Improving Treatment for People with Physical and Cognitive Disabilities

I'd like to welcome everybody to today's presentation on improving treatment for people with physical and cognitive disabilities. This is based on SAMHSA tip 29. That's the substance Abuse and Mental Health Services Administration treatment improvement protocol 29. You can download this for free from the SAMHSA website if you want to. Chances are you probably work with people who have physical and or cognitive disabilities, so it can be a great refresher. The nice thing about tips is, number one, they're free. Number two, they are written in very easy to understand plain language. It's not like reading the journal articles that I so regularly reference. Alrighty. So we are going to define the impact of disabilities on the seven categories of functional capacity. You didn't know there were seven categories, did you? Well, you don't need to know all of those categories by heart. We're just going to break it down so it gives us some structure to talk about. We'll explore unique challenges for people with disabilities, identify attitudinal, procedural and treatment barriers and methods to mitigate them. That's really what we want to focus on today. And then review other identified behavioral targets, particular issues that may be more prevalent or more pertinent for people with physical or cognitive disabilities. People with physical and cognitive disabilities have unique issues in treatment, just as every person is unique. But people with physical and cognitive disabilities also have additional needs, potentially on top of their regular presenting issue. We don't want to assume that just because somebody presents in our office with characteristics of depression, for example, that that is their only issue, even if that is their only obvious mood issue. We do want to at least keep in the back of our mind, if you don't screen for it, screening is better. But keep in the back of your mind that there may be a potential that the person has some cognitive disabilities or even unseen physical or hidden physical disabilities. People may have the same disability without having the same functional capacities or limitations. It's also vital to remember that somebody who is deaf, for example, may have very different abilities than somebody else who is deaf. Somebody with autism spectrum disorder may have very different functional capacities than somebody else with, guess what? Autism spectrum disorder. So we don't want to assume that we know what their needs are based on their disability, just like we don't want to assume that we know what their needs are based on their diagnosis. You know, obviously if they're depressed, they want to feel better, but what that looks like to that person or what their endpoint targets are may be very different than somebody else with whom you are working, that has depression. So your categories of functional capacity, self care, and that's you're bathing, you're feeding, all those basic activities of daily living, mobility and transportation. And this is not only getting from point A to point B, you know, going to the grocery store and that sort of thing, but also getting around the house, getting around Walmart or the grocery store, maybe even transferring from a wheelchair or from a walker to the bathtub or to the bed. So we do want to consider mobility and that, you know, some people might smoosh part of that under self care. But in this tip they didn't communication, expressive and receptive. They didn't talk a lot about this in or some of this stuff in the tip. So I'm going to point out that for example, people with not autism, fetal alcohol spectrum disorders often communicate. Their expressive skills are very age appropriate or even higher. They may be very good at talking the talk, but their receptive communication skills, what they understand is much lower generally. Not always everybody's different. But a lot of times there is a big gap between expression and reception. For people with fetal alcohol spectrum disorders. For example, you might have someone who is chronologically 18 who talks at the level of a 20 year old. You know, they can carry, they can speak at that level, but what they understand is only at the level of an eight year old. And it's really important to understand that because it can get really frustrating, especially when working with people who have an fasd. And remember there is fetal alcohol spectrum disorders. Some people have very low impact from the alcohol, some people have very high. But when you're working with somebody who has a wide gap between their expressive and they're receptive, it may feel like they are being intentionally resistant or willful or oppositional. In treatment, when they don't do what's asked or when they don't stay on topic in group, for example, it may not be that they're, you know, intentionally being malicious. And you know, I tend to think that they're not. What may be happening is they don't understand what they're hearing. So they're trying to keep up their parroting and they're mimicking what they hear, but it has no meaning to them. A lot of times it has no meaning to them. So, you know, think of it kind of like parroting. They hear a lot of things so they can talk the talk. We were talking the other day at the dinner table about cryptocurrency and that is something that is way over my head. Blockchain and you know, crypto and all the, and mining and all this other stuff. I know the words, I can throw the words out there with the best of them. I have very little idea what I'm saying. But you know, I can, I can nod and agree. And to that extent, you know, that would be an example of, you know, on a very minimal basis of how somebody with an FASD may get caught up in a situation where you think they know more than they do because they are parroting and, you know, repeating the same things. So we do want to pay attention to communication. Some people have difficulty with stuttering or cluttering. Some people have difficulty speaking in public. And that in public may even include group situations. I had one client many years ago who had a tic disorder and when his stress would go up, the tics would become much worse. And he was very self conscious about his tics. And so whenever he was in group or even he couldn't even eat in the cafeteria around other people because his