By Cindy McGlynn
Autumn 2005, Vol 9 No 1
Karl* is an artistic man who loves the Beatles and vintage clothing. He also has a substance use problem and a mood disorder, and has had three brain injuries. The first two, from beatings, left him with memory and concentration problems. As a result of the injuries, he is unable to keep food in his stomach, which reduces the effectiveness of the medications he needs for his other symptoms. Recently hit by a bus, Karl now feels even more confused. He was a heavy drinker before his injury, but the alcohol dependence and mood disorder surfaced post-injury. Unfortunately, like many people with the triple whammy of substance use and mental health issues and acquired brain injury (ABI), Karl finds himself turned away from services.
Traditionally, mental health issues, substance use problems and ABI are treated by different systems of care. Substance use programs screen out individuals with brain injury, and mental health and addiction programs are ill prepared to deal with clients with ABI. Increasingly, mental health and addiction intake workers are screening for ABI (see Partners sidebar), but even if it is detected, there are virtually no services designed to treat all three issues. “We create services for people in the majority, not the minority,” says Jean Budden, a social worker with the G.F. Strong Rehab Centre in Vancouver, British Columbia. “These are the people out on the fringes; they represent the minority, but they desperately need treatment.” Not surprisingly, people like Karl fall through the cracks.
The desperate need for treatment is reflected in research. A 2005 article in the Archives of General Psychiatry found that alcohol use problems frequently occur in people with acquired brain injury and that previous alcohol use problems increase the risk of developing mood disorders after ABI, which in turn increases the risk of alcohol relapse. At the Ohio Valley Center for Brain Injury Prevention and Rehabilitation, a leader in the field, approximately half of clients in the program have a history of alcohol use problems.
It is difficult to say how many people live with this triple whammy because there is virtually no research. Dr. Shree Bhalerao, director of medical psychiatry at St. Michael’s Hospital in Toronto, sees many such cases. “It’s not unusual, especially here in the inner-city,” says Bhalerao. “Most head injuries happen to males in their 20s to 30s from motor vehicle accidents and alcohol use. A typical profile is a patient with severe mental illness who may be homeless and living on the street with limited resources. Then they suffer an acquired brain injury.” Integrating all three issues is complicated. In the early 2000s, a Toronto-based group set out to develop ways to integrate treatment of all three issues, but realized that the wide range of mental health issues and symptoms make the establishment of assessment guidelines and treatment protocols for the triple diagnosis extremely difficult.
Yet the need for integrated services remains. At a recent concurrent disorders conference in Vancouver, Budden and colleague Rick Lawrie, an alcohol and drug intervention coordinator, tackled the issue head on. They described the symptoms of brain injury to concurrent disorders workers and discussed the unique needs of people with this triple diagnosis. “The information was brand new to most audience members,” says Budden. “Mostly frontline workers expressing frustration at not being able to help clients who likely had an acquired brain injury and a concurrent disorder.”
From a treatment perspective, the problem is multi-dimensional and can lead to misunderstanding of symptomatic behaviours. It may be difficult to distinguish between mental health, substance use and ABI-related symptoms because many overlap (see Symptoms sidebar). The memory problems, emotional outbursts and difficulty initiating tasks that are common to brain injury may also indicate mental health issues. “People with ABI frequently have difficulty initiating activities,” says Dennis James, deputy clinical director of the Addictions Program at the Centre for Addiction and Mental Health (CAMH) in Toronto. “This, combined with memory impairment, means that people may miss appointments or not do their “homework,” which can be seen as low motivation. But in fact, they really do want to address their problems.”
Usually the only route available is to treat the problems separately, but this too proves difficult. People with ABI who appear unmotivated and have poor impulse control often get kicked out of traditional substance use rehabilitation programs because the cause of the behaviours isn’t correctly identified. “It’s hard to get these people to a place that can help them,” says Bhalerao. “They have to almost be in perfect condition when they’re accepted at a rehab unit, and that just doesn’t happen with these people.”
