When looking for treatment for an individual with a disability, there are five barriers to keep in mind when comparing programs, including:
- Attitudes—staff training, experience, education, theory.
- Discriminatory policies.
- Practices and procedures in treatment including focus, medication policies, rigidity of rules, expectations, etc.
- Communication policies around support and networks.
- Physical and architectural barriers.
An individual will want to match his or her needs to the program that she/he chooses to attend. Treatment programs vary greatly on their focus, primary theory, expectations and flexibility on the needs of individuals with mental health and cognitive disabilities.
Here are some of the most common issues to consider:
Are they allowed? All? Some? None? What about prescriptions for pain or mental health issues? Is their medical staff on site or nearby? Is the facility accessible?
Some programs do not allow medications of any kind, even for mental health issues. Others will, but not narcotics, even with a doctor’s order. Also, most treatment programs do not have personal care attendants or doctors on staff. If this is needed, a hospital-based program tends to be the best fit.
Is the focus on the program group work, then family work, then individual time? Is there training and counseling for individuals who do not have the skills for positive group behavior? What is the counselor to client ratio? Is their opportunity for shorter more frequent individual time? How long are group sessions?
This is especially important for an individual who is struggling with social skills and norms. Some individuals need to be taught how to interact in groups before group work occurs.
Some individuals may need more frequent individual time such as three times a week for 15 to 20 minutes rather than one hour long session.
Does the individual have the cognitive skills to sit and learn for four or more hours at a time? Do they need more frequent breaks due to fatigue? Do they need more repetition and smaller chunks of information in order to retain it?
Is the focus disease concept of addiction or more multidimensional with environmental as well? Is the goal total abstinence or just to contain a relapse? Is it reality/cognitive-based, or more motivational, with supports? Is insight expected? Is it 12 Step-based?
Does the individual accept the disease concept? Is total abstinence a realistic goal for this individual?
Does this individual have the ability to form insight and then apply it to their situation or do they need motivation and external supports?
Does the person understand the concepts on the 12 Steps? Have they had any positive experiences with them? Is the person resistant to labels? Is the staff comfortable with someone who may be angry at their higher power or not have/want one?
What is the policy around relapse? Are their rest breaks for fatigue factor? How many rules are there to remember and follow? What are the policies if they are broken? What is the discharge policy?
Does the program discharge individuals for relapsing or work with it as a learning experience? Are their lots of rules to remember? Can this individual remember all of these rules? How many chances before discharge?
Can the schedule be modified for fatigue or other factors?
What is the teaching style? Is it lecture, homework, discussion? Are their compensatory strategies for individuals who do not read or comprehend? Do they teach Stop-Think strategies and incorporate them into memory strategies? Are multiple learning styles addressed? Do they understand disability issues?
Does the individual have the cognitive skills to be in a group focused treatment program? Can they be successful at written homework? What is their comprehension level? Reading?
Are memory aides and other non language based groups and tools used?
Is adjustment to disability, grief, loss and other disability specific issues discussed in group and individual sessions? Is the staff trained and comfortable with this?
Are they willing to work with other professionals? What type of discharge planning is completed prior to discharge? What is their re-admittance policy?
Are families welcome? Other professionals? Can a person come back if they relapse?
Types of Treatment Programs
There are six major types of treatment programs. Each type can vary quite a bit by the policy and expectations around it as well as the population that it tends to serve. Different programs are designed to meet different levels of need around structure, level of motivation to change, home and family needs and time in recovery.
- Inpatient programs are residential in nature and tend to be quite structured. Some residential programs are locked but most are not. They include room and board. They offer 30 hours of programming per week with individual counseling and case management. Average length of stay is 21 to 30 days.
- Extended Care programs are residential in nature. They also include room and board. They offer 15 hours of programming a week with individual counseling and case management. The focus is on relapse prevention and re-integration into the community. Average length of stay is 60 to 90 days.
- Halfway House programs are also residential in nature and tend to be structured especially in the mornings and evenings. They include room but not necessarily board. The goal is to have time during the day to look for work, go to work and/or attend school. Some halfway houses allow children and so parenting is also incorporated. Individual and group counseling occurs around these schedules. There is limited case management. Average length of stay is 75 to 90 days.
- Outpatient programs are non-residential programs that focus on hours of programming rather than days. It is less structured. Most individuals are working, in school, have families to take care of or are in the process of setting up these things. The focus is on group sessions with some individual counseling. There is limited case management. Average length of programming is 80 to 150 hours.
- Sober Houses are homes that have made it a house rule to not drink or use within its walls. Some are very strict about sobriety in and out of the home, others are more lenient stating that you cannot use there but can elsewhere. They tend to have limited structure and no formal programming. Some offer house run support groups or 12 step groups. Rent tends to go month to month. Some include some meals and utilities, others do not.