tics would be so bad that he couldn't actually feed himself. Same thing in group. When he would get stressed, he wouldn't be able to talk. So we needed to make special exceptions for him in, you know, obviously not calling on him in group and putting him on the spot. He was able to sit in group without any problem. He was able to hear and listen and take it in. But then we would have to have time, one on one time with his primary or with the, with the group facilitator who would check in with him to make sure he was understanding what was going on. And over time, you know, this was a residential program. Over the two months that he was with us, he did start developing more self confidence and he took some baby steps towards being able to talk in groups. In those groups that he got used to and he felt comfortable in, he actually was able to start participating a little bit. You know, he would have to think about what he was going to say ahead of time and then share with the group. So we do want to be aware of these things and we're going to talk more in detail about them in a minute. Learning issues is another area of functional capacity. How long somebody's attention span is, obviously ADD is one of those things, but also things like Alzheimer's and dementia and even alcohol related dementia or early stage detox can impair somebody's ability to pay attention for long periods of time. And when I say long periods of time, depending on the person, that could be five minutes or that could be 50 minutes. Comprehension goes along with that expressive and receptive communication. But we need to make sure that what we're communicating, we're communicating in a way that people understand. And it can be really frustrating for the clients if we are talking about something and using technical jargon, using lots of terms that they don't understand, or for going too quickly for them. People who have dementia, people who have cognitive disabilities, people who, you know, there are a lot of different issues that may make people's processing a little bit slower in that vein. You know, not that it's an indication of a cognitive disability at all, but I think it's important that we, as facilitators, and even in a one on one session, we are aware that some people are reflective learners. So when you're talking to somebody and you're presenting them with lots of information, or you're having an argument or even just having a session, you may talk and, you know, go on, on a, on a speech or diatribe for a minute. And then when you're finished speaking, if they're a reflective learner, they may not respond right away. They need a minute to let all those words come in, get processed, you know, sort them out. Then they have that aha moment. It's not that they are not listening. And people who are reflective learners get very frustrated very easily, or they can if you put too much pressure on them. My daughter is a reflective learner and she used to hate, she still does hate anything that is timed. You know, she would be doing, doing lessons online, for example, and she would have to do a certain number of, of math problems in a particular amount of time. And for her, she needed to learn the information, to digest it, to think about it. She's very bright, but she doesn't work at the same lightning speed that her brother does. So we do need to pay attention to are they comprehending what we're saying? Are we using words and communication styles that are appropriate to them, and are we giving them enough time to actually hear it, take it in, and understand it? Retention is the next part. One of the things that I talk about when I teach the class on adult education is there are multiple parts to learning. We have to get the information, we have to hear it, take it in somehow, whether we see it or we hear it, get that information in. So we have to acquire it, we have to conceptualize it, you know, put it into something that we can relate it to so we can figure out where to file it in our memory banks. And then we have to care about it because what we don't care about goes in one ear and out the other. You probably remember this from graduate school when you would have to cram, or even undergrad when you'd have to cram for an exam, for a class you really didn't care about. You memorized the stuff long enough to pass the test and then you didn't think about it again ever. So that is one of those things that we want to think about with retention. We want to make sure that people are understanding it and they care enough about it. They care about it enough to commit it to memory, and they know how to commit it to memory. And then application. Knowledge is great, but knowledge without application is kind of useless. One of the auditors that I had when I was a very young counselor came and was talking about the way that the Department of Children and Families, they were one of our biggest funders, the way they wanted treatment plans written. And what they wanted was to see a progression in the objectives that henceforth and forevermore was known as KSAs. Knowledge, skills and abilities. So we would teach them the knowledge. That was the first step, that was the first objective or objectives, and then they would develop the skills. They would figure out, okay, how do I use this? And then abilities is when they figured out how to generalize it and use it in real life so they could take it from the classroom and, and use it in the real world. So that's really important. We want to make sure that what people are learning in group or in session, they're able to actually translate into something useful. And regardless of what's going on for the person, we want to make sure that this is happening. Problem solving and abstraction is another area of functional capacity. How well can the person take this information, solve problems, handle obstacles when it comes to activities of daily living? You know, if they're able to drive and they're driving along and all of a sudden, oh, they get a flat tire, can they figure out what to do next? Social skills is another big issue, as well as executive functioning. People with mental illness often have impairments in memory and executive functioning that may impede learning and behavior change. Now, the foundation of this treatment improvement protocol was working with people with cognitive and physical disabilities. People