Transcript Slide 1

Alcohol Related Brain Damage
ARBD
Wernicke-Korsakoffs:
Clinical Characteristics
Acute presentation (Wernicke’s):
– Ataxia
– Global confusional state
– Opthalmaplegia (Abducens and conjugate gaze palsy ; 6th crainial)
– Nystagmus
Classical triad only occurs in 10% of cases
– Also: memory problems, vomiting, lethargy and hypotension, peripheral
neuropathy, malnutrition
Chronic /residual (Korsakoffs)
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Difficulty in learning new information
Preservation of immediate recall
No significant retrograde amnesia
Confabulation (often associated with translocation in time of genuine past
experiences, may be grandiose)
– Emotional disturbances; apprehension, anxiety, excitability
– Hallucinations (sometimes)
Alcohol Related Dementia
Cognitive characteristics
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Inaccurate memories, confabulation
Disorientation
Verbal and visual processing problems
Inability to screen out irrelevant information
Attention
Planning
Judgement
Processing new information
Apathy
Poor motivation
Neglect
Disinhibited
Impulsive
ARBD
Brain
Injury/infarction
ARD
WE
Neuro
syndromes
Prevalence
2ndry care studies
• Harvey 1998 (hospital records <65s)
(prospective study of all identified cases in 2
London areas over two years)
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EOD: 67.2/100,000 aged 30-64
34% Alzheimer's
18% vascular
12% front temporal
12.5% ARBD (peak between 50-60 years old)
• Smith and Atkinson 1995
– 21-24% alcohol is a contributing factor in all dementias
Prevalence overview
• Prevalence rates are very variable
• Condition is under-diagnosed
• From a secondary care view point Harvey’s results
are probably the most useful
• Women more vulnerable than men with earlier
onset.
• Prevalence likely to reflect socio-economic
deprivation and nutritional status
• 35 units per week, for five years
Outcomes
• Smith and Hillman (1999)
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25% make a complete recovery
25% make significant recovery
25% make slight recovery
25% make no recovery
Qualitative research project
• Steering committee
• Research commissioned by CSIP (Care
Services Improving Partnership)
• 13 people with diagnosed alcohol related
brain damage, identified through specialist
care provision service (Carenza care)
The patients’ perspective
• Being passed from pillar to post between services both
before and after diagnosis.
• Not being given information about Korsakoff’s disease
• A perception of Health Professionals that ARBD is self–
inflicted and therefore not worthy of an empathic approach
• A general view that recovery is not possible with ARBD
• The only option for care for someone with ARBD is an
Older People’s Mental Health Nursing Care Home
Summary findings
• ARBD is stigmatised;
– Self inflicted
– Low priority
– Double jeopardy; dementia and alcohol dependency
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Lack of professional responsibility for care
Lack of training in medical professions
Evidence of no clear clinical pathway
Lack of commissioning of care
Pilot service
• Nurse and social worker embedded into EOD team
• Designed to
– Optimise function and quality of life of the patient
– Prevent recurrent hospital re-admission
• Targeting;
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Under age of 65
Inpatients on acute medical and surgical wards
History of excessive alcohol drinking
Multiple admissions or long stays post medical stabilisation
Evidence of confusion
Post withdrawal
Not currently drinking (whilst in hospital)
Rehab programme
• Socialisation
– Social contacts
– Relationship development
• Behavioural
– Graded task
– Activity scheduling
• Cognitive restructuring
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Diary keeping
Memory aids
Planning
Problem solving
Categorisation of progress/outcome.
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Stabilisation
– Period in which the patient is withdrawn from alcohol and physically stable. Cognitive status
confirmed and diagnostic formulation established.
Rehabilitation
– Psycho-social rehabilitation and cognitive restructuring so as to regain optimum function
Maintenance
– Cognitive function stabilised at optimum level and settled in appropriate supportive
environment
Discharge
Relapse
– Recommenced uncontrolled drinking, periods of acute cognitive disturbance and evidence of
progressive cognitive deterioration related to drinking.
Death
Review
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19 cases
Average age:
57
Gender: 6 female 13 male
Six cases have experienced a major psychotic
illness whilst under care:
– Alcoholic hallucinosis
– Bipolar affective disease
– Depression.
Clinical outcomes
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19 cases reviewed
7 cases in rehab
8 cases in maintenance
3 cases dead (3 maintained)
1 case relapsed
Service utilisation
Reduction from 31 inpatient days per year prior to
engagement with service to 6 inpatient days per year
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6 Team support alone
2 Direct payments and team support
Enhanced domiciliary care plus team support
Residential supported living
OPA
Partner support
6 Specialist unit (working age adult unit/alcohol specialist unit)
Capacity and MHA issues
Of 30 cases for which we have audit data:
• 28 had significant cognitive impairment for at least six months post
assessment.
• 14 are currently being managed under mental capacity act due to lack
of capacity relating to managing their money and aspects of
accommodation choices.
• Guardianship used in one case, CTO in one case, acute admissions
under MHA; 5 cases
– Alcoholic hallucinosis
– Bipolar affective disorder
– Depression.
Main issues
• Issues relating to choices about whether the
individual understands the implications of
continuing to consume alcohol
– Alcohol dependency (denial)
– Cognitive problems associated with
understanding implications (dysexective
syndrome and memory problems)
Case study 1
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51 year old man
Highly intelligent, company director
Married, 3 children
Started drinking 1995
Multiple hospital admissions (15) excluding
periods in private alcohol dependency units.
• Pancreatitis, hepatitis, vomiting blood,
malnutrition
• One period of WE a year ago
Case study 1
Story concerning this admission:
• Admitted to medical ward following head injury (fall)
– Fronto temporal contusion and fracture with evidence of infarct
– GGT >1000
• Physically stabilised: neuro-rehab.
• Noted to have cognitive damage prior to discharge home
• Managed at home one week; re-admitted, acute alcohol
intoxication.
• Psychiatry liaison; referred to EOD service.
• Guardianship to specialised rehabilitation unit
Case study 1
• Very good progress, cognitive impairments
improved, self catering in structured
environment
• Appeal maintained guardianship
Case study 1
Neuropsychological report
• IQ 106
• Performance 20points lower than predicted value
• Processing speed much reduced: leading to missing
information
• Perceptual organisation low; ‘difficulty in seeing the whole
picture’
• Graded naming was good
• Problem solving tests (behavioural assessment of
dysexecutive syndrome): proneness to break rules,
problems in planning
• Sentence completion is very poor due to inability to inhibit
responses.
Case study 1
• He has frontal dysexecutive syndrome
likely to influence decision making,
planning and ability to undertake alcohol
rehabilitation
• This may be due to brain injury but
progressive improvement in abstinence
indicates alcohol
Case study 1
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Following 6 months in cognitive rehab centre;
Trial at home with three supportive visits a day
Lasted two weeks
Re-admitted due to drinking
Admission to residential alcohol rehab unit
4 Months later discharged home on section 25 with 6 has support a day
Lasted two weeks, small amount of drink led to convulsions
Re-admitted, no withdrawal
Discharged with same amount of support, 3 months later still in
community
• 6 months later ; sudden death…haematemasis
Case study 2
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42 year old women
Found by police in a skip after sexual assaults
No relatives
Long standing drinking
Multiple hospital admissions including periods in
acute hospitals.
• Protracted malnutrition and chronic liver disease
• Previous periods of WE a year ago
Neuropsychological profile
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Profound problems in learning new information
Retrograde amnesia
Varying confabulation
Processing speed much reduced: leading to missing
information
Perceptual organisation low; ‘difficulty in seeing the whole
picture’
Graded naming was good
Problem solving tests (behavioural assessment of
dysexecutive syndrome): proneness to break rules,
problems in planning
Sentence completion is very poor due to inability to inhibit
responses.
Case study 2
Story concerning this admission:
• Admitted to medical ward
– Fronto temporal contusion and fracture with evidence of
infarct/brain injury
– GGT >1000
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Physically stabilised
Psychiatry liaison; referred to service.
Guardianship to specialised rehabilitation unit 3 months
Placed in mental health sheltered accommodation under
guardianship with rehab package
Case study 2
• Very good progress, cognitive impairments
improved, self catering in structured environment.
Alcohol free
• Appeal maintained guardianship
• Maintained in community sheltered
accommodation
• General improvement in independence and
memory. Rehabilitative support withdrawn
• Quality of life good, guardianship closed
Overview
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ARBD is an acquired brain injury engendered through excessive alcohol
ingestion. Its management has some similarities to that of other acquired
brain injury.
Currently there are no national guidelines for the management of ARBD
There is no ‘therapeutic ownership’ or commissioning of ARBD:
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Old age services
Alcohol and drug dependency services
Neuropsychiatric services
General adult service
