NADD Bulletin Volume I Number 2 Article 1

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Overcoming Barriers to Effective Treatment for Persons with Mental Retardation and Substance Abuse Problems

Gerald N. Annand, M.A., LPC and Greg Ruff

Even though the incidence of addiction among persons with mental retardation is the same or greater than in the general population, there are very few recovering alcoholics who have mental retardation in our society. This is a failure not of persons with mental retardation, but of the Developmental Disabilities and the A/D treatment systems. When persons with mental retardation have alcohol or drug addiction need recovery, they face barriers that are not present for non-MR addicts. In addition, normal treatment expectations are ineffective and mainstream treatment programs inappropriate. The following case histories illustrate the problems.

Jerry, 43, is a typical alcoholic father of three. His alcoholism has destroyed his marriage of 21 years, estranged him from his children, and cost him his job. He knows his drinking has caused these problems in his life and that he must do something about his drinking. These crises have broken down his denial; they are external motivators for his recovery.

Randy, 28, is a person with a developmental disability and alcohol problem. He has never been married and has no children. His family long ago deposited him with the County Department of Developmental Disabilities for care and protection. He works in a sheltered workshop and though he may be sent home from work if he appears drunk, he will not lose his job. The DD Department is mandated to provide him with housing and food and in other ways to protect him from experiencing the consequences of his behavior. Despite their best efforts, Randy has been arrested for assault when he was drunk, has been evicted from his apartment for drunken destructive behavior, is on probation and has been jailed again for drunken violation of his probation, and has a restraining order preventing him from seeing his estranged girlfriend whom he strangled while drunk. Yet Randy does not see that his drinking caused these crises. He has no external motivation for recovery.

Jerry’s estranged wife, children, and employer have all been concerned about his drinking. They form a support group for his initiating recovery.

Randy’s family is for the most part only marginally involved with him. His father and brothers are drinking alcoholics. The Developmental Disability staff do not see Randy as alcoholic. They believe his problem is his dual diagnosis: MR and Antisocial Personality Disorder. He has no support group for initiating recovery.

After he sobered up a few days, Jerry remembered his alcoholic behavior and felt ashamed of it. He had violated many of his well formed convictions about appropriate behavior. He did not approve of the way he had acted because those actions violated his values. This provided a strong internal motivation for recovery.

Randy has difficulty with recent memory recall. This is worsened by the amnesiac effects of alcohol and drug use. He has never formed a clear self- image nor has he clear concepts of his behavioral values. He has no internal motivations for recovery.

When Jerry decided to seek treatment he had many options available to him. Although he had been fired, he continued his insurance coverage. It was a group policy that covered both residential and outpatient treatment. He chose residential.

When Randy was finally prevailed upon to accept treatment by his parole officer, only one treatment program was available to him. It was a mainstream residential program. The other patients did not have mental retardation.

In treatment, Jerry was given several books to read such as Alcoholics Anonymous , the “Big Book” of AA, Under The Influence, by James Milam and Katherine Ketcham, and I’ll Quit Tomorrow, by Vernon Johnson. He wrote a history of his use of alcohol and other drugs and was taught the symptoms of the disease. He then reviewed his history and identified the symptoms of progression and of the disease in his own use history. This completely collapsed his denial as he gained insight into the nature of the disease and how it had worked in him.

In treatment, Randy was given many of the same books to read. Randy can’t read. Randy can’t write, so he could not write a use history. Treatment staff tried to help him talk his use history into a recorder but he has trouble remembering, gets easily distracted into story telling, , and in other ways was not able to complete this assignment. Being cognitively impaired, Randy did not learn the symptoms of the disease nor had he the insight to identify them in his own life. His denial remained intact. This became one of the reasons he was unsatisfactorily discharged.

In Jerry’s treatment there were expectations of the rate of progress to be maintained. Failure to do so was seen as resistance. Jerry was once called into his counselor’s office and reprimanded for that. After that he maintained the expected rate of progress.

Randy was also expected to maintain a given rate of progress. When he failed to do so he was called to his counselor’s office and reprimanded. This occurred several times with no appreciable results. Although the staff knew Randy’s difficulty was cognitive not attitudinal, they felt they could not tolerate his rate of progress without destroying group morale. “If Randy doesn’t have to keep up, why do we?” This was one of the reasons for Randy’s early discharge.

