Thomas J. Sinclair
Persons with the dual diagnosis of mental retardation and alcoholism are currently a population not receiving services that are necessary for successful recovery. Substance abuse treatment centers and twelve-step programs of recovery must begin to address the needs of these individuals. There has been little empirical research on the prevalence of alcohol abuse for persons with mental retardation (McGillivray & Moore, 2001). Research estimates that people with mental retardation have a rate of substance abuse problems up to two times that of persons without disabilities. The estimates run from seven percent to twenty percent of individuals with dual diagnosis have some kind of substance abuse problem (Bachman, Drainoni, & Tobias, 2004; Christian & Poling, 1997; Cocco & Harper, 2002; Delaney & Poling, 1990; Greer, 1986).
The purpose of this commentary is fourfold. First, to state what the program of Alcoholics Anonymous (AA) is and is not for persons that participate in the program. Second, discuss the demands related to membership and active participation in a twelve-step program of recovery for an individual with mental retardation. Third, examine the needs of individuals with dual diagnosis. Fourth, discuss proactive methods to accommodate for the needs of persons with a dual diagnosis of mental retardation and alcoholism in the realm of a twelve-step program of recovery, Alcoholics Anonymous. It is the belief of this researcher that persons with a dual diagnosis of mental retardation and alcoholism need many of the same accommodations that are utilized to meet the needs of individuals with mental retardation in educational settings. The cognitive, listening, academic, and social demands of AA are similar to the demands persons with mental retardation find difficult to overcome in inclusive educational settings (Kochhar, West, & Taymans, 2000; Smith, Polloway, Patton, & Dowdy, 2004).
What is Alcoholics Anonymous? The preamble of AA best describes exactly what the program of recovery represents. Alcoholics Anonymous preamble states:
"Alcoholics Anonymous® is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for AA membership; we are self-supporting through our own contributions. AA is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety" (Alcoholics Anonymous, 2002).
First, skills and demands of these programs must be identified, in order to address these problems or issues. Presently, there are many barriers which block persons with mental retardation from gaining access to and actively participating in twelve-step recovery programs. Some of the skill demands of twelve-step programs are: reading, reading comprehension, cognitive processing, pace of the meeting, auditory processing, auditory discrimination, distractibility, understanding and decoding the literature, functionality of steps and concepts of program, and social skills deficits social interactions (Clark & Wilson, 1999; Degenhardt, 2000). Lack of knowledge on the part of sponsors, AA members, and counselors of how to meet the needs of individuals with mental retardation in AA is also a barrier to active participation (Lottman, 1993; U. S. Department of Health and Human Services, 2002). This is not an exhaustive list by any means. Accommodations are necessary and varied to meet the needs of individuals with mental retardation and alcoholism in the setting and structure of Alcoholics Anonymous.
Literature in AA is written at a level which is above the reading ability of many persons with mental retardation. The pamphlets are wordy, even when they are of the illustrated variety; the illustrations are very busy and involved and demand higher cognitive abilities for interpretation. The book Alcoholics Anonymous is written at a grade level of between eighth and ninth grade, which exceeds the abilities of many individuals with mental retardation. Also, many of the stories and instructions are difficult to understand and comprehend due to the presentation of many abstract thoughts, concepts and ideas.
The AA program is based on many spiritual principles that involve a medium or high level of cognitive ability. This cognitive ability includes such tasks as problem-solving, processing of concepts, ideas, and tasks to be undertaken by a member in order to recover. These concepts, tasks, ideas and tasks may need to be taught to a newcomer with mental retardation in a simpler form, with less wordy explanations. The connection to school strategies is to make it functional (Kochhar et al., West, & Taymans, 2000). While the program of Alcoholics Anonymous is a functional program of recovery, the material must be presented in a manner that enables the individual with mental retardation to understand and functionally use this information.
Alcoholics Anonymous meetings proceed in several different ways that can be very demanding for persons with mental retardation to follow. The most common types of meetings include: book study, step study, discussion, and speaker meetings. In a book study meeting the book, Alcoholics Anonymous is read and discussed. In step study meeting one of the twelve-steps is discussed and taught. In a discussion meeting the group takes turns in discussing a topic that is related to recovery from alcoholism. A speaker meeting is a person shares their story of alcoholism and recovery, their experience, strength and hope as AA characterizes these sharing sessions. In the book, step and discussion meetings the pace of interaction is often quicker than the processing ability of a person with mental retardation. Information can be missed or not understood, just as for a student in an inclusive classroom. Speaker meetings also can move quickly and comprehension can be a challenge.
