Running head: TBI AND SUD 1

Brain Injury and the Prevalence of Substance Use Disorder

A Masters Project

Presented to

The Faculty of the Adler Graduate School

In Partial Fulfillment of the Requirements

for the Degree of Masters of Arts

in Adlerian Counseling and Psychotherapy.

______________________________________________

By:

Donald Dean Raasch

______________________________________________

Chair: Tamarah Gehlen

Reader: Doug Pelcak

______________________________________________

September 2017

TBI AND SUD 2

Abstract

Traumatic Brain Injury (TBI) is a major public health problem in the United States, and,

like many invisible disabilities, is greatly misunderstood and overlooked by even trained

professionals in the medical, clinical mental health, and addiction fields. Impairments

such as memory, impulsivity, new mental health diagnoses, cognitive impairments and

other thinking differences persist long after the initial head trauma occurs; and can lead

those who have these injuries to self-medicate symptoms by using various substances,

making co-occurring disorders (CODs) a commonly experienced co-morbid disorder by

persons who have endured a TBI.

How the individual fits into their new post-injury world is an important part of their

treatment process. Their ability to learn and retain new information to help with their co-

occurring disorder remains a challenge for facilities that are providing treatment for their

afflictions, as well as those who are part of their support networks. While treatment that

is tailored to the personal experiences and symptomology of the individual client works

best, there are some foundational components that can be inter-woven into multiple

treatment modalities to assist in making treatment more accessible to those who have

TBI’s.

TBI AND SUD 3

Table of Contents

Abstract ............................................................................................................................... 2

Understanding the Scope of the Issue ................................................................................. 4

Comorbidity of TBI, Substance Use Disorders and Mental Health.................................... 4

Effects of TBI ..................................................................................................................... 7

mTBI ............................................................................................................................... 8

Neurobehavioral .............................................................................................................. 9

Cognition....................................................................................................................... 10

Neuropsychiatric ........................................................................................................... 11

Assessment of TBI ............................................................................................................ 12

Assessment of COD .......................................................................................................... 15

Treatment of TBI/COD ..................................................................................................... 16

Models and Philosophy of Care .................................................................................... 16

Principles....................................................................................................................... 18

Virtues ........................................................................................................................... 18

Successful Treatment Components ................................................................................... 20

Quadrant Model ............................................................................................................ 21

Education and ongoing Support System ........................................................................... 25

Adler ................................................................................................................................. 27

Style of Life .................................................................................................................. 29

Life Style Convictions .................................................................................................. 29

Inferiority ...................................................................................................................... 32

Coping Behaviors.......................................................................................................... 34

Safeguarding Behaviors ................................................................................................ 34

Task of Life ................................................................................................................... 35

Social Interest................................................................................................................ 39

Discussion ......................................................................................................................... 39

Future Research ................................................................................................................ 42

References ......................................................................................................................... 45

TBI AND SUD 4

Brain Injury and the Prevalence of Substance Use Disorder

Understanding the Scope of the Issue

While our awareness, both from the public and professional realms are increasing,

traumatic brain injuries (TBIs) are still misunderstood and often fail to be acknowledged

as a foundational basis from which many other disorders can originate. Like many other

invisible disabilities, TBIs are a silent epidemic that create lifelong struggles for those who

have been impacted, and many who would meet the criteria for a TBI may never be

diagnosed (Reyst, 2016). This is due to the difficulty of diagnosing a brain injury, as the

symptoms are not always immediately apparent, leading to a lack of a proper diagnosis

and/or inappropriate treatment modalities for effective rehabilitation. Individuals with

TBIs tend to suffer across all life domains: education, occupation, emotional and

relationally (Reyst, 2016). As a result, the individual may find other alternatives to cope

with their injury, such as substance misuse or abuse in order to medicate their emotions

and behaviors. (Adams, Corrigan, & Larson, 2012).

Comorbidity of TBI, Substance Use Disorders and Mental Health

According to the Centers for Disease Control and Prevention (CDC) there is an

estimated 2.5 million people who have sustained a TBI in the most recent study

(Corrigan, Cuthbert, Harrison, & Kreider, 2015). TBI is a contributing factor to a third of

all injury-related deaths in the U.S., and those reported, between 37-51 percent have

shown that alcohol was a contributing factor (Reslan, & Hanks, 2014). In one study, it

was found that an estimated 12% entering rehabilitation for a TBI 16 and older were

using illicit drugs in the month preceding their injury, while 23% were abusing alcohol

(Cuthbert, Harrison, Corrigan, & Kreider, 2015).

TBI AND SUD 5

In the 1980’s the National Head Injury Foundation, now known as the Brain

Injury Association of America, initiated a study to discover the relationship between

those with a TBI and the concerns with drug and alcohol use (Reyst, 2016). At the time

of this task force inquiry there were very few studies that were available for review. This

task force did, however, conclude that substance misuse before and after TBI may have

negative effects on interventions used to treat a TBI victim. Consequently, when

afflicted individuals do have problems in school, work, or in relationships with others,

they may attempt to self-medicate and are not likely to succeed in these endeavors, given

that the underlying disorder lies in the brain (Adams, Corrigan, & Larson, 2012).

To further complicate concerns with treating a TBI, other co-occurring mental

health disorders (COD) may play a significant role in the outcomes of the treatment

process (Hammond, & Knotts, 2010). Examples of issues that comorbidity present with

traumatic brain injuries are neuropsychiatric disorders (which happen after the initial TBI

has healed), anxiety and depression are most commonly seen; and symptoms of anger and

anti-social behaviors may also present. These additional complications lead to behavioral

and cognitive difficulties that can further thwart the long and already complex treatment

process, often resulting in clients leaving, or being discharged from programs, prior to

receiving full courses of treatment (Neumann, Malec, & Hammond, 2016).

To further this, Kramer and Weisman’s study (2001) compared populations with

TBI versus the general public, it was found the rate of depression, and panic disorder,

phobic disorder, bi-polar, and PTSD were significantly higher in those with a TBI

compared to those without. Mental health disorders that are associated or co-occur with a

TBI vary depending upon the severity of the head injury, where the injury occurred in the

TBI AND SUD 6

brain, as well as the premorbid symptoms that existed prior to the head injury

(Capobianco, Chesney, & Reynolds, 2006). Differential diagnosis of a mental health

condition can be difficult due to symptoms that may be similar to those that are caused by

the TBI.

Above and beyond the myriad of psychological symptoms and disorders that can

appear as a result of a TBI: Corrigan, Adams, & Larson (2013) report that up to two-

thirds of people receiving rehabilitation for TBI or treatment for substance abuse have a

history of both TBI and substance abuse. Studies have also indicated that if a person

misused alcohol or other substances before a TBI, the person is 10 times more likely to

continue to misuse of substances post injury (Corrigan, Adams, & Larson, 2013). When

looking at statistics that have this level of impact, it makes a strong case for why there

needs to be more education on detection, intervention, and ongoing support for person

with comorbid TBI and SUDs. When we look at the number of falls, fights and accidents

that occur as a result of alcohol and other drug use, this statistic becomes more

concerning as the events go without screening for TBI, concern grows further when we

consider that there are very few agencies across the United States that are equipped to

handle clients behaviors with TBI, much less fully educate the client and their loved ones

on the disorder and provide a fully integrated treatment experience. There is much work

to be done in creating a system that will provide an ongoing continuum of care to meet

the needs of the individual with a TBI suffering with MICD.

Many studies have been conducted to determine the prevalence of traumatic brain

injuries and substance use disorders. One-third to two-thirds of individuals who sustain a

TBI have a history of a SUD. (Reslan, & Hanks, 2014). The concerns with post injury

TBI AND SUD 7

SUDs are lower than pre-injury, however after two years post-injury it was found that

one-third with mild to severe TBI had reported heavy drinking, and or use related

consequences (Sacks, Fenske, & Gordon, 2009).

