The functional limitations of clients with coexisting disabilities.
In a study regarding current alcohol use, Moore and Li (1994) reported that 71.5% of people with spinal cord injuries drank, followed by hearing impairment (60.9%) and visual impairment (57.5%). Drinking was cause for concern in this sample because 51% of the respondents were also taking prescription medication and still others had medical/health concerns that could create problems with even minimal amounts of alcohol. These complicating factors makes it more likely that even relatively low levels of alcohol or drug use may become problematic (i.e., abuse) for people with disabilities.
A pattern of more pervasive substance abuse problems is maintained for people enrolled in state vocational rehabilitation programs as well. A survey of almost 2000 people with disabilities receiving vocational rehabilitation services in three Midwestern states found that illicit drug use of every major type was much higher in this sample when compared to the general population (RRTC, 1996). It was reported that marijuana and cocaine use in the past month was almost double the rate of the general population and crack cocaine use in the past year and in the past month was estimated to be about five times higher. Overall, the study estimated that about 25% of consumers receiving vocational rehabilitation services experienced substance abuse problems, most of which were unknown to the individuals' vocational rehabilitation counselors.
As indicated earlier, people with disabilities appear to be at greater risk for abuse alcohol or drugs because of the presence of physical, emotional, or cognitive problems that, in part, are attributed to their disabilities.
Like the general population, persons with disabilities face a variety of situations that may encourage illicit drug use. However, there are some drug abuse risk factors that are more frequently associated with disability.... problems of personal adjustment and unemployment, as well as the experienced medical and health difficulties. (Li & Moore, 2001, p. 5)
Further, social isolation and unstructured free-time also place people with disabilities at greater risk to develop problems with alcohol or drugs (Nelipovich & Buss, 1989). Within both the general and disability populations, drinking to cope with life's stress is viewed as a powerful predictor of alcohol abuse and drug problems (Cooper, Russell, & George, 1988; Heinemann, Schmidt, & Semik, 1994).
Given the prevalence rates of use and abuse, it seems certain that a sizable percentage of people with disabilities have problems with alcohol or drug use to such an extent as to require treatment. However, it is uncertain how many such people seek, obtain, and complete treatment. Importantly, it is also unclear how their disabilities and functional limitations affect treatment process and outcome. Clients receiving substance abuse treatment face a myriad of challenges when coping with their drug abuse/addiction problems. The challenges consist of more than just abstaining from alcohol or drugs. Clients are asked to separate themselves from people, environments or other stimuli that may trigger relapse, stop self-defeating behaviors such as denial and rationalization (strategies used to suppress painful feelings, but also get in the way of treatment progress), learn how to manage their emotions and cope with stress without resorting to alcohol or drugs, and change their belief systems and addictive-thinking patterns (Gorski, 1990). Substance abuse treatment is a daunting prospect for clients, even under the best of circumstances. The challenges presented in treatment may be compounded when clients' face functional limitations from disabilities that co-exist with their addiction or drug abuse.
Functional Limitations and Disability
The functional 1 imitations caused by various disabilities are of primary importance to understanding rehabilitation outcome and goal attainment. Functional limitations are understood to be the impairments in physical, behavioral, or emotional functioning that result directly from disability. Wright (1980) defined functional limitation as "The hindrance or negative effect in the performance of tasks or activities, and other adverse and overt manifestations of a mental, emotional, or physical disability...." (p. 68). Wright (1980) noted that diagnoses or medical conditions are of primary concern to medical professionals; rehabilitation counselors, however, are most concerned with functional limitations as they relate to attainment of client goals. Wright (1980) identified a number of important functional limitations that may result from various disabilities. He identified and discussed the following functional limitations: restricted environments (conditions that make certain environments unsafe, such as respiratory conditions making it difficult to be cold, hot, or dusty conditions), invisible limitations (concealed or unapparent conditions, such as heart conditions or back pain that restrict movement), uncertain prognoses (having an unstable or uncertain course, such as with multiple sclerosis). Livneh (1992) also identified a number of functional limitations important to vocational goals, including: mobility, sensory, communication, atypical appearance, and pain.
