Substance Abuse Substance Abuse and Traumatic and Traumatic Brain InjuryBrain Injury

Evidence-Based Techniques Evidence-Based Techniques

to Prepare People to Prepare People

for Lasting Changefor Lasting Change

Gary S. Seale, PhD LPA LCDCGary S. Seale, PhD LPA LCDC

Director, Clinical ProgramsDirector, Clinical Programs

Transitional Learning Center (TLC) at GalvestonTransitional Learning Center (TLC) at Galveston

Addictive Behavior - Defined

Addictive behavior patterns are repeated and become predicable in their regularity and excess

Abuse/dependence refers to a pattern of behavior that involves poor self-regulation, continues despite negative feedback (consequences), and often appears “out of control”

Reinforcers for engaging in the behavior are very strong and the behavior is an integral part of the person’s life and way of coping

Addictive Behavior - Defined

Failure to change, despite change is 1) possible, 2) in the best interest of the individual, is a characteristic of addiction

Change is the antithesis of addiction, but how do we help people change?

“ If I had six hours to chop down a tree, I would spend four hours sharpening the axe…”

- Abraham Lincoln

Scope of the problemScope of the problemStatisticsStatistics

Alcohol (ETOH) is Alcohol (ETOH) is THETHE most frequently most frequently used used depressant and the cause of depressant and the cause of considerable considerable morbidity and mortalitymorbidity and mortality

In the United States, as many as 90% of In the United States, as many as 90% of adults adults have had some experience with have had some experience with alcoholalcohol

Of those adults who have used alcohol Of those adults who have used alcohol 60% of 60% of males and 30% of females report males and 30% of females report an adverse an adverse life event related to alcohol life event related to alcohol use.use.

Most people learn from their experiences Most people learn from their experiences and and moderate or stop drinkingmoderate or stop drinking

Scope of the problemScope of the problemStatistics - continuedStatistics - continued

14 million Americans abuse alcohol or are 14 million Americans abuse alcohol or are alcohol dependent (1 in 13)alcohol dependent (1 in 13)

Alcohol abuse and dependence are more Alcohol abuse and dependence are more common in men than in women (5:1 common in men than in women (5:1

ratio)ratio) Men start drinking early; women start Men start drinking early; women start

drinking drinking heavily later in life; abuse heavily later in life; abuse and dependence and dependence progress more rapidly progress more rapidly in women, causing in women, causing more health-related more health-related problemsproblems

Size matters - differences in blood alcohol Size matters - differences in blood alcohol concentrations (BAC)concentrations (BAC)

Scope of the problemScope of the problemStatistics-continuedStatistics-continued

Social-cultural differences exist Social-cultural differences exist (family, religious, (family, religious, etc.)etc.)

Alcohol abuse and dependence rates Alcohol abuse and dependence rates are about are about equal in Caucasian and equal in Caucasian and African-American African-American populationspopulations

Slightly higher abuse and dependence Slightly higher abuse and dependence rates in rates in Latino malesLatino males

Very low in Asian populations (due to Very low in Asian populations (due to adverse adverse physical affects at low doses)physical affects at low doses)

Scope of the problemScope of the problemStatistics-continuedStatistics-continued

The earlier one starts drinking, the greater The earlier one starts drinking, the greater the the risk for developing alcohol abuse/risk for developing alcohol abuse/dependence (those drinking at 15 are 7X dependence (those drinking at 15 are 7X

more likely to develop alcohol use more likely to develop alcohol use problems problems compared to those that begin compared to those that begin at 21)at 21)

Health-related problems associated with Health-related problems associated with drinking include cancer, brain damage, drinking include cancer, brain damage, immune system dysfunction, fetal immune system dysfunction, fetal

alcohol alcohol syndrome, etc.syndrome, etc. 50% of fatal traffic accidents involve 50% of fatal traffic accidents involve

alcoholalcohol Many homicides and suicides involve ETOHMany homicides and suicides involve ETOH

Scope of the ProblemScope of the ProblemSubstance Abuse and TBISubstance Abuse and TBI

Males are about twice as likely to sustain a TBI Males are about twice as likely to sustain a TBI than than femalesfemales