While drinking, Jerry had bonded with his drinking buddies. He wondered who he would have as friends if he stopped drinking. The treatment program’s answer to this was that Jerry would bond first with his treat-ment group and then with AA/NA groups. In these groups Jerry felt accepted, an equal, “one of the guys”. Bonding with the group was a treatment expectation.

Randy had known for some time that he was “different”. He knew he wasn’t like other people. But when he drank and used drugs he felt just like everybody else! As the others became increasingly drug effected they treated him just like one of them. This was a powerful motivation for Randy to use. In the treatment program Randy was drug free and he knew again that he was “different”. In addition, his failure to accomplish the treatment goals the others achieved reinforced that feeling that he wasn’t one of them. Even though many of his treatment colleagues were nice to him, they treated him as though he was different. Thus Randy did not bond with the group. He failed another treatment expectation which was another reason for his early discharge.

Jerry quickly understood group protocol. He knew what “cross talk” was and refrained as requested. He gave appropriate feedback to his peers and did not get angry or violent when upset.

Randy had difficulty with group protocol. It seemed to him that if someone else was speaking that meant it was all right to talk and he would. He almost always “cross talked” when someone talked to or about him and he often got angry when receiving feedback. This became another reason for his early discharge.

While in treatment, Jerry maintained total abstinence from all mood altering drugs including alcohol. He was graduated from the treatment program with an emblem to prove it.

While in treatment, Randy maintained total abstinence from all mood altering drugs including alcohol. After 21 days of a 30 day treatment program, he was discharged unsatisfactorily for failure to progress and behavior inappropriate to the treatment setting. He was, in effect, discharged for being a person who has mental retardation!

After treatment, Jerry got his job back, was reconciled with his children, and developed a cordial relationship with his ex-wife. He attended AA meetings regularly, because he identified with the people there and felt at home. He remained abstinent from all mood-altering drugs, including alcohol.

Randy left treatment having failed again just as he had failed in school. He returned to the same job and had to live in the same hotel. He had no more money than before treatment and, most importantly, Randy had no group where he belonged. He attended a few AA meetings but did not identify with the members nor feel that he belonged. Within three days Randy was drinking and using drugs.

Randy’s experience was not unique. By l995, Rainbow Adult Living, a non-profit agency providing group homes, supported living, and semi-independent living programs for adults with mental retardation in Multnomah County, Oregon, had identified significant alcohol and drug use problems among the population they served. Recognizing that A/D issues were outside the sphere of training of most DD staff, Rainbow contracted with an alcoholism specialist to develop a treatment approach specifically for this population.

The task then, was to develop treatment strategies that would effectively address the problems of the mentally retarded substance dependent clients like Randy. These included: the lack of external motivation for recovery, the lack of a group supportive of his recovery, the lack of internal motivations for recovery, an inability to use cognitive skills or insight to achieve recovery, the lack of a recovery support group, and little anticipated change in quality of life from recovery. An intensive outpatient A/D treatment program called the 1st Step Program was developed. It consisted of group sessions with any MR client who had a problem which might be caused by or might be worsened by the use of alcohol or other substances. Abstinence nor a stated desire for abstinence were not requirements for attendance at group sessions. Groups were designed to develop a desire for abstinence. Also, all staff who have dealings of any kind with members of the group were trained to be support staff.


Since Randy had difficulty remembering what happened to him while drinking or making the cause/effect connection, his staff were recruited and trained to make that connection for him. Whenever Randy encountered his job coach, his DD staff or his A/D treatment staff, or any other staff, each one reinforced his memory and the cause/effect connection by saying such things as, “Randy, when you drink you get in trouble.” By repetition over time, Randy began to be able to recite the problem that happened to him when he drank and to connect the drinking and the behaviors. Staff believed this goal had been met when Randy said “OK, so I need to quit drinking! I don’t know how!”


The program addressed this problem on two levels. First, all Randy’s support staff were recruited and trained to consistently and universally present him with the same cause and effect information over and over. Thus his DD staff became a support group.

Second, the members of the 1st Step group were encouraged to congratulate and applaud the efforts of their peers towards sobriety.


Randy was encouraged to discuss his drinking and staff watched for indications of behaviors that seemed to trouble him. For example, when it was noticed that he seemed to feel bad about having strangled his girl friend, he was asked: “Randy are you ashamed of being violent with your girl friend?” His response was affirmative and emotional. Staff began to build a values list for him. “Randy is the type of man who doesn’t hurt women.” Other values were added. At one point as he was talking about stealing six packs of beer while drunk, he was asked, “Randy are you a thief?” He answered with a definite “No.”

