NADD Bulletin Volume IV Number 5 Article 3

Complete listing

SAMIRIS: Substance Abusers Who Have Both Mental Illness and Mental Retardation

Michael A. Mayer, Ed.S.

Introduction to the Problems

Substance abuse among people identified as having the diagnoses of mental retardation and mental illness is real, and the numbers of people abusing substances is growing at an alarming rate. “People with physical and cognitive disabilities are more likely to have a substance use disorder and less likely to get effective treatment for it than those without such a coexisting disability.” Further, according to a recent study by the Rehabilitation Research and Training Center on Drugs and Disability, at least one half of persons with a substance use disorder and a coexisting disability are not being identified as such by the systems providing them services (1995).

Historically, service systems have not wanted to serve this population. They are perceived as more difficult to treat, which many who provide services to this population would argue is an accurate perception. Treatment is often complex and of relatively long duration, which also tends to make it costly. There is a general acceptance that determining a diagnosis is difficult and treatment is even more complicated, as compared to those with co-existing mental illness and substance abuse issues, but without mental retardation.

Another unfortunate, but typical, scenario is that all three service authorities (mental health, mental retardation, and substance abuse) will deny the problem exists, resulting in no services or very limited services. If they are willing to admit the problem exists, they may believe that the situation is not serious enough to require treatment (partly because of a lack of understanding of the symptom presentation), or they shuffle the individual between services, suggesting that effective treatment can only occur after they have resolved issues that other services must address first (e.g. they must get sober before they can see the psychologist).

As noted by Treatment Intervention Protocol #29 from the Center for Substance Abuse Treatment,

“&ldots;by the time a person with a disability attempts to access treatment, the level of her substance abuse disorder may be rather severe because of social enabling, systems that do not identify early substance use and abuse, and the tendency among human service agencies to focus on disability rather than chemical dependency issues” (Substance Abuse and Mental Health Services Administration [SAMHSA], 1998).

Common statementss include the claim that there are no services (or vacancies); the claim that the person is ineligible (often in apparent violation of the ADA); or an admission that the problem is real, serious, etc., but the provider is afraid to admit/enroll the person for services due to incompetence (real or imagined) or due to “liability.”

Even if the individual is accepted for enrollment in traditional services they are frequently perceived as “different” or otherwise problematic. Regardless of the cause, getting treatment for substance abuse is a major challenge for the individual with multiple diagnoses and those who support them.

Some of the Documented Risk Factors for Alcohol and Other Drug Abuse in People Who Have Multiple Diagnoses

·Low self esteem and poor self concept

·Low expectancy of success (by themselves and others)

·Physical pain: Many people who have mental retardation—estimated at more than 70%—also have significant unmet medical needs. Unfortunately, there is also a very high historical incidence of abuse (especially physical/sexual abuse), neglect, and other major trauma, all of which have physical and emotional/psychological impacts.

·Emotional/psychological pain: Many are believed to be “self-medicating”—especially for anxiety and depression—the two most common forms of mental illness. Stress and anxiety are known factors for the general population and there is evidence that the stress and anxiety levels of people who have cognitive delays are even higher than the general population. There are also reports that indicate that many disorders are under-diagnosed among this population. There are some practitioners that believe, for example, that Post-Traumatic Stress Disorder and Disassociative Identity Disorders are grossly under-diagnosed in people who have mental retardation and abusing substances. Estimates claim that about 75% of abusers who have mental retardation also have mental illness.

·Deinstitutionalization: Many of the people who abuse alcohol and other drugs have spent extended periods of time in institutions. As more people have more freedom and choice, many will make the same mistakes made by the general population, especially those mistakes made during the adolescent and early adult years.

·Availability of substances: Currently, alcohol is drug of choice. However, all street drugs, including crack, are increasing. People who are identified as having a dual diagnosis are increasingly being seen in emergency rooms to address over-dosing on inhalants and over-the-counter medications.

·Positive family history for use/abuse: This risk factor has been identified for the general population and it holds true for people who have a dual diagnosis as well. Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effect (FAE), which result from pre-natal exposure to alcohol result in numerous problems, including a known increased risk for alcohol abuse. As is the case with heroin users, people who have FAS loose the myelin sheath that protects the nerves, resulting in significant pain. An estimated 33% of known substance abusers have FAS.

