A need for accommodation

The Substance Abuse and Mental Health Services Administration estimates that 4.7 million Amer-ican adults with physical disabilities also have a co-occurring substance use problem. People with disabilities, encompassing a range of conditions that includes deafness, arthritis, and multiple sclerosis, experience substance abuse at two to four times the rate seen in the general population. Among people with spinal cord injuries, orthopedic disabilities, visual impairments, and amputations, about 40 to 50% can be classified as heavy drinkers, according to federal statistics.

Despite the prevalence of substance abuse seen among disabled individuals, addiction treatment centers often struggle in trying to meet the needs of clients with physical disabilities. According to the U.S. Department of Health and Human Services, treatment centers often are inaccessible to people with physical disabilities. Barriers to effective treatment for this population can include cultural insensitivity by healthcare and health promotion entities; limited availability of supports, such as interpreters for deaf or hard-of-hearing individuals; and materials unavailable in formats appropriate for visually impaired people.

SAMHSA has offered guidance in this area for some time through the 29th Treatment Improvement Protocol in that series of written publications: Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities. This guide covers provider-focused topics such as screening for disabilities, individualized treatment planning, counseling techniques, community linkages, and organizational commitment to serving this population. Still, there remains a dearth of programs designed specifically to meet the needs of physically disabled clients.

Dennis Moore, EdD, director of Substance Abuse Resources and Disability Issues (SARDI), a program based in the medical school at Wright State University in Dayton, Ohio, says that in 1991, more than 40 disability-related treatment programs were in operation across the country. “The vast majority of them don't exist now—there are very few that do,” Moore says. He adds that programs that seek to fill this niche in treatment often find such efforts difficult to sustain, partly because of challenges in retaining funding.

Consumer-focused model

SARDI, which receives most of its funding from the regional board that oversees behavioral health services in the Dayton area, is involved with both clinical services and research. SARDI's Consumer Advocacy Model allows consumers to have direct input into their services. CAM started when psychologists at Miami Valley Hospital in Dayton contacted SARDI because a number of people going through their physical rehabilitation program had alcohol or drug problems.

“They didn't seem to be able to connect these individuals with treatment programs that were effective, and in fact most [of these clients] had trouble even getting into the programs because of physical accessibility issues,” says Moore.

SARDI started a program at Miami Valley Hospital in 1994, and within two to three years outgrew the space and relocated it to a community setting. The program serves 300 active consumers in an outpatient setting, with all clients referred from the public system. SARDI also is in the process of opening a residential facility for more severe cases, particularly for individuals with accompanying mental illness.

“You can run a program with that kind of philosophical background and end up with a census that large and have it based in a town no larger than Dayton—that says something about the need,” says Moore. CAM serves people with visual impairments, traumatic brain injury, hearing impairments, orthopedic injury, cognitive injury, and co-occurring mental illness.

SARDI follows several treatment principles that differ from those of most mainstream centers. First, it works to get a patient stable, rather than automatically focusing on immediate sobriety. “We spend a period of time simply engaging with a person to the point where he'll trust us,” says Moore. This is particularly true for people with co-occurring cognitive disabilities or mental illness.

SARDI also believes in less intensity of treatment but a longer duration of treatment; its public funders are aware of this approach and do not see it as problematic in the way a private insurer might. “We only deliver as much treatment as a person can tolerate or the minimal treatment that he needs to keep him at a good place or allow him to make progress,” says Moore. SARDI tries to keep its engagement with clients for up to two years, though the average time is closer to nine months.

The program also provides intensive case management for its clients. It places an emphasis on finding employment for clients, and SARDI is currently working on a clinical trial examining rapid supported employment services. SARDI also works extensively with other community agencies, including social welfare agencies, the Medicaid agency, housing authorities, and criminal justice entities. If clients are referred from one of these systems, SARDI provides monthly updates on their progress, says Moore.

As for treatment accommodations, Moore says the treatment process moves slower for his agency's clients, and fewer written and visual materials are used in treatment. Counselors also spend more individual time with clients before and after group meetings.

Assisting the hearing-impaired

One disability subgroup that can feel particularly isolated during treatment is the deaf or hard-of-hearing population. Elly Carpenter is the lead counselor for the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals, an 18-year-old, 15-bed inpatient program that is part of the University of Minnesota Medical Center's Fairview treatment center. “There was a concern in the deaf community that services in general were lacking for deaf people,” says Carpenter.

Mainstream programs might hire an interpreter to staff operations for a couple of hours a day, but that's not going to help a deaf person get engaged in a group setting with people who understand their language, says Carpenter. Because of this lack of services, deaf clients cannot take advantage of a full day of treatment or 12-Step meetings, she says.

The Minnesota program provides a staff fluent in American Sign Language that offers services from morning until night, says Carpenter. “If a deaf person comes into our program, he is going to be in his language and in his culture with other deaf patients and be able to communicate fully, through the entire intake process all the way through the treatment planning, groups, one-on-one, and aftercare planning,” she says.

The program provides interpreters for lectures and all 12-Step meetings. In addition, the program deemphasizes English and the written word, with staff needing to translate from English into ASL almost all written materials. Instead of writing out assignments, clients use art and drawings and different kinds of creative projects—more hands-on types of endeavors.

“A very intelligent deaf person does not necessarily have great English skills, so all of our videotapes are recorded onto DVD or videotape with ASL, so when they come in for orientation, all of it is in their language,” says Carpenter.

The standard program lasts for 28 days. Carpenter considers the 12-Step-oriented program a little more intense than a standard treatment program. “Our programming starts at 8:30 in the morning and it goes to about 9 at night,” she says. Some staff members are in recovery and some are deaf.

Aftercare represents a very difficult challenge for deaf patients who are returning to places that are more rural and lack interpreter services. “There's a lot of isolation, and finding an AA meeting and then finding an interpreter is really tough,” says Carpenter. All graduating patients are invited to contact the Minnesota program through a videophone, TTY, or video relay system, though program staff members try to identify resources in the patient's home area.

“Sometimes people relocate here just because they want to be close and they want to take advantage of the interpreted meetings in the Twin Cities area,” says Carpenter.

The Minnesota program, which accepts patients from all over the United States and Canada, is the only hospital-based program of its type in the country.

According to SARDI's Moore, the New York State Office of Alcoholism and Substance Abuse Services (OASAS) tracks the number of disabled clients seeking treatment in that state. The agency found that “even people who are coded as deaf and hearing-impaired tend to successfully complete treatment at the same rate as other people, and in some cases actually attain more of their treatment goals,” says Moore.

“Most people who have disabilities will successfully complete treatment, assuming you can get them in,” he concludes.