S u b s t a n c eAbuse Issuesafter Traumatic B r a i n I n j u r y

Living with Brain Injury

This brochure was

developed for

friends, family

members, and

caregivers of

persons with brain

injury. It also may

be used in

discussions with

health care

professionals and

others about the

problems one may

face when living

with brain injury.

Alcohol, Other Drugs and Brain Injury

John D. Corrigan, PhD, andGary L. Lamb-Hart, MDiv

The Ohio Valley Center for Brain InjuryPrevention and Rehabilitation

Department of Physical Medicineand Rehabilitation

The Ohio State University

Contents:

How much alcohol or other drugsis safe after brain injury?

How does alcohol or other drugsaffect a person who has had a brain injury?

How is the brain affected?

What about treatment for substance abuse after brain injury?

Are there treatment approaches that have been proven effective for people with brain injury?

How can substance abuseservices be adapted for people with brain injury?

What about AA or otherself-help approaches?

Internet Resources

Additional Information

18 Suggestions for Substance Abuse Treatment Providers Working With Clients Who HaveHad a Brain Injury21 The Nuts and Bolts of 12-Step Self Help Groups

About the Author’s

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How much alcohol or other drugs is safe after brain injury?

The answer to this question iscomplicated because some drugs areillegal and others are not; some drugs maybe prescribed by a physician.

Alcohol - because it is a legalsubstance for adults and is not prescribedby a physician - presents a more complexquestion. Our starting point is that certainlyno one should consume more alcohol afterbrain injury than would be considered safefor an adult who had not had an injury.Many people do not realize that adult menunder age 65 should not have more thantwo alcoholic drinks each day. For menover age 65 and for adult women, therecommended maximum is one drink perday.

So the question becomes afterbrain injury should an individual drink eventhese amounts? Based on informationabout how alcohol and brain injury addtogether to affect the brain and how itworks, we have concluded that there is nosafe amount to drink. We suspect thatespecially during the early period ofrecovery - the first several years when thebrain is attempting to spontaneously healand otherwise accommodate the injury -alcohol can inhibit these natural processes.

There are many reasons why it isnot safe to consume drugs that are illegal.There is a great risk for illegal drugs tointeract with prescribed medications tocreate additional medical problems. Illegaldrugs may cause complications of othermedical conditions. There is also thepotential for being arrested, and greatervulnerability to injury by being the victim ofviolence. And last (but certainly not least)there is the potential for additional brain

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damage from use of these uncontrolledsubstances.

Taking prescription drugs in greaterquantities than they are prescribed isanother form of drug abuse, and it too isnot advisable. Prescribed medications canbe as dangerous as illegal drugs when aperson takes more than the prescribedamount, or takes the prescribed amountmore frequently than indicated. Medicalcomplications and additional brain damagecan result from this kind of substanceabuse.

If you have had a brain injury youshould not drink alcohol,you shouldnot use illegal drugs, and youshould not take prescriptionmedications in greater quantity thanprescribed.

How does alcohol or other drugsaffect a person who has had a braininjury?

There are multiple reasons whyalcohol and other drug use after braininjury is not recommended. The "User'sManual for Faster, More Reliable Operationof a Brain after Injury" (Ohio Valley Center,1994; <www.ohiovalley.org>) describes 8reasons:

1. People who use alcohol or otherdrugs after they have a brain injurydon't recover as much.

Some brain cells (neurons) are killed andothers are disconnected at the time of abrain injury. Recovery means re-learningby making new connections betweenneurons. Using alcohol and other drugs

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after brain injury gets in the way of yourrecovery by interfering with newconnections between neurons.

2. Brain injuries cause problems inbalance, walking or talking that getworse when a person uses alcohol orother drugs.

For people whose brain injury causedproblems with balance, walking, or talking,alcohol and other drugs make the problemseven worse. Without brain injury, alcoholand other drugs can make people lose theirbalance or fall down. People who havebeen drinking or using other drugs may slurtheir speech. Problems walking and talkingcaused by your brain injury will beincreased by alcohol and other drugs.