Post injury TBI has been shown to indicate when a SUD is present negative

outcomes is prevalent (Reslan, & Hanks, 2014). When the use of alcohol occurs in a

mild to severe TBI, and increased risk for additional injuries is present, as is increased

cognitive issues are displayed with increased behavioral and emotional difficulties, and

contribution of indicators of a poorer style of life is expected (Reslan, & Hanks, 2014).

Physical and psychological harm to the client increases in occurrence when a SUD is

present with a TBI (Corrigan, Heinemann, & Moore, 2004).

The large number of individuals who suffer from a TBI and subsequent SUD

indicates the need for treatment at varying levels. Individuals with a TBI and SUD have

been neglected in receiving the proper treatment for their SUD due to their symptoms of

their TBI and lack of understanding by professional care givers (West, 2011). The

limited treatment modalities to treat those who are challenged by the symptoms of their

TBI can make it difficult to treat for their SUD due to cognitive, and behavioral concerns

in the treatment environment.

Effects of TBI

The extent of the effects of a traumatic brain injury on one’s life depends on many

different variables. The type of TBI, the age of the client when the injury was sustained,

if the substance use was present before and/or after the injury, the history of injuries

sustained, and the cause of the injury are all factors on the long-term effects. There are

three classifications of a brain injury. These classifications are determined using the

TBI AND SUD 8

Glascow Coma Scale (GCS). These are labeled Mild, Moderate, and Severe, which are

important to understand, as it will allow for the identification of the proper rehabilitation

and ongoing care (Rapp, Rosenburg, & Keyser, 2013). The area of the brain that is

affected as a result of the TBI is also a determination of the concerns with behavioral,

cognition, and neuropsychiatric outcomes (Vakil, 2005).

mTBI

The mild TBI (concussion) or mTBI as defined by American College of

Rehabilitation Medicine: as a traumatically induced physiologic disruption of brain

function, as manifested by at least one of the following:

• Any period of loss of consciousness.

• Any loss of memory for events immediately before the accident.

• Any alteration in mental state at the time of the incident. (Alteration of mental

state as someone feeling dazed, experiencing confusion, being uncertain in

answering simple questions, having decreased clear thinking, and not being

able to describe what happened prior to or after the injury).

• Focal neurologic deficit that may or may not be transient but where the

severity of the injury does not exceed post-traumatic amnesia (PTA) not

greater than 24 hours and loss of consciousness of approximately 30 minutes

or less.

• Normal imagery of the brain via a CT scan or MRI.

(Reyst, 2016).

The mTBI consist of 75% of all TBIs that have occurred in the US (Centers for Disease

Control and Prevention, 2013). One of the major concerns is the incidence of an mTBI

TBI AND SUD 9

often goes undiagnosed due to individuals who do not seek medical attention. The mTBI

often is misdiagnosed and treated incorrectly due to concerns with overlap of symptoms

of PTSD, depression, and anxiety disorders (Beauchamp, Godfrey, & Morse, 2011). The

mTBI may be ruled out and therefore not treated correctly resulting in maladaptive

behaviors by the individual to cope with the symptoms as well as ongoing negative

behaviors.

Neurobehavioral

Neurobehavioral complications sustained from a head injury can be the most

difficult for individuals to recover from. These behavioral complications are most often

misunderstood due to lack of proper diagnosis, and behaviors unexplained that are

exhibited by the individual (Work, & Colamonico, 2011). This is the area that may cause

the most frustrations for the individual while attempting to fit back into their world as

they once did. The individual who sustains a TBI in the moderate to severe category is

most likely to exhibit behaviors that are frustrating for not only the individual, but the

professional care givers as well as family and friends. Some of these concerns include

anger, uncontrolled mood swings, impulsivity, poor judgment, agitation, and aggression.

One of the challenges that face the professional caregiver is how to provide the

proper treatment to those individuals who display some of the behaviors described above

while also working to address consistency. In a study conducted by Rochat, Beni, and

Billieux (2010) a sample of 82 patients with moderate to severe TBI it was concluded

that providing the proper modality for treating impulsivity could be complicated and

challenging for rehabilitation and treatment centers to handle successfully. The study

revealed that impulsivity in individuals with a moderate to severe TBI might be the result

TBI AND SUD 10

of increased irritability, verbal or physical aggression, and loss of temper, impatience and

poor decision-making (Cloute, Mitchell, & Yates, 2008). These types of behaviors make

it difficult to provide a positive treatment environment and lack proper education into

these co-occurring concerns, and interfere with the client’s ability to see the need to

maintain programming.

Cognition

Currently there are 5.3 million people living with a long-term disability as a result

of a brain injury (Centers for Disease Control and Prevention, 2009). Cognitive concerns

that lead to the individuals struggle with memory, attention, decision-making, and

problem solving can lead to a life-long disability (Beauchamp, Catroppa, & Morse,

2011). Monitoring the appropriateness of a behavior or decision and impulsivity of

decision-making can lead to other concerns such as alcohol misuse, behavioral and

relational concerns, as well as mental health diagnoses. The efforts for improvement of

cognitive functioning in individuals with a moderate to severe TBI have been an ongoing

struggle on both the inter-personal and professional support levels.

Cognition has been defined as a complex collection of conscious mental activity

such as attention, perception, comprehension, remembering, or using language and can

generally be thought of as an individual’s ability to mentally represent, organize, or

manipulate the environment (Constantindou, & Thomas, 2010). The area of the brain

that is most challenged with cognition is the executive functioning for those who have

sustained a moderate to severe brain injury. The individuals interpersonal, social,

recreational, emotional, educational, and vocational areas are often affected with these

deficits (Flavell, 1979).

TBI AND SUD 11

In the book Essential Brain Injury Guide; roughly 95% of rehabilitation facilities

are trained and equipped to provide some sort of cognitive rehabilitation for those

individuals with a moderate to severe TBI (Reyst, 2012). The concerns with these

facilities are their inabilities to treat those who present with comorbid conditions.

Individuals who suffer from cognitive inabilities and show behavioral and emotional

concerns often reject the facilities treatment programs. Individuals who are diagnosed

with a SUD and need treatment for that comorbid condition will become frustrated in the

facilities inability to meet their needs (Reslan, & Hanks, 2014). Further complicating the

concerns, any damage to the frontal lobe may cause concerns with executive functioning.

Individuals are often dismissed from programs if the facility is not educated and prepared

for those who struggle with an injury to the frontal lobe affecting their executive

functioning and the resulting behaviors (Bewick, Raymond, & Malia, 1995).

Neuropsychiatric

Individuals who suffer from a TBI are at an increased risk for several types of

MHDs. These disorders include depression, bi-polar disorder, panic disorder, GA,

schizophrenia (Reekum, Cohen, & Wong, 2000). It has been suggested by Reekum,

Cohen, and Wong that the changes in biochemical makeup, post TBI, may suggest that

these disorders are a direct result of the TBI and not concerns with premorbid conditions.

This is a direct concern and needed awareness for treating an individual with a TBI and

for their ongoing care. Professional caregivers, family, as well as the individual with the

TBI must be aware of the possibility of ongoing changes with the individual regarding

their MH (Schonberger, Ponsford, Olver, & Ponsford, 2010).

TBI AND SUD 12

In one study conducted it was determined that those individuals with a severe TBI

had seen an increase in depression, Obsessive-Compulsive Disorder (OCD), panic

disorders, substance misuse, bipolar disorder, and schizophrenia when compared to a

non-TBI group (Kramer, Greenwald, & Weissman, 2001). It was concluded for the

individual with a severe TBI to participate in long-term treatment.

