Brin Injury nd Substnce Abuse: The Cross-Trining Advntge
My fntsy? Tht providers from both fields pick up their phones nd sy to ech other cn you help me? Dennis Jmes
1 Tble of Contents 2.... Foreword 3.... Project Tem 4.... Introduction 5.... How to use this eductionl pckge 7.... Informtion for both Brin Injury nd Substnce Abuse providers..... 8.... Definitions..... 8.... Effects of Brin Injury..... 9.... The Brin (digrm)..... 10... Substnce Abuse nd Brin Injury often go hnd in hnd..... 10... Why clients with this co-occurring condition fll through the crcks..... 11... Brin Injury nd Substnce Use cn be dngerous mix..... 11... How Substnce Abuse emerges..... 12... Symptoms tht my be common to Brin Injury nd Substnce Abuse..... 13... Symptoms of Brin Injury NOT ssocited with Substnce Abuse 15... Informtion on Substnce Abuse for Brin Injury providers..... 16... Red flgs: indictors tht increse risk of use..... 16... Signs tht your client my be using..... 17... Progression of Substnce Use..... 18... Wht Brin Injury providers cn do bout Substnce Abuse..... 19... CAGE Questionnire..... 20... Weighing the Pros nd Cons of Chnge..... 22... Model for stges of chnge nd tsks of Substnce Abuse tretment..... 26... Pths of Substnce Abuse tretment 29... Informtion on Brin Injury for Substnce Abuse providers..... 30... Brin Injury rehbilittion wht s done..... 31... Brin Injury rehbilittion who does it..... 32... Some wys to identify clients with Brin Injuries in intke..... 33... How clients with Brin Injuries my present in progrm..... 34... How to modify your pproch for clients with Brin Injuries..... 35... Wht to keep in mind 36... Questions nd Answers 40... Contcts nd References 44... Acknowledgements/Credits Bck Cover... Quick Review Bck Cover... Prticiption Feedbck Questionnire
2 Foreword This eductionl pckge (Brin Injury nd Substnce Abuse: The Cross-Trining Advntge mnul nd video) ws put together for providers who work in the fields of Brin Injury nd Substnce Abuse. Its im is to enble providers to recognize the co-occurring condition of Brin Injury nd Substnce Abuse nd modify their screening, ssessment nd tretment pproches to help clients more successfully re-integrte into the community. The pckge ws funded by the Ontrio Neurotrum Foundtion nd put together by Project Tem of Substnce Abuse nd Brin Injury providers, with input from other providers nd clients in both fields. We see it s first step in Brin Injury/Substnce Abuse cross-trining inititive for Ontrio. We begn putting the pieces together in 1999 nd completed it in September 2001. It ws long process, but not n rduous one, thnks to the importnce of the subject nd the dediction of the people who gve us their time, suggestions nd support. Project Tem
3 Project Tem Dennis Jmes, M.Sc. Clinicl Director Assessment & Generl Tretment Addiction Progrms Centre for Addiction nd Mentl Helth, Toronto Principl nd Chir/Ontrio Neurotrum Foundtion Project ph: 416 535-8501 emil: dennis_jmes@cmh.net Mitzi Jrrett, M.S.W. Socil Worker, Acquired Brin Injury The Rehb Choice (Affilited with The Riverdle Hospitl, Toronto) ph: 416 470-6716/1414 emil: mitzijtt@ol.com Shree Bhlero, M.D. B.A., B.Sc., PGD, F.R.C.P. (C) St. Michel s Hospitl, Toronto ph: 416 864-6060/2443 emil: bhleros@smh.toronto.on.c Chriss Courtney, M.H.Sc. B.Sc.OT, OTReg(Ont) Assistnt Executive Director Toronto Acquired Brin Injury Network ph: 416-597-3057 emil: bi.network@torontorehb.on.c
4 Introduction The links between Brin Injury nd Substnce Abuse re well documented, yet people with this complex co-occurring condition fce formidble, often insurmountble brriers in obtining pproprite cre becuse: Substnce Abuse providers ren t trined to identify or mnge the cognitive nd behviourl problems tht clients with Brin Injuries present. Brin Injury providers ren t trined to identify or mnge Substnce Abuse problems. As result, clients with this co-occurring condition often fll between the crcks. Their cses my be misunderstood, their tretment indequte nd their recovery jeoprdized. The gols of this mnul nd video re to: enhnce understnding of the functionl reltionships between Brin Injury nd Substnce Abuse improve identifiction, ssessment nd tretment of people with both Brin Injury nd Substnce Abuse problems increse collbortion between providers in the two sectors nd fcilitte more integrted progrmming We know this mteril is not going to solve the problems inherent in the system or turn nyone into n instnt expert in new field. We do hope, however tht it will begin much-needed dilogue between Brin Injury nd Substnce Abuse providers nd help integrte clients with this co-occurring condition bck into the community. Our premise is positive one: Even without new resources, we cn begin to mke difference in the lives of clients who hve both Brin Injuries nd Substnce Abuse problems.
5 Even without incresed funding there re things we cn do now. Dennis Jmes How to use this eductionl pckge While the pckge cn be used individully, prticipnts re encourged to use it in smll groups. Idelly, group prticipnts should red copy of the mnul before the group session, then come together to wtch the video, discuss the issues, fill out the questionnire on the bck cover pge nd send it bck to us. The questionnire will help us evlute your needs nd continue the cross-trining.
