and disabilities (World Health Organization, 1980). This complex system has been simplified here into four main categories:

1. Physical impairments are caused by congenital or acquired diseases and disorders or by injury or trauma. For example, spinal cord injury is a disorder that can cause paralysis, an impairment.
2. Sensory impairments include blindness and deafness, which may be caused by congenital disorders, diseases such as encephalopathy or meningitis, or trauma to the sensory organs or the brain.
3. Cognitive impairments are disruptions of thinking skills, such as inattention, memory problems, perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing (the ability to follow a set of steps in order to accomplish a task), misperception of time, and persevera-tion (constant repetition of meaningless or inappropriate words or phrases).
4. Affective impairments are disruptions in the way emotions are processed and expressed. For the purposes of this discussion, affective impairments are considered to include problems caused by both affective and mood disorders, such as major depression and mania. These impairments include the symptoms of mental disorders, such as disorganized speech and behavior, markedly depressed mood, and anhedonia (joylessness).

Figure 1-3 categorizes various disabilities according to these four classifications; however, some conditions may be more difficult to categorize and some individuals may experience multiple conditions.

Functional Capacities and Limitations

People may have the same disability without having the same functional capacities and limitations. It is, however, their capacities and limitations that will determine what accommodations should be made to the treatment plan. Treatment providers should look at each individual when determining the level and type of service needed rather than prescribing an approach or course of treatment based on the disability diagnosis. For example, one person with TBI may require a period of specialized services because of problems with attention span, unconstructive behaviors, or medical needs. Someone else with TBI may be stable enough to be integrated with nondisabled persons with minimal accommodation.

Though this TIP addresses accommodations and adjustments by disability, functional limitations are actually what will drive program modifications. There are seven categories of functional capacity and limitation that can impinge on a person's treatment. They are listed below with some of the specific functions that fall under each category.

1. Self-care
   • Eating
   • Grooming
   • Bathing
   • Dressing
   • Bowel and bladder management
   • Medication usage
2. Mobility
   • Positioning
   • Walking, with or without assistive devices
   • Use of wheelchair or other mobility aid
   • Use of stairs
   • Ability to operate motor vehicle
   • Use of public transportation (or other access to transportation)
3. Communication
   • Reading
   • Writing
   • Speaking
   • Listening
4. Learning
   • Attention
   • Comprehension
   • Retention
   • Application
5. Problem-solving
   • Awareness and recognition of problems
   • Identification of alternatives
   • Anticipation of possible consequences of various alternatives
   • Deciding on optimal alternative
6. Social skills
   • Understanding of social mores and values
   • Impulse control
   • Intimacy
   • Conversational skills
   • Empathy
7. Executive functions
   • Planning and organization
   • Motivation and initiation
   • Monitoring and reviewing
   • Decisionmaking

Life Problems Contribute to Substance Use Disorders

People with disabilities are more likely to use substances in part because they experience unemployment, lack of recreational options, social isolation, homelessness, and victimization or physical abuse more frequently than the general population (Susser et al., 1991; Vash, 1981; DeLoach and Greer, 1981; Marshak and Seligman, 1993). If they also have substance use disorders, such problems are further exacerbated.

Many adults with disabilities are underemployed or unemployed. Some 30 percent live below the poverty line, a rate approximately 20 percent higher than that for people without disabilities (LaPlante et al., 1997). People with disabilities at all income levels generally spend a large proportion of their income to meet their disability-related needs. Like others who have been isolated or unemployed over a long period of time, some people with disabilities lack the social skills and familiarity with workplaces needed to succeed in a job.

For many reasons, people with disabilities may rely on a smaller social network. They may be isolated because of their families' efforts to protect them, the physical difficulty of getting out to social settings, lack of opportunities to practice social skills, lack of physical stamina, trouble finding activities and negotiating transportation, poverty, and nondisabled people's discomfort with people with disabilities. An altered body image can make those with a recent disability onset (e.g., people using a wheelchair for the first time) reluctant to socialize. Additionally, physical limitations make some people fear violence or exploitation. People with disabilities are at greater risk of being victims of sexual abuse and domestic or other violence (Glover et al., 1995; Varley, 1984). They are more likely to be victimized because they are perceived as unable to protect themselves. Depression and low self-esteem associated with their disabilities can also play a role in some individuals' victimization, and in turn their substance use.

