Many people with disabilities cannot benefit from existing addiction treatment programs. There is a need not only for counselors who have specific training for working with people who are mentally and/or physically disabled but, also, a need for special programs for this particular group of clients.

According to the U.S. Department of Justice, the percentage of people with disabilities (19 percent) is larger than any other single ethnic, racial or cultural group in the United States. Because of related functional limitations and social stigma placed on those with disabilities, the population has continually struggled with barriers to employment and a lack of access to community services (Nightingale, 2000). Most providers know little about implementing treatment for people with disabilities (Tyas and Rush, 1993). Furthermore, there is a myth that disabilities or mental illness are byproducts of substance abuse (Helwig & Holicky, 1994).

Counselors at traditional programs might not be as experienced in working with people with multiple diagnoses. According to a survey of treatment centers in Los Angeles County, even though staff reported being able to meet the needs of dually diagnosed clients, they were not trained in treatment approaches for individuals with comorbid psychiatric disorders (Polinsky, Hser and Grella, 1998). Treatment approaches, which often include the use of medications for people with psychiatric disorders, sometimes contradict the typical practices in substance abuse programs.

While most programs surveyed by Polinsky, et al, did not serve individuals with mental, hearing, speech or visual impairments, they stated they were equipped for this population. Counselors need specialized training to serve individuals with disabilities (Helwig & Holicky, 1994). In addition, care providers assisting people with disabilities should have some cross training in substance abuse services to satisfy the demand for more specialized programs in order to meet the needs of disabled clients. Some studies indicate that up to 80 percent of individuals disabled by mental illness also have a substance abuse disorder (Bachman, Drainoni, & Tobias, 2004). Another study showed that 38 percent of individuals with traumatic brain injuries reported lifelong abuse of alcohol or drugs (Fann, Katon, Uomoto, & Esselman, 1995).

Making treatment more accessible
Most substance abuse treatment literature is not intended for people with limited reading skills and/or cognitive disabilities. In order to better serve persons with disabilities, literature should be modified – abstract terms should be simplified, and more graphics and illustrations should be used to clarify and reinforce treatment concepts. Providing examples that illustrate real-life situations, as well as role-playing exercises and repetition are important tools in treating this population. Creating treatment materials is time consuming and typically a trial-and-error process.

Since memory, concentration and focus are frequently ongoing issues, treatment sessions need to be shorter in duration and scheduled breaks should be provided. However, length of treatment tends to last two or three times longer than treatment in programs serving the general population. Groups should ideally be made up of six to eight people, much smaller than those of traditional programs. Programs should be flexible and willing to continually make modifications, since groups are made up of people with an array of educational levels, cognitive abilities, and learning styles. Throughout treatment, adjustments must be made for people of different abilities. Patience, creativity, and flexibility are paramount.

Barriers to treatment
Case management issues of transportation, accessibility, attendance, health care and case management typically arise when treating individuals with disabilities. A large number of persons with varying disabilities are unemployed or not employed at full capacity. Many persons with severe or multiple disabilities require specialized “medicars” to provide transportation to and from treatment. It is often difficult for persons with disabilities to attend self-help groups because, frequently, the meetings are held in the evenings when transportation carriers are not available. Consequently, there tends to be a low representation of persons with disabilities at Alcoholics Anonymous (AA) meetings.

In addition, physical and attitudinal accessibility continue to be major barriers for people with all types of disabilities in traditional treatment programs. Older buildings that house AA meetings, for example, may not have the ramps and elevators necessary for access. Some treatment facilities lack assistive devices such as telephone amplifiers, sonic alert lights and teletypewriters, that are relied upon by people who are deaf or hard of hearing.

Because of ongoing health issues and limited mobility, attendance rates in traditional treatment settings tend to be lower for persons who suffer from cognitive, physical and mental disabilities than for persons who do not have these impairments. Implementing and utilizing a variety of incentive programs for attendance and goal attainment is critical. Numerous and multiple case management issues can be obstacles to attendance as well. People with disabilities frequently require assistance with sorting out problems related to financial entitlements, housing, transportation and health care to help them focus on their treatment and successfully complete treatment.

