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PhysicalTrauma&AddictionTheInterplay
SpencerRichards,Ph.D.ServicesforOutpatientAddictionRecovery(SOAR)
StephenR.Sheppard,Ph.D.SubstanceAbuseResidentialRehabilitation
TreatmentProgram(SARRTP)
March2014
VETERANSHEALTHADMINISTRATION
GenericCaseStudy…Ø Age:Yours
Ø Gender:Yours
Ø Occupation:Yours
Ø SocialSupportSystem:Yours
Ø MentalHealth:LikelyObsessive-compulsiveTraits
Ø OtherStrengthsandWeaknesses:Yours
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GenericCaseStudyContinuedØ SuddenEvent:SingleMotorVehicleAccident
Ø Lossofconsciousness
Ø ImmediateparalysisatC8level
Ø EmergentCare:AirMed Transport,EmergencySurgery,IntensiveCare
And, then you wake up…
VETERANSHEALTHADMINISTRATION
PhysicalRehabilitationØMobility
• Learningtorollsidetoside• Sittingup• Transferringfrombedtowheelchair• Wheelchairmobility
ØActivitiesofDailyLiving• Bathing• Grooming• Dressing• Eating
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PhysicalRehabilitationØHealth
• SkinProtection• BladderFunction• BowelFunction• SexualFunction
Ø Pain• Musculoskeletal• Neuropathic
Ø Spasticity
VETERANSHEALTHADMINISTRATION
Howdoyouthinkyouwoulddo?Ø EmotionallyandExistentially?
ØWorkandFinances?
Ø SocialSupport?
Ø Recreation?How would you rebuild your Quality of
Life?What if…?
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GoalsforTodayØ Reviewtheoreticalmodelsofadjustmenttodisability
Ø Reviewfactorsthatinfluenceadaptation.
ØDiscusstheinterplaybetweensubstanceusedisordersandadaptationtodisabilityandchronicillness.
Ø Identificationofkeyclinicalroadblocksandintroduceabroadconceptualframeworkthatcanguideintervention.
VETERANSHEALTHADMINISTRATION
SpinalCordInjury(SCI)Ø Approximately17,000newcasesperyear
Ø 78%male
Ø AgeRange:16-30,ModalAge:about24
Ø Ethnicity• 61%Caucasian• 22%African-American• 13%Hispanic• 3%Asian
National Spinal Cord Injury Statistical Center 2018.
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VETERANSHEALTHADMINISTRATION
MoreSCIFacts&Figures
Ø Causes:MVA 38%Falls 32%Violence 14%Sports 8%
Ø LevelofInjury:IncompleteTetraplegia 47%CompleteTetraplegia 12%IncompleteParaplegia 20%CompleteParaplegia 20%
VETERANSHEALTHADMINISTRATION
HighRiskBehaviors
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SCIandSubstanceUse
Ø Approximately33%hadpre-injuryalcoholusedisorder.
Ø 31-50%wereundertheinfluenceofalcoholattimeofinjury.
Ø 32-35%wereusingillicitsubstancespriortoinjury
Ø 16-33%undertheinfluenceofillicitsubstancesattimeofinjury.
Ø 26%wereundertheinfluenceofalcoholandothersubstancesatthetimeofinjury.
Tetrault, M. & Courtois, F. (2014). Use of Psychoactive Substances in persons with spinal cord injury: A Literature Review. Annals of Physical Medicine and Rehabilitation. 57, 684-695.
VETERANSHEALTHADMINISTRATION
QualityofLife(WHO?)ØAnindividuals’PERCPTIONSoftheirpositioninlife.Ø IntheCONTEXToftheCULTUREandVALUEsystems.Ø InrelationtotheirGOALS,EXPECTATIONS,STANDARDSandCONCERNS.
Ø ItisaBROADCONCEPTaffectedinacomplexwayby:• PhysicalhealthandPsychologicalstate• Levelofindependence• Socialrelationships• Salientfeaturesoftheenvironment
Chan, F., Cardoso, E. D. S., & Chronister, J. A. (2009). Understanding Psychosocial Adjustment To Chronic Illness and Disability: A Handbook for Evidence-Based Practitioners in Rehabilitation. New York: Springer Publishing Company.
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QualityofLife
Productivity
SocialConnection
HealthRecreation
Spirituality
BasicNeeds
VETERANSHEALTHADMINISTRATION
QualityofLifeØNotastaticachievement
Ø Itisalifelongendeavor
A disabling condition virtually always results in physical & psychosocial pain.
Positive biopsychosocial adaptation is difficult and fundamentally important.