Isolation and functional limitations leave many people with disabilities with few recreational options, yet they often have much unstructured time on their hands. For example, people who are blind or have a visual impairment may face increased isolation, excess free time, and underemployment (Motet-Grigoras and Schuckit, 1989; Nelipovich and Buss, 1989). Some people may perceive bars or other places where alcohol is consumed as the only social gathering places open to them and drinking or drug use the only possible means of recreating or gaining social support (Greer, 1986).

Panel members report that employed assistants and caregivers for people with disabilities may often abuse their clients, steal from them, or otherwise exploit them. The caregiver for a substance-using client with a disability may purchase alcohol or drugs for the client or tolerate the client's self-destructive behavior.

Obvious Versus Hidden Disabilities

Identifying hidden disabilities is the key to successful substance use disorder treatment. A patient who repeatedly fails at treatment may not understand what he is told, or may not be able to read or remember materials. Many people who have disabilities (e.g., people with multiple sclerosis, seizure disorders, cardiac problems) look healthy much of the time, but these conditions often cause significant fatigue or limitations on walking, driving, or other physical activities. Treatment staff members may not accept or believe a client has a disability based on what they see, regardless of what the client says. In some cases, people may have had a lifelong investment in hiding their cognitive disabilities and will not volunteer or admit to their conditions.

Disabilities can also be hidden from clients themselves. A substance use disorder treatment program may be where a person first discovers she has diabetes, a learning disability, or a hearing loss. Even if a client knows he has a disability, he may not be aware of accommodations that could help him function better.

Whether they recognize it or not, treatment providers are already delivering services to a variety of people with disabilities. Some of these may be the same people who drop out of treatment, who do not seem to make progress, or who seem unmotivated. Such clients can be particularly frustrating for treatment providers; however, if functional limitations are recognized and treatment is modified accordingly, the program is likely to see better results.

The counselor must be especially sensitive when working with people who are not aware of or wish others to remain unaware of their disability. Chapter 2 elaborates some of the ways in which treatment staff can screen for cognitive disabilities that may not be readily apparent.

Attitudinal Barriers

Attitudes about "disability" influence the ways nondisabled people react to people with disabilities, which can affect the latter's treatment outcomes. The stereotypes and expectations of others also influence the ways people think about their own disabilities.

Perceptions, stereotypes, or beliefs held by providers can hinder their ability to treat a person with a disability. Following are some examples of commonly held beliefs that can pose barriers to treatment:

• People with disabilities do not abuse substances.
• People with disabilities should receive exactly the same treatment protocol as everyone else, so that they aren't singled out as different. Being mainstreamed into society means that you should do exactly the same things as everyone else.
• A person is noncompliant when her disability prevents her from responding to treatment.
• A person with a disability will make other clients uncomfortable.
• People with disabilities will sue the program regardless of the services offered.
• Serving people with disabilities requires going to extremes.
• Every person with a disability requires hospitalization rather than a residential or outpatient program.
• People with cognitive disabilities are not capable of learning how to stay sober.
• People with disabilities make too many demands and use their disability as an excuse for not fully participating in treatment.
• People with disabilities deserve pity, so they should be allowed more latitude to indulge in substance use.

Staff members who hold such beliefs about people with disabilities may screen out those who would be well served by their programs or deny a client an appropriate accommodation for her disability. On the other hand, these staff members may unwittingly enable clients to use their disabilities to avoid treatment. (For examples of inappropriate responses, see Figure 3-1 on Denial, Enabling, and Accommodation.)

Staff training is key to overcoming attitudinal barriers. For more information on staff training, see Chapter 5 for the discussion of Provider Knowledge of People with Disabilities. To learn the appropriate terms to use in referring to people with disabilities see Appendix C: How to Refer to People With Disabilities.

Discriminatory Policies, Practices, and Procedures

Programs can inadvertently discriminate when their policies, practices, or procedures present barriers to the treatment of people with coexisting disabilities. For example, a program may establish a discriminatory policy such as the following:

• We do not serve clients who are taking medication (even if the medication is for a medical condition, such as epilepsy). (Such discrimination is also often seen against clients in opioid maintenance therapy or those who require psychoactive medications for a psychiatric condition.)
• People who miss appointments must pay fines (even though disability-related problems may make it impossible for a person to make a scheduled appointment)
• Fire and safety regulations require that all clients be able to walk out of the building independently (which precludes the participation of a person who uses a wheelchair).
• All clients must participate in house chores such as washing dishes and mowing the lawn (which precludes the participation of people with particular physical disabilities).
• Every person must read two chapters of a book per day (even if some people do not have the necessary reading skills).

