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III-4.3200                                   JUNE 30, 1994









The Honorable Jesse Helms
United States Senate
403 Dirksen Senate Office Building 
Washington, D.C.  20510-3301

Dear Senator Helms:

     This letter is in response to your inquiry on behalf of your
constituent, Katherine P. Hux, MPH, Executive Director of the
North Carolina Psychiatric Association.  Ms. Hux requested
clarification of the term "reasonable accommodation" as it is
applied in title III of the Americans with Disabilities Act
(ADA).  She further sought to clarify whether patients or
physicians make the determination of what constitutes a
"reasonable accommodation."

     Based upon the content and context of Ms. Hux' query, it
would appear that her concerns relate most directly to the
auxiliary aids and services provisions of title III.  Such aids
and services are measures that are undertaken to ensure effective
communication for individuals with impaired speech, hearing,
and/or vision, as well as those who are profoundly deaf.  The
auxiliary aids requirement is intended to be flexible, reflecting
the variable nature of what constitutes "effectiveness." 

     In addition to the specific nature of the disability
involved, factors used to determine communication effectiveness
in any given circumstance are most generally related to the
length, complexity, and significance of the information being
exchanged.  Appointments for psychotherapy sessions, due to the
sensitive nature of the information being exchanged, their
length, complexity, and potential long-term impact on the
patient's well-being would appear to require the highest level of
communication effectiveness possible.  Further discussion of this
point may be found on page 35567 of the enclosed title III
regulation.

     The psychiatrist should weigh other factors that would
minimize the degree of burden on the practice, such as the
ability to spread costs throughout the general client population
and the provision of tax credits for small businesses for costs
incurred to provide auxiliary aids.  Eligibility criteria for
this credit is found in publication 907, available from the
Internal Revenue Service.  This document will be a useful
resource for the Psychiatric Association's membership.  

     Under section 36.301(c) of the regulation, when an
interpreter or other auxiliary aid or service is required to
ensure effective communication, the physician or therapist must
absorb the cost for this aid or service.  The auxiliary aid
requirement does not require a physician or therapist to take any
action that would result in an undue burden.  The term "undue
burden" means "significant difficulty or expense."  In
determining whether the provision of an interpreter or other aids
or services would result in an undue burden, the therapist should
consider the overall financial resources of the practice, not
just the fees paid for a particular procedure or treatment
session.  

     Ms. Hux also addressed the issue of a patient who demanded
that the physician pay for the interpreter of his or her choice. 
The auxiliary aids provisions of the ADA do not compel the
physician to comply with the unilateral determination of the
patient that a particular interpreter, or any auxiliary aid is
essential to effective communication.  Ideally, the psychiatrist
and patient would arrive at a mutually acceptable choice through
the consultation process.  This specific point is illustrated in
the Department's Title III Technical Assistance Manual,
Supplement - January 1993 at page 5.  Additional relevant
information may be found in the preamble discussion of section
36.303 on pages 35567-35568 of the title III regulation.  These
documents are enclosed.

     I trust that this information will be helpful in your
response to your constituent.

                                   Sincerely,




                                Deval L. Patrick
                           Assistant Attorney General
                             Civil Rights Division

Enclosures