Having identified some behavioral values he seemed to hold, the entire staff was recruited to begin to make the connections: “When you are sober you don’t hurt women, but when you drink you hurt your girl friend.” “When you are sober you are not a thief, but when you drink you steal.” As Randy began to integrate these facts into his self image staff began to say, “Randy, you need to not drink or use drugs so you will never again hit a woman.” Thus Randy began to experience and acknowledge the conflict he feels between his drinking behaviors and the kind of man he wants to be. He had internal motivation for recovery.


Since cognition and insight were not effective tools for Randy, the program utilizes a behavioral approach to recovery. In AA meetings people sometimes say, “You can’t think your way into sober acting, but you can act your way into sober thinking.” Since Randy tended to live a fairly structured life, it was reasoned that getting him in the habit of doing sobriety supportive activities would help him maintain abstinence. In 1st Step Groups and individual sessions Randy was aided in developing a 24-hour plan of activities. He was asked, “What will you do to stay sober between now and . . .”, the time of his next contact with someone who could help him plan. In the beginning he planned three times daily, then one time daily, and then one time weekly. Any day Randy had a plan and did at least one thing on his plan by choice, he stayed abstinent!


A part time staff person was assigned to provide 15 hours a week of sobriety supportive activities for Randy and any others who wanted to quit drinking. This staff was himself recovering from substance dependence and took the clients with him to at least 4 AA/NA meetings each week. Although he still has trouble identifying with group members, Randy enjoys the meetings and has attended some without staff.


Jerry once said, “If I just don’t drink my life’s bound to get better.” Since this was not true for Randy, the Rainbow staff began to build in life improvements geared to progress in his recovery. They rented an apartment and let Randy live in it as long as he was sober. They gave him more attention when sober than they did when he was drinking. That was a reversal of the pattern they had fallen into before training.

The final element of this effective approach was the absence of any rate of progress expectations. Clients could remain in or return to the premotivation stage of treatment as long as they wanted. Indication they had moved out of that phase into initial treatment were maintaining seven consecutive days of planned abstinence, preparing a 24-hour plan on 14 consecutive days, and stating their desire to become sober on each of 14 consecutive days.

Movement from initial to second level treatment occurs when the client has maintained planned abstinence for 30 consecutive days, has established a pattern of four AA/NA meetings each week for four consecutive weeks, can recite the problems drinking causes him (both external and internal), and has developed a consistent daily schedule of sobriety supportive activities.

Movement from phase three treatment occurs when the client’s life style is supportive of abstinence and requires no staff support, he has a social group supportive of his abstinence, and he has maintained abstinence for six additional months.

Those involved in the above program believe that effective treatment of mentally retarded persons with alcohol and other drug use problems can only occur in programs specifically designed to meet this populations’s social, cognitive, and behavioral needs. Although the movement for the past decades in developmental disability programming has been in the direction of mainstreaming and using community resources, this approach is not only inadequate for mentally retarded persons with alcohol/drug use issues, but damages their chances of recovery through learned failure.


American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC. Author.

Bellows, J. (1996). Recovery house: Residential facility for persons with mild mental retardation and substance dependence. UMI Dissertation Services.

Brady, K. (1993). Substance abuse in the dually diagnosed. The NADD Newsletter, 10, 5. Kingston, NY: NADD Press.

Cattan, & Grossman (1995). Cognitive limitations make it difficult for him to understand the concepts taught and therefore . . . he may be stigmatized, resented, or excluded . . .”. Handout distributed at the 1995 Annual Conference of the National Association for the Dually Diagnosed.

Lottman, T. (1992). Access to substance abuse services for people with mental retardation. Cincinnati: University Affiliated Cincinnati Center for Developmental Disorders.

Maine Department of Mental Health and Mental Retardation. (1984). The main approach: A treatment model for the intellectually limited substance abuser. Maine: Author.

University of Montana and the Montana Developmental Disabilities Planning and Advisory Council. (1989). Project adapt: A different approach to prevention and treatment of substance abuse among persons with developmental disabilities. Montana: Author.

Westermeyer, Kemp, & Nugent. (1996, Winter). Substance abuse among persons with mild mental retardation. American Journal on Addictions, 5, 1.

For more information contact:

Jerry Annand, MA, LPC
Annand Counseling Center
7320 SW Hunziker Suite 200
Tigard, OR 97223