Brain Injury and Substance Abuse: The Cross Training Advantage

Learn why brain injury and addiction together can make recovery so much harder — and how, if substance abuse providers and brain injury specialists collaborate, the success of their patients is greater.

[♫ soft music ♫] I feel lost inside myself. He scares me; he's scaring the kids. I don't know what to do anymore. People are talking, and I just can't follow what they're saying. I think a patient that does come to our clinic and may have both a substance and a head injury problem, it's possible for either of programs to miss one or the other. Both providers have told us that they need more information and skill-based learning in order to help clients better. When people have a brain injury and a substance use problem, they're frequently not treated together. It's actually unusual that that's paid attention to. They're not getting service properly now, and they're falling through the cracks, and these programs need to come together. [Brain Injury and Substance Abuse The Cross-Training Advantage] You're probably aware that brain injury and substance abuse are often connected. Approximately one-third of brain injury survivors have a history of substance abuse prior to the brain injury. Alcohol or drugs are directly involved in more than one-third of incidents that cause brain injury. 20% of people who do not have a substance abuse problem become vulnerable to substance abuse after a brain injury. Unfortunately, although the conditions are often concurrent, they are rarely treated together. Substance abuse programs often fail to identify people with brain injuries or screen them out as inappropriate. Brain injury programs, on the other hand, may ignore substance abuse or deal with it inadequately. So the client with this complex concurrent condition often falls between the cracks. This video and manual were put together by a group of providers who work in brain injury and substance abuse. [Dennis James, M.Sc. CENTRE FOR ADDICTION AND MENTAL HEALTH, TORONTO] The recommendation that we're making very strongly is that substance abuse providers and brain injury providers, as a very first step, talk to each other. There are some principles that we're tying to convey that substance abuse providers can do things differently and make some changes and be more sensitive that will assist in the service they provide. And brain injury providers can do more in assisting clients that they're working with, recognize and take some steps to deal with a substance use problem. For the purposes of this video, brain injury is damage to the brain caused externally by things like a fall or a motor vehicle crash. Brain injury can also be caused internally by things like an aneurysm, a stroke, or a tumor. Substance abuse is the consumption of alcohol, street drugs, even the misuse of prescribed drugs. [Annette Profile: 23 Years Old] Annette, who we'll see more of later, [Single] is a 23-year-old who has entered a substance abuse center [Cocaine Addiction Alcohol Addiction] seeking help for cocaine and alcohol addiction. What her providers don't know is that Annette is also suffering from an undiagnosed brain injury. [Paul Profile: 43 Years Old] Paul is a 43-year-old construction worker [Married with Two Children] who is in rehabilitation for a brain injury. [Construction Worker] Paul is now starting to drink heavily. [Suffered Brain Injury from Fall Starting to Drink Heavily] Paul was brought into emergency unconscious after a fall from a 25 foot scaffold. When he arrived, his Glasgow Coma Score was 4, which means he had minimal motor movement, eye movement, and verbal response. The first step, the most important one, was to stabilize Paul and then look for medical complications. Because of the nature of Paul's injuries, he was hospitalized for 3 months before being discharged to an outpatient rehabilitation program where he continues to receive therapy. Typically, someone with a brain injury in the acute care center will see a variety of people. The team often consists of physical therapists, occupational therapists, social work, nursing, psychiatrists if needed, of course the neurosurgeon if they've required any neurosurgery. [Charissa Courtney, M.H.Sc., B.Sc.OT. TORONTO ACQUIRED BRAIN INJURY NETWORK] If they've sustained orthopedic injuries, there could be an orthopedic surgeon involved. So there's a variety of people involved at the acute care level. It frustrates me. It frustrates me a lot. I feel helpless. I cannot do things. I cannot do things. When a client returns back into the community, often what happens is the same triggers that were encouraging them to use substances prior to the injury are still there. [Shree Bhalerao, M.D. B.A., B.Sc., PGD, F.R.C.P. (C) ST. MICHAEL'S HOSPITAL, TORONTO] Premorbid personality and characteristics and traits as well as the way they've coped in the past tend to play themselves out a little more quickly in the community if there's no followup. When someone has suffered a brain injury, their reaction to that may create a number of uncomfortable feelings. They may feel depressed about having suffered an injury. They may have problems in the family. There may be a disruption to their family relationships. There may be a disruption to friendships. They may lose a job or they may need to alter their job so they can't work in the same way that they used to. All of those things can lead to feelings of depression or anxiety, feelings that are very uncomfortable, and uncomfortable feelings can be alleviated by using a whole variety of drugs. [Mitzi Jarrett, M.S.W. THE REHAB CHOICE affiliated with THE RIVERDALE HOSPITAL, TORONTO] And when you combine a brain injury with using substances, let's say alcohol, what you do is you intensify all of those problems exponentially. The likelihood of you sustaining a second head injury is very high. With a second head injury, your brain does not recover the way it does perhaps after the first head injury. If you have a massive catastrophic head injury, it will get picked up, but those are the people who may be less likely for abusing substances, but the population of people that sustain a head injury or they get a concussion in their automobile or they go to the emerg because let's say they were drinking and stumbled and fell and hit their head; they get stitched up. Does anyone talk about head