Males are about 3 to 4 times more likely to be Males are about 3 to 4 times more likely to be under the under the influence of alcohol at the time of influence of alcohol at the time of injuryinjury

29% to 58% of persons who sustain a TBI are 29% to 58% of persons who sustain a TBI are under under the influence of drugs/alcohol at the time the influence of drugs/alcohol at the time of injuryof injury

About 50% of TBI survivors return to pre-injury About 50% of TBI survivors return to pre-injury use use patterns within the first year of injurypatterns within the first year of injury

54% of persons who sustain a second TBI are 54% of persons who sustain a second TBI are under under the influence at the time of injurythe influence at the time of injury

Scope of the ProblemScope of the ProblemSubstance Abuse and TBISubstance Abuse and TBI

Males are about 3 to 4 times more likely to Males are about 3 to 4 times more likely to be be under the influence of alcohol at the under the influence of alcohol at the time of time of injuryinjury

29% to 58% of persons who sustain a TBI 29% to 58% of persons who sustain a TBI are are under the influence of drugs/alcohol at under the influence of drugs/alcohol at the the time of injurytime of injury

About 50% of TBI survivors return to pre-About 50% of TBI survivors return to pre-injury injury use patterns within the first year of use patterns within the first year of injuryinjury

54% of persons who sustain a second TBI 54% of persons who sustain a second TBI are are under the influence at the time of injuryunder the influence at the time of injury

Scope of the Problem Scope of the Problem Substance Abuse and TBISubstance Abuse and TBI

TBI is among the leading killers and TBI is among the leading killers and disablers of all young adults under disablers of all young adults under the age of 35the age of 35

Medical and rehabilitation costs Medical and rehabilitation costs associated with TBI exceed 45 billion associated with TBI exceed 45 billion dollars annuallydollars annually

Scope of the problemScope of the problem

In purely economic terms, alcohol In purely economic terms, alcohol related related problems cost the American problems cost the American society an society an estimated $185 billion estimated $185 billion annually annually (ER/Hospital costs, (ER/Hospital costs, rehabilitation costs, law rehabilitation costs, law enforcement/incarceration, lost enforcement/incarceration, lost wages/productivity)wages/productivity)

In human terms, the cost can not be In human terms, the cost can not be calculated!calculated!

Treatment ChallengesTreatment ChallengesSubstance Abuse and TBISubstance Abuse and TBI

More frequent complications in the acute More frequent complications in the acute medical medical phase phase of recovery (i.e., of recovery (i.e., respiratory, vascular, edema respiratory, vascular, edema and ICP, etc.) and ICP, etc.) resulting in longer lengths of stay resulting in longer lengths of stay in acute in acute phasephase

Lower levels of consciousness (lower GCS Lower levels of consciousness (lower GCS scores) and scores) and longer lengths of comalonger lengths of coma

Greater agitation when emerging from comaGreater agitation when emerging from coma Greater levels of non-compliance and increased Greater levels of non-compliance and increased

risk of risk of leaving acute and post-acute care leaving acute and post-acute care AMAAMA

Greater risk of “losing” patient during follow-upGreater risk of “losing” patient during follow-up

Treatment ChallengesTreatment ChallengesSubstance Abuse and TBISubstance Abuse and TBI

29% to 40% of persons with TBI had substance 29% to 40% of persons with TBI had substance abuse abuse problems pre-injury.problems pre-injury.

A large number of persons who were not A large number of persons who were not problem problem drinkers before injury (up to 20%) drinkers before injury (up to 20%) are at risk for are at risk for developing abusive patterns developing abusive patterns after injuryafter injury

Persons who present for post-acute Persons who present for post-acute rehabilitation may rehabilitation may be “dry” but not “sober”be “dry” but not “sober”

Persons with TBI, because of multiple and Persons with TBI, because of multiple and complex complex changes associated with brain injury, changes associated with brain injury, may feel they may feel they have a “reason” to usehave a “reason” to use

Drug seeking, relapse, & leaving treatment are Drug seeking, relapse, & leaving treatment are frequent frequent occurrences that impact outcomes occurrences that impact outcomes

