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Quick Guide
For Administrators

Based on TIP 29
Substance Use Disorder
Treatment for People With
Physical and Cognitive
Disabilities

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Contents
Why a Quick Guide?  . . . . . . . . . . . . . . . . . . . 2
What is a TIP?  . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . 4
An Overview of the Americans With 
Disabilities Act (ADA)  . . . . . . . . . . . . . . . . . . .6
Attitudinal Barriers   . . . . . . . . . . . . . . . . . . 10
Discriminatory Policies, Practices, and
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 13
Communication Barriers  . . . . . . . . . . . . . . 20
Architectural Barriers  . . . . . . . . . . . . . . . . . 27
Funding Considerations  . . . . . . . . . . . . . . 35
Information Resources  . . . . . . . . . . . . . . . 38

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Quick Guide
For Administrators



This Quick Guide is based almost entirely on information contained
in TIP 29, published in 1998 and based on information updated
through October 1997. No additional research has been conducted
to update this topic since publication of the original TIP.
Based on TIP 29
Substance Use Disorder
Treatment for People With
Physical and Cognitive
Disabilities

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2
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities

WHY A QUICK GUIDE?

This Quick Guide was developed to accompany
Substance Use Disorder Treatment for People
With Physical and Cognitive Disabilities, Number
29 in the Treatment Improvement Protocol (TIP)
Series published by the Center for Substance
Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration. This Quick
Guide is based entirely on TIP 29 and is designed
to meet the needs of the busy administrator for
concise, easily accessed how-to information.

The Guide is divided into nine sections (see
Contents). These sections will help readers quickly
locate relevant material. The Resources section
on page 39 provides information on organizations
that can assist programs that offer services to
persons with disabilities. 

For more information on the topics in this Quick
Guide, readers are referred to TIP 29.

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What is a TIP? 3

WHAT IS A TIP?

The TIP series has been in production since 1991.
This series provides the substance abuse treatment
and related fields with consensus-based, 
field-reviewed guidelines on substance abuse
treatment topics of vital current interest.

TIP 29, Substance Use Disorder Treatment for
People With Physical and Cognitive Disabilities

 Addresses concerns of a broad range of readers
including clinicians, social workers, medical
personnel, mental health workers, program
administrators, and policymakers
 Includes extensive research
 Lists numerous resources for further information
 Is a comprehensive reference on substance
abuse and people with disabilities
See the inside back cover for information on how
to order TIPs and other related products.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities

INTRODUCTION

Nearly one-sixth of all Americans have a disability
that limits their activity. Countless others have
disabilities (mostly cognitive in nature) that go
unrecognized and undiagnosed. The Americans
With Disabilities Act (ADA) was signed into law in
1990 to ensure equal access to all community
services and facilitiesincluding public and
private substance use treatment facilitiesfor
all people, regardless of any physical or mental
impairment they might have. 

The ADA defines a disability as a physical or mental
impairment that substantially limits one or more
major life activities or a record of such impair
ment. Major life activities are defined as essential
functions such as personal care tasks, manual
tasks, walking, seeing, hearing, speaking, breathing,
thinking, learning, and working.

This Quick Guide provides a brief overview of the
steps that substance abuse treatment program
administrators can take to ensure compliance
with the ADA, accrediting agencies, and regulations
regarding the care of persons with disabilities. 

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Introduction 5

Readers are encouraged to familiarize themselves
with TIP 29 for a more extensive discussion of
these issues, and to reference the Resources section
on page 39 to learn more about organizations 
that can assist substance abuse treatment programs
that seek to comply with ADA regulations.

Note: This Quick Guide discusses the ADA and
issues of funding as they relate to substance
abuse treatment programs. Thus, for the sake of
brevity, any use in this text of the terms program
or programs by themselves should be taken to
mean a public or private facility that offers substance
abuse treatment services.

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6
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities

AN OVERVIEW OF THE AMERICANS
WITH DISABILITIES ACT (ADA)

The ADA is a Federal law initiated and championed
by persons with disabilities. The ADA states that
accommodations must be made by society, not by
individuals with disabilities, to guarantee equal
opportunity in public and private sector services
and in employment.

The ADA is organized into five titles:

Title I: Employment
Employers with 15 or more employees must
ensure that their employment practices do 
not discriminate against qualified people with
disabilities. (In California and other States, State 
and local laws may expand disability rights, including
extending ADA protections to employees of companies
with fewer than 15 employees.) Title I provides
protection for job applicants and employees during
all phases of employment. Employers must also
reasonably accommodate the disabilities of qualified
applicants and employees, unless an undue hardship
would result.

Title II: State and Local Government Services
Requires that public programs and services be
made accessible to persons with disabilities.

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An Overview of the Americans With Disabilities Act 7

Mandates nondiscrimination on the basis of 
disability in policy, practice, and procedures.