- Support Groups are quite varied and can be facilitated by professionals to members. They also tend to vary in regards to structure. All report not using while at group. They vary about using before or after group.
Successful Individual and Group Sessions
Use these strategies to help reinforce the goal of sobriety in both individual sessions and group work.
- Incorporate shorter individual sessions with more frequency to aid in repetition and retention.
- Limit written assignments and allow tape recorded or other medium work.
- Remind the individual to write their appointment in their planner or calendar including the memory aid of writing the goal of sobriety in their planner or calendar every day.
- Use a picture of things, loved ones, etc. as motivators.
- Use a “decision box” (a decision box is looking at the pros and cons of each possible solution, side by side, to make a decision) to show the benefits and consequences of using or not using chemicals to aid in moving the person out of ambivalence.
- Remind the person of all of the successes they have made in sobriety and in their life. Have them keep a journal or picture book.
- Individuals often use chemicals to cope with negative emotions and life changes. Validate these feelings and offer alternative coping mechanisms.
- Individuals are often angry at their higher power over their personal and/or family issues. Validate these issues also and suggest concrete things they have control and power over to do.
Use shorter group sessions, with two or three main points.
- Write key points on the board to improve retention, and ask the person to write them down as well.
- Be quiet while the group or individual is writing. It is difficult to concentrate, write and listen all at the same time.
- Use multi-modal group materials including tapes, videos, art, music, handouts, charts, posters etc.
- Art is a great way to put the feelings around chemical use into the visual world.
- Develop a signal for the person who tangents and needs help refocusing, and have the entire group use it.
- Use role playing to reinforce concepts.
Relapse Prevention: Remembering NOT to Use
Remembering NOT to use chemicals is probably the hardest part of long term sobriety as using chemicals becomes an obsessive habit that, with dependency, becomes a change in the chemistry of the brain. These changes in brain chemistry actually work against the person in early recovery as the brain craves alcohol and other drugs. The good news is as the brain heals and there is no alcohol or drugs in it, the cravings become less severe and less often. The key is not reinforcing the craving with use.
The relapse cycle starts long before the actual use of alcohol or other drugs. The good news is that this cycle can be stopped anywhere along the path, even after a drink or use has occurred. Success is stopping sooner the next time with the goals to stop the individual before any use takes place. Having a clear, concise written posted plan of supports, activities, people and structure is important
Remembering NOT to use by using the current memory and learning strategies has been shown to be an effective strategy in relapse prevention. Most of these strategies are inexpensive and easy to add to one’s current system. Some of the strategies include:
- Listing sobriety as a daily goal in a planner or on a calendar
- Listing an alternative activity to using/drinking in the planner at times where use often occurred.
- Using post it notes on money, stating what it is for, to help with
- Mapping out travel routes to avoid using places, liquor stores, bars, people who use, using homes and other trigger ‘hot spots’ ahead of time.
- Use a note card or picture to put in the person’s wallet or purse with their money to help remind them not to use. Include saying NO step by step instructions
- Have a reminder to not use on the refrigerator or anyplace where the person kept their chemicals.
- Put a reminder to not use in the area where the person used, in the car, in the bathroom, on the lazy boy chair, etc.
- Have a visual reminder on the person such as a bracelet, medallion
- Have a note by the phone with step by step instructions for saying NO for people who call and want chemicals or the person to use.
- Have a list of reasons either listed or pictures, of why the person does not want to use. Include short term and long term goals.
- Use direct deposit for money – as money is often a trigger.
- Have a list of several people and their telephone numbers and/or several meetings in the person’s wallet or purse.
- Have a sobriety reinforcing item at work or in the car such as a coffee cup, mouse pad, poster, picture, etc.
Adapting 12 Step Meetings
Since 1935, Alcoholics Anonymous (AA) has offered help and hope to millions. It has been an effective adjunct to chemical dependency treatment and an important source of support for continued sobriety. Many other support groups have evolved out of the AA 12-step philosophy, including Narcotics Anonymous and Overeaters Anonymous.
Yet in spite of the proven effectiveness of 12 Step meetings, many individuals with cognitive disabilities report that they have not had positive experiences with 12 Step meetings and are resistant to return. Often, the individual may have trouble expressing why they do not wish to return, and/or they are embarrassed at not understanding the meeting and react with frustration, anger and inflexibility.
Some of the problems reported include:
- Difficulty in understanding the “steps,” philosophy and language of AA and other 12 Step programs. These meetings often incorporate terms that are highly abstract.
- Difficulty with reading and comprehension skills that are often required, especially with meetings where participants take turns reading.
