Robert Katz, Ph.D. Program Director Brady Institute for Traumatic Brain Injury

Physical and Rehabilitation Department

Jamaica Hospital Medical Center

718-206-7824 Fax: 718-206-7436

The problem of substance abuse in TBI survivors has been well-documented in the literature. In her review article, Mtiguy (1991) cites alcohol as a major contributing factor in over 50% of head injuries sustained in the United States. For example, Rimel and Jane (1983) found that 52% of their sample of head injured survivors were legally intoxicated at the time of injury, and 29% had previously received substance abuse treatment. More recently, in their literature review, Delmonico, Hanley-Peterson, & Englander (1998) found that 20-60% of TBI survivors were identified as preinjury problem drinkers, with 30-50% of these survivors continuing to have problems with alcohol postinjury. Similarly, a literature review by Sander, Witol, & Kreutzer (1997) put preinjury alcohol abuse at 40-66%, and postinjury alcohol abuse between 27%-50% of TBI survivors. A seminal study by the National Head Injury Foundation Professional Council (1988) surveyed 1500 TBI survivors from 75 head injury facilities around the country and found that 40% of the survivors had moderate to severe substance abuse pretrauma. Another 15% were mild abusers. For over 95% of the TBI substance abusers, alcohol was overwhelmingly the substance of choice, followed by marijuana and then cocaine. Consistent with these findings, Kreutzer et al. (1990) found that between 30-40% of survivors admitted to substance abuse facilities across the country have had one to three mild head injuries in their lives.

The above incidence rates are considered to be quite alarming given the extensive data demonstrating the negative impact of substance use on brain injury survivors who have neuropsychological and psychosocial deficits and fatigue easily (Delmonico, Hanley-Peterson, & Englander, 1998; Kaitz, (1991). According to Sander, Witol, & Kreutzer (1997), potential risks have been shown to include slowed recovery, diminished benefits from rehabilitation efforts, and increased risk for seizures and reinjury through a second TBI. In addition, they also note chronic alcohol usage is associated with further cortical deterioration as well as other medical disorders such as liver, kidney and cardiovascular disease. Kaitz (1991) and Mtiguy (1991) site similar statistics in addition to the Kreutzer et al (1990) finding that TBI survivors have a significantly increased sensitivity to alcohol's effects postinjury. Finally, postinjury substance abuse has also been found to be a significant contributor to poor vocational outcome and retention (Ellerd & Moore, 1992; Haffey & Abrams, 1991 - Sale et al., 1991 - Wehman, West et al., 1989) postinjury

Despite the general agreement that substance abuse postinjury is a major problem that can significantly sabotage the rehabilitation process, few articles have addressed treatment approaches and even fewer have presented empirical data (Delmonico, Hanley-Peterson, & Englander, 1998; National Head Injury Foundation, 1988) to support their approaches. For example, the National Head Injury Foundation Substance Abuse Task Force White Paper(1988) makes treatment recommendations based on clinical observations and common sense. These recommendations include the following: a) longer and slower substance abuse treatment to compensate for cognitive and behavioral deficits; b) adding a substance abuse counseling program into the holistic brain injury rehabilitation program (occupational therapy, neuropsychology, physical therapy, speech therapy, cognitive remediation, vocational rehabilitation counseling, etc.) to address psychological dependency on substance as opposed to a separate substance abuse program; c) complete abstinence as even relatively small amounts of substance can worsen already compromised impulse control, judgment, balance, organization, etc.; d) the dedication of a special segment of the treatment dealing with the effects of substances on head injured persons, including the danger of combining alcohol or other central nervous system depressants with anti-seizure medications; e) modification of the many abstract elements of Alcoholics Anonymous and other Twelve Step programs to make the principles more concrete and understandable for brain injured persons; f) encouraging the survivor to stay with one AA/NA group to decrease confusion and to allow the group members to get comfortable with the survivor; g) the use of compensatory strategies (e.g., cue cards, memory books), videos, role playing, directive group therapies (particularly cognitive behavioral approaches), and other structured experiential techniques to improve retention of treatment information; h) stress management treatments to improve coping skills; i) preventive substance abuse counseling for brain injury patients who are not actively using substance; j) usage of community resources to maximize social interaction and quality of life and to reduce boredom, which could be an internal trigger for the use of substance; k) a focus on carefully restructuring the survivor's environment to remove cues for use of substance; and 1) family involvement in treatment.