Mental illness
“Denise” had been in and out of substance abuse treatment for several years. She lost custody of her two young daughters and moved between nursing homes and day programs while coping with a drug addiction and a severe mental illness. She finally found some stability in her life after she “had a chance to look at where I was” and “had a spiritual awakening” while hospitalized. With the assistance of her substance abuse counselor, Denise has been clean for two years. Her former counselor said Denise had been in denial about chemical dependency and her mental illness. She says Denise “continues to learn every day. It has not been easy at all.” In July 2003, Denise moved to a residential facility — a shared apartment setting for people diagnosed with mental illness.

Since March 2004, Denise has worked as a homemaker for senior citizens. She still attends AA meetings, and her goal is to live independently and regain custody of her children. She spends as much time as possible with her seven- and eight-year-old daughters. Denise shared her story entitled, “High on Life,” with others at Anixter Center’s Literacy Showcase.
“Working through 13 years of addiction and four years of recovery, I never thought I could make it this far,” Denise said. “However, my biggest accomplishment will be when I reunite with my children.”

Treating deaf or hard of hearing clients
Guthmann and Sandberg (1999) made several general statements that characterize the perception of substance abuse in the deaf community. The hearing community maintains greater awareness of substance abuse issues. The deaf community lacks awareness regarding substance abuse issues; and there is a negative stigma and a reluctance to discuss substance abuse problems. There also is a lack of research on substance abuse among deaf people. Guthmann and Sandberg theorize that a lower percentage of deaf people, relative to hearing people, actually utilize substance abuse treatment.

Two programs, Addiction Recovery of the Deaf, in Chicago, and the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals, are two of a very small number of programs in the United States, that offer treatment in American Sign Language. Both programs employ staff members who are proficient in American Sign Language and knowledgeable in deaf culture. Chemical dependency professionals in traditional programs know less about the special needs of the deaf and hard of hearing population than other special populations (Whitehouse, Sherman & Kozlowski, 1991). Whitehouse, et al also noted that the Federal Rehabilitation Act of 1973 guarantees services be as “equitable” and “effective” as those available to the general population.

Most deaf substance abusers receive the same services as the rest of the hearing population. Although the programs often hire a sign language interpreter for counseling sessions, this is not sufficient. Many people who are deaf already have faced isolation throughout their lives. Consequently, many people do not trust a hearing counselor, and trust is a vital component of recovery (Whitehouse, et al, 1991). According to Guthmann and Sandberg, communication barriers often exist within families who have deaf children. Most deaf people (about 90 percent) have parents who can hear (Schein, 1974), and, as Guthmann and Sandberg add, poor family communication can be a predictor of substance abuse.

Communication is always a major challenge for professionals serving the deaf community because persons who are deaf function at varying levels, and use several different forms of communication. In addition to American Sign Language, individuals use Pigeon Signed English, “home signs” and Signed English. There is a need for more chemical dependency professionals fluent in American Sign Language and sensitive to deaf culture to accommodate deaf clients with a variety of communication skills.

In addition, the admissions process is generally more time consuming when treating the deaf community. Simply setting up an appointment via the telephone relay service and a teletypewriter can be a lengthy process.

When substance abuse treatment concepts are being presented to persons who are deaf, it is useful to utilize a variety of teaching modalities that are not dependent on hearing. Whereas many programs use journals, programs serving persons with disabilities may require a person to draw a picture to represent his or her feelings. The concept of character analysis can be too advanced for some persons served; consequently, visual aides such as a poster with illustrations may be used to communicate feelings.

Because of the shortage of substance abuse programs for people who are deaf or hard of hearing, treatment groups typically include individuals with an array of disabilities. And, just as in society, the program incorporates a variety of people — hard of hearing, deaf, and people with cognitive disabilities and mental illness — in its groups. Many exercises are targeted toward team building and trust building. Working in a group toward a common goal generally helps people relate to each other.