·Criminal behavior: It is estimated that 50-75% of all offenders who have “learning problems” and/or mental retardation were drinking or drugging at the time of the arrest.

·Immature and approach/avoidance behavior: There is often significant ambivalence about “individuation,” becoming identified as a complete person separate from primary care providers. There seems to be a high percentage of people that “self-sabotage” the process of becoming a whole person. This is a problem in terms of risk factors (seeking approval from users, etc.) and treatment/recovery.

Complications of Use and Abuse in People Who Have Mental Retardation

·In people who have mental retardation, any use of drugs or alcohol is a cause to consider the need for treatment. This is true for a number of reasons, among them the shorter latency period, more severe withdrawal effects at lower levels of use, and the significant risks associated with the interactions of neuroleptics and other psychotropics with drugs and alcohol.

·Any use of drugs or alcohol increases cognitive, behavioral, and functional deficits. Unfortunately, people are permanently losing brain cells. Drinking and drugging on top of a pre-existing neurological impairment means there is little chance of full memory and skill return post-drugging or drinking.

·The typical person who has mental retardation and is using drugs or alcohol often presents a very scattered disability profile. This means that they may appear to have a very high level of social skills but may have a very low understanding of how to care for themselves.

·Abusers who also have FAS tend to present with many features of Borderline Personality Disorder (shallow and labile affect, “splitting” staff, etc.).

·Denial is the major defense mechanism used by the abuser (“It’s not a problem.”). They are faced with the dilemma of admitting a problem in order to get treatment, but with the likelihood of increased restrictions on their actions and another disability label. (Who wants to be identified as mentally retarded, mentally ill, and a substance abuser?)

·Because there are numerous life problems for the substance abuser that also has mental retardation and mental illness they are at greater risk for relapse and they often need types of treatment, training, and supports that are not commonly thought of as necessary. The Center for Substance Abuse Treatment TIP #29 (SAMHSA, 1998) lists several issues, among them: escaping from abusive situations, protecting themselves from victimization, finding employment, self-care, using public transportation, social skills training, healthy recreation, legal rights, and building peer networks.

·“Reverse normalization”: The individual believes that with enough drugs and/or alcohol it is possible to hide his or her disabilities from self and others. Being oblivious to the problems associated with having multiple diagnoses is seen as a way to improve their quality of life from the abuser’s perspective. The desire to be “normal” is so strong that the abuser will risk his or her life to attain it.

·People who have mental retardation are often taken advantage of by other abusers, but it feels like valued social contact; it feels/looks like acceptance, reciprocity, etc.. With no clear peer group, the substance abuser is an accepting alternative

·Drinking and drugging are skills most people can master, even if they have mental retardation. This can assist in developing a sense of social competency within the specific sub-culture. Part of the desire to learn these skills may come from the association that most people have with adulthood (and rebellion) and drinking or taking drugs. It has been speculated that the desire to be seen as an adult may be as powerful an incentive to drink or take drugs as the actual effect that the substances have.

Triggers for Drinking and Drugging

Trigger identification, determining what makes the person decide they need to drink or take drugs at that moment can be very difficult. Feeling stressed is one common answer. So are confusion, loneliness, being scared, tiredness, hunger, sexual frustration, embarrassment etc. If we can identify the primary triggers for the person, we have a better chance at developing better interventions, consistencies, and problem resolutions.

In people who have mental retardation, mental illness, and substance abuse problems there is little to no internal locus of control (sense of being in control of their own behavior). This is something staff and therapists need to teach in virtually every setting.

Social (in-)competence is a major problem area, and major cause for relapse. Because the individual who has mental retardation often feels that he/she is not in control of his/her own behavior, the concept of “empowerment” means dealing with the problem head-on.

Increased stress is associated with relapse into drug and/or alcohol abuse, as well as triggering the symptoms of other disorders. Some of the most common stressors include returning to the family home, problems at their primary residence, work-related issues, changes in relationships, and medical problems (including medication changes). Also, care must be taken when decreasing medications, changing behavior plans, etc. as these are also potentially major stressors.

Symptom Presentation in People Who Have Mental Retardation

·As mentioned earlier, people who have mental retardation go through the progression of the addiction disease process faster. They also tend to experience complications to their life and withdrawal symptoms at lower levels of use, etc..