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VETERANSHEALTHADMINISTRATION
Whatdoesitmeanto“adjust?”Ø Toundergoaprocessofpsychosocialadaptationwherethedisabilitybecomesintegratedintotheindividual’slife,identity,andself-concept.
Ø Stateofperson-environmentintegration.
Ø Thepersonincreasinglyexhibitssuccessinsolvingproblemsandmanagingenvironment.
Smedema, S.M., & Ebner, D. (2010). Substance Abuse and Psychosocial Adaptation to Physical Disability: Analysis of the Literature and Future Directions. Disability and Rehabilitation.32 (16), 1311-1319..
VETERANSHEALTHADMINISTRATION
Whatdoesitmeanto“adjust?”Ø Thepersonplacesvalueonexistingabilitiesandmovesbeyondpersonalloss.
ØHopefullycreateorrebuildasenseof“well-being”andQualityofLife
Smedema, S.M., & Ebner, D. (2010). Substance Abuse and Psychosocial Adaptation to Physical Disability: Analysis of the Literature and Future Directions. Disability and Rehabilitation.32 (16), 1311-1319..
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VETERANSHEALTHADMINISTRATION
StageModelsofAdjustmentØCrisis
Management:ØShockØAnxietyØDenial
ExperiencingLoss:ØDepression
ØAnger
ØAdaptation:ØAcknowledgement
ØAcceptanceØ…Adjustment
ØLegitimizesufferingandneedtoundergoaprocessofadaptation
ØPeoplearen’tnearlysomethodical…
ØSupport/Information…Processing…Action
VETERANSHEALTHADMINISTRATION
CaseExamples:TomØ “Tom”Slippedonice:C4Tetraplegia
Ø Caucasianman,Mid- 50’s
Ø Travellingsalesman
Ø Verynicewifeandgrownson
Ø Moderatetoheavyalcoholuse
Ø LONER!
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CaseExample:JimØ “Jim”Injuredwhilesnowmobiling
Ø Caucasianman,Mid-40’s
Ø Computerengineer
ØVerynicewifeandextendedfamily
Ø SOCIABLEANDWELL-CONNECTED
VETERANSHEALTHADMINISTRATION
“Somatopsychological Models”
ØEmphasizes the personal meaning of the disability and the value it holds for a person.
ØPerception of loss of personal value.
ØCoping or Succumbing to the Disability?• SUCCUMBING: Emphasizing negative affects, and
avoiding the challenge for change, fixated on unrealistic attempts to return to normal.
• COPING: Focusing on their intrinsic value, oriented on what can be done, and experiencing changes in their value system. Chan, F., Cardoso, E. D. S., & Chronister, J. A. (2009).
Understanding Psychosocial Adjustment To Chronic Illness and Disability: A Handbook for Evidence-Based Practitioners in Rehabilitation. New York: Springer Publishing Company.
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VETERANSHEALTHADMINISTRATION
FourMajorChanges
Ø Expansionofthescopeofvalues.
Ø Decreasedimportanceofphysicalmatters.
Ø Containmentoftheeffectsofthedisability.
Ø Shiftfrommakingcomparisonstopreinjurylifetointrinsicvalues(improvedself-concept).
VETERANSHEALTHADMINISTRATION
CaseExample:KerryØ “Kerry”-T1SpinalCordInjury-IntoxicatedCycling
Ø Early30’s
Ø Physicalandemotionalabuseinchildhood
Ø College-educatedandEmployed
Ø Avidoutdoorrecreation
Ø Moderatetoheavyalcoholandmarijuanausewhennotworking
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Somatopsychology ClinicalIntervention
ØEmphasizesanactiveapproachtocoping.
ØRecommendshelpingpersonsidentifyandexplorevalues.
ØWorktohelpreplacephysicalvalueswithmoreintangiblevalues.
ØHelppersonstakeprideinaccomplishment.
ØHelppersonsanticipateandprepareforchallenges.
VETERANSHEALTHADMINISTRATION
“Cyclical”ModelsofAdjustment
•Sadness/Depression•Anxiety/Fear•Anger•Etcetera…
•ShiftingPerceptions•ChangingValues•CopingChanges•EnvironmentalModification•Andsoon…
“Normal”
“Event”
Disarray!Processing
Adaptation
Kendall, E., & Buys, N. (1998). An integrated Model of Psychosocial Adjustment Following Acquired Disability. Journal of Rehabilitation. 64(3), 16-20.
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CaseExample:AdamØ “Adam”-C6TetraplegiainaMVA
Ø 17yearsold
Ø Multipleadversechildhoodevents
Ø Substanceuse:methamphetamine,alcohol,MJ
Ø “BootCamp”
Ø SupportiveUncle
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“Cyclical”ModelsofAdjustment
Ø Experiencingemotionalpainandworkingthroughitisanimportantpartoftheprocess.