with cognitive disabilities may have difficulty with, with learning and, or behavior change. Thinking about these categories of functional capacity and the presenting issues that we often see in clinic mood disorders, you know, how does that affect self care when a client comes in and they've got a mood disorder? You know, one of the key things that may set off my radar that they have, you know, clinical depression, for example, is if they look disheveled. We want to make sure that, you know, we want to look at these categories of functional capacity in terms of the presenting issue, the mood disorder or whatever, but also in terms of their other abilities, physical and cognitive. Can they take the information and process it? Are they capable of, you know, following through with these tasks? Mobility and transportation generally for somebody with mood issues is not that much of an issue, except for they have low energy, a lot of the time, communication, they may be alexthymic, they may have difficulty expressing their feelings, they may have low emotional iq, learning when people are clinically depressed, or have generalized anxiety, attention, comprehension, retention and application generally all are more difficult because they are really struggling. Their norepinephrine levels are low, Their dopamine levels are really low. Problem solving and abstraction can become problematic for people who emotionally dysregulate. Once they go from flat to furious. Once they are emotionally dysregulated, they may have difficulty with problem solving and figuring that out. So they may need assistance with distress tolerance skills, social skills, lack of them could contribute to the mood disorders or the mood disorders could contribute to agoraphobia or withdrawal from social functioning or social, social activities. So their social functioning skills may have decreased. We want to assess it and then obviously we want to look at their executive functioning. And you can go through each one of these for schizophrenia, addictions, eating disorders, adhd, personality disorders and intellectual disabilities. Each one of those diagnostic categories, if you will, has potential implications for every category of functional capacity. So if we are using a biopsychosocial approach to care, we want to make sure that we are assessing all of these things. Somebody who, you know, for example, has ADHD may struggle in paying attention in a 90 minute group, for example. So we do want to factor those things in. People who are in early recovery, early, early phases right after detox may have difficulty with being dizzy and having headaches, which makes self care potentially problematic. Making sure that they don't fall in the shower, for example. They may have difficulty with attention and comprehension. And depending on their drug of choice, they may have high levels of anxiety or high levels of exhaustion and depression that they have to deal with concurrently. So there are a lot of things that I think we typically overlook in our assessment that may help provide a more individualized treatment plan for each one of our clients. 20% or more of all people qualifying for state vocational rehabilitation services qualify for a diagnosis of substance abuse or substance dependence. So it's important to recognize that people with other disabilities are at higher risk, according to the cdc, are at higher risk of developing substance abuse or substance use issues. People with disabilities other than substance abuse. So they took out all of the people whose primary presenting issue was substance abuse, and they looked at people with all the other diagnoses in the DSM as well as physical disabilities. They found that consumers with disabilities other than substance abuse reported patterns of illicit drug use that were more frequent and heavier for every single drug. Compared with the general population, respondents with a disability were more likely to be heavy or moderate drinkers. 35% of them reported being heavy drinkers and 25% moderate. So that gives you an idea that there may be some issues that you know when you're working with a client that you didn't actually pick up in the screening. When you're talking about depression or anxiety, for example, they may also have concurrent substance misuse. Maybe it hasn't risen to the level of substance abuse yet, but they are, you know, heavy users, for example, which you know, puts them more at risk because every time they, they use, they're altering their neurochemical balance. People with mental illnesses, now this is specifically, mental illnesses are more likely than other people with disabilities to have a substance use disorder. Why do you think this is? I would encourage you to think about behavioral reasons, environmental reasons, and neurochemical reasons. I'll start with the neurochemical while y' all are thinking about it because some of you may be reflective learners neurochemically. People with mental illnesses, for example clinical depression, may have low levels of dopamine, may have low levels of serotonin. And by engaging in pleasurable behaviors, by using substances like alcohol or, you know, other things, they may be self medicating and increasing those neurotransmitters. The same thing can happen with things like sex addiction and gambling addiction that can. Both of those are very powerful ways that people may self alter their levels of dopamine, norepinephrine and serotonin. Neurochemically, we want to look at what is the function of the substance for the person. Is it self medication and, or is it helping them escape? Just numb, just kind of check out for a little while. And that would be more like your marijuana, your alcohol and your opioids. Environmentally, people with mental illnesses, especially severe and persistent mental illnesses, may be in environments in which there is a high level of substance abuse around them or substance use around them and they may have difficulty refusing. People with fetal alcohol spectrum issues are often very gullible and tend to follow and mimic people around them, so they tend to be at very high risk of being led astray. But other people as well. I had one client who had schizophrenia and concurrent substance use issues anyway, and in the neighborhood that she lived in, in her own words, the crack dealers came to her, came to her house every day, like