·In people who have a dual diagnosis, alcohol and some drugs can induce or exaggerate Alzheimer-like and/or dementia symptoms. These symptoms may be related to other medical causes, but they may also be related to drug toxicity, brain damage caused by the alcohol or other drugs, or withdrawal syndromes.

·Concrete thinking, limited vocabularies, etc: When screening people who have cognitive disabilities, one must be as specific as possible—rather than asking if they “use alcohol,” ask if they “like to drink beer, wine, wine coolers, etc.”. Also when screening, use street names for all common drugs as they rarely know the formal names.

Treatment Complications

Numerous barriers exist to effective treatment. Boredom is a major problem for virtually every substance abuser, as is unemployment or under-employment. The literature demonstrates that “addressing and overcoming barriers to employment&ldots;may greatly enhance the prospect for recovery and should be addressed as a component of treatment planning.”

Another related problem is that virtually all abusers are tired all the time, and thus, they do not feel they have the energy to do things that will help to end the boredom. Reasons the abusers complain of tiredness include depression and being out late at night. They also include being awake during times of perceived threat when they should be sleeping. This is true whether the person is experiencing symptoms of PTSD (hyper-vigilance) or if they are truly at increased risk because they are homeless, can not go to their home because they are high or drunk, can not find their way home, etc.. The more sleep they miss, the more problems with managing emotions and behavior are likely.

Many substance abusers will, despite the evidence to the contrary, deny anxiety or stress and will actively resist relaxation and similar programs. They may perceive these programs as making them more vulnerable. (Some may also not understand the terminology of “anxiety” or stress and thus, “scared” may be a better term to use.)

Treatment Implications

Treatment must deal with all of the predictable issues, especially the labels people put on themselves. They begin to believe the labels, and therefore, when they behave in ways that are consistent with the labels they have adopted, they do not see anything wrong. Many of these predictable issues are associated with the normal process of individuation. One predictable issue is resistance to treatment. In most cases, being clean and sober is not nearly as much fun as substance abuse, despite efforts of professionals to convince them it is. Sobriety is also much harder than we typically present. “Clean” (or recovery) community supports are frequently not very supportive of people who have mental retardation.

From their perspective, life does not get better. The abuser does not believe they have lost much by drinking or drugging. They see the loss of their drinking and drugging “friends” and the freedom (and the sensations of being under the influence) as much greater losses. Replacement of the friends and others who are sharing the experience are part of the value of group supports and therapies. The power of “positive peer profiles” (examples) cannot be over-stated.

What Should We Do First?

When someone is ill, they deserve treatment. Treatment must begin by addressing what may be putting lives in real jeopardy—life and safety issues, such as liver failure and a lack of a home—and must be addressed first. Teaching people how to not becoming a victim to others must take priority over the traditional paternalism (“Just keep them home and they won’t have access to drugs or alcohol.”).

There is a relatively new, but potentially very dangerous, “choice” argument to allow people to opt out of treatment (“It’s his choice to be drunk.”). Respecting “choice” can be difficult, especially when it appears that the choice is not “informed.” Real choice equals informed choice, and informed choice requires having all of the information. In order for informed (competent) choice to take place, effective treatment supports are necessary, so that the choices the person makes are made with a clear mind and understanding of the potential benefits and consequences. The individual who is abusing substances will not make good choices—that’s part of the disease/diagnosis/addiction. For the individual who abuses substances, addiction means doing whatever is necessary to have access to the drug of choice—even at great risk. There is a major demonstrated lack of skills in “self-determination” (because the addiction is determining the behavior), risk-assessment, and choice making for this population.

Due to the historic caretaking role of the mental retardation system, professionals, family members, etc. frequently undermine treatment efforts. This is largely because they do not understand that abusers who have mental retardation actually have more in common with other abusers than they do with other people who have mental retardation (even though the treatment needs are substantially different in many ways). Cross-system education efforts, including families and friends whenever therapeutically possible, is typically mentioned by programs that claim success in treatment.

Unfortunately, families may often present major problems for treatment teams. Reasons for these problems include:

·the family feels as though they are being accused of causing the problems

·treatment/sobriety conflicts with their behavior or values

·miscommunication, perceptions, attitudes, and the like.

The net result, regardless of the cause of the conflict, is sabotage of the assessment and/or treatment. Families (and family surrogates—including direct support staff) all too frequently end up enabling the problems, and are also co-dependent. Because of its importance, all staff working in programs designed to assist people who have substance abuse problems must have training on enabling and co-dependency.

