Alcohol and Other Drug Use
Among Post Secondary
Deaf and Hard of Hearing Students
Katherine A. Sandberg
Minnesota Chemical Dependency Program for
Deaf and Hard of Hearing Individuals
MCDPDHHI as a Model Program
The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals (MCDPDHHI) was established in 1989 to meet the chemical dependency treatment needs of deaf and hard of hearing individuals in an environment that was cognizant of and responsive to the communication and cultural needs of these persons. Initially designed with an adolescent focus, the Program has expanded to serve persons aged sixteen years and above. In 1990, the Program was the recipient of a grant from the Center for Substance Abuse Treatment under the Critical Populations section to serve as a model program for substance abuse treatment of deaf and hard of hearing persons. The grant, initially funded for 3 years and later renewed for an additional 2 years, provided for the development of clinical approaches, specialized treatment materials, outreach and training services and dissemination of products and information. Through the support of the grant funding, two national conferences were held that focused on substance abuse and deafness. A number of materials were developed and the approaches developed by the Program were captured in print and videotape so they could be replicated in other areas. In addition, the Program also received a grant from the Office of Special Education and Rehabilitation Services. This grant provides intensive four day Professional Development Forums focused on training professionals who work with deaf and hard of hearing clients who may be chemically dependent. To date, 19 of these trainings have been held with more than 350 participants from a variety of professions including vocational rehabilitation, education, interpreting, counseling and others. An additional five trainings will be provided according to the current funding.
Program participants come from across the United States and Canada. As of this date, more than 490 persons have received treatment services at the Program. While the Program serves a diverse spectrum of clients, the majority of the clients are deaf (88%), male (78%) and Caucasian (77%). However, males and females representing a variety of ethnic groups have participated in the Program including those of Native American/Canadian, Hispanic and African American backgrounds. Hard of hearing persons as well as deaf persons with additional physical challenges including cerebral palsy, Ushers Syndrome and other vision problems have been clients in the Program. Clients come from a range of family backgrounds, social situations and educational experiences and vary in age from 15 to 74 years of age with the largest percentage of clients in the 25 to 35 years of age range.
A variety of funding sources have covered the cost of client treatments. Thirty-seven percent of clients are funded by Medicare; 19% are funded by Medicaid. Private insurance is the funding source for 21% of the clients and funding for the remainder of clients comes from sources including Indian Health, vocational rehabilitation, HMOs and Canadian funding sources. The average length of stay is approximately 35 days with shorter stays often being dictated by limitations of funding sources.
When clients come to the Program, they are asked to indicate their preferred mood altering chemical. Alcohol is the most commonly preferred chemical (57%) followed by cocaine (18%), marijuana (12%) and crack (9%). Other drugs including heroin, hallucinogens, tranquilizers, inhalants and PCP represent the preferred drug for about 3% of the admissions. Aside from the preferred chemicals, most clients are polysubstance users meaning that they use a combination of alcohol and other drugs. In addition to chemical dependency, clients who participate in treatment at the Program often present with issues related to physical health, mental health, abuse, sexually transmitted diseases, family issues and legal or employment status.
With the support of the grant from the Center for Substance Abuse Treatment, the MCDPDHHI has developed a number of materials in the area of alcohol and other drug abuse for use with deaf and hard of hearing persons. "Dreams of Denial" is a 23-minute video presented in voice, sign and captions and designed to be an education/prevention tool for adolescents through adults. The video tells the story of a deaf man who is struggling with chemical dependency and raises a number of issues faced by deaf persons related to the use of alcohol and other drugs. The video includes information about peer pressure, Twelve Step groups, treatment, family issues and barriers faced by deaf and hard of hearing persons in recovery. The video comes with an instruction guide which provides complete information for use of the video in a variety of settings.
"Choices" is a curriculum developed by the Program to address the areas of risk taking and decision making skills. The concepts taught in the curriculum are applicable to a wide range of age levels. The curriculum offers instruction and skill building on free/forced choices, a model decision making process, strategies for identifying alternatives, risk assessment and practical application of the skills taught. The curriculum is presented in a workbook format with complete teaching instructions.
"Clinical Approaches Manual" is the complete description of therapeutic approaches developed at the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Within the manual program philosophy and techniques are described in detail. Sample assignment sheets as well as behavior management strategies are included. In addition to assignments based on the Twelve Steps of Alcoholics Anonymous, the manual includes assignments for specialty groups such as grief group and evaluation assignments. A videotape, "An American Sign Language Interpretation of the Twelve Step Program", was developed to accompany the manual. This hour long video presents an explanation in ASL of each of the Twelve Steps and is also voiced and captioned. The video may be used in conjunction with the assignments given in the manual.
