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hello, i'm ivette torres, and welcome to another edition of the road to recovery . today we'll be talking about treatment and recovery in behavioral health for individuals with a disability. joining us in our panel today are dr. h. westley clark, director, center of substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland. john de miranda, executive director, national association on alcohol, drugs and disability inc. and president and chief executive officer, stepping stone of san diego, san diego, california. dr. barbara l. kornblau, j.d., disabilities attorney and professor, school of health professions and studies,

university of michigan-flint, flint, michigan. ed hammett, consumer advocate, marbury, maryland. dr. clark, how many people in the united states have a disability? that number is not exactly clear, but we estimate roughly 53 million people have a disability, and it may be larger because, again, it turns on new classification schema. but at least 53 million. john, how do we define a disability? well, a disability is really kind of a legal and an administrative term. and in some quarters you might be considered disabled, but by another jurisdiction you might not be considered disabled. but i use the term, often, physical sensory, cognitive, and developmental disability to really clarify what we're talking about. so, barbara, in terms of a real sense, so there are individuals who may have had accidents

are now paraplegic, quadriplegic- in terms of those with a substance use or mental illness, are they covered under the ada? yes, they are covered under the ada. the ada defines disability as someone who has a substantial limitation in a major life activity, a history of having a substantial limitation, or someone who is regarded as having a substantial limitation in a major life activity. so people with-in recovery probably have a history of having had a substantial limitation. they may have one at present, or people may regard them because they're in recovery, there may be that stigma to it that creates that you have a disability feeling. and, dr. clark, let's talk about the americans with disability act of 1990. when it was passed, what type of coverage did it offer for those with a disability? basically, it represents an effort to prevent

discrimination against people with a disability. when you talk about alcohol and drugs, it- you have to approach it differently because there are- are some limitations. for alcohol-and alcohol and drugs, illicit drugs are treated differently. alcohol-if you have past history of alcohol abuse and dependence requiring treatment or contributing to a-your disability, you are covered. if people regarded you, as barbara pointed out, as having a history of alcoholism, you're covered. if you are a current drinker and your job does not have a policy which restricts you from being either under the influence or having a dui or an alcohol-related condition, you can be covered.

alternatively, with illicit drugs- if you are a current user of illicit drugs, you are not covered. if you have a history of using illicit drugs but are not a current user, you're covered under the ada, and if you have a past history and you're regarded as having a history of illicit drug use, you're covered. ed, let's talk about a little bit, you're a person with a physical disability, but you also are in recovery yourself. do you want to tell us a little bit about your story? yes. i suffer from alcoholism. i had alcoholism before my physical disability occurred. alcoholism was-was, my disability was due to the alcoholism. i was in a blackout the night that i was-i was mugged;

i was left a paraplegic from that-that episode. and-i then through rehabs, treatment much later, i drank for 10 more years after my disability and found my way into a rehab after- after some more trouble with the law. and found the experience fairly devastating, really. it-it was back in a time when- when treatment centers weren't- weren't really well equipped for-for people like me. so did you become very familiarized with the law in order to be able to access treatment yourself? not really, not at the time, no. my alcoholism had-had-had-had-had ventured so deep- i was so deeply into-

into alcoholism that i was just looking for any- any sort of breath of fresh air. i was-i was-i reached a bottom as it's said in-in-in the alcoholism world. and-and i didn't-i didn't really question whether- whether i was eligible or not, i just went to the rehab. they-they-as i said, they were ill equipped to handle me, they built some plywood ramps, it was an old school. and we made due, we made due. dr. clark, using ed's experience, let's go back and cover again- so individuals with a physical disability as well as alcohol and drug use disorders as well as mental health, does the act differentiate? i know you spoke a little bit about the differences between legal and illegal drugs, but are there different types of coverage under the act

for a physical disability or for a mental illness or for substance use disorders? well, i mean, the act requires reasonable accommodation to the individual. so ed talks about approaching substance abuse treatment facilities afterwards, and they made an effort to make a reasonable accommodation; he seemed satisfied with it. but he also talked about when he lost the use of his limbs, he was still drinking; so that's part of what we're trying to deal with is making sure that people don't use a disability as an excuse for not addressing both of his issues at the time. so people start focusing on the apparent disability and not deal with the co-occurring issue, which, as-as ed pointed out, was-was his continued drinking. so both situations needed to be addressed. in-in a sense that's one of these sort of

