Coexisting Disability: Responding
to Consumers Who Experience
Disability and SUDS
D. Shane Koch Rh.D, CRC, CAADC
Professor
Southern Illinois University Carbondale
“You mean people who are blind use drugs?”
(12/12,000)
• Professional Experience
– Youth with AODA Disorders
– Research Agenda
– Programmatic Interventions
• When there are two there are three
Disability
• Impairment
• Record of Impairment
• Regarded as having an Impairment
Challenges
What are the barriers faced by AODA
and Rehabilitation Professionals who
seek to serve these consumers?
Why Coexisting Disabilities
Challenge the Rehabilitation Culture
• AODA is not our problem
• CRC’s are not trained to screen and provide case
management for AODA
• Don’t ask - Don’t tell
• AODA is not a “legitimate disability”
• Misunderstanding of AODA as “Recreational
Option”
• Only focus is on employment
Why Coexisting Disabilities
Challenge Our AODA Treatment
Culture
• We are not trained to deal with disability
• We are afraid of “harm” (Non-Maleficence and
Beneficence)
• We don’t even know that these folks are out
there
• We tend to be less focused on employment,
independent living, and other “disability
centered objectives”
Rehabilitation Service System Barriers
• Consumers tend to be stereotyped as malcontents
• Policy and procedures can lead to “programmatic
insanity” (circular referrals)
• Few specialized programs
• Lack of clarity in agency policies and federal legislation
• Tendency to be disconnected from the AODA service
system and the recovery community
• Although AODA is a protected disability AODA
providers remained unaware and isolated from the
disability community.
Rehabilitation Service Systems BarriersSome Unanswered Questions
•
•
•
•
•
“Waiting Periods” -Work can hurt you?
When is a person rehabilitated?
What do we do about relapse?
What about illegal drug use?
What about pharmaceutical abuse?
The Case Management Dilemma?
•
•
•
•
Who’s on first?
The “Chicken and the Egg”
Lack of effective models
Lack of appropriate programs
Ericksonian Dilemma
• Who is Carlton Erickson?
• Coexisting Disabilities and the Challenges they
Present
– Pain Management
– Dick Beardsley and the “Runner’s Toughest Race”
• Beneficence and Nonmaleficence
– Balancing pain management with risk of iatrogenic
effects
Who exactly are these
folks?
AODA as a Primary and Coexisting
Disabilty
AODA is a Primary Disability
• AODA is a primary disability
– AODA were identified as disabilities in two major pieces of
federal legislation (93-112 and the ADA)
– What about social security?
• Many AODA counselors misunderstand the
implications of this protection
– Legal protections (employment discrimination)
– Ethical Guarantees (advocacy and stigma)
AODA is a Coexisting Disability
• The label is a problem
– Coexisting, Co-occurring, Co-morbidity
– MICA, Dual Diagnosis
• Three types of Coexisting Disabilities
– Onset Before
– Co-Occurring Onset
– Onset After
AODA Consumers Acquire a
Disability
• Examples: Traumatic Brain Injury, Spinal Cord Injury,
Visual Impairment and Blindness, HIV
• The individual already has substantial impairment due
to the AODA disability
• It is unlikely that the rehabilitation system will address
the substance abuse issues
• Consumers get “buried in the system”
• They then get enmeshed in negative AODA
subcultures
• Callahan
Co-Occurring Onset
• Examples: Mental illness, and all chronic degenerative
medical disorders
• Many times these folks get identified in the community
mental health system and do receive services
(SAMHSA Initiatives)
• Many of the “physical” disabilities get buried in the
medical and rehabilitation systems
• No progress is made to failure to address the AODA
AODA Occurs After A Disability
• Temporarily Able Bodied (TAB’s) folks acquire a
disability and then begin to use AODA to adjust
• Beardsley
• These folks often get missed as well because they did
not have a prior diagnosis
• The medical and rehabilitation systems often do not
screen for the AODA
• Often times existing support systems play into
“negative secondary gains”
To Summarize
• There are definite professional cultural barriers that
impede service delivery
• There are definite systems barriers that impede service
delivery
• These consumers have varied needs and represent
diverse populations
• We need to generate more awareness and interest in
serving this population across all disciplines
• These are consumers who can become independent,
productive participating members of our communities
with our help!