Simultaneous treatment by substance abuse, mental health, and mental retardation professionals is absolutely necessary. Substance abuse treatment for people who have mental retardation is too intensive to do alone, and there is too much to know to do it alone. Recovery simply cannot occur by treating one of the presenting problems at a time. All treatment is driven by team agreement that each will do what they are best at, without undermining the efforts of anyone else. The team probably should have a written plan its own implementation—how members will behave and how they will hold each other accountable.

People who abuse substances tend to be very skilled at distracting the therapists and others in the environment from the primary problem. They tend to have equal skill at splitting staff (getting staff to fight with each other, violate rules, etc.). Their efforts seem designed to make sure that no one gets close to the hurts, etc. under the problems. Often gentle professional reminders must be provided to the treatment team about this fact. It is also important to make certain that direct support personnel remember this (via training and supervision), and the importance of staying in the “here and now.”

Further, the treatment plan must be real (practical from their perspective), concrete, and realistic (attainable). Success requires sobriety reward systems. This includes contracts for treatment, with clear protocols for what happens if criteria are met, as well as what happens when the contract is broken. Many professionals working with this population expect that they will need to enforce the consequences of a broken agreement as often as they will be able to provide the rewards for sobriety.

Maintaining sobriety today and tomorrow must have significant incentives. The goal is to focus on sobriety today and establish hope and a goal for tomorrow. The staff and therapist must reward the abuser until he or she can reward themselves. Cause and effect are often difficult concepts for the substance abuser with mental retardation to understand, thus the need for incentives and rewards.

Most abusers have no significant goals or a picture of a valued life to work toward. Staff and therapist alike must help them plan for a better future. Both staff and therapist must also help them to understand how they got closer to their goals by being clean and sober.

“For treatment to succeed, all clients must understand the particular strengths that they can bring to the recovery process. A strengths-based approach to treatment is especially important for people with disabilities, who, because they have so frequently been viewed in terms of what they cannot or should not attempt, may have learned to define themselves in terms of their limitations and inabilities “(Moore & Li, 1996).

The individual may need to explore several methods for learning something or finding a reasonable way to sustain a drug free lifestyle, attain goals, etc.. Failure of the individual to achieve goals may indicate that the plan lacks the discrete steps necessary to meet those goals. Further, treatment plans can not be “static,” and treatment providers must continually evaluate and revise the plan. In is critically important that providers continually and “systematically address what has been learned in the program and how it will be applicable in the next state of treatment or aftercare.”

Similar to the vast majority of people who have mental illness and are abusing substances, there are significant personality and developmental deficits. For example, socio-emotional and coping skill development is typically arrested at the age (developmental level) that the substance abuse is initiated. Thus, the teaching of social skills, including problem solving, must occur on a regular (daily) basis in the natural and logical environment. The literature demands service coordination and constant efforts to increase coping and social skills. These are essential for recovery.

It is therefore also important to understand that staff and treatment professionals must “meet” the individual where he or she is (both physically and emotionally) because they cannot get to where you are. For example, it is not reasonable to expect that the abuser who has mental retardation to keep regular appointments with their therapist(s) without significant incentives and support.

Practical examples include such things as playing basketball, as an alternative to time that would normally be spent drinking or drugging. Learning how to celebrate or relax with coffee and pie instead of beer is another example of “practical treatment” for people who are abusers and also have mental retardation.

Another practical example is that counseling session times should be flexible, so that sessions can be shortened, lengthened, or more frequent, depending upon the individual treatment plan or the need of the moment.

Direct support staff need to support the concept of normalization with the person who is in recovery from substance abuse. It is normal to have feelings and to want to express them. However, for many people who have a dual diagnosis of mental retardation and mental illness, part of their problem is the history of denial of their feelings and/or lack of vocabulary for their feelings. Staff must work to undo this as best they can.

Staff must be careful that neither their behavior nor their words suggest that the feelings the individual is experiencing are not important or otherwise valid. The feelings expressed must be assumed to be real, even if they sound confused or outrageous. At no time should shock or disgust or any other negative reaction be displayed by staff when the recovering abuser is making an effort to communicate their feelings (unless directed otherwise by a responsible, treating clinician). The responses of the direct support staff are critical during the entire recovery process. The individual who is in recovery must know that there are others he or she can trust to be supportive (and yet firm and consistent) regardless of what they are experiencing. Issues of trust and expressing (or not expressing) feelings (often due to fear of the consequences of telling the truth) complicate the treatment. This is a very important area of treatment for direct support staff to participate in.