3. People who have had a brain injuryoften say or do things without thinkingfirst, a problem that is made worse byusing alcohol and other drugs.

Every brain has a program called, "GoodIdea/Bad Idea." The program tells us whatis appropriate and what is not. Forexample, we may think to ourselves thatsomeone's sweater is really ugly, but"Good Idea/Bad Idea" keeps us fromsaying this out loud. For some people, abrain injury takes away the fine linebetween good ideas and bad ideas and"lets it all hang out." Alcohol can alsocause a person to say whatever comes tomind, no matter who it hurts. Alcoholtogether with a brain injury shuts off the"Good Idea/Bad Idea" program, and that'sa bad idea.

4. Brain injuries cause problems withthinking, like concentration or memory,

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and using alcohol or other drugs makesthese problems worse.

Many people have to learn new skills, orre-learn old ones, following a brain injury.People have trouble with concentration,memory, word finding, problem-solving andother thinking skills, depending on wherethe brain is injured. Alcohol and otherdrugs also interfere with the ability to thinkand learn new things. Adding alcohol andother drugs with your brain injury justmakes thinking that much harder.

5. After brain injury, alcohol and otherdrugs have a more powerful effect.

The brain is more sensitive to alcohol andother drugs after an injury. There are notas many neurons to absorb the alcohol orother drugs. No matter how much alcoholor other drugs a person was able to usebefore, it's less now. Also, alcoholinterferes with prescribed medications. Youget drunk faster and lose the good effect ofthe medicine.

6. People who have had a brain injuryare more likely to have times that theyfeel low or depressed and drinkingalcohol and getting high on other drugsmakes this worse.

Being depressed is fairly common after abrain injury. Sometimes it is the injury tothe brain that causes depression. It is alsothe change in a person's life that leads todepression. Everything is different-thereare financial worries, and there is boredom.Many people turn to using alcohol andother drugs to try to make this depressiongo away. They say it makes them lessworried, more relaxed and happier. That

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may be true, for a while, but it quicklymakes things worse. Alcohol depressesthe brain and that depresses you.

7. After a brain injury, drinking alcoholor using other drugs can cause aseizure.

Seizures are a problem for about 5% ofpeople who have a brain injury. Eventhough that is a low number, seizures areserious and steps need to be taken toavoid them. Some people require anti-seizure medication. Mixing alcohol andother drugs with these medications is verydangerous and can INCREASE the chanceof seizure. Taking yourself off medicationsto drink is DANGEROUS. Doubling up onanti-seizure medications to drink isDANGEROUS. Get the facts from yourdoctor, and then use your brain.

8. People who drink alcohol or useother drugs after a brain injury are morelikely to have another brain injury.

Among people who have had one braininjury, the chance of a second injury isthree times greater. Brain injuries maycause problems with balance, coordination,vision and judgment that lead to otherinjuries. By drinking alcohol or using otherdrugs after a brain injury, you are morelikely to have another injury. Also, witheach brain injury it takes less force tocause greater harm.

How is the brain affected?

There is mounting researchevidence about the bad effects of alcoholand other drug use after brain injury.

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Several studies have found use andassociated with such unwanted outcomesas unemployment, living alone and feelingisolated, criminal activity, and lower lifesatisfaction. While these studies haveobserved associations between substanceuse and negative outcomes, cause andeffect is not fully understood.

Brain injury does damage to yourbrain; abuse of alcohol or other drugs doestoo. There is research showing that whenbrain injury and substance abuse arecombined they have a worse effect on thebrain than either one has alone.

As an example, Ian Baguley andcolleagues from Australia (see graphbelow) studied the P300 wave in event-related evoked potentials--an indication ofhow fast the brain detects new information.Their research showed that either heavysocial drinking or previous traumatic braininjury requiring hospitalization slowed brainfunctioning, and when combined they hadan "additive effect." An additive effectmeans that both together (heavy socialdrinking and previous brain injury) wereworse than either one alone.

