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Drug And Alcohol Rehabilitation

Alcohol and Other Drug Abuse by the Physically Impaired

Alcohol and other drug abuse is a problem among some clients with physical impairments (Anderson 1980-1981; Boros 1980-1981; Greer 1986), although the scope of the problem is not known precisely (Hindman and Widem 1980-1981; Greer 1986). Thurer and Rogers (1984) found that 53 percent of a sample of physically impaired clients rated help with alcohol or other drug problems as a "substantial need" or "great need" among the physically impaired.

The lack of services to meet this need can be traced in part to the training received by rehabilitation counselors, who often are taught to expect that their future clients will have only one disability. When multiple disabilities are discussed in rehabilitation education, they usually are described in terms of such pairings as brain injury with convulsive disorders, cerebral palsy with speech problems, and low back injury with a learning disability. Physically impaired clients with alcohol or other drug problems often are described in training materials as having one primary disability and almost never as having long-term dependence on alcohol or other drugs.

This article examines possible explanations for the lack of discussion of alcohol and other drug problems in most counselor training programs. It also presents some strategies to rectify this omission.

AN APPROPRIATE INTERVENTION ROLE

FOR REHABILITATION COUNSELORS

In the author's view, four general guidelines on the appropriate role of the rehabilitation counselor in intervention for alcohol and other drug abuse can be inferred from the ethical standards and principles of the profession (as discussed in the accompanying sidebar):

1) The rehabilitation counselor

who knows that a client abuses

alcohol or other drugs, and that

the abuse may interfere with the

client's rehabilitation program,

is professionally obligated to

bring this fact to the client's

attention. The counselor should

apprise the client of all available

intervention options. 2) The rehabilitation counselor

should make alcohol or other

drug abuse intervention a part

of the Individual Written Rehabilitation

Plan, if the client

consents. 3) The client has a right to refuse

any suggested intervention. 4) If the client refuses intervention

and if the client's persistent

abuse of alcohol or other drugs

will seriously impair potential

benefits from rehabilitation

services, the counselor may terminate

services to the client.

Services should be terminated

only after reasonable effort to

secure the client's compliance

has failed. Upon termination,

the counselor is obligated to

refer the client elsewhere.

The abuse of drugs prescribed by a physician is a specific area of client drug abuse in which direct confrontation by the rehabilitation counselor may not be indicated. Diazepam (Valium), for example, can be abused (Hepner et al. 1980-1981), and a counselor may have reason to believe that a client is receiving and/or using diazepam beyond appropriate therapeutic limits. In such situations, the counselor would, without delay, confer with the rehabilitation agency's medical consultant. If the patient is found to be abusing a drug that is prescribed within therapeutic limits, the medical consultant, not the counselor, would decide what action to take. Similarly, if it is suspected that the client is receiving a larger than therapeutic dose of a psychoactive medication, the medical consultant would intervene; the counselor is bound by professional ethics to avoid confrontation with the client on the issue of the practices of the treating physician.

CURRICULUM ISSUES IN REHABILITATION

COUNSELOR EDUCATION

The traditional model for graduate programs in rehabilitation counseling was established in the mid-1950s (Wright 1980). Although aspects of this model still are debated, most curriculums closely resemble a model proposed in 1956 (Graves et al. 1987; Wright 1987; Walker and Myers 1988). This course work typically consists of 1) an introduction to vocational rehabilitation, 2) medical aspects of rehabilitation, 3) psychosocial adjustment to disabling conditions, 4) assessments in vocational rehabilitation, 5) counseling technique and practice, 6) occupation information and career development, 7) current topics in rehabilitation (often taught as a seminar), 8) an internship experience, and 9) electives.

As noted earlier, publications used in this curriculum tend to avoid the topic of multiple disabilities, including the pairing of physical impairment with alcohol or other drug dependence. Only one text on psychosocial adjustment to disability, for example, mentions alcohol and other drug abuse (Vash 1981). Two significant publications stand as exceptions to the general rule of omitting alcohol and other drug abuse from teaching materials used in the rehabilitation education curriculum. One of these is the computer-generated simulation program developed by Chubon (1986). The other exception is a brief discussion of the impact of alcohol and other drug problems on the development of the rehabilitation plan for disabled clients incorporated in the training materials for the Preliminary Diagnostic Questionnaire or PDQ (Moriarty 1982). The PDQ, a preliminary screening tool, has two questions dealing with client abuse of alcohol and other drugs.

To improve coverage of alcohol and other drug issues in rehabilitation counselor education, professionals in the field need to address the paucity of literature on this topic. Specific topics that may be included are definition of terms, epidemiology, social and family effects, client education needs, pharmacology and pathology, and legal and ethical issues (NIAAA 1985). The AID Bulletin,(1) a quarterly newsletter about alcohol and other drug abuse among persons with disabilities, is particularly useful. Another potential resource is the bibliography of materials related specifically to alcohol and other drug abuse among the physically/intellectually impaired, available from the National Clearinghouse for Alcohol and Drug Information (NCADI 1987). Graduate students in rehabilitation education should be encouraged to contribute to the literature on alcohol and other drug use among the disabled by conducting research on the topic.

