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Treating Trauma: 2 Ways to Help Clients Feel Safe, with Peter Levine

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Introduction to TRE® Tension and Trauma Releasing Exercises - Shake it Off Slideshow Presentation

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Introduction

Between 1993 and 1998, the Research and Training Center on Community Integration of People with TBI interviewed hundreds of individuals about their lives after experiencing traumatic brain injuries. People were eligible to be part of this sample if they viewed themselves as someone who has experienced a brain injury and has a disability. A comparison group of individuals who view themselves as non-disabled was also interviewed. These samples include men and women from all regions of New York State - rural areas, cities, and suburbs. People as young as 18 and as old as 65, of all races, income levels, and life experiences participated in this research. In each issue of TBI Consumer Report, we share some of the insights resulting from these interviews. Here we use results from our research and from that of others to focus on the challenge of coping with SUBSTANCE ABUSE after TBI.

Is Substance Use/Abuse a Big Problem for Individuals at the Time of Injury?

Yes. Several studies have shown that before their injury people who sustain a TBI are twice as likely (35 percent) as others in the community (17 percent) to be either a significant user or abuser of drugs or alcohol - sometimes both. Furthermore, use of drugs and/or alcohol often causes accidents that lead to TBI, for example, while driving under the influence of alcohol.

Does Substance Use/Abuse Continue to Be a Big Problem After TBI?

This question is a bit trickier to answer. Many different research groups have explored this topic and have found that as many as 25 percent of the people in their studies have used/abused alcohol and/or marijuana at some time after brain injury. However, fewer people say they are currently using/abusing. In fact, in these studies of people with TBI who were three to 10 years post injury, only about 10 percent of those who were asked if they now drink or use drugs said "Yes."

The good news here is that people with TBI may be doing better in the long run than most people in avoiding substance use and abuse. These data may reflect the positive outcomes of prevention and treatment programs aimed at reducing alcohol/drug problems after TBI. But, this rosy picture is not as optimistic as it first appears, as even one person is too many - because of the heavy burden that alcohol and/or drugs add to the lives of people who have had a brain injury.

What Are the Specific Negative Effects of Drug/Alcohol Use After TBI?

Use/abuse of substances creates a major, additional challenge for the individual after TBI - at a time when he or she doesn't need to carry an even heavier load. Use of alcohol/drugs after TBI is known to result in:

Slower recovery from the brain injury;

Further damage to an already injured brain, ;

Increased frequency of aggressive and/or antisocial behaviors;

Interference with thinking processes already diminished due to injury; and

More failure in work, school, and parenting roles.

What Can We Learn from Others Who Have Kicked the Habit After TBI?

In addition to interviewing hundreds of people with TBI, the RTC also invited a small group of individuals who had successfully kicked their habit or stayed clean after TBI to discuss their insights about what was most helpful to them:

The importance of early treatment for those identified as known substance abusers. The group members told us that it was critically important that, at the time of inpatient hospitalization and during subsequent rehabilitation, professionals quickly identify their drug or alcohol abuse problem. This is important because, with identification, education about the consequences of continued use/abuse post TBI can be provided, and individuals can be referred to drug treatment programs at discharge from inpatient rehabilitation. People with TBI who were substance abusers at time of injury viewed their time spent in the hospital after TBI as mandatory detox.

Missing the covert drug users. Individuals with a less obvious drug or alcohol history and those who did not need inpatient rehabilitation were not likely to be educated about the negative consequences of continued use. Without such education, many continued, or began, to use drugs or alcohol as a means of self-medicating the numerous problems that emerge after TBI. Members of the group felt that early education would have been extremely helpful - everyone with a TBI should be brought up to speed, whether they are social drinkers, nonusers, or heavily into abuse. Indeed, our large-interview study supports the group's comments, in that we found that individuals who were nonusers at the time of injury - and who, thus, were less likely to have received education aimed at prevention - were at higher risk of developing a substance use disorder after TBI than were those who were substance abusers prior to their injury.

The double challenges of TBI and substance abuse. Group members also discussed the dual challenges they faced - as individuals with TBI (with one set of challenges) who also were abusers of alcohol/drugs (adding a second set of difficulties). In this vein, they talked about dealing with the typical losses associated with TBI (for example, cognitive problems, excessive fatigue, and personality changes), while at the same time needing to redefine their lifestyle, that is, the "persons, places, and things" that had maintained an active drug life. Combined, the two sets of challenges made redefining a new self and a new life much more difficult.

Identifying with a disability group. Because of the double challenges associated with TBI and substance abuse, a major problem people face is not knowing where to find the best support. When individuals sought help from community substance abuse programs, professionals and participants in these programs tended to underestimate TBI-related problems (cognitive, physical, and personality changes), making remarks such as, "Oh, we all have problems like that." Conversely, when people sought help from TBI-focused programs, professionals and members of the TBI community were often uncomfortable talking about the person's drug history or attempts at sobriety. Many members of the group felt that each source of potential help fully understood only half of their problems and challenges, which was often more frustrating than helpful. The group recommended a solid solution to the problem. People with post-TBI substance abuse problems should take advantage of inpatient and outpatient rehabilitation programs that offer a combined approach to TBI/substance abuse prevention. Further, the group encouraged individuals with TBI to find a mentor with TBI who is currently attending a community-based program such as Alcoholics Anonymous. This person can shepherd the individual in the community and help vouch for the specific challenges of TBI, which otherwise are likely to be misunderstood within this setting.

Ways of staying clean. The focus groups discussed ways of living life after TBI without using/abusing drugs or alcohol. Many individuals spoke of a strong reliance on 12-step programs, such as Alcoholics Anonymous or Narcotics Anonymous. Others emphasized the need to change the "persons, places, and things" that had acted as triggers for continued drug/alcohol use - for example, avoiding friends who were users/abusers and activities in which use/abuse typically occurred. Many found solace in spirituality, either through seeking a higher meaning on their own or finding an organized religious group. The latter created a new social bond that provides positive and meaningful activities rather than the harmful "persons, places, and things" associated with continued substance use. Finally, some members of the group discussed their attachment to pets - finding meaningful connection and affection in caring for animals.

What Are the Implications?

In sum, our findings and those of other researchers suggest that people who experience brain injuries often have a prior history of substance use/abuse. After TBI, a drop in use/abuse occurs, but a significant number of individuals - too many - use drugs/alcohol at some time after injury. The voices of people with TBI who had successfully kicked the habit point to several needed next steps. First, all individuals with TBI should be screened for prior drug/alcohol use patterns at the time of injury. Second, all individuals, regardless of prior usage, should be educated about the negative consequences of continuing, or starting, to use drugs or alcohol after injury. Third, those with TBI who have drug/alcohol problems need rehabilitation programs that provide dual treatment - not aimed just at TBI or at substance use, but at both. Finally, linkage with community-based prevention programs, such as AA, via a mentor (that is, a person with a TBI already involved in the community program) was encouraged.

More Information

This article was based on research conducted by the RTC: Ashman, T.A., Spielman, L.A., Hibbard, M.R., Silver, J.M., Chandna, T., and Gordon, W.A. (2004). Psychiatric challenges in the first 6 years after traumatic brain injury: Cross-sequential analyses of Axis I disorders. Archives of Physical Medicine and Rehabilitation, 85 (4, Suppl 2), S36-S42.

Hibbard, M., Uysal, S., Kepler, K., Bogdany, J., and Silver, J.M. (1998). Axis I psychopathology in individuals with TBI. Journal of Head Trauma Rehabilitation, 13(4), 24-39.