In all aspects of therapy, the substance abuser will test limits. However, it is critical that they have safe times, places, and people where they can “dump the garbage” they’re carrying. They need to feel acceptance and that others understand how awful they feel about themselves and their lives, without anyone trying to minimize their perceptions or memories. Direct staff can make the difference between the individual saying, ”I am clean. I am sober. I am proud” or “I am clean. I am sober. I am miserable”.

All staff and therapist(s) need to work on developing strong therapeutic alliances—mutual agreements to work together on common goals—with the individual and each other. One of the best ways to do this is to schedule time to have fun with the individual in recovery. Many of the abusers simply do not know how to have fun without drugs or alcohol. One example is using the smell of fresh (or recently microwaved) Mrs. Field’s Cookies in a bag to teach deep breathing as a part of relaxation.

A Few Therapeutic Strategies

While there are no standardized treatment programs for this population, there are many therapeutic techniques in use. The following examples should not be considered exhaustive, only representative of a few of the techniques available to treating professionals.

First, it is important to note that it is generally agreed among most professionals that group therapy is a primary treatment modality. It is also generally accepted that traditional programs that focus on strong confrontation is not typically considered a valuable technique, and frequently result in regressive behavior by the participants. Individual therapy is frequently used in conjunction with group therapy, skills groups, peer support sessions and the like, but it is rarely considered the primary or singular treatment.

There are pharmacologic treatments for both the mental illness, the cravings, and for behavior modification. These are rarely effective in isolation but are frequently used in conjunction within a coordinated plan of services and supports.

Finally, there are specific types of therapy, such as Dialectical Behavior Therapy, applied behavior analysis, and the like. Some of these, and traditional programs for recovery, are discussed in more length at the end of the paper. In any case, most inpatient and residential programs are reasonably eclectic, utilizing “what works” to try and coordinate a system of long-term community supports.

One of the most successful specific techniques used by the author is known by participants as “getting out of the place.” This simply means creating new, positive routines that increase the likelihood of recovery success and decrease the likelihood of relapse. The phrases: “intervene in the old routine” and “develop new constructive consistencies” are used to underscore the intention of this concept.

The team begins by building on whatever positive rituals the person already has—even if that is limited to taking a shower in the morning. Then you tack on a “new constructive consistency”, such as brushing their teeth. The process continues until the person has a way of behaving that is both comfortable and immediately successful (they can see/feel the results of their efforts almost immediately). The desired result is to create positive rituals to get the person out of the place (emotionally and behaviorally) that they have known best when drinking and drugging.

Simultaneously the effort is made to teach the person reasonable alternatives to their old (drinking and drugging) patterns and routines. The intervention needs to occur well before the problem behavior would normally occur. The basketball example used earlier can be used here as well, if it replaces a high-risk behavior/routine.

Many of the substance abusers who have mental retardation “lack the hard wiring” to solve significant problems. They are often passive and withdraw from problem solving. Many believe that others have the power and they have none. Consequently, when developing treatment and relapse prevention strategies, there is a need to work with them to have potential solutions decided in advance of the problem. These need to be planned, rehearsed, and then rehearsed some more. That is part of the reason for “intervening in the old routine” so early and why “new constructive consistencies” are needed to replace old problem behaviors.

Again, since social incompetence is such a frequent issue for this population, social skills should be taught on daily basis with the individual who is in recovery. Many social skill activities can be worked into virtually any other activity and should be incorporated into the person’s regular positive routines/rituals.

Other Therapeutic Strategies

·Classes that feature open and honest communication with no topic off-limits also seem to help maintain sobriety.

·Art therapy: Drawing how I feel before I drink, when I drink, after I drink, when I don’t drink.

·Drama, dance, etc. also are reported to help the individual to express feelings, act out experiences, etc. in ways that are beneficial.

Some Areas that Require Special Attention for People Who Have Mental Retardation and Substance Abuse Problems

·Practical and social intelligence: What are others expecting of me? Is this reasonable? How should I respond? What might happen if I do/don’t do it?&ldots;etc.

