1. 24/09/2012
Alcohol and Brain Injury
 People who use alcohol or other drugs after they have had a brain injury do
not recover as much.
Substance Abuse and  Brain injuries cause problems in balance, walking or talking that gets worse
when a person uses alcohol or other drugs.
Acquired Brain Injury  People who have had a brain injury often say or do things without thinking
first, a problem that is made worse by using alcohol and other drugs.
Dr Howard F Jackson  People who abuse alcohol render themselves more likely to encounter
Consultant Clinical Neuropsychologist
undesirable influences,
 Brain Injury increases the vulnerability to further brain injury as a result of
Founder and Clinical Director intoxication.
TRU Ltd  Excessive intoxication may cause further brain injury
Alcohol and ABI Alcohol and Brain Injury
 Brain injuries cause problems with concentration, memory, social
judgment, executive functioning, self-control, and emotional stability.
Using alcohol or other drugs exacerbates these cognitive impairments.
 Alcohol use was found to be the main factor in
getting into trouble with the law after ABI
After brain injury, alcohol and other drugs have a more powerful effect.
(Jackson, et al, 1992).

 People who have had a brain injury are more likely to have times that
they feel low or depressed and drinking alcohol and getting high on
 There are significant problems with supporting other drugs makes this worse in the long-term.
individuals with ABI who are intoxicated. Police
will often refuse to keep them until they are  After a brain injury, drinking alcohol or using other drugs can increase
the likelihood of a seizure.
sober and return to a unit with potentially
vulnerable other residents is often untenable.  People who drink alcohol or use other drugs after a brain injury are
more likely to have another brain injury.
Alcohol and ABI Services Social Influences
Within the unadapted home and community, the full
impact of various deficits may be experienced for the
Access to Brain Injury Services are often first time. Rather than deal with the emotional
consequences of such awareness (e.g., depression,
restricted due to Alcohol Abuse frustration and boredom) the individual may seek refuge
in the bottle, especially if such a pattern existed in the
past.
Access to Substance Abuse Service are
often restricted due to ABI. In sharp contrast to the rejection experienced in other
social situations, members of the drug culture extend a
warm and friendly welcome and cognitive and physical
limitations are readily accepted.
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2. 24/09/2012
Abuse of Other Substances Substance Abuse BLIPS
 Antidepressants,  BLIPS - Brief Limited Induced Psychosis
 Pain Killers,
 Cannabis
 Hypnotics  Alcohol
 Amphetamines
 Anticonvulsants  Cocaine
 LSD, Psilocybin (Magic Mushrooms)
 Tobacco
 Ecstacy
 Caffeine  Steriods?
Incidence Mistaken Identity
 Out of 80 clients at TRU 16 of them present  Individuals with acquired brain injury are more
with alcohol abuse as a core problem. Of these likely to present as intoxicated (eg slurred, slow
4 had poly-substance abuse.
speech, incoherence. emotional lability, etc)
 Two others have core issues of substance abuse
involving substances other than alcohol.  Individuals with acquired brain injury are likely
to present with psychiatric symptoms (paranoia,
 Ponsford (2007) found 25.4% drinking at a delusions, etc), especially under the influence of
hazardous level (australian study). Only 9% psychotropic substances – the Case of PD
presented with other drug problems. Main
abusers were young men.
Different Responses to Alcohol
 Aggressive Response - Case of CM
Treatment of Substance
 At Risk Response - Case of CH Abuse After ABI
 Passive Response – Case of JC A systemic rehabilitation approach
 Pleasant (Slightly embarrassing) response
– Case of HJ
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3. 24/09/2012
A Rehabilitation Programme for
Substance Abuse after ABI 1. Engagement
1 Engagement
2 Detoxification
Legal Issues
(MHA, MCA, Court Order)
3 Establishing Operations (an alternative ‘substance-free’
life-style)
Motivational Issues
4 Addressing Functional Value of Substance Abuse (and
substituting) (Incentives, Insight, Commitment)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
Engagement Motivational Interviewing
 Short term effect without ongoing MI
The Stages of Change Model
 Insight or intention does not equate with behaviour (good in theory, bad
in practice)
STAGE 1: PRE-CONTEMPLATION
 Slippage in the MI stages (episodic memory impairments)
STAGE 2: CONTEMPLATION
 Difficulty with reaching the contemplative stage due to impaired abstract
thinking
STAGE 3: PREPARATION
STAGE 4: ACTION  Difficulty with preparation stage due to impairments in ability to plan.
STAGE 5: MAINTENANCE  Difficulty with action stage due to initiative and memory problems.
 Difficulty with maintenance due to executive dysfunction
STAGE 6: LAPSE / RELAPSE
 Resistance of Conceptual Attributions.