Ø Peopleinterrupttheprocessifthey“block”painfulfeelingsorget“stuck”indepression,anxiety,etc.
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CommonGroundofAdjustmentModels
ØLegitimizeemotionaldistressandpain.
ØAcknowledgepeopleneedtodealwithpain,somehow.
ØAcknowledgepeopleneedtoavoidpainpartofthetimeinordertocontinuefunctioning.
Across all models OVERUSE of AVOIDANT coping strategies is
problematic!
VETERANSHEALTHADMINISTRATION
PersonalityFactorsRelatedtoAdjustment
Ø Sociable.
Ø InternalLocusofControl.
ØActiveCoping:Willingto“leanin”tothechallenge.
ØAbletotoleratefrustrationanddiscomfort.
Ø Stablesenseofselfandself-worth.
Ø Cognitiveflexibility-BenefitFinding
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OtherIndividualFactorsRelatedtoAdjustment
Ø Priorexperienceorhavingarolemodel.
ØHistoryofPsychiatricDisorderorSubstanceAbuse.
Ø SocialSupport.
ØMaritalStatus.
ØAgeandGender.
Ø Socioeconomicstatus.
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DisabilityFactorsRelatedtoAdjustment
Ø Painorothercomplications(e.g.,spasticity,infections).
ØDegreeofimpairment:Generallythemoreimpairmentthemorechallenging.
Ø Bodyimagechanges.
Ø Prognosis:Poorerprognosiscanbeaharderadjustment,but…
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EnvironmentalFactorsRelatedtoAdjustment
Ø EnvironmentalObstaclesandAccessibility.
Ø LackofPositiveStimulation.
Ø Isolation.
Ø CulturalAttitudesandBeliefs.
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Values Behaviors Goals
Heredity
Personality/Early Experiences
Beliefsabout SelfandtheWorld
INJURY/ILLNESSADJUSTMENTDIFFICULTIES
CognitiveFactors(Unhelpful)
•High perceived stress•Wishful thinking or avoidance•Uncertainty about illness•Appraisal of illness as threatening•Dysfunctional cognitions•Helplessness•Perceived barriers to health behaviours•Unhelpful illness/symptom representations•Unhelpful beliefs about pain
Behavioral Factors (Unhelpful)•Coping through avoidance•Unhelpful responses to symptoms (avoidance/resting)
Disruption of Emotional Equilibrium and Quality of Life
SUCCESSFULADJUSTMENT
CognitiveFactors(Helpful)
•Positivere-appraisal•Perceived control over life•Self-efficacy regarding illness•Optimism/Hope•Benefit finding•Self-efficacy regarding general life•Acceptance of illness•Spirituality
Behavioral Factors(Helpful)
•Problem-focussedstrategies•Seekingsocialsupport•Health behaviors
Social/environmental Factors•High perceived social support•Positive relationships/interactions
Adapted from: Dennison, L., Moss-Morris, R., * Chalder, T. (2009) “A model of cognitive and behavioral factors of adjustment in patients with multiple sclerosis. Clinical Psychology Review, 29, 141-153.
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MentalHealthandSCIØApproximately30-50%experiencedepression.
ØDeclines2-5yearspost-injury.
Ø SomestudiesshowanincreaseindepressionlaterinlifewithSCI.
ØApproximately20-40%experienceanxiety
ØAntidepressantsandpsychologicalTxhelp.
VETERANSHEALTHADMINISTRATION
OtherRelevantPsychosocialFactors
ØDivorceratesareelevatedcomparedtothegeneralpopulation.
ØMaritalsatisfactionisgenerallyhigherforcouplesthatmetaftertheinjury.
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HowwillaHistoryofSubstanceUseDisorderImpactAdjustment?
ØAvoidantcoping?!?
Ø Co-occurringmentalhealthdisorders.
Ø Socialsupportchallenges.
ØVocationalfunctionandincome?
ØAndsoon…
VETERANSHEALTHADMINISTRATION
ConsequencesofAlcoholIntoxicationattheTimeofInjury
ØExtendedlengthofhospitalstay,includingICU.
ØLongertimeonventilator.
ØGreaterriskofcomplications:pneumonia,bloodclots,urinarytractinfections,andpressuresores.
ØHigherpost-injurymortalityrate.
Crutcher, C.L., Ugiliweneza, B., Hodes, J.E., Kong, M., & Boakye, M. (2014). Alcohol Intoxication and Its Effects on Traumatic Spinal Cord Injury Outcomes. Journal of Neurotrauma. 31, 798-802..