RRTC/SARDI Summary (2004)
• Significant prevalence of SUD’s
among persons with disabilities
seeking employment
• Needs of this population impact
many systems
• Costs of rehabilitation are high in
some cases
• Lack of progress directly impacts
employment and community
integration
• Persons with disabilities have
difficulty accessing appropriate CD
treatment
• Stigma impedes progress on issue
• Approaches must cross disciplines
and cultures
• Involvement of disability
community pivotal to success
• Federal role in solutions important
due to cost and complexity
Professional Obligations
Understanding Accessibility
Legal Obligations
• The rehabilitation legislation prohibits
discrimination on the basis of disability
• We are obligated to make reasonable
accommodations
• We are protected by “undue hardship”
What should we consider when making
our programs accessible or “ask the ape”
• Attitudes
– How will the program welcome consumers?
– How do professional attitudes affect the service
environment?
• Programming
– Is the programming accessible?
– Have reasonable modifications occurred?
• Environment
– Does the consumer have equal access?
– Mobility, safety, and participation
How attitudes impact rehabilitation
service delivery
• Enabling
–
–
–
–
Misunderstanding of “Spread of Effect”
“If I were disabled I’d drink too…”
Results in discrimination in referral and access to treatment
“justified AODA”
• Stigma Based on Cause
– Ethical issues of individuals who cause their own disabilities?
– Prevention effects?
• Consumers and Counselor resist “one more label
– Negative effects of labeling
– Failure to consider the positive benefits of treatment
• Dangerousness
Programmatic Accessibility
• Review your program mission and vision and how it relates to
your programming: i.e. What is really essential?
• Review TIP 29 in the context of your own program
• Invite rehabilitation counselors and consumers to identify
barriers at your program. (This also helps to fix linkage and
systems issues)
• Systems Issues
– Caveat: “Magic Bullet” trainings seldom produce long-term positive
effects
– Need to impact systems! (Often through the use of “local heroes”
(raising awareness)
Some questions to think about?
• If you are serving a person who is blind will you
need to braille all of your materials?
• Would you need to pay for it?
• If a person is deaf, will they need
accommodations with written literature?
• Cultural diversity within the populations of
persons with disabilities
Environment
• Is our environment accessible?
– Is our own environment safe?
– When we refer do we think about accessibility?
• Use your local ADA experts and agency ADA
advocates
• Ask for ADA tours involving consumers and
rehabilitation counselors
Examples of Reasonable
Accommodations for TBI/AODA—
SARDI
(2004)
• Curriculum modifications
• Advocacy services
•
•
•
•
•
•
•
•
Modified accessible 12 step programs
High ration of staff to clients
Varied group size and formats
Cognitively accessible groups
Memory aids – memory books
Appropriate reading materials
Medication assistance and advocacy
Large print versions of materials
•
•
•
•
•
•
•
•
Sign language interpreters
ADL training
Intensive case management
Longer stay and lower
treatment intensity
Repetition of curriculum and
concepts
Alumni groups
Benefits, food, housing
transport
Tolerance of behavioral
deviance
Discriminatory Policies, Practices
and Procedures (TIP 29)
• We do not serve clients who are taking medications
• Fire and safety regulations require that all clients be able to walk
out of the building
• All clients must participate in house chores
• Every persons must read two chapters of a book per day
• Client excluded from a residential setting because he needs
assistance in transferring from the wheelchair to the bed
• Client is discharged for being late when he is delayed while
waiting for a “handicapped-accessible” bus- (rain and
wheelchairs example)
How can we measure the success of
today’s presentation?
• If you folks go forward with the commitment to
become “local heroes”
• Educate rehabilitation counselors and agencies
about your programs-Marketing!
• Sponsor cross trainings for mutual CEU credit
• Become the “disability guy” (counterpart to the
“addict guy” in the VR world)
How can we measure the success of
today’s presentation?
• Work with your agency to develop protocols
(Screening and Intake)
• Work with your agency to develop case
management strategies
• Work with your colleagues in rehabilitation to
develop more effective IPE’s (Treatment Plans
for Employment)
How can you learn more?
• Pick up the TIPS on alcohol, drugs and disability
(29 and 38)
• Take a look at the literature
– Dennis Moore
– Deb Guthman
– Koch and Nelipovich
• Journal of Teaching in the Addictions Volume 3
(1)
Resources
• Alcohol, Drugs, and Disability
– Rehabilitation Institute (www.siu.edu)
– NAADD (www.naadd.org)
– SARDI (www.med.wright.edu/citar/sardi)
– RRTC on Substance Abuse and Employment (Wright State
University)
– TIP 29 and 38
• Advocacy
– Join Together
– FAVOR
– The Johnson Institute
• If you need my support…contact me at [email protected] or
find me at www.siu.edu after September (618-536-7704)