Title III: Public Accommodations
Title III requires places of public accommodation
to be accessible to, and usable by, people with
disabilities. Places of public accommodation are
all private businesses and privately owned and
operated programs that offer goods and services
to the general public.

Substance abuse treatment programs operated by
private agencies (whether or not they receive
Federal, State, or local funding) are considered
places of public accommodation under the ADA
and are therefore subject to Title III requirements. 

Title IV: Telecommunication
Title IV has mandated the establishment of a
national network of telecommunication relay services
that is accessible to people with hearing or speech
disabilities. It also requires captioning of all federally
funded television public service announcements.

Title V: Nonretaliation, and Other Provisions
Title V explicitly prohibits retaliation against people
exercising their rights under the ADA. It sets forth
specific responsibilities for the adoption of
enforcement regulations by Federal agencies. 
It also includes a number of miscellaneous provisions.

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8
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


The Civil Rights Division of the U.S. Department of
Justice has provided the following overview of the
responsibilities of Title III entities. Under the ADA,
a privately operated substance abuse treatment
program must

 Provide services to people with disabilities in an 
integrated setting, unless separate or different
measures are necessary to ensure equal opportunity.
 Eliminate eligibility standards or rules that deny
individuals with disabilities an equal opportunity
to enjoy the activities, benefits, and services of
alcohol and drug programs.
 Make reasonable modifications in policies, practices,
and procedures that deny equal access to individuals
with disabilities, unless a fundamental alteration in
the nature of the program would result.
 Furnish auxiliary aids when necessary to ensure
effective communication, unless an undue burden
or fundamental alteration would result.
 Remove architectural and structural communication
barriers in existing facilities where readily
achievable.
 Provide alternative means of delivering services
when removal of barriers is not readily achievable.
 Provide equivalent transportation services 
and purchase accessible vehicles in certain 
circumstances. (If the program provides 

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An Overview of the Americans With Disabilities Act 9

transportation to its clients, equivalent accessible
transportation for clients with disabilities must be
provided.)
 Maintain accessible features of facilities and
equipment.
 Design and construct new facilities and, when
undertaking alterations, alter existing facilities
in accordance with the Americans With
Disabilities Act Accessibility Guidelines issued
by the Architectural and Transportation Barriers
Compliance Board and incorporated in the final
Department of Justice Title III regulation.
 These requirements have been categorized into
four fundamental groups of obstacles:
- Attitudinal barriers
- Discriminatory policies, practices, and 
procedures
- Communication barriers
- Architectural barriers

The following four sections will discuss how privately
operated substance abuse treatment programs can
take action to overcome these potential obstacles to
treating people with disabilities.

For more detailed information, see TIP 29, 
pp. 123125.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities

ATTITUDINAL BARRIERS

An attitudinal barrier can be defined as a way of
thinking or feeling that results in limiting the
potential of people with disabilities to function
independently within society and to be treatable
and recognized as wanting help with their 
substance abuse problems. 

Disability-Awareness Training
Staff training is key to overcoming attitudinal barriers.
Disability-awareness training should include efforts 
to ensure that staff members

 Overcome their fears and stereotyping of people
with disabilities 
 Learn the rights of people with disabilities and
the responsibilities of substance abuse treatment
programs under the ADA
 Develop skills and resources to provide equally
effective services to people with disabilities
People with disabilities who are familiar with the
ADA and substance abuse treatment can provide
the best initial training for program staff. A local
independent living center should be an excellent
resource for meeting persons with disabilities who
can provide assistance.

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Attitudinal Barriers 11

It is crucial that providers who attend disability
awareness training have the opportunity to meet
and ask questions of people with a wide variety of
disabilities, especially people with disabilities who
are in recovery. Panel discussions often provide
the best opportunity for these dialogs and serve
as a possible springboard for further contact and
cooperation. Also, written materials are an invaluable
addition to any disability awareness training.

Seeking Out Clients With Disabilities
Not only is it the responsibility of substance abuse
treatment programs to seek out clients with disabilities,
but such actions are also a clear indication of a 
programs commitment to removing attitudinal barriers. 

The following actions have proven effective in creating
a client base of people with disabilities:

 Institute an ongoing campaign to publicize your
program to people with disabilities.
 Also include advocacy groups for parents of children
with disabilities, and advocacy organizations for 
people with specific disabilities, such as arthritis,
cerebral palsy, multiple sclerosis, muscular 
dystrophy, and vision and hearing disabilities. Dont
forget your local mental health association, or local
veterans and seniors groups.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


 Establish links with organizations in your 
community that provide advocacy and services 
to people with disabilities, such as independent
living centers. Invite their representatives to 
speak at staff meetings and send your staff 
to speak at their events.
 Actively seek qualified persons with disabilities
when searching for advisory board members.
 Actively seek qualified persons with disabilities
when hiring new staff members.
 Develop prevention and treatment services that
target specific populations of persons with 
disabilities. Consider providing initial information or
counseling services in disability-specific settings.