This article was based also on research conducted by others: Allen D.N., and Landis, R.K. (1998). Neuropsychological correlates of substance use disorders. In P.J. Synder and D.K. Nussbaum (eds), Clinical neuropsychology: a pocket handbook for assessment. Washington, D.C.: American Psychological Association.

Fann, J.R., Katon, W.J., Uomoto, J.M., and Esselman, P.C. (1995). Psychiatric disorders and functional disability in outpatients with traumatic brain injury. American Journal of Psychiatry, 152, 1493-1499.

Kreutzer, J.S., Wehman, P.H., Harris, J.A., Burns, C.T., and Young, H.F. (1991). Substance abuse and crime patterns among persons with traumatic brain injury referred for supported employment. Brain Injury, 5, 177-187.

Van Reekum, R., Bolago, I., Finlayson, M.A.J., Garner, S. and Links, P.S. (1996). Psychiatric disorders after traumatic brain injury. Brain Injury, 10, 319-327.

TBI Consumer Report is a publication of the Research and Training Center on Community Integration of Individuals with Traumatic Brain Injury, supported between 1993 and 2004 by Grant Nos. H133B30038 and H133B980013, to the Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York City, from the National Institute on Disability and Rehabilitation Research, United States Department of Education.

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TBI Consumer Report: Coping with Substance Abuse After TBI | BrainLine

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Between 1993 and 1998, the Research and Training Center on Community Integration of People with TBI interviewed hundreds of individuals about their lives after experiencing traumatic brain injuries. People were eligible to be part of this sample if they viewed themselves as someone who has experienced a brain injury and has a disability.

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Who Is at Risk for Developing a Substance Abuse Problem After TBI?

Many people who incur a traumatic brain injury have a substance abuse problem prior to their injury (see 1.3 elsewhere). As a result, it is not surprising that a number of people after they have had traumatic brain injury also have a substance abuse problem. Adolescents and adults who are hospitalized for traumatic brain injury are much heavier drinkers than their peers who have not incurred a TBI. However, for traumatic brain injury as well as for other injuries, there is often a "honeymoon" after the injury when the amount of drinking stops or reduces (Bombardier, Temkin, Machamer & Dikmen, 2003; Corrigan, Lamb-Hart & Rust, 1995; Kreuzer, Doherty, Harris & Zasler, 1990; Krueutzer, Witol, Sander, Cifu, Marwitz & Delmonico, 1996).

A few studies of persons with traumatic brain injury have found that alcohol use gets worse in the period 2 to 5 years after the injury and that unless something is preventing them, many resume their prior levels of alcohol and other drug use (Corrigan, Rust et al., 1995; Kreutzer, Witol et al., 1996; Kreutzer, Witol et al., 1996; Corrigan, Smith-Knapp et al., 1998). Situations that limit resuming use include having to live in an institutional setting where alcohol and other drugs may be less available, or living under closer supervision of family members who help the individual consume less. Of course, use may reduce or stop if the individual is provided information about the effects of alcohol and other drugs after traumatic brain injury or, for people with actual substance abuse problems, being provided treatment.

In addition to the large number of individuals who had a substance use disorder before their injury and return to those levels after, some studies have indicated that between 10% and 20% of persons with traumatic brain injury develop a substance use problem for the first time after their injury (Corrigan et al., 1995; Kreutzer et al., 1996). Thus, taken together, it is a very high proportion of individuals who have been hospitalized for traumatic brain injury who will be at risk for developing a problem after their injury - either because they had one before or because of the vulnerabilities created by the injury itself.

"Substance abuse is a risk factor for having a traumatic brain injury and traumatic brain injury is a risk factor for developing a substance abuse problem." -John Corrigan

How many people who have traumatic brain injuries are intoxicated at the time of injury?

At least 20% of adolescents and adults who are hospitalized and at least 30% of those requiring rehabilitation are intoxicated at the time of their injury. It is not surprising that there is a significant link between being intoxicated and incurring a serious injury. Whether because of diminished motor control, blurred vision, poor decision making or greater vulnerability to being victimized, a number of persons incur a traumatic brain injury while they are intoxicated. There is a lot of information available about how susceptible to injury people are when they have blood alcohol levels that exceed the legal limit. There is every indication that other drugs also put people at risk for injury. Three studies that have provided estimates of the number of people intoxicated at the time of their injury are shown below:
In persons hospitalized
Colorado TBI Surveillance and Follow-up System: 21% BAC .08 (n=2,151 hospital admissions in Colorado 16 years old).
In persons treated in rehabilitation:

TBI Model Systems: 37% BAC .10 (n=3,893 admissions to Model Systems acute rehab centers).

OSU Suboptimal Outcomes Study: 25% BAC .10, 12% + drug screen, 32% either (n=356 consecutive admissions for acute rehab).

How common is a history of substance abuse before the injury?

Corrigan (1995) reviewed published literature on persons with TBI who were intoxicated at time of injury and those who had a prior history of substance use disorders, whether or not they were intoxicated. Based on articles reporting these variables, having a prior history of substance abuse was more common than being intoxicated at the time of injury. Additionally, clinicians and researchers who used screening tools during the hospital stays found significantly higher rates than those who relied on later medical record review. This result suggests that more people will be identified if a systematic method of inquiring is used; rather than counting on patients to volunteer information or relying on reports of intoxication at injury.

Since that review, there are several additional sources of data on the frequency of prior substance use disorders in adolescents and adults treated in acute rehabilitation. Results from the following articles are graphed below:

TBI Model Systems National Database (n=1,262; Corrigan et al., 2003): 43% problem alcohol use or worse, 29% illicit drug use, 48% history of either;

OSU Suboptimal Outcomes Study (n=356 consecutive admits to acute rehab): 54% alcohol abuse or worse, 34% other drug abuse or worse, 58% history of either;

University of Washington (n=142 consecutive admits to acute rehab, Bombardier, Rimmele & Zintel, 2003): 58% at-risk alcohol use or worse, 39% recent illicit drug use, 61% history of either.

For adolescents and adults who require inpatient rehabilitation-as many as 60% may have a prior history of substance use disorder.

How common is TBI among persons receiving substance abuse treatment?

While there has not been a definitive, population-based study of how many individuals receiving treatment for substance abuse problems have incurred traumatic brain injuries, a collection of studies in the last 20 years suggests that it may be as high as 50%. The studies are summarized below and their results are graphed in the accompanying figure. The lowest rate observed was 38% of persons in treatment, the highest was 63%. Visual inspection of the graph supports an estimate of 50%, if not more.
Articles included in graph (below)

Alterman & Tarter (1985) found 53% of a sample of 76 male alcoholics had histories of TBI.

Hillbom & Holm (1986) found 38% of a sample of 157 alcoholics had a history of TBI with loss of consciousness or hospitalization.

Malloy, et al. (1990) found 58% of a sample of 60 alcoholics had TBI marked by loss of conscious-ness, hospitalization, or major neurological change.

Gordon et al. (2002) found 63% of 243 clients screened in 13 publicly funded programs in upstate NY had TBIs; 48% of 404 screened in 12 facilities in NYC.

At OSU, 119 clients in residential treatment, intensive outpatient or ambulatory detoxification at a publicly funded substance abuse facility:

68% 1 TBI with loc 5 minutes, or required ER visit or hospitalization;
35% 1 TBI with loc 1 hour or requiring hospitalization;
60% 1 TBI with early effects that did not persist at time of interview;
53% 1 TBI with early effects that persisted at time of interview.