Treatment ChallengesTreatment ChallengesSubstance Abuse and TBISubstance Abuse and TBI

TBI survivors report that very small TBI survivors report that very small amounts of amounts of substances previously used substances previously used can have a big can have a big impact on cognition impact on cognition and behaviorand behavior

TBI survivors and family members report TBI survivors and family members report that that cognitive, physical, and cognitive, physical, and emotional deficits emotional deficits stemming from stemming from injury are exaggerated with injury are exaggerated with substance substance useuse

Prescriptions may be offered without Prescriptions may be offered without considering substance abuse historyconsidering substance abuse history

Traditional Treatment Traditional Treatment ApproachesApproaches

Substance Abuse and TBISubstance Abuse and TBI Minnesota (Hazelton) Model was heavily Minnesota (Hazelton) Model was heavily

influenced by influenced by Jellenik’s disease concept of Jellenik’s disease concept of alcoholismalcoholism

Emphasizes group work to help patients Emphasizes group work to help patients understand understand the nature of their illnessthe nature of their illness

Requires patients to accept a diagnostic Requires patients to accept a diagnostic label and label and recovery is dependent upon recovery is dependent upon complete abstinencecomplete abstinence

Resistance is seen as denial of the problem Resistance is seen as denial of the problem and must be and must be confrontedconfronted

Uses 12-step principles in recoveryUses 12-step principles in recovery

Traditional Treatment Traditional Treatment ApproachesApproaches

Substance Abuse and TBISubstance Abuse and TBI

Persons with TBI may resist traditional Persons with TBI may resist traditional approaches due approaches due to negative initial to negative initial experiences with 12-step experiences with 12-step programsprograms

Requires patient to accept yet another diagnostic Requires patient to accept yet another diagnostic labellabel

Difficulty with concepts central to 12-step Difficulty with concepts central to 12-step programs programs (i.e., “higher power”, “spiritual (i.e., “higher power”, “spiritual awakening”, “first awakening”, “first things first”, “one day at a things first”, “one day at a time”, etc.)time”, etc.)

Heavy handed confrontation results in Heavy handed confrontation results in defensivenessdefensiveness

Conflicts between recommendations of treatment Conflicts between recommendations of treatment team team and advice from “old timers”.and advice from “old timers”.

An Alternative Treatment An Alternative Treatment Approach – Stage ChangeApproach – Stage Change

Transtheoretical Model (TTM) of Transtheoretical Model (TTM) of intentional intentional behavior change behavior change focuses on: 1) focuses on: 1) howhow individuals individuals change and, 2) identifies change and, 2) identifies key key change dimensionschange dimensions involved in this involved in this process. process.

TTM Model of Intentional Behavior Change

PrecontemplationPrecontemplation – not seriously considering change in the near future

ContemplationContemplation – considering change, experimentation, increasing the pros for change and decreasing the cons PreparationPreparation –

commitment to change, planning

ActionAction – implementation, revising the plan

Maintenance Maintenance – integrating change into lifestyle, coping

TerminationTermination

Lapse & Lapse & RelapseRelapse

How Addictions Develop PrecontemplationPrecontemplation – person is not seriously

considering engaging in the behavior (i.e., drinking) in the near future. Lack of

interest can be due to: 1) little information or knowledge, 2) value system that excludes consideration of behavior, or 3) a conscious decision not to engage in behavior

Protective factors include: religious involvement, good family relations/interactions, parental monitoring, peers with similar views/values, good self-regulation, economic and social stability

How Addictions Develop (continued)

ContemplationContemplation – person begins to consider engaging in behavior (i.e., drinking); begins to consider positive/negative aspects of behavior (i.e., images, media messages, modeling, etc.); experimentation

Task of this stage is to gather information and weigh pros/cons

Experiments with behavior until a decision is made to move ahead to Preparation or back to Precontemplation

How Addictions Develop(Continued)

PreparationPreparation – continued experimentation and gradual (but deliberate) setting of the stage for regular engagement of the behavior (i.e., drinking).