The symptoms of Brin Injury nd Substnce Abuse cn be so similr, it s esy to confuse them. Shree Bhlero
7 Informtion for both Brin Injury nd Substnce Abuse providers The following section is intended to help Brin Injury nd Substnce Abuse providers understnd the correltion between the two conditions, recognize their symptoms nd begin to cope with the complexities involved in identifying nd treting clients with this co-occurring condition.
8 Definitions Substnce Use is the use of ny psychoctive substnce. Substnce Abuse, for the purpose of this video nd mnul, is the problemtic use of lcohol nd street drugs; it lso includes the problemtic use of prescribed drugs. Brin Injury 1 is dmge to the brin, which my be cused: trumticlly (e.g., from n externl force such s collision, fll, ssult or sports injury) or through medicl problem or disese process tht cuses dmge to the brin (n internl process or pthology such s stroke, neurysm or tumour) The dmge occurs fter birth nd is not relted to: congenitl disorder developmentl disbility process tht progressively dmges the brin Effects of Brin Injury As different prts of the brin control different physicl nd cognitive functions, how person is ffected by brin injury will depend on the loction nd severity of the injury, mking every brin injury unique. It is often difficult to determine the extent of dmge clients will suffer, but impirments cn be lifelong. The min gol of rehbilittion is to mximize functioning.
9 The Brin 2 Frontl lobe - Personlity, judgement, resoning, problem solving, nd inhibition, perhps the highest corticl functions, re the function of this lobe. An re designted for lnguge comprehension clled Broc s re is contined within the left frontl lobe hemisphere. Prietl lobe - The right side ffects left-side motor function, including strength, co-ordintion, nd senstion. The left side ffects right-side motor function. Occipitl lobe - This is the primry visul re where the brin receives the visul picture from the eyes nd interprets it. Cerebellum - Chiefly involved with muscle function, the cerebellum helps mintin blnce nd provide smooth directed movements. Spinl Cord Temporl lobe - The right side is responsible for perceptul skills, such s sptil reltionships nd visul orgniztion. The left side controls expressive lnguge nd is clled Wernicke s re. Although memory is function of the brin s whole, memory is strongly lnguge bsed. Dmge to the temporl lobe significntly ffects these skills. Brinstem - Considered the stlk of the brin, ll nerve fibres pss through here, including the crnil nerves. The brinstem performs sensory, motor, nd reflex functions. Of primry importnce re the vitl nerve centres tht control hert ction, blood vessel dimeter, nd respirtion.
10 Substnce Abuse nd Brin Injury often go hnd in hnd Approximtely one-third of (trumtic) Brin Injury survivors hve history of substnce buse prior to their injury. 3 Alcohol or other drugs re directly involved in more thn onethird of incidents tht cuse Brin Injury. 4 Twenty percent of people who do not hve Substnce Abuse problem become vulnerble to Substnce Abuse fter Brin Injury. 5 Why clients with this co-occurring condition fll through the crcks Providers re trined to identify nd tret either Brin Injury or Substnce Abuse, not both. Clients with this co-occurring condition often lck insight nd my not relize the seriousness of the problem. Substnce Abuse progrms my screen out clients identified s hving Brin Injury. Symptoms of Brin Injury nd Substnce Abuse cn present in similr wys nd my go unidentified. The effects of Brin Injury cn be invisible but they my prevent clients from successfully following Substnce Abuse progrm. Clients with Brin Injuries my lck the motivtion necessry to begin Substnce Abuse progrms.
11 Brin Injury nd Substnce Use cn be dngerous mix Alcohol nd drugs re neurotoxins tht negtively ffect recovery fter Brin Injury by interfering with the bility of nerve endings to reconnect. Alcohol nd drugs hve more intense effect fter Brin Injury. Substnce Abuse cn increse cognitive impirment, depression, seizures nd disinhibition; nd cn cuse problems with blnce, wlking nd tlking. Substnces interct with prescribed mediction. Substnce Abuse cn led to nother Brin Injury. Ech subsequent Brin Injury requires less force to do more dmge. How Substnce Abuse emerges As long s client is in hospitl or in rehbilittion, Substnce Abuse my not be problem. It cn begin or return to previous levels within two yers of dischrge nd cn ccelerte two to five yers fter dischrge.
12 Symptoms tht my be common to both Brin Injury nd Substnce Abuse short term memory loss impired thinking difficulty with blnce nd co-ordintion impulsivity mood disturbnces (diminished emotionl control) personlity chnges diminished judgement ftigue depression sleep problems decresed frustrtion tolernce
13 Symptoms of Brin Injury tht re NOT ssocited with Substnce Abuse problems with lerning, ttention nd memory (inbility to focus, concentrte nd remin on tsk; decresed bility to process informtion or red; decresed comprehension; decresed bility to follow) difficulty with problem-solving initition problems (difficulty getting strted, following through, being motivted) word-finding difficulty persevertion (repetition of n ide or ction) disorgniztion (poor time-mngement, misplcing items) tngentil remrks (going off topic) sequencing difficulties (inbility to do tsks in order or follow steps) inpproprite socil behviour hedches, dizziness or poor blnce disorienttion (becoming lost or hving trouble locting ddresses, remembering lndmrks) lck of insight (inbility to recognize one s own deficits; inbility to pprecite the consequences of own behviours; low self-wreness) difficulty generlizing lerning from one sitution to nother Plese refer to the list of contcts nd references t the bck of this mnul for more informtion on these issues.