Benshoff and Janikowski (2000) believed that functional limitations were important to understanding substance abuse treatment. People with limitations in communication (e.g., visual impairment) may be unable to read printed materials such as the "Big Book" or other Alcoholics Anonymous (AA) literature so often found in treatment facilities. Others may have hearing impairments that require the use of an interpreter during group or individual counseling sessions that create problems with confidentiality, trust (Guthmann & Blozis, 2001) and the therapeutic relationship. People with mobility limitations (e.g., spinal cord injury) may have difficulty accessing treatment facilities or AA group meetings that are held in places without elevators or ramps. Limitations associated with pain (e.g., back injury) may make it difficult for clients to attend counseling sessions on a regular basis, or may require clients to use pain medication that is often seen as contrary to the goal of drug abstinence.
Clearly, how functional limitations manifest themselves during the treatment process has not been widely researched and clearly warrants further investigation. The purpose of this study was to investigate how treatment facilities identify coexisting disabilities in their clients and how they respond to their associated functional limitations. Program directors were asked about how and when they identify coexisting disabilities and the frequency and nature of those disabilities. Further, they were asked about the frequency of various types of functional limitations encountered by clients and how they impacted client treatment, as well as vocational and educational goals.
The "Disability, Functional Limitations, and Substance Abuse" (DFLSA) survey was developed by the authors to explore the incidence and nature of co-existing disabilities among clients admitted for substance abuse treatment, including how client functional limitations affected treatment delivery. The survey was designed to gather information from Program Directors of state licensed substance abuse treatment facilities. The survey was divided into areas of: Program and Staff Data, Client Disabilities, and Client Functional Limitations (a fourth section of the survey regarding Staff Training is considered beyond the scope of the present article and discussion of these items and data are not presented here).
The section on Program and Staff Data included nine (9) items that gathered descriptive information regarding the number of full and part-time staff employed by the program, the educational degrees and certifications held by the staff, the number of treatment supervisors in the facility, the number of staff who specialize in vocational rehabilitation services, the numbers of clients served, client length of stay, and program location (urban, suburban, town, rural).
Client Disability data were collected from four (4) items that gathered information on the average percentage of clients admitted to treatment who were diagnosed with coexisting physical or sensory disabilities, the percentage of clients diagnosed with coexisting psychiatric disabilities, the rank order (most to least) of co-existing disability types, if co-existing client disability is screened for as part of the intake process, and how frequently coexisting disability may be missed at intake, but later discovered in the course of treatment.
In addition to gathering information about the incidence of disability, the authors were most interested in examining how the functional limitations associated with coexisting disability affected the attainment of treatment and vocational goals. For the purposes of this study, functional limitation was defined as physical, behavioral, cognitive, emotional or social impairments or barriers to treatment, or other life-goals that result from disability. Based on work by Wright (1980) and Livneh (1992), a limited list of prevalent functional limitations were presented in the survey: (1) Mobility: getting from one location to another is limited; (2) Communication: information exchange between the client and others is impaired; (3) Atypical Appearance: physique or appearance that differs significantly from the cultural norm to constitute disfigurement (e.g., visible lesions); (4) Invisible Limitation: medical impairments that are not visible but nonetheless create special problems in achieving goals (e.g., cardiac problems, diabetes, AIDS, Epilepsy) (5) Restricted Environment: a medical impairment that makes the client uncomfortable or unsafe in a particular environment (e.g., inability to filter atmospheric contaminants as with respiratory disability) (6) Pain: localized or generalized pain of such a nature or extent that it impairs the client's ability to attend to the demands of the environment; (7) Consciousness: neurological/cognitive limitation that causes periodic unconsciousness or lack of connection to the environment (e.g., seizures); (8) Uncertain Prognosis: unstable medical conditions with periods of exacerbation or remission that results in psychological problems such anxiety about the future, fear of death and dying, social withdrawal; (9) Debilitation: excessive weakness and fatigue upon exertion preventing the exercise of strength and limiting stamina; and (10) Coordination: inability to produce, direct, and/or control body movements, gross and fine motor skill impairment.
The survey presented the 10 functional limitations and their definitions (including examples of disability types that may result in such limitations). After each functional limitation definition participants responded to four (4) recurring questions. For example questions about limitations related to mobility were as follows:
a. How frequently do your counselors address client mobility limitations?
1=Never 2=Yearly 3=A Few Times Per Year 4=Monthly 5=Weekly 6=Daily
b. To what extent do mobility limitations interfere with overall treatment and goals for your clients?