injury? No. Brain injury is very unique, and the reason it's unique is because different parts of the brain control different physical functions and different cognitive functions so that if someone sustains an injury, the effects of that brain injury will vary depending on where the person's been injured, what part of their brain has been injured, and also the severity of the injury. Clients with brain injuries can exhibit many of the same symptoms as clients with substance abuse problems. These are just a few. [Short Term Memory Loss, Impaired Thinking, Diminished Judgement, Depression, Fatigue, Personality Changes] These symptoms, however, are usually associated with brain injury and not substance abuse. [Lack of Insight, Problems with Learning, Attention Inappropriate Social Behaviour, Initiation Problems, Tangential Remarks] The emotional aspect can be anything from increased depression and much higher levels of anxiety to mood fluctuation. [Substance Abuse Group] You can evidence something that we call disinhibition, which is that you are engaging in inappropriate statements and inappropriate behaviors. Anyway, he was lying there, and I jumped out of the car, and I went over-- I wasn't driving the car. My boyfriend was driving the car at the time. Maybe if you could just wait until Janet is finished telling her story. This is getting really hard, Annette. I mean ever since we've all gotten together, you keep interrupting everybody every time they open their mouth, like you always have something to jump in and say. So those are some of the behavioral aspects. Cognitively, there's a huge range that can be affected. A lot of these folks don't understand in the way they used to. They don't remember in the way they used to. They have a lot of trouble focusing. The way the people are saying things, I'm getting lost in what they're saying, and then I think of a thought of my own, and I have to say it right away or then I'm really completely lost. I don't remember a lot of things, and it hurts. It hurts a lot that I don't remember. I don't feel normal anymore. I can't do things. [Paul's wife] I'm really frustrated about it. I don't like the behavior in front of my kids. It's hard enough that they don't have a dad anymore. He's like another kid to us. I have to remind him about everything. I call every day just to make sure he's done the lists that I've left around the house. The drinking behavior in front of the kids is awful. They didn't have a dad for the longest time, and now he's drunk around the house all the time. Making observations, especially if you're visiting the client in their home, I think is an important point, and I think another important point too is to not be afraid to ask about substance use, whether it's alcohol or drugs. I notice that you've got quite a few beer bottles sitting there on your counter, which I didn't notice in the previous times when I've been out to visit you. Have you had a party recently? No, no, no. No, no parties. No, it's like always, you know, when I'm home, I'm having a couple beers. There's nothing wrong with it, right? There's nothing wrong with having a couple beers. Once in a while, you get tired; you want to have a couple beers, right? Alcohol and drugs have a more intense effect after a brain injury even when the client is using within clinically safe guidelines. Among other things, substances can increase cognitive impairment and depression. They can also cause seizures and problems with balance, walking, and talking. So I start with an educational piece because the person may be in denial that they're drinking, they may not want to tell me, they may be covering up, they may not think it's any of my business, and so I will present this as, "This is just a regular normative aspect of how I work with folks." I educate them about having a head injury and using substances. I also will do this for the family because I want the family involved from the get-go. I want them to be a re-enforcer for abstinence. I want them to be fully aware of the risks involved. Hello Raj, it's Ann Marie calling. I got your number from a colleague, and I was out on home visits a couple of days ago, and I met with a brain injured client who I think would benefit from your substance abuse program. We have a framework that we refer to as motivational interviewing, which has as its fundamental principle to try to assist people in moving gradually and slowly through a process of stages of change to make some actual behavioral changes, but there's a buildup to those behavioral changes. The first step would be to try to assist this person in simply recognizing that that's the case. [CAGE Questionnaire] Have you ever felt you ought to cut down on your drinking? I don't drink that much. Have people annoyed you by criticizing your drinking? You're doing it right now. You're supposed to be a therapist, right, and you're doing it right now. My wife does it. The kids don't like it and neighbors. Have you ever felt bad or guilty about your drinking? Yes, because of my kids. The intervention task is to try to assist this person in tipping the balance where they're now thinking about do I or don't I and maybe I do to make that one little step to yes, indeed there is something that is harmful or there's something that's damaging. Let me ask you then, what is it about your drinking that isn't good? Nothing bad is happening. It just--I cannot cope with sitting at home doing nothing. Okay, well this is a good start, Paul. If the provider has been successful in that and a person is now saying, "Yeah, I think I do need to do something," then to assist them in setting the stage and setting the groundwork, what kind of help. That would be the place where a provider might very well want to give this person the telephone number of the local AA group or maybe offering to attend an AA meeting with them or if there's a treatment service in the area to assist the person in connecting or getting telephone numbers for an assessment. Paul's provider has identified his drinking problem, discussed the pros and cons with him, educated and engaged his family, and connected with a substance abuse professional. What I see is really fundamental. It's for the ABI team to set up the program. It is not acceptable to just say, "Here's a number" or "Contact Suzie in this program." No way. When a client enters a substance abuse