1. Substance Abuse and Traumatic Brain Injury Evidence-Based Techniques to Prepare People for Lasting Change Gary S. Seale, PhD LPA LCDC Director, Clinical Programs Transitional Learning Center (TLC) at Galveston

3. Addictive Behavior - Defined Addictive behavior patterns are repeated and become predicable in their regularity and excess Abuse/dependence refers to a pattern of behavior that involves poor self-regulation, continues despite negative feedback (consequences), and often appears “out of control” Reinforcers for engaging in the behavior are very strong and the behavior is an integral part of the person’s life and way of coping

4. Addictive Behavior - Defined Failure to change, despite change is 1) possible, 2) in the best interest of the individual, is a characteristic of addiction Change is the antithesis of addiction, but how do we help people change?

5. “ If I had six hours to chop down a tree, I would spend four hours sharpening the axe…” - Abraham Lincoln

6. Scope of the problem Statistics Alcohol (ETOH) is THE most frequently used depressant and the cause of considerable morbidity and mortality Alcohol (ETOH) is THE most frequently used depressant and the cause of considerable morbidity and mortality In the United States, as many as 90% of adults have had some experience with alcohol In the United States, as many as 90% of adults have had some experience with alcohol Of those adults who have used alcohol 60% of males and 30% of females report an adverse life event related to alcohol use. Of those adults who have used alcohol 60% of males and 30% of females report an adverse life event related to alcohol use. Most people learn from their experiences and moderate or stop drinking Most people learn from their experiences and moderate or stop drinking

7. Scope of the problem Statistics - continued 14 million Americans abuse alcohol or are alcohol dependent (1 in 13) 14 million Americans abuse alcohol or are alcohol dependent (1 in 13) Alcohol abuse and dependence are more common in men than in women (5:1 ratio) Alcohol abuse and dependence are more common in men than in women (5:1 ratio) Men start drinking early; women start drinking heavily later in life; abuse and dependence progress more rapidly in women, causing more health-related problems Men start drinking early; women start drinking heavily later in life; abuse and dependence progress more rapidly in women, causing more health-related problems Size matters - differences in blood alcohol concentrations (BAC) Size matters - differences in blood alcohol concentrations (BAC)

8. Scope of the problem Statistics-continued Social-cultural differences exist (family, religious, etc.) Social-cultural differences exist (family, religious, etc.) Alcohol abuse and dependence rates are about equal in Caucasian and African-American populations Alcohol abuse and dependence rates are about equal in Caucasian and African-American populations Slightly higher abuse and dependence rates in Latino males Slightly higher abuse and dependence rates in Latino males Very low in Asian populations (due to adverse physical affects at low doses) Very low in Asian populations (due to adverse physical affects at low doses)

9. Scope of the problem Statistics-continued The earlier one starts drinking, the greater the risk for developing alcohol abuse/ dependence (those drinking at 15 are 7X more likely to develop alcohol use problems compared to those that begin at 21) The earlier one starts drinking, the greater the risk for developing alcohol abuse/ dependence (those drinking at 15 are 7X more likely to develop alcohol use problems compared to those that begin at 21) Health-related problems associated with drinking include cancer, brain damage, immune system dysfunction, fetal alcohol syndrome, etc. Health-related problems associated with drinking include cancer, brain damage, immune system dysfunction, fetal alcohol syndrome, etc. 50% of fatal traffic accidents involve alcohol 50% of fatal traffic accidents involve alcohol Many homicides and suicides involve ETOH Many homicides and suicides involve ETOH

10. Scope of the Problem Substance Abuse and TBI Males are about twice as likely to sustain a TBI than females Males are about twice as likely to sustain a TBI than females Males are about 3 to 4 times more likely to be under the influence of alcohol at the time of injury Males are about 3 to 4 times more likely to be under the influence of alcohol at the time of injury 29% to 58% of persons who sustain a TBI are under the influence of drugs/alcohol at the time of injury 29% to 58% of persons who sustain a TBI are under the influence of drugs/alcohol at the time of injury About 50% of TBI survivors return to pre-injury use patterns within the first year of injury About 50% of TBI survivors return to pre-injury use patterns within the first year of injury 54% of persons who sustain a second TBI are under the influence at the time of injury 54% of persons who sustain a second TBI are under the influence at the time of injury

