Journal of Substance Abuse Treatment, Vol. 5, pp. 99-104, 1988 Printed in the USA. All rights reserved.

0740-5472/88 $3.00 + .00 Copyright © 1988 Pergamon Press plc

ORIGINAL CONTRIBUTION

Neuropsychologically Impaired Alcoholics: Assessment, Treatment Considerations, and Rehabilitation

SHARON M. GORDON, MA, BRUCE P. KENNEDY, MEd, AND JOHN D. MCPEAKE, PhD

Beech Hill Hospital, Dublin, New Hampshire

Abstract-Recently there has been a resurgence of interest in the neuropsychological status of the alcoholic. The research documenting neuropsychological deficits has consistently shown impair­ments in abstract reasoning ability, visuospatial and visuomotor ability, and learning and memory skills. Despite these findings, it appears that many alcohol treatment clinicians interpret patient behavior from a psychological perspective and treatment programs make unwarranted assumptions about patients' ability to profit from standard treatment approaches. This paper discusses these issues, and presents an outline of an innovative cognitive rehabilitation program designed specif­ically to meet the needs of neuropsychologically impaired alcoholic patients.

Keywords-Alcoholism, assessment, neuropsychological impairment, cognitive rehabilitation.

INTRODUCTION

THE NEUROPSYCHOLOGICAL STATUS Of the alcoholic and its clinical implications has received renewed con­sideration in the literature (Goldman, 1986; Miller, 1985; Wallace, 1986). It is of interest that the current discussion is not devoted to the more florid organic impairments represented by alcoholic amnestic disor­der, that is, Korsakoff's Syndrome, or Wernicke's encephalopathy, but rather to more moderate or "sub­tle" neuropsychological dysfunction.

While it has taken the research and clinical com­munities a number of years to recognize the im­portance of these more subtle cognitive deficits in alcoholics, they have long been acknowledged by re­covering persons in Alcoholics Anonymous (AA). The vernacular "mocus" has been coined to describe this condition. Awareness of cognitive deficits is echoed in self-help slogans such as: "I'm here 'cause I'm not all there;" "Bring the body, the mind will follow" and admonitions such as "50 miles into the woods 50 miles out" as well as "It takes time." Recovering AA mem­bers seem to have grasped the importance of time in

Requests for reprints should be sent to Sharon M. Gordon, Director of Neuropsychological Assessment and Cognitive Rehabilitation, Beech Hill Hospital, Dublin, NH 03444.

allowing the brain to heal or "recover" from the toxic effects of alcohol. In addition, many slogans and say­ings point toward a cognitive rehabilitative plan or process within AA: "Learn to listen listen to learn," "Keep it simple," "Don't make any major decisions for a year," and "Follow suggestions."

While time and abstinence have traditionally been seen as the cures for cognitive impairment by treat­ment professionals, the findings of researchers such as Goldman (1986) have suggested that an active cognitive retraining program may be an important additional component to existing alcohol treatment programs. This paper will describe such a program after briefly reviewing the nature of the neuropsychological deficits observed in alcoholic patients and their implications for current treatment programming.

THE NATURE OF NEUROPSYCHOLOGICAL DEFICITS IN ALCOHOLICS

Research has found a variety of neuropsychological deficits in persons with chronic alcohol consumption. These deficits include impairments in abstract reason­ing ability, visuospatial and visuomotor ability, and. learning and memory skills.

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A review of the literature by Parsons and Farr (1981) found that alcoholics scored significantly lower than nonalcoholics on measures of abstract reasoning in 93% of the studies they reviewed. Laine and But­ters (1982) interpreted this poor abstract reasoning performance as a function of inadequate hypothesis generation and testing strategies.

Fitzhugh, Fitzhugh, and Reitan (1960) in a land­mark study, demonstrated that alcoholics perform slower on visuospatial and visuomotor tasks than nonalocholics. Betera and Parsons (1978) found that alcoholics' visual scanning abilities were impaired. These impairments were not necessarily related to motor ability, but probably represented higher level perceptual dysfunction.

Ryan and Butters (1980) using paired-associate learning and short term memory tests found that alco­holics had difficulty with retention and comprehen­sion of novel information. Additional research has supported these findings (Becker, Butters, Hermann, & D'Angelo, 1983; Brandt, Butters, Ryan, & Bayog, 1983; Cutting, 1978).