the Avon lady. And, you know, that was. That stuck with me for 20 some odd years after she said that. And it's important to recognize that people with disabilities may be at a lower socioeconomic status and as such, may be living in environments in which there is more open access to drugs. That's not to say that there isn't easy access to drugs for people with a high ses, but a lot of times, because of the legal consequences, as people go up in socioeconomic status, the drugs availability becomes more hidden. So they're not just out there behaviorally. People with mental illnesses may have lower impulse control. They may think, oh, that's a good idea, and be more likely to engage in it. I had another client, again, who was also schizophrenic. And I remember one day I was talking to him, and bless his heart, he admitted that he had used cocaine all weekend. And I was very concerned. And I, you know, call him Jim Bob. I was like, jim Bob, you know, I'm concerned that you're using cocaine, because that's really not a good thing to be doing. You know, on top of your antipsychotics, it kind of works against, you know, cocaine, increases dopamine, Antipsychotics are trying to bring it down. You know, it's not helping you out at all. And he said, and it's dangerous. You know, I didn't bother explaining all the reasons. I told him, you know, I'm worried it's dangerous. And he looks at me, doesn't miss a beat. He goes, oh, don't you worry, Ms. Dawn. I made sure to quit taking my medication three days before the weekend, so it was completely out of my system. All right, well, in one way, that kind of showed good judgment. You know, obviously he didn't want to die, and he was able to think it through that, and he was making a conscious choice ahead of time to use the substances. Substance use in itself was another issue that we had to talk about. What was the appeal of the cocaine, why was it worth doing that, and the potential consequences. So, anyway, we do want to remember that behavior is communication. So if people are using substances, what is that? Communicating conditions more prevalent in people with developmental disabilities more than the general population. And this is somewhat true with all disabilities, not just developmental disabilities, but they can experience social isolation for a lot of reasons, as you can see. Especially it tends to be more prevalent in people who have had a disability from a young age. Their families may have wanted to protect them so much. Their families may have hovered and isolated or shielded them so much that they were socially isolated. You know, the families had their best interest at heart, but they may not have developed social skills or friendships or social supports that were necessary for the developmental process. They may have physical difficulty getting out to social settings. Obviously, before they can drive, they have to rely on caregivers. But if they are not able to drive, for example, if they have epilepsy, they may not be able to drive. I can't remember what the parameters are for how long they have to be seizure free before they can get a driver's license. But you know, there are certain conditions that may prohibit people from being able to get a driver's license. And not everybody lives on a bus line. Lack of opportunities to practice social skills. If the person gets up, goes to school or work, comes home and that's all they do, and their school or work does not allow them a whole lot of time to engage with others, then they may not have a chance to practice actual socialization. And they may not have time to really develop those social skills. And think about jobs people have. If they're working at the Jiffy Lube and they're changing oil on cars, or if they're working in an accounting office where they're in a cubicle by themselves all day long, there are white collar and blue collar jobs that do that appeal more, put it that way, that appeal more to introverts because they don't involve a whole lot of socialization. And if our people are engaged in those jobs and they don't have other hobbies and recreation and those things, other opportunities, they may have inhibited social skill development. They may have a lack of physical stamina, potentially due to obesity. Now, some disabilities in and of themselves may reduce physical stamina because of their very nature. It may require more effort. For example, for somebody who walks with a walker, that takes a lot more effort than not for somebody who has some sort of cardiorespiratory issue. It could take a whole lot more energy for them just to walk around or do things than it does for somebody else. But then we also see that a lot of people with mental illness are obese. There is a higher prevalence of obesity in people who are, who have mental illness and they Hypothesize that could be due to lack of understanding about nutrition. It could be due to self medicating. They gravitate towards foods that increase endorphins, serotonin and dopamine, like simple sugars and high fat foods. It could be because they have less opportunity to get out so they stay home. And they tend to stay home and eat and be sedentary. There are a lot of hypotheses, but we do want to consider our clients physical functioning level, physical stamina level, when we are planning or helping them plan some of their wraparound services. Lack of energy due to medications. Clients who are on prescription prescriptions for opioids, for benzodiazepines or for antipsychotics are all typically potentially going to have much lower energy levels because these all impact energy. There are certain SSRIs that are known to be very sedating. We do want to pay attention to the medications that our clients are on and help them figure out if the medications are sedating and inhibiting their quality of life. Encouraging them to advocate for themselves with their physician to talk about. All right, can I alter when I'm taking this medication? My stepfather, for example, used to take Paxil in the evening because it was so sedating. He couldn't take it in the morning or he'd be, you know, groggy all day long. But he would take it in the evening before he went to bed and it would help him sleep more. I had another client who was on an antipsychotic and they found that the sweet spot for her to take her medication was about 4 in the afternoon. So by the time she was ready