reverse discrimination issues when dealing the physical limitation but not dealing with the alcohol or the substance abuse issue. and for this dialogue, it's really important for people to recognize that you can have these co-occurring or co-morbid situations, and both need to be addressed. and once the facility or once he was ready, and i-i can't speak to that process, but once the facility, they made plywood ramps, they were making efforts to reasonably accommodate his situation, and-and he obviously appreciated that. that's really the unique issue here is that individuals, you know, have both the physical and then an emotional or- or a substance use disorder, disability, and-and in order to be able to fully serve them, the service delivery systems, john, have to be prepared, correct? yes, this is an important aspect of the americans with disabilities act. it really requires that alcohol and drug treatment providers

be able to accommodate and for people like ed to access those services. unfortunately the training, the preparation, the programmatic changes that need to take place are often not there because this is a very low incidence, we don't see a lot of people presenting for treatment, and it's also an expense issue. so access to care is a major problem. this is-it's also important to remember that any agency that receives funding from the federal government under section 504 of the rehabilitation act of 1973 also has an affirmative mandate to serve people with disabilities. and, barbara, who monitors this? well, there are no ada police or section 504 police. so it's really monitored by advocates. so someone like ed in ed's situation- it was very nice that the facility built, you know, plywood ramps, but those ramps were probably not the ramps that are specified to the code, to-to standards,

so it would have been up to someone like ed to turn them in, essentially. you're in an awkward position because you finally find a place that is willing to take you, and then how can you turn them in if they're willing to take you? but, you know, at some point there has to be a balance where there's education by advocates to say, you know, thank you for making that ramp, but it's a little too steep and it's dangerous for me- i could fall off it. i have some pictures of some ramps that you can do that would be more safe for me and-and more inclusive. so it really is an advocate-led thing. so, in essence, if there is a problem, one goes to a state agency that's supposed to monitor the ada, and they would send someone out, dr. clark, and then they would look at the building. is this done on a state or-or-barbara? it depends. in some places the local communities have adopted the ada's standards into their own building code. in others, you might have to go to either state agency

or to the department of justice online or whoever is funding, whoever is the funding agency- they have an office of civil rights that you can find online for their agency for 504 enforcement. so you can go to them and file an administrative complaint and say, hey, why don't you take a look at them? because they're really not functioning the way they're supposed to be. very good. dr. clark, one of the things we didn't touch on, and i want to do that now, is on medication-assisted therapy- are they covered under the ada, as well? well, an individual on medication-assisted therapy is covered under the ada. they are in a therapeutic environment, and so it is illegal to discriminate against that person. now, that said, there are some regulations that militate against certain medications. for instance, if you are to dot on methadone,

then you can't operate a truck or bus under the dot; you can't use their-the dot approval process. but that has less to do with being on medication-assisted treatment and more to do with their policies about certain kinds of medications, and even though there are challenges to that, that tends to be the issue. so, in short, mat is covered by the ada, and an individual should not be discriminated against because they're on medication-assisted treatment. now if they're currently using, despite the fact they're on medication-assisted treatment, then it's a different matter. the ada won't protect them. and when we come back, i want to continue to talk a little bit about that and also about some access issues. we'll be right back. [music]

it's really important to coordinate care especially, for anybody, but especially for people with disabilities because they may have some physical health issues going on that, either medications that they're taking because of the disability or- or as a consequence of the disability, that may have implications for what kind of treatment that they would get from behavioral health needs. frankly, there's also, i think, some pretty good evidence that with a longstanding disability, especially if you're not getting the services you need to live a fulfilling life, then you're going to have some depression, anxiety, some other kinds of behavioral health issues and that may lead to substance abuse and other things. so the relationship between the disability and, frankly, the community's acceptance of that and the community's willingness to help a person with disabilities to live a fulfilling life may have an impact on substance and mental health treatment needs. so it's always important to treat an individual

in their whole environment and their whole context. but particularly when you put together the medications, the life circumstances, and just the ways in which they need special support in order to be able to fulfill their lives. the americans with disabilities act, otherwise known as the ada, was passed in 1990 and has an amendment to it in 2008 that guarantees certain civil rights or gives certain civil right protections to an individual who has a disability as defined by the act. and it prohibits discrimination similar to other civil rights acts that prohibit discrimination based on sex or age or national origin. it-it says that if you do have a disability that- if your organization that is controlled by the act must make reasonable accommodations for you. so a person with a disability should be able to get gainful employment,