For more detailed information, see TIP 29, 
pp. 125128.

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Discriminatory Policies, Practices, and Procedures 13

DISCRIMINATORY POLICIES, 
PRACTICES, AND PROCEDURES

The ADA requires that privately operated substance
abuse treatment programs make reasonable 
modifications to policies, practices, or procedures to
ensure equal opportunity and avoid discrimination
against people with disabilities. 

Reasonable modification means any modification
that does not fundamentally alter the nature of
the services provided. Clients should be consulted
as to the modifications they need to successfully
participate in the program. An administrative
review should be performed by the program director
or another individual who is thoroughly familiar
with the program and has the authority to effect
policy changes.

Programs may require that people with disabilities
meet essential eligibility criteria in order to participate
in programs and services, and they may refuse
services to individuals with disabilities who cannot
meet these admission requirements. Programs
must, however, demonstrate that these requirements
are essential and that no person with a disability
is unnecessarily excluded or limited from participation
in programs and services. 

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14
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


Essential requirements are those that are fundamental
to the nature of a program or activity. For example: A
program cannot require that clients present a valid 
drivers license in order to receive services because the
ability to drive is not essential to recovery. Other forms
of identification, such as a social security card or 
birth certificate, should be accepted in lieu of a 
drivers license.

Admissions 
Discriminating against people with disabilities
often occurs during first contact. An important
first step is to review your admissions procedures.
These include recruitment, referral, screening,
and intake of clients with disabilities; everything
that occurs prior to receipt of services or participation
in the program.

 Programs may not refuse to admit people solely
based upon disability. Blanket policies, practices,
and procedures that prohibit the participation of
people with disabilities or place quotas upon the
number of such individuals who can be admitted
are discriminatory.
 Programs should not presume that an individual
or class of individuals with a disability can or
cannot participate in any aspect of a program. 
 An important step in ensuring nondiscrimination
is to establish procedures by which each individual

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Discriminatory Policies, Practices, and Procedures 15

is evaluated based upon his or her unique
needs and abilities.
 Even if architectural or communications barriers
seemingly prevent program access for people
with certain disabilities, a program must give
each individual with a disability an opportunity
to determine for him- or herself whether he or
she can function within the programs constraints.
 If architectural, financial, or other constraints
limit the number of people with disabilities that
a program can serve at any given time, the program
must make every effort to ensure that individuals
with disabilities are provided with other options
for services such as a referral to a comparable
program. The individual with a disability should
be apprised of all options and his or her preference
for placement must be given primary consideration.
 The Department of Justice does not consider it
discriminatory for a program with a specialty in
a particular area to refer an individual with a
disability to a different program if 1) the individual
is seeking a service or treatment outside the
referring programs area of expertise; and 2) 
the program would make a similar referral for
an individual who does not have a disability.
 The ADA does not prohibit the establishment of
target programs to serve communities of persons
with disabilities, such as a residential treatment

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16
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


facility for persons who are deaf. Nevertheless,
the existence of special programs does not
relieve substance abuse treatment programs of
their obligation to provide reasonable modifications
and auxiliary aids and services to individuals
choosing to participate in the regular program.
Disabilities That Pose a Direct Threat to the
Health and Safety of Others 
A program may deny participation in activities to a
person based upon disability when the individuals
disability legitimately presents a direct threat to the
health or safety of others, and cannot be eliminated
or reduced to an acceptable level by reasonable
changes. The program must establish that the 
perceived threat is real and not based upon
preconceptions or unwarranted fears about the
individuals disability. Assessments must consider
both the particular activity and the actual abilities
and disabilities of the individual.

The Department of Justice indicates that a direct
threat assessment must be based on reasonable
judgment that relies on current medical evidence,
or on the best available objective evidence, to
determine

 The nature, duration, and severity of the risk
 The probability that a potential injury will actually
occur

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Discriminatory Policies, Practices, and Procedures 17

 Whether reasonable modifications of policies,
practices, or procedures will mitigate or eliminate
the risk
Inquiries Regarding Disability
Inquiries regarding disability made prior to acceptance
into a program are generally unnecessary and
should not be made. Once a person has been
accepted into the program, necessary inquiries
can be made regarding special accommodations
that an individual may need. Application forms,
consent forms, and other documents where such
inquiries are made should be reviewed and
revised accordingly.

Necessary inquiries include questions asked to
provide program modifications, auxiliary aids and
services, health care, or emergency services to
the client, questions asked to assess the clients
conformance with legitimate health and safety
requirements, and questions asked for some
other essential purpose. 

