Substance Use Disorders and Cognitive Deficits

1. Substance Use Disorders and Cognitive Deficits Presented by: Thomas G. Beckers BS, LADC Program Services Manager Vinland National Center

2. Goals • Recognize common symptoms of traumatic brain injury (T.B.I.) – and Cognitive Deficits • Incorporate compensatory practices to modify Substance Use Disorder (S.U.D.) Treatment

3. “Traumatic Brain Injury is an important public health problem in the United States. Because the problems that result from TBI, such as those of thinking and memory, are often not visible, and because awareness about TBI among the general public is limited, it is frequently referred to as the “silent epidemic”.” Marilynn Lash: The Essential Brain Injury Guide (4th Edition) The Brain Injury Alliance of America, 2007. Traumatic Brain Injury

4. SAMPLE: 295 people with co-occurring mental health and substance use disorders enrolled in a prospective study of integrated treatment of substance abuse. SETTING: Outpatient community mental health center in Washington, District of Columbia. MAIN MEASURES: The Ohio State University TBI Identification Method. Standardized measures assessed psychiatric diagnoses, symptom severity, current and lifetime substance use, and history of institutionalization. Prevalence

5. RESULTS: • 80% screened positive for TBI, and 25% reported at least 1 moderate or severe TBI. • TBI was associated with current alcohol use and psychiatric symptom severity and with lifetime institutionalization and homelessness. • More common among participants with post-traumatic stress disorder, borderline personality disorder, and antisocial personality disorder. • Men (vs. women) and participants with psychotic disorders (vs those with mood disorders) had an earlier age of first TBI with loss of consciousness. • The Prevalence of Traumatic Brain Injury Among People with Co-Occurring Mental Health and Substance Use Disorders • McHugo GJ, KrassenbaumS, Donley S, Corrigan JD, Bogner J, Drake RE. • Head Trauma Rehabilitation 2017 May/Jun;32(3):E65-E74. Prevalence

6. Leading Causes of TBI • 1.) Falls: • Leading cause of TBI • Account for 47% of all TBI related ED visits, hospitalizations and deaths in the US in 2013 • 2.) Being Struck by or against an object: • Second leading cause accounting for 15% of ED visits, hospitalizations, and deaths in the Us in 2013

7. Leading Causes of TBI 3.) Motor Vehicle Accidents: Third overall leading cause of TBI related ED visits, hospitalizations and deaths accounting for 15% in 2016 Taylor CA, Bell JM, Breiding MJ,XuL. Traumatic Brain Injury-Related Emergency Department Visits, hospitalizations, and Deaths – United States, 2007 and 2013 MMWR Serveil Summ 2017;66(No.ss-9):1-16. DOI: http://dx.doi.org/10.15585/mmwr.ss66609a1

8. Challenges with Providing SUD Treatment to TBI Clients • Problems with self regulating thoughts, feelings and behaviors • Difficulty benefiting from experience and remembering information from one session to next • Intention and behavior may be disconnected • Difficulty maintaining relationships due to problems with perceiving, understanding and behaving according to Norms • Wide variance in expressive and receptive abilities

9. Challenges with Providing SUD Treatment to TBI Clients • Lack of experienced staff and referral sources who understand how to adjust their approach • Misinterpretation of symptoms: labeled as “noncompliant” or “resistant” • Lack of varied forms of stimulation, structure and support • Alternative forms of curriculum

10. Assessing Learning and Communication Style • Ask how well the person reads, writes, observe through examples. Which do they prefer? • Ask about and observe a person’s attention span. Be attuned to whether attention seems to change in different environments • Ask about what other people say about their learning/communication style • Ask about previous IEP’s or tutors when engaged in past education environments

11. Assessing Learning and Communication Style • “What helps you with___________________?” • Remembering new material • Remembering Names • Finishing your work • Staying on Track • Paying attention • Remembering things you see or hear • Making choices that keep you healthy and safe

12. Cognitive Processes • Alertness • Attention • Processing • Memory • Executive Functioning

13. Problem > Alertness • Schedule cognitive heavy or intense groups during optimal hours • Allow clients to move around if needed • Use peppermint oil • Practice sleep hygiene • In residential sites, allow people to move rooms if necessary to achieve compatible environments