How does substance abuse affect a person who has had a traumatic brain injury?

There are multiple reasons why alcohol and other drug use after traumatic brain injury is not recommended. The substance abuse education series "User's Manual for Faster, More Reliable Operation of a Brain after Injury" (Ohio Valley Center, 1994) enumerates eight reasons:

1. People who use alcohol or other drugs after they have a brain injury don't recover as much

2. Brain injuries cause problems in balance, walking or talking that get worse when a person uses alcohol or other drugs.

3. 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.

4. Brain injuries cause problems with thinking, like concentration or memory, and using alcohol or other drugs makes these problems worse.

5. After brain injury, alcohol and other drugs have a more powerful effect.

6. 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 other drugs makes this worse.

7. After a brain injury, drinking alcohol or using other drugs can cause a seizure.

8. People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury.

How is the brain affected?

There is mounting evidence about the adverse effects of alcohol and other drug use after traumatic brain injury. Several studies have observed an association between use and such unwanted outcomes as unemployment, living alone and feeling isolated, criminal activity and lower life satisfaction (Sherer et al., 1999; Corrigan et al., 1997; Kreutzer et al., 1996; Kreutzer et al., 1991; Corrigan et al., 2003). While these studies have observed associations, the causal links or processes have not been fully explained.

There are also studies suggesting an "additive effect" on brain structure and function for substance abuse and traumatic brain injury (Barker et al., 1999; Baguley et al., 1997; Bigler et al., 1996). One example is the study by Ian Baguley and colleagues from Australia (see graph below). Their 1997 study of event-related evoked potentials (an indication of how fast the brain detects new stimuli) showed a clear additive effect of heavy social drinking and traumatic brain injury requiring hospitalization. Those subjects who had either of these conditions were slower responding then people with neither; and those with both were slower still.

Are there treatment approaches that have been proven effective for people with traumatic brain injury?

Clinicians and researchers have repeatedly observed that cognitive and emotional impairments caused by brain injury present unique problems when addressing co-existing substance use disorders (Langley, 1991; Center for Substance Abuse Treatment, 1998; Corrigan, Bogner et al., 1999). While several models of how substance abuse treatment can be adapted to traumatic brain injury rehabilitation were proposed in the past (Blackerby & Baumgartnen, 1990; Langley, 1991), most presumed protracted inpatient or residential treatment that is no longer available to most persons with traumatic brain injury. Bombardier and colleagues have recommended brief interventions based on motivational interviewing techniques for use during acute rehabilitation (Bombardier, Ehde & Kilmer, 1997; Bombardier & Rimmele. 1999). Cox, Heinemann, et al. (2003) found some support for Structured Motivational Counseling in a study using a non-random comparison group.

A community-based model for treatment of substance abuse and traumatic brain injury was proposed by Corrigan and colleagues (Corrigan, Lamb-Hart & Rust, 1995; Bogner, Corrigan, Spafford & Lamb-Hart, 1997; Heinemann, Corrigan & Moore, 2004). The model uses consumer and professional education, intensive case management, and inter-professional consultation to address substance use disorders in adults with traumatic brain injury. Program evaluation data suggest significant differences in outcomes depending on whether discharge occurred before an eligible client could be engaged in treatment (eligible but untreated), after initiation of treatment but before treatment goals were met (premature termination) or upon mutual agreement with staff that goals had been met (treated). The Network's three programmatic outcomes (abstinence, return to work or school, and subjective well-being) assessed three months post-discharge are shown below. The median length of stay for those discharged successfully is 2 years. As might be expected, drop-out is a significant problem in this model. Retrospective analysis of 1,000 consecutive referrals indicated that 66% of those eligible for treatment either are not engaged initially or drop out prematurely.

How can existing substance abuse services be adapted for people with traumatic brain injury?

There should be a very high priority placed on doing research about the effectiveness of current substance abuse treatments for persons with traumatic brain injury. However, until more is known, current treatments and services need to be adapted to accommodate disability arising from traumatic brain injury. The Ohio Valley Center for Brain Injury Prevention and Rehabilitation have made a number of suggestions for substance abuse treatment providers., shown below.

Suggestions for Substance Abuse Treatment Providers Working with Persons Who Have Limitations in Cognitive Abilities
The substance abuse provider should determine a person's unique communication and learning styles.

Ask how well the person reads and writes; or evaluate via samples.

Evaluate whether the individual is able to comprehend both written and spoken language.

If someone is not able to speak (or speak easily), inquire as to alternate methods of expression (e.g., writing or gestures).

Both ask about and observe a person's attention span; be attuned to whether attention seems to change in busy versus quiet environments.

Both ask about and observe a person's capacity for new learning; inquire as to strengths and weaknesses or seek consultation to determine optimum approaches.

The substance abuse provider should assist the individual to compensate for a unique learning style.

Modify written material to make it concise and to the point.

Paraphrase concepts, use concrete examples, incorporate visual aids, or otherwise present an idea in more than one way.

If it helps, allow the individual to take notes or at least write down key points for later review and recall.

Encourage the use of a calendar or planner; if the treatment program includes a daily schedule, make sure a "pocket version" is kept for easy reference.

Make sure homework assignments are written down.

After group sessions, meet individually to review main points.

Provide assistance with homework or worksheets; allow more time and take into account reading or writing abilities.

Enlist family, friends or other service providers to reinforce goals.

Do not take for granted that something learned in one situation will be generalized to another.

Repeat, review, rehearse, repeat, review, rehearse.

The substance abuse provider should provide direct feedback regarding inappropriate behaviors.

Let a person know a behavior is inappropriate; do not assume the individual knows and is choosing to do so anyway.

Provide straightforward feedback about when and where behaviors are appropriate.

Redirect tangential or excessive speech, including a predetermined method of signals for use in groups.

The substance abuse provider should be cautious when making inferences about motivation based on observed behaviors.

Do not presume that non-compliance arises from lack of motivation or resistance, check it out.

Be aware that unawareness of deficits can arise as a result of specific damage to the brain and may not always be due to denial.

Confrontation shuts down thinking and elicits rigidity; roll with resistance.

Do not just discharge for non-compliance; follow-up and find out why someone has no-showed or otherwise not followed through.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Baguley, I. J., Felmingham, K. L., Lahz, S., Gordan, E., Lazzaro, I., & Schotte, D. E. (1997). Alcohol abuse and traumatic brain injury: Effect on event-related potentials. Archives of Physical Medicine and Rehabilitation, 78 (11), 1248-1253.

Bigler, E. D., Blatter, D. D., Johnson, S. C., Anderson, C. V., Russo, A. A., Gale, S. D., Ryser, D. K., MacNamara, S. E., & Bailey, B. J. (1996). Traumatic brain injury, alcohol and quantitative neuroimaging: Preliminary findings. Brain Injury, 10 (3), 197-206.

Bogner, J.A., Corrigan, J.D., Mysiw, W.J., Clinchot, D., & Fugate, L.P. (2001). A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes following traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 82(5), 571-577.

Bogner, J. A., Corrigan, J. D., Spafford, D. E., & Lamb-Hart, G. L. (1997). Integrating substance abuse treatment and vocational rehabilitation following traumatic brain injury. Journal of Head Trauma Rehabilitation, 12 (5), 57-71.

Cahalan, D., & Cisin, I. H. (1968). American drinking practices: Summary of findings from a national probability sample: I. Extent of drinking by population subgroup. Quarterly Journal of Studies on Alcohol, 29, 130-151.

