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Consider cognitive impairment

January 31, 2013
by Gary A. Enos, Editor
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The patients with whom Edmund C. Haskins, PhD, is most familiar tend to suffer a higher degree of cognitive impairment than what the typical patient receiving addiction treatment might have experienced. But Haskins, author of an evidence-based practice manual tailored to cognitive rehabilitation professionals, believes that even mild to moderate cognitive impairment seen in an addiction treatment client can pose a significant barrier in the course of treatment and recovery.

“With substance abusers, for a period of time after they’ve stopped using they’re not operating at their best,” says Haskins, author of the 2012 book Cognitive Rehabilitation Manual: Translating Evidence-Based Recommendations into Practice. “I know that in many cases professionals do not even want to do neuropsychological testing for a month.”

Haskins says the cognitive rehabilitation field has seen a good amount of research pointing to holistic approaches to treatment as the most effective strategies for assisting individuals with traumatic brain injury (TBI) from various causes. He believes specialty addiction treatment programs can employ the same outlook toward the patients they see who are dealing with impairments in executive functioning and other cognitive processes. This is particularly common in individuals with a history of heavy use of stimulants such as methamphetamine or cocaine.

“You can’t do adequate therapy unless you make accommodations for an individual’s possible brain damage,” says Haskins. He serves as coordinator of neuropsychology at Hook Rehabilitation Center in Indianapolis, where his treatment work focuses on patients participating in a day treatment program for brain injury.

Clinical elements

In his work with brain injury and stroke patients, Haskins says he sees a constellation of issues, many of which he believes apply similarly to a number of addiction treatment patients as well.

His patients are having cognitive problems in areas that include executive functioning (problem-solving, reasoning, planning, judgment) and memory. Emotional problems as well as neurobehavioral problems in areas such as impulsivity are also frequently present, he says.

On top of that, many of these individuals likely are experiencing family problems, and other social stressors such as difficulties addressing finances. “Families might be having trouble controlling the person, or they are placing restrictions on activities that the patient finds intolerable,” Haskins says.

He adds, “When the extent of the brain injury becomes clear, the atmosphere of the therapy changes.” Experts in working with brain injury patients say that even in medical circles, cognitive rehabilitation remains a relatively poorly understood subject in healthcare.

Some of the aforementioned cognitive issues might typically appear with a milder level of severity in the addiction treatment client when compared with the stroke patient, but that doesn’t mean they shouldn’t be addressed in the addiction treatment setting. This can of course occur either by building in-house expertise within addiction treatment facilities or by working with outside service providers.

Haskins says that when issues around a patient’s challenges in executive functioning aren’t sufficiently addressed, treatment programs will tend to blame the patient for not cooperating with the typical treatment regimen. In addiction treatment, that’s when potentially dangerous labels such as “treatment-resistant” tend to get applied to patients.

Accommodations such as writing down more details of treatment and offering useful homework can help ease the treatment process for the cognitively impaired client, says Haskins, who is an adjunct professor of psychology at Indiana University-Purdue University Indianapolis.

Research-based guide

Responding to the need to base clinical services on the best available evidence from research, Haskins authored the Cognitive Rehabilitation Manual under the sponsorship of the American Congress of Rehabilitation Medicine. The book’s guidance, Haskins says, is based largely on investigation conducted by Keith Cicerone, director of neuropsychology at the JFK Health System in the New York metropolitan area. It details treatment methods to as great a degree as it explores the theory behind them.

Haskins says each chapter of the book is devoted to a different aspect of cognitive functioning, from attention to memory to deficits in social communications skills. The information is based on previous evidence-based reviews of scientific literature on cognitive rehabilitation, and is relevant to therapists, physicians and psychologists.

Given that the book was developed for novices in cognitive rehabilitation therapy, its data also should be accessible to specialty addiction treatment professionals seeking to broaden their knowledge of cognitive impairments in patients, according to Haskins.