Based on experiences and positive/negative consequences, person may modulate or stop behavior, or develop less controlled (out of control) use

Powerful physiological and psychosocial reinforcers; pros for continuing behavior increase and cons decrease; hard to believe negative messages from peers, parents, media, etc.

How Addictions Develop(Continued)

Action Action – regular and predictable engagement in behavior (i.e., drinking); behavior can be well controlled/modulated with few or no negative consequences. Negative consequences triggers re- evaluation and self-regulation

Behavior may be poorly regulated with negative consequences. Behavior occurs in many situations (more cues); over use becomes normalized and peer group, attitudes & beliefs shift to support behavior

Alterations in self-regulatory feedback; negative consequences normalized

How Addictions Develop(Continued)

Maintenance Maintenance – the behavior is an integral part of the persons life (can be well regulated; “social drinking”)

Poor self-regulation; out of control behavior; behavior continues despite negative consequences; failure to change despite change is possible and in the best interest of the person

DeflectionsDeflections (negative consequences = technical problems) and DisconnectionsDisconnections (between behavior & consequences)

How People Recover

PrecontemplationPrecontemplation – not seriously considering change in the near future

ContemplationContemplation – considering change, experimentation, increasing the pros for change and decreasing the cons PreparationPreparation –

commitment to change, planning

ActionAction – implementation, revising the plan

Maintenance Maintenance – integrating change into lifestyle, coping

TerminationTermination

Lapse & Lapse & RelapseRelapse

Screening & EvaluationScreening & EvaluationSubstance Abuse and TBISubstance Abuse and TBI

Establish criteria to determine who should Establish criteria to determine who should receive receive substance abuse treatmentsubstance abuse treatment

Record review (positive blood chemistry at Record review (positive blood chemistry at the time of the time of accident; positive history of accident; positive history of CD treatment)CD treatment)

Clinical interview with patient and family Clinical interview with patient and family (pre/post (pre/post injury use patterns, substance of injury use patterns, substance of choice, choice, consequences of use, previous consequences of use, previous treatment or treatment or attempts to stop, attempts to stop, patient/family view of substance patient/family view of substance use)use)

Formal assessment (SASSI, Formal assessment (SASSI, CAGE, AUDITCAGE, AUDIT))

Evaluate Readiness to Evaluate Readiness to ChangeChange

Pre-contemplation (not aware a problem exists)Pre-contemplation (not aware a problem exists)Recovery Goal: problem recognition; accurate Recovery Goal: problem recognition; accurate

appraisalappraisal Contemplation (“turning point”/ “hitting Contemplation (“turning point”/ “hitting

bottom”)bottom”) Recovery Goal: decisional balance favoring changeRecovery Goal: decisional balance favoring change

Preparation (what is the plan?; what are the Preparation (what is the plan?; what are the resources?)resources?) Recovery Goal: develop a plan; ID resourcesRecovery Goal: develop a plan; ID resources

Action (commitment to plan; strategies)Action (commitment to plan; strategies) Recovery Goal: teach strategies; implement planRecovery Goal: teach strategies; implement plan

Maintenance (lapse & relapse prevention)Maintenance (lapse & relapse prevention) Recovery Goal: sustaining change in many contextsRecovery Goal: sustaining change in many contexts

Termination Termination

Goals and Strategies for PreContemplation

Planting Seeds for Change

Precontemplation = not seriously considering change in the near future. Usually due to one of the following “R’s”- Reluctance- Rebellion- Rationalization- Resignation- Revelry

Goals & Strategies for PreComtemplation

(continued) RevelryRevelry – having too much fun. Consequences

have not accumulated or are not severe; decisional balance not tipped toward change

- GoalGoal: arouse concern; help person see negatives of behavior and positives of change

- StrategiesStrategies: how behavior affects others; engage emotional arousal (portrayal of

consequences: example, new smoking commercials); “YET”

Goals & Strategies for PreContemplation

(continued) RebellionRebellion – passionate about their ability

to make choices; don’t want anyone telling them what to do.