Centers for Disease Control and Prevention. (1998). Behavioral Risk Factor Surveillance System user's guide. Atlanta, GA: Author.

Center for Substance Abuse Treatment (1998). Substance use disorder treatment for people with physical and cognitive disabilities. Treatment Improvement Protocol (TIP) Series Number 29. Washington, DC: U.S. Government Printing Office.

Corrigan, J. D. (1995). Substance abuse as a mediating factor in outcome from traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 76 (4), 302-309.

Corrigan, J. D., Bogner, J. A., & Lamb-Hart, G. L. (1999). Substance abuse and brain injury. In M. Rosenthal, E. R. Griffith, J. D. Miller & J. Kreutzer (Eds.), Rehabilitation of the adult and child with traumatic brain injury (3rd ed.). Philadelphia, PA: F.A. Davis Co.

Corrigan, J. D., Bogner, J. A. , Mysiw, W.J., Clinchot, D., & Fugate, L. (1997). Systematic bias in outcome studies of persons with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 78 (2), 132-137.

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

Corrigan, J. D., Rust, E., & Lamb-Hart, G. L. (1995). The nature and extent of substance abuse problems among persons with traumatic brain injuries. Journal of Head Trauma Rehabilitation, 10 (3), 29-45

Corrigan, J. D., Smith-Knapp, K., & Granger, C.V. (1998). Outcomes in the first 5 years after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 79 (3), 298-305.

Dikmen, S., Machamer, J. E., Donovan, D. M., Winn, H. R., & Temkin, N. R. (1995). Alcohol use before and after traumatic head injury. Annals of Emergency Medicine, 26, 167-176.

Ewing, J. A. (1984). Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association, 252, 1905-1907.

Jernigan, D. H. (1991). Alcohol and head trauma: Strategies for prevention. Journal of Head Trauma Rehabilitation, 6 (2), 48-59.

Kaplan, C.P., and Corrigan, J.D. (1994). The relationship between cognition and functional independence in adults with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 75, 643-647

Kreutzer, J. S., Witol, A. D., & Marwitz, J. H. (1996). Alcohol and drug use among young persons with traumatic brain injury. Journal of Learning Disabilities, 29 (6), 643-651.

Kreutzer, J. S., Witol, A. D., Sander, A.M., Cifu, D. X., Marwitz, J. H., Delmonico, R. (1996). A prospective longitudinal multicenter analysis of alcohol use patterns among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 11 (5), 58-69.

Langley, M. J. (1991). Preventing post-injury alcohol-related problems: A behavioral approach. In B. T. McMahon & L. R. Shaw (Eds.), Work worth doing: Advances in brain injury rehabilitation. Orlando, FL: Paul M. Deutsch Press, Inc.

National Association on Alcohol, Drugs and Disability. (1998). Access limited--Substance abuse services for people with disabilities: A national perspective. San Mateo, CA: Author.

Selassie, Pickelsimer, Tyrell, Gu & Turner (2003)

Silver, Kramer, Greenwald & Weissman (2001)

Substance Abuse and Mental Health Services Administration. (1998). National Household Survey on Drug Abuse: Population estimates 1998. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

U.S. Department of Health and Human Services. (1990). Nutrition and your health: Dietary guidelines for Americans (3d ed.). Washington, DC: U.S. Government Printing Office.

Whiteneck, G., Mellick, D., Brooks, C., Harrison-Felix, C., Noble, K., Sendroy Terrill, M. (2001). Colorado Traumatic Brain Injury and Follow-up System Databook. Craig Hosptial, Englewood CO.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines (10th Revision). Geneva: Author.

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Substance Abuse and Traumatic Brain Injury | BrainLine

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Many people who incur a traumatic brain injury have a substance abuse problem prior to their injury (see 1.3 elsewhere). As a result, it is not surprising that a number of people after they have had traumatic brain injury also have a substance abuse problem.

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Explore Headway's range of e-booklets and factsheets which cover many of the symptoms and practical issues association with brain injury. People with a brain injury and their families can order free copies of our information from the Headway helpline.

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Introduction

Behavior change is difficult for any individual to accomplish. The process, however, can be infinitely more difficult for those who suffer from a traumatic brain injury (TBI) due to physical, cognitive, and emotional impairments associated with an injury. Successful reintegration into the community and return to activities of choice is often dependent on the individual's ability to modify maladaptive behaviors that may result from the injury. Behavioral challenges that frequently require intervention following brain injury include aggression, disinhibition, difficulty relating to others, and a host of other behaviors.

A total reversal of behavioral problems after a brain injury may not be possible. A more realistic goal is to modify behaviors. There are several interventions available to assist with the modification of those behaviors that negatively effect goal achievement, successful community reintegration, or quality of life for individuals with TBI. The intent of this article is to describe and provide examples of current options for therapeutic intervention and examine their effectiveness for individuals with TBI.

Proactive Measures

There are a number of steps that can be taken proactively to set the stage in developing effective plans for behavior change.
Developing Trusting Relationships
It is important to build a trusting relationship with an individual who has had a brain injury. Much of what occurs during rehabilitation is based on trust that the individuals providing services understand what is important to the person receiving services. There must be trust that the recommendations providers make and activities they encourage, are designed to help the individual achieve his/her goals.

Trust is developed through honest, caring, and consistent interactions. It is important to be realistic with the individual. You cannot promise to 'make him/her better.' We, as family members or professionals, do not have all the answers to the individual's problems. We may be most helpful by providing a comfortable, nonjudgmental atmosphere in which the individual can discuss his/her concerns and preferences, even if the concerns and the accompanying behaviors do not appear to be logical. The knowledge gained from such discussions is invaluable when developing behavior plans or carrying out treatment.

The importance of relationships in behavior change goes beyond relationships between professionals and a person with brain injury. Following a brain injury, an individual may feel isolated and depressed (Denmark & Gemeinhardt, 2002). Success in coping with or adapting to changes after injury, as well as in modifying maladaptive behaviors, is highly dependent upon the feedback and support an individual receives from his/her social network. A supportive network may include professionals, family, old friends, new friends, and persons who have had similar experiences.
Understanding the Behavior
Developing adaptive behavior first requires recognizing what may be contributing to the problematic behavior. Triggers, antecedents, and precipitating factors are terms describing that which precedes the behavior. Triggers to acting-out behavior may be internal or external (Caraulia & Steiger, 1997). Examples of internal causes of behavioral problems can be fatigue, hunger, lowered self-esteem, etc. External triggers may include a frustrating task, interaction with certain individuals, change in structure/ routine, increased level of stimulation, etc. In addition to understanding what may trigger maladaptive behavior, it is important to understand what occurs following the behavior that may serve to reinforce and hence maintain the behavior. For example, if a given behavior consistently results in a rewarding experience such as increased attention, the frequency of the behavior will most likely increase. Modification of antecedents and consequences to change behavior is discussed in more detail under the heading Behavior Therapy.
Recognizing and Responding to Precursors
Individuals often provide non-verbal and verbal signs prior to displaying the behavior of concern. A person's change in behavior can represent a negative internal state. There may be signs of anxiety such as pacing and fidgeting. The face may become flushed; he/she may have difficulty maintaining eye contact or may display decreased attention to a task. An individual may also exhibit verbal signs, such as muttering to him/herself or increasing the volume of speech. Clearly, it is important to be aware of sudden, often subtle, changes in behavior (both non-verbal and verbal) in order to effectively intervene. Intervening early in the sequence of behavioral escalation is one of the most effective strategies for behavior change.