Very few services are commissioned in England
ARBD is not a common problem but patients require significant psychosocial care (high mortality and morbidity).
Therapeutic service are likely to be cost neutral or potentially cost efficient.
The Neuropsychiatry of ABI and
Substance Misuse in Forensic
Context
Dr Czarina Kirk
Consultant Neuropsychiatrist
St George Healthcare Group
Declaration
I am employed by St George Healthcare Group
which is a for profit health care organization.
Some of the content of this presentation
refers to services which we currently provide
within this organization.
Hippocrates
“..... I am of the opinion that the brain
exercises the greatest power in the man.”
“On the Sacred Disease” written 400BC
• “Men ought to know that from nothing else but the brain come
joys, delights, laughter and sports, and sorrows, griefs,
despondency, and lamentations. And by this, in an especial manner,
we acquire wisdom and knowledge, and see and hear, and know
what are foul and what are fair, what are bad and what are good,
what are sweet, and what unsavory; some we discriminate by habit,
and some we perceive by their utility.
By this we distinguish objects of relish and disrelish, according to
the seasons; and the same things do not always please us. And by
the same organ we become mad and delirious, and fears and
terrors assail us, some by night, and some by day, and dreams and
untimely wanderings, and cares that are not suitable, and ignorance
of present circumstances, desuetude, and unskillfulness. All these
things we endure from the brain, when it is not healthy...”
Diagnoses
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Behavioural and personality change
Cognitive disorders
Depression
Sleep disorders
Anxiety including OCD
Post-traumatic stress disorder
Psychoses
Mania
Epilepsy
• +/- substance misuse/dependence
Epilepsy
• Complex relationship between substance
misuse , epilepsy and severe mental illness
• No increase in offending in epilepsy
population, however in prisons epilepsy is
found significantly more commonly.
Gunn et al BJPsych 118,337-343
• High profile cases of epilepsy and serious
violent offences extremely rare.
A
andand
figures
A few
fewfacts
facts
figures
• Psychological sequelae > physical sequelae
• 27% have diagnosis of moderate / severe
depression
• Post ABI – x2-5 more likely to develop
psychotic illness
• Diagnosis of schizophrenia x2 more likely to go
on and have a brain injury
(Stats from Australian Brain Injury Association)
Schizophrenia, Substance Misuse and Offending
• 47% life time prevalence substance misuse in patients with
schizophrenia and patients with schizophrenia were 4.6 times
more likely to have drug or alcohol problems than the general
population.
The Epidemiological Catchment Area Study Regier et al 1990
• Schizophrenia vs gen population X3 more likely to be
convicted of criminal offence and X3 more convictions
• X6 more likely to be convicted of offence if comorbid
substance misuse and schizophrenia cf schizophrenia alone
• 9 / 2681 charges of murder
Criminal Offending in Schizophrenia Over a 25-Year Period Marked by Deinstitutionalization and Increasing
Prevalence of Comorbid Substance Use Disorder Cameron, Mullen et al Am J Psychiatry 161:716-727, April 2004
ABI vs Schizophrenia. Diagnostic dilemma?
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ABI disrupts thought processes - delusions
Attention difficulties (concentration, tracking, filtering)
Perceptual disturbance – hallucinations
Changes to gait
Dysphasia
Memory impairment – recent memory
Impairment of executive functioning (frontal lobe syndrome)
– Planning
– Organization
– Ability to adapt emotions or responses
– Impulsivity/ disinhibition
– Apathy
Suspicious if…..
Suspicious if ....
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Symptoms don’t quite fit
Poor compliance/ disengagement
Frequent outbursts / low frustration tolerance
Treatment resistance
Deterioration despite treatment
Offending
OFFENDING
DA
ABI
OFFENDING
SMI
OFFENDING
Offending
Offending
OFFENDING
A Case History
• 42 yr old man
• Diagnosed paranoid schizophrenia age 22
• More than 15 admissions to psychiatric hospitals –
poor compliance with medication, poor engagement
in community. “Dis-social PD”. Vagrant lifestyle.
• Comorbid alcohol dependence and cannabis misuse
• 5 custodial sentences theft x2, DUI, GBH. Most
recent sexual offence on remand.
• Court asks for psychiatric opinion and transfer to
hospital
contd
• Confused, disorientated, paranoid ideas, agitated,
sexually disinhibited
• Seizure while in custody
• Multiple scars to head
• Commenced on antipsychotics, withdrawal treated
• Remains agitated, aggressive and assaultative to staff
• Transferred to medium secure unit
• Social Worker discovers previous history of ABI on 3
occasions
Management
• Neuropsychiatric assessment
• Neuropsychology assessment
• Protect the brain – lower doses of medication,
?anti-convulsant
• Manage comorbidity including physical illness
• Simplify the environment
• Cognitive rehabilitation
• Look to the future – modified motivational
interviewing, SOTP
Cognitive Rehabilitation
• Evidence-based technique developed for brain
injured population with frontal lobe deficits
• Emerging evidence for use with other conditions
causing cognitive impairment including treatment
resistant schizophrenia
• Compensatory
framework
model
within
a
relational
Cognitive Rehabilitation
• Relational model: recognises prime importance of
therapeutic engagement
• Collaborative model: harnesses hope & active
involvement in care planning & goal setting
• Non-aversive model: avoids negative interactions by
using alternatives such as distraction, positive
behavioural
support
and
communication
via
compensatory systems – notebooks and planners
• Total environment approach: aims to support individuals
in such a way as to enable them to function at their best
& achieve their own goals thus reducing triggers for
antisocial behaviour & compensating for their relative
deficits. Use of mobile phones, electronic diaries as
prompts.
Success is ....
• Partnership
• Based upon hope
• Empowering
• Focus upon strengths
• Fostering knowledge, expertise
• Encouraging self-help & peer support
• Supporting development of valued social
roles – vocational rehab
• People aren’t disabled, environments
are disabling
Thanks
• Dr Jonathon Rogers – Neurorehabilitation
Lead St George Healthcare Group
• Cognitive Rehabilitation Service Ashworth
Hospital
• Guy Soulsby – Brain Injury Rehabilitation
Centre Merseycare NHS Trust
The neuropsychology of Substance
Misuse and Brain Injury: The forensic
context
Ryan Aguiar
Consultant Clinical Neuropsychologist
Forensic Neurorehabilitation Service
Ashworth Hospital
Merseycare NHS Trust
Aim:
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To understand the effects of substance
misuse on specific parts of the brain
To understand the effects of alcohol &
Cocaine on cognition
To understand the Neurobehavioural
effects of substance misuse
The interactional effects of substance
misuse and impaired brain function
Brain injury & substance abuse
Scale of the problem:
Occurs more frequently than in the general population
44% to 79% of TBI patients have premorbid substance
abuse
53% had blood alcohol levels above legal limit at the time
of injury resulting in TBI
21-37% report history of illicit drug use.
However alcohol and illicit drug use decreases after brain
injury with gradual increase as time post injury elapses
Higher rates of substance misuse in those less impaired.
(cited in Taylor et al, 2003)
Whistle-stop tour of neuroanatomy
Major division of the brain
The
Amygdala
Subdivisions of the frontal lobes
Dorsolateral
Orbital/ventral
Medial
Neurocognitive effects of Cocaine abuse
Cocaine use affects regional blood flow and cerebral glucose metabolism in
prefrontal cortex and limbic areas causing neurobehavioural effects
(depression, anxiety, aggression).
Prefrontal brain regions (orbitofrontal cortex, ACC, DLPFC and amygdala) are
activated during intoxication, craving and binging and deactivated during
withdrawal. These regions are also critical in such areas as decision making
and evaluating salience of a stimulus (Goldstein & Valkow 2002). Addiction
results as a dysregulation of the cognitive and emotional decision making
controlled by these structures culminating in an inability to abstain from
drug taking.
Cocaine use is associated with increase risk for stroke through effects of
vasoconstriction (narrowing of blood vessels) and is dependent on
frequency & duration of use (Kaufman et al 1998). The anterior and middle
cerebral arteries are more vulnerable (Herning et al, 1999)
Neurocognitive effects of Cocaine abuse
contd
Acute cognitive effects show enhancements in attention tasks due to
the stimulant properties of the drug (Bolla & Cadet, 2007)
Long-term neuropsychological sequelae are subtle and mostly affects
executive functions of attention, planning and mental flexibility
(Bolla & Cadet, 2007), decision making and judgement (Bechara et
al, 2001 & Grant et al, 2000)
Increased incidence of violence and aggression then in other drug
groups possibly associated with greater irritability and paranoia.
Evidence found showing deactivation of the orbitofrontal cortex and
the middle frontal gyrus resulting in weakening of the frontal
functions of response monitoring and inhibition during anger
activation (drexler,et al, 2000)
Neurocognitive effects of Alcohol abuse
Acute intoxication effects:
Effects of alcohol depend on the blood alcohol concentration: low
doses = stimulatory effect; high doses= depressant effect on
behaviour.
Impairments in attention, concentration, verbal processing and
executive function can be seen in acute intoxication stages.
Acute intoxication also results in impaired psychomotor function
Impulsive and aggressive behaviour-both aspects reflects impairment
of disinhibitory functions of the brain due to the stimulant properties
of alcohol. There is reduced latency towards sexual arousal, greater
tendency towards motor responses without careful evaluation of
information.
Impaired error monitoring and self-monitoring
Neurocognitive effects of Alcohol abuse
Chronic effects: frontal lobe, limbic system and cerebellum vulnerable