From Baguley, I. J., Felmingham, K. L., Lahz,S., Gordan, E., Lazzaro, I., & Schotte, D. E.(1997). Alcohol abuse and traumatic braininjury: Effect on event-related potentials.Archives of Physical Medicine andRehabilitation, 78 (11), 1248-1253.

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P300 Amplitude

16141210

86420

Controls Alcohol TBI TBI+Alcohol

In this graph based on Baguely andcolleagues study, the higher the bar, thefaster the research participants respondedto new information. Those subjects whowere either heavy social drinkers or hadbeen hospitalized for a traumatic braininjury were slower responding then peoplewith neither; and those with both wereslower than those who had just one of theconditions.

The effects of alcohol and otherdrugs are different for people who havehad a brain injury. It is important to get thefacts about how alcohol and other drugsaffect the brain. When your review the datait becomes clear that there is no amount ofalcohol or other drugs that is safe forpeople who have had brain injuries.

What about treatment for substance abuse after brain injury?

Many people benefit fromprofessional help when their drinking orother drug use is too much and is creatingproblems for them. One sign that a personcould use some assistance is when theyhave tried to cut down on their own, butsomehow the problem continues. Anothersign is when people who care about aperson begin worrying that he or she isdrinking to much. Finally, if a persons isfacing legal or medical problems-includinghaving another injury- it is advisable toseek help.

In substance abuse treatment,perhaps the most well known andfrequently used theory is the Stages ofChange model developed by JamesProchaska and Carlos DiClemente. Thismodel describes how ready a person is toaddress problems related to their alcohol or

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other drug use. Stages start withprecontemplation (a person sees noproblem when there is one), and includecontemplation (weighing the pros and consof changing), determination (deciding tochange), action (making a specific plan forchange), and maintenance (sustainingsuccessful change despite urges to useagain). Substance abuse counselorsusually tailor treatment to a person's Stageof Change. Regardless a person'sreadiness to address an alcohol or otherdrug use problem, there is alwayssomething a professional substanceabuse counselor or treatment programcan provide.

Are there treatment approachesthat have been proven effective forpeople with brain injury?

There has not been very muchresearch about what substance abusetreatment methods do or do not work forpeople who have had brain injuries. Mostclinicians feel that techniques foundeffective for people in general can also beeffective for people who have had braininjuries; however, sometimes specialconsiderations or accommodations may beneeded to make the treatment useful andeffective. Following are brief descriptionsof common treatment approaches foralcohol and other drug abuse.

Motivational Interventions havebeen used to help individuals becomeready to participate in treatment. Researchin the substance abuse field hasdemonstrated that motivationalenhancement techniques are associatedwith greater participation in substanceabuse treatment and positive treatment

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outcomes. Motivational enhancementtechniques must be matched to a person'sStages of Change. Motivationalinterventions seem like a promisingapproach to facilitating positive change forpeople with substance abuse problems andbrain injuries, though like most therapeuticapproaches it needs to be adapted to theindividual's ability for insight and self-management.

Cognitive-Behavioral Therapyuses cognitive and/or behavioral strategiesto identify and replace an individual'sirrational beliefs that arise from substanceabuse (e.g., "the only time I feelcomfortable is when I'm high") with rationalbeliefs (e.g., "it's hard to learn to becomfortable socially without doing drugsbut people do it all the time"). Cognitive-Behavioral Therapy can be conducted aspart of individual or group treatment.Whether or not someone has had a braininjury, Cognitive-Behavioral Therapies needto be adapted to a person's capability forunderstanding the connections betweenbeliefs and feelings.

