Increase the understanding of addictions and treatment issues in persons with coexisting disabilities Increase the understanding of disability, addiction, and its relationship with the environment Increase awareness of the barriers in existence for individuals with coexisting disabilities and alternatives toward resolution Identify psychosocial concerns and treatment practices with persons with disabilities who also have an addiction to alcohol or other drugs
Hector Del Valle and faculty at the University of Central Florida’s School of Social Work Discussions with treatment providers in addictions and treatment providers with expertise in working with individuals with disabilities
Partnerships
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Coalition for a Drug Free Community Center for Independent Living Center for Drug Free Living National Association of Alcohol, Drugs and Disabilities (John de Miranda)
Hector Del Valle
Physical, mental, emotional, and spiritual aspects of a person with a disability and in recovery 19 years
A. B.
C. D.
Drug and alcohol history within own family and feeling ashamed. Started using himself at the age of 12-13 including marijuana, cocaine, acid up until his senior year in High School. Captain of the gymnastics team, started missing practices. MVA- age 17- was the driver, had been drinking and using other drugs, blacked out, remembers being cut out of the vehicle and waking up in the emergency room. Sustained a spinal cord injury- quadriplegia at the C5-6 level. Recalls the nurse stating, “That is what you get for drinking and driving”. He felt the reality of the situation but it didn’t last long.
E. Rehab- continued with the use of drugs and alcohol secondary to families and staff engaging in and partying with the patients. F. Due to the emotional and physical pain- wanted to “numb out”. G. Alcohol level was .20 and no one asked about the accident or whether he had a problem. H. Wanted to help other people but negated own issues including addiction for many years. Continued to be a speaker against drinking and driving but was still using. I. When speaking in a treatment facility, reality hit due to individuals approaching him and asking about his recovery. At that time, he made a conscious choice to seek help but found it difficult secondary to facilities being inaccessible.
J. Felt alone, misunderstood and would relapse. K. Found assistance and has been in recovery since 1989. Continues to speak with his mission being to help make communities accessible and friendly to individuals with disabilities. Gain a better understanding of the disability. L. Work together to learn what can be done to facilitate change and increase awareness. Help students entering the social work profession to better understand the dynamics of an individual with a disability and addiction. Increase their comfort level and self-awareness. M. Culture and substance use
1. 2. 3.
“Why so many?” “What can be done?” “Where do we go from here?”
a) b)
c)
The alcohol and drug problems were overlooked. The only focus was on the disability. Treatment programs for individuals with substance abuse problems exist but more needs to be done regarding prevention, intervention and treatment by decreasing barriers. There is a misperception that taking care of the physical part of a person is actually taking care of the person as a whole.
Disability (congenital vs. catastrophic)
• Americans with Disabilities (ADA) Act defines disability as a “physical or mental impairment that substantially limits one or more of the major life events of such an individual.” (EEOC, 1991, p. I-25). ADA defines: Physical and Mental impairment & Major life events within the document.
• •
“It is characterized by compulsive, at times uncontrollable craving, seeking, and use that persist even in the face of extremely negative consequences…with relapses possible even after long periods of abstinence.” (Leshner, NIDDA)
Substance Dependence Disorder requires the following: the presence of a maladaptive pattern of substance use, resulting in distress or clinically significant impairment and involving at least three of the following symptoms (all of which must occur within the same 12 month period): (DSM-IV-TR)
Tolerance Withdrawal problems Use of the substance longer than intended Unsuccessful attempts to control or reduce consumption Spending excessive amounts of time procuring, using the substance, or recovering from its effects, and Continued use despite the presence of recurrent physical or psychological problems (APA, 2000, p, 197)
National Defense Act 1916 National Rehabilitation Act Social Security Act 1935 Expanded coverage to anyone with a disability 1956 Supplemental Securities Income (SSI) 1974 Rehabilitation Act 1973 Equal Education for all Handicapped Children Act 1975 now IDEA – Individuals with Disabilities Education Act Americans with Disabilities Act (ADA) 1990 New Freedom Initiative, January 2001
Physical impairments are caused by congenital or acquired diseases and disorders or by injury or trauma. (SCI, Amputation, Diabetes, Spina bifida) Barriers to Effective Treatment • Physical – Medical issues include: UTI, Stomach, Pressure Sores, Etc. or assistance needed for activities for daily living (ADL’s) & no one trained to provide needed services
Sensory impairments include blindness and deafness, which may be caused by congenital disorders, diseases such as meningitis, or trauma to the sensory organs or the brain. (TIP, p.4) Barriers to Effective Treatment
› Lack of resources to accommodate individual’s who are deaf or blind (interpreters, printed materials in different formats)
Cognitive impairments are disruptions of training skills, such as inattention, memory problems, perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing, misperception of time, and perseveration (constant repetition of meaningless or inappropriate words or phrases). (TBI, Learning Disability, Mental retardation, ADHD) (TIP, p. 4)
• Barriers to Effective treatment • Programs may be unprepared to handle individuals who have communication difficulties, decreased comprehension, retention and understanding of basic concepts Affective impairments are disruptions in the way emotions are processed and expressed including problems caused by both affective and mood disorders, such as depression, bipolar disorder, eating disorder, anxiety, PTSD.