Brin Injury providers feel helpless when their clients re using.we hve to give providers knowledge nd skills. Chriss Courtney
15 Informtion on Substnce Abuse for Brin Injury providers This section is intended to give Brin Injury providers n overview of Substnce Abuse, help them identify it nd give them some tools to help move clients into pproprite Substnce Abuse progrms.
16 Red flgs: indictors tht increse risk of use prior history of Substnce Abuse socil isoltion (estrngement from friends, fmily nd co-workers) strined fmily/mritl reltions nd lck of support boredom (not working, no ctivities) difficulty in djusting to chnged circumstnces (client my be ngry, depressed, nxious) self-medicting to feel norml (to del with chronic pin, grief nd sense of loss) Signs tht your client my be using deteriortion in functioning incresed irritbility nd gittion decresed self-cre/chnge in physicl ppernce incresed errtic behviour missed ppointments physicl evidence of lcohol: smell/red eyes physicl evidence of street drugs: dilted pupils
17 Progression of Substnce Use Substnce Use often proceeds through the following five stges. Use: socil or recretionl use Misuse: occsionl bouts of problemtic use Abuse: repeted occsions of misuse Dependency: using s coping strtegy Addiction: physiologicl dependence on the substnce leding to withdrwl if use is discontinued They re depressed, socilly isolted, stigmtized. Even if they didn t use before the injury, they re t risk to strt fter. Mitzi Jrrett
18 Wht Brin Injury providers cn do bout Substnce Abuse Educte client nd fmily bout the risks of clients with Brin Injuries using substnces. Engge fmily/socil network in ctively supporting the client to ddress the issue. Tke history of client s prior nd current use. Be specific sk, Wht s the most you ve used? The lest? Ask client bout his/her fmily history of Substnce Use. Ask wht effect use is hving on client s life (socil, fmily, job, legl). Use CAGE Questionnire (p. 19) nd Weighing the Pros nd Cons of Use (p. 20) to engge client with the issue. Gin n understnding of the Model for Chnge (p. 22). It my help you move your client through the stges. Assess stressors nd risk fctors tht might cuse client to begin using (isoltion, boredom, depression, job loss, etc). Help client find meningful substnce-free ctivities. Provide support for behviourl chnges before, during nd fter the Substnce Abuse progrm to build motivtion nd reinforce new behviours. Estblish ongoing contct with professionls in Substnce Abuse progrms to exchnge informtion nd mke sure the Substnce Abuse progrm is meeting the client s lerning needs.
19 CAGE Questionnire to screen for possible drinking problem 6 1. Hve you ever felt you ought to Cut down on your drinking? 2. Hve people Annoyed you by criticizing your drinking? 3. Hve you ever felt bd or Guilty bout your drinking? 4. Hve you ever hd drink first thing in the morning (Eye-opener) to stop your nerves or get rid of hngover? Two or more ffirmtive nswers indicte probble lcoholism. Any single ffirmtive nswer deserves further evlution. Mke Contct Mke contct with Substnce Abuse providers to help identify potentil Substnce Use nd move client into pproprite Substnce Abuse progrm. Mintin ongoing contct with Substnce Abuse provider to help individulize progrm chnges nd monitor client s progress.
20 Weighing the Pros nd Cons of Chnge Mke copies of the following questionnire for your clients. It my help you pproch the topic of Substnce Abuse in non-confronttionl wy. Its purpose is to help clients rech cler decision bout whether they wnt to chnge their behviour. 7 Quitting Drinking / Drug Use PROS (wht s good bout quitting) CONS (wht s not good bout quitting)
21 Continuing to Drink / Use Drugs PROS (wht s good bout continuing) CONS (wht s not good bout continuing)
22 Model for stges of chnge nd tsks of Substnce Abuse tretment This Stges of Chnge Model cn be pplied to most behviourl chnges. 8 It s presented here to give Brin Injury providers frmework they might dpt for ddressing Substnce Abuse issues. STAGE LAPSE 6: TASKS / RELAPSE STAGE 1: PRE-CONTEMPLATION TASKS TASKS CONTEMPLATION STAGE 2: RECOVERY 5: MAINTENANCE STAGE TASKS TASKS PREPARATION 3: STAGE TASKS 4: ACTION STAGE
23 STAGE 1: Pre-contempltion Although others cn see problem with substnces, the client is not wre of one. Tsks of provider Give personl nd fctul informtion to client nd the fmily. Fctul informtion could include the dngers of Substnce Abuse fter Brin Injury. Personl informtion could include description of problems tht could occur in the household when client buses substnces. Ask for the fmily s support. Discuss the problems in generl wy, e.g., Wht would hve to hppen to show you tht you hd problem with substnces? STAGE 2: Contempltion The client is thinking bout whether or not there is problem. This stge is chrcterized by mbivlence, fer of chnge, wishful thinking. Tsks of provider Move client one step further by looking t the pros nd cons of using/not using. Hve client continue to think bout wht would hve to hppen to led to chnge. Mintin neutrl role s fcilittor without becoming confronttionl.