A relapse prevention workbook entitled "Staying Sober: Relapse Prevention Guide" provides individuals with information about the process of relapse and offers strategies for preventing or intervening on the relapse process. This workbook is designed to be used with a counselor or other professional and gives clients the opportunity to use various methods of communicating their ideas. The book identifies common relapse triggers, explores feelings of recovery and relapse and reviews important principles of self care in recovery.
The National Information Catalog is a listing of materials designed for deaf and hard of hearing consumers targeting substance abuse and related topics. The catalog provides a description of the materials and information about where they can be obtained. The Program also published a newsletter which carries articles and announcements related to substance abuse and deafness. The Program also makes available numerous articles and printed materials about this subject area.
Program staff continue to be active in sharing information with interested persons including professionals serving deaf and hard of hearing persons, consumers, educational institutions and community members. The program is active in the local Minneapolis-St. Paul area providing prevention/education and intervention services at school programs for deaf and hard of hearing students. Likewise, Program staff provide consultation and presentations to other agencies serving deaf and hard of hearing persons. The Program frequently receives requests to provide presentations at local, regional and national conferences. Although the primary purpose of the Program is to provide chemical dependency treatment services, staff is also committed to outreach and training services as time permits.
Chemical Use, Abuse and Dependency
Continuum of Chemical Use
The use of mood altering chemicals is often viewed on a continuum from no use of mood altering chemicals through dependent use of these chemicals. On the "no use" end of the continuum are generally those people who have never used mood altering chemicals. Although this position may be viewed as an absolute, it seldom exists this way. Usually, we consider that someone is abstinent (no use) when they abstain from alcohol and other common drugs of abuse. Typically our consideration of chemicals does not include prescription and over the counter medication, caffeinated beverages, tobacco, household or work place chemicals and various kinds of food. For the remainder of this discussion, we will consider alcohol and other drugs. Most people, at some time in their lives, move into the portion of the continuum called "use". Usually, this begins in the adolescent years with experimental use of mood altering chemicals. At the most conservative end, the "use" portion of the continuum includes moderate or occasional administration of the chemical either as appropriate medical use or appropriate social/recreational use. It is often in the area of social use where ambiguities arise based on the various norms which help to define what is appropriate. Among the sources for these norms are the culture(s), religion, parental influence, peer group and personal values. When the norms from these sources are unclear or conflicting, ambiguities arise. As one moves along the continuum, use remains moderate but becomes more frequent and then habitual. The beginning of risk behavior emerges when one uses mood altering chemicals for the thrills or with the intent to get high or drunk. In this stage, there may be use to relieve stress feeling like one needs the chemical to deal with pressures.
At the point at which ones use of mood altering chemicals interferes with normal functioning, one crosses into the area of abuse. Characteristics of abusive use include use of excessive amounts of chemicals; inappropriate use (including thrill-seeking, intent to get drunk/high, spree use); continued use in spite of negative consequences; rationalizations/minimizing use; lack of awareness about the degree of impairment; and inability to change in spite of plans.
Dependency is defined in a variety of ways by different sources. It generally includes a kind of craving that must continue to be satisfied by repeated use (for its usually pleasurable effects) even when negative effects accompany or result from the use. Dependent or addictive use of mood altering chemicals means significant interference with normal functioning and usually deviates significantly from cultural norms. The notion of the use being beyond the control of the individual is generally accepted as part of the criteria. Also, there is a feature of preoccupation with the drug, usually to the exclusion of most other things in the individuals life.
The progression from abstinence or use to dependency can vary in the length of time it takes to happen. Generally, the younger a person is when the progression begins, the more quickly it advances. An elderly person may also experience a more rapid progression toward dependency. While it is possible for a person to move back and forth from one area to another, it is generally agreed (at least in the disease model of chemical dependency) that an individual cannot move from dependency back to non-problematic use. In fact, a dependent person who experiences a period of recovery (abstinence) and then relapses, immediately returns to the low point or extreme of his or her dependent use (as opposed to beginning the progression again).
Risk Factors for Developing Chemical Dependency
Although there is significant debate about the etiology of substance abuse problems, a number of factors are thought to increase a persons risk for developing difficulties with the use of mood altering chemicals. Probably foremost among the risk factors is family history of chemical dependency. Studies, mostly focused on alcohol use, show an increased risk of developing addiction when parents have a history of substance abuse. Some studies seem to show involvement of biological factors, but whether this risk stems from environmental factors or genetic ones, it appears to be an important warning sign. Several other factors are also thought to contribute to the development or seriousness of substance abuse problems. Use of mood altering chemicals at an early age often progresses to abusive use more quickly than in adults.