In another study conducted for long-term outcomes of those with a severe TBI, it

was concluded that increased prevalence of cognitive, behavioral, and emotional changes

experienced five years later (Pondsford, & Curren, 1996). The authors of this study

concluded that a potential for ongoing development of MHD’s would need to be

monitored ongoing as the individual pursues wellness.

The individual will realize many changes as they progress and adapt to their new

lives post TBI. These changes may cause the awareness they can no longer achieve the

things they were once accustomed to achieving (Pondsford, & Curren, 1996). This may

cause many different reactions by this individual and progress during their treatment

process. Professional caregivers must be prepared to continue to provide treatment and

understand these frustrations by the individual to allow for a positive rehabilitation

process.

Assessment of TBI

While there is some awareness of the frequency of comorbidity in TBI and SUDs,

this tends not to be a primary focus when assessing clients for various addiction or TBI

treatment options. Proper screening of clients would include collateral information of

client’s history of either significant accident, fall or to other injuries that may have led to

a TBI (diagnosed or not). A TBI that was diagnosed, or being diagnosed with a SUD can

TBI AND SUD 13

allow for proper treatment of the co-occurring disorder (Corrigan, Whiteneck, & Mellick,

2004). Having this awareness is vital as alcohol misuse following TBI has been shown to

increase risk for injuries and seizures, increased cognitive, behavioral, and emotional

difficulties, and contribute a poorer life satisfaction overall (Schretlen, & Shapiro, 2003).

A further complication to this scenario is that there is still a large division between

addiction, mental health, and medical professionals and it is rare that even if screening

tools are used, unless the practitioner the client is working with is able to address all three

tasks, or has the awareness of how to successfully coordinate the series of treatments

needed to address all areas of impairment (Schonberger, Ponsford, Olver, & Ponsford,

2010).

Ongoing concerns for MH professionals in treating those with a TBI is

determining the symptoms that present are that of the TBI or related to a previous MH

disorder (Salloway, 1994). Understanding that the MH problem can provide barriers for

ongoing treatment and rehabilitation complicates this (West, 2011). The symptoms that

are presenting may cause the individual to be unaware of the need for physical

rehabilitation for their TBI and cause them to become frustrated. They may then be

forced to seek treatment for their MH symptoms and not receive the needed care for their

TBI due to the inability of clinicians to appropriately provide differential diagnosis in

order to refer to the best course of treatment (Ponsford, & Curren, 1996).

While appropriate treatment is vital to be able to assist the individual with the TBI

in having an understanding of their condition, as well as working on new skills to be at

their highest level of functioning, treatment is only one component of the recovery

process. The individual’s support network outside of treatment and ongoing is vital to

TBI AND SUD 14

the continued growth of the client or the sustaining of the gains made while in treatment

and ongoing is vital to the continued growth of the client or the sustaining of the gains

made while in treatment (McFarlane, 1999).

As with all psychiatric disorders, there is a continuum from mild to severe, the

greater the impact to all areas of life, and the greater need for support. This process can

easily become confusing and direr if the TBI is not acknowledged or treated (Ariciniegas,

2011). Ongoing concerns and proper care is contingent on the proper diagnosis of the

head injury itself along with any co-occurring disorders.

The identification of a TBI, especially for those with a mild head injury, can be

done with proper screening techniques. In this screening, an understanding of prior TBIs

can be obtained and further assessed as to existing and untreated symptoms. This can

prevent continued frustrations by the individual and treatment modalities can fit the needs

of that individual (Shouminto, & Koutzoukis, 1999). Screening tools used range from

simple to complex.

Examples of tools used are the Acute Concussion Evaluation (ACE) or HELPS

tools, to more complicated screeners, such as the ImPACT. ImPACT is seen most

recently in sports when an athlete is to be screened for a concussion. A tool used by the

military is the Warrior Administered Retrospective Casualty Assessment Tool

(WARCAT) (Brenner, Helmick, & Schwab, 2009). A tool that is interview-based to

assess history of a TBI in the criminal justice system is called the Traumatic Brain Injury

Questionnaire (TBIQ). This test allows for a simple identification of those who may

have suffered from a mild head injury, which may go undetected. As many medical and

therapeutic practices rely on various assessments and screening tools already, it would

TBI AND SUD 15

not take much to obtain, train, and then implement the use of these tools in order to better

work with clients in ensuring that due process has been followed in order to check for the

potential, or presence, of a TBI; and then move to provide the needed psycho-education

and treatment.

Collateral information for each client is important in allowing a better

understanding of the conditions that existed prior to the head injury and those mental

health disorders that may have been caused by the TBI. With the understanding that

mental health problems exist with a TBI the mental health services are incorporated into

the rehabilitation program. Ongoing awareness of the mental health diagnosis and

treatment must continue after the rehabilitation program of the TBI, as many additional

stressors exist post rehabilitation (Goldstein, & Levin, 2001).

Assessment of COD

Many assessment tools exist for screening TBI clients for a SUD. The CAGE tool

is brief and allows for the need to continue assessing if a client may have a SUD (Ewing,

1984). The AUDIT tool is used to review if the client may have dependency concerns

with a substance, or assesses amount of alcohol and other harmful effects alcohol causes

in their life (Babor, Higgins-Biddle, Saunders & Monteiro, 2001). The model used for

prevention and treatment is known as the four-quadrant model. This model is used to

assess and determine the best type of treatment, the environment where the treatment

should take place, and the severity of use. Information on concerns surrounding

substance use could also be obtained in a diagnostic or clinical interview without the use

of these particular tools.

TBI AND SUD 16

The type of care and the understanding by the caregivers is important to the

outcome of the treatment provided to an individual with a TBI and a COD. It is

important to have all participants in the treatment process to understand their role. The

interventions used must allow for education of not only the person with the TBI/COD

receiving the treatment, but the family members who will be there in support of the

individual. Acknowledgment of the diagnosis of a TBI by all members, including the

client, is important when starting the treatment process (Medley, Powell, Worthington,

Chohan, & Jones, 2010).

Treatment of TBI/COD

The type of care an individual receives has been viewed as a variable dependent

on the professional caregiver’s model of care they perceive as providing the best outcome

for the individual. The 4-quadrant model expresses the type of facility and level care

needed depending on the severity of the TBI. The type of care or model of disability of

care used is dependent on the philosophy of the professional care provider (Draper, &

Ponsford, 2009).

Models and Philosophy of Care

There are several models used for rehabilitation of those with a TBI and other co-

morbid disorders. Person-centered care is the approach that is most widely accepted by

the Disability Act. Carl Rogers’ Rogerian method has been identified as the most

effective in this philosophy of care for those with a TBI/COD (Reyst, 2016). This

approach allows for the client to guide the type of care needed for a successful outcome.

The team of caregivers allows the environment and self-advocacy of the client to guide

and change the desired outcome based on the need of the individual (Reynolds, Chesney,

TBI AND SUD 17

Capobianco, 2006). This is why the Functional Model of Disability has been identified

as the primary model of care when working with clients who have TBIs and other co-

morbid disorders to help them adapt to their new normal and re-integrating into their lives

(Smart, 2009).

There are five models of disability of care that are used within the rehabilitation

of care in the TBI facilities. These models are as follows (Reyst, 2016):

1-Moral Model: It is stated as the oldest model of disability. This model relates to one’s

religious beliefs and considers the disability as a result of sin or individuals who are bad

in nature.

2-Biomedical Model: This is also referred to as the medical model and pursues the

knowledge associated with one’s health.

