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Multiple disabilities, multiple strategies

February 27, 2012
by Gary A. Enos, Editor
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Assisting the cognitively impaired client requires patience from the clinical team

When a cognitive impairment compounds the effects of an individual’s substance use disorder, no one type of treatment strategy is likely to produce enough of the desired outcome. Administrators of a treatment facility near Minneapolis that specializes in the co-occurrence of these issues are constantly looking for features to add to the clinical program, while expecting that ongoing research eventually could help clarify which treatments can work best for specific patients.

“The government will be doing more brain mapping, and as a result of this, techniques will be refined,” says Duane Reynolds, associate director of Vinland National Center, based in the Minnesota community of Loretto.

All of Vinland’s adult patients have a substance use issue along with some cognitive impairment. According to 2010 data for the organization, brain injury is the most common disability in Vinland’s patient population, affecting 71% of its patients overall. The next most common disabilities seen in the Vinland population are mental illness, learning disabilities and developmental disabilities.

Reynolds says that various relaxation strategies can be employed successfully with the cognitively impaired population. Vinland Center uses mindfulness-based stress reduction techniques to a great degree, he says. A typical patient will learn to be mindful of his body and what the person’s stressors are, and that might progress to the patient’s learning the benefits of controlling his breathing.
Eventually the person might participate in chair yoga, says Reynolds; this can help significantly for individuals who are experiencing balance problems.

Patient profile

For many of the patients affected by multiple disabilities, cognitive impairment constitutes something of a hidden disability. It is not uncommon for many of Vinland Center’s patient to have received multiple treatments in the past and to have routinely fallen short of expectations in treatment, says Reynolds, as cognitive issues could fall under the radar in some treatment settings.

Asked to describe a typical Vinland patient with a substance abuse issue and a cognitive impairment, Reynolds cites a man in his late 30s who suffered a brain injury more than seven years earlier, possibly from a trauma such as a motorcycle accident. (About three-quarters of Vinland’s patients are men.) Often the person is not married, and family members have had to step in to make important life decisions; the person has trouble with setting goals and planning for the future.

Alcohol, marijuana, methamphetamine and pain medications are common drugs of choice in this population, Reynolds says. Often the criminal justice system has become involved in the person’s life.

In a sense the Vinland Center patient’s substance use issue is considered primary, but treatment is offered under an integrated model. The first sentence of Vinland’s mission statement reads, “Vinland National Center enables individuals with multiple disabilities to live productive and fulfilling lives through a whole person approach that addresses the mind, body and spirit.” This approach encompasses vocational services and housing supports as well as behavioral health treatment.

Reynolds says working with this population requires a great deal of patience, and he tends to look for that quality at least as much as intelligence and ability when hiring clinical staff members. Having a “good heart first” is essential to being successful, he says.

Helping patients make choices

Motivational Interviewing (MI) is a clinical approach that Reynolds says can help Vinland’s core population make better choices. Vinland’s clinical program employs a variety of strategies to encourage emotional control in patients, and more reasonable responses to stressors.

The clinical team might work on a patient’s “centering skills,” Reynolds explains, perhaps by having the person focus on a common object as a way to get him/her to stop and think before acting. This is an evidence-based approach reinforced by the work of researchers at the University of Minnesota, he says.

The program also makes it a priority for clients to understand and recognize the 12 Steps, while realizing that some of the Step work might pose a difficult challenge for the cognitively impaired client. Still, the traditions of Alcoholics Anonymous (AA) become important to this group, and the earning of AA medallions has a powerful impact.

Reynolds hopes that further government research into the workings of the brain ultimately will lead to more tailored treatments for subgroups of patients. “We don’t really know yet with medications whether we can target our interventions,” he says in citing one example. Similarly, he asks,
“What’s best for the PTSD patient, the accident victim, the person dealing with grief and loss?”

While clinical services certainly carry critical importance, Reynolds says Vinland also consistently finds it necessary to use a portion of its revenues for the provision of non-reimbursable services that also make a major difference. For instance, patients have access to an exercise physiologist who helps them work on physical health improvement. “We want to improve their walking ability before they leave, to strengthen their muscles,” Reynolds says.

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