Unnecessary inquiries include those asked to
screen out the participation of people with disabilities,
to satisfy ones curiosity, or to discriminate in the
provision of treatment, health care, emergency
services, etc. 

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18
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


While programs cannot require that clients disclose
information about disability, they may give clients
an opportunity to voluntarily provide such information.
This is especially true if the intention is to use
such information in order to accommodate the
client. Moreover, programs should have a written
policy and procedure in place to ensure that
records pertaining to a clients disability are kept
confidential and not used in a discriminatory fashion.

Costs of Personal Equipment and 
Attendant Services 
ADA compliance measures may result in an additional
cost for serving clients with disabilities. Programs
may raise the fee for all clients, but they may not
place a surcharge on particular individuals with
disabilities or groups of individuals with disabilities
to cover these expenses. 

A public accommodation is not required to provide
equipment or services of a personal nature. These
would include wheelchairs, prescription eyeglasses,
hearing aids, or assistance in eating, toileting, and
dressing.

Service Animals for the Disabled 
Programs must allow a service animal (such as a
guide, hearing, or companion dog) to accompany
a person with a disability for all services except
when doing so would fundamentally alter the 

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Discriminatory Policies, Practices, and Procedures 19

particular activity or jeopardize the safe operation
of the program. It is the responsibility of the animals
owner to feed, walk, and care for the service animal
in any other way.

Protection From Retaliation or Coercion 
Programs may not take any retaliatory action
against persons who exercise their rights under
the ADA or individuals who assist others in exercising
their rights. This prohibits the suspension or 
termination of employees for advising persons
with disabilities of their right to reasonable 
modifications and auxiliary aids and services 
in the program.

For more detailed information, see TIP 29, 
pp. 128134. For samples of non-discriminatory
language that can be used in written policies, 
see TIP 29, pp. 146149.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities

COMMUNICATION BARRIERS

The ADA requires programs to ensure that 
communication with people with disabilities is as
effective as communications with others. This
includes outreach, education, prevention efforts,
intake interviews, group meetings, counseling 
sessions, telephone and mail communications,
and provision of medical services. Communication
barrier removal is especially important for people
with sensory and/or learning disabilities.

Auxiliary Aids and Services
In many cases, ensuring effective communication
entails the provision of auxiliary aids and services,
a wide range of practices and equipment that
allow people with disabilities to communicate and
access information. 

The type of auxiliary aid or service necessary will
vary in accordance with the nature and duration
of the communication and the individual persons
preference and ability to use a particular aid or
service.

 Examples for individuals who are deaf or 
hard of hearing include qualified interpreters, 
computer-aided transcription services, written
materials, assistive listening systems, telephones
compatible with hearing aids, closed caption

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Communication Barriers 21

decoders, telecommunications devices for deaf
persons (TDDs), and videotext displays.
 Examples for individuals with vision impairments
include qualified readers, taped texts, audio
recordings, Braille materials, large print materials,
and assistance in locating items.
 Examples for individuals with speech impairments
include TDDs, computer terminals, speech 
synthesizers, and communication boards.
Programs should be prepared to provide the
widest variety of auxiliary aids and services possible
to people with disabilities, at all phases of a
clients participation. The ADA suggests that individuals
with disabilities be given the opportunity to request
the auxiliary aids and services of their choice, and
that primary consideration be given to the choice
expressed by the individual.

Fundamental Alteration
The ADA does not require privately operated programs
to provide any auxiliary aids and services that
would fundamentally alter the nature of the program
and the services they offer or result in an undue
financial burden. A fundamental alteration is
defined by the Department of Justice as a modification
that is so significant that it alters the essential
nature of the goods, services, facilities, privileges,
advantages, or accommodations offered.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


For example: A program determines that it would
be an undue financial burden to provide professional
interpreting services for all aspects of services but
resolves to provide an interpreter for weekly counseling
sessions and all group meetings. Furthermore, the
program welcomes clients who are deaf to bring
friends or relatives to interpret for them and
makes a computer terminal available for typed
communications between the deaf client and 
program staff.

Sign-Language Interpreting Services 
A program must ensure that any interpreter it hires
or otherwise provides is qualified. There are a
number of sign languages used. The most common
methods of communication are American Sign
Language and signed English. 

A qualified interpreter is able to sign to the individual
who is deaf what is said by the hearing person, and
can voice to the hearing person what is signed by
the individual who is deaf. This communication must
be conveyed effectively, accurately, and impartially
through the use of any necessary specialized 
vocabulary, and in the type of sign language the
deaf person uses.

Telephone Communications 
If your program has frequent or extensive telephone
communications with clients and members 

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Communication Barriers 23

of the general public, a TDD makes telephone
communications accessible to individuals who are
deaf, hard-of-hearing, or speech impaired. A TDD
allows individuals to communicate over regular
telephone lines through text rather than voice. 