12. Scope of the Problem Substance Abuse and TBI Males are about 3 to 4 times more likely to be under the influence of alcohol at the time of injury Males are about 3 to 4 times more likely to be under the influence of alcohol at the time of injury 29% to 58% of persons who sustain a TBI are under the influence of drugs/alcohol at the time of injury 29% to 58% of persons who sustain a TBI are under the influence of drugs/alcohol at the time of injury About 50% of TBI survivors return to pre-injury use patterns within the first year of injury About 50% of TBI survivors return to pre-injury use patterns within the first year of injury 54% of persons who sustain a second TBI are under the influence at the time of injury 54% of persons who sustain a second TBI are under the influence at the time of injury

13. Scope of the Problem Substance Abuse and TBI TBI is among the leading killers and disablers of all young adults under the age of 35 TBI is among the leading killers and disablers of all young adults under the age of 35 Medical and rehabilitation costs associated with TBI exceed 45 billion dollars annually Medical and rehabilitation costs associated with TBI exceed 45 billion dollars annually

14. Scope of the problem In purely economic terms, alcohol related problems cost the American society an estimated $185 billion annually (ER/Hospital costs, rehabilitation costs, law enforcement/incarceration, lost wages/productivity) In purely economic terms, alcohol related problems cost the American society an estimated $185 billion annually (ER/Hospital costs, rehabilitation costs, law enforcement/incarceration, lost wages/productivity) In human terms, the cost can not be calculated! In human terms, the cost can not be calculated!

16. Treatment Challenges Substance Abuse and TBI More frequent complications in the acute medical phase of recovery (i.e., respiratory, vascular, edema and ICP, etc.) resulting in longer lengths of stay in acute phase More frequent complications in the acute medical phase of recovery (i.e., respiratory, vascular, edema and ICP, etc.) resulting in longer lengths of stay in acute phase Lower levels of consciousness (lower GCS scores) and longer lengths of coma Lower levels of consciousness (lower GCS scores) and longer lengths of coma Greater agitation when emerging from coma Greater agitation when emerging from coma Greater levels of non-compliance and increased risk of leaving acute and post-acute care AMA Greater levels of non-compliance and increased risk of leaving acute and post-acute care AMA Greater risk of “losing” patient during follow-up Greater risk of “losing” patient during follow-up

17. Treatment Challenges Substance Abuse and TBI 29% to 40% of persons with TBI had substance abuse problems pre-injury. 29% to 40% of persons with TBI had substance abuse problems pre-injury. A large number of persons who were not problem drinkers before injury (up to 20%) are at risk for developing abusive patterns after injury A large number of persons who were not problem drinkers before injury (up to 20%) are at risk for developing abusive patterns after injury Persons who present for post-acute rehabilitation may be “dry” but not “sober” Persons who present for post-acute rehabilitation may be “dry” but not “sober” Persons with TBI, because of multiple and complex changes associated with brain injury, may feel they have a “reason” to use Persons with TBI, because of multiple and complex changes associated with brain injury, may feel they have a “reason” to use Drug seeking, relapse, & leaving treatment are frequent occurrences that impact outcomes Drug seeking, relapse, & leaving treatment are frequent occurrences that impact outcomes

18. Treatment Challenges Substance Abuse and TBI TBI survivors report that very small amounts of substances previously used can have a big impact on cognition and behavior TBI survivors report that very small amounts of substances previously used can have a big impact on cognition and behavior TBI survivors and family members report that cognitive, physical, and emotional deficits stemming from injury are exaggerated with substance use TBI survivors and family members report that cognitive, physical, and emotional deficits stemming from injury are exaggerated with substance use Prescriptions may be offered without considering substance abuse history Prescriptions may be offered without considering substance abuse history

19. Traditional Treatment Approaches Substance Abuse and TBI Minnesota (Hazelton) Model was heavily influenced by Jellenik’s disease concept of alcoholism Minnesota (Hazelton) Model was heavily influenced by Jellenik’s disease concept of alcoholism Emphasizes group work to help patients understand the nature of their illness Emphasizes group work to help patients understand the nature of their illness Requires patients to accept a diagnostic label and recovery is dependent upon complete abstinence Requires patients to accept a diagnostic label and recovery is dependent upon complete abstinence Resistance is seen as denial of the problem and must be confronted Resistance is seen as denial of the problem and must be confronted Uses 12-step principles in recovery Uses 12-step principles in recovery