for bed, you know, a couple hours later, she was good and tired. But by the time she was waking up the next morning, it was almost out of her system. If she took it much later than that, she had a hard time getting out of bed and getting to work. We do want to help clients understand that there are often workarounds, but they need to advocate for themselves. Trouble finding or getting to recreational activities, for example, for people in wheelchairs, they may not have the same wealth of recreational activities available to them. So we do want to help people find activities that they enjoy. Meetup.com is a site online that has groups and there are all kinds of different groups. You know, there are groups for people who like board games. There are people groups for people who like sci fi. There's lots of different groups. And I encourage people to consider going on there if they don't know where to start. Faith based organizations also generally have a lot of options for potential outings and occasional recreational activities. Poverty is another huge issue that can contribute to social isolation. Travel is expensive. As gas prices go up, it gets more expensive to drive. If you have a car, it gets more expensive to ride. It's expensive to ride the bus or the train. So poverty in and of itself can prohibit people from moving around. Non disabled people's comfort with people with disabilities is another issue that we need to address. And some of this can be helping our clients with their self esteem so they can present themselves in a way that is open and inviting and hey, here I am instead of do you mind if I kind of maybe hang out? When people are more optimistic and assertive, it tends to make people without disabilities less uneasy. If they feel like they're not worried about offending the person with the disability. It's also easier and we can also help with this by doing community education in our communities to remove some of that stigma. Altered body image in those with a recent disability, if they were recently confined to a wheelchair, if they recently had an insulin pump installed or an ostomy bag installed. It's also really important to recognize that these changes to physical appearance. Our society is very hung up on physical appearance. But these changes can make somebody very self conscious and potentially very withdrawn and it can also impact self esteem. So there are a lot of issues. These can be target issues in the treatment plan for people with disabilities. Over 10,000 people come to BetterHelp every day looking for a counselor. BetterHelp makes it easy for you to move your practice online and focus on what you love most. Helping others better helps easy to use platform. Takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18,000 therapists at BetterHelp helping to improve people's mental health and lives. Identifying hidden disabilities is another key to successful treatment. A person who repeatedly fails at treatment may not understand what they're being told to do or may not be able to read or remember materials. If you have a client, for example, who has dyslexia and a lot of times people with dyslexia their the dyslexia never gets diagnosed. My mother worked for years with the Literacy foundation in North Carolina and the number of the frequency with which she told me about people she was working with who were not able to read but it wasn't because English was their second language. A lot of them it was because they had some level of dyslexia or vision impairment. So we do need to identify some of these things. Just because somebody is not completely blind doesn't mean that they can see well enough to read. I don't wear my glasses all the time, and my husband this weekend kept trying to show me stuff on his phone, and I'm like, honey, you realize I can't see pediddly squats without my glasses on. You know, I can get around the house, but when it comes to looking at something on a mobile device, you know, I can. No. And this may be the case for our clients, and they don't even realize that their vision is bad. So paying attention to those things, screening in clients who have low literacy levels for vision impairment and dyslexia is really important because being able to read is so essential to functioning in our society. And when you can't read, it impacts your sense of safety, your sense of self empowerment, your self esteem, all those things. Many people who have disabilities like multiple sclerosis, seizure disorders, cardiac problems, autoimmune issues like fibromyalgia, Crohn's disease, eczema, look healthy much of the time. But these conditions often cause significant fatigue or limitations on walking, driving, or other physical activities, or even just sitting. So we do want to ask people about any health conditions that they may have. People with fetal alcohol spectrum disorders, autism spectrum disorders, adhd, ptsd, et cetera may have not gotten effective differential diagnoses in the past. We don't want to assume that just because we're seeing an adult that any developmental disabilities they have were diagnosed when they were developing. A lot of times people will get a diagnosis, they won't get a comprehensive diagnosis. Back when I started diagnosing, we still had the five axis system that we used in the DNA, DSM 3 and the DSM. I think we still used it in the DSM 4, but now we don't use that system anymore. So I'm finding when I get reports from other clinicians, a lot of times there's much less attention to all of the biopsychosocial domains. Don't forget physio. Don't forget that there can be physiological issues that contribute to symptoms that cognitive dysfunction, mood issues, chronic pain, low levels of omega 3s can contribute to increases in pain and exacerbation of autoimmune issues. So it's always helpful if a client is willing to go to the doctor, get their vitamin D, their iron, their thyroid levels tested, their gonadal hormone levels tested, and their A1C or their blood sugar levels tested. Gonadal Hormones are really integral in energy levels, in weight levels, and in mood. Both testosterone, estrogen, and progesterone and are involved in issues like premenstrual dysphoric disorder, menopause, polycystic ovarian syndrome, low testosterone. There are a lot of syndromes that we see that may be contributing or confounding the mood or mental health issues that the person is presenting with. Same thing with their blood sugar levels. 