If you provide a separate TDD phone line, that
number should be listed wherever you advertise
the number for regular telephone service. The
Department of Justice advises that TDDs must 
be provided when customers, clients, patients, or
participants are permitted to make outgoing calls
on more than an incidental convenience basis.

Media Materials 
Communication barriers also appear when programs
attempt to send outreach materials to people with
disabilities. Alternative formats include but are not
limited to the following:

 Print materials may be made available to blind
or visually impaired individuals in audiotape,
large print, computer disk, Braille, or raised text
format.
 Print materials may be made available to people
with limited upper body use in computer disk
format.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


 Videotapes may be made available to deaf or
hard-of-hearing individuals in captioned format
(with subtitles).
 Audiotapes may be made available to deaf or
hard-of-hearing individuals in print format.
Programs should include the following in all outreach,
prevention, and other materials that they produce:

 A statement of the programs responsibilities
under the ADA and its commitment to provide
effective communication to people with disabilities
 A description of the accommodations and
resources that the program has available for
people with disabilities
Additional considerations

 No new or existing outreach, prevention, or
other materialswhether produced or distributed
by the programshould contain any discriminatory
language or representation of people with 
disabilities.
 When selecting or designing new materials, it is
recommended that programs make an effort to
incorporate positive representations of people
with disabilities. 
 An appropriate number of materials should
address issues specific to disability. For instance,
since over 15 percent of Californias population

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Communication Barriers 25

are people with disabilities, it is recommended
that at least 15 percent of a California-based
substance abuse treatment programs materials
address the needs of this population. 
 It may be an unwieldy task for a program to
review each of the materials that it currently 
distributes. As an alternative, programs may
choose to establish a procedure by which persons
can file a complaint if they find any material to
be discriminatory against people with disabilities.
Open Meetings and Other Public Events
The following are minimum guidelines for holding
an accessible meeting or other public event:

 Make invitations, flyers, and other announcements
available in alternative formats upon request.
 Include clip-and-return form and phone numbers
on announcements that allow persons with
disabilities to contact your program in advance
and request accommodations such as large-print
handouts or sign-language interpreter services.
 Hold public events at a wheelchair-accessible
location. At a minimum, these sites should have
wheelchair-accessible parking, entrances, travel
paths, seating, toilet facilities, and public phones.
 If possible, secure a sign language interpreter
for the event. Otherwise, provide notice in your

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


ads that a sign language interpreter will be
available if requested 72 hours in advance.
 If possible, make written handout materials
readily available in the following common 
alternative formats: large print, computer disk,
and audiocassette.
 Place refreshments and handout materials in
an accessible location.


For more detailed information, see TIP 29, 
pp. 134138.

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Architectural Barriers 27

ARCHITECTURAL BARRIERS

Under the ADA, privately operated programs
should remove architectural (or physical) barriers
to program areas in existing facilities where it is
readily achievable to do so. Readily achievable is
defined by the Department of Justice as easily
accomplishable and able to be carried out without
much difficulty or expense.

Both the landlord and the tenant have the full
responsibility for complying with all applicable ADA
Title III requirements. Title III allows that barriers
be removed slowly, over time, as it becomes readily
achievable to do so. 

Programs are obligated to evaluate their existing
resources and determine which barriers can be
removed. Such a survey should be performed by a
person who is thoroughly familiar with physical
access standards and the operation of substance
abuse treatment programs. The Department of
Justice also advises that the process include 
consultation with individuals with disabilities or
organizations representing them.

Because the California Department of Alcohol and
Drug Programs (DADP) has its own obligations
under the ADA and the Rehabilitation Act of 1973,
readers whose programs are based in California

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Substance Use Disorder Treatment for People With Physical and
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are encouraged to familiarize themselves with
their States specific guidelines. The Pacific
Research and Training Alliance (PRTA) in Oakland,
California can offer assistance in this area.

Defining Architectural Barriers
Architectural barriers are physical elements of a facility
that impede access by people with disabilities. Certain
architectural features, such as bathrooms and meeting
rooms, must be made accessible. The following are
additional examples of architectural barriers that may
require action:

 Impediments such as steps and curbs that prevent
access by people who use wheelchairs
 Telephones, drinking fountains, mirrors, and
paper towel dispensers mounted at a height
that makes them inaccessible to people using
wheelchairs 
 Conventional doorknobs and operating controls
that impede access by people who have limited
manual dexterity
 Deep-pile carpeting on floors and unpaved
exterior ground surfaces that are a barrier to
access by people who use wheelchairs and
other mobility aids 
 The location of temporary or movable structures,
such as furniture, equipment, and display racks

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Architectural Barriers 29

New Construction Versus Alteration 
The ADA establishes different standards for 
architectural barrier removal from existing facilities
than for facilities undergoing a new construction or
alteration project. In existing facilities where retrofitting
may be expensive, the requirement to provide access
is less stringent than it is in new construction and
alterations, where accessibility can be incorporated
in the initial stages of design and construction, 
often without a significant increase in cost. 