24 STAGE 3: Preprtion At this point client is redy to engge in some kind of chnge rther thn simply contemplte it for some time in the future. Tsk of provider Gther informtion on Substnce Abuse progrms in client s re. Decide which progrms re best suited to client s cognitive functioning. Get telephone numbers, mke initil contcts. Tlk with Substnce Abuse providers bout client s cognitive difficulties nd decide wht modifictions could occur in the progrm to suit client s lerning needs. Keep in mind tht Alcoholics Anonymous or other 12-step progrms re sometimes the best option for clients with Brin Injuries s they operte on one-dy-t--time bsis. STAGE 4: Action Client stops using. S/he my enter progrm, detoxifiction centre or 12-step group. Tsk of provider As lck of motivtion nd short-term memory loss re common in clients with Brin Injuries, it s good ide to hve provider or fmily/support system ttend sessions with client. Provider should tlk with Substnce Abuse progrm leders to discuss wht modifictions would help client follow through.
25 STAGE 5: Mintennce Client consolidtes nd internlizes chnges with prctice nd support. Tsks of provider Keep in contct with client, fmily nd Substnce Abuse providers to monitor progress of client nd mke further modifictions to progrm s necessry. Continue reinforcing behviourl chnges. STAGE 6: Lpse/Relpse Often people in Substnce Abuse recovery return to initil use. Tsks of provider Return to previous stge nd tsks. Consider new strtegies to consolidte lerning for client. Assess or get ssessed the possible need for detoxifiction. Mke relpse prevention plns with client nd help him/her revise or re-dpt these plns. Wht to keep in mind Client my not follow liner progression of stges. Returning to using is often prt of norml recovery. Providers should continue with support.
26 Pths of Substnce Abuse tretment 1. Client recognizes tht s/he hs problem nd seeks forml progrm. 2. Client is interviewed, ssessed, ccepted or referred to progrm. 3. Client ttends tretment, which my rnge from individul counselling to n intensive residentil progrm. (Most intensive progrms re three weeks in durtion with sessions on stress reduction, self-esteem, wys to reduce crvings, preventing relpses, identifying triggers. Additionl support is offered in recovery homes, which hve longer-durtion supportive housing.) 4. Client my be introduced to Alcoholics Anonymous or other progrm nd encourged to ttend. (Some progrms incorporte 12-step pproch in their structure.) 5. Client continues with support nd regulr meetings for period of time tht vries with progrms. Alcoholics Anonymous or other 12-step progrms my be ttended insted of or in ddition to forml tretment. These progrms my be most effective for clients with Brin Injuries.
27 Something s simple s going to n ddictions meeting with your client cn mke ll the difference in the world. Chriss Courtney Plese refer to the list of contcts nd references t the bck of this mnul for more informtion on this section. The next section is written specificlly for Substnce Abuse providers.
They hve trouble reding, trcking, understnding, sequencing, focusing. It s esy to give up nd simply stop going. Mitzi Jrrett
29 Informtion on Brin Injury for Substnce Abuse providers This section is intended to give Substnce Abuse providers n overview of the complexities of Brin Injury nd its rehbilittion. It s lso intended to help Substnce Abuse providers identify Brin Injuries nd mke whtever chnges they cn to their progrms to ccommodte clients who hve this co-occurring condition.
30 Brin Injury rehbilittion wht s done therpy for physicl deficits (mobility, co-ordintion, blnce, pin reduction nd strength) cognitive retrining (strtegies to improve memory, problemsolving, ttention, comprehension, lnguge skills) eduction for client nd fmily bout Brin Injury behviour mngement (control inpproprite behviours) help with ctivities of dily living (time mngement, estblishing routines) counseling client nd fmily to djust to chnged circumstnces connecting client to multiple progrms nd dvocting on his/her behlf with vrious systems (legl, fiscl, housing, voctionl)
31 Brin Injury rehbilittion who does it Becuse the effects of Brin Injuries re so wide-rnging, rehbilittion involves multi-disciplinry tem pproch tht my use some or ll of the following professionls during the course of tretment. physiotherpist occuptionl therpist speech-lnguge therpist behviour therpist rehbilittion worker socil worker physitrist (rehbilittion physicin) neuro-psychologist neuro-psychitrist nurse other As long s the ptient is in the hospitl or rehbilittion, Substnce Use isn t problem. It s when they get bck in the community tht problems begin. Shree Bhlero
32 Some wys to identify clients with Brin Injuries in intke or ny time you suspect Brin Injury Look for these signs: symptoms listed on pge 12 physicl signs like scrs or irregulrities of the fce nd hed problems with blnce, speech nd/or co-ordintion. problems with thought processes tngentil thinking Ask these questions : Hve you ever been involved in crsh? (motor vehicle, fll, sports ctivity) Hve you ever hd stroke? Hve you ever fllen or been hit on the hed? How often? When? Hve you ever hd periods of unconsciousness? Hve you ever been hospitlized? Be specific. When? How mny times? Ws surgery done? When? Where? Are you on ny seizure mediction? Are you on ny other mediction? (Mediction could be msking or excerbting symptoms. This question will lso rule out dditionl medicl conditions)
33 How clients with Brin Injuries my present in progrm They my: miss sessions not identify with group miss informtion, misunderstnd wht s sid nd fll behind sk bout mteril lredy covered get stuck on one word or topic tlk too much or go off on tngent hve difficulty keeping up with the converstion hve poor follow-through on homework nd ssignments not pick up on socil cues mke socilly inpproprite remrks (overly personl/blunt) become esily frustrted, irritble, imptient nd overly emotionl be unble to remember new informtion lthough historicl memory is sound
34 Mke Contct With the client s consent, mke contct with Brin Injury providers, therpists or physicins mentioned in sessions with client. If you discover there hs been Brin Injury, sk Brin Injury specilist wht you cn do to tilor the sessions to the client s lerning style. Keep the contct going throughout the progrm to monitor the progress of client nd individulize progrm chnges s necessry. How to modify your pproch for clients with Brin Injuries Slow down in sessions. Simplify your lnguge. Offer informtion in smll bites Give client extr time or individul time. Repet informtion using short, simple phrses. Encourge note-tking or hnd out printed notes. Anticipte higher frequency of off-topic remrks. Keep instructions brief nd cler. Get feedbck sk Do you understnd? Summrize ides nd points. Redirect client when s/he goes off topic, tlks excessively or behves inppropritely.