1=No Interference 2=Mild 3=Moderate 4-Severe 5=N/A
c. To what extent do mobility limitations interfere with vocational/educational service goals for your clients? 1=No Interference 2=Mild 3=Moderate 4=Severe 5=N/A
The fourth recurring question addressed the program's response to the functional limitation and was answered using a separate response continuum:
d. How does your program typically address or deal with mobility limitations in the course of treatment?
1=Refer the client to another provider for services while continuing treatment;
2=Refer the client to another provider for services while postponing treatment;
3=Make accommodations or restructure how treatment is delivered;
4=No referrals or accommodations are possible & deliver treatment in a standard manner;
After initial item development, further refinement of the DFLSA was performed by a panel of three (3) experts in the areas of substance abuse treatment, disability, and survey development. The panel (one Program Director and two substance abuse researchers) independently reviewed the instrument and each made minor recommendations regarding item wording and survey format to improve the usability of the instrument (i.e., improved clarity of item response formats, reduced "white space" and cluttered appearance, eliminated two items considered to be redundant, added items on client length of stay and program location). The final version of the survey was submitted to a New York Office of Alcohol and Substance Abuse Services (OASAS) administrator for review and approval.
Participants and Procedures
Program Directors from licensed alcohol and drug treatment programs in the state of New York were sampled from the following treatment categories: Inpatient, Outpatient, and Residential. Personnel in the New York State OASAS assisted with sampling and provided mailing labels that were used by the authors to contact facilities. The Program Directors were mailed the following packet of materials: explanation and consent, a letter of support from OASAS, the survey, and return envelope. Instructions, information about the research, and consent statements were on the face page attached to the survey. Return envelopes were coded to identify the treatment program and were used to follow-up with Program Directors who did not respond to the first mailing. The study was reviewed and approved by the Institutional Review Board of the University at Buffalo and potential respondents were assured that their identity would remain confidential and data would be reported in grouped format only. The survey packet was mailed to a total of 313 licensed programs in the state of New York. Follow-up post cards were sent to each non-responding Program Director four weeks after the initial mailing. Five survey packets were returned undelivered because of incorrect addresses. Of the 200 outpatient facility directors contacted, 69 completed the survey, 2 were returned because of bad addresses, and the remaining 129 did not respond (35% return rate). One hundred and thirteen surveys were sent to residential and impatient facilities; 32 were completed and 3 were returned due to bad addresses (29% return rate).
Program and Staff Data
Descriptive statistics summarizing the sample programs and their staff are presented in Table 1. Medians, as well as means, were chosen to represent the central tendencies because the distributions of these variables deviated from normality. There are some outliers at the high end of the scales, inflating the means somewhat. This sample represents a wide range in terms of size and scope. The largest facility had 125 full-time and 83 part-time staff, while the smallest had two full-time and no part-time staff. The mean number of full and part-time staff was very similar for the residential and outpatient facilities (M=12.1, SD= 7.3; M=12.9, SD=21.3, respectively; mean and variance differences were not significant).
Education levels of staff varied widely, ranging from high school graduates to doctoral level staff. The total number of staff who had at least completed the associate's degree was calculated. The range was from 5 to 70, with a median of 12 staff members with at least an associate's degree. Programs also reported on the specialty credentials of staff. The range of certified or licensed staff was from 0 to 50, with a median of 4. The mean number of full-time treatment supervisors was approximately three. All except one program has at least one person who specialized in providing vocational rehabilitation.
These programs were varied in terms of the number of clients seen and the length of treatment provided. The mean number of clients seen in the most recent year and maximum capacity were influenced by one very large program that reported serving a maximum 1350 clients at one time and 6400 in the most recent calendar year. Note that the medians are considerably smaller than the means as a result. Length of stay was reported for both inpatient (in days) and outpatient services (in weeks). The inpatient data were normally distributed with a mean of 240 inpatient days (SD=108). The outpatient data were positively skewed toward the lower end of the distribution. All except four of the 71 respondents who completed this item indicated that the average length of outpatient stay was 60 weeks or less. Four programs reported values over 100 (from 113 to 180 weeks).
Nearly half of the responding programs are located in urban environments (48%), with 17% reporting suburban locations, 8% towns, and 23% rural locales. A series of oneway analysis of variance tests indicated that there were no significant differences in program size (total number of staff, maximum capacity, and number served in last year) by location.