Removal That Is Readily Achievable
Determinations as to which barriers can be removed
without much difficulty or expense must be made 
on a case-by-case basis. The Department of Justices
regulation contains a list of examples of modifications
that may be readily achievable, such as the installation
of ramps, repositioning shelves and telephones,
widening doors and creating designated accessible
parking spaces.

Factors to consider

 The nature and cost of removal
 The overall financial resources of the site or
sites involved 
 The number of persons employed at the site 

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Substance Use Disorder Treatment for People With Physical and
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 Legitimate safety requirements necessary for
safe operation, including crime prevention
measures 
 Any other impact of the action on the operation
of the site
Priorities for Barrier Removal 
Because available resources may not be adequate
to remove all existing barriers, the regulation suggests
a way to determine which barriers should be mitigated
or eliminated first. These priorities are not mandatory:
Programs are free to exercise discretion in 
determining the most effective mix of barrier
removal measures to undertake in their facilities.

First Priority: Enable individuals with disabilities
to physically enter the facility. This priority recognizes
that providing physical access to a facility from
public sidewalks, public transportation, or parking
is generally preferable to any alternative arrangements
in terms of both business efficiency and the dignity
of individuals with disabilities.

Second Priority: Ensure access to those areas of
the facility where services are made available to
the clients. 

Third Priority: Provide access to restrooms 
(if restrooms are provided for clients). 

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Architectural Barriers 31

Fourth Priority: Remove any remaining barriers to
using the programs facility (for instance, by installing
visual alarms, adding Braille floor indicators to 
elevator panels, or lowering telephones).

Alternatives to Barrier Removal
When a program can demonstrate that the
removal of barriers is not readily achievable, the
program must make its services available through
alternative methods, if such methods are readily
achievable. 

Factors to consider

 When services are provided to an individual with
a disability through alternative methods because
a programs facility is inaccessible, the program
may not place a surcharge on the individual with 
a disability for the costs associated with the 
alternative methods.
 Security is a factor that may be considered when a
program determines if an alternative method of
delivering its services is readily achievable.
 The readily achievable obligation does not extend
to areas of a facility that are used exclusively by
employees as work areas. However, if one or more
employees have disabilities that need to be
accommodated through barrier removal, then 
barrier removal must be carried out unless it

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Substance Use Disorder Treatment for People With Physical and
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poses an undue hardship to the employer 
(as established by Title I of the ADA).
 Portable ramps are permitted only when the
installation of a permanent ramp is not readily
achievable. A portable ramp should have railings
and a firm, stable, non-slip surface, and should
also be properly secured. 
 The readily achievable standard does not
require barrier removal that would necessitate
extensive restructuring or burdensome expense.
However, the programmatic access standard
would require that program services be moved
to an accessible site when needed. Therefore,
small privately operated programs with limited
budgets generally would not be required to
remove a barrier to physical access posed by a
flight of steps, if removal would require extensive
ramping or an elevator.
 Privately operated programs are not required to
lease space that is accessible. However, upon
leasing, the barrier removal requirements for
existing facilities apply. In addition, any alterations
to the space must meet the accessibility
requirements for alterations.
ADA Requirements and Historic Buildings 
Barrier removal would not be considered readily
achievable if it would threaten or destroy the historic
significance of a building or facility that is eligible for

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Architectural Barriers 33

listing in the National Register of Historic Places
under the National Historic Preservation Act (16
U.S.C. 470, et seq.), or is designated as historic
under State or local law.

Maintaining Accessibility 
Privately operated programs must maintain in working
order equipment and features of facilities that are
required to provide ready access to individuals with
disabilities. 

Access routes must not be blocked by obstacles
such as furniture, filing cabinets, or potted plants.
Similarly, accessible doors must be unlocked
when the facility is open for business. 

Other instances to consider

 Placing a vending machine on the accessible
route to an accessible restroom would be violation
if it obstructed the route.
 Placing ornamental plants in an elevator lobby
may be a violation if they block the approach to
the elevator call buttons or obstruct access to
the elevator cars.
 Using an accessible route for storage of supplies
would also be a violation, if it made the route
too narrow or crowded to be accessible.

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Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


 An isolated instance of placement of an object
on an accessible route would not be a violation,
if the object is promptly removed.
Equipment Failure
Mechanical failures in equipment such as elevators
or automatic doors occur from time to time, but
the obligation to ensure that facilities are readily
accessible to and usable by individuals with 
disabilities would be violated if repairs were
not made promptly or if improper or inadequate
maintenance causes repeated and persistent 
failures. Inoperable or out of service equipment
does not meet the requirements for providing access.