35 Wht to keep in mind Client my lck insight s result of the injury nd my not recognize his/her cognitive deficits. Avoid confronttion over inpproprite behviours. This will only esclte the sitution. Insted, redirect client nd roll with resistnce. Be flexible, but mke cler wht s cceptble. Don t ssume tht non-complince rises from lck of motivtion or resistnce. Check it out with client. The Brin Injury my hve hppened five yers go but the effects could still be there. Find out if they ve been hospitlized, if they ve hd periods of unconsciousness, hd surgery. Shree Bhlero Plese refer to the list of contcts nd references t the bck of this mnul for more informtion.
36 Questions nd Answers Questions were solicited from providers in both Brin Injury nd Substnce Abuse. The most frequently-sked questions re included with response from the Project Tem. Q: Wht s the best wy to respond to client when s/he denies hving Substnce Abuse problem? A: First of ll, don t confront or try to rgue clients out of their point of view. You might sk for description of how they see their Substnce Use, wht they like bout it, wht they don t like bout it. You might lso sk them to describe why they think others believe there is problem. Above ll, be ptient nd be prepred to rise the issue repetedly, but gently. Q: Wht strtegies hve not been successful for clients with Brin Injuries in Substnce Abuse progrms? A: The reson we were motivted to put this eduction pckge together ws tht we recognized tht too often, the impct of either Brin Injury or Substnce Abuse ws ignored or missed. This is the lest successful strtegy. Q: Are there smller Substnce Abuse groups for clients with Brin Injuries? A: It would seem to be good ide to develop smller support groups. However, to our knowledge, there currently re no groups like this in opertion in Ontrio.
37 Q: Wht should I do if client with Brin Injury is slowing down Substnce Abuse group? A: Redirect the client bck to the topic being discussed. If the client is tlking excessively or cn t finish with the topic, feel free to mke cler tht you need input from others, need to move on etc. Remember tht clients with Brin Injuries my not pick up on socil cues (e.g., tht the group is becoming frustrted) so the fcilittor needs to mke cler wht s pproprite nd set limits. Q: Wht strtegies do Substnce Abuse providers suggest to encourge clients who re reluctnt to go into Substnce Abuse progrms? A: Reluctnce implies certin level of willingness or desire to ttend but with reservtion. First nd foremost, try to determine wht is producing the reluctnce. Relize tht certin degree of reluctnce is common mong people entering Substnce Abuse progrm. Support in the form of informtion gthering or pre-rrnged nd prepred ppointments with Substnce Abuse progrm or provider my be very helpful. Accompnying the clients to n Alcoholics Anonymous (or ny other) meeting cn provide ressuring experience. Q: Is client with Brin Injury more vulnerble to substnces thn s/he ws before the injury? A: Yes. Alcohol nd drugs re neurotoxins tht ffect recovery by interfering with the bility of nerve endings to reconnect fter Brin Injury. Substnces hve more powerful effect fter Brin Injury. This effect is even more powerful on women thn men. Substnces cn interct with prescribed mediction. Substnce Use cn led to high-risk behviour, which cn led to nother Brin Injury. Ech subsequent Brin Injury requires less force to do more dmge.
38 Q: How mny drinks re considered sfe fter Brin Injury. A: There is no specific number of drinks tht is considered sfe fter Brin Injury. Ech client is unique nd ech Brin Injury is unique, so ech person s tolernce for lcohol nd other substnces vries. Totl bstinence my not be relistic for some clients nd in such cses, use should be miniml nd ctivities while using should be limited. Q: Should Substnce Abuse progrms ccept people with Brin Injuries? A: In most instnces, yes. Substnce Abuse providers will probbly need to mke some modifictions to how they present their mteril to tke cognitive impirments into ccount. There lso hs to be good mtch between the client nd the progrm. Some clients with Brin Injuries cnnot successfully prticipte in Substnce Abuse progrm. For these people, integrting Substnce Abuse mteril into Brin Injury progrmming is better solution. Q: How do I get client with Brin Injury to gree nd stick to n greement bout how much nd how often s/he will use? A: This is like ny behviourl contrct with client. Agreement nd complince rtes re higher if the client supplies the prmeters. Q: Are there fmily support systems in Substnce Abuse centres tht the fmily cn ttend for support? A: Mny Substnce Abuse progrms hve fmily support groups nd fmily eduction groups. Within the Alcoholics Anonymous frmework, Al Anon is specificlly for fmily members.