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ConsequencesofIntoxicationattheTimeofInjury
Ø Lessactiveinrehabilitation.
Ø Lowerleveloffunctionalindependenceatthetimeofdischarge.
Ø Morelikelytobedepressed.
Ø Increasedprobabilityofbankruptcyfollowinginjury.
Strongly suggestive of avoidant coping and difficulty adjusting.
Crutcher, C.L., Ugiliweneza, B., Hodes, J.E., Kong, M., & Boakye, M. (2014). Alcohol Intoxication and Its Effects on Traumatic Spinal Cord Injury Outcomes. Journal of Neurotrauma. 31, 798-802..
VETERANSHEALTHADMINISTRATION
“RockBottom?”
ØApproximately50%ofpersonswithapre-injuryhistoryofalcoholorothersubstanceusedisorderreturntopre-injurylevels.
ØAsmallpercentageofpersonswithoutapre-injuryhistorydevelopapost-injurysubstanceusedisorder.
Tetrault, M. & Courtois, F. (2014). Use of Psychoactive Substances in persons with spinal cord injury: A Literature Review. Annals of Physical Medicine and Rehabilitation. 57, 684-695.
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RelapseAfterInjury…
VETERANSHEALTHADMINISTRATION
HowDoesSubstanceUseDisorderImpactAdjustment?
Ø Increasedlikelihoodofdepression.
Ø Limitedactivityandparticipation
Ø Lowerqualityoflife
Ø Increasedlikelihoodofphysicalcomplications(e.g.,pressuresores,UTI).
Ø Earliermortality.Tetrault, M. & Courtois, F. (2014). Use of Psychoactive Substances in persons with spinal cord injury: A Literature Review. Annals of Physical Medicine and Rehabilitation. 57, 684-695.
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Let’sPausetoStretch…
OK…So, we’ve identified major challenges.How do we navigate out of this?
VETERANSHEALTHADMINISTRATION
Assembling Parts to a Whole (WHO)
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Maximizing participation is the stepping stone to improved Quality of Life!
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Challenges of Rebuilding Basic Function and Activities
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Motivation is a key challenge!
VETERANSHEALTHADMINISTRATION
Challenges of Rebuilding the Environment
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Solving problems and addressing environmental barriers…
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Challenges of Rebuilding Personal Factors
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Function
PersonalFactors
Activity
Participation!!!
QualityofLife
Environment
Emotions…self-concept…changing values…
VETERANSHEALTHADMINISTRATION
ConclusionsØ Seriousphysicaltraumarepresentsanextraordinarychallenge.
Ø Substanceabuseisthesinglebiggestcontributortotraumaticinjuryresultingindisability.
Ø Substanceusepredictsamorechallengingrehabilitation.
Ø But,thereisroomforresilienceandextraordinarysuccesses.
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Questions
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References
Ø Chan,F.,Cardoso,E.D.S.,&Chronister,J.A.(2009).UnderstandingPsychosocialAdjustmentToChronicIllnessandDisability:AHandbookforEvidence-BasedPractitionersinRehabilitation.NewYork:SpringerPublishingCompany.
Ø Crutcher,C.L.,Ugiliweneza,B.,Hodes,J.E.,Kong,M.,&Boakye,M.(2014).AlcoholIntoxicationandItsEffectsonTraumaticSpinalCordInjuryOutcomes.JournalofNeurotrauma. 31,798-802..
Ø Dennison,L.,Moss-Morris,R.,*Chalder,T.(2009).Amodelofcognitiveandbehavioralfactorsofadjustmentinpatientswithmultiplesclerosis.ClinicalPsychologyReview,29,141-153.
Ø Kendall,E.,&Buys,N.(1998).AnintegratedModelofPsychosocialAdjustmentFollowingAcquiredDisability.JournalofRehabilitation. 64(3),16-20.
Ø Tetrault,M.&Courtois,F.(2014).UseofPsychoactiveSubstancesinpersonswithspinalcordinjury:ALiteratureReview.AnnalsofPhysicalMedicineandRehabilitation.57,684-695.
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DifficultyAdjustingandHealthManagement
Ø Self-MonitoringandSelf-Careareessential.
Ø Emotionaladjustmentcansignificantlyinfluenceself-care.
ØMortalityandSpinalCordInjury• Pulmonary• Infection:BladderandSkin• HeartDiseaseandcancer• Suicide(10-15%,5-7Xhigherthangeneralpublic)
Among persons with SCI…Depression may well be the #1 cause of death in the first 2-5 years…