Examples of discriminatory practices include the following:

• A client is excluded from the residential setting because he needs assistance in transferring from the wheelchair to the bed (even though this task is readily learned by program staff and is required only twice per day for 2 minutes at a time).
• A client is discharged from outpatient treatment for missing three sessions, when the client was actually delayed by waiting for a "handicapped-accessible" bus that does not run on a set schedule.

The ADA sets forth many requirements to protect people with disabilities from administrative barriers. Programs should periodically review their existing policies, practices, and procedures and adopt new ones as needed in order to avoid discrimination. Rules and treatment plans can be specifically tailored to meet the needs of each person, and consequently the specific treatment requirements will vary for some people. An individualized treatment approach permits more latitude in assigning different types of chores or homework to individuals and in using different techniques or learning modalities (e.g., allowing a client who has great difficulty speaking in a group setting to turn in an oral report on audiocassette). Also, when all clients receive individualized treatment there will be less friction when one client is permitted to do an assignment differently.

Barriers to Communication

These barriers exist when a program's communications with people with coexisting disabilities are less accessible than its communications with others. To eliminate communications barriers, programs should have available a wide range of auxiliary aids and services.

Architectural Barriers

Physical barriers include the absence of elevators or ramps, narrow hallways, poor lighting, wall telephones too high for people in wheelchairs, deep pile carpets that interfere with wheelchairs or crutches, conventional doorknobs that impede access to people with limited manual dexterity, or even a lack of transportation from the property's boundaries (where public transportation may drop off a person) to the facility's entrance. Programs should consider other types of modifications as well in order to make their buildings safer for all participants.

A person who is blind or visually impaired can typically move safely within an environment once it becomes familiar. The treatment provider should early on give clients who are blind a complete orientation to the facility. Signage to accommodate people who are blind and visually impaired is widely available and includes signs and elevator settings that are properly color contrasted or have raised Braille words and numbers. In addition, loose rugs, wall-mounted fire extinguishers, and lighting that is too bright or too dim can create mobility problems for individuals who are visually impaired.

When barriers cannot readily be removed, a program must find alternate methods to make its services available. A program that offers counseling in an upstairs room must offer counseling downstairs when needed, if it is not able to add a ramp or elevator. If an onsite adjustment cannot be made, an outpatient program must find an alternate site where it can deliver the same level of care it provides at its nonaccessible site. A residential program may find it necessary to make an appropriate referral as a temporary solution, while it takes the steps necessary to change its facilities for future clients.

Deaf and Hard of Hearing

Many members of the Deaf Community benefit from specialized services, which generally are better equipped to handle specific cultural, language, and communications issues that may arise. People who are deaf or hard of hearing and use sign language tend to identify themselves as part of a deaf community. Many will prefer to be served by programs that specifically address their needs and whose staff is fluent in sign language. Unlike many other people with disabilities, people who are deaf often do not identify with a medical model of disability and instead embrace a cultural model that emphasizes their abilities within the Deaf Community and their own language and values.

Most people who are deaf seeking substance use disorder treatment prefer segregated programs to mainstreamed programs. This allows clients who are deaf to participate in a group with deaf peers and a counselor who is fluent in sign language. Direct communication will facilitate greater participation by clients who are deaf than communication through an interpreter. Such a group provides an environment of peers who share similar life experiences and a common language, generally considered important for the recovery process.

Yet having a group that is all deaf is not realistic for most programs. It is more likely that, on occasion, there will be only one client who is deaf in a program, and the rest of the clients will be able to hear. In this case, the program will need to hire one or more sign language interpreters to facilitate comprehensive communication among the client who is deaf, hearing clients, and hearing staff. In some instances, the program may want to refer the person to a specialized program serving people who are deaf and hard of hearing. If a sign language interpreter is not available, the leader of the group may try to communicate with the person through pencil and paper, trying to explain some of the issues. Without the presence of the interpreter, however, the individual who is deaf will miss much of the information shared during a therapeutic group.

Some individuals who are late-deafened or hard of hearing do not use sign language, did not grow up with other people who are deaf, and do not identify with Deaf Culture. This population is actually larger than the population who uses sign language (Minnesota Chemical Dependency Treatment Program for Deaf and Hard of Hearing Individuals, 1996). These individuals will generally prefer to be served by programs for the general population alongside clients who can hear. The types of accommodations they need will differ from what is needed to effectively treat clients who identify with Deaf Culture. These accommodations will usually consist of the use of devices either to amplify sound or to print what individuals in the program are saying. These people have grown up using English as a primary language and do not have the second language issues that are common to individuals who are deaf whose primary language is ASL.