39 Q: Are Substnce Abuse providers ever mde prt of Brin Injury tem s n internl or externl support? A: Recently, some Substnce Abuse providers prticipted in Brin Injury rehbilittion. Our belief is tht there should be more of this kind of co-opertion nd we hve creted this eductionl pckge to support this view. Q: Wht do clients with Brin Injuries need from Substnce Abuse Providers to feel more comfortble in our progrms? A: They need to know tht the provider is sensitive to the person with cognitive difficulties nd is willing to mke the process esier by repeting, slowing down, using hndouts, simplifying speech. They need the provider to communicte directly with them by sking, How it is going? Wht would help? Are you ble to follow? Q: Is the Alcoholics Anonymous Model pproprite/effective for people with Brin Injuries? A: AA hs proven very effective support nd model for mny people nd the most effective support for some people. The ccessibility nd frequency of meeting, the vilbility of supportive contcts combined with esily-remembered reminder slogns could be prticulrly helpful for some people with Brin Injuries. Q: Given their cognitive difficulties, how do you help clients with Brin Injuries trnsfer wht they hve lerned in tretment into their dily lives? A: People with Brin Injuries do hve trouble generlizing informtion lerned in progrm to their everydy life. It s vitl tht rehbilittion providers nd fmily members ctively reinforce nd support the client to follow through on new routines nd behviours.
40 Contcts Addiction Clinicl Consulttion Service: 1-888-720-2227 When you need professionl dvice to help your client with n lcohol or drug problem. Cndin Assocition for Mentl Helth: 1-800-463-6273 Alcohol nd drug tretment in Ontrio, A Guide for People Seeking Help. Centre for Addiction nd Mentl Helth: 1-800-463-6273 Website: www.cmh.net Drug nd Alcohol Registry of Tretment (DART) Office Line: 519-439-0174 Crisis Line: 1-800-565-8603 Website: www.drt.on.c Drug nd Alcohol Tretment Info Line: 1-800-565-8603 Help Is Just Cll Awy. Metro Addiction Assessment Referrl Service: 416-599-1448 Ohio Vlley Center for Brin Injury Prevention nd Rehbilittion: 614-293-3802 Website: www.ohiovlley.org (Ask bout their Substnce Abuse Informtion Series) Ontrio Brin Injury Assocition: 1-800-263-5404 Website: www.obi.on.c (for informtion on Brin Injury nd contcts for locl ssocitions) Regionl Assessment Referrl Service For nerest loction nd contct informtion cll DART Toronto Acquired Brin Injury Network: 416-597-3057 Website: www.torontobinetwork.c emil: bi.network@torontorehb.on.c References Endnotes 1. Toronto ABI Network definition of ABI, My 1999. 2. Brin Injury: The Perspective from the Other Side of the Looking Glss. Ontrio Brin Injury Assocition 3. Corrign, 1995; Kolkowsky-Hynes et l., 1999; NHIF tsk force cited in Sprdeo et l., 1990. 4. Boyle et l., 1991; Corrign, 1995; Dikmen et l., 1995; Drubch et l., 1993; Loiselle et l., 1993.
41 Endnotes continued 5. Ohio Vlley Center for Brin Injury Prevention nd Rehbilittion. (1997). Substnce use nd buse fter brin injury; A progrmmer s guide. Columbus, OH: The Center. 6. Ewing J.A., Detecting Alcoholism. The CAGE questionire. JAMA 1984;252;1907 7. Miller, W. R., & Rollnick, S. (1991). Motivtionl interviewing. New York: Guilford. 8. Prochsk, J.O., DiClemente, C. C., & Norcross, J.C., 1992. Books / Reports Krywonis, M., Chlmers, H., & Phillips, K. (1996, November). Acquired brin injury nd substnce buse: Provincil tretment nd trining issues. Toronto: Addiction Reserch Foundtion. Mrion, D. W. (1999). Trumtic brin injury. New York: Thieme Medicl Publishers. Journl Articles Bigler, E. D., Bltter, D. D., Johnson, S. C., Anderson, C. V., Russo, A. A., Gle, S. D., Ryser, D. K., McNmr, S. E., & Biley, B. J. (1996). Trumtic brin injury, lcohol nd quntittive neuroimging: Preliminry findings. Brin Injury, 10(3), 197 206. Bombrdier, C. H. (1995). Alcohol use nd trumtic brin injury. Western Journl of Medicine, 162(2), 150 151. Bombrdier, C. H., Ehde, D., & Kilmer, J. (1997). Rediness to chnge lcohol drinking hbits fter trumtic brin injury. Archives of Physicl Medicine nd Rehbilittion, 78(6), 592 596. Bombrdier, C. H., Kilmer, J., & Ehde, D. (1997). Screening for lcoholism mong persons with recent trumtic brin injury. Rehbilittion Psychology, 42(4), 259 271. Bombrdier, C. H., & Rimmele, C. T. (1999). Motivtionl interviewing to prevent lcohol buse fter trumtic brin injury: A cse series. Rehbilittion Psychology, 44(1), 52 67. Boyle, M. J., Vell, L., & Moloney, E. (1991). Role of drugs nd lcohol in ptients with hed injury. Journl of Rehbilittion nd Socil Medicine, 84(10), 608 610. Corrign, J. D. (1995). Substnce buse s mediting fctor in outcome from trumtic brin injury. Archives of Physicl Medicine nd Rehbilittion, 76(4), 302 309.