·Role taking (practicing new ways of behaving): This addresses two issues. The first aspect is related to the individual’s inability to see themselves as being different (clean and sober, respectable, etc.). Secondly, many people who abuse substances effectively operate with the belief that, “My experience can’t be different from someone else.” Consequently, many have a very difficult time understanding how their behavior effects others and ultimately, themselves.

·Taking turns: While related to the above, this issue is also directly related to the problem of the inability to delay gratification or tolerate discomfort, which is common among people who abuse drugs and/or alcohol.

·Person perception: This means understanding perspectives of others. It also can refer to using the comments of others to “check” their own behavior.

·Concrete Cognition: Because of the limitations on thinking, examples must be clear, frequently presented, dramatic, visual, etc.

·Self-Regulation: This is an area that requires continual work. Anger management, relaxation, leisure skills, etc. This also includes un-learning institutionalized behavior such as trading sex for cigarettes, drugs, or alcohol.

·Self-Awareness: This includes being aware of their deficits and/or ability, without being either very pessimistic or denial based to the point of being somewhat grandiose.

·“Executive Functioning”: This refers to the difficulty planning for a deficit and having/developing the tools to compensate for their deficits. They also rarely understand how they can use any current skill to maintain being clean and sober.

·Sexuality and Intimate Relationships: These are often major therapy and training issues. Unfortunately, few staff, agencies, or professionals want to deal with issues related to sex or the HIV risk, etc. to the extent that these individuals require. It should be noted that in some larger cities, people who have mental retardation may prefer to be identified as gay, lesbian, or a substance abuser rather than being identified as having mental retardation. Additionally, prostitution is also a reality for a fair number of substance abusers that have mental retardation. They may start out selling clothes, jewelry, etc. (often to raise money for the drug or alcohol habits of family members) and end up selling their bodies either for money or for the drugs and/or alcohol.

·Aggressive Behavior: Part of the goal of therapy must be to prevent aggressive behavior.

·Assertiveness and Self-Protection: Teaching people how to avoid being victimized is also important. Violence among substance abusers, especially sexual violence, is very high, thus physical and sexual abuse issues are often major topics to address in both group and individual therapy.

·Reversing Social Isolation/Community Membership: Unemployment and a lack of recreational options are reported as major contributing factors for substance use and abuse. Community membership helps give the individual positive roles to play in the home community, improving self-esteem, etc.

The goal of addressing these issues is to prevent “remembered behavior being repeated”. The goal is not to get the individual to be better at behaving “like people who have mental retardation should behave” (being more compliant with rules or staff requests). Rather the goal is to get the individual to take positive control of their lives and complete responsibility for their behavior. The goal is to help them to fit into the “normal” environment of others who are clean and sober—regardless of any other disability.

Some Comments and Concerns about Traditional Treatment Programs

The recovery programs most commonly cited have 12 steps and 12 traditions. These are often very difficult for a person who has mental retardation to understand or apply to their lives. Several efforts have been made to translate the steps of recovery into language that most people who have mental retardation will understand and use. When appropriately supported to attend meetings and truly become a member of a small recovery community some individuals find this an effective adjunct to their sobriety.

However, being incorporated into traditional chemical dependency groups, especially into groups that use peer confrontation as a part of the treatment, often results in regression. Further, in traditional chemical dependency programs the individual who has mental retardation often:

·feels rejected by another group—the abuser (former “friend”)

·feels rejected (unwelcome) within the new group

·is taken under the wing of another (former?) abuser that (unintentionally?) fosters negative, co-dependent, or enabling roles.

Other issues include:

·Finding good sponsors within Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) is generally considered difficult.

·Some AA/NA members/groups are very anti-medication. For people who need medications to function in life this is confusing.

·Some of the abstract concepts of these groups can be very difficult for the individual. An example is “powerlessness”. This is especially true due to the therapy issues associated with empowerment and “being in control of your life”.

Inpatient programs have widely varying degrees of success. It is important for the first several days (especially during detoxification) for the individual to be where medical services are immediately available. The number of days on an inpatient unit seems to have very little effect on long-term sobriety. Intensive case management, systems cross-training, and after-care services seem to be better predictors of longer periods of sobriety. Especially noteworthy is that there are many cross-agency issues that can hinder treatment.