20. Traditional Treatment Approaches Substance Abuse and TBI Persons with TBI may resist traditional approaches due to negative initial experiences with 12-step programs Persons with TBI may resist traditional approaches due to negative initial experiences with 12-step programs Requires patient to accept yet another diagnostic label Requires patient to accept yet another diagnostic label Difficulty with concepts central to 12-step programs (i.e., “higher power”, “spiritual awakening”, “first things first”, “one day at a time”, etc.) Difficulty with concepts central to 12-step programs (i.e., “higher power”, “spiritual awakening”, “first things first”, “one day at a time”, etc.) Heavy handed confrontation results in defensiveness Heavy handed confrontation results in defensiveness Conflicts between recommendations of treatment team and advice from “old timers”. Conflicts between recommendations of treatment team and advice from “old timers”.

21. An Alternative Treatment Approach – Stage Change Transtheoretical Model (TTM) of intentional behavior change focuses on: 1) how individuals change and, 2) identifies key change dimensions involved in this process. Transtheoretical Model (TTM) of intentional behavior change focuses on: 1) how individuals change and, 2) identifies key change dimensions involved in this process.

22. TTM Model of Intentional Behavior Change Precontemplation Precontemplation – not seriously considering change in the near future Contemplation Contemplation – considering change, experimentation, increasing the pros for change and decreasing the cons Preparation Preparation – commitment to change, planning Action Action – implementation, revising the plan Maintenance Maintenance – integrating change into lifestyle, coping Termination Lapse & Relapse

23. How Addictions Develop Precontemplation Precontemplation – person is not seriously considering engaging in the behavior (i.e., drinking) in the near future. Lack of interest can be due to: 1) little information or knowledge, 2) value system that excludes consideration of behavior, or 3) a conscious decision not to engage in behavior Protective factors include: religious involvement, good family relations/interactions, parental monitoring, peers with similar views/values, good self- regulation, economic and social stability

24. How Addictions Develop (continued) Contemplation Contemplation – person begins to consider engaging in behavior (i.e., drinking); begins to consider positive/negative aspects of behavior (i.e., images, media messages, modeling, etc.); experimentation Task of this stage is to gather information and weigh pros/cons Experiments with behavior until a decision is made to move ahead to Preparation or back to Precontemplation

25. How Addictions Develop (Continued) Preparation Preparation – continued experimentation and gradual (but deliberate) setting of the stage for regular engagement of the behavior (i.e., drinking). Based on experiences and positive/negative consequences, person may modulate or stop behavior, or develop less controlled (out of control) use Powerful physiological and psychosocial reinforcers; pros for continuing behavior increase and cons decrease; hard to believe negative messages from peers, parents, media, etc.

26. How Addictions Develop (Continued) Action Action – regular and predictable engagement in behavior (i.e., drinking); behavior can be well controlled/modulated with few or no negative consequences. Negative consequences triggers re- evaluation and self-regulation Behavior may be poorly regulated with negative consequences. Behavior occurs in many situations (more cues); over use becomes normalized and peer group, attitudes & beliefs shift to support behavior Alterations in self-regulatory feedback; negative consequences normalized

27. How Addictions Develop (Continued) Maintenance Maintenance – the behavior is an integral part of the persons life (can be well regulated; “social drinking”) Poor self-regulation; out of control behavior; behavior continues despite negative consequences; failure to change despite change is possible and in the best interest of the person Deflections Disconnections Deflections (negative consequences = technical problems) and Disconnections (between behavior & consequences)

28. How People Recover Precontemplation Precontemplation – not seriously considering change in the near future Contemplation Contemplation – considering change, experimentation, increasing the pros for change and decreasing the cons Preparation Preparation – commitment to change, planning Action Action – implementation, revising the plan Maintenance Maintenance – integrating change into lifestyle, coping Termination Lapse & Relapse

29. Screening & Evaluation Substance Abuse and TBI Establish criteria to determine who should receive substance abuse treatment Establish criteria to determine who should receive substance abuse treatment Record review (positive blood chemistry at the time of accident; positive history of CD treatment) Record review (positive blood chemistry at the time of accident; positive history of CD treatment) Clinical interview with patient and family (pre/post injury use patterns, substance of choice, consequences of use, previous treatment or attempts to stop, patient/family view of substance use) Clinical interview with patient and family (pre/post injury use patterns, substance of choice, consequences of use, previous treatment or attempts to stop, patient/family view of substance use) Formal assessment (SASSI, CAGE, AUDIT) Formal assessment (SASSI, CAGE, AUDIT)