Treatment for ABI also takes time – up to three times longer than treating addiction or mental health issues alone, according to Lawrie. Budden says this slow progress can be frustrating for frontline workers with long waiting lists. “With brain injury you do things much more slowly,” says Budden. “There’s a cycle of getting better, slipping back and getting better again. To get someone with a brain injury through this cycle usually takes five years.”
Although there are no established, widespread strategies to help frontline workers deal more effectively with people with ABI and concurrent disorders, health care workers should learn about all three areas. The crucial starting point, says Lawrie, is for frontline workers in all three fields to screen for triple diagnosis. When ABI and concurrent disorders are detected, workers can follow practical guidelines to help treatment, according to Marty Wolfe, program director of the Traumatic Brain Injury Network at Ohio State University Hospital in Columbus. “Part of what we usually see is a reduced attention span,” says Wolfe. “Keep information as simple as possible and make eye contact to make sure individuals stay with you.”
Wolfe also advises repeating information and encouraging clients to write things down. Provide feedback in a direct but kind manner. And follow up or assist clients in the community where possible – people with ABI often have difficulty applying learned information to real-life settings and may have a short fuse if they get confused, for example, about accessing services from a different agency (see Practical tips sidebar for more strategies).
Wolfe also recommends that workers listen to their instincts. Sometimes recognizing the triple diagnosis begins by realizing that a client’s symptoms simply don’t make sense. “I’ve done workshops with large groups where participants say, ‘This patient didn’t seem to be a typical user, or a typical person with personality disorder,’” explains Wolfe. “After learning about ABI and concurrent disorder, they say, ‘Suddenly this patient makes sense.’”
*not his real name
Source: Rick Lawrie, G.F. Strong Rehab Centre, Vancouver, British Columbia
short-term memory loss
difficulty with balance and coordination
mood disturbances (diminished emotional control)
decreased frustration tolerance
Source: Brain Injury and Substance Abuse: The Cross-Training Advantage
Through a grant from the Ontario Neurotrauma Foundation, a group of ABI and addiction workers developed Brain Injury and Substance Abuse: The Cross-Training Advantage, a video and training package that raises awareness between the addiction and ABI fields and provides frameworks for care. The manual can be downloaded for free from the ABI Network. Here are practical tips taken from the guide for workers in both fields.
• Educate ABI clients and family about the risks of using substances.
• Involve family and social networks in supporting the client to address the issue.
• Take a history of client’s past and current substance use. Be specific – ask, “What’s the most you’ve used? The least?”
• Ask what effect substance use is having on client’s life (social, family, job, legal).
• Assess stressors and risk factors that might cause client to begin using (eg., isolation, boredom, depression, job loss).
• Help clients find meaningful substance- free activities.
• Establish ongoing contact with addiction professionals to exchange information and ensure client gets appropriate treatment.
• Screen for ABI, which includes asking about crashes, blows to the head, falls, fights periods of unconsciousness and hospitalizations.
• Adapt substance abuse treatment for people with ABI:
– slow down and simplify language
– provide extra time for clients to complete tasks
– repeat information and use short, simple phrasing
– encourage clients to take notes
– anticipate off-topic remarks
– keep instructions brief and clear
– encourage feedback– ask “Do you understand?”
– Give rest periods and reduce distractions
• Consult with ABI specialists about how to tailor treatment to the client’s learning style and remain in contact throughout to monitor progress and make changes.
An 18-month Toronto-based pilot project is examining ways to integrate substance use treatment with ABI rehabilitation. The pilot is a partnership between Community Head Injury Resource Services of Toronto, the Acquired Brain Injury Network and the Addictions Program at the Centre for Addiction and Mental Health (CAMH). The goals are to develop greater capacity for the participating agencies to work with people with a concurrent brain injury and substance use problem, and to develop strategies to build greater system capacity. Plans include modifying harm reduction, motivational interviewing and relapse prevention resources from CAMH for use with and by people with cognitive impairments, and conducting outcome studies based on the use of the adapted resources. For more information, contact Carolyn Lemsky at CHIRS at 416 240-8000.