- Trouble with the speed of the meeting.
- Difficulty understanding the unwritten and/or unspoken social dynamics, codes of conduct and expectations/unwritten rules.
- A feeling of social isolation due to being misunderstood or unaccepted due to disability.
- Being excluded from those “extra” social activities such as going to the coffee shop after a meeting, in part from not understanding the social dynamics of the meeting.
This is not to say that AA and other 12 Step meetings are ineffective or inappropriate for individuals with cognitive disabilities. In fact, the fundamental principles embodied in the 12 Steps are quite concrete and universal. These principles can be summarized into three basic statements:
- What I am doing is hurting me and I need to stop.
- In order to stop, I need help.
- In order to get help, I need to get along better with others
and take better care of myself.
Individuals with cognitive disabilities have reported that positive experiences do occur when they have developed a close supportive relationship with one individual who accompanies them to meetings and acts as a facilitator in their inclusion in those “extra” social activities which are so important. Support networks can assist in fostering positive experiences by contacting the meeting facilitator and setting up a tour and buddy for the individual prior to attendance at the first meeting.
Support networks can also break complex, abstract concepts—such as HALT (Hunger, Anger, Lonely, Tired), Easy Does it, and One Day at a Time—into concrete concepts by applying and reinforcing them the to principles listed above. Also, incorporating pictures to demonstrate the meaning of each step has proven helpful.
By taking a few minutes before an individual starts attending AA and other 12 Step meetings, we can eliminate many of the obstacles that prevent individuals with cognitive disabilities from fully utilizing the strength and support offered.
The 12 Steps
There are multiple versions of the 12 Steps, written for different purposes for different groups of people. The following are the original 12 Steps (in italics) as well as the Adapted 12 Steps more concretely defined (in bold).
Step 1. We admitted that we were powerless over alcohol and drugs that our lives had become unmanageable.
- Admit that if you drink and/or use drugs your life will be out of control. Admit that alcohol and drugs are not making your life better.
Step 2. We came to believe that a power greater than ourselves >could restore us to sanity.
- You start to realize that someone can help you put your life in order. This someone could be a Higher Power/God, an AA group, counselor, sponsor or any helpful person.
Step 3. We made a decision to turn our will and our lives over to the care of God as we understood him.
- You decide to get help from others and/or God/Higher Power. You open yourself up to guidance.
Step 4. We made a searching and fearless inventory of ourselves.
- Here’s where you get unnervingly honest with yourself. Take a hard look at and make a list of your negative behaviors, both in your past and currently. Then think about what you’re doing right by making a list of positive behaviors in your past and in the present.
Step 5. We admitted to God, ourselves and another human being the exact nature of our wrongs.
- Meet with someone you can trust and discuss what you wrote in Step 4. It could be a family member, a friend or a professional.
Step 6. We are entirely ready to have God remove all these defects of character.
- Now, the decision to sincerely try to change your negative behaviors and capitalize upon your positive ones.
Step 7. We humbly asked him to remove our shortcomings.
- Ask the people that you believe can help you put your life in order to help you be a responsible person.
Step 8. We made a list of all persons we had harmed and became willing to make amends to them all.
- Make a list of the people your negative behaviors have hurt. Be ready to apologize or make things right with them.
Step 9. We made direct amends to such people wherever possible, except when to do so would injure them or others.
- Contact these people and apologize or make things right, but only if this will not cause them more harm.
Step 10. We continued to take personal inventory and when we were wrong promptly admitted it.
- Keep a close eye on yourself and your behaviors. Correct problems immediately. If you hurt another person, apologize and make corrections.
Step 11. We sought through prayer and mediation to improve our conscious contact with God as we understood him praying only for knowledge of his will for use and the power to carry that out.
- STOP and THINK about how you are behaving several times a day. Are your behaviors responsible and positive? If not, ask for help. Reward yourself when you are able to behave in a responsible and positive fashion.
Step 12. We are having a spiritual awakening as the result of theses steps, we carry the message to alcoholics and addicts and to practice these principles in all our affairs.
- If you work these steps, you will feel better about yourself and create positive change in your life. Whenever you can, try to help others by sharing what you have learned and your success stories.
Is 12 Step Group Attendance a Challenge?
- Are you tired of finding yourself power-struggling with individuals over going to 12 Step support meetings such as Alcoholic’s Anonymous (AA)?
- Do these individuals attend meetings but seem to have difficulty internalizing the concepts?
- Do these individuals state that no one there understands them or has the same problem they do?
If you answered yes to any of these questions, the problem may not be the meeting, AA itself, or even the individual. The problem may be that the structure of the meeting and the learning style of the individual do not match.