General Guidelines

In order to select the most appropriate intervention for modifying behavior during rehabilitation, the following guidelines, outlined by White, Seckinger, Doyle, and Strauss (1997), need to be considered:

Include the individual with TBI when developing a strategy. If a plan is developed without client input, it is not likely to be effective.

Prioritize the functional needs of the individual. Consider his/her strengths and weaknesses.

Analyze the tasks required for goal achievement. Individuals have more success if they can incorporate what they have already learned and know.

Consider the learning style. Individuals can learn from written information, oral information, or a combination of both. Ensure the intervention is compatible with the learning style of the individual.

Consider the individual's willingness to participate in the therapy or strategy.

Ensure that the strategy is practical. Time and funding constraints, family concerns, and environment limitations (i.e., in-patient vs. day-patient) should be considered.

Therapeutic Interventions

Several different approaches have been used to modify behavioral problems in individuals with TBI, some with more success than others. Most of the therapeutic intervention strategies were developed originally for individuals with learning disabilities, emotional dyscontrol, and psychiatric disorders. Studies have shown that with some adjustments or combination of approaches, these intervention strategies can benefit individuals with TBI (Alderman, 2003). However, most researchers agree that additional studies should be conducted to better measure the effectiveness of therapeutic interventions that have been adapted for use with persons with TBI (Denmark & Gemeinhardt, 2002; Kinney, 2001; Manchester & Wood, 2001; Schlund & Pace, 1999).
Insight Oriented Psychotherapy
Insight oriented psychotherapy can be defined as a process to gain more awareness and insight into our thoughts, feelings, and behaviors (Pologe, 2001). Theoretically, the more awareness one has of thoughts, feelings, and behaviors, the more one is able to change them. Therefore, insight oriented psychotherapy guides an individual to gain this awareness in order to change behavioral patterns. This type of therapy requires the individual to attend to task, maintain thought process, recall what is occurring (or occurred) during therapy, use reason, and develop insight. Considering these requirements, it is understandable that individuals with TBI, who may have problems with attention, memory, thought organization, or abstract processing, may not benefit from insight oriented psychotherapy. For this reason, Wood and Worthington (2002) concluded that insight oriented psychotherapy could only be implemented with individuals who have suffered mild or moderate debilitating effects.

For individuals with traumatic brain injuries who do not have severe cognitive deficits, insight oriented psychotherapy may be very beneficial. Prigatano (1986) suggested that a goal of psychotherapy for individuals with TBI should be to increase understanding of what has happened, the injury, and its effects. It should also help the person develop strategies for acceptance of injury, achieve self-acceptance, be realistic, and adjust to role and relationship changes. Finally, the process may be used to increase social appropriateness and develop behavioral strategies. Insight oriented psychotherapy for individuals with TBI is often conducted in a group in the rehabilitation setting. The group setting adds opportunities for feedback from peers that may enhance insight. Group therapy may not be productive, however, for individuals who are unable to filter out external stimuli and selectively attend to the task at hand, for those who become overly stimulated in a group setting, or for those who easily become frustrated or aggressive (Bennett & Raymond, 1997).
Cognitive Behavioral Therapy
Cognitive behavioral therapy is a specific form of psychotherapy that is concerned with how people's behavior is shaped by their interpretation and perception of their experience (Alderman, 2003). It aims at assisting the individual in understanding the link between beliefs, thoughts, feelings, and behavior. That is, there is often a belief (realistic or not; adaptive or maladaptive) that underlies one's thoughts and results in a pattern of behavior that is consistent with that belief. Needless to say, belief patterns that existed prior to the injury or those that are developed post-injury affect progress in rehabilitation.

In cognitive behavioral therapy, the individual is required to analyze maladaptive behavior in regard to any underlying beliefs that may be untrue, unrealistic, or counterproductive to meeting basic needs. The benefit of this approach is that one can alter behavior by changing beliefs or the way one thinks when it may not be possible to change the external situation (Albert Ellis Institute & Abrams, 2004). For example, a teenager may be suspended multiple times for fighting in school. She reveals to her counselor that she has the following belief: "the way to deal with hostility is to be hostile in return - an eye for an eye and a tooth for a tooth." Her counselor suggests alternative beliefs that would alter her emotional response and help her to avoid fights in school. In this case, alternative beliefs might include, "ignoring or walking away from another person's hostility keeps me out of trouble" or "being hostile in return doesn't improve the situation in the long run." The process requires that an individual take an active role in the application of techniques. Homework may be assigned so that techniques are practiced. Furthermore, the individual may be required to monitor his/her own behavioral responses (self-monitoring). This process builds awareness of behavioral patterns (including frequency, type of response, etc.), and leads to the individual taking more responsibility for altering his/her own behavior (Denmark & Gemeinhardt, 2002).

Effectiveness of cognitive behavioral therapy with individuals who have a TBI is dependent upon the individual's level of cognitive functioning. For example, the following personal characteristics are required to participate in Rational Emotive Behavioral Therapy (REBT) which is a form of cognitive behavioral therapy: self-direction, good ability to tolerate frustration, flexibility, acceptance of uncertainty, self-acceptance, nonutopianism (accepting the fact that one will never achieve a utopian or ideal existence), and ability to take responsibility for one's own emotional disturbances (Ellis & Dryden, 1997). Additionally, in REBT self-defeating thoughts and feelings are openly challenged. Discussion in either individual or group settings can be quite direct and demanding. Consequently, it has been suggested that a more flexible protocol of REBT be implemented for individuals with TBI. It should be more collaborative, less directive, and more flexible. In this sense, the therapist might adapt to the needs of the individual rather than the individual adapting to the REBT (Kinney, 2001). Manchester and Wood (2001) advocate that if REBT or another form of psychotherapy is used with persons with brain injury that the sessions be highly structured, repetitive, and include role play. They suggest that through procedural learning (repetition and structure), the likelihood will increase that cognitive behavioral therapy will be successful.
Behavior Therapy
The goal of behavior therapy is to manipulate the person's environmental antecedents (that which consistently precedes a behavior) and consequences (that which follows or results from the behavior) in order to decrease the likelihood of maladaptive behaviors occurring and increase more positive, adaptive behaviors (Denmark & Gemeinhardt, 2002). Typically, individuals who are not appropriate for insight oriented psychotherapy or cognitive behavioral therapy are able to benefit from behavior therapy. Behavior therapy is currently accepted as an effective intervention for modifying behavior following TBI. For example, there is evidence suggesting that if behavior therapy intervention is properly implemented to meet the needs of the individual, outbursts significantly decrease in a group home setting for individuals with TBI (Denmark & Gemeinhardt, 2002). Traditionally, behavior therapy has focused on modification of maladaptive behaviors. However, it has also been effective in helping individuals to relearn other skills such as self-care, budgeting, etc.

Terms and Concepts in Behavior Therapy
Identifying and modifying antecedents
As mentioned previously, analyzing the environment for antecedents to problem behavior and adapting the environment in which the behavioral problems occur can be critical in decreasing the severity and frequency of the behavior. For instance, an outburst could be preceded by a lot of noise, too many people in the room, too many demands, or simply fatigue or hunger (Ponsford, 1995). In the initial stages of working with an individual with TBI and assessing reasons for undesirable behaviors, consider the environment's comfort and pleasantness, level of stimulation, and adequacy in terms of privacy. Consider cultural issues that may contribute to behavioral problems. For instance, most Europeans prefer to bathe rather than shower. Attempting to impose a change in these cultural practices may, in fact, cause an undesirable behavior to occur. External expectations that do not take these issues into account may become a source of frustration for the individual and can contribute to behavioral problems.