Other papers (Kaitz, 1991) have reiterated these recommendations and added other suggestions based on clinical observations such as the need to limit the size of groups and to pace them according to member ability level. Blackerby and Baumgarten (1990) presented a comprehensive approach including an Alcoholics Anonymous model, education, cognitive behavioral techniques, and leisure education in a group setting.

More recently, some success has been achieved by treatment models based on the Stage Theory of Behavioral Change of Addictive Behavior developed by Prochaska and DiClemente (1992), a model which has been gaining increasing acceptance in the substance abuse treatment community. This theory was developed following many years of ground breaking research on addictive behaviors in which Prochaska and DiClemente showed that persons attempting to modify addictive behavior move through a series of linear stages. The stages range from precontemplation (patient has no intention to change behavior in the foreseeable future) all the way to maintenance (stage in which people work to prevent relapse and consolidate the gains attained during action). The stage that the patient is in can suggest prescriptive treatments of choice. In other words, the extent to which the professional is able to match the treatment intervention with the patient's stage in the behavioral change process will determine the effectiveness of the treatment.

The most popular and well-documented treatment approach based on the Prochaska and DiClemente (1992) theory is Motivational Interviewing (Miller and Rollnick, 1991), an approach designed to help clients build commitment and reach a decision to change. Motivational Interviewing draws on strategies from client-centered counseling, cognitive therapy, systems theory, and the social psychology of persuasion. According to Miller and Rollnick, most substance abuse treatment programs advocate aggressively confrontational interventions based on the empirically unproven assumption that substance abusers have usually high levels of certain defense mechanisms (e.g., denial, resistance) which render them unmotivated and poor candidates for traditional psychotherapies and which necessitate therapies to crush their defenses. The authors believe that these programs are unethical as well as ineffective. For example, they cite a study which found that problem drinkers randomly assigned to confrontational counseling had significantly higher levels of resistance (arguing, denying a problem) than did those given a client centered motivational interview treatment. In this same study, therapist behaviors in a single session were highly predictive of client's drinking over 1 year later. The more a therapist had confronted, the more a client was drinking; the more the therapist had been supportive and listening, the more the client changed.

Instead, Motivational Interviewing views patient denial as normal ambivalence which the patient needs to learn to tolerate and work through, as in any behavioral change process. According to Miller and Rollnick (1991), it is the therapist's handling of this ambivalence that determines the degree of client resistance and change. Motivation is seen as a state of readiness or eagerness to change, which may fluctuate and which can be influenced by a skillful, empathic therapist. As such, interventions that are recommended include reflective listening, supporting patient self-efficacy, presenting discrepancies between patient behavior and important goals, and strategies to increase the patient's sense of hope. Similarly, patient relapse is viewed as a normal process, again based on empirical studies showing that patients normally relapse several times on the way to any successful behavioral change. Blaming, labeling, power struggles, attempts to get the patient to focus on treatment issues which the patient is not yet ready for, and arguing are avoided. Motivational Interviewing can be integrated with other strategies and can also be used to prepare a motivational foundation for other approaches (12 Step, behavioral training, etc.).