For more detailed information, see TIP 29, 
pp. 139145.

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Funding Considerations 35

FUNDING CONSIDERATIONS

Treatment for people with coexisting disabilities
can add new complexities, as well as opportunities,
to the process of securing funding. While this is not
an area directly addressed by the ADA, it is still an
issue of vital importance to program administrators.

Sources of Funding
Services may acquire funding from a variety of
sources, including

 Federal block grants such as the Substance
Abuse Prevention and Treatment (SAPT) and the
Community Mental Health Services (CMHS)
Block Grants
 Medicaid, which includes options that allow
for non-medical services (e.g., the Medicaid
rehabilitation option)
 Medicare and Supplemental Security Income for
people with disabilities
 Health Resources and Services Administration
(HRSA) funds for migrant health, people with
HIV/AIDS, and Maternal and Child Care
 Private organizations
 Veterans services
 Developmental services 

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36
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


 Local tax dollars
 Private foundations, such as United Way
Blended Funding
To provide sufficient funding for the longer and more
complex supports that may be required for a person
with a coexisting disability, blended funding is highly
recommended. When several agencies have a 
mandate to provide care, as is the case for many
people with coexisting disabilities, each may have
access to funds for case management. Blending
funding can enable the coordinating team to create
a pool of funds sufficient to fund a single case 
manager at an acceptable level. 

Shared Costs
Programs might consider collaborating with 
rehabilitation and other providers to share resources.
For example, a program might carry educational 
and treatment services into a vocational rehabilitation
site. Carry-in services reduce the overall cost of 
separate programs and may, in certain cases, allow
for third-party payment for both providers. In these
cases, there is not a blending of funding, but rather
a sharing of costs and a potential for mutual billing.

Funding Under Managed Care
For people with coexisting disabilities, managed care
policies can pose a serious barrier to getting the level
of treatment they require. Examples of managed care

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Funding Considerations 37

policies or limitations that could adversely affect
clients include

 Lack of access to Health Maintenance
Organizations (HMOs) 
 Being placed on a waiting list by public HMOs 
 Loss of funding due to capitation policies when
treatment is required over a long time 
 Restrictions on needed ancillary medical or
physical care 
 Not being allowed to use accessible treatment
options 
Poor self-advocacy skills, often coupled with low
self-esteem, may impair a persons ability to
push the system in order to get needed care. A
case manager may have to either find strategies
to overcome the adverse effect the managed care
providers policies have on the client or seek to
change those policies through direct communication
with the managed care agency.

For more detailed information, see TIP 29, 
pp. 9294.

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38
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities

INFORMATION RESOURCES

Federal ADA Enforcement Agencies
Architectural and Transportation Barriers
Compliance Board: The Access Board
Suite 1000
1331 F Street, NW
Washington, DC 20004-1111
(800) USA-ABLE (voice)
(800) 993-2822 (TDD)
(202) 272-5434 (voice/TDD)
(202) 272-5447 (fax)
http://www.access-board.gov

Equal Employment Opportunity 
Commission (EEOC)
1801 L Street, NW
Washington, DC 20507
Complaints and Information
(800) 669-4000 (voice)
(800) 699-6820 (TDD)
Documents/Public Information Center
(800) 669-3362 (voice) 
(800) 800-3302 (TDD)
(513) 791-2954 (fax)
(800) 669-4000 (referral to regional offices)
http://www.eeoc.gov

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Information Resources 39

Department of Justice (DOJ)
Civil Rights Division
Disability Rights Section
P.O. Box 66738
Washington, DC 20035-6738
(800) 514-0301 (voice)
(202) 514-0301 (voice) 
(800) 514-0383 (TDD)
(202) 307-1198 (fax)
http://www.usdoj.gov/crt/ada/adahom1.htm

Federal and Federally Funded ADA Technical
Assistance Agencies 
Administration of Developmental Disabilities
370 L'Enfant Promenade, SW
Washington, DC 20447
(202) 690-6590

Clearinghouse on Disability Information
OSERS/U.S. Department of Education
Room 3132, Switzer Building
400 Maryland Avenue, SW
Washington, DC 20202-2524
(202) 205-8412 (voice)
(202) 732-1252 (fax)

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40
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


Library of Congress National Library Service for
the Blind and Physically Handicapped
1291 Taylor Street, NW
Washington, DC 20542
(800) 424-9100
http://www.loc.gov/nls

MRI/Penn Research and Training Center 
on Vocational Rehabilitation for Persons 
with Mental Illness
Matrix Research Institute
University of Pennsylvania Department 
of Psychiatry
6008 Wayne Avenue
Philadelphia, PA 19144
(215) 438-8200
http://www.matrixresearch.org/index2.html