Fluharty and Glassman (2001) examined the use of antecedent control to improve outcome for an individual with frontal lobe injury and intolerance for auditory and tactile stimuli. The individual suffered from profound memory, reasoning, and insight deficits. Therefore, traditional behavior modification using reinforcement and consequences was unsuccessful. The individual was unable to recall what behavior resulted in reward or consequence and had limited ability to understand the effects of his behavior. The treatment team made changes to the environment by eliminating noise and touch, which had previously served as triggers for problem behaviors. These changes were effective in reducing the problem behaviors. Clearly, understanding antecedents is a very important factor in the process of changing behavior.
Identifying and modifying consequences
Consequences serve to encourage or discourage a specific behavior or behavioral pattern. For example, others' reaction to an unwanted behavior may impact the individual's response resulting in the escalation (or de-escalation) of the behavior. This is referred to as an integrated experience - both individuals' behavior and attitude affect each other (Caraulia & Steiger, 1997). Individuals who display maladaptive behaviors are the most challenging to rehabilitate and may be excluded from rehabilitation settings because staff members lack the skills to respond effectively. If participating in a program that does not specialize in the treatment of maladaptive behavior, there is a natural tendency for staff to intensify interactions with the individual during the crisis situation (or when maladaptive behavior is exhibited) and to provide less attention to the individual when he/she is not displaying the maladaptive behaviors. The attention paid to the maladaptive behavior becomes a rewarding or reinforcing consequence. According to Alderman (2003), a benefit of using behavior therapy techniques is that staff members are required to attend to the individual when he/she is displaying desired, productive behaviors, reversing the tendency to attend to undesirable behaviors.
Positive reinforcement
Positive reinforcement refers to the use of rewards, privileges, incentives, attention, and praise to increase a desired behavior. When positive things happen following a behavior, the behavior is likely to increase.
Negative reinforcement
Negative reinforcement refers to the removal of noxious stimuli in order to increase desired behavior. For example, when inappropriate or aggressive behavior successfully stops the continuation of an unpleasant or physically taxing physical therapy session (unpleasant stimuli), the inappropriate or aggressive behavior is likely to occur in the future (Braunling-McMorrow, Niemann, & Savage, 1998).
Punishment
Punishment consists of unpleasant consequences following undesirable behavior. When behavior leads to a negative consequence (punishment), it is less likely to occur (Braunling-McMorrow, et al., 1998). It should be noted that punishment is consistently found to be less effective than positive reinforcement for creating and maintaining behavioral change. When the threat of the punisher has been removed, the behavior may resume.
Differential reinforcement
Differential reinforcement refers to a variety of positive reinforcement strategies and is one of the most widely used concepts in behavior therapy. The primary focus of differential reinforcement is to positively reinforce a desirable behavior that will replace the undesirable behavior. Four categories of differential reinforcement are defined below with an example as described in the American Academy for the Certification of Brain Injury Specialists (AACBIS) Training Manual for Certified Brain Injury Specialists (Braunling-McMorrow et al., 1998).

Differential Reinforcement of Other Behavior (DRO) - In using DRO, the individual receives a reward for specified periods of time in which there has been no occurrence of the undesirable behavior. For example, someone who has a verbal outburst twice per hour would receive a reward for each 30-minute interval in which no verbal outbursts occur.

Differential Reinforcement of Incompatible Behavior (DRI) - In DRI, a behavior that is incompatible with the undesirable behavior is identified and reinforced. For example, if one touches others repetitively when asked not to do so, an incompatible behavior would be keeping one's hands in one's pockets. The individual would receive positive reinforcement when engaging in the incompatible behavior.

Differential Reinforcement of Alternative Behavior (DRA) - DRA involves identifying an alternative behavior that is not necessarily incompatible with the target behavior and reinforcing it. For example, if one is overly talkative during vocational activities, an alternative behavior (e.g., remaining on task) is reinforced, while the undesirable behavior (e.g., talking) is ignored.

Differential Reinforcement of Low-Rate Behavior (DRL) - DRL involves the reinforcement of the reduction of undesirable behavior. For example, if someone displays 20 verbal outbursts per day, it is unrealistic to implement a plan that requires zero verbal outbursts to earn reinforcement. Rather, implementing a plan in which a lower frequency of the undesirable behavior, (i.e., displaying no more then 15 verbal outbursts per day), is more realistic. When the individual displays a lower rate of an unwanted behavior, reinforcement is provided.

Individual Behavior Plans

Reinforcement systems may be combined to develop an individual behavior plan. Individual behavior plans are detailed plans that include strategies and interventions designed to address specific issues that are impeding an individual's progress toward goals. The plan takes into account the individual's strengths and weaknesses and individual learning style. Since precision and consistency of application is important for learning to occur and for new behavioral patterns to develop, scripts are incorporated into the plan. A script is a set of written instructions that direct individuals working with the person with brain injury on how to respond to certain behaviors or situations. A behavior plan addresses antecedents and consequences. It defines a way of responding that teaches, elicits, and reinforces adaptive behavior, minimizes reinforcement of maladaptive behavior, and ensures the safety of the individual. Prompts, cues, instructions, and gestures are used to elicit the desirable behavior that is subsequently reinforced. Verbal instructions, visual cues (pictures), physical guidance (hand-overhand), and modeling can be used to facilitate learning (Wood, 2001). Verbal mediation is another method used to elicit adaptive behavior. Verbal mediation is used when the precursors of maladaptive behavior become evident. Mediation is used to evoke thoughts (why am I feeling this way?) and problem solving (alternatives in dealing with the problem situation). In the area of non-violent crisis intervention, Caraulia and Steiger (1997) developed a verbal mediation strategy that is called CPI COPING. COPING stands for: recognition of lack of "control" which prompts the following sequence: "orient" the person to the facts, identify "patterns" of behavior, "investigate" alternatives to the behavior, "negotiate" using a behavioral or incentive plan, and "give" back empowerment. While its development was not geared specifically to individuals with TBI, several of the steps have been useful when practicing verbal mediation with individuals with TBI. When prompting or verbal mediation elicits adaptive behavior, the behavior is reinforced.

Specific reinforcers or rewards must be identified for the individual for whom the plan is being developed. Remember, we are all unique in our preferences and what one person may find reinforcing or rewarding may not be reinforcing for another. To identify preferences for reinforcers, can ask the individual, ask family or friends, or simply observe the individual. Primary reinforcers include, but are not limited to, praise, encouragement, and attention. Secondary reinforcers such as tokens or points may be earned and traded in for special outings, increased time in certain activities or with preferred individuals, or desired purchases. Rewards may be provided each time the desired behavior occurs or at scheduled times such as at the end of the day. Cognitive factors may influence the schedule of reinforcement (ResCare Premier, 2002). For example, memory problems may interfere with the effectiveness of a reward program that involves a lengthy delay; the individual may not recall what they did or didn't do to obtain the reward. Alternatively, rewards given too frequently may result in the individual becoming satiated. The frequency of delivery of reinforcers must be identified in the behavior plan.