30. Evaluate Readiness to Change Pre-contemplation (not aware a problem exists) Pre-contemplation (not aware a problem exists) Recovery Goal: problem recognition; accurate appraisal Contemplation (“turning point”/ “hitting bottom”) Contemplation (“turning point”/ “hitting bottom”) Recovery Goal: decisional balance favoring change Recovery Goal: decisional balance favoring change Preparation (what is the plan?; what are the resources?) Preparation (what is the plan?; what are the resources?) Recovery Goal: develop a plan; ID resources Recovery Goal: develop a plan; ID resources Action (commitment to plan; strategies) Action (commitment to plan; strategies) Recovery Goal: teach strategies; implement plan Recovery Goal: teach strategies; implement plan Maintenance (lapse & relapse prevention) Maintenance (lapse & relapse prevention) Recovery Goal: sustaining change in many contexts Recovery Goal: sustaining change in many contexts Termination Termination

31. Goals and Strategies for PreContemplation Planting Seeds for Change Precontemplation = not seriously considering change in the near future. Usually due to one of the following “R’s” - Reluctance - Rebellion - Rationalization - Resignation - Revelry

32. Goals & Strategies for PreComtemplation (continued) Revelry Revelry – having too much fun. Consequences have not accumulated or are not severe; decisional balance not tipped toward change Goal - Goal: arouse concern; help person see negatives of behavior and positives of change Strategies - Strategies: how behavior affects others; engage emotional arousal (portrayal of consequences: example, new smoking commercials); “YET”

33. Goals & Strategies for PreContemplation (continued) Rebellion Rebellion – passionate about their ability to make choices; don’t want anyone telling them what to do. Goal - Goal: link freedom and autonomy with change; shift energy dedicated to the behavior to Contemplation and Preparation stages of change Strategy - Strategy: point out they are not free, but slaves to the behavior (Motivational Enhancement therapies and Motivational Interviewing techniques)

34. Goals and Strategies for PreContemplation (continued) Resignation Resignation – hopeless and helpless about change; overwhelmed by problems (including drinking); have tried to change and failed; “been addicted too long – it’s too late for change” Goal - Goal: infuse hope and a vision of the possibility of change Strategies - Strategies: focus on resilience in other areas of life; show data that “bad addicts” recover; “letter from the future”

35. Goals and Strategies for PreContemplation (continued) Reluctance Reluctance – hesitant about prospects of change; change means leaving comfort zone (friends, routines, etc.) Goal - Goal: increase confidence in the ability to change; provide reassurance they will be able to function without drinking. Strategy - Strategy: focus on past successes with difficult tasks; enlist support of individuals who have made similar changes (and been successful)

36. Goals and Strategies for PreContemplation (continued) Rationalizing Rationalizing – the person with all the answers, for example “..might be a problem for others, but not me”, “I’ll quit when I have serious responsibilities like a wife and kids”, “I only drink beer and never drink before noon” Goal - Goal: more accurate self-appraisal and recognition of consequences Strategies - Strategies: don’t argue; reflect back looking for ambivalence or discrepancies with the behavior and the person’s values beliefs; provide resources and have them research for themselves; natural consequences

37. General Strategies for PreContemplation problem identification Remember – the overarching goal is problem identification Patience and persistence Try not to argue, nag, threaten, etc. Time your conversation – don’t attempt it when the person is drunk Listen, reflect back, provide support for change (be ready if they ask for help) Honest, accurate, objective feedback Reasonable boundaries; natural consequences

38. Goals and Strategies for Contemplation Contemplation Contemplation – thinking about change. Caution: rushing in without considering costs, or getting stuck in chronic contemplation - Goal - Goal: gathering information, examining the information, engaging in a comparative process (while moving toward pros for change) - Strategy - Strategy: Decisional Balance Exercise; reinforce self- efficacy (they have the “stuff” necessary for change – BAT exercise)

39. Goals and Strategies for Preparation Preparation Preparation – preparing for action = planning Goal - Goal: making and strengthening the commitment to change; developing a sound, reasonable plan for action that is likely to be successfully implemented by the individual Strategy - Strategy: conduct risk assessment; ID strengths and weaknesses; develop strategies and assess resources; complete change plan work sheet

40. Goals and Strategies for Preparation (Continued) Plan should be built around the person – self knowledge and patterns of behavior Consider social relationships, role expectations, recreational activities, vocational pursuits, living arrangements Complete a Brief Situational Confidence Questionnaire – arrange scenarios in a hierarchy Determine skills needed for success in each scenario (relaxation, assertiveness, etc.)