42 Journl Articles continued Corrign, J. D., Lmb-Hrt, G. L., & Rust, E. (1995). A progrmme of intervention for substnce buse following trumtic brin injury. Brin Injury, 9(3), 221 236. Delmonico, R. L., Hniey-Peterson, P., & Englnder, J. (1998). Group psychotherpy for persons with trumtic brin injury: Mngement of frustrtion nd substnce buse. Journl of Hed Trum Rehbilittion, 13(6), 10 22. Dikmen, S. S., Mchmer, J. E., Donovn, D. M., Winn, H. R., & Temkin, N. R. (1995). Alcohol-use before nd fter trumtic hed-injury. Annls of Emergency Medicine, 26(2), 167 176. Drubch, D. A., Kelly, M. P., Winslow, M. M., & Flynn, J. P. (1993). Substnce buse s fctor in the cuslity, severity, nd recurrence rte of trumtic brin injury. Mrylnd Medicl Journl, 42(10), 989 993. Fuller, M. G., Fishmn, E., Tylor, C. A., & Wood, R. B. (1994). Screening ptients with trumtic brin injuries for substnce buse. Journl of Neuropsychitry nd Clinicl Neurosciences, 6(2), 143 146. Gentiletto, L. M., Rivr, F. P., Donovn, D. M., Jurkovich, G. J., Drncing, E., Dunn, C. W., Villveces, A., Copss, M., & Ries, R. R. (1999). Alcohol interventions in trum center s mens of reducing the risk of injury recurrence. Annls of Surgery, 230(4), 473 480. Gurney, J. G., Rivr, F. P., Mueller, B. A., Newell, D. W., Copss, M. K., & Jurkovich, G. J. (1992). The effects of lcohol intoxiction on the initil tretment nd hospitl course of ptients with cute brin injury. Journl of Trum, 33(5), 709 713. Jurkovich, G. J., Rivr, F. P., Gurney, J. G., Fligner, C., Ries, R., Mueller, B. A., & Copss, M. (1993). The effect of cute lcohol intoxiction nd chronic lcohol buse on outcome from trum. Journl of the Americn Medicl Assocition, 270(1), 51 56. Kelly, D. F. (1995). Alcohol nd hed-injury: An issue revisited. Journl of Neurotrum, 12(5), 883 890. Kelly, M. P., Johnson, C. T., Knoller, N., Drubch, D. A., & Winslow, M. M. (1997). Substnce buse, trumtic brin injury nd neuropsychologicl outcome. Brin Injury, 11(6), 391 402. Kolkowsky-Hyner, S. A., Gourley, E. V., Kreutzer, J. S., Mrwitz, J. H., Cifu, D. X., & McKinley, W. D. (1999). Pre-injury substnce buse mong persons with brin injury nd persons with spinl cord injury. Brin Injury, 13(8), 571 581. Kreutzer, J. S., Mrwitz, J. H., & Witol, A. D. (1995). Interreltionships between crime, substnce buse, nd ggressive behviours mong persons with trumtic brin injury. Brin Injury, 9(8), 757 768.
43 Kreutzer, J. S., Witol, A. D., & Mrwitz, J. H. (1996). Alcohol nd drug use mong young persons with trumtic brin injury. Journl of Lerning Disbilities, 29(6), 643 651. Kreutzer, J. S.,Witol,A. D., Snder,A. M., Cifu, D. X., Mrwitz, J. H., & Delmonico, R. (1996). A prospective longitudinl multicenter nlysis of lcohol use ptterns mong persons with trumtic brin injury. Journl of Hed Trum Rehbilittion, 11(5), 58 69. Kreutzer, J., Snder, A., & Fernndex, C. (1997). Misperceptions, mishps nd pitflls in working with fmilies fter trumtic brin injury. Journl of Hed Trum Rehbilittion, 12(6), 63 73. Kwsnic, C. M., & Heinemnn, A. (1994). Coping with trumtic brin injury: Representtive cse studies. Archives of Physicl Medicine nd Rehbilittion, 75(4), 384 389. Lngley, M. J., Lindsy, W. P., Lm, C. S., & Priddy, D. A. (1990). A comprehensive lcohol buse tretment progrmme for persons with trumtic brin injury. Brin Injury, 4(1), 77 86. Lech, L., Frnk, R., Boumn, D., & Frmer, J. (1994). Fmily functioning, socil support nd depression fter trumtic brin injury. Brin Injury, 8(7), 599 606. Loiselle, J. M., Bker, M. D., Templeton, J. M., Jr., Schwrtz, G., & Drott, H. (1993). Substnce buse in dolescent trum. Annls of Emergency Medicine, 22(10), 1530 1534. Pires, M. (1989). Substnce buse: The silent sboteur in rehbilittion. Nursing Clinicins in North Americ, 24(1), 291 296. Prochsk, J. O., DiClemente, C. C., & Norcross, J.C. (1992). In serch of how people chnge; Applictions to ddictive behviors. Americn Psychologist, 47, 1102 14. Rivr, F. P., Koepsell, T. D., Jurkovich, G. J., Gurney, J. G., & Soderberg, R. (1993). The effects of lcohol buse on redmission for trum. Journl of the Americn Medicl Assocition, 270(16), 1962 1964. Snder, A. M., Witol, A. D., & Kreutzer, J. S. (1997). Alcohol use fter trumtic brin injury: Concordnce of ptients nd reltives reports. Archives of Physicl Medicine nd Rehbilittion, 78(2), 138 142. Solomon, D. A., & Mlloy, P. F. (1992). Alcohol, hed injury, nd neuropsychologicl function. Neuropsychologicl Review, 3(3), 249 280. Sprdeo, F. R., Struss, D., & Brth, J. T. (1990). The incidence, impct, nd tretment of substnce buse in hed trum rehbilittion. Journl of Hed Trum Rehbilittion, 5(3), 1 8.