Sometimes substance abusetreatment needs to take place in anenvironment where there is 24-hour perday supervision and treatment. One of themost common residential treatmentapproaches is the TherapeuticCommunity, or "TC". TC has been usedto address the needs of people withsubstance use disorders for more than 30years and its methods and effectivenesshave been well-documented. TC viewssubstance abuse as a problem of conduct,attitudes, moods, values, and emotionalmanagement. The approach focuses oncreating a community, including otherpeople addressing these problems, thatpromotes self-evaluation and recovery. For

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persons who have had brain injuries, theTC approach may need to be adapted toallow increased flexibility, decreasedintensity, and greater individualization.

When it comes to the use ofprescription medications for the treatmentof substance abuse, there are not a lot ofchoices. Foremost among addiction-related medications is methadone for thetreatment of heroin and other opioidaddiction. Methadone cannot be dispensedoutside designated methadone treatmentprograms. A new drug, buprenorphine, isavailable for the treatment of opioid abuseand dependence when prescribed andmonitored by a certified physician. In ourclinical work we have seen that prescriptionmedications for depression or anxietyare sometimes important for getting startedon changing alcohol or other drug abuse.Another medication, disulfiram or antibuse,is a well-established medication used todiscourage alcohol consumption. However,its use by individuals with brain injuries isgenerally discouraged. Naltrexone hasbeen used to reduce a person's cravingsfor alcohol, but there is no research on itseffectiveness for people who have hadbrain injuries.

Substance abuse treatment oftenincludes both the individual and family orfriends. The greater a person's cognitiveimpairments after brain injury, the moreimportant it becomes that people in his orher surroundings are willing to be involvedin the treatment process. Similarly, forpeople who do not see themselves ashaving a problem (those who areprecontemplative), it is more important thatfamily and friends be willing to joinprofessionals to get a person startedaddressing their substance use.

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How can substance abuse servicesbe adapted for people with braininjury?

There should be a very high priorityplaced on research about the effectivenessof current substance abuse treatments forpersons with brain injury. However, untilmore is known, current treatments andservices need to be adapted toaccommodate disability arising from braininjury.

When a person with a brain injuryseeks help for a substance abuse problem,significant barriers to treatment may beencountered. The individual, family orfriends may need to advocate for the rightto appropriate treatment:

Too many publicly funded substance abuse programs still have physical facilities that prevent or limit accessibility for individuals who use a wheelchair. This is against the law for publicly funded agencies. They should be asked tomake services accessible in the same way everyone else receives them.

Admission criteria may discriminate against individuals withbrain injuries, out right or indirectly.For instance, requiring abstinence from all mood-altering substances including prescribed medications prevents some individuals from receiving services. This is not appropriate.

If a person with a brain injury is ableto get through the front door, literally andfiguratively, a new set of barriers often arisethat come from the cognitive impairmentsand unique learning styles common after

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brain injury. Professionals at the OhioValley Center for Brain Injury Preventionand Rehabilitation at Ohio State Universityhave made a number of recommendationsfor working collaboratively with substanceabuse treatment professionals. Theserecommendations assume that acollaborative relationship can be developedwith the individual provider that allows forexchange of ideas and information withoutanyone becoming defensive. Establishingsuch a relationship is by no means a given,but it is the cornerstone for long-termsuccess in treatment.

Below are recommendations that anindividual, family member or friend mightmake to a substance abuse treatmentprovider who is inexperienced in workingwith people with brain injuries. Theserecommendations cover identification ofunique issues, adaptive or compensatorystrategies based on the individual's ownlearning style, provision of feedbackregarding inappropriate behavior, andcautions regarding jumping to a conclusionabout a person's motivation. Theserecommendations are also summarized atthe end of this brochure in "Suggestions forSubstance Abuse Treatment ProvidersWorking With Clients Who Have Had aBrain Injury."

The substance abuse provider should determine a person's uniquecommunication and learning styles.