Our own clinical observations, based upon tests and interviews with patients at Beech Hill Hospital, a chemical dependency inpatient facility, support the research findings described above. Table 1 below presents the Impairment Index and the scores from the Category Test, Tactual Performance Test (Locali­zation), and part B of the Trail Making Test from the Halstead-Reitan Test Battery. These scores are con­sidered to be the most sensitive general indicators of brain impairment (Jarvis & Barth, 1984). The--data were obtained from test protocols of 23 male and 7 female inpatients with an average age of 47 (range 30-65), 12.5 (SD = 2.4) mean years of formal school­ing, and a mean full scale IQ of 92.4 (range 81-111).

The patients showed impairments across all the indicators despite average IQ levels. These impair­ments are characterized by difficulties in abstract reasoning, critical judgement, conceptual tracking, and memory skills.

Most of these deficits are not obvious in the phys­ical presentation of the patient nor in the verbal skills observed. These impairments do not usually become apparent with standard medical or neurological exam­

TABLE 1 Summary of Halstead-Reitan Neuropsychological Test Battery Data

Sub-test

Mean

SD

Full Scale IQ

92.4

8.2

Impairment index

0.67

0.22

Category Test

78.1

29.9

TPT Localization

2.1

1.5

Trails B

104.5

42.2

inations. In order to observe them, more sensitive measures such as the Halstead-Reitan Neuropsycho­logical Test Battery must be employed (Reitan & Wolfson, 1985).

To date the research has not been conclusive as to the exact etiology of neuropsychological impairment in alcoholics (Grant, 1987). The research does how­ever suggest that these impairments need to be as­sessed in light of a multitude of factors and their interactions (Grant, Adams, & Reed, 1984). These include: consumption and duration of use (Guthrie & Elliot, 1980; Lplberg, 1980), other drug use (Grant, Reed, Adams, & Carlin, 1979; Hill & Mikhael, 1979), age (Adams & Grant, 1984; Craik, 1977), alcohol related medical complications such as liver dysfunc­tion (Rehnstrom, Simert, Hansson, Johnson, & Vang, 1977) and head injury. An in-depth discussion of these factors is beyond the scope of this paper. They should however be considered in the assessment, diag­nosis, and treatment of alcoholics.

The research presented above suggests that neuro­psychologically impaired alcoholics, regardless of eti­ology, are not capable of organizing and integrating the material that is presented within the framework of traditional alcohol rehabilitation treatment programs. As a result their ability to participate fully in such treatment programs may be compromised. These con­clusions, while initially speculative, have been receiving increasing support from current treatment outcome research.

NEUROPSYCHOLOGICAL STATUS AND TREATMENT OUTCOME

Evidence has been accumulating that neuropsycholog­ical status has a significant relationship to alcohol rehabilitation treatment outcome (Abbott & Gregson, 1981; Berglund, Leijonquist, & Horlen, 1977; Greg­son & Taylor, 1977; Sussman, Rychtarik, Mueser, Glynn, & Prue, 1986; Walker, Donovan, Kivalhan, & O'Leary, 1983). Many of the components of tradi­tional treatment programs consist of educational in­formation presented in a lecture format or in verbally mediated group and individual therapy sessions. The types of deficits in conceptual thinking and memory 'found in some alcoholics may preclude many of them from fully assimilating and applying this information, thus compromising their participation in treatment. For example, an investigation by Leber, Parsons, and Nichols (1985) which assessed the effects of neuropsy­chological deficits on patient participation in treatment found that the degree and type of neuropsychological impairment were highly correlated with clinical ratings of patient progress and prognosis. The patients receiv­ing poor clinical progress and prognosis ratings were significantly more impaired than those receiving fa­vorable ratings.         '

Neuropsychologically Impaired Alcoholics

This poor prognosis has traditionally been attrib­uted to a patient's resistance to therapeutic interven­tion characterized by their "unwillingness" to: follow suggestions, complete assignments, be punctual at scheduled therapeutic activities, and actively partici­pate in group therapy. This resistance or "denial" has been explained as a psychological defense mechanism utilized by the patient to avoid the consequences of their drinking and its relationship to their maladaptive behavior. Breaking through this "denial" has been seen as the critical task of treating the alcoholic. It is interesting to note however, that in other brain in­jured populations such as head injury, this type of behavior is directly attributed to cerebral trauma rather than psychogenic processes (Horvath, 1986). We sug­gest that much of the perceived resistance in some alcoholic patients may be due to cerebral dysfunction rather than conscious or unconscious psychodynamic processes. Failure to address these issues by proper patient assessment and treatment planning reduces the effectiveness of treatment.