44 Acknowledgements This mnul nd video were funded by the Ontrio Neurotrum Foundtion with input from the Centre for Addiction nd Mentl Helth, the Toronto Acquired Brin Injury Network nd the Toronto Are Addiction Service Colition. We would like to thnk the providers nd clients in both Brin Injury nd Substnce Abuse fields who looked through the mteril, provided their input nd help. Specil thnks nd pprecition to Hether Chisvin without whose ptience, dediction nd professionlism this trining mnul nd video tpe would not hve been possible. Production Credits Reserch, Writing, Script writing, Mnul writing: Hether Chisvin ph: 416 967-1578 emil: hether@chisvin.com Production: Silverhmmer Productions Inc. Dremctchers Mnul Design: Ptricio Dvil emil: reddesign@symptico.c Photogrphy: Ed Wilkinson-Lthm
A quick review for Brin Injury providers Educte the client nd the fmily bout the risks of people with Brin Injury using substnces. Engge the fmily/network in ctively supporting the client to ddress the issue. Tke history of client s prior nd current use. Be specific sk wht s the most you ve used; the lest. Ask client bout his/her fmily history of Substnce Use. Ask bout the impct on the client s life (socil, fmily, job, legl). Use CAGE Questionnire (see p. 19)nd Pros nd Cons of Use (p. 20) to engge the client with the issue. Gin n understnding of the model for stges of chnge (p. 22). It my help you move your client through the stges. Assess stressors nd risk fctors tht might cuse client to begin using (isoltion, boredom, depression, job loss). Help client find meningful substnce-free ctivities. Provide support for behviour chnges before, during nd fter Substnce Abuse progrm to build motivtion nd reinforce new behviours. Estblish ongoing contct with professionls in Substnce Abuse progrms to exchnge informtion nd mke sure the Substnce Abuse progrm is meeting the client s lerning needs. for Substnce Abuse providers. Look for signs of Brin Injury (p. 12). Ask specific questions in ssessment (p. 32). Contct locl Brin Injury Provider for help nd dvice. Followup pprent non-complince with questions bout possible Brin Injury (p. 32). Look for signs of trouble in progrm (p. 33). Modify your pproch to meet client s lerning style (p. 34).
Brin Injury nd Substnce Abuse: The Cross-Trining Advntge Prticiption Feedbck Questionnire This questionnire will help up ssess your needs nd continue with this eduction progrm. If you re using the mteril individully, plese copy this questionnire, complete it nd fx it bck to Dennis Jmes t CAMH (416) 425-7896. If you re conducting smll group, plese mke copies of the questionnire for ll prticipnts nd mil them to Dennis Jmes, Clinicl Director, Assessment nd Generl Tretment, Addiction Progrms, CAMH, 33 Russell Street, Toronto Ontrio, M5S 2S1. 1 Plese indicte which field you re in (plese circle one): (Brin Injury) (Substnce Abuse) 2 How did you use this pckge? (individully) (in group) 3 () Do you hve experience working with clients with Brin Injuries? (Yes) (No) If yes, for how mny yers? (b) Do you hve experience working with clients who buse substnces? (Yes) (No) If yes, for how mny yers? 4 () The level of the mterils in the mnul for Brin Injury providers ws: (too bsic) (bout right) (too dvnced) (b) The level of mterils in the mnul for Substnce Abuse providers ws: (too bsic) (bout right) (too dvnced) 5 () The content of the video for Brin Injury providers ws: (too bsic) (bout right) (too dvnced) (b) The content of the video for Substnce Abuse providers ws: (too bsic) (bout right) (too dvnced) 6 Did this pckge supply the informtion you were hoping for? (Yes) (No) Plese rte the next group of sttements using the following scle: 1 = strongly gree 2 = gree 3 = neutrl 4 = disgree 5 = strongly disgree 7 I believe this trining progrm hs: () (b) Incresed my skill set 1 2 3 4 5 Incresed my wreness of this problem 1 2 3 4 5
7 continued (c) Incresed my comfort/confidence 1 2 3 4 5 8 I feel I cn use informtion I hve lerned in this progrm in my interctions with clients nd their fmilies. 1 2 3 4 5 9 Would you find workshop on Brin Injury nd Substnce Abuse helpful? (Yes, hlf-dy) (Yes, full-dy) (No) 10 Wht did you find most helpful in this pckge? 11 Wht could hve been done differently? 12 Other comments: Specil thnks to Jeff Loudermilk nd Kthy Wong from St. Michel s Hospitl Mentl Helth Service, Toronto, who will be evluting the dt we receive.
ONF 2001 Plese feel free to copy for eductionl purposes.