A substance abuse provider'ssuccess in working with an individual withunique cognitive abilities will rely heavily ontheir ability to identify strengths andweaknesses. We have had our greatestsuccess by avoiding neuropsychologicaljargon and focusing the provider's attention

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on basic issues of communication andlearning. Understanding that a particularindividual learns better with written, oral orvisual input. When expression is an issue,often it is a simple matter of givingproviders permission to ask questions sothat they can learn to work more effectivelywith an augmented communication deviceor understand dysarthric speech.

With regard to learning style,simplifying the concepts of attention andlearning can be very useful. In particularwe find it important that the providerunderstand the issues of shortenedattention span (including the interactionwith fatigue), as well as the impact ofenvironmental stimuli on attention(particularly how noisy or busy locationscan affect attention). With regard to newlearning, distinctions between languageand non-language styles are important, asis understanding memory impairmentswhen the exist. It is important tounderstand how attention affects both initialcomprehension and later recall.

The substance abuse provider should assist the individual to compensate for a unique learning style.

Substance abuse treatmentprograms have come to rely heavily on theuse of groups for educational, not justexperiential, purposes. Manycompensatory strategies applicable toclassroom settings are appropriate insubstance abuse treatment, as well.Simple strategies like using writtenreminders for cueing recall, or schedules tostructure time are not standard in manyprograms (though all clients would probably

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benefit). The use of groups also reducesindividual attention, which may limit one-on-one opportunities to mediate thetreatment experience. In programs that usean Alcoholics Anonymous (AA) treatmentapproach, materials that have beenmodified to include greater visual cues aswell as less abstract reasoning areavailable.

The substance abuse provider should provide direct feedback regarding inappropriate behaviors.

For some individuals with cognitiveimpairments there also may be problemswith inappropriate social behavior. In ourexperience, this behavior can be the mostchallenging for substance abuse treatmentprograms. Providers are often caught offguard by impulsive behavior, disinhibitedexpression of emotions, or intrusion onpersonal space. Consequently, they areusually ineffective in dealing with thesebehaviors, as well. Again, a minimalamount of instruction and permission tointervene can go a long way toward makingthe substance abuse treatment providermore comfortable with sociallyinappropriate behavior. We have alsofound that advanced structuring so thatsomething has been said about thebehavior before its first occurrence buildsboth trust and confidence.

The substance abuse provider should be cautious when making inferences about motivation based on observed behaviors.

Perhaps the most destructive factorundermining access to treatment forpersons with brain injury is a tendency for

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substance abuse treatment providers toconclude a person is not motivated whenthe behaviors are really a result ofcognitive impairments. For instance, theleader of a group asks a question to whicheach member is to respond. When it is theopportunity for individuals with memoryproblems to respond, they have nothing toadd. Group leaders think this is resistance;however, upon inquiry, individuals reportthat what they wanted to say when thequestion was first posed had beenforgotten by the time it comes their turn tospeak. Perhaps most frequent is thetendency for substance abuse providers toinfer that missed appointments or latearrival are signs of resistance to treatmentor denial of one's substance abuseproblem. There can be many reasons whyan individual with a brain injury might missan appointment or be late, includingresistance to treatment and denial. Poorplanning, poor memory, difficultiesarranging or handling transportation needto be considered as alternative hypothesesbefore the counselor jumps to theconclusion that the missed appointment issomehow related to motivation.

The relationship that is establishedbetween a client and a substance abusecounselor is the single most importantfactor for successful treatment of alcoholand other drug problems. This relationshipis often called the therapeutic alliance. Youwill know you are developing a therapeuticalliance if after meeting with your counselora few times you feel like he or she listensand understands you, has confidence inyou and your ability to change, and issomeone you can trust. The need for apositive therapeutic alliance is especiallycritical for individuals with both a traumatic

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brain injury and a substance abuseproblem.

What about AA or other self-help approaches?