3-Environmental Model: this model is based on the causality of the disability is due to

the environment dictates the outcomes and causes of the disability.

4-Functional Model: The functional model looks at the individual and pursues the person-

centered treatment. This model has been identified as being recommended for treating

those with a TBI (Reyst, 2016).

5-Sociopolitical Model: This model bases it foundational views on the principal that it is

society’s responsibility for accommodating those with a disability rather than the person

with the disability to fit into society.

The goal of any treatment relationship is to establish a relationship with the

individual that fosters and encourages growth and achievement of goals. This approach is

deeply reflective of the Functional Model described above.

TBI AND SUD 18

Principles

The Commission on Rehabilitation Counselor Certification has established six

principles and five virtues that are important in the therapeutic relationship and process of

treatment of those with a TBI. These also are reflective of the philosophies of the person-

centered care approach by Carl Rogers (Reyst, 2016).

The six ethical principles are as follows:

1- Autonomy: Every person has the right to make his or her own decisions.

2- Beneficence: Person providing treatment has the obligation to do good for the

person they are treating.

3- Non-maleficence: Persons providing treatment should avoid causing harm to the

person served in all considerations.

4- Fidelity: Persons providing services should keep promises made and inspire

faithfulness.

5- Justice: Persons should demonstrate equality and fairness.

6- Veracity: Persons providing treatment have an obligation to be truthful in

professional interactions and to demonstrate an unwillingness to tell a lie, which

affect the quality of service received by an individual served.

Virtues

1- Integrity: The capacity to act consistently on deeply held personal values.

2- Prudence: The ability to act with discernment and to act in good faith.

3- Trustworthiness: The capacity to act and to follow through on promises and

commitments, even in the face of difficulty.

4- Compassion: Deep concern for another’s welfare and empathy for their pain.

TBI AND SUD 19

5- Respectfulness: An Attitude that recognizes others concerns and that commits the

person to avoid actions that would diminish another’s rights ore dignity.

The primary goal for the rehabilitation of any individual should always be to

allow that individual to realize the maximum potential of their abilities post injury

(Schaub, Peters, & Peters, 2012). The multidisciplinary team of caregivers should share

a collaborative effort throughout the rehabilitation process. Each member of the team

should have some level of education in the other disciplines of care to allow for

collaboration when setting the treatment planning and achievement of those goals

throughout the rehabilitation process.

Some of the concerns for proper treatment for those with a TBI and SUD are

physical barriers. These barriers have been associated for the denial for those who may

have a disability relating to their TBI (West, 2011). As a result of their TBI individuals

may have a need for a wheel chair or walker to assist them in mobility at the early onset

of the rehabilitation. Many SUD treatment facilities are not equipped with the proper

entryways, railings within the complex and for inpatient facilities the proper bed or

bathing facilities. In one study, it was found that 20-40% SUD treatment facilities

(inpatient and outpatient) were found to have these stated barriers (West, 2011).

In this same study, it was revealed that when these barriers exist within the

treatment facility for SUD denial of services were realized in those with a TBI. Service

denials based on physical inaccessibility to individuals with TBI are at a rate of 42-68%

(West, 2011). Results of the inability for a person with a TBI and a COD to receive the

proper treatment can only continue or worsen the problems the individual has already

incurred.

TBI AND SUD 20

Successful Treatment Components

Individuals with a TBI and COD have increased complications with proper

diagnosis and proper treatment of the specific disorder identified. The type of treatment

and the proper facility to treat individuals with a TBI and COD present increased

challenges. These challenges include poorer treatment compliance, poorer medication

adherence, poorer housing options, higher rates of recidivism, higher increase of diseases,

and emergency room visits as compared to those with only one of these conditions

(McDonnell, Kerbrat, Comtois, & Russo, 2012). This leads to the complexity of the

proper treatment modality as well as treatment facility for placemat.

When a TBI is suspected a thorough screening must take place at the time of the

suspected injury, for past injuries as well as substance misuse and/or Mental Health (MH)

diagnosis that occurred prior to injury (Corrigan, & Katz, 2007). When an individual is

treated for a TBI with a COD, the possibility for a positive outcome can be in jeopardy

due to the lack of knowledge by the caregiver for the COD. Education and awareness for

the family members and health care providers is necessary for proper ongoing treatment.

Acknowledgement of the prevalence of a TBI with a COD is discussed in many

research documents. The understanding of the importance to properly diagnose a TBI

and the severity of the TBI is an ongoing concern. Individuals that are diagnosed with a

SUD are most likely to have incurred a TBI in some severity level (Sachs, Fenske, &

Gordon, 2009). The identification of a TBI is essential when treating an individual with a

SUD. The treatment process and recommendations for an individual with a TBI and

COD can be challenging to ensure the cognition issues, behavioral, and emotional

sequelae are understood and treated correctly (Corrigan, Heinemann, & Moore, 2004).

TBI AND SUD 21

In a study conducted by Taylor, Kreutzer, and Demm, (2003); it was concluded

that when a TBI and SUD co-occur; complications in a traditional treatment were

discovered. When those identified to have a TBI co-occurring with a SUD it was difficult

to treat and posed a significant challenge to produce positive results. The treatment staff

did not understand complications during the treatment process for the SUD such as,

cognitive, emotional, and behavioral issues. Specific accommodations for these

challenges were identified as needed to allow the individual to benefit fully from the

treatment process.

Quadrant Model

Health care providers for those with a TBI and COD have utilized the four

Quadrant Model for decision making for the proper treatment of the individual. The

Quadrant model was first introduced in 1993 and has been adjusted and developed for the

purpose of TBI and COD by the Ohio Center for Brain Injury and Prevention and

Rehabilitation. It is referred to as The 4 Quadrant Model of Opportunities for Substance

Misuse Intervention with Persons with a Traumatic Brain Injury (Clark, McGovern, &

Samnaliev, 2007).

The model itself is designed to be a four-box matrix composed of low and high

severities of a SUD and TBI. The importance of this model is to allow the proper referral

by caregivers and agencies to provide the designation for the help needed for the

individual with a TBI and COD. The proper diagnosis of the TBI and COD are important

to allow the matrix to be used properly and provide for the optimal treatment and setting

(Reyst, 2016).

TBI AND SUD 22

The following Model is presented by The Ohio Valley Center for Brain Injury

Prevention and Rehabilitation:

The level of care and severity defines each quadrant. In Q1, low severity has

been identified in both the SUD and TBI. The SUD is screened using screening and brief

interventions (SBI). The individual who recently had a head injury is screened for the

level of their SUD. Motivational interviewing is used for assessment of their readiness to

change and the referral is made based on the severity of their SUD. In Q1 it has been

identified as using the Acute Medical Setting, primary care and emergency settings.

Quadrant 2 is in a rehabilitation setting for the TBI allowing for a low severity in

their SUD diagnosis and a high severity for their TBI. Persons who have been identified

in this quadrant are most likely to increase their substance use during their rehabilitation

process if not identified by and acted on by the rehabilitation team. The individual

should receive education and ongoing screenings for their level of use. SUD treatment

should be evaluated and awareness of the concern should remain as a part of the

treatment plan throughout the process.

The 3rd quadrant shows the SUD is a high severity rating and low severity with

the TBI. A licensed treatment counselor should treat the individual. The TBI does

present with some cognitive difficulties and may show the client as being disengaged and

showing behaviors of wanting to discontinue the treatment program prematurely. The

repo ire and alliance built with the client is important as well as the understanding of the

symptoms of the TBI playing a role in the treatment process. The counselor must show

understanding by the client in group settings and interventions assigned. Allowing for

TBI AND SUD 23

the client to be understood regarding the challenges of the result of the TBI will allow for

a more positive outcome in the SUD treatment experience.