34.5% of all U.S. adults, not just people with disabilities. 34.5% of all US adults have prediabetes based on their fasting glucose or A1C levels, according to the CDC. Let that sink in for a second. So more than a third of our population has prediabetes right now, and it may be even higher since we were all locked down during COVID I think most of us gained a little bit of weight. That's important to recognize because diabetes can have significant implications for alterations in mood as the body has more difficulty regulating insulin levels, which triggers that stress response. Commonly held beliefs that pose barriers. People with disabilities do not abuse substances. Well, I think we covered that already. People with disabilities, cognitive, physical or otherwise, are at risk for abusing substances, some more than others. Mainstreaming means people with disabilities should receive exactly the same treatment protocol. No individuals are individuals, regardless of whether they have disabilities or not. It is my belief that pretty much no two individuals are going to have the exact same treatment protocol. There are going to be at least minor differences. Mainstreaming means helping people with disabilities function as effectively as possible within your setting, but providing accommodations to make that so that way they don't feel like they're being, you know, pushed over to a, you know, a special group. They are part of the treatment cohort, but they may need additional assistance or modifications. If they can't read, they may need, or they're visually impaired. They may need, for example, the resources to be on audio tape or on video that they can listen to. They may also, if they have ADHD or other problems with long attention spans, they may need to review lessons, have them videotaped, and then review the lessons in smaller chunks afterwards. That way they can actually pick up on the information. Same thing for people that have slower cognitive processing. Provide them handouts with bullet points in plain language, encourage them to participate in the groups, but also having the information recorded so they can go back and listen to it afterwards as many times as they need to, pause it when they need to so they have time to process what's going on and then potentially even have worksheets that they complete showing their comprehension of what's going on. Another myth is a person is non compliant when her disability prevents her from responding to treatment. No, that means treatment's wrong. That means we need to adjust treatment. We need to examine why the non compliant. Now, there are people with disabilities, cognitive and physical disabilities, and people without cognitive or physical disabilities who may be treatment non compliant because they are not motivated to be there. The court's telling them they have to be there. Somebody else is telling them they have to be there. We need to examine the reason. What is the behavior communicating to us? Does the non compliance say, you don't understand who I am and I have no desire to listen to you? Does the non compliant say, I don't understand what you're asking me to do? Or I can't remember it? Or does the non compliant say, yeah, you've missed the point. You're not hearing me. There are a lot of different things. We need to examine what that means. But a person with a disability shouldn't be singled out. We don't want to lump people in together. There are a lot of reasons for non compliance again, in people with and without disabilities. A person with a disability will make other clients uncomfortable. Everybody's responsible for their own comfort. And as a clinician and as an administrator, it is our responsibility to help people feel comfortable with one another. And if that means having a discussion, introducing the person, helping people learn how to feel comfortable around someone with a disability, then that's what we need to do. And through that, we are educating the group about the commonalities that they have with the person with the disability so they feel more comfortable around not only that person, but other people with disabilities. People with disabilities will sue the program regardless of the services offered. No behavior is communication. What does a lawsuit generally mean? A lawsuit generally means my needs were not met. I felt abandoned, I felt discriminated against. I felt something. So we need to evaluate our programs for their responsiveness to people with disabilities. Serving people with disabilities requires going to extremes. No, it doesn't. A lot of times people with disabilities are very happy if you are willing to do what's necessary to help them out. Treatment center I used to work for was a very small treatment center, so they were exempt from having to build ramps and everything. But there was a little lip at the door. And we had one person who was in a wheelchair that ended up coming into treatment. And, you know, they didn't throw a huge fuss about needing a ramp built or something, but they did need. When they got there, they called on their cell phone and they needed somebody to come out and help them over the lip. They were fine as long as they had assistance getting in the door. It wasn't a huge, big deal to them. So being compassionate and being open and saying, okay, how can we solve this problem together? Is really what it's about. The person with the disability just wants to feel respected. People with both a mental illness and a coexisting disability may need assistance with escape from abusive situations, whether they are physical or cognitive disabilities. They may have a certain amount of financial dependence, for example, on other people who may be physically, emotionally, or financially abusive. So we do want to screen for abuse and know what resources are available in our communities. They may need assistance learning to protect themselves from victimization. This is especially true, I think, with people who have intellectual disabilities, fetal alcohol spectrum issues, or autism spectrum disorders, for example, where they are potentially a target for people who are more antisocial, who are willing to manipulate them. They may need assistance finding volunteer work or other means of gaining a sense of productivity. Your local and state vocational rehabilitation