- GoalGoal: link freedom and autonomy with change; shift energy dedicated to the behavior to Contemplation and Preparation stages of change

- StrategyStrategy: point out they are not free, but slaves to the behavior (Motivational Enhancement therapies and Motivational Interviewing techniques)

Goals and Strategies for PreContemplation

(continued) ResignationResignation – hopeless and helpless

about change; overwhelmed by problems (including drinking); have tried to change and failed; “been addicted too long – it’s too late for change”

- GoalGoal: infuse hope and a vision of the possibility of change

- StrategiesStrategies: focus on resilience in other areas of life; show data that “bad addicts” recover; “letter from the future”

Goals and Strategies for PreContemplation

(continued) ReluctanceReluctance – hesitant about prospects of

change; change means leaving comfort zone (friends, routines, etc.)

- GoalGoal: increase confidence in the ability to change; provide reassurance they will be able to function without drinking.

- StrategyStrategy: focus on past successes with difficult tasks; enlist support of individuals who have made similar changes (and been successful)

Goals and Strategies for PreContemplation

(continued) Rationalizing Rationalizing – the person with all the

answers, for example “..might be a problem for others, but not me”, “I’ll quit when I have serious responsibilities like a wife and kids”, “I only drink beer and never drink before noon”- GoalGoal: more accurate self-appraisal and recognition of consequences- StrategiesStrategies: don’t argue; reflect back looking for ambivalence or discrepancies with the behavior and the person’s values beliefs; provide resources and have them research for themselves; natural consequences

General Strategies for PreContemplation

Remember – the overarching goal is problem problem identificationidentification

Patience and persistence Try not to argue, nag, threaten, etc. Time your conversation – don’t attempt it

when the person is drunk Listen, reflect back, provide support for

change (be ready if they ask for help) Honest, accurate, objective feedback Reasonable boundaries; natural consequences

Goals and Strategies for Contemplation

ContemplationContemplation – thinking about change. Caution: rushing in without considering

costs, or getting stuck in chronic contemplation

- Goal- Goal: gathering information, examining the information, engaging in a comparative

process (while moving toward pros for change)

- Strategy- Strategy: Decisional Balance Exercise; reinforce self- efficacy (they have the “stuff” necessary for change – BAT exercise)

Goals and Strategies for Preparation

PreparationPreparation – preparing for action = planning

- GoalGoal: making and strengthening the commitment to change; developing a sound, reasonable plan for action that is likely to be successfully implemented by the individual

- StrategyStrategy: conduct risk assessment; ID strengths and weaknesses; develop strategies and assess resources; complete change plan work sheet

Goals and Strategies for Preparation

(Continued) Plan should be built around the person –

self knowledge and patterns of behavior Consider social relationships, role

expectations, recreational activities, vocational pursuits, living arrangements

Complete a Brief Situational Confidence Questionnaire – arrange scenarios in

a hierarchy Determine skills needed for success in

each scenario (relaxation, assertiveness, etc.)

Goals and Strategies for Action

ActionAction – taking action to interrupt the habitual pattern of the behavior; person separates from the old pattern of behavior and begins to create a new one (establish a new pattern of behavior)- GoalGoal: break free from the behavior by using the strategies of the plan; revise the plan in the face of difficulties; manage temptations and slips that can provoke relapse- StrategyStrategy: Implement the Change Plan

Strategies for Action(continued)

Set a start (target) date for implementation Change routines and manipulate environment

where possible Teach coping strategies until mastery is reached

(ok to use technology – Tactical Breathing Trainer)

Instructions may need to be specific (written scripts); therapist may need to model behavior

Reward approximations Manage slips (lapses) as an “event” not a failure

Goals and Strategies for Maintenance

MaintenanceMaintenance – making change permanent; notnot engaging in the behavior becomes established as the norm- Goal: actively counter any threats and temptations; check and renew commitments; ensure decisional balance remains negative for re-engaging in the behavior; establish protective environment and satisfying lifestyle- StrategiesStrategies: revisit reasons to change; recognize progress and success; generalize behavior across settings

Other Skills TrainingOther Skills TrainingUsing the treatment team to establish positive everyday Using the treatment team to establish positive everyday

routinesroutines

Advanced activities of daily living Advanced activities of daily living (ADL’s)(ADL’s)