structures to chronic effects of alcohol abuse (Oscar-Berman &
Marinkovic, 2001)
Frontal lobe volume loss as well as reduced metabolism associated with
executive dysfunction and neurobehavioural disorders.
Atrophy of the cerebellum-affects cognitive flexibility, speed of
allocation of attention, attention shifting, inhibition perseverative
errors. Disruption of the frontal lobe and cerebellar circuitry results
in the behavioural impairment seen in alcoholism (Sullivan et al,
2003).
Deficient emotional processing, and impaired formation of new
memories due to amygdala and hippocampus dysfunction
Anterograde amnesia due to damage to the thalamus and
hypothalamus-Korsakoff syndrome
Neurobehavioural effects of Alcohol abuse
Alcohol is the single largest factor associated with violence
contributing to 2/5 of homicides-17% committed by
patients with severe mental illness (Shaw et al, 2006).
Aggression associated with lower level of serotonin in the brain in
susceptible individuals. Alcohol results in significant lowering of
Serotonin levels in the brain.
Serotonin depletion though alcohol consumption may result in
aggression in susceptible individuals (e.g. brain injured) 1. either
direct facilitation of aggression and promotion of approach
behaviour, 2. overcoming anxiety, 3. Impairing executive function
involved in assessment of risky situations (Pihl et al, 1998)
Common & significant neurobehavioural
disorders following brain injury
Cognitive, emotional, behavioural and personality changes following
brain injury- “Neurobehavioural Disability” (Wood, 2001).
Comprises of:
 Executive dysfunction
 Attention impairments
 Impaired insight
 Impaired social judgement
 Poor impulse control
 Mood lability/irritability
(Wood, 2001)
Neurobehavioural disorders following brain
injury
Neurobehavioural disorders commonly
associated with damage to the frontal
and temporo-limbic areas of the brain
Orbital frontal lobe damage=poor impulse
control, aggression, social disinhibition,
irritability
Medial prefrontal cortex= apathy,
motivational disorders
Dorsal lateral frontal lobe= executive
function
(Alderman, 2004)
Temporo-Limbic lobe damage:
Memory impairment, emotion processing
&regulation (amygdala), changes in
sexual function, stimulus response
learning
Neurobehavioural disorders following brain
injury
3 Mechanisms:
De-inhibition: Damage to frontal areas of the brain lobes of the brain
is associated with loss of control over subcortical and limbic
structures (amygdala & hypothalamus) involved in impulses and
emotive arousal (Grafman et al, 1996) resulting in a de-inhibition of
Limbic structures (Silver et al, 2005)
Social cognitive/ Social Perceptual impairments: misperceiving
and misinterpreting interpersonal interactions (Blair et al, 2000).
Impaired learning and regulation of stimulus response
contingencies : an impairment arising out of impaired limbic
(amygdala) and frontal function (Blair, 2004)
Substance misuse & brain Injury- an
unhealthy alliance
Alcohol & Cocaine
And
Brain injury
Substance misuse & brain Injury- an
unhealthy alliance
Alcohol
Cocaine
Impairs: decision making,
planning, concentration,
executive function, judgement,
Error monitoring,
inhibitory functions &
self monitoring
Brain injury
Substance misuse & brain Injury- an
unhealthy alliance
Substance
Misuse
Brain Injury
Aggressive &
violent acts
Issues for treatment/Management
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Management of alcohol withdrawal in acute brain
injury care.
Absence of substance abuse management skills in
brain injury rehabilitation services- need to consider
referral to specialist services and work in conjunction
Prognosis is poor in continued substance misuse
Minimise social and emotional disability
Address resistance to substance misuse management
Engage and involve families
Educate patient and families about interaction effects
between brain injury and substance misuse.
references
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Bechara A. et al, (2001).Decision making deficits linked to a dysfunctional
ventromedial prefrontal cortex. Neuropsychologia, 39, 376-389.
Grant, S et al (2000) Drug users showing impaired performance in a
laboratory test of decision making. Neuropsychologia, 38, 1180-1187
Goldstien, RZ & Valkow, ND (2002) Drug addiction and its underlying
neurobiological basis…American Journal of Psychiatry, 159, 1642-1652
Kaufman, MJ et al (1998) Cocaine induced cerebral vasoconstriction
detected in humans with MRA. Journal Of the American Medical
Association, 279, 376-380.
Herning, RI et al (1999) Neurovascular deficits in cocaine abusers.
Neuropsychopharmacology, 21, 110-118.
Bolla, KI & Cadet, JL (2007) Cocaine. In Kalechstein, A & Van Gorp, WG
(Eds) Neuropsychology And Substance Use: State Of The Art And Future
Directions. Taylor & Francis.
Drexler k et al., (2000). Neural Activity related to Anger in Cocainedependent men. The American Journal of Adictions, 9, 331-339.
references
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Sullivan, EV et al, (2003).Disruption f of Frontocerebellear circuitry in
alcoholism. Alcoholism :Clinical and Experimental Research, 27, 301-309
Oscar-Berman M & Marinkovic K (2007). Alcohol. In In Kalechstein, A &
Van Gorp, WG (Eds) Neuropsychology And Substance Use: State Of The
Art And Future Directions. Taylor & Francis.
Shaw et al, (2006). Role of alcohol and drugs in homicides in England
and Wales. Addiction, 101, 117-1124.
Pihl, Ro & LeMarquand D (1998) Serotonin and aggression and the
alcohol-aggression relationship. Alcohol and Alcoholism 33, 55-65.
Alderman, N (2004). Behaviour Disorders. In Ponsfrod, J. (Ed). Cognitive
and Behavioural rehabilitation: From Neurobiology To Clinical Practice.
The Guilford press.
Taylor et al, (2003). TBI and Substance Abuse: A Review and analysis of
the literature. Neuropsychological Rehabilitation, 13 (1/2) 165-188
Blair, RJR & Cipolloti, L (2000) Impaired social response reversal .Brain,
123, 112-1141
Blair, RJR (2004). The roles of orbiatal frontal cortex in the modulation of
antisocial behaviour. Brain & Cognition, 55, 198-208.
Alcohol and Tbi –Make mine a double
BISWG Conference 2010
Steve Shears MSc Psych, MBACP (Accred)
Training Manager and Therapist
Headway – the brain injury association
Substance Misuse Definition DSMIV
DSM-IV Definition of substance abuse.
‘A maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by three (or more)
of the following, occurring at any time in the same 12 month period.
1) Tolerance to the substance.
2) Withdrawal
3) Substance is taken in larger amounts or over a longer period of
time than was intended.
4) Persistent desire or unsuccessful efforts to cut down or control
substance use.
DSM IV DEFINITION Cont…
5) A lot of time is spent trying to obtain the substance.
6) Important social, recreational and occupational
activities are given up or reduced because of substance
use.
7) The substance use is continued despite a knowledge
that the substance is causing or making worse a
psychological or physical problem.
Substance Misuse and TBI – the
nature of the problem
Combination of substance misuse and Tbi is worse than
either alone as it relates to brain structure, function and
psychosocial outcomes (Corrigan and Bogner 2007)
This has been the findings of a number of researchers
using MRI imaging and ERP investigations
Risk Factors Alcohol Use After TBI
(Source BIUSA)
Alcohol and other drugs interfere with new connections between
neurons.
It can exacerbate post-brain injury balance problems and lead to
falls (and further brain injuries)
Brain injury sometimes leads to people saying the first thing that
comes to mind. Alcohol tends to have this effect anyway so
increases the possibility of social/relationship problems.
Brain injury causes cognitive problems like concentration difficulties
and alcohol and other drugs make this worse.
The brain is more sensitive to alcohol and other drugs following
brain injury.
Scale of the problem
Various estimates in literature review research about the prevalence
of pre and post-injury alcohol problems in people who were living
with Tbi it was up to 60% (Delmonico 1998) for pre-injury and up to
50% for post-injury (Sander et al 1997)
Other studies note that some people give up alcohol/substances
following abi and this might represent a ‘window of opportunity’ for
people to give up (Bombardier 2002,1997)
Substance misuse is more prevalent in people with disabilities than
the general population (Centre for Substance Abuse Treatment US
1998 and Corrigan 2005)
A difficult combination?
In traumatic brain injury (tbi) the frontal lobes of the brain
often bears the brunt of the external forces on the head.
The frontal lobes are the seat of reasoning and impulse
control and self-monitoring in the brain.
If these functions are diminished then it might be argued
that substance misuse issues could be complicated by
these cognitive deficits?
Integrated programmes and
motivational issues
Interesting work going on at Ohio Valley centre for brain
injury prevention and rehabilitation in substance abuse
treatment and brain injury.
This includes information and self-help literature for TBI
survivors about substance use and brain injury.
Researchers from Ohio Valley also wrote the BIUSA
information booklet about this subject.
www.ohiovalley.org/abuse/umanual/index/html
Substance misuse and brain injury –
Ohio Valley, USA
Part of the manual www.ohiovalley.org
The human brain is often com pared to a computer, full of bits of
information, able to make swift, steady connections. Just like a
computer, the brain has many programs like the ones that allow us to
move, think and make decisions.
Part of the manual (II)
www.ohiovalley.org
The effects of alcohol and other drugs are different for people after a
brain injury. This User’s Manual presents facts about how alcohol and
other drugs affect people with brain injuries. These facts – like software –
are ready to be installed. But you’re the operator.
If you have had a brain injury, take time to study this manual. Read.
Think. Decide. We hope after you’ve done that, you will install new
alcohol/other drug software – a new set of facts, attitudes and beliefs – in
your brain.
Part of the manual (III)
Summary of findings using
educational intervention in rehab
