Physical Trauma & Addiction The Interplay. Generic Case Study. Spencer Richards, Ph.D. Services for Outpatient Addiction Recovery (SOAR)

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1 Physical Trauma & Addiction The Interplay Spencer Richards, Ph.D. Services for Outpatient Addiction Recovery (SOAR) Stephen R. Sheppard, Ph.D. Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) March 2014 Generic Case Study Ø Age: Yours Ø Gender: Yours Ø Occupation: Yours Ø Social Support System: Yours Ø Mental Health: Likely Obsessive-compulsive Traits Ø Other Strengths and Weaknesses: Yours 1

2 Generic Case Study Continued Ø Sudden Event: Single Motor Vehicle Accident Ø Loss of consciousness Ø Immediate paralysis at C8 level Ø Emergent Care: AirMed Transport, Emergency Surgery, Intensive Care And, then you wake up Physical Rehabilitation Ø Mobility Learning to roll side to side Sitting up Transferring from bed to wheelchair Wheelchair mobility Ø Activities of Daily Living Bathing Grooming Dressing Eating 2

3 Physical Rehabilitation Ø Health Skin Protection Bladder Function Bowel Function Sexual Function Ø Pain Musculoskeletal Neuropathic Ø Spasticity How do you think you would do? Ø Emotionally and Existentially? Ø Work and Finances? Ø Social Support? Ø Recreation? How would you rebuild your Quality of Life? What if? 3

4 Goals for Today Ø Review theoretical models of adjustment to disability Ø Review factors that influence adaptation. Ø Discuss the interplay between substance use disorders and adaptation to disability and chronic illness. Ø Identification of key clinical roadblocks and introduce a broad conceptual framework that can guide intervention. Spinal Cord Injury (SCI) Ø Approximately 17,000 new cases per year Ø 78% male Ø Age Range: 16-30, Modal Age: about 24 Ø Ethnicity 61% Caucasian 22% African-American 13% Hispanic 3% Asian National Spinal Cord Injury Statistical Center

5 More SCI Facts & Figures Ø Causes: MVA 38% Falls 32% Violence 14% Sports 8% Ø Level of Injury: Incomplete Tetraplegia 47% Complete Tetraplegia 12% Incomplete Paraplegia 20% Complete Paraplegia 20% High Risk Behaviors 5

6 SCI and Substance Use Ø Approximately 33% had pre-injury alcohol use disorder. Ø 31-50% were under the influence of alcohol at time of injury. Ø 32-35% were using illicit substances prior to injury Ø 16-33% under the influence of illicit substances at time of injury. Ø 26% were under the influence of alcohol and other substances at the time of injury. 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, Quality of Life (WHO?) Ø An individuals PERCPTIONS of their position in life. Ø In the CONTEXT of the CULTURE and VALUE systems. Ø In relation to their GOALS, EXPECTATIONS, STANDARDS and CONCERNS. Ø It is a BROAD CONCEPT affected in a complex way by: Physical health and Psychological state Level of independence Social relationships Salient features of the environment 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. 6

7 Quality of Life Basic Needs Productivity Spirituality Social Connection Recreation Health Ø Not a static achievement Quality of Life Ø It is a lifelong endeavor A disabling condition virtually always results in physical & psychosocial pain. Positive biopsychosocial adaptation is difficult and fundamentally important. 7

8 What does it mean to adjust? Ø To undergo a process of psychosocial adaptation where the disability becomes integrated into the individual s life, identity, and self-concept. Ø State of person-environment integration. Ø The person increasingly exhibits success in solving problems and managing environment. 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), What does it mean to adjust? Ø The person places value on existing abilities and moves beyond personal loss. Ø Hopefully create or rebuild a sense of well-being and Quality of Life 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),

9 Stage Models of Adjustment ØCrisis Management: ØShock ØAnxiety ØDenial Experiencing Loss: ØDepression ØAnger ØAdaptation: ØAcknowledgement ØAcceptance Ø Adjustment ØLegitimize suffering and need to undergo a process of adaptation ØPeople aren t nearly so methodical ØSupport/Information Processing Action Case Examples: Tom Ø Tom Slipped on ice: C4 Tetraplegia Ø Caucasian man, Mid- 50 s Ø Travelling salesman Ø Very nice wife and grown son Ø Moderate to heavy alcohol use Ø LONER! 9

10 Case Example: Jim Ø Jim Injured while snowmobiling Ø Caucasian man, Mid-40 s Ø Computer engineer Ø Very nice wife and extended family Ø SOCIABLE AND WELL-CONNECTED Somatopsychological Models Ø Emphasizes the personal meaning of the disability and the value it holds for a person. Ø Perception of loss of personal value. Ø Coping 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. 10

11 Four Major Changes Ø Expansion of the scope of values. Ø Decreased importance of physical matters. Ø Containment of the effects of the disability. Ø Shift from making comparisons to preinjury life to intrinsic values (improved self-concept). Case Example: Kerry Ø Kerry -T1 Spinal Cord Injury-Intoxicated Cycling Ø Early 30 s Ø Physical and emotional abuse in childhood Ø College-educated and Employed Ø Avid outdoor recreation Ø Moderate to heavy alcohol and marijuana use when not working 11

12 Somatopsychology Clinical Intervention ØEmphasizes an active approach to coping. ØRecommends helping persons identify and explore values. ØWork to help replace physical values with more intangible values. ØHelp persons take pride in accomplishment. ØHelp persons anticipate and prepare for challenges. Cyclical Models of Adjustment Shifting Perceptions Changing Values Coping Changes Environmental Modification Adaptation And so on Normal Event Processing Disarray! Sadness/Depression Anxiety/Fear Anger Etcetera Kendall, E., & Buys, N. (1998). An integrated Model of Psychosocial Adjustment Following Acquired Disability. Journal of Rehabilitation. 64(3),