41. Goals and Strategies for Action Action Action – taking action to interrupt the habitual pattern of the behavior; person separates from the old pattern of behavior and begins to create a new one (establish a new pattern of behavior) Goal - Goal: break free from the behavior by using the strategies of the plan; revise the plan in the face of difficulties; manage temptations and slips that can provoke relapse Strategy - Strategy: Implement the Change Plan

42. Strategies for Action (continued) Set a start (target) date for implementation Change routines and manipulate environment where possible Teach coping strategies until mastery is reached (ok to use technology – Tactical Breathing Trainer) Instructions may need to be specific (written scripts); therapist may need to model behavior Reward approximations Manage slips (lapses) as an “event” not a failure

43. Goals and Strategies for Maintenance Maintenancenot Maintenance – making change permanent; not engaging in the behavior becomes established as the norm - Goal: actively counter any threats and temptations; check and renew commitments; ensure decisional balance remains negative for re-engaging in the behavior; establish protective environment and satisfying lifestyle Strategies - Strategies: revisit reasons to change; recognize progress and success; generalize behavior across settings

44. Other Skills Training Using the treatment team to establish positive everyday routines Advanced activities of daily living (ADL’s) Advanced activities of daily living (ADL’s) Social Communication Skills Social Communication Skills Leisure/Recreation Leisure/Recreation Productive Activities Productive Activities Compensatory Strategies Compensatory Strategies Adjustment to disability Adjustment to disability

45. Homework Substance Abuse and TBI Homework tasks provide a link between clinical intervention in structured settings and the “real” world Homework tasks provide a link between clinical intervention in structured settings and the “real” world Objective is to promote generalization Objective is to promote generalization Examples of homework assignments include: using relaxation techniques in a stressful situation; using assertive responses on a job trial; practicing problem-solving in a dispute with a room-mate, etc. Examples of homework assignments include: using relaxation techniques in a stressful situation; using assertive responses on a job trial; practicing problem-solving in a dispute with a room-mate, etc. Provides opportunities for team interaction (i.e., putting homework assignments on “to do” list) Provides opportunities for team interaction (i.e., putting homework assignments on “to do” list)

46. Structured Generalization Substance Abuse and TBI Allows opportunities to practice strategies in actual community settings where substance abuse might occur (involve other disciplines) Allows opportunities to practice strategies in actual community settings where substance abuse might occur (involve other disciplines) Therapist accompanies patient to a setting where use might occur Therapist accompanies patient to a setting where use might occur Therapist coaches patient to engage in competing behavior or use strategies practiced in therapy sessions Therapist coaches patient to engage in competing behavior or use strategies practiced in therapy sessions Patient is heavily reinforced for appropriate behavior Patient is heavily reinforced for appropriate behavior Patient experiences success Patient experiences success

47. Patient Education Substance Abuse and TBI Typically takes place in a group setting Typically takes place in a group setting Information on a variety of topics is presented/discussed: common myths and fallacies about substance use; relationship of substance use and TBI; effect of substances on brain and behavior, and recovery; identifying triggers; and relapse prevention Information on a variety of topics is presented/discussed: common myths and fallacies about substance use; relationship of substance use and TBI; effect of substances on brain and behavior, and recovery; identifying triggers; and relapse prevention Identification of community supports (including attending an AA meeting) Identification of community supports (including attending an AA meeting) Placement of written materials in a notebook Placement of written materials in a notebook

48. Family Education Substance Abuse and TBI Information provided on a variety of topics: the relationship between substance abuse and TBI; effect of substances on the brain and behavior; medication interactions, etc. Information provided on a variety of topics: the relationship between substance abuse and TBI; effect of substances on the brain and behavior; medication interactions, etc. Signals of impending lapse (relapse) Signals of impending lapse (relapse) Sharing of the Change Plan Sharing of the Change Plan Identification of community supports (for both patient and family Identification of community supports (for both patient and family

49. Follow-up Substance Abuse and TBI Follow-up contact is made at identified intervals following discharge (ex. 1, 6, and 12 months post discharge). Follow-up contact is made at identified intervals following discharge (ex. 1, 6, and 12 months post discharge). Patient and/or family can contact the facility at any time between scheduled follow-up if a problem occurs. Patient and/or family can contact the facility at any time between scheduled follow-up if a problem occurs.