live in an appropriate housing, and function in society. before, addiction and depression kept me from living my life. now, every step i take in recovery benefits everyone. there are many options that make the road to recovery more accessible-it begins with the first step. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s department of health and human services. [music] the goal of-of the work that i do in-in the community today is-is-is to do just that, to-to,

to make what we have available as seamless as possible to the person with a disability- that's all that the person with the disability is looking for. that they just want the same recovery that we all enjoy, and-and they want to be able to do the same, the same service positions. they want to be able to help others. the biggest part of recovery from-from any disease is being able to give it away and share it with someone else. and-and give back. barbara, you wanted to add a few thoughts on medication-assisted therapies? yes, dr. clark makes a very good point that medications therapy is covered by the ada. on the other hand, i think there's a big need out there for education. because if you're in a drug-tested environment, you're going to come back with a weird drug test, something they're not used to; it's not going to look like a clean drug test.

so there may be a need for some education on to employers to explain to them that this person is not using drugs, they're taking medication to assist with their therapy and that this is okay. the other thing i think is important is that it's not just illicit drugs but the illegal use of drugs. so if you're using somebody else's prescriptions, that's not legal and that's not protected by the ada. very good point-it's prescription misuse. okay, john, i want to go to you on the issue of availability. are there enough services that are made available to individuals with a disability for substance abuse and mental illnesses? well, the short answer to your question is no, no, no. in the course of our involvement as the national association on alcohol, drugs and disability, we would often go into the field with a checklist, visiting alcohol and drug programs. do you have a ramp?

many times there's a ramp but are staff trained? is there a telecommunication device for the deaf? what other kinds of accommodations are there? and often found that people were not in compliance. and as a result, people with disabilities, and we've interviewed literally hundreds, often have to jury-rig their recovery. a good example was a woman in berkeley, california, that we interviewed. she was a student of uc berkeley, became a paraplegic as a result of a horse riding accident. when she was ready to start attending 12-step meetings, many, because they were in church basements or on the second floor, were inaccessible. so she actually, as a result- was at that time in her life getting very involved in her own kind of movement therapy as a result of her disability. and her movement therapist said, well, you know, let's see if we can bring your recovery into this venue. and that's how she credits her recovery. and, in fact, today she's a-a part of an international

able/disabled dance troupe that tours internationally. she's still a wheelchair user, 20 years in recovery. very good. and, barbara, john just spoke of only two aspects: a ramp or the hearing impaired. what other provisions should substance use disorder and mental illness services be looking at? well, i think now we know that there is a crisis with the number of children with autism. and as they turn into adults, they are also affected by things like anxiety and depression, and they seek self-medication in the form of drug use. and there's going to be a need for programs for them to-for recovery. and 12-step programs don't always work with them because it's not concrete enough with the way they think. the idea of asking forgiveness from people- they don't understand how other people think and feel. so that's not something that is meaningful to them. so, you know, in the future, well, now going forward,

i shouldn't even say in the future, we need programs to meet those needs. there are also people with intellectual impairments who may not be able to sit in-in a group like everyone else and discuss feelings and may need things brought down to a lower vocabulary, for example. they still have the same feelings, but it's the ability to express them. so i think we-it's a real comprehensive look. dr. clark. that's the important issue when we talk about dealing with various aspects of disability- is you need to focus on the person who presents because there are over 50 official disability categories, and the most important thing is individual assessment and being able to accommodate. so someone has a literacy issue or a cognitive issue or a developmental issue, we need to be able to accommodate that.