The following case study illustrates how neuropsy­chological impairment may influence a patient's abil­ity to comply with standard treatment regimens and how this "noncompliance" may be misinterpreted as denial.

Case Study

JMC was a 55 year old, right-handed, married female with 14 years of education. She had a 30 year history of significant alcohol consumption as well as the use of prescribed tranquilizers which she denied abusing. Prior to entering our facility, she was treated for nine days at a general hospital for injuries sustained in a fall. While in this hospital her alcoholism was de­tected and she was referred to us for further assess­ment and treatment. Her discharge diagnoses from that facility were as follows: chronic alcoholism, cere­bral concussion, metabolic encephalopathy, dehydra­tion, hypokalemia, and hyponatremia.

Upon entering our facility, initial diagnostic im­pressions included: alcohol abuse and dependence, hypertension currently at borderline levels, history of abnormal liver function tests and chronic edema pos­sibly secondary to cirrhosis of liver, cigarette smoker, and menopausal.

JMC's behavior in the early phase of treatment was seen as rigid and noncompliant. This was character­ized by consistent refusal to comply with hospital rules and emotional outbursts when confronted by staff on these issues. She seemed unable to make the connection between her serious medical complications and her alcohol consumption, and was more con­cerned with personal appearance than involvement in therapeutic activities. For example, she became quite belligerent and threatened to leave treatment when

told she could not have her hair styled during time allotted for therapy sessions.

This noncompliant behavior was interpreted by some clinical staff members as "denial" and an administrative discharge was considered. However, at a treatment team meeting, the possibility of organic involvement was suggested and the patient was re­ferred for a neuropsychological assessment. The neuro­psychological exam conflicted with the initial clinical impression. JMC performed within the range charac­teristic of impaired brain functions across 100% of the Halstead-Reitan Neuropsychological Test Battery and performed at a level that exceeded less than 2% of her age-peers. She was found to have difficulty with abstract analysis, critical judgment, conceptual tracking skills, flexibility of thought processes, mem­ory skills, and general levels of alertness, attention and concentration. This test protocol was consistent with those indicating alcoholic deterioration of brain functions and a possible metabolic disturbance. A subsequent CAT scan finding confirmed the presence of cortical atrophy.

The types of deficits JMC presented indicated an inability to adjust to a novel situation such as enter­ing treatment for alcoholism. Once these deficits were identified, it became apparent that her noncompliance was a function of her impairments and the clinical staff's unrealistic expectations. By altering JMC's treatment plan to allow for more structure and super­vision, and by simplifying treatment goals, JMC was able to successfully complete treatment.

Many patients seen in alcohol rehabilitation settings manifest similar behaviors that may also be associated with neuropsychological impairment. This suggests that a reconceptualization of the resistive or noncom­pliant patient is needed. Failure to address these issues through comprehensive patient assessment and treat­ment planning, may result in sub-optimal or anti­therapeutic treatment. In addition to using more so­phisticated assessment techniques, alcohol rehabilita­tion facilities need to develop treatment approaches that specifically address the problems of neuropsycho­logically impaired individuals.

A COGNITIVE REHABILITATION PROGRAM

In an effort to address the needs of the neuropsy­chologically impaired individual we have developed a cognitive retraining program that incorporates a multi­disciplinary approach to treatment. Upon entering the facility patients are assessed by a treatment team that consists of physicians, psychologists, nurses, and ther­apists. Patients who meet two of the following criteria are then referred for neuropsychological assessment: history of head injury, cerebral vascular disease, liver dysfunction or other metabolic disturbances, difficul-

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ties with memory, inability to learn or retain new material, difficulty following instructions, and evi­dence of impaired judgment or noncompliance.

The Halstead-Reitan Neuropsychological Test Bat­tery is used in the assessment process as well as EEG and CAT scans as warranted. Based on these test re­sults referrals are made to the cognitive retraining program. This program is part of the core treatment program which consists of medical detoxification, edu­cational seminars, AA/NA meetings, group therapy, individual therapy, activities therapy, and aftercare.

