Disabilities
Background Issues
There are four primary disability categories. Some conditions may be more difficult to categorize and some people may experience multiple conditions:
• Physical impairments are caused by congenital or acquired diseases and disorders or by injury or trauma. For example, spinal cord injury is a disorder that can cause paralysis. Physical disabilities include spina bifida, spinal cord injury, amputation, diabetes, chronic fatigue syndrome, carpal tunnel syndrome, and arthritis.
• Sensory impairments may be caused by congenital disorders, diseases such as encephalopathy or meningitis, or trauma to the sensory organs or brain. Sensory disabili ties include blindness, deafness, and visual and hearing impairments.
• Cognitive impairments are disruptions of thinking skills, such as inattention, memory
problems, perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing (the ability to follow a set of steps to accomplish a task), misperception of time, and perseveration (inappropriate repetitions). Cognitive disabil ities include learning disability, traumatic brain injury, mental retardation, and AD/HD.
• Affective impairments are disruptions in the way emotions are processed and expressed. In this TIP, affective impairments are consid ered to include problems caused by both affective and mood disorders, such as major depression and mania. These impairments include the symptoms of mental disorders, such as disorganized speech and behavior, markedly depressed mood, and anhedonia (joylessness). Affective disabilities include depression, bipolar disorder, schizophrenia, anxiety, and posttraumatic stress disorder (PTSD) (CSAT 1998e, pp. 34).
People with disabilities are at much higher risk than the general population for substance abuse or substance dependence (Rehabilitation Research and Training Center on Drugs and Disability [RRTC] 1996). While 10 percent of the general population has a substance use disorder, studies consistently find that 20 percent of people qualifying for State vocational
rehabilitation services meet diagnostic criteria for substance dependency (Moore and Li 1994; RRTC 1996; Robert Wood Johnson
Foundation 1994; Schwab and DiNitto 1993). Other studies have found that the use of prescription medication in combination with alcohol and the use of other people’s prescrip tion medications are common for some people with physical disabilities (Moore and Polsgrove 1991). The routine of taking particular medica tions may itself provide feelings of control, stability, or safety. Additionally, some physicians prescribe medications in a palliative manner in an attempt to assist with disabilities they cannot cure, such as chronic pain or multiple sclerosis.
People with disabilities are more likely to use alcohol or drugs in part because they experience
unemployment, reduced recreational options, social isolation, homelessness, and abuse more frequently than the general population
(DeLoach and Greer 1981; Marshak and Seligman 1993; Susser et al. 1991; Vash 1981). If these people also have substance use disorders, such problems are further exacerbated. People with disabilities are at risk for social isolation. They may be isolated because of their families’ efforts to protect them, the physical difficulty of getting out to social settings, lack of opportu nities to practice social skills, lack of physical stamina, trouble finding activities and
negotiating transportation, poverty, and/or the discomfort people without disabilities experience when interacting with people with disabilities. An altered body image can make those with a recent disability onset (such as people using a wheelchair for the first time) reluctant to socialize.
In addition, physical limitations make some people fear violence or exploitation. People with disabilities are at greater risk of sexual abuse and domestic or other violence (Glover et al. 1995; Varley 1984). They are more likely to be victimized because they are perceived as unable to protect themselves. Depression and low selfesteem associated with their disabilities can also play a role in some people’s
victimization and substance use. Isolation and functional limitations leave many people with disabilities with few recreational options, yet they often have much unstructured time available. For example, people who have a visual impairment may face increased isolation, excess free time, and underemployment (Motet Grigoras and Schuckit 1986; Nelipovich and Buss 1989). For more information, see TIP 29,
Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT
1998e).
Application to Family Therapy
Frequently, people who do not have disabilities are uncertain how best to respond to those who do (Sue and Sue 1999).
Specific Populations 132
Family therapists should take care to ensure that the language they use in describing physical and cognitive disabilities is sensitive and appro priate. As a general rule, one should always put people first, before their disabilities, refer ring to “people with disabilities” rather than “disabled people.” One should never refer to the disability in place of the person—not “the schizophrenic” but rather “a person with schiz ophrenia.” A person with a disability should not be called a “patient” or “case,” unless the context refers to a relationship with a doctor. It is key that the therapist learns how well a person understands his or her disability. Some people will have a clear knowledge of the ways in which they are functionally limited, whereas others may deny having any limitations. Similarly, in the area of individual strengths, some people will have received extensive support from family, friends, and professional caregivers to pursue their interests and develop unique talents, but others may have been over ly sheltered or may have experienced repeated failures. A treatment provider should confer with a disability expert on the delicate topic of how to discuss a client’s disability with him. Providers may be uncomfortable when first confronted with a person with a physical or cognitive disability. That unease can lead them to err in one of two directions: either enabling the person to use his disability to avoid treat ment or refusing to recognize that a legitimate need for accommodation exists. Accommodation does not mean giving special preferences—it means reducing barriers to equal participation in the program. If a client believes that he or she needs an accommodation, the treatment provider will still need to determine if the request is legitimate or an attempt to manipulate the treatment program. However, a provider’s vigilance in avoiding enabling may predispose him to reject legitimate requests for accommo dation. If there is any doubt on the part of the provider regarding the legitimacy of the person’s request, he or she should consult a disability expert in order to make this determination. Failure to make good faith efforts at
accommodation could result in significant legal
difficulties for programs or providers (for more information about the Americans With
Disabilities Act see TIP 29, Substance Use
Disorder Treatment for People With Physical and Cognitive Disabilities [CSAT 1998e]).
Appropriate approaches may depend on the type of disability. For example, multiple family therapy may help families to normalize and process the feelings of guilt and shame that stem from having a family member with a disability and a substance use disorder. Perez and Pilsecker
(1989) note the useful ness of integrating
family therapy into an