The survey asked a series of questions about the prevalence of disabilities beyond substance abuse. Respondents were instructed to report on the presence of disabilities in addition to substance abuse. Disabilities were defined as "any medically or psychiatrically diagnosable condition causing a functional limitation in achieving one or more life goals". Specifically, they were asked to report the percentage of clients who have diagnosed physical or sensory disabilities, as well as the percentage with psychiatric diagnoses. The range on both variables was from approximately zero to 100%. However, the mean percentages were much greater for psychiatric (M=33%, SD=21.8) relative to physical/sensory disabilities (M=12.9%, SD=19.7). In addition, the psychiatric disabilities were approximately normally distributed while the physical/sensory disabilities were skewed toward the low end of the scale (i.e., only five programs reported that more than 50% of their clients had or experienced physical or sensory disabilities, in addition to substance abuse). Respondents were also asked to rank order seven categories of disabilities in terms of prevalence within the client population. In Figure 1, a bar chart of the mean ranks provides further evidence of the relatively high prevalence of psychiatric disabilities. There is also a distinct clustering of sensory, physical, and HIV/AIDS at the low end of the prevalence rankings. Respondents who indicated the "Other" disability category, which was ranked third overall in order of prevalence, generally did not provide specific information regarding the types of disabilities to which they were referring.
[FIGURE 1 OMITTED]
The survey inquired about identification of additional disabilities during an initial screening vs. discovery during treatment. All but three program directors (97%) reported that they screen for disabilities other than substance abuse during intake. Nearly all programs (95%) screen for additional disabilities via interview, but 30% also reported using checklists and record reviews for this determination. When asked how often additional disabilities are discovered during treatment, 65 programs reported that they occasionally (n=51) or frequently (n=14) identify new disabilities once treatment has begun. Only three programs reportedly never encounter additional disabilities during treatment.
Frequency of Client Functional Limitations
Respondents were asked to report on the frequency, impact, and staff response to ten functional limitations. The scale included six options, ranging from daily to never. In Figure 2, the frequency ratings are displayed as means with 95% confidence intervals. The frequencies are arranged from least to most frequent. Invisible limitations, defined as impairments that cannot be seen but create problems in achieving goals (e.g., cardiac problems, diabetes, AIDS, epilepsy, etc.), are clearly the most frequently seen. The mean frequency was 4.2 (SD=1.4), which indicates that counselors are typically addressing these kinds of issues on more than a monthly basis. Pain was the second most frequent limitation beyond substance use (M=3.9, SD=1.4; meaning almost monthly), followed closely by uncertain prognosis (M=3.5, SD= 1.4) and communication (M= 3.5, SD=1.5). The least frequently seen functional limitations were coordination (M=2.2, SD=1.4) and restricted environment (M= 2.4, SD=1.6). All of the functional limitations in the survey are generally seen at least a few times per year, but there is variability across programs in the frequency.
Impact of Client Limitations on Treatment
In order to examine the impact of the ten functional limitations, respondents were asked to rate the degree to which each problem area interferes with treatment goals. Goals were broken into two categories: overall treatment and goals and vocational/educational service goals. In Table 2, the means and standard deviations for these ratings are listed. There is a very distinct pattern in the data, with a significantly larger impact on vocational/educational goals than overall treatment goals for each problem area. Overall, it appears that the impact on vocational/educational goals is approximately one half scale point more than the mean ratings for the overall treatment goals.
Findings within the two classes of goals also provide insight into the perceptions of program directors. Uncertain prognosis was rated to have the greatest impact on overall treatment goals. Medical conditions such as cancer and multiple sclerosis are characterized by irregular trajectories (commonly described by clients as a "roller coaster" kind of experience). Almost inevitably this aspect of illness generates anxiety and other complex issues that may interfere with treatment in many ways: hospitalization, side effects of other treatments, and difficult confrontations with end-of-life issues, all of which may supersede traditional rehabilitation goals. On the other hand, atypical appearance, restricted environment, and mobility issues reportedly have the least impact on progress toward treatment goals, perhaps reflecting traditional strengths of rehabilitation counselor training. This pattern was repeated in the rating of interference with vocational/educational goals, with uncertain prognosis at the high end of the ratings, and the same trio of atypical appearance, restricted environment, and mobility having the least impact.