Quadrant 4 presents the largest challenge as they individual is presenting with a

high severity rating for the SUD as well as the TBI. A specialized TBI and SUD facility

is required which includes expertise in both TBI and SUD. Case management that is

more focused on the individual that includes a lower caseload to allow for more

personalized care. A team of professionals must be involved in the ongoing treatment

that will address all of the client’s individual needs. There are few of these specialized

facilities that can be specialized in the needs of the care required in this quadrant.

In a study funded by the Center for Substance Abuse Treatment, (CSAT) the

quadrant model was used. The intent of the study was to investigate the predictive

validity and stability of initial quadrant placement. The study then reevaluated 3 months

later with the same subjects (McDonnell, Kergrat, & Comtois, 2012).

As the researchers discovered the results proved the validity of the quadrant

model. It was identified that 84% of those placed in their initial quadrant saw a decrease

in severity in both of their severity ratings. The use of the quadrant model allowed for

changes in diagnosis and the level of care and treatment as progress was made. The

flexibility of the model and the awareness of the caregivers of the treatment needed for

each individual allowed for their proper level of care (McDonell, Kerbrat, & Comtois,

Russo, 2012).

Additional benefits of the utilization of the 4-quadrant model are the

consideration of unique collaboration of all health care providers. The individual with a

TBI and COD will need a continuum of care and a collaborative effort by various health

TBI AND SUD 24

care providers. The utilization of the 4-quadrant model allows for services for the

individual along their process of healing in a unilateral and accepted model by all care

givers (Reynolds, Chesney, & Capobianco, 2006).

The primary goal for the rehabilitation of any individual should always be to

allow that individual to realize the maximum potential of their abilities. The

multidisciplinary team of caregivers should share a collaborative effort throughout the

rehabilitation process (Warren, Bennett, Rainey, & Roden-Forment, 2016). Each

member of the team should have some level of education in the other disciplines of care

to allow for collaboration when setting the treatment planning and achievement of those

goals throughout the rehabilitation process (Draper, & Ponsford, 2009).

There are many organizations that are involved in providing services and ongoing

treatment within the multidisciplinary continuum of care. In 1980 more specialized

models were developed by a group known as the National Head of Injury Foundation,

which is now referred go as the Brain Injury Association of America (BIAA) in 1995.

This organization now provides ongoing teachings and certification for professional care

providers known as Certified Brain Injury Specialist (CBIS).

The organization that is known for the ongoing research and recommendations of

the proper model of care is called The U.S. Department of Education’s National Institute

on Disability and Rehabilitation Research (NIDRR). The model that was established in

1987 is known as TBI Model Systems of Care (TBIMS). These centers compile and

release new and informed analysis of modalities of treatment for TBI professionals.

Currently there are 16 TBIMs across the country that provide these new and innovative

treatment modalities (Reyst, 2016).

TBI AND SUD 25

When an individual has sustained a head injury the appropriate selection for the

needs of care can be difficult. The opportunity to understand the best and most

appropriate level of care can be a challenge. The type of facility that is being reviewed

must meet certain credentials for those with a TBI. Accreditation, staff qualification,

process, philosophies of treatment modalities, and overall services provided all need to be

considered (Heinemann, Corrigan, & Moore, 2004). Care facilities may only offer a

limited type of service without meeting all of the specific needs of the individual. Having

the right case management is a vital component as the individual begins the rehabilitation

process and ongoing treatment.

Education and ongoing Support System

Psychoeducation for not only the individual of the TBI/COD, but those family

members who will be there in support and facilitation of the individuals ongoing care, is a

priority in the outcome of that care (Schonberger, Ponsford, & Oliver, 2010). Family

members who will be participating in the ongoing treatment of the individual will be a

functional part of the team that comprises the support the individual will need. This

education needs to be all encompassing in all aspects of the individuals TBI, MH, and

SUD. Family members will also need to be aware of their own emotions and feelings as

they too are affected by the outcomes of the individual with TBI/MHD/SUD (Draper, &

Pondsford, 2009).

From the start of the rehabilitation process the family members and friends are an

integral part of the care team. This is a very powerful experience as the family members

role is a lifelong understanding of the disability while accepting the changes that have

occurred post injury. The “new normal’ is not only realized and adapted to by the

TBI AND SUD 26

individual with the TBI, but the family members and friends who continue to care for

their loved one must also realize the new way of life. The psychological and emotional

changes will continue to be explored and challenges will be realized ongoing for the

remainder of their lives.

The caregivers will realize post injury changes and the family system will be

affected by these changes. The individual will remain psychically present, however the

personality, thinking, memory, and recognition will be different. The relationship that

once was pre-injury will have changed and in most cases these changes will be life

altering. The individual with the TBI and the caregiver members and friends will

experience a process of grief and loss as a result of these post injury changes.

The loss realized is known as ambiguous loss. This is defined as a loss that

occurs without closure due to the complicated and, in some cases, uncertain outcomes

(Peterson, & Sanders, 2015). Due to the lack of understanding and the difficulty of

accepting the changes closure is difficult and sometimes never realized. This process can

add to the difficulty in the ongoing changes within the family system and understanding

how to address their new roles and functioning become complicated.

The process for coping with grief and loss within the family system is very

difficult. Education and acceptance are the key characteristics of a positive direction for

healing. A program was developed to help caregivers cope with this grief and loss

realized by the family and the individual with the TBI. A curriculum was developed

called “Caregiving and Traumatic Brain Injury: Coping with Grief and Loss”. It is a

structured, educational support group that was developed for caregivers of individuals

with a TBI (Peterson, Sanders, 2015). This support group has provided ongoing hope

TBI AND SUD 27

and continued education for those providing the ongoing care of the individual with a

TBI. Many TBI caregivers provide decades of long term care for their loved ones as

behavioral, and emotional concerns will persist (Frosch et al., 1997).

Adler

Individual psychology has long been considered instrumental in many other

current psychological philosophies used today. One of which, mentioned earlier is

known as client centered therapy developed by Carl Rogers. The understanding that each

person with a TBI/COD will present with a different need of care and modalities used to

reach their goal. Dr. Adler discovered concerns with physical disability long ago with the

identification of the organ inferiority. Adler stated: “Physical defects, whether congenital

or acquired, invariably cause feelings of inferiority, and we can generally trace a special

effort to compensate for the specific defect” (Dreikurs, 1948, p. 42).

Adler argued that a disability, if treated correctly, could be a catalyst for the

individual to be more successful in life then pre-injury. Adler continues to state that if

the person is treated correctly, with individual care, they will go on to not only be

interested in themselves, but those around them (Carlson, Watts, & Maniacci, 2006).

Gemeinschaftsgefūhl or translated into English, “social interest” or “social feeling” is the

outcome Adlerian psychology provides as a goal when treating individuals with a MHD

that helps define a sense of wellness (Mosak, & Maniacci, 1999).

There are several areas within Adlerian psychology that could benefit the

professionals who provide care for those with a TBI/COD. Awareness that each

individual is different and he or she must be viewed as such when applying treatment is

one characteristic that is a key component. Empathy and understanding of the individual

TBI AND SUD 28

is important as the individual now has no connection with his community and seeks to

find happiness again in their world. Helping the individual find “social feeling” is the

goal of Adlerian techniques, which is the desired end result in helping those with a

TBI/COD.