One type of secondary reinforcement system used within rehabilitation settings is the "token economy." Ponsford (1995) recommends that a psychologist supervise this type of system. The individual may receive tokens as reward for desired behavior; they may then exchange the tokens for certain material rewards. A set of rules is established outlining the behaviors desired, the frequency with which the tokens may be earned, and how they can be exchanged. Tokens can be given immediately or at specified time intervals. A specified time interval is effective if you are teaching the individual to remain on task or to sustain learned behavioral changes. Difficulties with this system have been noted by Ponsford (1995) who points out that some individuals with TBI find the system demeaning. Therefore, she suggests that a point system be implemented instead. The points are earned, similar to tokens; praise and encouragement is provided at the time that points are awarded. The point system is very effective for both individuals with TBI and staff members as it increases both parties' awareness of the expected behavior. The system promotes consistency and provides the opportunity for social reinforcement. Both token and point systems provide a visual cue so the individual can monitor his/her progress and successes throughout the day. Incentive programs such as point or token systems are used successfully to encourage participation in rehabilitation activities and development of adaptive behavior.

In addition to incentive programs, incidental and structured feedback may be incorporated into a behavior plan. Incidental feedback involves providing a prescribed response at the time that the alternative, adaptive behavior is observed. Structured feedback is a review with the individual of recent events or activities that have occurred. An individual may not have insight into what happened and why. Structured feedback provides an opportunity to get the facts and to analyze elements of the intervention plan that may not be working. The process can be a learning opportunity, an opportunity to develop preventive strategies for the future, and can be helpful in developing self monitoring skills. The review may occur at intervals throughout the day (at lunch, dinner, etc.). Each interval's activities or events are reviewed.

Schlund and Pace (1999) conducted a study to examine the benefit of systematic feedback to reduce maladaptive behaviors in three individuals with TBI. Their study concluded that the implementation of this feedback resulted in a reduction of both the variability and frequency of maladaptive behavior.
Summary of guidelines for an individual behavior plan
The following are guidelines for implementing a successful behavior plan (Alderman, Davies, Jones, & McDonnel, 1999; Braunling-McMorrow, 1998; Ponsford, 1995; ResCare Premier, 2002; Wood, 2001).

The individual with TBI should be included in the development, design, and implementation of the behavior plan. If the individual has input into the plan, it increases motivation to participate.

The behavior targeted for change should be identified and clearly defined.

The alternative behavior to be reinforced must be identified and clearly defined.

Scripts and directions for teaching and eliciting the adaptive behavior should be included.

Types and timing of reinforcement should be defined. The plan should be as positive as possible. The focus of a behavior change plan should be on teaching and rewarding desired behavior. Rehabilitation is a difficult process. Encouragement and praise should be given liberally for all attempts to complete the desired behavior.

It is a misconception that punishment or loss of privileges is the most effective response to undesirable behaviors. Punishment should be used only after all other interventions have been attempted and exhausted and when the maladaptive behavior is extreme, putting the person or those in his/her environment at risk. If this type of intervention is necessary, all stakeholders (family, rehabilitation providers, funders, case managers, etc.) must be in agreement in regard to the strategy used. The strategy is then used in conjunction with incentives for positive behaviors.

The plan should be a tool for teaching. Some individuals may display 'avoidance' and 'escape' behaviors. When a demand is initiated, individuals with TBI may respond by acting out in order to escape the task. However, being proactive and teaching alternative behaviors can help the individual to cope with the task. For example, identify the skills needed to complete the avoided task, teach the skills to the individual in small, manageable steps, develop an advance agreement to complete the avoided task at a specified time thereby giving the individual the ability to prepare for the task, and follow task completion with a positive reinforcer to increase the likelihood that the desirable response will occur.

The plan should be carried out in all contexts. Behavior does not happen in a vacuum, it is influenced by environmental factors and therefore can be displayed in the home, in the community, in the rehabilitation setting, etc. Consistency in implementing the program is critical for its success. Any inconsistencies may cause confusion and may indirectly reinforce the undesirable behavior. All individuals implementing the plan should receive training in all aspects of the plan.

The plan should include opportunities for feedback.

The frequency in which the desired and undesired behavior occurs should be documented. This process serves two purposes. First, tracking behavioral frequency provides feedback for the individual regarding his/her progress. Second, by tracking behavioral patterns, the effectiveness of the individual behavior plan can be evaluated and revised as needed. It may be necessary to adjust expectations if the desired behavior is too easy or too difficult or to adjust the frequency or type of rewards.

Relaxation Training
Relaxation training is used to reduce one's experience of anger and tension (Denmark & Gemeinhardt, 2002). It is thought that an individual cannot exhibit both relaxation and anger/tension responses at one given time. Therefore, the individual learns relaxation strategies that he/she can implement when feelings of anger/tension emerge in daily life. Some examples of these techniques are progressive muscle relaxation (focused relaxation of each muscle group in the body - feet, legs, torso, etc.), guided imagery (visualizing relaxing, peaceful, or encouraging experiences), biofeedback (monitoring the relaxation response by using electrodes which monitor and provide feedback about the activity of a muscle), breathing exercises, and forms of meditation (Denmark & Gemeinhardt, 2002). It is useful to incorporate role-play into relaxation sessions. The individual practices initiating relaxation techniques while thinking about potential real-life situations. There is very little literature that evaluates outcomes for the use of relaxation therapy techniques for individuals with TBI. This technique, however, has been used with success for individuals with learning disabilities and for children (Denmark & Gemeinhardt, 2002).
Social Skills Training
Social skills training programs are implemented with individuals who lack interpersonal skills and the ability to effectively communicate their desires in a problem situation or conflict (Denmark & Gemeinhardt, 2002). This type of program is geared toward individuals with problems in social interactions and includes focus on the development of social skills, assertiveness, and problem solving techniques. Social skills acquisition includes teaching the individual how to listen and understand others. Assertiveness teaches the individual to express him/herself constructively rather than in a confrontational manner. Problem-solving techniques allow the individual to develop conflict resolution skills. For individuals with TBI, this type of training can be especially useful as many individuals have difficulty expressing themselves, which often results in frustration and maladaptive responses. Denmark and Gemeinhardt (2002) suggest that role modeling the problem situations in a safe environment is the most beneficial. The role-playing allows the individual to learn appropriate responses or strategies at his/her own rate. It also provides opportunities for repetition and rehearsal of skills. The individual is able to internalize the behavior which helps to circumvent cognitive deficits such as planning, sequencing, and comprehension.
Anger Management
Novaco (1975) introduced one of the first multi-component approaches to anger management. He used a combination of behavioral, relaxation, and assertiveness training during three phases of treatment. The three phases included: 1) cognitive preparation, 2) skill acquisition, and 3) application of training. Medd and Tate (2000) conducted a study with persons with brain injury using a variation of Novaco's principles. They modified the training by outlining anger syndromes and common difficulties relevant to TBI and developed handouts summarizing the sessions. The program encouraged the participants to increase their awareness of emotional, behavioral and cognitive changes that occur when they become angry. The participants practiced relaxation techniques, self talk methods, and time outs. Medd and Tate (2000) concluded that this type of intervention was beneficial to the individuals in their study. However, they also recognized that the individuals in their study had a relatively high level of cognitive ability with only minimal memory impairments noted. They questioned the effectiveness of this type of approach with individuals who had more severe cognitive impairments.

Another multicomponent anger management program was developed by Deffenbacher (1995) and was called ideal treatment package. This included assessing the individual's anger and then working at developing self-monitoring, stimulus and response control, relaxation, cognitive restructuring, and interpersonal skills (Denmark & Gemeinhardt, 2002). A study has not been conducted to date regarding the application of this program with individuals with TBI.