Source – email discussion with Prof John Corrigan, Ohio Valley Centre
1. Few patients report using any alcohol by 30 days after
discharge from acute rehabilitation; and none reported
using illicit drugs.
2. Attitudes and beliefs regarding expectations for
alcohol use (alcohol expectancies) and, to a lesser
degree, whether an individual needs to change the
amount they drink (readiness to change) were highly
associated with drinking any alcohol at 30 days postdischarge
Educational intervention Cont…
3. Having knowledge about the negative effects of
alcohol or illicit drug use after TBI was associated with
positive attitudes and beliefs
4. Problem use of alcohol or other drugs preceding injury
also had a significant association with attitudes and
beliefs after
5. When those receiving educational interventions were
able to recall 3 or more facts about TBI and substance
use at 30 days post-discharge, all were abstaining from
alcohol and illicit drugs.
Educational Intervention Cont…
6. Among subjects with longer lengths of post-traumatic
amnesia (and thus more likely to still be somewhat
confused when provided the educational intervention),
the videotape plus booklet intervention was superior to
using the booklet only.
Retention in substance misuse
programmes
There are difficulties in engaging and retaining in
treatment people who have substance misuse and brain
injury.
Retention and length of time in treatment is correlated to
positive outcomes. Individuals who stay in treatment are
more likely to achieve and maintain sobriety.
The treatment factor most consistently found to be
related to retention in treatment is therapeutic alliance.
The most consistent client factor is readiness to change
(Corrigan and Bogner, 2007)
Leading the horse to water?
Pre-treatment motivation amongst those with substance
misuse problems is not uniformly high, even amongst
those that don’t have the added complication of brain
injury. Bombardier (2002) used modified RCQ with TBI
survivors.
Newman (1997) – individuals gain strong primary
reinforcement from substances – in contrast, their
relationships with others have been less gratifying and
less socially reinforcing.
Research into engaging people with
abi and substance misuse problems
Research by Corrigan et al (2005) conducted a
randomised clinical trial using three methods of
intervention –
Reduction of Logistical Barriers
Motivational Interviewing
Provision of Financial Incentives
Control condition was an Attention Control Condition
Research into engaging cont…
Primary dependent variable was whether an
Individualised Service Plan (ISP) was signed within 30
days.
Outcomes – clients that were assigned to the Barrier
Reduction and Financial Incentive conditions were more
likely to sign ISPs within 30 days than the Attention
Control or Motivational Interviewing conditions.
Clients in the Financial Incentive condition were more
likely to sign more quickly and have perfect attendance.
Mediating effect – psychiatric symptoms –longer to sign.
Research into engaging cont…
This particular study did not look at the role of
client motivation or therapeutic alliance.
Retention in treatment – the next
step
Further research by Corrigan and Bogner (2007) looked
at whether, compared to Attention Control, Financial
Incentives and Barrier Reduction would improve initial
treatment attendance?
The further hypothesis was that this improved
attendance would lead to a greater therapeutic alliance
between the client and therapist.
And this in turn would lead to reductions in premature
termination of therapy.
The specific hypotheses tested
were:
1. The provision of financial incentives and the
reduction of logistical barriers will be equally
effective at reducing missed appointments
during the first month of treatment.
Specific Hypotheses Cont…
2. The provision of financial incentives and the
reduction of logistical barriers will be equally
effective at improving the therapeutic alliance
established in the first three months of treatment
as viewed by both the client and the counsellor.
Specific Hypotheses Cont…
3. The provision of financial incentives and the
reduction of logistical barriers will be equally
effective at reducing premature termination from
treatment.
The study participants
All clients were participating in a treatment programme
exclusively for TBI and substance use disorders – the
TBI Network at Ohio State University.
Programme has been in existence for 14 years.
Average active caseload = 100
74 participants in the study 62% Male 38% Female
57% Non Hispanic Caucasians and the rest were mainly
African Americans
Age range 21 to 69 Average age 42.5
Study Participants Cont…
Average education 11th Grade –8% had a Bachelor’s
degree.
18% Competitively employed – 68% primary income was
from Government supports.
Primary drugs of choice –Alcohol 58%, Marijuana 18%,
Crack Cocaine 15%
All participants had at least 1 TBI with impairments of
functional abilities. Have substance disorder as defined
by DSM IV, have signed ISP and have access to
telephone.
Study Participants Cont…
Participants randomly selected for:
Financial Incentive – 24
Barrier Reduction – 26
Attention Control – 24
Client rating of the therapeutic alliance was acquired by follow-up
contact via phone 3 months after client had signed ISP by blinded
research assistant using Helping Alliance Questionnaire –II (Haq-II).
The counsellor was then filled out their version of the Haq –II.
Completion – 36% still in treatment, 39% prematurely terminated,
24% closed, goals met.
Status at study completion
60%
Premature termination
50%
50%
Goals met
40%
33%
33%
35%
30%
23%
17%
20%
10%
0%
Financial incentive
Barrier reduction
Attention control
Outcomes Hypothesis 1
Mixed support for the proposed model
Most robust finding was that financial incentives
increases appointment attendance during the first month
of treatment.This effect was observed despite the
Financial Incentive group actually scheduled and
attended more appointments than those in the Barrier
Reduction and Attention Control conditions.
Barrier reduction also improved early attendance but the
result was not statistically significant.
Outcomes Hypothesis 2
Interventions did not have a significant
independent effect on perceived therapeutic
alliance, though attendance did. Perfect
attendance increased both the client’s and
counsellor’s perceived therapeutic alliance.
Outcomes Hypothesis 3
There was no significance in terms of the planned
analysis in rates of premature termination by
intervention.
However, there was a significant difference in clinical
outcomes, if not statistical significance, by interventions.
For example the control group was three times more
likely to terminate therapy early.
Reflections
The financial incentive of the gift certificate did have an effect on
increasing attendance – this was an effect also seen in the earlier
study on incentives to sign a ISP.
Remarkably this was despite the fact the gift certificate was not
immediately given to the participants and the fact that TBI often
affects the orbital frontal cortex of the brain.
Damage in this area of the brain often leaves people with problems
in managing impulsivity and delayed gratification.
Reflections Cont….
There appears to be some evidence that substance
misuse programmes for people living with brain injury
can be effective.
Motivation for staying in treatment seems to be
enhanced in the early stages of treatment by the
financial incentive and barrier reduction interventions.
More research into enhancing the therapeutic alliance
might be advantageous – I have suggested the
SRS/ORS –client-directed outcome measures to Prof
Corrigan – www.talkingcure.com
References
Arenth, P.M., Bogner, J.A., Corrigan, J.D., & Schmidt, L. (2001).The utility of
the Substance Abuse Screening Inventory-3 for use with individuals wit brain
injury. Brain Injury, 15, 499-510.
Bombardier CH, Ehde D, Kilmer J. 1997. Readiness to change alcohol
drinking habits after traumatic brain injury. Arch Phys Med Rehabilitation
Jun;78(6):592-6.
Bombardier CH, Heinemann. (2000) The construct validity of the readiness
to change questionnaire for persons with TBI. Journal of Head Trauma
Rehabilitation. 2000 Feb;15(1):696-709.
References
Corrigan JD, Bogner J, Lamb-Hart G, Heinemann AW,
Moore D (2005) Increasing substance abuse compliance
for persons with traumatic brain injury. Psychology of
Addictive Behaviours 2005, Vol 19, No 2, 131-139.
Corrigan JD and Lamb-Hart G. (2004) Substance abuse
issues after traumatic brain injury. Brain Injury
Association of America. [Online pdf] Accessed 24/09/05.
Available at: www.biusa.org
Corrigan JD & Bogner J (2007) Interventions to promote
retention in substance abuse treatment. Brain Injury,
April 2007; 21(4): 343-356.
References Cont…
DSM-IV (1994) The Diagnostic and Statistical Manual of
Mental Disorders. The American Psychiatric Association.
Miller, Norman S. (1995). Diagnosis and Treatment of
Addictions in Traumatic Brain Injury. Alcoholism
Treatment Quarterly, vol. 13, no. 3, 1995, pp.15-30.
Neuroscience of Psychoactive Substance Use and
Dependence. (2004) World Health Organisation (WHO)
References Cont….
Ohio Valley Centre for Brain Injury Prevention a nd Rehabilitation.
Substance abuse and brain injuries users manual: effects of alcohol
on your brain [Online] Accessed 25/09/05. Available at:
www.ohiovalley.org/abuse/umanual/index/html Readiness to
Change Manual (1993&2000) Heather and Rollnick.
SASSI-3
Scrhttp://www3.parinc.com/products/product.aspx?Productid=SASSI
-3
Substance Abuse and
Acquired Brain Injury
Dr Howard F Jackson
Consultant Clinical Neuropsychologist
Clinical Director
TRU Ltd
Alcohol and Brain Injury
 People who use alcohol or other drugs after they have had a brain injury do
not recover as much.
 Brain injuries cause problems in balance, walking or talking that gets worse
when a person uses alcohol or other drugs.
 People who have had a brain injury often say or do things without thinking
first, a problem that is made worse by using alcohol and other drugs.
 People who abuse alcohol render themselves more likely to encounter
undesirable influences,
 Brain Injury increases the vulnerability to further brain injury as a result of
alcohol intoxication.
Alcohol and ABI