Individuals who lack education about alcohol and other drugs, or who do not have resources to support a drug free lifestyle, may be more at risk. When an individual has very successful experiences with mood altering chemicals, this tends to provide a positive reinforcement for continued use. Similarly, lack of negative consequences connected to chemical use may also serve to support ongoing use.
Signs & Symptoms in Life Areas
One way of assessing the impact alcohol and other drugs have on a persons life is to consider the consequences of that use in various life areas. Typical life areas to be considered include physical health, financial issues, family relationships, work/school performance, legal issues and social interactions. Taken together, these areas give a fairly complete picture of the individuals life. When a person is abusing mood altering chemicals, the impact in each of these life areas may provide an indicator as to the extent of the chemical abuse. The following are some of the consequences commonly seen in the respective life areas.
These signs can help to detect a problem with the use of alcohol or other drugs. One or a small number of symptoms alone is probably not significant but in combination, they can point to difficulties. Change is also a significant factor to consider. Changes in these areas that are not attributable to other causes may also be indicative of a problems in this area. By looking at the life areas as named above, one can begin to get a complete picture of how chemical use impacts the individuals life as a whole.
In the treatment setting, the life area consequences mentioned above may be used in assessing the extent of a persons chemical use. However, specific criteria are used to make an official diagnosis for the purpose of planning and monitoring treatment. The American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is a commonly used for diagnostic standards. The DSM-IV criteria for alcohol dependence include a maladaptive pattern of alcohol use; increased tolerance; characteristic withdrawal symptoms; inability to cut down or stop; giving up or reducing social, occupational or recreational activities because of drinking; time spent focused on drinking or obtaining alcohol; and continued drinking despite physical or psychological problems caused by the use of alcohol. Use of these criteria enable treatment providers to demonstrate the need for treatment services.
Intervening on Chemical Use
Many times, prevention is thought of in the narrow sense as efforts intended to prevent or delay the use of alcohol and other drugs. If prevention/education efforts are viewed in this context, it appears that these efforts have little place in the post-secondary setting since many, if not most, post-secondary students will have already used mood altering chemicals. However, if prevention/ education is viewed in a broader context as a continuum, aimed at the continuum of use, application in the post-secondary setting is possible. Primary prevention, efforts aimed to prevent use before it starts, will not be appropriate for most post-secondary students. However, it is important to remember that some young people will leave high school without having experimented with alcohol or other drugs. These students can benefit from education and training in the areas of self esteem, relationships, decision making, communication, empowerment and refusal skills, all of which are included in prevention/education. In addition, information about the drugs themselves remains an important component, possibly more important with deaf students who may be lacking in their knowledge of these chemicals.
Secondary prevention involves prevention services aimed at individuals who have experienced some chemical use. Different strategies and techniques will be used when dealing with students who have had their own encounters with alcohol or other drugs. Topics such as consequences of chemical use, risks of chemical use, identification of pressures to use drugs and making choices are important in these prevention/education efforts. In addition to education, students can also benefit from support services such as counseling, support groups and help centers. Institutional policies and procedures which help to identify developing problems with alcohol/drugs and respond to them in a constructive way are also a part of secondary prevention. Post-secondary programs should have accessible counselors who are knowledgeable about alcohol and other drugs. Programs may be involved in sponsoring activities that serve as alternatives to alcohol and drug use. They may offer counseling, support groups and other resources students can access for assistance. Programs should also be aware of outside resources that students can utilize for help with alcohol or other drug problems. There should be an awareness of where students can obtain an assessment if problems arise.
Tertiary prevention refers to efforts that seek to prevent resumed use or relapse in individuals who have abused chemicals. Generally, this kind of activity includes the types of services recommended after a treatment experience. Aftercare often includes ongoing counseling, relapse prevention efforts, Twelve Step meetings and sponsorship. Post-secondary programs might support Twelve Step meetings by providing meeting space, assisting with interpreter services and making lists of AA or NA meetings available. Again, counselors who are familiar with alcohol/drug abuse can provide on-going counseling, support and education.