Within an AA meeting people are often moving around getting coffee, going to the restrooms and whispering; this can be a distraction for persons of all abilities. The discrimination of this input, noise, and activity can distract the person who is already having problem comprehending and following the discussion (U. S. Department of Health and Human Services, 2002).
The literature in AA is written at level that take reading levels above that of early elementary school. Literature is often worded such that many interpretations may occur, thus confusing a person with reading and cognitive challenges (Smith et al., 2004). Literature that is "adapted" for a person with special needs often is illustrated with very detailed busy drawings. This drawing can confuse a person with processing challenges and result in misunderstanding.
Any group interaction causes demands on the social skills repertoire of individuals with disabilities. Active participation in the program of AA requires some basic social skills. Some of the social skill demands are: initiating conversations, taking turns, respecting personal space, appropriate language, asking for help, and reading of social cues (Kochhar et al., 2000). In persons with adaptive skills deficits these can be demanding tasks that limit the ability to actively participate in a twelve-step group situation (Clark & Wilson, 1999).
Some of the present accommodations in place for individuals with mental retardation are books and literature on tape, video explanations of the program and steps, and speakers (audio reproductions of sharing their personal story) on tape, and some illustrated pamphlets that are to enhance understanding (Kochhar et al., 2000; Smith et al., 2004). Alcoholics Anonymous and other twelve-step programs of recovery must take these accommodations to another level to improve the participation and success of individuals with mental retardation that cross the doors of these programs.
Accommodations that need to be made are: lower the reading levels, comprehension simplification, such as, using fewer words in explaining the steps, utilize books on tapes when reading the basic textbook of AA, highlighting key points in the book for improved comprehension, studying in smaller sections (less material), smaller group meetings, individual attention, assistance with social demands and skills, and training of the people already achieving successful sobriety to meet the unique needs of persons with mental retardation (Kochhar et al., 2000; Smithet al., 2004).
It is this researcher's opinions that to best address the needs of individuals with a dual-diagnosis of mental retardation and alcoholism we must train those people that function as a teacher or trainer within the programs of recovery. Therefore, sponsors and people on the disabilities committees must be trained in strategies to address the needs of individuals with mental retardation within the context of the program of Alcoholics Anonymous. While, these individual sponsors have the best intentions in mind they need the tools and awareness to address the unique needs of individuals attempting to recover with mental retardation as an intervening issue. Simple considerations to be made, strategies to use and challenges and needs of individuals with disabilities should be presented in a pamphlet or other document provided to the sponsor through the program of Alcoholic Anonymous.
It is essential for success with persons with dual-diagnosis that AA become more proactive in addressing the needs of individuals with mental retardation and cognitive challenges within the context of the steps, sponsorship, meetings and materials available. This can be accomplished through the education, training and provision of strategies, tips and possible needs of individuals to sponsors for individuals with mental retardation that come to AA. If we educate the sponsors they will be better prepared to address the barriers that keep persons with dual-diagnosis of mental retardation and alcoholism actively participating and succeeding in recovery.
It is this researcher's contention that these simple strategies, accommodations and modifications can be done with some basic training and common sense thought. The book should be read in small portions with another member to enhance understanding. The twelve steps, major ideas, concepts, tasks, and actions can be simplified for understanding and action. Meetings could be smaller or people sharing talking at a slower pace inconsideration of persons with mental retardation or cognitive processing challenges. The twelve steps can be simplified into one or two word phrases in order to enhance functional use of there tools of recovery. These are common educational strategies utilized to address the same demands and needs in educational settings (Kochhar et al., 2000; Smith et al., 2004).
Until the time comes where twelve-step programs of recovery and AA in particular become more proactive in meeting the needs of individuals with disabilities the success rates and lasting sobriety for persons with dual-diagnosis will continue to be abysmal. Improvement of participation and success can only occur if these programs look at what they presently doing and assist the member with sober time to meet the needs of individuals with mental retardation within the existing structure of the program of Alcoholics Anonymous.
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For more information: Dr. Thomas Sinclair, firstname.lastname@example.org.