Conclusion

In conclusion, several therapeutic approaches exist to assist individuals with brain injury to develop adaptive behaviors. At this time, there is not enough outcome data to dictate which therapy works best. The challenge for those who work with persons with brain injury is to find the intervention or combination of intervention strategies that works best for each individual. It is unlikely that one approach will ever be the 'sole treatment' for behavioral problems following brain injury. Unique individuals require unique and individualized treatment.

References

Albert Ellis Institute, & Abrams, M. (2004). Retrieved May 17, 2004, from Albert Ellis Institute Web site: http://www.rebt.org.

Alderman, N., Davies, J. A., Jones, C., & McDonnel, P. (1999). Reduction of severe behavior in acquired brain injury: Case studies illustrating clinical use of the OAS-MNR in the management of challenging behaviors. Brain Injury, 13(9), 669-704.

Alderman, N. (2003). Contemporary approaches to the management of irritability and aggression following traumatic brain injury. Neuropsychological Rehabilitation, 13(1/2), 211-240.

Bennet, T. L., & Raymond, M. J. (1997). Emotional consequences and psychotherapy for persons with traumatic brain-injury: Management of frustration and substance abuse. Journal of Head Trauma Rehabilitation, 13(6), 10-22.

Braunling-McMorrow, D., Niemann, G.W., & Savage, R. (Eds.). (1998). Training manual for the certified brain injury specialist (CBIS) (2nd ed.). Houston, TX: HDI Publishers.

Caraulia, A. P., & Steiger, L. K. (1997). Nonviolent crisis intervention: Learning to diffuse explosive behavior. WI: CPI Publishing.

Deffenbacher, J. L. (1995). Ideal treatment package for adults with anger disorders. In: H. Kassisnove (Ed.), Anger disorders: Definition, diagnosis, and treatment (151-172). Washington D.C.: Taylor & Francis.

Denmark, J., & Gemeinhardt, M. (2002). Anger and its management for survivors of acquired brain injury. Brain Injury, 16(2), 91-108.

Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy (2nd ed.). New York: Springer.

Fluharty, G., & Glassman, N. (2001). Use of antecedent control to improve the outcome of rehabilitation for a client with frontal lobe injury and intolerance for auditory and tactile stimuli. Brain Injury, 15(11), 995-1002.

Kinney, A. (2001). Cognitive therapy and brain injury: Theoretical and clinical issues. Journal of Contemporary Psychotherapy, 31(2), 89-102.

Manchester, D. & Wood, R. L. (2001). Applying cognitive therapy in neuropsychological rehabilitation. In R. L. Wood & T. M. McMillan (Eds.), Neurobehavioral disability and social handicap following traumatic brain injury. Hove, England: Psychology Press.

Medd, J., & Tate, R. L. (2000). Evaluation of an anger management therapy programme following acquired brain injury: A preliminary study. Neuropsychological Rehabilitation, 10(2), 185-201.

Novaco, R. W. (1975). Anger Control. Lexington, KY: D.C. Health.

Pologe, B. (2001). About psychotherapy. Retrieved March, 2004, from http://www.aboutpsychotherapy.com.

Ponsford, J. (1995). Traumatic brain injury: Rehabilitation for everyday adaptive living. Hove, England: L. Erlbaum Associates.

Prigatano, G. P. (1986). Psychotherapy after brain injury. In G. P. Prigatano, D. J. Fordyce, H. K. Zeiner, J. R. Roeche, M. Pepping, & B .C. Woods (Eds.), Neuropsychological rehabilitation after brain injury. Baltimore: John Hopkins University Press.

ResCare Premier. (2002, June 19). Developing individual behavior plans [CO.Beh.401]. In Training, education, and mentoring system. St. Louis, MO: R. Estes (Ed.).

Schlund, M. W. & Pace, G. (1999). Relations between traumatic brain injury and environment: Feedback reduces maladaptive behavior exhibited by three persons with traumatic brain injury. Brain Injury, 13(11), 889-897.

White, S. M., Seckinger, S., Doyle, M., & Strauss, D. L. (1997). Compensatory strategies for people with traumatic brain injury. NeuroRehabilitation, 9, 205-212.

Wood, R. L. (2001). Neurobehavioral disorders: Their origin, nature and rehabilitation. Seminar provided at the meeting of the Ontario Brain Injury Association in conjuction with Brock University, St. Catharines, Ontario.

Wood, R. L., & Worthington, A. D. (2002). Neurobehavioral rehabilitation: a conceptual paradigm. In R. L. Wood & T. McMillan (Eds.), Neurobehavioral disability and social handicap following traumatic brain injury (107-132). Hove, England: Psychology Press.

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Interventions For Behavioral Problems After Brain Injury | BrainLine

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Behavior change is difficult for any individual to accomplish. The process, however, can be infinitely more difficult for those who suffer from a traumatic brain injury (TBI) due to physical, cognitive, and emotional impairments associated with an injury.

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A brain injury can make it hard to think clearly; to make plans; and to remember important information. It can result in a wide range of physical problems: sleeping issues, headaches, dizziness, vision impairment, and more. It can make people feel angry, irritable, anxious or sad. Managing and treating those symptoms is a big step toward recovery. Here is some information about the most common symptoms and how to address them.

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A brain injury can make it hard to think clearly; to make plans; and to remember important information. It can result in a wide range of physical problems: sleeping issues, headaches, dizziness, vision impairment, and more. It can make people feel angry, irritable, anxious or sad.

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Information for people with a brain injury, their family members and carers

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Table of Contents 1.Assessment Issues 2.Cognitive/Academic Issues 3.Self-Regulation/Executive Function Issues 4.Behavioral Issues 5.Social/Emotional Issues 6.Family Issues 7.Physical/Medical Issues

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People who have been diagnosed with a mild traumatic brain injury have a 56% increased risk of developing Parkinson' disease, new research has suggested.1

The study, published in Neurology, included 325 870 US veterans, half of whom had been diagnosed with either a ...

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Single mild concussion increases risk of Parkinson's disease, study suggests

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People who have been diagnosed with a mild traumatic brain injury have a 56% increased risk of developing Parkinson' disease, new research has suggested.1 The study, published in Neurology, included 325 870 US veterans, half of whom had been diagnosed with either a ...

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Head injuries in childhood and adolescence are strongly linked with a range of outcomes including psychiatric disorders, low educational attainment, increased risk of disability, and early death, a study of Swedish health and census data has shown.

The more severe the injury, the number of times it is repeated, and the older the person is at the time of injury all increase the risks, researchers reported in PLOS Medicine.1

Amir Sariaslan, of the University of Oxford, UK, and colleagues studied the records of more than 1.1 million Swedish people born from 1973 to 1985, of whom 104 000 (9.1%) had a diagnosis of traumatic brain injury before age 25. This means that they had an injury sufficiently serious to cause some alteration of consciousness and warrant a visit to a hospital emergency department. This would include concussion but also lesser symptoms such as feeling dazed. All of those with a diagnosis of traumatic ...

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Head injuries in youth are often linked to psychiatric disorders and disability, study finds

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Head injuries in childhood and adolescence are strongly linked with a range of outcomes including psychiatric disorders, low educational attainment, increased risk of disability, and early death, a study of Swedish health and census data has shown.

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Nature's Lessons in Healing Trauma: An Introduction to Somatic Experiencing® (SE™)

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TRE®  Tension, Stress, Trauma Release     A Revolutionary Way To Feel Better