People With Sensory Disabilities

The majority of people who are blind use a cane; fewer use guide dogs. Either way, people who are blind or visually impaired will require assistance in orienting themselves to a new environment. Treatment providers should try to describe or guide a person through a new environment. Instead of stepping back and allowing the person to fumble, the counselor should offer "sighted guide" assistance, during which the person who is blind holds the sighted person's arm just above the elbow and they walk in tandem. Pulling a person by his arm is not appropriate.

People who are blind live in a more touch-oriented world than the sighted population. It is acceptable for the counselor to put the blind person's hand on the back of the chair she is to use. A service animal, however, should not be distracted from its job; the animal should not be touched or petted, nor should one even ask permission to do so.

Word use is important. The counselor must use more descriptive and detailed language and strive to avoid phases like "over there" or "like this." There is no need to avoid words like "see" and "look"--they are part of everyone's daily language.

Finally, more than 80 percent of people considered "blind" have some residual vision. This remaining vision is typically light- or glare-sensitive. It is helpful to ask if the lighting in the current environment is uncomfortable. Figure 3-6 in the next chapter presents these and other suggestions for working with people who are blind in the form of an easy-to-follow list of suggestions.

Communication is the key issue when dealing with individuals who are deaf and hard of hearing. Regardless of the model of communication used by the person who is deaf or hard of hearing, the visual aspect of communication will be important. Therefore, it is important to look directly at the person when communicating so he can see facial expressions and has the option of lip-reading. When interviewing a person who is deaf with an interpreter, it is still important to look directly at the client. Speak directly to him just as if there was no interpreter present.

People With Physical Disabilities

Persons with disabilities that limit their mobility can encounter situations like sidewalks without curb cuts or front doors that cannot be opened from a wheelchair. They are understandably annoyed if they are stymied by these barriers and then hear those responsible for the facility explain, "We hardly ever get someone with a wheelchair here." Providers should not assume that someone in a wheelchair is unusually resistant to treatment just because she expresses anger at not being able to enter the facility through the same entrance or use the same restroom as other clients.

People who use wheelchairs often come to regard the chair as an extension of themselves, and touching the chair may be offensive to them. Never take control of the wheelchair or touch any other adaptive equipment without permission.

Initial Screening

Through the screening process, the provider can begin to understand the circumstances in a client's life that are likely to have a bearing on treatment. All such circumstances, whether or not they are disabilities, should be incorporated into the treatment plan.

Questions relating to disabilities can and should be incorporated as seamlessly as possible into a comprehensive screen, rather than treated as an altogether separate subject. After discussion of the substance use disorder, the interviewer can bring up visibly obvious impairments, such as those requiring the use of a wheelchair or cane. The questions can be framed by the program's desire to respond to individual needs: "Do you need any accommodations to participate in this program?" This question should be posed to everyone, not only to those the interviewer thinks have a disability.

The possibility of hidden impairments can be explored subtly during the conversation. For example, during a routine medical history, a question about past hospitalizations can elicit information about a previous brain or head injury, thus alerting the interviewer to the possibility of traumatic brain injury (TBI). Similarly, a client's answers to routine questions about past and current medications may point to the possibility of cognitive or affective impairments (see Case Study below). A client's referrals from other service providers such as VR services can also offer insights into less obvious impairments.

Setting always influences the screening process; this is especially true when testing or interviewing for disabilities. An individual's problems with mobility, for example, may make it necessary for the interviewer to travel to his home, where there may be distractions of children or other family members. However, a person might not be willing to speak openly in front of other family members, even if they already know about her disabilities. Wherever the interview takes place, it is important to create a sense of privacy in talking with the client.

Figure 2-1 presents a basic screening instrument for identifying impairments and functional limitations that can be handed to a client preceding an interview. The text can be used verbatim (with the instructions given at the top of the figure) as a form all clients would receive before a screening and assessment session. In the answers to questions such as these, the interviewer should be looking for things such as the history and symptoms of diseases or disorders that can provide clues to impairments and disabilities. If the questions and discussions based on the screen indicate an impairment, the client should be referred to a disabilities expert for a more in-depth screening.

Figure 2-2 presents the questions from Figure 2-1 in the manner they might be asked during a spoken (or signed) interview, with the numbers of the relevant questions provided in parentheses. This figure also provides further questions that might be asked and ideas for how the information gained in the interview could be used in followup treatment planning. Throughout the screening interview, it is important for the screener to pay attention to the individual's affect and behavior in order to pick up on possible cognitive or affective impairments. Screening for psychiatric disorders is discussed in TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994).