In a recent study Bombardier & Rimmele (1999) demonstrated the promise of this approach with a TBI population. They found that of the TBI patients receiving a brief Motivational Interviewing intervention on an acute inpatient TBI rehabilitation unit, 89% reported drinking no alcohol during a typical week at I year after discharge, compared with 55% of control alcoholics, a significant difference. However the subject pool was too small (12 originally with only 9 participating in follow-up) to be conclusive, The authors believe that this technique is particularly good for patients in precontemplation or contemplation stage (using the Prochaska and DiClemente model discussed below), which most of the subjects were. It was also interesting that both groups showed substantial reductions in drinking consistent with previous studies showing spontaneous changes in drinking after TBI (e.g., Kreutzer, Doherty, Harris, & Zasler, 1990) among patients who are not institutionalized after TBI. This is consistent with the hypothesis that TBI triggers a period of contemplation about alcohol use among problem drinkers. During acute inpatient rehabilitation, there may be a window of opportunity to motivate persons with TBI to abstain or severely restrict their use of alcohol.

After observing that their TBI survivors who were most in need of substance abuse treatment were not yet abstinent, Delmonico, Hanley-Peterson, and Englander (1998) developed a group treatment approach based on the Prochaska and DiClemente (1992) Stage theory-inspired Harm Reduction philosophy originated in the Netherlands and now used in many community based public health interventions. Harm Reduction is a set of strategies and tactics that encourage substance abusers to reduce the harm done to themselves and others by their substance abuse. Harm Reduction does not seek to remove a persons' primary coping mechanisms until others are in place. In this model, the goal is to start where the person is and reinforce any positive changes with a bias toward promoting ego building instead of ego breaking, as in many 12 step modeled programs. Any reduction in drug-related harm and increase in making healthy choices is considered a success. Delmonico et al. report clinical observations of treatment success but offer no empirical support for these conclusions.

Corrigan, Lamb-Hart, and Rust (1995) present a holistic, outpatient community-based case management model of treatment based on the Prochaska and DiClemente Stages of Change theory (1992). AD survivors were eligible regardless of their current substance usage (abstinence was not a requirement for treatment), attitudes or beliefs about alcohol/drug use (level of denial), or acceptance of a substance abuse label. Patients were screened for substance abuse (e.g., General Health and History Questionnaire, Quantity-Frequency Variability Index, Stages of Change Readiness and Treatment Eagerness Scale, Michigan Alcohol Screening Test, Cage) as part of a comprehensive assessment. Based on the Stage of Change which the patient is in, patient is placed into a weekly substance abuse education group while on inpatient rehabilitation. As an outpatient, survivors are offered an 8-week substance abuse group which meets one hour weekly, as well as an ongoing support group if they wish to continue. The goal is to help the patient move to a higher stage of the behavioral change process (e.g., precontemplative to contemplative). Compensatory strategies (e.g., repetition, review, visual cues, mnemonics, role playing, paraphrasing) are used to improve learning. For patients who are unable to attend the outpatient group, individualized educational interventions are provided. Patients are also provided with education regarding the availability of substance abuse treatments and are offered an AA group for persons with head injuries. A family support group is also offered for family members of head injured substance abusers. Systems advocacy, service coordination, employment services, and a neuropsychological assessment are also offered. Preliminary results appear positive as a 6 month follow-up found that the average frequency of alcohol use decreased by 77%, while use of other drugs decreased by 89%. Quantity used per occasion decreased by 33% and the number of patients abstaining from alcohol/drugs increased almost 300%. Vocational status also increased with the number of patients in competitive employment doubling, while those doing volunteer work increased 300%.

Based on the above literature review, The Brady Institute for Traumatic Brain Injury housed in The Jamaica Hospital Medical Center is in the process of developing a substance abuse treatment program for TBI survivors as part of their interdisciplinary rehabilitation program. Therapists will use clinically accepted screening tools, clinical interviews, family interviews, medical evidence (e.g., blood alcohol level, alcohol/drug-related illnesses such as cirrhosis of the liver), and/or legal evidence (arrests due to drunk driving, buying drugs, etc.) to identify survivors who meet the entrance criteria and have the need. These survivors will be further assessed to determine the stage of the behavioral change process with regard to their substance abuse and will be invited to join the Substance Abuse Education Group.