now, a specific program may have problems because they don't have a critical mass, or a group therapy may not work for an individual with- who suffers from schizophrenia or who suffers from a cognitive disability or something like autism where there is a relationship issue. but you have to figure those things out. on the other hand, someone with physical limitations may simply need accommodation for the physical limitation if there's no corresponding cognitive issue. so the most important thing is an individual assessment and a willingness to accommodate the-the needs of that individual. and with regard to traumatic brain injury, we expect a large number of individuals coming back from the wars to suffer from either traumatic brain injury or spinal cord injuries et cetera. we need to be able to accommodate that and recognize that subissues, when you look at prevalence rate,

is associated with traumatic brain injury and-and-and spinal cord injury. in the case of our returning veterans, it's a matter of recognizing that drinking is, if you suffer from traumatic brain injury, drinking is a no-no. the problem is, from a social point of view, drinking is a yes-yes. because that's what they did with their buddies et cetera, et cetera. the problem with alcohol and tbi is it's disinhibiting, and that's a problem. because then you start getting into trouble. so treatment programs need to be able to assess for tbi or assess for cognitive dysfunctions. and we need screening tools that will allow us to do that. or when you're talking with family members or buddies or partners, you're able to make those assessments because it will help you address the issue because many people, especially early in the recovery process, aren't willing to acknowledge that they have

cognitive problem, or they may say, i understand, when in fact they don't. but you're saying, if i heard you correctly, that there may be 50 different variations of-of disabilities that i need to be able to assess for. how do i as a service provider seek the help in order to be able to assess that and not only that, how do we then create a plan, a treatment plan, with the correct methodology and the right components to be able to-to improve an individual's life? it cannot be a cookie-cutter approach, and i think that's another issue- that if i use the same recipe for everybody, i'm not going to produce the desired result. so it can be a burden on a program, but imagine it's a burden who's presenting for care. so the issue is assessment. i think dr. clark is absolutely right.

it is the client who is the expert, and you need to ask them about their disability, because their particular disability may be slightly different in terms of accommodation than somebody else who has the same category of disability, but the manifestation is very different. ed? yes, in reference to some of the self-help groups that i work with in maryland, we have a-a current effort going on just to show that you can outreach in the smallest and the slightest ways. maybe it's not really considered a small and slight way, but what we've-we've found is there's a lot of folks who just cannot read. there's millions of americans who cannot read or read at-at such a low level that when, when we're speaking in our-our groups and we say here's this literature- just read this literature and everything will be fine. and they cannot read it.

so our effort is to put audiotapes and videotapes out to-to the groups themselves, to-to the libraries in our counties, to the corrections facilities, and treatment facilities, and it's amazing how fast it took off because i've-i've been in the presence of people who-no one, no one wants to admit that they can't read. it's one-one of your deep, dark secrets. well, thank you, and when we come back, we are going to talk about more about the types of materials that one has to have and tools that we have to have in order to best address the issue of disabilities. we'll be right back. [music]

recovery benefits everyone. i started my own company. i got my dad back. my friends believe in me. "daddy's home." "hi, dad." substance abuse and mental disorders can be treated. it all starts on day 1. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s department of health and human services. [music]

awakenings program is a special substance abuse program designed for the deaf and the hard of hearing. i have worked here for 20 years. that's a long, long time, so i've seen awakenings program grow bigger and bigger and bigger. before, we only had six beds, men only. so now it's an integrated co-ed program, and it's expanded to 14 beds. we provide 14 beds plus outpatient services to about 20 clients. then, recently, we added a new program- it's a dmh program for the department of mental health for the deaf. people should know that awakenings program is the largest service provider in the u.s. specifically for the deaf and the hard of hearing. and so here at awakenings program all of the staff is able sign an asl very fluent. and at all times everybody is comfortable and able to express their feelings

and work on their background and develop a better treatment plan to help them meet their goals. being around deaf culture, being around other deaf helps, yeah. it's more of the ability to communicate quickly. you know if something's wrong or pops up, and they learn to manage it by getting feedback with other peers here, and they learn to get through problems. i was really surprised that they provided opportunities for the deaf and service the deaf, so really it impressed me to stay sober. since i've been here 15 months, i finally realized who i am. and i'm really grateful for this program to have taught me on recovery. so i needed a program to teach me how to develop a better behavior and build more hope

that it comes to me and i can improve and change. the willingness to grow as a human, that starts mentally- they have to believe in themselves and as well taking care of themselves physically. all of that comes together here, and you can usually see it in the client's eyes after three or four months. there's a shine there-i know that sounds like a cliché- but it's there oftentimes after 3 or 4 months. it's the ability that i can change. i do believe, you know, that there is hope in recovery and for the rest of my life, and what's really cool is when a family comes for a visit or a graduation and they see the person is really different, but they're not sure why. you know, and it's more than just sobriety; it's about living. what experience they get from this program