13 Case Example: Adam Ø Adam -C6 Tetraplegia in a MVA Ø 17 years old Ø Multiple adverse childhood events Ø Substance use: methamphetamine, alcohol, MJ Ø Boot Camp Ø Supportive Uncle Cyclical Models of Adjustment Ø Experiencing emotional pain and working through it is an important part of the process. Ø People interrupt the process if they block painful feelings or get stuck in depression, anxiety, etc. 6/11/ 18 13

14 Common Ground of Adjustment Models ØLegitimize emotional distress and pain. ØAcknowledge people need to deal with pain, somehow. ØAcknowledge people need to avoid pain part of the time in order to continue functioning. Across all models OVERUSE of AVOIDANT coping strategies is problematic! Personality Factors Related to Adjustment Ø Sociable. Ø Internal Locus of Control. Ø Active Coping: Willing to lean in to the challenge. Ø Able to tolerate frustration and discomfort. Ø Stable sense of self and self-worth. Ø Cognitive flexibility-benefit Finding 14

15 Other Individual Factors Related to Adjustment Ø Prior experience or having a role model. Ø History of Psychiatric Disorder or Substance Abuse. Ø Social Support. Ø Marital Status. Ø Age and Gender. Ø Socioeconomic status. Disability Factors Related to Adjustment Ø Pain or other complications (e.g., spasticity, infections). Ø Degree of impairment: Generally the more impairment the more challenging. Ø Body image changes. Ø Prognosis: Poorer prognosis can be a harder adjustment, but 6/11/ 18 15

16 Environmental Factors Related to Adjustment Ø Environmental Obstacles and Accessibility. Ø Lack of Positive Stimulation. Ø Isolation. Ø Cultural Attitudes and Beliefs. 6/11/ 18 Heredity Personality/Early Experiences Beliefs about Self and the World Values Behaviors Goals SUCCESSFUL ADJUSTMENT Cognitive Factors (Helpful) Positive re-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-focussed strategies Seeking social support Health behaviors Social/environmental Factors High perceived social support Positive relationships/interactions INJURY/ILLNESS Disruption of Emotional Equilibrium and Quality of Life ADJUSTMENT DIFFICULTIES Cognitive Factors (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) 6/11/18 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,

17 Mental Health and SCI Ø Approximately 30-50% experience depression. Ø Declines 2-5 years post-injury. Ø Some studies show an increase in depression later in life with SCI. Ø Approximately 20-40% experience anxiety Ø Antidepressants and psychological Tx help. Other Relevant Psychosocial Factors Ø Divorce rates are elevated compared to the general population. Ø Marital satisfaction is generally higher for couples that met after the injury. 17

18 How will a History of Substance Use Disorder Impact Adjustment? Ø Avoidant coping?!? Ø Co-occurring mental health disorders. Ø Social support challenges. Ø Vocational function and income? Ø And so on Consequences of Alcohol Intoxication at the Time of Injury ØExtended length of hospital stay, including ICU. ØLonger time on ventilator. ØGreater risk of complications: pneumonia, blood clots, urinary tract infections, and pressure sores. ØHigher post-injury mortality rate. 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,

19 Consequences of Intoxication at the Time of Injury Ø Less active in rehabilitation. Ø Lower level of functional independence at the time of discharge. Ø More likely to be depressed. Ø Increased probability of bankruptcy following injury. 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, Rock Bottom? ØApproximately 50% of persons with a preinjury history of alcohol or other substance use disorder return to pre-injury levels. ØA small percentage of persons without a preinjury history develop a post-injury substance use disorder. 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,

20 Relapse After Injury 6/11/ 18 How Does Substance Use Disorder Impact Adjustment? Ø Increased likelihood of depression. Ø Limited activity and participation Ø Lower quality of life Ø Increased likelihood of physical complications (e.g., pressure sores, UTI). Ø Earlier mortality. 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,

21 6/11/18 Let s Pause to Stretch OK So, we ve identified major challenges. How do we navigate out of this? Assembling Parts to a Whole (WHO) Function Activity Participation!!! Environment Quality of Life Personal Factors Maximizing participation is the stepping stone to improved Quality of Life! 21

22 Challenges of Rebuilding Basic Function and Activities Function Activity Participation!!! Quality of Life Environment Personal Factors Motivation is a key challenge! Challenges of Rebuilding the Environment Function Activity Participation!!! Quality of Life Environment Personal Factors Solving problems and addressing environmental barriers 22

23 Challenges of Rebuilding Personal Factors Function Activity Participation!!! Quality of Life Environment Personal Factors Emotions self-concept changing values Conclusions Ø Serious physical trauma represents an extraordinary challenge. Ø Substance abuse is the single biggest contributor to traumatic injury resulting in disability. Ø Substance use predicts a more challenging rehabilitation. Ø But, there is room for resilience and extraordinary successes. 23

24 Questions 46 References Ø Ø Ø Ø Ø 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. 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, 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, Kendall, E., & Buys, N. (1998). An integrated Model of Psychosocial Adjustment Following Acquired Disability. Journal of Rehabilitation. 64(3), 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,

25 Difficulty Adjusting and Health Management Ø Self-Monitoring and Self-Care are essential. Ø Emotional adjustment can significantly influence selfcare. Ø Mortality and Spinal Cord Injury Pulmonary Infection: Bladder and Skin Heart Disease and cancer Suicide (10-15%, 5-7X higher than general public) Among persons with SCI Depression may well be the #1 cause of death in the first 2-5 years 25