Substance abuse treatment should be comprehensive and holistic, including services such as:

• family psycho-education
• disability and medication management and education
• independent living skills education
• anger management, stress management and assertiveness training
• HIV risk reduction, counseling and testing
• STD and infectious disease education
• interpreted self-help meetings and/or meetings hosted by deaf and hard of hearing persons
• health and wellness education
• case management and crisis intervention
• educational, vocational and residential referrals
• medical and psychiatric services
• domestic violence and victim assistance counseling

Recovery and personal stories
“Chuck” came to residential treatment for persons who are deaf in May 2004. He had been in and out of jail several times for drug possession. Chuck had serious anger issues and a great deal of negative feelings. He left the residential treatment program after three months but, soon, relapsed and returned. Since then he has recognized that he does not want be alone and in jail. He began to trust the staff and listened to his peers. His thoughts became more positive, and he was less defensive in his AA meetings. His sponsor is a deaf alumnus. Chuck now lives in a recovery home nearby.

Success rates for persons who are deaf are relatively high for people who complete 90 days in the inpatient program. Of the people who transfer to outpatient, 20 percent stay sober for six to eight months. Still, many people cycle between jail, relapses and treatment. People who complete the program receive individualized aftercare services and participate in alumni groups.

“Dave” did not believe he needed a treatment program after getting a DUI. His family urged him to attend an outpatient program for persons who are deaf, but he resisted and said he was a “social drinker.” He finally acquiesced and went through the program. He admitted his behavior was inappropriate and realized that with the assistance of counselors and through his actions he could do something about it. By the time the program ended, he wanted to stay longer.

Funding and the future
There are few substance abuse treatment and sober housing options for people with co-existing disabilities. There also is a lack of cross-training and guides to best practices for staff who serve this population. Vast changes in policy, advocacy and attitudes will be necessary for specialized programs to catch up with traditional programs. Treatment for special populations is more expensive because of the need for smaller group sizes, modified materials and additional staff. If more programming options were available, treatment services could be better customized for the individual. As people with disabilities exit treatment programs, they face the same challenges that many people with substance abuse issues face, except to a much grander degree — a shortage of sober living arrangements, employment opportunities, sober leisure activities and sober support systems. Enhancing choices in substance abuse treatment programs should be part of a larger paradigmatic shift in integrating people with disabilities into the community. All treatment programs should be fully accessible, physically, attitudinally and programmatically.

Natalie Zubenko, M.A., CADC, MISA II, is the director of Anixter Center’s Substance Abuse Treatment Programs, a unique program for persons with disabilities in Chicago, Illinois. For additional information visit www.anixter.org.

References
Bachman, S.S., Drainoni, M., & Tobias, C. (2004). Medicaid managed care, substance abuse treatment and people with disabilities: review of the literature. Health and Social Work, 29, 189-196.
Fann, J.R., Katon, W.J., Uomoto, J.M., & Esselman, P.C. (1995). Psychiatric disorders and functional disability in outpatients with traumatic brain injuries. American Journal of Psychiatry, 152, 1493-1499.
Guthmann, D. & Sandberg, K.A. (1999). Providing substance abuse treatment to deaf and hard of hearing clients. Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals Web site.
Helwig, A.A. & Holicky, R. (1994). Substance abuse in persons with disabilities; treatment considerations. Journal of Counseling and Development, 72, 227-233.
Nightingale, D.S., Thompson, T., Pindus, N., Holcomb, P., Lee, E., Valente, J., & Trutko, J. (2000). Early implementation of the welfare-to-work grants program; Findings from exploratory site visits and review of program plans.
Polinsky, M.L., Hser, Y., & Grella, C.E. (1998). Consideration of special populations in the drug treatment system of a large metropolitan area. Journal of Behavioral Health Services & Research, 25, 7-21.
Schein, J.D. & Delk Jr., M.T. (1974). The Deaf Population of the United States. Silver Springs, Maryland: National Association of the Deaf.
Tyas, S. & Rush, B. (1993). The treatment of disabled persons with alcohol and drug problems: Results of a survey of addiction services. Journal of Studies on Alcohol, 54, 275-282.
Whitehouse, A., Sherman, R.E., & Kozlowski, K. (1991). The needs of deaf substance abusers in Illinois. American Journal of Drug and Alcohol Abuse, 17, 103-113.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2006, v.7, n.1, pp.62-66.

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