Social Communication SkillsSocial Communication Skills Leisure/RecreationLeisure/Recreation Productive ActivitiesProductive Activities Compensatory StrategiesCompensatory Strategies Adjustment to disabilityAdjustment to disability

HomeworkHomeworkSubstance Abuse and TBISubstance Abuse and TBI

Homework tasks provide a link between Homework tasks provide a link between clinical clinical intervention in structured settings intervention in structured settings and the “real” and the “real” world world

Objective is to promote generalizationObjective is to promote generalization Examples of homework assignments include: Examples of homework assignments include:

using using relaxation techniques in a stressful relaxation techniques in a stressful situation; using situation; using assertive responses on a assertive responses on a job trial; practicing job trial; practicing problem-solving in a problem-solving in a dispute with a room-mate, etc.dispute with a room-mate, etc.

Provides opportunities for team interaction Provides opportunities for team interaction (i.e., putting (i.e., putting homework assignments on “to homework assignments on “to do” list)do” list)

Structured Structured GeneralizationGeneralization

Substance Abuse and TBISubstance Abuse and TBI Allows opportunities to practice strategies in Allows opportunities to practice strategies in

actual actual community settings where substance community settings where substance abuse might abuse might occur (involve other disciplines)occur (involve other disciplines)

Therapist accompanies patient to a setting Therapist accompanies patient to a setting where use where use might occurmight occur

Therapist coaches patient to engage in Therapist coaches patient to engage in competing competing behavior or use strategies behavior or use strategies practiced in therapy practiced in therapy sessionssessions

Patient is heavily reinforced for appropriate Patient is heavily reinforced for appropriate behaviorbehavior

Patient experiences successPatient experiences success

Patient EducationPatient EducationSubstance Abuse and TBISubstance Abuse and TBI

Typically takes place in a group settingTypically takes place in a group setting Information on a variety of topics is Information on a variety of topics is

presented/discussed: common myths and presented/discussed: common myths and fallacies fallacies about substance use; about substance use; relationship relationship of substance use of substance use and TBIand TBI; effect of ; effect of substances on brain and substances on brain and behavior, and behavior, and recovery; identifying triggers; and recovery; identifying triggers; and relapse relapse preventionprevention

Identification of community supports Identification of community supports (including (including attending an attending an AA meeting)AA meeting)

Placement of written materials in a notebookPlacement of written materials in a notebook

Family EducationFamily EducationSubstance Abuse and TBISubstance Abuse and TBI

Information provided on a variety of Information provided on a variety of topics: the topics: the relationship between relationship between substance abuse and substance abuse and TBI; effect of TBI; effect of substances on the brain and substances on the brain and behavior; medication interactions, etc.behavior; medication interactions, etc.

Signals of impending lapse (relapse)Signals of impending lapse (relapse) Sharing of the Change Plan Sharing of the Change Plan Identification of community supportsIdentification of community supports

(for both (for both patient and familypatient and family

Follow-upFollow-upSubstance Abuse and TBISubstance Abuse and TBI

Follow-upFollow-up contact is made at identified contact is made at identified intervals intervals following discharge (ex. following discharge (ex. 1, 6, and 12 1, 6, and 12 months post discharge).months post discharge).

Patient and/or family can contact the Patient and/or family can contact the facility at facility at any time between any time between scheduled follow-up if a scheduled follow-up if a problem problem occurs.occurs.

TLC Addiction & Substance Abuse TLC Addiction & Substance Abuse ProgramProgram(ASAP)(ASAP)

Sample size = 12Sample size = 12 Male/Female ratio = 11:1Male/Female ratio = 11:1 Injury severity = severe (GCS, TFC, PTA)Injury severity = severe (GCS, TFC, PTA) Injury etiology = MVA (5), Fall (3), GSW Injury etiology = MVA (5), Fall (3), GSW