In addition to characterizing the frequency and impact of the additional problems, the survey respondents were asked how their programs typically respond to each issue. Response options included referring to another provider while continuing treatment, referring to others for treatment and postponing treatment, making accommodations or restructuring services to meet individual needs, deliver the standard treatment, or identify another method of response. Table 3 summarizes the frequency of use of each of these options. The most frequently endorsed option was to make accommodations or restructure treatment followed by continuing treatment while referring to additional services. The percentage of programs that either provide an unmodified standard treatment or postpone treatment while the coexisting problem is treated elsewhere via referral ranged from 4-18%. Clearly the programs are attempting to maximize participation despite complications.
[FIGURE 2 OMITTED]
The present study provides a view of the treatment of substance abuse and coexisting disabilities and functional limitations in New York state. The sampling frame in our statewide survey may not generalize nationally, but some confidence in the statistical estimates may be drawn from the considerable diversity in the program characteristics, which is likely to be similar to program characteristics across the US (National Association of State Alcohol and Drug Abuse Directors (NASADAD), 2002), and the fact that the patterns observed in the data are quite clear. Implications of the present data may be tentatively considered as we pursue a national replication sample.
Implications for Assessment & Evidence-based Treatment
As the era of evidence-based treatment continues to evolve, practice guidelines related to assessment and treatment will need to account for complicating factors such as those included in the present study. Young, Rosen, & Finney (2005) recently reported survey results showing that screening for post-traumatic stress disorder (PTSD), which has been associated with poorer outcomes in substance abuse treatment, is rarely conducted with standardized and validated procedures in the Veterans' Administration (V A) substance abuse programs they studied. Similarly, the results of the present study indicate that nearly all programs in the sample have some screening for disability and functional limitations in their initial assessment. Despite this effort however, most discover such issues only after treatment has begun. The most frequent assessment method is the initial interview, sometimes supplemented with a checklist. Future studies in this area might examine the status of assessment practices in depth, with consideration of the availability and feasibility of improving assessment standards in substance use programs. This issue may present a significant challenge considering the potential training gap between, for example, doctoral and bachelor's level staff in assessment. Nonetheless, greater reliability and validity in assessment will help to improve the sensitivity of program evaluations through the identification of coexisting disabilities and functional limitations that mediate or moderate treatment outcomes.
One encouraging step in this direction was recently reported by Hunter, et al. (2005) in their evaluation of a multicomponent intervention focused on the co-occurrence of anxiety and substance use disorders. Although long-term outcome data are not yet available for the program, Hunter et al. reported that staff knowledge and job satisfaction were significantly improved by the intervention, a logical but perhaps underappreciated benefit of the combination of greater self and program efficacy in treating cases with coexisting disorders. Improved specificity in the assessment of coexisting conditions might also lead to more cost-effective use of resources such as inpatient treatment. For example, Bartu, Freeman, Gawthorne, Codde, & Holman (2003) found that amphetamine users were three times as likely as opioid users to undergo inpatient psychiatric treatment. The causes underlying this pattern of treatment utilization are not known, but documentation of the differential likelihood of inpatient care suggests that increased attention be given to assessment of psychiatric comorbidities of amphetamine users in order to make the best use of available resources.
Impact of Coexisting Conditions on Vocational Treatment Goals
A very striking pattern in the reported impact of functional limitations on treatment and vocational goals was observed. The impact of uncertain prognosis was rated to be the greatest of all, a finding that may indicate a need for consideration of staff readiness to deal with complex chronic conditions with variable trajectories, as well as further study of vocational issues for clients in these circumstances. Pain is another issue that appears to be both relatively frequent, and to have a relatively high impact on vocational goals. Improved assessment and treatment of pain phenomena may be an area with great potential to decrease motivation to self-medicate via substance use.
Evidence of Program Commitment in Cases of Coexisting Disorders
There is good news in these data in the reports of efforts to accommodate and provide treatment despite increasing complexity, and also in the reports of limited impact of issues such as mobility. It is clear that when programs are able to identify coexisting issues, they are determined to carry out a treatment plan to the best of their ability, either through accommodation or through continuing treatment with additional support via a referral to another provider. The commitment that underlies this report provides a source of optimism for the future. In addition, the present study suggests that such issues as mobility, appearance, and environmental limitations have largely been successfully addressed in substance abuse programs, and other issues such as uncertain prognosis and pain may now be elevated as priorities in future research, assessment, and treatment.