Dr. Adler and his philosophies had many contributions to various psychological

theories. One of the theories of present day is the effort of Carl Rogers and his client

centered approach. As stated earlier in this paper the client centered approach is

recognized by the National Brain Institute as being the highest accepted modality of

treatment for those who suffer from a TBI/COD. This is due to the ability and allowance

of the client to be the deciding factor in their treatment process. Dr. Adler discovered

that the awareness of the client and the process of wellness are realized through

Gemeinschaftsgefūhl, or social interest as translated into English. Empathy towards

others and the caring of one’s fellow man is a sign of wellness in those who are seeking a

purpose in their lives (Mosak, & Maniacci, 1999).

Those who suffer from a TBI/COD are struggling to find a place in their world

and are attempting to understand their purpose. Awareness by the caregiver of the person

with a TBI/COD is of the highest importance when attempting to understand and provide

rehabilitation and treatment for the individual. Adler has reported that every person is

different and presents a life style that is adaptable until a person is presented with a

problem they are not ready to handle on their own (Carlson, Watts, & Maiacci, 2006).

This is the concern with those who incur a TBI/COD. An individual with a TBI/COD is

most likely to have lost their sense of self and purpose due to their disability. Those who

TBI AND SUD 29

provide care must begin the rehabilitation/treatment process with the understanding that

the individual will realize their new normal and the need for guidance.

Style of Life

One of Adler’s biggest contributions to helping others is his concept of style of

life. When one considers this concept, it can be best understood as an individual’s way of

life that has developed and allows an individual to achieve their goals that they have

established (Mosak, & Maniacci, 1999). When a person incurs a TBI their ability to

understand their world has changed due to the concerns of the damage to the brain. A

person no longer has the ability to understand consciously or unconsciously the

environment around them. Something as simple as speech or recollection of long term

and short-term memory has been impaired. A person’s ability to function in their world

becomes confusing and frustrating as a result goals become unattainable.

Adler discussed the makeup of an individual’s style of life as life style

convictions comprising of four distinct beliefs (Mosak, & Maniacci 1999). These four

components are, self-concept, self-ideal, Weltbild (a picture of the world), and ethical

convictions. It is important for the professional caregiver and the personal care giver to

understand these four components when treating and understanding an individual with a

TBI/COD. The understanding of these four components will allow the caregiver to be

aware of what the individual’s beliefs are to guide in a more effective treatment process.

Life Style Convictions

The first of the four convictions is the self-concept. This is described as how

people define themselves. This is the part of the person in how they see themselves and

evaluates who they are (Mosak, & Maniacci, 1999). Adler describes this area of the life

TBI AND SUD 30

style as how one compares themselves to others. When an individual is being treated for

their TBI/COD they will often evaluate how they compare to others around them. Many

times this is where they begin to realize they are different from others and begin to

understand they are different then what they use to be prior to their head injury and

resulting COD.

An individual’s self-concept is involving their awareness of how they fit into the

world with their disability. The socialization with others becomes compromised due to

the loss of self. In treating the individual, the consideration that the identity of a person

has been lost must be realized and developed within the treatment process. The use of

empathy ongoing in this process has been strongly identified by Adler when developing

one’s self-concept (Carlson, Watts, & Maniacci, 2006).

The concept of how one measures themselves and evaluates how they fit into their

own standards is known as self-ideal or as Carl Rogers coined the term as the ideal self

(Mosak, & Maniacci, 1999). The conviction of the self-ideal is the understanding of how

an individual’s future goals maybe achieved. When these goals become disrupted due to

an event such as a TBI, an individual will realize concerns with adapting and changing

these goals. It becomes important for the treatment planning of the individual with the

TBI/COD to take into account the self-ideal and how one view themselves after their

injury. Goal setting for short term as well as long term is important when establishing

ongoing treatment planning. The identification of achievable goals based on the

awareness of the individual’s strengths not their challenges from their disability

(Goldstien, & Levin, 2001).

TBI AND SUD 31

This conviction can have some concerning results if not understood. Cautious

goal setting during the treatment process is important for the success and positive

outcomes. The self-ideal is the area where the individual with the TBI/COD begins to

better understand how they can adapt to their new world and their disability. It also

where an individual can deal with their new way of life in despair and build goals that

cannot be achieved based on their disability. Adler stated: “Our ability to change what we

are, to build better worlds, and to envision grander possibilities finds its source in the

self-ideal; by for it is through the self-ideal that we can mercilessly discourage and

cruelly punish ourselves for not attaining what we dream about” (Mosak, Maniacci. 1999,

p. 53).

Weltbild, (translated meaning “World View”) is the term used for the conviction

about the ‘not self”. It is what Adler called the conviction where people develop opinions

about the world, others, and life (Mosak, & Maniacci, 1999). It is this conviction that

some of the other convictions are formed from. Individuals have a vision of their world

around them and maneuver their lives to adapt to this worldview.

Individuals with a TBI/COD have difficulty in understanding the world and how

they now fit after their injury. Rehabilitation and Treatment planning will need to take

into the social views and ability of the individual to navigate in their new world and how

it is different. How they formed their awareness of the world is either forgotten or has

changed due to their injury.

The fourth conviction is referred to as the Ethical conviction. This conviction is

where the individual with the TBI/COD will struggle, as it is the learned cognition of

right from wrong. This conviction allows the individual to demine the consequences of

TBI AND SUD 32

their behavior and the decision to execute the behavior or to avoid it due to consequence

of that behavior (Mosak, & Maniacci, 1999). The individual with a TBI/COD has lost

their ability to know right from wrong due to their brain injury. They must relearn their

own personal convictions and pattern behaviors on only what they may remember or

begin to relearn.

Impulsivity is a behavior that is most common in the symptoms of a brain injury

as discussed earlier in this paper. The damage to the frontal lobe is realized as being a

concern with the individuals executive functioning and impulsivity (Parry-Jones,

Vaughan, & Cox, 2006). The ethical conviction that Adler has described must be

understood as being compromised when establishing a treatment plan. When attempting

to establish outcomes of learning and addressing any of their goals established for a SUD

for example, the challenges will be apparent. The individual and the caregiver may

become frustrated due to the inability to process what are right or wrong behaviors and

the inability to control impulses, which may contribute to an ongoing SUD.

The understanding of how an individual’s life style is formed is important when

providing care for those who suffer from a TBI/COD. Each person is uniquely different

and must be treated and understood as such. The individual will sometimes be the last to

understand these changes, however these changes need to be understood and,

acknowledge allowing for proper ongoing care.

Inferiority

Adler strongly believed that the awareness of ones inferiorities is to be human and

to allow an individual to deal with their stress in life. Adler wrote:

TBI AND SUD 33

Inferiority is the basis for human striving and success. On the other hand the sense

of inferiority is the basis for all our problems of psychological maladjustment.

When the individual does not find a proper concrete goal of superiority, an

inferiority complex results. The inferiority complex leads to a desire for escape,

and this desire for escape is expressed in a superiority complex, which is nothing

more than a goal on the useless side of life offering the satisfaction of false

success. This is the dynamics of psychological life. (Stone, 2014, p.79)

Individuals that suffer from a TBI are affected in many ways allowing for a

feeling of inferiority. Adler has conveyed these inferior feelings will affect our self-

concepts, as well as our self-ideals. This feeling of inferiority within an individual will

cause stressors that are important in the proper development of who we are as a human

race. It is when these feelings of inferiority are not dealt with properly that problems may

develop and cause an individual to display maladaptive behaviors (Carlson, Watts, &

Maniacci, 2006).

These maladaptive behaviors can be seen within an individual with a TBI as their

lives have been disrupted. How the person views himself or herself and what they want

to be, becomes confusing. If the individual is not cared for properly during their

rehabilitative process a person will find relief in negative behaviors that may cause harm

to them such as a COD. These behaviors then become what Adler refers to as an

inferiority complex.