(2), (2), Work injury (1), Aneurysm (1)Work injury (1), Aneurysm (1) Average Age: 31 (range = 20-47)Average Age: 31 (range = 20-47) Length of time since injury: 4.5 mo (1-12)Length of time since injury: 4.5 mo (1-12) SASSI results = all were high probabilitySASSI results = all were high probability 7 were under the influence at injury; 6 7 were under the influence at injury; 6

had previous had previous CD treatmentCD treatment

TLC - ASAPTLC - ASAPTreatment ServicesTreatment Services

Activities of Daily Living – 10-12 hrs/wkActivities of Daily Living – 10-12 hrs/wk Physical Therapy – 5-10 hrs/wkPhysical Therapy – 5-10 hrs/wk Speech/Language Therapy – 1-3 hrs/wkSpeech/Language Therapy – 1-3 hrs/wk Neuropsychology – 2-4 hrs/wkNeuropsychology – 2-4 hrs/wk Neurocognitive therapy – 5-7 hrs/wkNeurocognitive therapy – 5-7 hrs/wk Leisure/Recreation – 8-12 hrs/wkLeisure/Recreation – 8-12 hrs/wk Productive Activities – 5-30 hrs/wkProductive Activities – 5-30 hrs/wk ASAP – 1-3 hrs/wkASAP – 1-3 hrs/wk

TLC - ASAP TLC - ASAP Data Outcomes – 6 Month Follow-upData Outcomes – 6 Month Follow-up

Chemical use since discharge: 75% reported Chemical use since discharge: 75% reported no use; no use; 25% reported some use25% reported some use

Of those who reported use after discharge, 2 Of those who reported use after discharge, 2 reported reported “controlled drinking”; one resumed “controlled drinking”; one resumed heavy illicit heavy illicit drug use and was jailed; one drug use and was jailed; one was referred for was referred for inpatient detox and inpatient detox and treatmenttreatment

Living status improved: 1 living in own home, 9 Living status improved: 1 living in own home, 9 in the in the family home, 1 in a treatment center, family home, 1 in a treatment center, 1 in jail1 in jail

Productive activity improved with 4 patients Productive activity improved with 4 patients engaged in engaged in work/school, and 6 seeking workwork/school, and 6 seeking work

TLC - ASAPTLC - ASAPOutcome AnalysisOutcome Analysis

Analysis of 6-month outcomes revealed Analysis of 6-month outcomes revealed only 2 only 2 patients were attending AA patients were attending AA meetings meetings regularly and attributed regularly and attributed abstinence to 12-step abstinence to 12-step support support meetingsmeetings

Other patients who were abstinent Other patients who were abstinent reported reported using other strategies: using other strategies: exercising; exercising; meditation/relaxation; meditation/relaxation; attending church; and attending church; and attending attending alternative community support alternative community support groups (i.e., Rational Recovery)groups (i.e., Rational Recovery)

Substance Abuse and TBISubstance Abuse and TBIConclusionsConclusions

There is no single method of treatment for There is no single method of treatment for substance substance abuse that is universally abuse that is universally applicable and successfulapplicable and successful

Counselors and therapists should be familiar Counselors and therapists should be familiar with with traditional as well as alternative traditional as well as alternative treatment models treatment models and methodsand methods

Cognitive-behavioral techniques and Cognitive-behavioral techniques and comprehensive comprehensive treatment approaches treatment approaches that incorporate Stage that incorporate Stage Change Theory Change Theory (TTM) and Motivational (TTM) and Motivational Interviewing have Interviewing have demonstrated some success for demonstrated some success for persons persons with TBIwith TBI

What to do if Someone You What to do if Someone You Know has a Problem with Know has a Problem with

AlcoholAlcohol Stop all “cover ups”Stop all “cover ups” Time your intervention (talk while the Time your intervention (talk while the

person is person is sober & right after an sober & right after an incident)incident)

Be specific (how drinking is affecting you)Be specific (how drinking is affecting you) State limits (be prepared to follow State limits (be prepared to follow

through -through - don’t make threats)don’t make threats) Provide resources or refer person to Provide resources or refer person to

someone in someone in recoveryrecovery Get support for yourselfGet support for yourself

What to do if Someone You What to do if Someone You Know has a Problem with Know has a Problem with

AlcoholAlcohol Examine benefits of stopping Examine benefits of stopping

unhealthy unhealthy drinking patternsdrinking patterns Set a goal (to stop or cut down)Set a goal (to stop or cut down) Examine situations that trigger Examine situations that trigger

drinking and find drinking and find new ways to new ways to handle that situationhandle that situation