Professional treatment sometimeshas natural limits and continuing carebeyond formal treatment is critical toachieving a long-term, satisfactory outcomefor individuals affected by substance usedisorders. Self-help or peer supportprograms can be an important interventionand an easily available source ofcontinuing care. Self-help approachesbegan with Alcoholics Anonymous, or"AA", and have grown to address a widevariety of addictions. Rational Recoveryand Moderation Management are twoother self-help approaches for alcoholproblems. Narcotics Anonymous (NA)and Cocaine Anonymous (CA), bothbased on AA, are two of the largest self-help organizations addressing illegal druguse.

AA, NA and CA use the "12-step"method, with its focus on developingpersonal responsibility within the context ofpeer support. AA, NA, or CA groups arenot for everyone at all stages of recovery.For those still at a point that they areresistant to exploring their use ofsubstances as problematic, the introductionof AA/NA/CA may be too early andcounterproductive. Forcing a self-helpgroup on a person who is precontemplativemay create greater resistance later in theprocess of recovery when AA/NA/CA couldbe very helpful. A person may find supportin other areas of their life that are asproductive as AA/NA/CA, and it may bebetter to cultivate these natural supports.

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However, we have always found thatpeople who participated in self-help groupsbefore their injury can be more open toinvolvement after.

When attendance at AA, NA or CAgroups are being considered there is acertain amount of planning that needs totake place. We think it is important toaccompany a person who has had braininjury and has never attended self-helpgroups to the first few meetings. Havingsomeone to share the initial experiencewith, and talk about it afterward, can makethe difference between dropping out orstaying with the group. We have alsofound that it is very useful to becomefamiliar with the nuts and bolts of self-helpgroups before attending. It is useful to beable to anticipate what will happen at ameeting. Included at the end of thisbrochure is a description of the "Nuts andBolts of Using Self-Help Groups." Wesuggest looking this over before attendinga meeting.

Internet Resources

GeneralSubstance Abuse and Mental Health

Services Administration<www.samhsa.gov>

National Institute on Alcohol Abuse andAlcoholism <www.niaaa.nih.gov>

National Institute on Drug Abuse<www.nida.nih.gov>

Alcohol Screening<www.alcoholscreening.org>

Treatment ApproachesCognitive Behavior Therapy

<www.nacbt.org>Motivational Interviewing

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<www.motivationalinterview.org/clinical/overview.html>

Therapeutic Communities of America<www.tcanet.org>

TBI and Substance AbuseOhio Valley Center for Brain Injury

Prevention and Rehabilitation<www.ohiovalley.org>

SynapShots (section on SubstanceAbuse) <www.SynapShots.org>

Self-Help GroupsAlcoholics Anonymous <www.alcoholics-

anonymous.org>Cocaine Anonymous <www.ca.org>Moderation Management

<www.moderation.org>Narcotics Anonymous <www.na.org>Rational Recovery <www.rational.org>

Additional Information

Suggestions for Substance AbuseTreatment Providers WorkingWith Clients Who Have Had a BrainInjury

The substance abuse treatment providershould determine a person's uniquecommunication and learning styles.

Ask how well the person reads and writes; or evaluate via samples.

Evaluate whether the individual is able to comprehend both written and spoken language.

If someone is not able to speak (or speak easily), inquire as to alternate methods of expression (e.g., writing or gestures).

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Both ask about and observe a person's attention span; be attuned to whether attention seems to change in busy versus quiet environments.

Both ask about and observe a person's capacity for new learning; inquire as to strengths and weaknesses or seek consultation todetermine optimum approaches.

The substance abuse treatment provider should assist the individual tocompensate for a unique learning style.

Modify written material to make it concise and to the point.

Paraphrase concepts, use concrete examples, incorporate visual aids, or otherwise present an idea in more than one way.

If it helps, allow the individual to take notes or at least write down key points for later review and recall.

Encourage the use of a calendar or planner; if the treatment program includes a daily schedule, make sure a "pocket version" is kept for easy reference.

Make sure homework assignments are written down.

After group sessions, meet individually to review main points.

Provide assistance with homeworkor worksheets; allow more time and take into account reading or writing abilities.

Enlist family, friends or other service providers to reinforce goals.