14. Problem > Attention Important to consider because it affects downstream cognition Look for: • Client being “checked out” • History of “thrill-seeking” • History of need for sensory stimulation Accommodations: • Use space and movement to grab attention • Begin groups with active participation • Have simple cues to reduce distractions • Keep instructions simple! • Use curriculum that can be converted into games

15. Problem > Processing Slower processing does not mean they cannot comprehend – they just need more time. Look for: • May tire easily • Difficulty tracking conversation – watch them in groups • They may report difficulty with comprehension Accommodations: • Keep emotional tone “cool”. When doing more emotional work, allow for time to process • Stress goes up – processing speed slows down • Break instructions/homework down into smaller parts • Keep instructions simple • Take breaks – low intensity options for groups

16. Problem > Memory Making choices based on previously learned information is compromised when a memory deficit exists Look for: • Inconsistent performance on a task • What works best ? – verbal memory? – written ? • What is a past example of learning and how did it occur? Accommodations: • Use visual field to support memory • Bring a note book to session - write down key points of session • Create repeatable routines • Use of reminders and ringtones through digital devices

17. Problem > Executive Functioning > Initiation Sometimes a client can tell you what they want to do but struggle to begin the steps necessary to complete a task Look for: • Set a task and see if they begin • Notice how often you need to prompt for behavior • History - either through client or collaterals Accommodations: • Simplify – break down into small, manageable pieces • Assign only manageable piece – hold back some of the materials • Place reminders of needed behaviors in places that can be seen • Use timers and auditory cues to begin and end behaviors • Use motivational incentives – ‘Fishbowl’

18. Problem > Executive Functioning >Impulsivity Impulsivity is very common. Hard to stop a particular behavior. Very small gap from thought to behavior. Look for: • May do or say things without recognizing effect on others/self • A lot of personal information, very early on in sessions • May interrupt conversations regularly Accommodations: • The talking stick – helps shape behaviors in groups • Using timers to measure clients ability to complete a task • Using motivational incentives to shape pro community behaviors - Fishbowl pulls weekly • Clear direct feedback that is directed at behavior, not client • Clear and direct expectations with limits and consequences

19. Problem > Executive Functioning >Planning &Organizing Many people with TBI struggle to hold or organize information and need support to plan and organize certain tasks Look for: • Lacks significant future focus • Misses deadlines • Often late or does not show up for appointments Accommodations: • Stressing the need to develop and maintain routines throughout day • Use visual cues to find place to keep important things in order • Use a system that matches the needs of the person • Write down key points of session. Bring a note book to session • Remind the person of the point – what to expect and goal of the session. Have them repeat the instructions back

20. Problem > Executive Functioning > Mental Flexability The trouble with adjusting to changing situations and unfamiliar circumstances Look for: • Agitation and irritation when things unexpectedly change • Perseveration • Has difficulty with ideas about a plan B – “plan A will work !” Accommodations: • Rehearse different strategies in different environments to increase ability to generalize skills • Create or support the biggest support system possible. Think “safety net” first • Allow plenty of time for sessions regarding transitions

21. Problem > Executive Functioning > Self Awareness People with cognitive deficits may not be aware of how they are being experienced by others Look for: • May dominate interactions with others • Low awareness of problems or lacks a desire to change • Often sets unrealistic goals Accommodations: • Identify and use appropriate self disclosure – “ This is my experience when______________.” • Motivational incentives for behaviors that support community • Being clear about wanted behaviors and unwanted behaviors • Coaching clients to provide positive feedback regarding behaviors

22. In closing… • People with Brain Injuries do benefit from treatment when compensatory skills are taught and practiced • Teaching non-brain injury peers about brain injury helps with group cohesion by helping those with injuries feel accepted • People suffering from brain injuries are participating in traditional programs • Staff members of these programs can benefit from further education, which can lead to a heightened sense of empathy

23. Thank You for Your Attention and Interest! • Don’t hesitate to contact me directly if you would like more information about this topic: tbeckers@vinlandcenter.org