Get social supportGet social support Relapses are a part of recovery and Relapses are a part of recovery and

should be should be treated as single treated as single episodes, not failure (no episodes, not failure (no guilt)guilt)

Resources

- The Houston Council on Alcohol and Drugs303 Jackson Street, Houston, Texas

77007713-942-4100

- The Texas Commission on Alcohol and Drug Abuse (TCADA) http://www.dshs.state.tx.us/mhsa

- Substance Abuse and Mental Health Services Administration (SAMHSA)

http://www.samhsa.gov

Resources - Continued

Substance Abuse/Brain Injury (SUBI) Bridging Project (140-page workbook with exercises)

Ohio State University Brain Injury Substance Abuse Education Project – John Corrigan, PhD

Questions?Questions?(hopefully, some answers)(hopefully, some answers)

““Thank you, Thank you, thank you very thank you very

muchmuch!”!”

ReferencesReferences

Sparadeo, FR, Strauss, D, Barth, JT. Sparadeo, FR, Strauss, D, Barth, JT. The The Incidence, Impact, and Treatment of Substance Incidence, Impact, and Treatment of Substance Abuse in Head Trauma RehabilitationAbuse in Head Trauma Rehabilitation. . Journal Journal of Head Trauma Rehabilitation,of Head Trauma Rehabilitation, 1990; 5 (3): 1-8 1990; 5 (3): 1-8

Strauss, D. Strauss, D. An Overview of Substance Abuse An Overview of Substance Abuse and Brain Injuryand Brain Injury. . Brain Injury Source,Brain Injury Source, 2001; 2001; 5(4): 8-11;40-415(4): 8-11;40-41

Ruff, RM, et. al. Ruff, RM, et. al. Alcohol Abuse and Alcohol Abuse and Neurological Outcome of the Severely Head Neurological Outcome of the Severely Head Injured.Injured. Journal of Head Trauma Journal of Head Trauma RehabilitationRehabilitation, 1990; 5 (3): 21-31, 1990; 5 (3): 21-31

ReferencesReferencesContinuedContinued

Miller, WR & Rollnick, S. (1991). Motivational Miller, WR & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change Interviewing: Preparing people to change addictive behavior. New York: Guillford Press.addictive behavior. New York: Guillford Press.

Jones, GS. Jones, GS. Substance Abuse Treatment for Substance Abuse Treatment for Persons with Brain Injuries: Identifying Models Persons with Brain Injuries: Identifying Models and Modalities.and Modalities. NeuroRehabilitationNeuroRehabilitation, 1992; , 1992; 2(1): 27-342(1): 27-34

Langley, MH, Lindsay, WP, Lam, CS. Langley, MH, Lindsay, WP, Lam, CS. A A Comprehensive Alcohol Abuse Treatment Comprehensive Alcohol Abuse Treatment Programme for Persons with TBIProgramme for Persons with TBI. . Brain InjuryBrain Injury, , l990; 4(1): 77-86.l990; 4(1): 77-86.

ReferencesReferencesContinuedContinued

Corrigan, JD & Mysiw, WJ (2013). Corrigan, JD & Mysiw, WJ (2013). Substance Misuse Among Persons with Substance Misuse Among Persons with Traumatic Brain Injury.Traumatic Brain Injury. In: Brain Injury In: Brain Injury Medicine – Principles and Practices, 2Medicine – Principles and Practices, 2ndnd Ed. Ed. Zasler, Katz & Zafonte, Eds. Demos Medical Zasler, Katz & Zafonte, Eds. Demos Medical Publishers, New YorkPublishers, New York

DiClemente, CC. (2006). Addiction and DiClemente, CC. (2006). Addiction and Change: How Addictions Develop and Change: How Addictions Develop and Addicted People Recover. Guilford Press, Addicted People Recover. Guilford Press, New York.New York.

Duhigg, C. (2012). The Power of Habit. Duhigg, C. (2012). The Power of Habit. Random House, New York.Random House, New York.