Adler believed that to experience stress and resulting inferiority feelings is a

positive life event (Mosak, & Maniacci, 1999). It is here where a person develops and

face challenges that allow for goals to be established to meet those challenges and

TBI AND SUD 34

develop as a human. When an individual is faced with a TBI it becomes more than a

challenge to overcome these stressors. Adler has determined an individual faces two

choices. The first being the acceptance of the challenge and to overcome them with what

is termed “coping behaviors”. The other choice that results in more negative life

outcomes has been phrased as “safeguarding behaviors” which is where most with a TBI

find themselves if not understood by the care professional and dealt with initially in the

rehabilitation process.

Coping Behaviors

One of the most recognized areas of an individual dealing with a challenge is

known as compensation. To compensate is one’s ability to adapt and overcome the

challenge of the concern (Mosak, & Manaiacci, 1999). It involves the awareness of the

concern and to find the resources to take on the challenge and build the goals necessary to

take on the deficiency (Carlson, Watts, & Maniacci, 2006). If the individual with a TBI

is treated correctly, the challenges are identified, and goals are established to deal with

the concern a more positive outcome will result. It is when these challenges are not

recognized or dealt with by the individual and less desirable behaviors or “safeguarding

behaviors” may result.

Safeguarding Behaviors

Adler defines safeguarding behaviors in an individual as a protection against three

factors. The first concern is the fear of threat or harm to oneself. The next involves a

social threat and how we believe others view us and how we will be treated as a result.

The last is our fear of loss of self-esteem and how we view ourselves. These three views

by the individual are what Adler termed as “sideshows” (Mosak, & Maniacci, 1999).

TBI AND SUD 35

The individuals create behaviors to allow others to focus on another issue and distract

from the real concern (Mosak, & Maniacci, 1999).

Individuals who suffer from a TBI will discover negative strategies to detract

from the symptoms of their TBI. In developing a SUD as a result of a TBI the individual

will allow for the SUD (sideshow) to be the cause for the individuals inferiority feeling

and not the symptomology of the TBI (main event) (Mosak, & Maniacci, 1999). The

caregivers will focus on the most obvious of concerns and that is the individual’s

behavior with SUD. The sideshow of the SUD distracts the more challenging treatment

and achievement of goals related to the TBI. Diagnosis of the TBI is often missed and

the more revealing symptoms are often treated missing the underlying concerns of the

TBI that are causing the problems for the individual (Reyst, 2016).

How an individual chooses to deal with challenges in their lives is based in the

concept Adler described as inferiority. When the challenge of a TBI faces the individual,

those who are the caregivers must make decisions. These decisions will allow the

individual with the TBI to cope with their challenge or develop safeguarding behaviors.

Caregiver’s education and awareness of these concepts will allow for a more positive

rehabilitation/treatment process.

Task of Life

Individual psychology understands that individuals must face challenges within

five areas of life. These areas are referred to task of life. Adler determined that the task

of life is always challenging individuals and their cognition and understanding of their

lives (Mosak, & Maniacci, 1999). When these tasks are challenged an individual must

adapt to these challenges as they affect the five tasks of life. A TBI often will affect the

TBI AND SUD 36

cognitive ability of an individual and therefore challenge one if not all tasks of life. If a

person does not adapt to these challenges as it affects their task of life, an individual will

suffer additional stressors and may look for solutions that may cause additional suffering

such as a COD.

The first task of life that an individual will face ongoing is the Work Task. It is

what we do with our time. Adler believed that this task of life provided an individual

with sense of community in which a person could find purpose. In this task Adler found

six sub tasks as described by Mosak and Maniacci (1999):

1- Occupational choice: “What do you want to be when you grow up?”

2- Occupational Preparation: The training we receive and potentially give to others.

3- Satisfaction: How satisfied are we with our work?

4- Leadership: Determining whether we will be leaders or followers, who we

perceive as leader and followers, and how leadership is demonstrated.

5- Leisure: What do we do when we are not working?

6- Sociovocational Issues: How we deal with coworkers.

The Social Task is asking how we get along with others. This is the task that

gives us a sense of belonging. Not only how we see ourselves, but also how we interpret

others acceptance of our belonging. Adler believed the more we felt belonging the less

likely the feelings of inferiority (Mosak, & Maniacci, 1999). If others accept me then I

will not feel inferior. The individual with a TBI is often challenged with their perception

of how they fit into their new world and misinterpret their sense of belonging.

The Sexual Task is what Adler reported as the most difficult challenge to meet.

The individual must meet expectations of another person on a consistent basis. Adler

TBI AND SUD 37

identified the difficulty lies in how men view women as inferior (Mosak, & Maniacci,

1999). This is where roles and definitions are examined and must be understood by the

individuals within the relationship. Individuals who were in a relationship prior to their

TBI often find a problem with the roles and understanding of this task of life post injury.

Marriages are often strained and challenged and the outcome is often divorce due to the

ongoing challenges the TBI and possibly the COD has presented into the new

relationship post TBI (Warren, Bennett, & Roden-Foreman, 2016).

The Self Task is where an individual decides how they feel about who they are. It

is where the outcome how an individual feels about themselves, which influences the

other life tasks (Mosak, & Maniacci, 1999). The four main subtasks are as follows:

Survival: The areas this subtask centers on: biological, psychological, and social.

This subtask is where an individual will struggle if not discussed and brought to

the attention of the caregivers as well as the individual with the TBI. It asks

questions of oneself regarding how do I belong, how do I fit in, am I taking care

of myself correctly. When a TBI is realized by an individual these questions may

not even be a part of who they are. According to Adler the survival subtask is

crucial to how an individual belongs and survives the challenges of life. (Mosak

& Maniacci, 1999, p. 106).

Body Image: It is here where the individual decides if they like what they see

when they look into the mirror and how they perceive themselves as being acceptable to

themselves. After a TBI a person’s physical self may change due to the severity of the

way in which the TBI was acquired. Often large scars are left from multiple surgeries on

their skulls. A person’s ability to walk is affected long term and will not allow them to

TBI AND SUD 38

achieve the same abilities they once were able to accomplish. The individual must accept

the change in order to have a positive outcome during their rehabilitation/treatment.

Opinion: The opinion of oneself makes up the way in which we affect our life

style. It is the building block of an individual’s feeling of security, self-esteem,

superiority, and inferiority (Mosak, & Maniacci, 1999). Understanding how and

individual’s opinion of themselves after a TBI is an important part of understanding

interventions that need to take place for a positive recovery. This “opinion” of oneself

should be an ongoing understanding by the caregiver as it shapes the progress of the

recovery efforts.

Evaluation: The understanding and acceptance of a “good me” or a “bad me”. It

is how one decides how to “control” oneself (Mosak, & Maniacci, 1999).

The Spiritual Task is how the individual deals with five-sub task as identified by Mosak,

and Maniacci, (1999): Relationship to God, Religion, and Relationships to the Universe,

Metaphysical Issues, and the Meaning of Life.

The final task is the Parenting and Family Task: How the family dynamics play a

role in which the individual is a human being. The makeup of how we fit into our family

structure and relating to our families. The individual who begins to realize their life has

changed due to their TBI will become confused in how they fit in their family structure.

What roles they once shared with their partner has changed due to their cognitive

challenges and inability to have long term memory (Perlick, Dyck, & Norell, 2011). This

task is an area of focus for the professional caregiver as well as the individual’s family

members. The individuals TBI is important to implement as a part of the treatment

process affect Psychoeducation for family members on this task.

TBI AND SUD 39

Social Interest

How an individual meets the challenges of life is within the tasks they live each

and every day. An individual life style interacts with these tasks of life and it determines

how an individual will interact with others within their community (Ansbacher, 1992).