The authors wish to thank Mr. Kenneth Perez, Upstate Coordinator, Vocational Rehabilitation and Employment Services of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and Ms. Angela K. Warner, Executive Director of the Institute for Professional Development in the Addictions (IPDA) at the time of the study, for their contributions to survey development and data collection.
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Timothy P. Janikowski
University at Buffalo--SUNY
James P. Donnelly
University at Buffalo--SUNY
Jenifer C. Lawrence
University at Buffalo--SUNY
Timothy P. Janikowski, 409 Baldy Hall, University at Buffalo, Buffalo, NY 14260.
Table 1. Characteristics of Programs and Staff Members Program & Staff Characteristics Min Max M (SD) Mdn Number of Staff Total 4 200 19.3 (29.1) 13 Full-time 2 125 12.6 18.0) 8 Part-time 1 80 5.4 10.1) 3 Degrees of Staff Doctorate 1 6 1.8 1.1) 1 Masters 1 32 4.9 (5.4) 4 Bachelors 1 39 4.7 (6.1) 3 Associates 1 25 3.3 (4.2) 2 High School 1 83 7.5 (14.5) 3 Certification/Licensure 0 50 6.7 (7.2) 4 Number of treatment supervisors Full-time 1 29 2.7 (3.4) 2 Part-time 1 1 1.0 (0.0) 1 Number of specialists in vocational 0 14 2.2 (2.2) 2 rehabilitation Maximum # of clients served at one 11 1350 189.8 (209.4) time 116.5 Total # of clients served in the 4 6400 536.4 (873.6) 251 last calendar year Average length of stay Inpatient (days) 14 496 240 (108) 260 Outpatient (weeks) 6 180 34.1 (32.0) 26 Table 2 Impact of Client Functional Limitations on Progress toward Overall Treatment and Vocational/Educational Goals Functional Limitation Overall Vocational/Educational Treatment M(SD) M(SD) Mobility 1.6 (.67) 2.1 (1.16) Communication 2.0 (.77) 2.4 (1.18) Atypical Appearance 1.5 (.63) 2.0 (1.18) Invisible Limitation 2.0 (.79) 2.4 (1.10) Restricted Environment 1.6 (.83) 2.0 (1.26) Pain 2.2 (.78) 2.5 (1.10) Consciousness 2.1 (.99) 2.5 (1.33) Uncertain Prognosis 2.3 (.80) 2.7 (1.16) Debilitation 2.0 (.75) 2.4 (1.25) Coordination 1.9 (.90) 2.3 (1.40) All 1.8 (.46) 2.3 (.94) Functional Limitation t(p) Mobility 5.17 [much less than] 001) Communication 5.12 (<. 001) Atypical Appearance 4.16 [much less than] .001) Invisible Limitation 3.77 (<. 001) Restricted Environment 3.09 (.003) Pain 2.57 (.012) Consciousness 4.07 [much less than] .001) Uncertain Prognosis 3.85 [much less than] .001) Debilitation 4.18 (<. 001) Coordination 3.57 (.001) All 4.21 [much less than] 001) Note. 1=No Interference, 4=Severe Interference Table 3 Percentages Program Directors Responses to Client Functional Limitations Problem Response 1 Response 2 Response 3 Response 4 5 (%) (%) (%) (%) Mobility 30 3 60 1 Communication 32 6 57 2 Atypical 30 1 57 7 appearance Invisible 39 2 52 5 limitation Restricted 37 7 37 10 environment Pain 40 3 50 5 Consciousness 41 8 41 8 Uncertain 36 7 46 6 Prognosis Debilitation 32 0 56 7 Coordination 35 7 43 11 Problem Response 5 (%) Mobility 5 Communication 3 Atypical 6 appearance Invisible 2 limitation Restricted 10 environment Pain 2 Consciousness 2 Uncertain 4 Prognosis Debilitation 6 Coordination 4 Note. Response 1 =Refer the client to another provider while continuing treatment Response 2= Refer the client to another provider while postponing treatment Response 3=Make accommodations or restructure how treatment is delivered Response 4=No referrals or accommodations are possible and deliver treatment in the standard manner Response 5=Other (describe)
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|Author:||Janikowski, Timothy P.; Donnelly, James P.; Lawrence, Jenifer C.|
|Publication:||The Journal of Rehabilitation|
|Date:||Oct 1, 2007|
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