Attitudinal – provision of care, special needs, people believe that the individual with a disability is “entitled” to get high or has the “right” to drink in order to cope with the injury or disability and life in general Philosophy of being substance free (medications), stereotyping, myths Financial - insurance coverage or lack of it! VR funding, Medicaid, Medicare, Self-pay, and what is in it for providers? Fragmented services Stigma and discrimination
Persons with disabilities experience substance abuse rates 2-4 times that of the general population (NAADD). Persons with spinal cord injuries, orthopedic disabilities, vision impairment, and amputations can be classified as heavy drinkers in approximately 40-50% of cases. Deafness, arthritis, or multiple sclerosis have shown substance abuse rates of at least double the general population estimates.
Substance abuse prevalence rates approach or exceed 50% for persons with TBI’s. SCI’s or mental illness vs. 10% of the general population (NAADD). 70-75% of individuals who sustain a SCI is as a direct result from drinking or using other drugs (results from research from student at Lucerne; “of 74 patients, 56 of the accidents indicated the patient was involved with or current user of alcohol while 18 indicated no history of alcohol use”). Shortened length of rehab stays have hindered the psychological intervention secondary to the process being focused on physical independence. They need follow-up as an outpatient (NAADD).
Table 1 Estimated Population In Need of Services Population of the U.S. 2002 Estimate Number of individuals with Disabling Condition (2000 Census) Number of Individuals with Disabling Condition and Co-Existing Substance Abuse Problem (1999)
291,157,621
49,746,248
4,685,700 (NAADD)
Florida Census 2000 – 15,982,378 2001 - 16,396,515 Persons with a disability (5+ years) 2000 – 3,274,566 Orange County 2000 – 896,344 2001 – 923,311 Persons with a disability 2000 – 165,831 Spinal Cord Injury – 10,000 in Florida (approx. 550 new injuries each year)
Abuse of prescription medications Unemployment Chronic pain Depression Fewer social supports or negative influences Isolation Increased stress on family Limited access to transportation
Excess free time, lack of interests or opportunities Enabling by well-meaning family, friends and professionals Lack of access to appropriate substance abuse prevention resources Age and circumstances of disability onset
Psychosocial Issues Related to Disability & Addiction (physical, emotional, spiritual)
Loss of control Social withdrawal, feelings of isolation Low energy level Poor self-esteem – identity Body image Inadequate coping skills Inadequate social skills
Impulsivity Poor self-awareness relative to medical or psychological needs Anger Feelings of hopelessness Panic that life without substances will be unbearable considering the disability Problems with life management skills
Work/school problems (attention or learning issues) Peer pressure Recurring medical problems Chronic pain- medication may become an issue; importance of physicians working together Long term medication use Denial – of the substance use and/or the disability Issues are not new – but a disability may exaggerate the severity of these issues or their impact on their recovery
Approximately 3% of children born in the U.S. have congenital, or some type of birth defect including Down’s Syndrome, spina bifida, congenital heart defects, etc. These and other birth defects can result in a wide range of mobility, hearing, visual, and intellectual/emotional impairments
Children with any type of disability can be adversely impacted (isolation, victimization by bullying, pity, etc.) Parents and professionals play an important role Young people may feel that substance use will help them “fit in” Self-reported reasons for drug use by teens include enjoying the high, for social fun, to cope with negative feelings, peer pressure
Learn to balance special needs of child or teen with those of other family members Maintain normal routines and promote shared family values and priorities Avoid blaming and learn to find meaning in having challenges Be proactive in learning about the disability and possible solutions to problems related to substance use Effective communication
Selingman & Darling, Ordinary Families, Special Children, 2007)
Older adults are less likely to receive a diagnosis of alcoholism Age related changes can trigger or increase serious problems Physical symptoms may include changes in eating habits, poor hygiene or self-neglect Agitation, irritability without cause Frequent falls or unexplained bruising
Reasons for silence and lack of treatment:
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Mistaking the symptoms for dementia Depression, mismanagement of medications Shame Multitude of physicians involved in the case
As reported by Victoria Adams with the Center for Drug Free Living
p. 9)
People with disabilities do not abuse substances People with disabilities should receive the same treatment protocol as everyone else so that they don’t feel singled out as different 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 People with disabilities deserve pity, so they should be allowed more latitude to indulge in substance use (CSAT, 1998,
Bio-Psych-Social-Spiritual Model - Social work and other professionals conceive of addiction holistically, with attention to biological, psychological, and social components in its causation and consequences. (Van Wormer & Davis, 2003, p. 11) The Strengths Perspective - geared toward direct practice – helps in developing a healthy outlook on life; altered lifestyle – what is going well, instead of what isn’t
Motivational Interviewing – channels the strength of resisting change into motivation to make change Guiding Principles
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Express empathy Develop discrepancy Roll with resistance Support self-efficacy
Solution Focused - helps the client focus on one problem at a time. The process consists of carefully crafted questions designed to elicit client strengths and resources and to help the client decide how to best use those strengths and resources to achieve the desired treatment objectives such as staying clean.
› Meet the client at his or her model of the world. › Transform the client from being a "visitor" to being a
"customer."
› Start with the end in mind (miracle question and well-
formed outcome conditions).
› If it “ain't” broke (in the client's mind) don't fix it.
12-Step Model - works better if the client works with a sponsor The person who commits to the 12-Step approach needs to have the willingness, honesty and open-mindedness to spiritual principles and to remember this is a spiritual not a religious program.
Building trust and credibility Accommodations to increase function Modifications for counseling sessions (flexibility with time and length of session, accessible written materials) Address grief and loss issues around disability and the addiction Assess his or her motivation to use alcohol and other drugs Identify and evaluate goals
Resolve conflicts among interfering goals Develop skills for reaching realistic goals Homework activities are designed to be positive, goal-oriented, and immediately measurable If a treatment goal is not met, it is important to look first at whether or not accommodations were sufficient to support the process, instead of immediately blaming the individual for resistance to treatment (Van Wormer & Davis, 2003, p. 273, 274)
Need to assess:
› the client’s level of acceptance of each disability, › the client’s skills for coping with the disabilities, and › the client’s knowledge about the disabilities
(McNeece & DiNitto, 1998, p. 377)
• Substance use, disability and the aging population • Alcohol, drugs, prescription medications and disability • Importance of a medical examination and prescription assessment of all clients with coexisting disabilities by a medical professional • Recurrent or chronic pain
Collaboration & communication are key Understanding accommodation - “reducing barriers to equal participation in the program – NOT giving special preferences” (CSAT) Program policies, procedures, and practices aim to ensure accessibility and promote success for everyone. Treatment plans need to be individualized Providers need to understand the degree to which a disability affects a person’s life (ex. A person with CP or SCI, the task of getting up and ready in the a.m. can be exhausting – staff may need to consider pacing assessments and treatment)
Orange County Coalition for A Drug Free Community – the Addictions and Disabilities Workgroup Purpose & Goals Education & Resource Guide Public Service Announcement (PSA)
To improve an individual’s prognosis for recovery To ensure compliance with legal mandates To increase teamwork among providers in addressing advocacy issues – embrace the value of each team member To improve coordination of services
To access or leverage scarce financial resources effectively To identify appropriate accommodations and procedural modifications To advocate for the best services and supports that honor and assist in recovery Lack of identification of potential problems – once identified, need to educate, not negate or neglect
Where Do We Go From Here? Questions?