Group activities/interventions will include educational lectures, videos, structured experiential exercises, group psychotherapeutic interventions including interpersonal, client centered, and behavioral approaches (e.g., self-monitoring, stress management training). Therapists will attempt to match the substance abuse treatment interventions with the survivors' stage in the behavioral change process. Therapists will reinforce any positive, healthy changes/decisions to promote ego building and to instill hope. Therapists will use compensatory strategies (e.g., cue cards, memory books, black board) to maximize learning. Therapists will reassess survivors periodically to evaluate progress. Survivors will also be reassessed following a relapse. Survivors who decline to attend Group will be offered individual substance abuse counseling consistent with stage of behavioral change. If individual treatment is also declined, survivor will be offered educational materials to peruse on their own.

References

Corrigan, J. D., & Lamb-Hart, G. L. (1995). A programme of intervention for substance abuse following traumatic brain injury. Brain Injury, 9(3), 221-236.

Blackerby, W. F., & Baumgarten, A. (1990). A model treatment program for the head injured substance abuser: Preliminary findings. Journal, of Head Trauma Rehabilitation, 5(3), 47-59.

Bombardier, C. H., & Rimmele, C. T. (1999). Motivational interviewing to prevent alcohol abuse after traumatic brain injury. Rehabilitation Psychology, 44(1), 52-67.

Delmonico, R. L., Hanley-Peterson, P., & Englander, J. (1998). Group psychotherapy for persons with traumatic brain injury: Management of frustration and substance abuse. Journal of Head Trauma Rehabditation, 13(6), 10-22.

Ellerd, D. A., & Moore, S. C. (1992). Follow-up at twelve and thirty months of persons with traumatic brain injury engaged in supported employment placements. Journal of Applied Rehabilitation Counseling, 23, 48-50.

Haffey, W. I-, & Abrams, D. L. (199 1). Employment outcomes for participants in a brain injury work reentry program: Preliminary findings. Journal of Head Trauma Rehabilitation, 6(3), 24-34.

Kaitz, S. (199 1). Integrated treatment : safety net for survival. Headlines, Summer, 11-16.

Kreutzer, J. S., Doherty, K., Harris, J., & Zasler, N. (1990). Alcohol use among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 5(3), 9-20.

Miller, W. A., & Rollnick, S. (199 1). Motivational Interviewing: Preparing people to change. New York: The Guilford Press.

Mtiguy, J. (1991). Alcohol & head trauma. Headlines, Summer, 3-9.

National Head Injury Foundation, Professional Council, Substance Abuse Task Force, (1988). Substance Abuse Task Force White Paper. Washington, D.C.: Author.

Prochaska, J. 0. & DiClemente, C. C. (1992). In search of how people change: applications to addictive behaviors. American Psychologist 47(9), 1102-1114.

Sander, A. M., Witol, A. D., & Kreutzer, J. S. (1997). Alcohol use after traumatic brain injury: Concordance of survivors' and relatives' reports. Archives of Physical Medicine & Rehabilitation, 78, 138-142.

Rimel, R. W. & Jane, J. A. (1983). Characteristics of the head-injured survivor. In M. Rosenthal, E. R. Griffith, M. R. Bond, & J. D. Miller (Eds.), Rehabilitation of the Head Injured Adult. (pp. 9-21.)

Sale, P., West, M., Sherron, P., Wehman, P. H. (1991). Exploratory analysis of job separations ftom supported employment for persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 6(3), 1 -11.

Wehman, P., West, M., Fry, R., Sherron, P., Groah, C., Kreutzer, J., & Sale, P. (1989). Effect of supported employment on the vocational outcomes of persons with traumatic brain injury. Journal of Applied Behavior Analysis, 22, 395-405.