Alcohol use was found to be the main factor in
getting into trouble with the law after ABI
(Jackson, et al, 1992).
There are significant problems with supporting
individuals with ABI who are intoxicated. Police
will often refuse to keep them until they are
sober and return to a unit with potentially
vulnerable other residents is often untenable.
Substance Abuse and ABI
fMRI evidence shows cannabis use to decrease the
functioning of frontal and temporal areas of the brain as well
as reduced memory functioning.
Structural MRI studies have found 12% and 7% smaller
hippocampi and amygdalas respectively in chronic cannabis
abusers (Yücel and Solowij, 2008)
Alcohol and Brain Injury


After brain injury, alcohol and other drugs have a more powerful effect.
People who have had a brain injury are more likely to have times that
they feel low or depressed and drinking alcohol and getting high on other
drugs makes this worse in the long-term (although better in the shortterm).

After a brain injury, drinking alcohol or using other drugs can increase the
likelihood of a seizure.

People who drink alcohol or use other drugs after a brain injury are more
likely to have another brain injury.
Alcohol and ABI Services
Access to Brain Injury Services are often
restricted due to Alcohol Abuse
Access to Substance Abuse Service are
often restricted due to ABI.
The MHA excludes alcohol problems
Social Influences
Within the unadapted home and community, the full
impact of various deficits may be experienced for the
first time. Rather than deal with the emotional
consequences of such awareness (e.g., depression,
frustration and boredom) the individual may seek refuge
in the bottle/joint/line/pill , especially if such a pattern
existed in the past.
In sharp contrast to the rejection experienced in other
social situations, members of the drug/alcohol culture
extend a warm and friendly welcome where cognitive
and social limitations are readily accepted.
Abuse of Other Substances

Antidepressants,

Pain Killers,

Hypnotics

Anticonvulsants

Tobacco

Caffeine
Incidence



Out of 80 clients currently at TRU 16 of them
present with alcohol abuse as a core problem.
Of these 4 had poly-substance abuse.
Two others have core issues of substance abuse
involving substances other than alcohol.
Ponsford (2007) found 25.4% drinking at a
hazardous level (australian study). Only 9%
presented with other drug problems. Main
abusers were young men.
Mistaken Identity


Individuals with acquired brain injury are more
likely to present as intoxicated (eg slurred, slow
speech, incoherence. emotional lability, etc)
Individuals with acquired brain injury are likely
to present with psychiatric symptoms (paranoia,
delusions, etc), especially under the influence of
psychotropic substances – the Case of PD
Functional Reasons For Abusing
Other Drugs.