Rational Recovery is an attempt to address many of the concerns of the traditional programs. One program reported in the literature reported some positive results. Brady describes what is reported to be a relatively successful program based on Rational Emotive Therapy that teaches people who have mental retardation to recognize the “Addictive voice of the Beast that wants to take over their life”. This program then teaches the substance abuser to distance themselves from the evil Beast that wants to control them. It also uses positive visualization of themselves and their lives as a contrast to the Beast. They work to prevent the “poisoning a friend” (themselves).

Some Final Comments on Other Programs

 ·Programs based on the adolescent treatment model of Re-ED (Re-Education of the Emotionally Disturbed) and Anger Management skill groups have been reasonably successful in maintaining people in their sobriety.

·Treatments similar to those for people who are lower functioning and have Borderline Personality Disorder (Dialectic Behavior Therapy based programs) are also being tried with positive initial indications.

·The Minnesota Recovery Model has mixed results at best.

·Several non-traditional residential treatment programs of varying sizes have been initiated with mixed results.

·Faith communities (churches, etc.) can help. Some churches have been very supportive. Many of the people the author has worked with who have mental retardation seem to find strength and encouragement in the belief that God will help them. Unfortunately, some of the faith communities are very reluctant to be involved and some are openly opposed to assisting in the recovery process.


Recovery from substance abuse for the person who has a dual MI/MR diagnosis can take a very long time. It depends on many factors, including how involved the person has been with the drugs and/or alcohol, family influences, systems issues, etc. Most residential programs take 18 to 24 months or longer. For some it may five years to reach early stages of recovery and up to 10 years to be stable in recovery.

Overall, recovery appears to based largely on the quantity and quality of the supports, the coordination of those supports, the health of the body and brain, and the how long the individual was using. It is almost much slower than we would like.

There are a myriad of issues to be addressed for successful treatment. The growing number of individuals requiring these services and supports has already resulted in more articles in the professional literature and major efforts by the U.S. government to establish a consensus on appropriate treatments. This will hopefully translate to more funding, better identification, scientific program evaluations, etc..

The individual can not be secondary to the treatment process for successful recovery and maintenance. They must find a valued life that is more appealing than alcohol and other drugs. Cross systems education and appropriate modifications to meet the general needs of the population and the specific needs of the individual are critical to achieve the desired outcomes.


Moore, D. & Li, L. (1996). Final Report to NIDRR: Results of an Epidemiologic Survey of Drug Use Among Persons with Disabilities. Dayton, OH: Rehabilitation Research and Training Center on Drugs and Disability, 1996.

Rehabilitation Research and Training Center on Drugs and Disability. (1995). National Needs Assessment Survey Results Summary. Dayton, OH: Rehabilitation Research and Training Center on Drugs and Disability.

Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Abuse Treatment. (1998). Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities (TIP #29). Rockville, MD: U.S. Dept. of Health & Human Services.

Information Resources

The Center for Substance Abuse Treatment

SAMHSA’s National Clearing House for Alcohol

and Drug Information

800-729-6686 (voice); 800-487-4889 (TDD)

National Association on Alcohol, Drugs,

and Disability

2165 Bunker Hill Drive

San Mateo, CA 94402-3801

650-578-8047 (voice/TDD); 650-286-9205 (fax)

Rehabilitation Research and Training Center on

Drugs and Disability

Wright State University, School of Medicine,

PO Box 927, Dayton, OH 45401-0927

937-259-1384 (voice); 937-259-1395 (fax)

SARDI Project: Substance Abuse Resources

and Disability Issues

Wright State University, School of Medicine,

PO Box 927, Dayton, OH 45401-0927

937-259-1384 (voice); 937-259-1395 (fax)

AHRC, Substance Abuse and Persons with

Mental Retardation/Developmental Disabilities,

AHRC, New York City Sobriety Services Program

200 Park Ave. South

New York, NY 10003


Mayer, M.A. & Poindexter, A. (1997). Substance Abuse & Fetal Alcohol Syndrome. In Self-Instruction Program Series on Mental and Behavior Disorders in People Who Have Mental Retardation.


3326 Chapel Hill Blvd., Suite A-130

Durham, NC 27707


For further information:

Mike Mayer, Eds
The Institute
110 Boone Square, Ste. 19
Hillsborough, NC 27278-2665