50. TLC Addiction & Substance Abuse Program (ASAP) Sample size = 12 Sample size = 12 Male/Female ratio = 11:1 Male/Female ratio = 11:1 Injury severity = severe (GCS, TFC, PTA) Injury severity = severe (GCS, TFC, PTA) Injury etiology = MVA (5), Fall (3), GSW (2), Work injury (1), Aneurysm (1) Injury etiology = MVA (5), Fall (3), GSW (2), Work injury (1), Aneurysm (1) Average Age: 31 (range = 20-47) Average Age: 31 (range = 20-47) Length of time since injury: 4.5 mo (1-12) Length of time since injury: 4.5 mo (1-12) SASSI results = all were high probability SASSI results = all were high probability 7 were under the influence at injury; 6 had previous CD treatment 7 were under the influence at injury; 6 had previous CD treatment

51. TLC - ASAP Treatment Services Activities of Daily Living – 10-12 hrs/wk Activities of Daily Living – 10-12 hrs/wk Physical Therapy – 5-10 hrs/wk Physical Therapy – 5-10 hrs/wk Speech/Language Therapy – 1-3 hrs/wk Speech/Language Therapy – 1-3 hrs/wk Neuropsychology – 2-4 hrs/wk Neuropsychology – 2-4 hrs/wk Neurocognitive therapy – 5-7 hrs/wk Neurocognitive therapy – 5-7 hrs/wk Leisure/Recreation – 8-12 hrs/wk Leisure/Recreation – 8-12 hrs/wk Productive Activities – 5-30 hrs/wk Productive Activities – 5-30 hrs/wk ASAP – 1-3 hrs/wk ASAP – 1-3 hrs/wk

52. TLC - ASAP Data Outcomes – 6 Month Follow-up Chemical use since discharge: 75% reported no use; 25% reported some use Chemical use since discharge: 75% reported no use; 25% reported some use Of those who reported use after discharge, 2 reported “controlled drinking”; one resumed heavy illicit drug use and was jailed; one was referred for inpatient detox and treatment Of those who reported use after discharge, 2 reported “controlled drinking”; one resumed heavy illicit drug use and was jailed; one was referred for inpatient detox and treatment Living status improved: 1 living in own home, 9 in the family home, 1 in a treatment center, 1 in jail Living status improved: 1 living in own home, 9 in the family home, 1 in a treatment center, 1 in jail Productive activity improved with 4 patients engaged in work/school, and 6 seeking work Productive activity improved with 4 patients engaged in work/school, and 6 seeking work

53. TLC - ASAP Outcome Analysis Analysis of 6-month outcomes revealed only 2 patients were attending AA meetings regularly and attributed abstinence to 12-step support meetings Analysis of 6-month outcomes revealed only 2 patients were attending AA meetings regularly and attributed abstinence to 12-step support meetings Other patients who were abstinent reported using other strategies: exercising; meditation/relaxation; attending church; and attending alternative community support groups (i.e., Rational Recovery) Other patients who were abstinent reported using other strategies: exercising; meditation/relaxation; attending church; and attending alternative community support groups (i.e., Rational Recovery)

54. Substance Abuse and TBI Conclusions There is no single method of treatment for substance abuse that is universally applicable and successful There is no single method of treatment for substance abuse that is universally applicable and successful Counselors and therapists should be familiar with traditional as well as alternative treatment models and methods Counselors and therapists should be familiar with traditional as well as alternative treatment models and methods Cognitive-behavioral techniques and comprehensive treatment approaches that incorporate Stage Change Theory (TTM) and Motivational Interviewing have demonstrated some success for persons with TBI Cognitive-behavioral techniques and comprehensive treatment approaches that incorporate Stage Change Theory (TTM) and Motivational Interviewing have demonstrated some success for persons with TBI