Another necessary component of curriculum revision is the inclusion of casework experiences in existing courses and fieldwork. Such experiences could be modeled after those developed for education in other health professions (ADAMHA 1986). This approach would incorporate four basic elements:

* integration of relevant alcohol

and other drug abuse content into

existing courses and seminars * inclusion of alcohol and other

drug abuse program facilities in

clinical experiences involving

practicum and internship sites * exposure during fieldwork to such

self-help groups as Alcoholics

Anonymous, Al-Anon, and Narcotics

Anonymous * participation in client experiences - including

role playing and video-taping

(see Spickard et al. 1989) - as

well as exercises designed to

clarify the students' own values

concerning alcohol and other

drug use. These experiences also

could include simulations designed

to explore approaches to

confronting the manipulative

client.

EDUCATION TO DISPEL HARMFUL

ATTITUDES

The process of educating rehabilitation counselors on issues relating to alcohol and other drug abuse among clients with physical impairments is complicated by the prevalence of potentially harmful attitudes and beliefs among counselors. Attitudes that could be addressed during the education of rehabilitation counselors include the following:

* having expectations that are lower

than they should be for clients

with alcohol-related problems * the belief that "mourning" behaviors

or the lack of "normality"

justify client abuse of

alcohol * misplaced sympathy that can be

manipulated by an alcohol abusing

client * acceptance of abuse of alcohol or

other drugs as the norm based on

the counselor's own problematic

use.

Two independent studies (Allen et al. 1982; Goodyear 1983) have documented a marked negative attitude among rehabilitation counselors toward clients with alcohol-related problems. One of the most ominous findings of both studies is that many counselors considered the rehabilitation potential of such clients to be minimal or nonexistent.

A second factor influencing perceptions of rehabilitation personnel toward alcohol or other drug abuse behavior is the "requirement for mourning" identified by Wright (1983). This "requirement" implies that persons with physical impairments are viewed by most nondisabled individuals as being in a state of loss. In this state, the individual is expected to "mourn" the loss by exhibiting such behaviors as denial, depression, and lack of motivation. Some nondisabled individuals include alcohol or other drug abuse as a mourning behavior that may be expected of a physically impaired person.

DeLoach and Greer (1981) identify "deification of normality" as a similar phenomenon, in which the absence of impairment is perceived by the nondisabled as the only desirable state of existence. When an individual adopts this rigid belief, all manner of maladaptive behavior - including alcohol and other drug abuse - is justified by the physically impaired client's lack of "normality." Awareness of an alcohol problem in a disabled individual thus may provoke the reaction, "If I were that poor so-and-so, I would drink myself into oblivion too!"

Another confounding factor is the ability of many disabled clients to manipulate nondisabled persons and to play on their sympathy. Vash (1981) states that some tendency toward manipulation is necessary for persons with severe impairments to function effectively. However, Greer and colleagues (in press) cite a case in which a disabled individual applied much of his skill at generating sympathy to the procurement of drugs. Many nondisabled counselors and counselor trainees view disabled persons - especially those disabled from birth - as being naive, innocent, and free from the vices of so-called "normal" people. If a manipulative client works with a counselor who holds such an attitude, the results can be extremely counterproductive.

The counselor's attitudes toward his or her own use of alcohol or other drugs may further complicate the issue. Because there are few data documenting the nature and prevalence of counselor attitudes toward alcohol and other drug use, data from other health professions may provide insight. The results of recent surveys indicate that as many as 95 percent of medical students use alcohol and 53 percent have used other drugs (NIAAA 1985, p. 33). This same source indicates that 10 percent of such students drink excessively. If the prevalence of alcohol and other drug use is similar among rehabilitation counselor trainees, it is possible that their attitudes toward alcohol or other drug use among their future clients may tend to be permissive.

The need to confront student counselors about their attitudes toward alcohol or other drug use presents a challenge to rehabilitation educators. Such student attitudes vary from condemnation of any use of alcohol or other drugs to permissive tolerance of clearly excessive use, with most counselors' attitudes falling somewhere between these extremes. Either extreme is counterproductive in interacting with a disabled person who is abusing alcohol or other drugs.

An NIAAA curriculum guide for alcohol and other drug abuse education for pediatricians suggests including in the curriculum a discussion of the abusing health professional and the effects of such abuse on the professional's judgement, learning, decisions, and overall professional productivity (NIAAA 1985). Although this approach could be adopted for rehabilitation professionals, the NIAAA curriculum guide notes that discussion of such issues in a course format tends to be "impersonal, generalized, or intellectualized" (p. 33).