They relieve my pain (cannabis)
They help me sleep (cannabis, hypnotics)
They keep me alert (amphetamines,
proplus, red bull)
They keep me calm and chilled (cannabis)
They give me confidence (cocaine)
They help me stay in control
It bonds me to my mates
Different Typologies of Alcohol
Abuse








Impulsive Intoxication – Case of RM
Stimulus Bound Drinking – Case of AA
Escalating Drinking - Case of NC
Suggestible Drinking – Case of CH
Encouraged Drinking – Cases of JC & KW
Social Anxiety Drinking – Case of JSS
Addicted Drinking – Cases of KW & BW
Bored Drinking – Case of JE
Substance Abuse BLIPS

BLIPS - Brief Limited Induced Psychosis







Cannabis
Alcohol
Amphetamines
Cocaine
LSD, Psilocybin (Magic Mushrooms)
Ecstacy
Steriods?
Different Responses to Alcohol

Aggressive Response - Case of CM

At Risk Response - Case of CH

Passive Response – Case of JC

Calming-Social response – Case of HJ
The Stages of Change Model
STAGE 1: PRE-CONTEMPLATION
STAGE 2: CONTEMPLATION
STAGE 3: PREPARATION
STAGE 4: ACTION
STAGE 5: MAINTENANCE
STAGE 6: LAPSE / RELAPSE
Motivational Interviewing in ABI

Short term effect without ongoing MI

Insight or intention does not equate with behaviour (good in theory, bad
in practice)

Slippage in the MI stages (episodic memory impairments)

Difficulty with reaching the contemplative stage due to impaired abstract
thinking

Difficulty with preparation stage due to impairments in ability to plan.

Difficulty with action stage due to initiative and memory problems.

Difficulty with maintenance due to executive dysfunction

Resistance of Conceptual Attributions.
General Points for Treatment
Educate client and family about the risks of clients with Brain Injuries
using substances.
Engage family/social network in actively supporting the client to address
the issue.
Take a history of client’s prior and current use. Be specific — ask,
“What’s the most you’ve used? The least?”
Ask client about his/her family history of Substance Use. Ask what effect
use is having on client’s life (social, family, job, legal).
Functional Analysis – what are the ABC’s? – How can these functions be
addressed without substance abuse?
Gain an understanding of the Model for Change in relation to the client
and target the relative components of change (whilst protecting the
client).
Substance Abuse and ABI

Knowledge is not the sole answer


Most interventions for substance abuse
involve educational or self-exploration
approaches as the primary therapeutic
approach.
Most interventions fail to address habitual
behaviours directly.
General Points for Treatment

Assess stressors and risk factors that might cause client to begin
using (isolation, boredom, depression, job loss, etc).

Help client find meaningful substance-free substitute activities.



Provide support for behavioural changes before, during and after
the Substance Abuse program to build motivation and reinforce new
behaviours.
Ongoing Cognitive Behavioural Therapy (contextual CBT) to address
the antecedent triggers to substance abuse
Lapses are likely to be frequent and so management plans for the
‘individual under the influence’ need to be in place prior to risk
taking in their gradual return of the community.
Some Interventions One Might Consider
A Behavioural/Habitual Approach

No-alcohol contact – non-alcohol related settings

No alcohol contact – alcohol related settings


Planned/Controlled alcohol contact – alcohol
related settings with supervision
Planned Controlled alcohol contact – alcohol
related settings without supervision
Some Interventions One Might Consider

A graded exposure contingent on previous performance
and reliability in engagement with the rehabilitation
programme.

AA type educational/abstinence programmes and
support groups for ABI clients.

Controlled Drinking programmes

Cognitive behavioural therapies related to alcohol abuse.