55. What to do if Someone You Know has a Problem with Alcohol Stop all “cover ups” Stop all “cover ups” Time your intervention (talk while the person is sober & right after an incident) Time your intervention (talk while the person is sober & right after an incident) Be specific (how drinking is affecting you) Be specific (how drinking is affecting you) State limits (be prepared to follow through - don’t make threats) State limits (be prepared to follow through - don’t make threats) Provide resources or refer person to someone in recovery Provide resources or refer person to someone in recovery Get support for yourself Get support for yourself

56. What to do if Someone You Know has a Problem with Alcohol Examine benefits of stopping unhealthy drinking patterns Examine benefits of stopping unhealthy drinking patterns Set a goal (to stop or cut down) Set a goal (to stop or cut down) Examine situations that trigger drinking and find new ways to handle that situation Examine situations that trigger drinking and find new ways to handle that situation Get social support Get social support Relapses are a part of recovery and should be treated as single episodes, not failure (no guilt) Relapses are a part of recovery and should be treated as single episodes, not failure (no guilt)

57. Resources - The Houston Council on Alcohol and Drugs 303 Jackson Street, Houston, Texas 77007 713-942-4100 - The Texas Commission on Alcohol and Drug Abuse (TCADA) http://www.dshs.state.tx.us/mhsa - Substance Abuse and Mental Health Services Administration (SAMHSA) http://www.samhsa.gov

58. Resources - Continued Substance Abuse/Brain Injury (SUBI) Bridging Project (140-page workbook with exercises) Ohio State University Brain Injury Substance Abuse Education Project – John Corrigan, PhD

59. Questions? (hopefully, some answers)

60. “Thank you, thank you very much!”

61. References Sparadeo, FR, Strauss, D, Barth, JT. The Incidence, Impact, and Treatment of Substance Abuse in Head Trauma Rehabilitation. Journal of Head Trauma Rehabilitation, 1990; 5 (3): 1-8 Sparadeo, FR, Strauss, D, Barth, JT. The Incidence, Impact, and Treatment of Substance Abuse in Head Trauma Rehabilitation. Journal of Head Trauma Rehabilitation, 1990; 5 (3): 1-8 Strauss, D. An Overview of Substance Abuse and Brain Injury. Brain Injury Source, 2001; 5(4): 8-11;40-41 Strauss, D. An Overview of Substance Abuse and Brain Injury. Brain Injury Source, 2001; 5(4): 8-11;40-41 Ruff, RM, et. al. Alcohol Abuse and Neurological Outcome of the Severely Head Injured. Journal of Head Trauma Rehabilitation, 1990; 5 (3): 21-31 Ruff, RM, et. al. Alcohol Abuse and Neurological Outcome of the Severely Head Injured. Journal of Head Trauma Rehabilitation, 1990; 5 (3): 21-31

62. References Continued Miller, WR & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behavior. New York: Guillford Press. Miller, WR & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behavior. New York: Guillford Press. Jones, GS. Substance Abuse Treatment for Persons with Brain Injuries: Identifying Models and Modalities. NeuroRehabilitation, 1992; 2(1): 27-34 Jones, GS. Substance Abuse Treatment for Persons with Brain Injuries: Identifying Models and Modalities. NeuroRehabilitation, 1992; 2(1): 27-34 Langley, MH, Lindsay, WP, Lam, CS. A Comprehensive Alcohol Abuse Treatment Programme for Persons with TBI. Brain Injury, l990; 4(1): 77-86. Langley, MH, Lindsay, WP, Lam, CS. A Comprehensive Alcohol Abuse Treatment Programme for Persons with TBI. Brain Injury, l990; 4(1): 77-86.

63. References Continued Corrigan, JD & Mysiw, WJ (2013). Substance Misuse Among Persons with Traumatic Brain Injury. In: Brain Injury Medicine – Principles and Practices, 2 nd Ed. Zasler, Katz & Zafonte, Eds. Demos Medical Publishers, New York Corrigan, JD & Mysiw, WJ (2013). Substance Misuse Among Persons with Traumatic Brain Injury. In: Brain Injury Medicine – Principles and Practices, 2 nd Ed. Zasler, Katz & Zafonte, Eds. Demos Medical Publishers, New York DiClemente, CC. (2006). Addiction and Change: How Addictions Develop and Addicted People Recover. Guilford Press, New York. DiClemente, CC. (2006). Addiction and Change: How Addictions Develop and Addicted People Recover. Guilford Press, New York. Duhigg, C. (2012). The Power of Habit. Random House, New York. Duhigg, C. (2012). The Power of Habit. Random House, New York.