program without a diagnosed brain injury, as Annette has, it's very easy to miss the symptoms of that injury. Clients with brain injuries may make tangential remarks, fall behind the group, not pick up on social ques, and get stuck on a word or a topic. I used to have this cousin that would talk really fast all the time right at you, and I could never understand what he was saying because it was so much, but I understood what other people were saying, but not him because he just was like a really, really, fast, fast, fast talker, and that's kind of what it's like in group, except I feel like everybody is talking like that. I just wanted to talk to you a little bit about some concerns I had around some of what seems to be happening for you in group. You seem to be having some difficulty following what the other group members are talking about when you were saying that it feels to you like you get lost in what's happening for people. Uh-hunh (affirmative). So I'm just wondering if you can say a little bit more about that and tell me what's going on for you. I don't know how to explain it other than people are talking and I just can't follow what they're saying. I can't follow the story lines. Do you know what I mean? And I blank out, and I blank back in, and I think after my car accident, that would happen to me a lot. It would be really hard for me to figure things out, but then I would have a drink or I would go out to a party and stuff, and then it wouldn't seem as bad. I would kind of be able to focus a bit more and my head wouldn't feel as fuzzy. As a substance abuse provider, what I want you to do is, first and foremost, to become more sensitive to the fact that a portion of the clients that you're going to work with will have suffered a brain injury, and of those people, not all but some of them will have some consequences of having had that experience. I would like it to start to talk with the brain injury provider in relation to what you're seeing and how this person is presenting and to think about ways that you may need to modify the usual program that you provide and the usual intervention in order to accommodate and make it more helpful and more possible for this person to get help. I got your name from a colleague of mine, and I'm just calling because I have a client who I suspect might have a brain injury, and I was calling to see if I could get some guidance as to how I might work with her differently. I've spoken to a brain injury specialist and have just been given some information that has given me a different understanding about what might be happening for you. It's possible that when you had the car accident a couple of years ago that you may have suffered some kind of injury that hasn't been diagnosed. So what I'm going to try to do is arrange for a referral for you to see a physician who is a specialist in this area so you can get some further consultation around this. Armed with the knowledge of how to deal with Annette's learning needs, her provider is slowing down in sessions, giving her written handouts, anticipating a higher frequency of off-topic remarks, and being flexible while making clear what's acceptable. I would think that the substance abuse provider-- it would be really helpful if they knew something about head injury. I realize there are limitations in what they can do. They can't customize every offering for every brain injured person that comes into their setting, but there are some very specific things that can happen that I think will be real efficacious and very much worth while. That's why I'm suggesting you see a medical specialist who will be able to answer some of those questions. [Dennis James, M.Sc. CENTRE FOR ADDICTION AND MENTAL HEALTH, TORONTO] We should be trying to open the doors more and at least assessing and reviewing the possibility that we can be helpful instead of screening out people who have sustained a brain injury. [Mitzi Jarrett, M.S.W. THE REHAB CHOICE affiliated with THE RIVERDALE HOSPITAL, TORONTO] I'd like each set of providers to feel more comfortable with the issues. Nobody feels comfortable with this. The brain injured people are scared, and perhaps scared is too harsh a word. They feel out of their depths and over their heads. [Shree Bhalerao, M.D. B.A., B.Sc., PGD, F.R.C.P. (C) ST. MICHAEL'S HOSPITAL, TORONTO] On both substance abuse providers and brain injury providers, we should all be asking the question, "Does one have the other?" [Charissa Courtney, M.H.Sc., B.Sc.OT. TORONTO ACQUIRED BRAIN INJURY NETWORK] So it would be nice if providers could consult with one another so that they're both treating the client from the same perspective and working together. It's absolutely critical that both the substance abuse providers and the providers in head injury make the effort to do all this cross-linking and cross-communication and modifying their programs, doing additional program elements. With substance abuse providers and brain injury providers being more sensitized that there can be cross training and cross helping, that there can be collaborations in providing service, providing treatment, I think that many more people can be helped. [♫ music playing ♫] Make sure that you read the manual that accompanies this video. It expands on all the information presented here and includes references and resources. There's also a questionnaire we'd appreciate you filling out and sending back to us so we can evaluate this package and your needs. [We would like to thank the providers and clients in both Brain Injury and Substance Abuse fields who looked through the material, provided their input and help.] We encourage you to copy both the manual and the video and share them with your colleagues. [Credits] [This Project Funded By: Ontario Neurotrauma Foundation] [Ontario Neurotrauma Foundation © 2001] [References]
Posted on BrainLine April 1, 2011.

From the Toronto Rehabilitation Institute. Used with permission.

Comments (1)

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Thank you so much. My son had several severe TBIs. Please help me help him. Most of his family abandoned him at 12, he's been incarcerated (except for a few months) since he is 26. He is now looking at the rest of his life in there. I need some specialists and a lawyer who specializes in TBI. I need help NOW. I can't do this myself, it's too big. Sincerely, Daleen & Brandon