departments, or whatever they're called, are available and they offer a wealth of different services from screening and counseling to job placement, volunteer opportunities, supported employment. They can be a great assistance to someone who has a severe and persistent mental illness, for example, and needs some sort of activity to help them integrate into the community. They may need assistance developing pre vocational skills such as activities of daily living and using public transportation. What do you wear to a job? How do you get there, all of those basics that we take for granted. They may need to learn social skills if they've got a fetal alcohol spectrum disorder, autism spectrum disorder, or just have had a lack of enrichment opportunities. What I mean by that is people who just have not had the opportunity to socialize may need assistance developing social skills. If they were isolated a lot as a young person, or if they've isolated themselves a lot in recent years, they may not feel socially competent. So they may need to learn skills or have a refresher so they feel confident and confident in the social arena. They may need to learn how to engage in healthy recreation. I can't tell you the number of people that I've worked with over the years when I've asked them, what are your hobbies? What do you like to do? I don't know. Their lives pretty much existed of using, sobering up and using again. By the time they came to residential treatment, there was very little work or socialization or recreation in between. So it was important to help them step back. But even people who aren't in recovery from addiction, it may have been so long since they've had the energy to actually recreate, or maybe they have been laser focused on their career, let everything else slide. They may not know what they like to do. So we may need to step in and help them here. And remember, we're talking about people who are presenting with whatever you treat in your clinic, some sort of mood disorder maybe, and they may potentially also have a physical or cognitive or both disability. People with both a substance use disorder and a coexisting disability may need assistance becoming educated about their legal rights to accessible environments and services as well as employment. Askjan.org is a great site for finding out about reasonable accommodations based on diagnosis. It's a great place that your supervisors can go to find out about accommodations they can make for clients who have disabilities. Great place clients can go to find out about accommodations they can request from treatment centers, from employers, et cetera. As I said earlier, vocational rehabilitation services, they're available in every state. You just have to look up, you know, type in your state. And vocational rehabilitation, you will find the link to the state office and probably local offices as well. They may need assistance finding out about financial benefits to which they are entitled. And a lot of times VR can help with that as well and building new peer networks. And depending on your person, if they're in recovery from addiction, then they may be going to 12 step meetings. If they are, you know, there are other support groups, but like I said earlier, there are also other recreational groups out there. Meetup.com is a great place. Facebook may still have groups, you know, local groups that they can connect with. Faith based organizations, anywhere where they can connect with positive people. It doesn't necessarily even have to be, and probably preferably not necessarily a group that's dedicated toward serving people with the same disability. What we're really looking for is to help them integrate and find social supports with things that interest them and not necessarily with people who share their disabilities. Other commonly held beliefs that pose barriers. People with cognitive disabilities are not capable of learning new behaviors. Yes, they are. We just sometimes have to present it more slowly and we may have to repeat it more often. For example, people with fetal alcohol spectrum issues or with dementia may have good days where they remember things and bad days where they don't. So having lists, having pictograms that can help them know what they're supposed to be doing that can serve as prompts can be very helpful. People with Disabilities use their disability to avoid fully participating. We want to look at what's the function of the behavior. If there are significant rewards when they refuse to participate, well, then maybe they are using it to try to avoid participating. But a lot of times they are telling us about accommodations they need because they have lower stamina or increased pain or more difficulty concentrating. And so we need to listen to what it is that they're needing. People with disabilities deserve pity and lots of latitude. Most people with disabilities don't want pity. We do want to recognize that we need to have empathy, that life can be more challenging for people with disabilities because they have other obstacles, more so than we do, and that they have to contend with on a daily basis. But most of the time they are not asking for extra latitude. What they want is to be able to have the accommodation so they can fully participate. People with disabilities want to be quote, unquote normal. And some people with disabilities wish they didn't have that disability. Other people with disabilities are very offended at the idea that they should want to get rid of this issue that they have. You know, people who are deaf, embrace being deaf, embrace being part of the deaf culture. So it's important that we don't assume that people, every person, wants to be able bodied just like us. Discriminatory policies and procedures. We do not serve clients who are taking medication. Even if medication is for a medical condition such as epilepsy. You can see where this might be a problem. Fire and safety regulations require all clients to be able to walk out of the building independently. Well, that doesn't work for people who are in a wheelchair or even people with autism spectrum disorders, for example, who may freak out when that fire alarm starts going off. And they may start stimming and not be able to walk out on their own. All clients must participate in house chores. Some people are going to be sensitive to cleaning chemicals. Some people