Psychological Interventions for anxiety, anger, social
interactions, self-esteem, boredom, etc. management.
Out and About Group
Raising Alcohol Awareness
in Brain Injured Clients
Cate Devane
Senior Staff Nurse
York House
Brain Injury Rehabilitation Trust
Group Structure
• To provide information about alcohol
– Facts and figures
– Effects on the body
– Alcohol and Brain Injury
• 6 weeks of sessions
• Closed group
• Offer support in the community
Proposed 6 week structure
•
•
•
•
•
•
Week One
– How alcohol affects your body.
– Give us your ideas on which bits of the body are affected by alcohol and we will
add them to a life sized body map.
Week Two
– What happens when you drink alcohol?
– We will discuss the effects of alcohol on your body, and everyone is invited to join
in with their ideas.
Week Three
– Why do people drink or not drink?
– Tell us your views and we will share our information.
Week Four
– Facts about alcohol.
– A fun quiz where you can show off your knowledge!
Week Five
– Visit to a pub to try out your new knowledge!
Week Six
– Lapse and Relapse Prevention.
– What happens if you have had a drink when you were advised not to? How do you
stay stopped?
Skills Base of Facilitators
• 3 x Occupational Therapists
• Rehabilitation Assistant / Programme
Planner
• Rehabilitation Support Worker
• Senior Staff Nurse
Group Demographics
•
Group 1
•
Group 2
•
Group 3
–
–
–
–
–
–
–
–
November 2008
3 Older gentlemen + 1 younger lad
6 weeks didactic but quickly became client led
Followed out into the community
March 2009 - A new group
3 younger male members
8 weeks client led discussion
Followed out into the community
– February 2010
– Merger of Group 1 & 2 members
with 2 new members (1 being female)
– Directly into the community – client led discussions
Our findings from the groups
• In removing clients usual coping
strategy of drinking at times of
difficulty it is necessary to offer
support in its place, this is only
acceptable from a trusted source, so
an aim of the group is to provide
support when group members are in
difficulty
Our findings from the groups
• Use of group structure to build
therapeutic relationships with staff
– Working relationship in and out of the
group
– Role models
• Male relationships
• ‘Parental’ relationships
Our findings from the groups
• The growth of trust between clients
and facilitators is central to this
group functioning during the practice
of difficult new behaviours. Trust
between clients and facilitators
provides support for clients
Our findings from the groups
• In the community it is very difficult
for staff to give direct instruction to
clients on behaviour, at this point the
relationship between clients and staff
is very equal and dependant on trust
between all concerned
Our findings from the groups
• Congratulation of self efficacy is
powerfully reinforced in the group,
especially when other group members
offer this support
Our findings from the groups
• Clients may go round the cycle of
change many times, a service may
witness only one of these attempts to
change, this still has value
Our findings from the groups
• Risk taking is carefully assessed
beforehand but a risk nevertheless
and has proved beneficial for the
clients involved
Our findings from the groups
• Toleration of difference in others
continues to be an important benefit
from membership of this group
Our findings from the groups
• The group proved useful to clients on
many different levels apart from
alcohol issues
• There was a correlation between
managing alcohol in the group and
progress in other areas
Summary
• Establishing new patterns of behaviour is difficult and more
so with a brain injury. Support with challenges is important,
groups do this well
• Clients who have a dependence on alcohol or drugs resulting
in an inability to maintain abstinence or controlled use will
have problems finding less restricted placements and
consequent restrictions on their choices. In practicing non
drinking York House clients are able to demonstrate that
control is possible
• Practicing non drinking demonstrates to clients that they
are able to do this, far more than talking about it in
however useful a session
• York House alcohol group, combination of teaching about
alcohol and the effects on the individual, and practicing the
theory in the community
Client’s own words
• ‘When I got drunk I got into fights, got
knocked down’ (alcohol related ABI)
• ‘If you're out all night there will be
someone sitting up waiting for you,
thinking you are lying in a ditch’
• ‘I used to drink when I was lonesome,
after my dad died’ (alcohol related ABI)
• ‘I would drink 5 litres of whisky a day’
Where are they now?
• Group 1
– Allan discharged to less restrictive BIRT unit
– Charles discharged to less restrictive unit in his
preferred area
– Wayne discharged due to difficulties with complying with
rehabilitation
– George discharged to a BIRT community house in the local
area
• Group 2
– Neil discharged back home unable to comply fully with
rehabilitation restrictions
– Ted continue to work with the group, has joined Group 3
– Sam discharged to less restrictive BIRT unit
• Group 3
– Ongoing
BISWG Conference
22nd April 2010
Clients and Crime – Practitioners Legal
Responsibilities
Jonathan Betts
Partner
Irwin Mitchell LLP, Manchester
Clients and Crime – Practitioners Legal Responsibilities
•
•
•
•
Some legal basics
Prevention
Managing Criminal Incidents
How the law affects you – both civil and
criminal
• BUT recognising your role and restrictions
Clients and Crime – Practitioners Legal Responsibilities
How can I help you?
•
•
•
•
Maybe I can’t!
To tell you the obvious?
BUT the “law” does matter in your work
Make life better for those we care about
Clients and Crime – Practitioners Legal Responsibilities
Why does the law matter in your work?
•
•
•
•
The application of the rule of law
You have a duty
A little knowledge may make a real difference
You may be able to tell the lawyers to stick it!
Clients and Crime – Practitioners Legal Responsibilities
Courts – the basics
Criminal
(Punishment –
fine/imprisonment)
Magistrates
Crown
Beyond reasonable doubt
Civil
(Resolution –
damages and
costs)
County
High/CA/HL
Balance of probability
Clients and Crime – Practitioners Legal Responsibilities
The Law
• Statutory Law – “Acts of Parliament”
–
–
–
–
–
–
–
–
–
Care Standards Act 2000
Law Commission Report on Adult Social Care
Offences Against the Person Act 1861
Misuse of Drugs Act 1971
Sexual Offences Act 2003
Human Rights Act 1989
Mental Health Act 1983
Mental Capacity Act 2005
Corporate Homicide Act 2008
Clients and Crime – Practitioners Legal Responsibilities
The Law
•
•
•
•
•
Common Law
Applies to both Criminal Law and Civil Law
Civil Law - Negligence
Causation
Consent
Clients and Crime – Practitioners Legal Responsibilities
Your Rules
• Regulation by your Professional/Regulating
Body
• Objectives of Regulation
• Methods of Regulation
• Employment Contract
Clients and Crime – Practitioners Legal Responsibilities
Legal Principles
• An individual has a right to autonomy
– Independence
– Freedom
– Self Government – see code of practice
• An individual is accountable for their own actions
• An individual is innocent until proved guilty
• Capacity Act s1(1) - An individual assumed to have
capacity
• The Law will not interfere unless it is just and
reasonable to do so
Clients and Crime – Practitioners Legal Responsibilities
Intervention before Commission - prevention better than cure?
•
•
•
•
•
•
•
You may have a duty to do something rather than nothing
Consult
Mental Capacity Act & DOLS
Best Interests Assessments
Court of Protection – Financial Deputy
Any help better than none?
Community rehab teams
Clients and Crime – Practitioners Legal Responsibilities
Criminal Culpability
• Cardinal principle – an act does not make a person
legally guilty unless the mind is legally blameworthy
• Actus Reus - The act (or omission) as defined by Law
• Mens Rea – Guilty Mind
Clients and Crime – Practitioners Legal Responsibilities
Perpetrator/Principal Offences
•
•
•
•
•
•
Violent Crime and sexual assaults – OAPA 1861
The Misuse of Drugs Act 1971
Burglary / Theft
Criminal Damage
Antisocial Behaviour
Prevention better than cure?
Clients and Crime – Practitioners Legal Responsibilities
What if…. Commission of an offence?
• Fitness to be interviewed
• PACE Codes Of Practice – Code C
– “If an officer has any suspicion, or is told in good faith, that a person of any
age may be mentally disordered or otherwise mentally vulnerable, in the
absence of clear evidence to dispel that suspicion, the person shall be treated
as such for the purposes of his code”
• You may be the only one around to deal with this issue
Clients and Crime – Practitioners Legal Responsibilities
What if…… the client commits a crime?
• Information sharing crucial! Assumptions
• BUT confidentiality? DPA 1998 s.29 (1)(a)
“Personal data processed for the prevention or detection of crime…is exempt from …. Sanctioninformation commissioner supports this”
•
•
•
•
Representation – Responsible adult at interview
Medical/Neuropsychiatric assessment
Safeguarding
Criminal solicitors and Magistrates don’t really understand
Clients and Crime – Practitioners Legal Responsibilities
What if…..further action is taken
•
•
•
•
CPS decision to charge – is it in the public interest to prosecute?
Avoidance or Fairness?
Pre trial disclosure – medical reports - make them understand!
Trial – Capacity Code for Crown Prosecutors
- Fitness to stand trial? - preliminary issue supported by medical evidence
- “If report states strain of criminal proceedings lead to considerable
worsening of the defendants mental health consider very carefully before
proceeding”
• Defences
• Sentencing
Clients and Crime – Practitioners Legal Responsibilities
But now the really scary bit! Could this be you?
•
•
•
•
•
Accessories and Abettors Act 1861 (as amended)
Aiding - Giving help, support or assistance
Abetting -Inciting, instigates or encourages
Counselling - Advising and/or instructing
Procuring - Bringing about
Clients and Crime – Practitioners Legal Responsibilities
The Balance
• Case of Coney (1882) - It is no offence to stand by; a mere accidental
spectator to the commission of an offence and failure to prevent an
offence is not generally enough.
• The Criminal Law Act 1967 Section 3 (1) - A person may use such force as
is reasonable in the prevention of crime or in affecting or assisting in a
lawful arrest of offenders of suspected offenders or of persons unlawfully
at large.
Clients and Crime – Practitioners Legal Responsibilities
But, standing by could now be enough
Corporate Homicide 2007
• Application to your employers? Companies/organisations can be found
guilty of corporate manslaughter as a result of serious management
failures resulting in a gross breach of a duty of care
Clients and Crime – Practitioners Legal Responsibilities
Sexual Assault by touching- Sexual
Offences Act 2003 Section 3