Do not take for granted that something learned in one situation will be generalized to another.

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Repeat, review, rehearse, repeat, review, rehearse.

The substance abuse provider treatment should provide directfeedback regarding inappropriatebehaviors.

Let a person know a behavior is inappropriate; do not assume the individual knows and is choosing to do so anyway.

Provide straightforward feedback about when and where behaviors are appropriate.

Redirect tangential or excessive speech, including a predetermined method of signals for use in groups.

The substance abuse treatment providershould be cautious when makinginferences about motivation based onobserved behaviors.

Do not presume that non-compliance arises from lack of motivation or resistance, check it out.

Be aware that unawareness of deficits can arise as a result of specific damage to the brain and may not always be due to denial.

Confrontation shuts down thinkingand elicits rigidity; roll with resistance.

Do not just discharge for non-compliance; follow-up and find out why someone has no-showed or otherwise not followed through.

If information about a person's cognitiveabilities or neurobehavioral problems areavailable from a medical rehabilitation

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professional (physiatrist, rehabilitationpsychologist, neuropsychologist, speech-language pathologist or occupationaltherapist), substance abuse treatmentproviders would be well-advised to gainpermission to consult with thatprofessional.

The Nuts and Bolts of 12-Step Self Help Groups

Finding a meeting

Most phone books will list a numberfor the closest AA/NA/CA central office,which can provide you with a list ofmeetings. Your local substance abusetreatment agency can also direct you tomeetings. Or you can go to<www.alcoholics-anonymous.org> and lookup you regional group's website to findcontact numbers.

Kinds of Meetings

There are four basic types ofmeetings based on whether they are"Open" or "Closed", and whether they usea "Lead" or "Discussion" format. Openmeans that the meeting is just that- open toanyone that would like to attend regardlessof admitting a problem with alcohol or otherdrugs. A closed meeting is only for thosewilling to admit a problem. Lead meetingsare meetings in which a primary speakerwill share their personal story of recovery.Discussion meetings are round tablediscussions and normally occur in smaller,more intimate settings. Ourrecommendation is that a person unfamiliarwith self-help groups start with an OpenLead meeting.

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What to Expect.

Most meetings will last about anhour. It will be helpful to arrive 10-15minutes early to allow time forintroductions, choosing a seat (save themwith a hat or coffee cup), and just adjustingto the surroundings. At AA/NA/CAmeetings it is normal to use only firstnames (this is part of the anonymity ). AtAA meetings greetings are usually ahandshake, at NA meetings hugs are acommon form of greeting. There willusually be a literature table that you canlook over. If you arrive on time, you will beconspicuous. Choosing your seat isimportant. We suggest that you sit in themiddle of the room, toward the front wherethe "old timers" will usually sit. These arethe folks that a new person should get toknow. On the fringes of the room willnormally be those who are required to bethere by the courts and not really investedin recovery-they will be the last in and thefirst out.

At most Lead meetings there will becoffee and possibly a snack. There maybe a 50/50 drawing. The meeting willbegin with the Chair having someparticipants lead a group reading of theTwelve Steps and Twelve Traditions. Therewill be acknowledgement of those thathave reached important milestones in theirrecovery, and announcements ofimportance to the group. The leader willthen introduce the speaker. The speakerwill then give their lead. They will tell whattheir life was like before they started todrink or use, what happened after theystarted to drink or use, what brought themto recovery, and what their life is like now.There will then be time for responses to thespeaker and a closing using the Lord's

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Prayer. An offering will be taken which isentirely optional and is used to support thegroup through the purchase of literature,coffee, and other expenses. After themeeting there will be people standingaround visiting (another good time forintroductions), while others clean up theroom. Sometimes plans will be made to goout for a meal or coffee together.