National Institute on Disability and Rehabilitation
Research
U.S. Department of Education
Room 3060
400 Maryland Avenue, SW
Washington, D.C. 20202
http://www.ed.gov/offices/OSERS/NIDRR

-----------------------------------------------
Information Resources 41

National Institute on Neurological Disorders 
and Stroke

Building 31, Room 8A06
31 Center Drive, MSC 2540
Bethesda, MD 20892-2540
(301) 496-5751 (voice)
(800) 325-9424 (voice)
(301) 402-2186 (fax)
http://www.ninds.nih.gov
National Research and Training Center on
Psychiatric Disability
University of IllinoisChicago

Suite 900
104 South Michigan Avenue
Chicago, IL 60603-5901
(312) 422-8180
http://www.psych.uic.edu/uicnrt

Presidents Committee on Employment of People
With Disabilities
3rd floor
1331 F Street, NW
Washington, DC 20004-1107
(202) 376-6200 (voice)
(202) 376-6205 (TDD)
(202) 376-6219 (fax)
http://www.dol.gov/dol/odep

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42
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


Rehabilitation Research and Training Center for
Persons Who Are Deaf or Hard of Hearing
University of Arkansas
4601 West Markham Street
Little Rock, AR 72205
(501) 686-9691
http://www.uark.edu/depts/rehabres/ 

Rehabilitation Research and Training Center on
Blindness and Low Vision
Mississippi State University
P.O. Drawer 6189
Mississippi State, MS 39762
(601) 325-2001
http://www.msstate.edu/dept/rrtc/blind.html
Rehabilitation Services Administration
U.S. Department of Education
Switzer Building
330 C Street, SW
Washington, D.C. 20202-2500
(202) 205-54654
http://www.ed.gov/offices/OSERS/RSA/

Research and Training Center in Rehabilitation for
Persons With Long-Term Mental Illness
Boston University/Sargent College
Center for Psychiatric Rehabilitation

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Information Resources 43

930 Commonwealth Avenue
Boston, MA 02215
(617) 353-3549
http://www.bu.edu/cpr
Research and Training Center on Community
Integration of Individuals With Traumatic Brain
Injury

Mount Sinai School of Medicine
One Gustave L. Levy Place, Box 1240
New York, NY 10029-6574
(212) 241-7917
http://www.mssm.edu/tbinet

Research and Training Center 
on Community Living
University of Minnesota
College of Education and Human Development
Institute on Community Integration
RTC on Residential Services and 
Community Living
150 Pillsbury Drive, SE
Minneapolis, MN 55455
(612) 624-5005
http://rtc.umn.edu

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44
Substance Use Disorder Treatment for People With Physical and
Cognitive Disabilities


Research and Training Center on Improving
Community-Based Rehabilitation Programs
University of WisconsinStout
College of Human Development
Stout Vocational Rehabilitation Institute
Menomonie, WI 54751
(715) 232-1219
http://www.rtc.uwstout.edu

Research and Training Center on Rural
Rehabilitation Services
University of Montana
Rural Institute on Disabilities
52 Corbin Hall
Missoula, MT 59812
(406) 243-5467
http://ruralinstitute.umt.edu/

Substance Abuse Resources for Persons
With Disabilities
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)
http://www.naadd.org/

-----------------------------------------------
Ordering Information
 TIP 29 Substance Use Disorder
   Treatment for People With
Physical and Cognitive Disabilities



TIP 29-Related Products
KAP Keys for Clinicians
based on TIP 29
Quick Guide for Clinicians
based on TIP 29

Do not reproduce or distribute this publication for a fee without 
specific, written authorization from the Office of Communications,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.



Easy Ways to Obtain Free Copies 
of All TIP Products
1. Call SAMHSAs National Clearinghouse for Alcohol
and Drug Information (NCADI) at 800-729-6686, 
TDD (hearing impaired) 800-487-4889
2. Visit CSATs Web site at www.csat.samhsa.gov

-----------------------------------------------
Other Treatment Improvement
Protocols (TIPs) that are relevant to
this Quick Guide:



See the inside back cover for ordering information for all
TIPs and related products.


DHHS Publication No. (SMA) 01-3592
Printed 2002
TIP 9, Assessment and Treatment of Patients
 With Coexisting Mental Illness and Alcohol 
and Other Drug Abuse (1994) BKD134
TIP 14, Developing State Outcomes Monitoring
 Systems for Alcohol and Other Drug Abuse
 Treatment (1995) BKD162

TIP 27, Comprehensive Case Management for
 Substance Abuse Treatment (1998) BKD251
TIP 37, Substance Abuse Treatment for Persons
 With HIV/AIDS (2000) BKD359
TIP 38, Integrating Substance Abuse Treatment
and Vocational Services (2000) BKD381