Another workable solution to the problem may be inviting students to discuss with the instructor, outside of class, their own concerns about their use or abuse of alcohol and other drugs. Also, students with academic or personal problems may be provided an opportunity to explore the possibility of alcohol or other drug use as a contributing factor to these problems.

Another approach that may encourage examination of attitudes toward alcohol and other drug use is to supplement class sessions with audiovisual materials. One curriculum for health professionals (Liepman et al. 1986) offers a comprehensive appendix of videotapes and films designed to stimulate such exploration.

All student counselors need to be exposed to the issue of clients who abuse alcohol or other drugs: The profession can do no less than make the effort to shape the views of future counselors according to facts rather than myths about the issue.

REFERENCES

Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). Consensus Statements from the Conference on Alcohol, Drugs, and Primary Care Physician Education: Issues, Roles, and Responsibilities, November 12-15, 1985; Rancho Mirage, California. Rockville, Maryland: National Institute on Alcohol Abuse and Alcoholism, 1986.

ALLEN, H.A.; PETERSON, J.; AND KEATING, G. Attitudes of counselors toward the alcoholic. Rehabilitation Counseling Bulletin 26(3):162-164, 1982.

ANDERSON, P. Alcoholism and the spinal cord disabled: A model program. Alcohol Health & Research World 5(2):37-41, 1980-1981.

BOROS, A. Alcoholism intervention for the deaf. Alcohol Health & Research World 5(2):26-30, 1980-1981.

CHUBON, R.A. Genesis II: A computer-based case management simulation. Rehabilitation Counseling Bulletin 30(1):25-32, 1986.

DELOACH, C.P., and Greer, B.G. Adjustment to Severe Physical Disability: A Metamorphosis. New York: McGraw-Hill, 1981.

GOODYEAR, R. Patterns of counselors' attitudes toward disability groups. Rehabilitation Counseling Bulletin 26(3):181-184, 1983.

GRAVES, W.; COFFEY, D.; HABECK, R.; and Stude, E. NCRE position paper: Definition of the qualified rehabilitation professional. Rehabilitation Education 1(1):1-7, 1987.

GREER, B.G. Substance abuse among people with disabilities: A problem of too much accessibility. Journal of Rehabilitation 52:34-38, 1986.

GREER, B.G.; ROBERTS, R.; AND MAY, G., EDS. A study of substance abuse in a vocational evaluation sample. Journal of Rehabilitation (in press).

HEPNER, R.; KIRSCHBAUM, H.; AND LANDES, D. Counseling substance abusers with additional disabilities: The center for independent living. Alcohol Health & Research World 5(2):11-15, 1980-1981.

HINDMAN, M., AND WIDEM, P. Special issue: The multidisabled. Alcohol Health & Research World 5(2):5-10, 1980-1981.

LIEPMAN, M.R.; ANDERSON, R.C.; AND FISHER, J.V., EDS. Family Medicine Curriculum Guide to Substance Abuse. Kansas City, MO: The Society of Teachers of Family Medicine, 1986.

MORIARTY, J.B. Training Manual for the Administration of the Preliminary Diagnostic Questionnaire. Morgantown, WV: West Virginia Rehabilitation Training Institute, 1982.

National Clearinghouse for Alcohol and Drug Information (NCADI). NCADI Update: Alcohol and Other Drugs and the Physically/Intellectually-Impaired. Rockville, MD: the Clearinghouse, 1987.

National Council on Rehabilitation Education. Code of professional ethics for rehabilitation counselors. Rehabilitation Education 2(1):65-74, 1988.

National Institute on Alcohol Abuse and Alcoholism. Pediatric Minimal Knowledge and Skills: The First Step in Developing a Curriculum in Alcohol and Other Drugs for Pediatricians. DHHS Pub. No. (ADM)281-85-0014. Rockville, MD: the Institute, 1985.

RUBIN, S.E., AND ROESSLER, R.T. Foundations of the Vocational Rehabilitation Process. 3d ed. Austin, TX: Pro-Ed, 1987.

SPICKARD, A.; JOHNSON, N.P.; AND BURGER, C. Learning through experience: Interviewing real(?) patients. Alcohol Health & Research World 13:36-39, 1989.

THURER, S., AND ROGERS, E.S. The mental health needs of physically disabled persons: Their perspective. Rehabilitation Psychology 29(4):239-248, 1984.

VASH, C.L. The Psychology of Disability. New York: Springer Publishing, 1981.

WALKER, M.L., AND MYERS, R.W. A counter-proposal: Defining the qualified rehabilitation professional. Rehabilitation Education 2(1):49-57, 1988.

WRIGHT, B. Physical Disability: A Psychological Approach. New York: Harper & Row, 1983.

WRIGHT, G.N. Total Rehabilitation. New York: Little, Brown and Company, 1980.

WRIGHT, G.N., ED Special issue: Research on professional rehabilitation competencies. Rehabilitation Counseling Bulletin 31(2):1987.

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