The program is designed to address the four prob­lem areas seen in these individuals: attention and con­centration skills, visuospatial skills, memory skills, and problem-solving skills. One aspect of this training utilizes computer programs developed by Bracy (1987) of the Neuroscience Center in Indianapolis, Indiana which specifically address all of the above areas. Pa­tients spend one hour five times a week working with the cognitive rehabilitation specialist and utilize these programs. The computer assisted remediation pro­grams are structured hierarchically beginning with attention and concentration skills. Once the patient meets criteria as measured by performance in this area, they move on to the other areas in the following order: visuospatial, memory, and problem solving. While the patient interacts with the computer, they receive constant feedback on their performance, as well as summary data following each session. This feedback helps them to adjust their responses during sessions and track their overall progress towards es­tablished goals.

Four basic software packages developed by Bracy (1987) are used in these computer assisted cognitive retraining sessions: Foundations I, Visuospatial, Memory II, and Problem Solving. Foundations I con­tains 11 programs designed to retrain attention and concentration skills. Attention and concentration are elementary components of learning, memory, and cognition. Deficits with attention and concentration interfere with a patient's ability to assimilate auditory or visual information. It follows this that patients with these impairments have difficulty absorbing the material presented in the educational seminars and other therapy sessions that utilize these media. Foun­dations I addresses these deficits through the use of both auditory and visual cues that require a patient to concentrate and attend in order to make appropriate responses.

One of the programs in Foundations I, Visual Reaction Stimulus Discrimination I, randomly creates blue or yellow one inch squares on the computer mon­itor. The patient must respond by pushing a joystick button when the yellow square appears on the screen, but inhibit making a response when the blue square is flashed on the screen. By using this program, patients are able to increase their attention span and their abil­ity to concentrate.

The skills learned with this program and the others in Foundations I, help patients increase their ability to attend to a task. Patients are encouraged by the cog­nitive rehabilitation specialist to generalize these skills to other components of treatment, such as listening attentively during educational seminars and participat­ing meaningfully in group therapy sessions.

The Visuospatial package is comprised of 10 pro­grams that retrain deficits in visuoperception and vis­uomotor functioning. The ability to mentally visualize objects and their spatial relationships accurately, is critical to such tasks as remembering directions, walk­ing, driving, using tools, performing household chores, etc. Patients presenting these deficits often have dif­ficulty maneuvering about the hospital grounds: not only do they bump into things and misplace objects such as books and personal items, but they have dif­ficulty finding their way to the various therapeutic activities on the hospital grounds.

The Maze I module of the Visuospatial package, addresses these deficits by presenting patients with a maze on the screen through which they must maneu­ver a block using a joystick. The object is to move the block as fast as possible without hitting the barriers of the maze. This program not only helps the patient with visuospatial and visuomotor skills, but also in­creases attention and concentration.

The Memory II package teaches patients skills that aid in encoding, categorizing, and organizing infor­mation. Patients with memory deficits often have difficulty grouping information presented to them into meaningful associations which may then be re­ferred to when needed. In impaired individuals we often see haphazard approaches to collecting and inte­grating new information which undermine recall and consequently, learning. For patients to benefit from treatment that involves learning new behaviors and concepts, they must have the ability to store and re­trieve information.

The Verbal Memory (Categorizing) program in the Memory II package teaches patients techniques for organizing and categorizing information. The pro­gram generates a list of words on the screen that must be organized into four categories by the patient. Once patients complete this step, the screen is cleared and a prompt appears on the screen asking the patient to recall the word list. The patient answers each prompt by typing out one of the words, until the whole list is recreated. This program also allows therapists to create their own word lists that are relevant to each individual patient. For example, words may be cate­gorized under relevant headings such as: "AA slo­gans," "situations or places to avoid upon discharge," "feelings I have when I drink," and "feelings I have when I'm sober." These programs not only teach tech­niques to enhance the patients' memory functioning, but in the process, connects them with the basic com­ponents of a sober lifestyle.

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103

The Problem Solving Skills package consists of nine programs which address the "executive" func­tions of logical analysis, abstract reasoning and hy­pothesis testing. Deficits in these areas limit patients' ability to adapt to novel and complex situations such as alcoholism treatment and participation in AA. The programs that comprise the Problem Solving Skills package, such as Knight's Challenge, require patients to use reasoning and logic to solve complicated and abstract problems. When using Knight's Challenge, patients are presented with a chessboard on the screen. Two chess pieces are also displayed, a white knight and a black knight. The patient using the white knight must avoid capture by the computer controlled black knight. To do this the patient must formulate strate­gies that take into consideration all of the possible movements of both pieces. These programs help pa­tients to consider their behavior and its consequences.