A Rehabilitation Programme for
Substance Abuse after ABI
2. DETOX
1 Engagement  Higher risk of epilepsy/death
2 Detoxification
 Increased risk of delerium tremens
3 Establishing Operations (an alternative ‘substance-free’
life-style)
4 Addressing Functional Value of Substance Abuse (and
 Idiosyncratic response to medication
substituting)
5 Addressing False Attributions/Attitudes  Increased behavioural problems with
withdrawal
6 Helping the client take control (Relapse prevention)
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4. 24/09/2012
A Rehabilitation Programme for 3. Establishing Operations
Substance Abuse after ABI
1 Engagement  Developing a life-style without substance
misuse:-
2 Detoxification
3 Establishing Operations (an alternative  Sleep/Wake Cycle
‘substance-free’ life-style)  Exercise and Healthy Diet
4 Addressing Functional Value of Substance Abuse (and  Goal-orientated activity
substituting)  Pain Management, etc
 Self-structuring
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
A Rehabilitation Programme for
4. (Dys)functional Value of
Substance Abuse after ABI
Alcohol Misuse
1 Engagement
2 Detoxification  Initial function may change over time
3 Establishing Operations (an alternative ‘substance-free’
life-style)  If the functional reasons for misusing are
4 Addressing Functional Value of Substance
not addressed then relapse or unhelpful
Abuse (and substituting) substitutions are likely.
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
4. Different Typologies of Alcohol 4. Functional Reasons For
Abuse – Functional Value Abusing Other Drugs.
 Impulsive Intoxication – Case of RM  They relieve my pain (cannabis)
 Stimulus Bound Drinking – Case of AA  They help me sleep (cannabis, hypnotics)
 Escalating Drinking - Case of NC  They keep me alert (amphetamines,
 Suggestible Drinking – Case of CH proplus)
 Encouraged Drinking – Cases of JC & KW  They keep me calm and chilled (cannabis)
 Social Anxiety Drinking – Case of JSS  They give me confidence (cocaine)
 Addicted Drinking – Cases of KW & BW  They help me stay in control (cocaine)
 Bored Drinking – Case of JE
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5. 24/09/2012
A Rehabilitation Programme for 5. False Attributions/Attitudes
Substance Abuse after ABI
1 Engagement
 I can’t get drunk since my ABI
2 Detoxification
3 Establishing Operations (an alternative ‘substance-free’  It improves my social functioning
life-style)
4 Addressing Functional Value of Substance Abuse (and  It calms me down
substituting)
5 Addressing False Attributions/Attitudes  Being normal is getting drunk/stoned
6 Helping the client take control (Relapse prevention)
5. False Attributions/Attitudes A Rehabilitation Programme for
Substance Abuse after ABI
1 Engagement
 Rational Self Analysis (and other CBT
2 Detoxification
Approaches) – Adapted for ABI
3 Establishing Operations (an alternative ‘substance-free’
life-style)
 Peer pressure discussion groups (EQUIP)
4 Addressing Functional Value of Substance Abuse (and
substituting)
 Education (Direct, Implicit)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse
prevention)
6. Helping the client take control 6. Contingent Pathways to Self-
(Relapse prevention) Management
1 Establishing and Maintaining Commitments (WRAP).  No-alcohol contact – non-alcohol related settings
2 Identifying Triggers and developing risk assessment  No alcohol contact – alcohol related settings
and management.
 Planned/Controlled alcohol contact – alcohol
3 Coping strategies (Neuropsychological : self- related settings with supervision
structuring, problem solving, risk evaluation)
 Planned Controlled alcohol contact – alcohol
4 Systematic and Contingent Exposure and related settings without supervision
Desensitisation (De-conditioning)
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6. 24/09/2012
General Guidance
Substance Abuse and ABI
Educate client and family about the risks of clients with Brain Injuries
using substances.
 Knowledge is not the sole answer - Engage family/social network in actively supporting the client to
address the issue.
 Most interventions for substance abuse Take a history of client’s prior and current use. Be specific — ask,
“What’s the most you’ve used? The least?”
involve educational or self-exploration
approaches as the primary therapeutic Ask client about his/her family history of Substance Use. Ask what
effect use is having on client’s life (social, family, job, legal).
approach.
Gain an understanding of the Model for Change . It may help you move
your client through the stages.
 Most interventions fail to address habitual
behaviours directly.
Practical Help
 Assess stressors and risk factors that might cause client to
begin/maintain using (isolation, boredom, depression, job loss, etc).
 Help client find meaningful substance-free activities.
 Provide support for behavioural changes before, during and after
the Substance Abuse program to build motivation and reinforce new
behaviours.
 Establish ongoing contact with professionals in Substance Abuse
programs to exchange information and make sure the Substance
Abuse program is meeting the client’s needs.
 Refer for Specialist ABI substance abuse rehabilitation
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