aren't going to have the physical agility to do so. Every person must read two chapters of a book per day. Well, that doesn't work if you're working with somebody who is visually impaired or does not have literacy levels. To do so. Clients must be able to bathe and put themselves to bed. That doesn't work if you have a client, for example, who needs assistance transferring from a wheelchair to the shower or a wheelchair to the bed. Discharge fines due to factors beyond the client's control, like inability to sit still or stay awake. We need to examine whether those behaviors are a result of of their disability, like ADHD or medications that they're taking missing appointments because the accessible bus is on a random schedule. That's not their fault. OCD or agoraphobia. I've had clients who have had times where they just couldn't make it, couldn't leave the house because their ocd. In that particular case, her OCD rituals that she went through, she messed them up and she had to start all over again. And those rituals at that point in her treatment were still taking multiple hours at a time. And intoxication. And I have a question mark by that one, how your department handles that. But if somebody is repeatedly unable to attend due to intoxication facilities I've worked at, generally what we do is transfer them to the higher level of care. We're not discharging them, but we're recognizing that they're not able to stay clean and sober at that level of care. Barriers to communication. If they are speaking slowly, that can get frustrating. We need to give them time to speak. Cognitive slowing due to traumatic brain injury, medications, dementia, even thiamine deficiency, which can cause cognitive slowing and dementia like symptoms. Thiamine deficiency can be seen not only in alcohol detox, but also in people with anorexia or who have had gastric bypass surgery. So getting up to date on what the signs of Korsakoff syndrome look like are really important. Difficulty with extended attention. How can you modify your sessions for people who have difficulty with extended attention? Differences between their ability to express and receive information. We talked about that one already. Difficulty reading and literacy issues. Talked about that one already. You know, oftentimes responding with audio recordings, stuttering and expressive communication issues. You know, the person may need to communicate through writing or drawing. Hearing or visual impairment, including dyslexia and colorblindness. It's important to remember that some people have not gotten these diagnosed. Additionally, depression, clinical depression can contribute to blurred vision, headaches, and physical and cognitive slowing. So we need to. Is your vision problem because of depression or because of, you know, a vision problem? Poor acoustics can also make it extra difficult for people with hearing loss. So paying attention in a. Like in a group, for example, to shutting the door so you don't have background noise that is distracting from what's going on in group. Other issues include sensory hypersensitivity to smells, lighting, flickering lights, bright lights, sounds including ballasts, getting ready to go out, or, you know, lots of activity outside of the therapy room, and touch and temperature. Sometimes even a vent blowing on somebody may be painful to them. Are there any questions? I know I ran off a little bit at the mouth today. I apologize, but obviously I got excited about this topic. Clinicians may inadvertently overlook some confounding issues for people with cognitive or physical disabilities, focusing only on their presenting issue. Assisting people in achieving their highest quality of life means ensuring they're able to be safe and meet their biopsychosocial needs by screening for obstacles and providing resources linkages. We can't do everything where they're counselors or their social workers. We need to link to other resources. For more resources and information, see tip 29, treatment for people with physical and cognitive disabilities as well as contact your local department of vocational rehabilitation. All righty. And Jennifer had asked a question. And in response to your question, Jennifer yeah, that's a whole different presentation. But families of people with disabilities do struggle with a lot of additional stress and financial stress, occupational stress, interpersonal stress. So it is important to identify what issues and going back to the categories of functional capacity for those families, we want to look at this and ask in assisting living, caring for a person with a disability, how is that impacting your self care? How does that impact your mobility and transportation? You know, you can't just necessarily hop on the on any old Uber, for example, if your loved one has a wheelchair, how does that impact your ability to communicate with your loved one? If they have expressive and receptive challenges, how does that impact your life when you're trying to, especially obviously if you're working with somebody who's a younger person, if you're trying to help them learn, learn to brush their teeth, learn to get dressed for toddlers and younger people and even up through school when they're struggling in school, how can you help them, advocate for them and empower them in the academic setting? Problem solving and abstraction. What problems or challenges or obstacles are you regularly faced with in caring for your loved one with a disability? How can we assist you? Let's think about what are some ways to solve those problems? Social interactions. You know, what challenges does your loved one have with social interactions? Is it that they're not available, that they don't want to do them? That when they go, they engage in inappropriate behaviors like biting? What's going on? And how can we help you help them? And how can we help you help yourself so you're not like stressed to the hilt every time you go into a social situation expecting the worst? So you can handle, you can feel empowered, you can feel efficacious in social situations, even if your loved one acts with inappropriate social skills. So again, we want to go through each one of these areas of functional capacity for the loved ones and examine how the person with the disability living in their household, how does that impact the family and how does that impact each individual?