Adler used the term, Gemeinschaftsgefūhl, community feeling, to describe the importance

of the identification of the feeling of belonging using empathy towards others. The

willingness and ability of social connectedness is based mainly on how ones achieve

happiness in their world (Ansbacher, 1992). How an individual showed community

feeling displayed how well they felt about themselves and the world they lived in

(Mosak, & Maniacci, 1999).

As stated earlier when an individual incurs a negative life event, such as a TBI,

that individual will have a difficult with their life tasks. Their style of life will be

disrupted. The individual will question how they fit into the world. This will cause

unwanted stressors the individual is ill prepared for. These stressors will result in

maladaptive behaviors, such as substance misuse, causing less community feeling by the

individual. The individual will withdraw from their lives and slowly slip away from their

support networks such as their family and friends. Their safeguarding behaviors,

substance misuse, now serve a purpose and allow the individual to avoid the help they

need to again realize their sense of community (Mosak, & Maniacci, 1999).

Discussion

Multiple sources have identified for many decades that individuals who have

incurred a TBI will most likely suffer from a co-occurring disorder that can involve

substance use and or a mental health diagnosis as a result of their injury (Corrigan,

TBI AND SUD 40

Adams, & Larson 2013). This creates a strong complexity in diagnosis and treatment of

the TBI and co-occurring disorder due to similar symptomology of these disorders.

Maladaptive behaviors are a result of the individual with a TBI to cope with their new

normal after their injury due to many factors (Reslan & Hanks, 2014). The awareness of

the prevalence of a co-occurring disorder with a TBI must be realized by caregivers to

allow for a positive recovery from the TBI.

At the time of the diagnosis of the TBI the professional caregivers should have the

training to identify the need for substance use screening post injury (Ponsford, Tweedly,

& Taffe, 2013). Prevention programming at the time of planning for continuum of care

of the TBI, the professional providers need to implement a form of education and

prevention models for substance use and the awareness of the concerns for a SUD. Early

interventions should be implemented for the individual with the TBI from the beginning

of the primary care planning and provide the proper recommendation for the appropriate

facility to provide the best level of care. However, as has been outlined above, the

availability of such programs is limited, as is awareness of TBIs, and this prohibits

appropriate care to impacted individuals and their loved ones.

The identification of the proper treatment and rehabilitation of these concerns has

shown to be a challenge for caregivers. The understanding and awareness for the need to

properly treat the disorder along with the TBI has been identified as an area of

opportunity for the providers that treat the TBI and the provider who treat the SUD.

Education by both professional fields are important to allow for the proper care facility as

well as the modality used to treat and rehabilitate the individual with a TBI and co-

occurring disorder.

TBI AND SUD 41

Beyond the fundamental step of identifying the traumatic brain injury and

providing a continuum of care, the medical and behavioral health fields must also

consider the family as they will be a primary source of support and caregiving for the

affected individual with the TBI and other CODs. Supporting the family members who

care for the individual is an important aspect of a positive ongoing recovery for the

family as well as the individual (Schonberger, Possford, Olver, & Ponsford, 2010). The

diagnosis of the TBI affects the entire family system, which has been proven to show

symptoms in depression, anxiety, and burden in roles changes, financial difficulties and

substance abuse, as well as other MH concerns for the caregivers within the family

system (Carroll & Coetzer. 2011). With education and support for the loved ones in the

care-giving role, this can ease the strains put on relationships and help provide support

for the system as a whole to create a better outcome for all parties involved.

Family members and those individuals with a TBI will realize intense grief and

loss, known as ambiguous loss (Petersen & Sanders. 2015). The family dealing with the

grief and loss respond differently to the change in their lives due to the loved ones TBI.

This is a difficult area to provide care due to the many unanswered questions, uncertainty

to the recovery, and the need for help with the ongoing care for the individual with the

TBI. Programs like the Caregiver Support Program, as well as individual and family

therapy with a therapist who understands the concept of ambiguous loss (and ideally TBI)

allows for structure and ongoing education to help family caregivers receive coping skills

to deal with their new lives and stressors in their new way of life (Petersen & Sanders.

2015).

TBI AND SUD 42

Future Research

The awareness of the need for research regarding the relationship of a TBI and

SUD has been known since 1988, when a task force was assembled. The outcome of

those limited studies has inspired the ongoing research showing the undeniable results

that a TBI will co-occur with SUD and MH diagnosis at some severity level at any point

during the individual’s life. The outstanding questions remain as the need for the proper

education of these concerns within the cross section of professional caregivers. Those

who are treating for TBI have limited knowledge in the complexities of treating a SUD.

Conversely those professionals who are trained and licensed in treating a SUD have

limited or no knowledge of a TBI and the rehabilitation process. The treatment and

rehabilitation of a SUD or TBI on its own shows significant concerns with the proper

treatment and placement in the proper facility. The challenges increase immensely in the

treatment process due to the concerns with the SUD co-occurring with the TBI.

The accessibility of treatment for those with a TBI and a SUD needs to be a

primary focus. The awareness of the co-occurring concerns must be a part of the

education process of the SUD counselor. Accessibility and adaptation of the physical

plant of the treatment facility in a SUD environment needs to be modified to

accommodate those who have physical challenges as a result of their TBI. The

modalities of the treatment process should be reviewed to accommodate for the

challenges the individual that has a TBI co-occurring SUD. Additional research needs to

be conducted to discover the most effective modality for the needed behavioral changes

these individuals desperately need.

TBI AND SUD 43

The rehabilitation professionals will also need a better understanding and

education on the prevalence of the co-occurring concerns of a SUD with a TBI. Both

systems of care need to provide a model that is initiated at the start of the primary care of

the TBI. Research has indicated the positive outcomes in the rehabilitation process when

a collaborative team of caregivers implements their expert level of care along the

continuum of care. Additional research is needed to discover what the effectiveness of

having a SUD counselor may be as a part of the professional care team along the process.

Research is also needed to better understand the correlation between pre and post

SUD concerns in those with a TBI. Understanding the individual who has had previous

SUD treatment, pre-injury, and the overall success of the outcome of the treatment will

help with understanding the concerns with treating their SUD post injury. The outcomes

of these studies will allow caregivers to have a better understanding how to treat those

with a pre-injury history and the challenges that will occur during the rehabilitation

process. These insights will allow for better recommendations of treatment for both the

TBI and the SUD during the rehabilitation process.

Individuals who suffer from a TBI that is moderate to severe may experience a

lifelong disability. The need for ongoing research in identification of progress and level

of need of care during the life of an individual with a TBI and a co-occurring disorder

will be important. Future research is needed in the understanding of the aging process

and the specific needs that may occur that are different than the general population. Little

is known as to the long-term effects of moderate to severe TBI and co-occurring

disorders in the aging process.

TBI AND SUD 44

There remain many unanswered questions for the proper care of individuals with

a TBI and co-occurring disorder. The education needed for professionals at all levels of

care of the individual with a TBI remains an opportunity that has been highlighted for

decades with little follow-through. These individuals will experience lifelong difficulties

along their rehabilitation process with relationships with family, friends and caregivers,

finding professionals with needed expertise for their brain injury as well as their co-

occurring disorders. Individuals with these conditions are at an ongoing risk and

providing the proper awareness of these changing needs continues to be the challenge for

health professionals. The opportunities for partnerships between the TBI and the SUD

care professionals remains strong, and, if integration were to happen across these and the

medical fields, the ability to diagnose, address and assist those impacted would yield

better results. By taking a socially interested role, members of the field can begin using

this research and awareness with their clients at all contact points, thereby helping to

change the awareness for clients and professionals, and asserting the Adlerian principle

that anything can also be different.

TBI AND SUD 45

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