The cognitive rehabilitation therapist is actively involved in all of the computer assisted sessions. He or she provides encouragement, humour, and sup­port, helping to create an enjoyable learning environ­ment for patients. The therapist works with the patient to insure that each session is a positive expe­rience by adjusting the difficulty levels, providing hints and suggestions, giving praise, and making sure that each session ends with a successfully completed exercise.

In addition to the individual cognitive rehabilita­tion sessions, all patients participate in a group that meets two hours weekly. In this group, special; train­ing is given in memory and problem solving which augments the skills learned in the individual sessions.

Weeks 1 and 2 concentrate on memory skills. In week 1, the group members learn a basic memory technique called chaining. This involves learning to memorize items in a specified order by creating a story that involves all the items in sequence, a sample exercise is as follows:

During weeks 3 and 4 the group focuses on orga­nization skills, flexibility of thought processes, and the ability to formulate divergent hypotheses. Several different strategies are used to accomplish this. In one exercise, patients are asked to tell a story about an ambiguous picture using an organizational guideline, for example, who, why, when, where, etc. Each group member sees the same picture, but each story must be different. This helps patients to decrease rigid think­ing by teaching them that there can be various expla­nations for a situation or behavior and also reinforces logical analysis by giving them a guideline to follow. Role plays are also used. Group members are assigned roles such as counselor/patient, job applicant/em­ployer, new AA member/AA sponsor, etc. to develop different points of view as well as giving them expe­rience with situations they may encounter following discharge.

The patients also complete assignments in the Re­covery Skills Workbook developed at Beech Hill Hos­pital (Gordon, 1987). The workbook augments the skills learned in group and individual sessions. It con­sists of ecologically relevant material that utilizes AA slogans and suggestions, hospital therapy schedules, and a self-test that assesses a patient's grasp of the concepts presented in treatment. For example:

Exercise 7

The words below are scrambled. Rearrange them so that they form a logical sentence.

1. first first things

2. keep simple it

3. person I am bad not a

4. time at day a one

book meeting friend car coffee

5. winners the with stick

Week 2 sessions teach the technique of association to improve memory. Patients are taught how to re­member information by associating items with places that are familiar to them such as the spatial arrange­ments of their home. A sample technique is as fol­lows: In order to remember a number of key concepts of recovery it is suggested that the group members visualize the rooms of their house or apartment. At their front door they imagine their AA sponsor knock­ing on the door. In their living room they visualize one wall painted white with a large black lettered sign "Don't Drink." In the kitchen is a Big Book which takes up all of the room because of its importance. In their bedroom are twelve steps leading to the attic in which are all the members of their group listening to a discussion speaker on the topic "Remember when."

Read each sentence aloud. Pick one for your per­sonal slogan. Write it down again. My personal slogan is:

The workbook exercises are used as "homework assignments" which are completed by the patient on a daily basis. In addition to the exercises, the work­book includes a daily meeting schedule that not only helps patients to remember their daily appointments, but encourages structure and reinforces the "one day at a time" philosophy. A structured format for note taking is also included in the workbook and patients are instructed to use this to summarize the content of the educational seminars immediately following each presentation.

The research and our clinical experience clearly

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demonstrates that a patient's neuropsychological sta­tus has profound clinical implications. Misinterpreta­tions of behavior based on simplistic approaches to clinical assessment can result in the mismanagement of a patient's treatment. The relationship between neuropsychological status and treatment outcome sug­gests that these issues need to be addressed during the course of treatment. Our clinical experience, a sophisticated understanding of AA, and Goldman's (1986) findings all concur that time alone is not enough for recovery of cognitive skills in many impaired alcoholics. It follows that cognitive rehabili­tation is an important treatment component for these individuals and can lead to improvements in treatment progress and outcome.

Another important consideration that should not be overlooked, is the effect of these cognitive deficits on a patient's ability to function in the work place. Having impaired individuals return to jobs requiring a high level of functioning immediately upon dis­charge should be heavily weighed. Some individuals may need specialized training as well as additional time before they can resume full work responsibilities. Ongoing cognitive rehabilitation in outpatient settings or on job sites should be considered in aftercare planning.

Further research is needed to fully assess the im­pact of cognitive rehabilitation on patient status in treatment and subsequent recovery. The authors are currently investigating these relationships.

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