A person (A) commits an offence if:
(a) He intentionally touches another person (B)
(b) The touching is sexual
(c) B does not consent to the touching and
(d) A does not reasonably believe that B consents
Clients and Crime – Practitioners Legal Responsibilities
Civil Culpability - Bloody Risk Assessments!
• Initial Assessment of Client – Sources and
Records?
• Continuing Risk Assessment
• Information sharing
• Cover yourself
Clients and Crime – Practitioners Legal Responsibilities
Civil Culpability – Negligence and Human Rights
•
•
•
•
•
•
•
•
You have a duty of care
You have obligations under the Human Rights Act
Show you have complied with it – record, record, record
Breach – the “reasonable social worker”
Causation
Damages / Compensation
Your records will be scrutinised by people like me
So – shout if you are exposed
Clients and Crime – Practitioners Legal Responsibilities
Other Sanctions
• Regulatory General Social Care Council Code of
Practice and (Conduct) Rules 2008
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–
–
–
Sanctions
Factors
Mitigation
Local Guidelines and Procedures
• Breach of Employment contract
• Adverse Press / Public Criticism
• Your conscience !
Clients and Crime – Practitioners Legal Responsibilities
What does this mean for you?
•
•
•
•
•
•
•
Risk assess
Information sharing
Prevention better than cure
Understand your responsibilities and your power
Are you behaving reasonably?
Social justice?
Make your views count
BISWG Conference
22nd April 2010
Thank you
Jonathan Betts
Partner
Irwin Mitchell LLP, Manchester
DDI 0161 838 3055
Brain Injury Social Work Group
Annual Conference 2010
Thursday 22nd April
Bridgewater Hall, Manchester
Mad, Bad and Dangerous to Know?
Supporting offenders
with an Acquired Brain Injury
Dr Ivan Pitman
Consultant in Neuropsychology and Rehabilitation
Redford Court, Brain Injury Rehabilitation Trust
We know…
crime is common in the UK...
Daily Mail Online 03rd July 2009
We know…
crime is costly (£)…
• In 2000 Home Office figures show that crime
cost households in England and Wales an
estimated £60 billion a year
–
–
–
–
–
Each murder costs an average of £1.1m
Each wounding costs an average of £19,000
The average car theft costs £4,800
Fraud costs £14 billion
Criminal damage costs £510
• In 2009 figures show that the cost of crime in
England and Wales had risen to an estimated
£78 billion a year.
Daily Mail Online 3rd July 2009
We know…
crime is costly (emotionally)…
Fear of crime makes UK most watched
country in Europe 26 April 2004
Fear of crime 'trapping elderly‘ 20 May, 2003
“A GENERATION of teenage girls on
inner-city London estates is growing
up in a climate of fear because [of]
gang rape “ 8 January 2009
We know…
different views exist on response…
…LOCK
THEM UP AND
THROW AWAY THE KEY…
‘Have your say’ 17 August 2007
Inmate in 'holiday
camp' jail… 17th October 2008
PUNISHMENT
V
Reward
We know…
who commits crime…
Official crime statistics show that most crimes are
committed by young working-class males in urban
areas
• AGE: People aged 14-20 are
most likely to commit crimes
• GENDER: Males commit five
times more crime than females.
We know…
who sufferers ABI…
Research highlights:
• males 2 - 3x more likely to suffer ABI
• ages 15 – 29 5x more likely to suffer ABI
• those with lower socio economic background
more likely to suffer ABI
Therefore young men from lower social
background who are likely to be risk takers are
more likely to suffer an acquired brain injury.
Remind you of any one?
We know…
neurodevelopmental impact…
 Evidence of ‘lost’ / ‘forgotten’ childhood injuries
 Frontal Lesions have dramatic and lasting
effects down stream – sleeper affect
 Evidence of damage earlier results in more
devastating executive functioning impairments
(very little plasticity)
 Clinical experience highlights several
examples of early childhood ABI then poor
adolescent development with anti-social
behaviour in contrast to high achieving siblings
We know…
ABI in prisons…
• Actual numbers of prisoners with ABI unknown as no
data sought on reception (‘First Reception Health
Screen’)
• Review of the literature
- significant variation rates of incidence /
prevalence
- dependent upon population, context and definition
- degree of deficit and type of deficit more
important than presences
We think…
large prevalence in prisons…
Pat Mottram (2007) on study of HMP Liverpool,
Styal and Hindley – sampled 2,298 prisoners and
found 48% reported head injury – much higher
than community rates
Head Injuries
100%
80%
60%
40%
20%
77
21
27
0%
Liverpool
Styal
Hindley
No
Yes
We think…
large prevalence in prisons…
Prof Huw Williams (in prep) on study of HMP Exeter
– sampled 453 prisoners and found 60% reported
head injury – much higher than community rates
140
estimated:
120
10%
100
Severe
80
5.6 % Moderate
60
Count
40
49.4% Mild
20
0
Missing
Any tbi?
No
Yes
We think…
higher risks of re-offending…
Mewse, Mills, Williams & Tonks et al (in prep)
70
60
50
40
Any tbi?
Yes
10
No
es
nyc
efer
obf
olb
s
e
uRa
nc
ex
S
ffe
o tio n
gs p
ru c e
D e
/d
es
ud
nc
ra
fe
F
of s
g
in
ce
riv fen
f
D
t o eft
n
le /t h
io g
V ftin
i
pl
ho
S
0
Most serious offence currently in custody for
er
ht
ug
a
sl
an
m
r/
de
er
ur
th
M
O
20
y
ar
gl
ur
B
ng
si
is
M
Count
30
Missing
We think…
can play a role in violence…
Turkstra et al. (2003)
Compared matched group of offenders & nonoffenders
FOUND – ABI was not more common
BUT Offenders more severe and associated with
assaults and anger issues.
THEREFORE ABI is not necessary for crime, but
that ABI may more readily contribute to ‘expression
of violence’ and increase the risk “threshold” in
vulnerable adults.
We think…
misuse substances…
Pitman et al (in prep)
Patients with a history of substance
misuse
84%
Of those patients with a history of
substance misuse those with a history
of multiple substances misuse
69%
Of those patients with history of
substance misuse those patients who
misused prior to there head injury
69%
Some think…
it’s all in the brain anyway…
The criminal brain
www.futurepundit.com
www.criminal-lawlawyer-source.com
May 3 1997
Brain Scans Show Abnormalities
In Psychopaths March 16, 2004
Brain Scan Machines Show
Crime-Fighting Promise
So what do we know…
•
•
•
•
•
•
•
Young men are at higher risk
Younger the injury - higher the risk of offending
High rates of ABI in prisons
Higher risk of reoffending
Higher levels of violent offending
High levels of substance misuse
Complex association of pre / post injury factors
The complexity of
supporting offenders with ABI…
‘It’s not only the kind of injury that
matters, but the kind of head’
C. Symonds 1937
Rehabilitation
for Offending
Behaviour
Rehabilitation
for Cognitive
Deficits
Traditional model of
forensic care…
• The focus of change is aimed at altering the
attitude and behaviour of the offender.
• Intervention and care is often a ‘consequential’
based approach.
• This approach is based on the notion that
individuals must learn from their actions and
change accordingly.
Rehabilitation of Offenders
Offending Behaviour Programmes
R&R
Reasoning and Rehabilitation
ETS
Enhanced Thinking Skills
SOTP
Sex Offenders Treatment Programme
ASOTP
Adapted Sex Offenders Treatment Programme
CALM
Controlling Anger and Learning to Manage it
CSCP
Cognitive Self Change Programme
Briefing Paper – Head Injury
and Offending October 2001
Highlighted that within the criminal justice system ABI
remains a ‘hidden disability’
Highlighted concern as to lack of identification of ABI
within Prison populations.
Highlighted concern as to the lack of understanding as
to the impact of ABI
Highlights difficulties of ABI prisoners to adapting to
the prison regime, comply with prison regulations and
effectively access education and rehabilitation
Key areas
previously highlighted…
•The need for specific staff training
•The need to raise awareness and recognise of
ABI as a significant disability
•Adaptations of offence focused treatments
•Access to specialist services
•The need for planned release
What can be done identification…
• better screening for head injury at pre-sentencing
and on admission to prison services
• for better understanding of risk and for rehabilitative
purposes
• Especially those with executive (& socio-affective)
difficulties who may have difficulty in changing
behaviour patterns in response to contingencies.
• Data systems need to be developed for monitoring
trends, causes etc. To guide preventative measures
and for appropriate resources & service provision
Research by the
DT FOUNDATION…
The DT Foundation is a division of the Disabilities Trust which
funds philanthropic activities and development initiatives across the
health and social care sector.
Collaborative
study
looking
at
identification of incidence and prevalence
of prisoners with a history of ABI on
admission to HMP Leeds.
HMP Leeds
Bradley
Report
(April
2009)
recommended identifying the needs of
vulnerable prisoners and building robust
support mechanism.
What can be done prevention…
• Prevention of injuries in childhood
• Adolescents and young adults need to target
drugs, alcohol, violence
• Especially in context of inner cities and areas of
lower socio-economic status
What can be done rehabilitation…
•Alderman (2003) – aggressive and violent
behaviour associated with impaired executive
functioning after ABI could be reduced through
programmed work (structured, skills-based
problem-solving focus)
•Mullin & Simpson (2007) – found Enhanced
Thinking Skills was most effective with offenders
with the lowest executive ability
•In non-ABI CBT group-work reduces sex
offending recidivism by 50% (Hanson et al., 2002)
The role of rehabilitation…
Leon-Carrion & Ramos (2003)
Retrospective study of violent and non-violent prisoners
with history of head injury as a child or adolescent.
FOUND both violent offenders and non-violent had
histories of head injury
BUT the violent offenders tended NOT to have had
rehabilitation post-injury
THEREFORE rehabilitation of head injury is a
measure for crime prevention
What can be done –
everyday management…
• Risk Assessments – identifying vulnerabilities from
both past an current behaviours to produce risk
reduction plans.
• Management of the whole person – cognitive,
behavioural, emotional, social
• Parallel behaviours – identification of ongoing
maladaptive behaviour and beliefs
• Self-generated risk reduction plan
So what do we do…
• Researchers need to continue to develop simple
and agreed methods of identifying individuals and
the severity of their problems
• Society needs to target know high risk groups
appropriately to achieve cultural shift
• Services need to identify risks, parallel behaviours
and support risk reduction plans
• Clinicians need to offer and refine suitable
rehabilitation
Authors contact details…
Dr Ivan Pitman
Consultant in Neuropsychology & Rehabilitation
Brain Injury Rehabilitation Trust
Redford Court
7 Birt Close
Toxteth
Liverpool L8 7SZ
Tel: 0151 280 8181
E-mail: [email protected]