Sponsorship

Sponsorship is another form ofsupport available in self-help groups. It isoften very helpful to have people new torecovery and AA/NA/CA connected with a"sponsor" to help them along the way. Forpersons with brain injury the sponsorneeds to be aware that they may havesome unique needs and require a certainamount of accommodation. There aresome guidelines for potential sponsors thatwere developed under the auspices of theBrain Injury Association of America when itwas the National Head Injury Foundation.This "Letter to Sponsors" is available at theNASHIA website <www.nashia.org> underresource materials developed for thewebcast on substance abuse and TBI.

Supporting Attendance

It is hard to go to any unfamiliarplace, and a self-help meeting can be evenmore daunting. Attending the first fewmeetings with a companion can be veryhelpful. If the companion is familiar withAA/CA/NA, they can introduce theindividual to some of the "old timers"(persons with quality recovery and goodmotivation) until they feel some familiaritywith the group. Because of problems aperson may have generalizing what goes

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on in the meeting to their own situation,time should be set aside after the meetingto talk about the experience, answerquestions, and reinforce the points thatmade an impact.

12 Steps

All AA/NA/CA rely on the TwelveSteps as a means to recovery. Asoriginally written the Twelve Steps arerather abstract, and may not be understoodby some people with cognitive impairments.An alternative version of the 12 Steps wasdeveloped for the NHIF White Paper that ismore concrete and is available at theNASHIA website <www.nashia.org> underresource materials developed for thewebcast on substance abuse and TBI. Noteveryone with a brain injury may be able to"work the steps"; however, they can stillbenefit from the other helpful aspects ofAA/NA/CA, including fellowship with non-users, a safe place to socialize, andexposure to the stories of those attemptingto recover. The social environment of aself-help group provides many differentavenues for learning or practicing newways to look at our behavior and makechanges.

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About the Author’s

John D. Corrigan, PhD, is a Professor inthe Department of Physical Medicine andRehabilitation at Ohio State University andDirector of the Ohio Valley Center for BrainInjury Prevention and Rehabilitation. He isthe Project Director for the Ohio Regional Traumatic Brain Injury Model System, amulti-center, longitudinal research programfunded by the National Institute onDisability and Rehabilitation Research. Dr.Corrigan directs the "TBI Network," a program providing community-basedtreatment for substance abuse after braininjury. He serves on the AdvisoryCommittee to the National Center on InjuryPrevention and Control at the Centers forDisease Control and Prevention. He is aformer member of the boards of directorsof the Commission on Accreditation ofRehabilitation Facilities (CARF), the BrainInjury Association of America, and the American Psychological Association'sCommittee for the Advancement of Professional Practice (CAPP). He serveson editorial boards of leading journals inrehabilitation and has received local and national awards for his service andresearch in the field, including the BrainInjury Association of America's WilliamFields Caveness Award.

Gary L. Lamb-Hart, M.Div., CCDC III,ICADC, is the Center Manager for the OhioValley Center for Brain Injury Preventionand Rehabilitation at Ohio State Univeristy.He is also a Team Leader for the Center's efforts in substance abuse prevention andtreatment following brain injury. He makespresentations to a wide range ofprofessionals, survivors and family

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members about the issues of substanceabuse and brain injury throughout theUnited States and has co-authored several articles, a book chapter and materials onthis subject. He is a member of theInternational Association of MotivationalInterviewing Trainers. He has been achemical dependency professional since1988 in the state of Ohio. He worked in apublicly funded not-for-profit agency prior tojoining the staff of the Ohio Valley Center.Prior to entering the chemical dependencyfield he had careers as a pastor andcorporate accountant. He has a Bachelorof Science degree in Social Science fromNorthern Arizona University, Flagstaff,Arizona and a Master of Divinity degreefrom the Iliff School of Theology, Denver,Colorado.

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Notes

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Substance Abuse Issues afterTraumatic Brain Injury is one in aseries of brochures on "Livingwith Brain Injury.”

Depression

Employment

Substance Abuse

Information: 1.800.444.6443w w w . b i a u s a . o r g

Published in 2004 by the Brain Injury Association of America