Assessment of Problem Use
Knowing and recognizing potential signs of chemical abuse, as discussed above, is an important step in helping students who may be experiencing problems. Change in behaviors as well as the appearance of several of the signs mentioned may be indicative that some kind of intervention is needed. An significant aspect of chemical dependency is the denial exhibited by the individual. In the absence of outside feedback, many people are able to rationalize, minimize and in other ways deny the problem. Chemical use becomes such an integral part of ones life that one is unable to see the negative effects or is unable to attribute them to the use of the alcohol or other drugs. This is where caring persons have the opportunity to help intervene. While accusations about chemical use may lead to even stronger denial, sharing of genuine concerns can be an effective technique to help someone realize how their use is having a negative impact. The use of "I" statements and naming specific concerns or behaviors can be helpful. For example, a concerned staff person might say, "I notice you have been missing a lot of school. I see that your grades have slipped and you often look as if you are sick. I care about you and am concerned that you might need some help." Such communication is less likely to raise the young persons defenses and lets them know that someone cares. Another important action that can be taken is allowing post-secondary students to experience the consequences of the choices they make. Sparing someone from consequences only serves to reinforce their notion that there is no problem.
Students who may be experiencing problems related to their use of alcohol and other drugs should be referred to a qualified individual for an assessment. Unfortunately, with deaf and hard of hearing students, an assessor who is able to communicate directly is often impossible to find. It is crucial that students who go for drug and alcohol assessments be provided with a qualified interpreter when the assessor is not skilled in communicating with deaf persons. A valid assessment hinges on being able to communicate clearly and accurately.
Referring to Treatment
If a student is determined to be in need of treatment services, it is important for post-secondary staff persons to be familiar with resources for treatment services. Only a few chemical dependency programs exist nationally that work specifically with deaf and hard of hearing persons. Some students may need the services of such programs. Others may be able to successfully participate in mainstream type programs with the use of an interpreter or other communication aids. Careful consideration should be given to the services and programming provided to clients when selecting a treatment program. Treatment services should meet the needs of the client and offer the client education, support, counseling, and skill building directed toward recovery from alcohol/drug abuse problems. Almost without exception, other issues or problems arise during the course of chemical dependency treatment. Some commonly identified problems include grief/loss, ineffective coping skills, abuse issues, poorly developed social skills and mental health concerns. While important and often closely linked to the use of chemicals, these problems are generally more effectively addressed in sobriety.
Post-secondary staff members who help refer a student to treatment may want to participate in on-going communication with treatment staff during the course of treatment. With the agreement of the individual and signing of proper releases, this communication can help to establish a support system for the student upon completion of treatment. Direct communication with the student can provide a sense of support for the difficult process of recovery.
As previously mentioned in the discussion of tertiary prevention, aftercare is essential to ongoing recovery. Treatment is an important step in the process but the real work of recovery begins after treatment. Generally aftercare recommendations include ongoing counseling (both individual and group if possible), attendance at Twelve Step meetings (Alcoholics Anonymous, Narcotics Anonymous, etc.), and obtaining and maintaining contact with a sponsor. For deaf and hard of hearing persons, these components of an aftercare plan may be difficult to obtain. Although an increasing number of AA and NA meetings are accessible through an interpreter and more counselors with training in chemical dependency and deafness are available, there still exists a serious lack of resources that are accessible to deaf and hard of hearing persons. These barriers present additional challenges to deaf and hard of hearing young people pursuing recovery.
The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals has done some follow-up work with clients who have participated in the program. In relation to predictors that seem to correlate with maintaining sobriety, three are particularly significant. These follow-up studies show that three factors have a strong positive influence on the maintenance of sobriety: someone, such as family or friends, to talk with about sobriety; employment; and involvement in self help groups. In other words, individuals who have the support of other sober people, who engage in some kind of work and who can communicate with someone about their recovery are more likely to stay sober. It appears that these factors can help clarify how young deaf and hard of hearring students can best be supported in recovery.
The use of alcohol and drugs at post-secondary programs continues to be a problem for some students including deaf and hard of hearing students. The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals serves as a model program in providing appropriate, accessible chemical dependency treatment services to deaf and hard of hearing people. Materials developed by the Program, can provide useful tools in addressing and dealing with this problem. Awareness of the signs and symptoms of chemical abuse and dependency puts post-secondary programs in the position of being able to provide education, support, counseling and referral to students who may be experiencing problems. Support for students who are in recovery is also an important component of post-secondary program offerings.
For more information about the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing or any of its materials, please contact the Program at:
Minnesota Chemical Dependency
Deaf and Hard of Hearing Individuals
2450 Riverside Avenue
Minneapolis, Minnesota 55454