Case Study

"John," a 26-year-old white male, was referred from a local criminal justice agency after an arrest for driving under the influence (DUI). A high-school graduate, he lived with his mother and had held a series of entry-level jobs, none for more than 8 months. He had no obvious disabilities and stated that he is at the program because he "got into trouble." The screening questions presented below reflect a portion of a lengthier interview; John's answers to the questions will assist providers in planning his treatment program.

Q: Do you feel you have a disability, or has anyone ever told you that you have one?

A: No, nothing like that.

Q: Have you ever had to stay in a hospital overnight, or gone to an emergency room for any reason?

A: I've had some falls, and once I broke my arm. I went to the emergency room. But I never had to stay overnight.

Q: Have you ever seen a doctor for a long period of time, more frequently than just one visit or for routine check-ups?

A: Yes when I was in grade school.

Q: What was going on for you that you needed to see the doctor so often?

A: I'm not sure. I think I was overactive. I was on some kind of medicine.

Q: Do you know what kind of medication it was?

A: It was "rid-lin" [Ritalin] or something like that.

Q: Were you ever diagnosed with a learning disorder?

A: I don't think so.

Q: Were you ever in special education classes in school or did you receive any kind of tutoring?

A: I had some tutoring for math.

Q: Have you ever been given a hearing test?

A: Yeah. When I was in school they did hearing tests. I always passed them with flying colors. I don't have any hearing problems.

Q: Do you ever have to ask people to repeat what they're saying? Or has anyone ever complained to you that you don't listen?

A: Yeah, well my boss at work always says that I don't listen. And my teachers at school used to tell my mother that I don't hear what people are saying to me.

Q: Did you ever need to wear glasses?

A: No.

Q: When was the last time that your eyes were checked?

A: Oh, about 2 years ago. I was having some problems at work because they have really bright lights in the building. That would give me a headache sometimes. The eye doctor said that my eyes looked good. I guess I just don't like bright lights.

Q: Have you ever been hit on the head or had any blows to the head?

A: Now that you mention it, there was this one time in high school after football practice. Some of us were fooling around and I got into a fight. I don't know what happened. But I had to get some stitches and I had a headache for a few days.

Q: Did you lose consciousness?

A: I don't know. I guess there were some things I don't remember that people told me about later.

Q: What's the first thing you remember after the fight?

A: Riding in the ambulance.

Q: What did they do at the hospital?

A: I got some stitches in my forehead and they kept me around for a while to keep an eye on me.

Q: Did you notice any changes in your abilities since then?

A: No, not really.

Q: Have you had problems with bad or frequent headaches since the fight?

A: I guess sometimes I have headaches.

Q: Have you ever talked to a doctor about them?

A: No, not really.

[This is a problem that may need to be followed up with a physician visit. If neuropsychological testing was never done after the accident, it should be performed now if funds are available.]

Q: Have you ever received benefits of any kind? Like from a government agency?

A: No.

Q: Let's talk about your work history for a while. How many jobs have you had in the past three years?

A: Oh, about four or five.

Q: What was the longest job that you held?

A: Last year I worked for 8 months as a grocer's assistant. I quit because the boss was getting on my case. I don't think he liked me very much.

Q: Why do you think that?

A: Well, he would yell at me or tell me that I didn't do my job right. I should have been given a better job there, but he would say that I couldn't figure out how to do the job I had. He said I was forgetful.

Q: Do you think that you are forgetful?

A: Yeah, I guess so. I just sometimes forget things at work. There's too much to remember all at once.

Q: How were you taught your job?

A: Well, I followed this guy around and did what he told me to.

Q: Did that work? Do you feel that you learned the job?

A: It was OK when we worked together. Then they gave me a big list of stuff and I was supposed to just follow the list, but it didn't make sense.

Q: Were you able to read the list OK?

A: I guess some of it I didn't understand.

Q: Were you able to ask someone to explain the tasks required?

A: No, I just kind of figured it out. I don't like to ask a lot of questions. People don't always understand what I'm asking about anyway.

Q: Do you ever have trouble controlling your anger?

A: Maybe when I'm drinking.

Q: Do you ever feel anxious or on edge?

A: Sometimes. When I'm bored.

Q: How about feeling depressed? Or really happy for no reason?

A: No.

Q: Is English your first language? Did you speak any other language when you were growing up?

A: No, I only speak English.

Q: Tell me about your reading habits. What kind of stuff do you like to read? How often do you read?