____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
interfere with the process of rehabilitation by adversely affect- ing cognition. Because rehabilitation is a learning process, substance use that impairs learning also limits the benefits of rehabilitation. Substance use can also limit the beneficial out- comes of rehabilitation by causing medical complications that interfere with the rehabilitative process (McIntyre et al., 2015). One of the most critical factors in rehabilitation from physi- cal disability is a sense of self-efficacy and a generally positive attitude about one’s future. Substance use can increase the likelihood of feelings of anxiety, depression, and social isola- tion and lead to a lack of appropriate self-care. These factors undermine the basis of a rehabilitative strategy. VISUAL DISABILITY Brooks and colleagues (2014), in a study of 69 individuals with significant visual impairment, found that 32% of this volunteer study sample could be classified as having a moderate to high probability of substance dependence and that 17% were in fact dependent on alcohol or some other substance. These percentages are higher than would be expected in a sample of individuals without a vision impairment. Substance abuse in individuals with vision impairment may be an attempt to cope with visual impairment or may be an outgrowth of social isolation, underemployment, and an excess of unstructured time. However, the small sample size limits generalizability of the findings. What is not limited is the special consideration that needs to be given even to moderate substance use among individuals whose vision impairment is the result of diabetes or glaucoma because substance use can worsen the underlying physical conditions. Likewise, substance-impaired balance, orientation, and mobility are also issues with vision-impaired individuals in general. It is important to note that treatment for vision-impaired individuals with SUDs must make mate- rials available in formats that take into consideration their communications needs (e.g., talking books or educational material in Braille). HEARING IMPAIRMENT In cases of hearing loss, the time of onset makes for significant differences in social integration. People whose hearing loss is congenital often form their own communities, giving rise to a unique culture in which a good deal of support and affirma- tion is generally available for individual members, but in which there can be considerable mistrust of the hearing world. People whose hearing loss is the result of later injury or disease may be more prone to social isolation. In both instances, facility in speech reading, vocal training, and sign language ability will determine the acculturation to the hearing community. However, lack of understanding of the communications needs of individuals with a hearing impairment by the hearing community, together with mistaken notions that people with hearing impairments are somehow less intelligent or capable than the hearing, adds to social stigma and social isolation. When understood from this context, the mistrust that many people with hearing impairments have of the hearing world and its institutions seems quite reasonable. Although there are
no studies of the incidence of SUDs in the hearing-impaired population, anecdotal evidence would seem to indicate that it is no more common than in any other group. With that said, it is also no less common. Unfortunately, very few treatment providers are equipped to meet the needs of individuals with hearing impairments. Consider the simple act of making a tele- phone call to a treatment provider to arrange for an evaluation. If the provider does not have appropriate telecommunications equipment (TDD), the individual with a hearing impairment might have to rely on a hearing relative or friend to make the contact and compromise his or her confidentiality. Beyond this, most treatment providers are reluctant to contract with and bear the cost of professional interpreters, often requiring the individual with a hearing impairment to provide these ser- vices at his or her expense. Even fewer providers have qualified staff skilled in the use of sign language. It is important that the provider understands the dilemmas that such a person faces. He or she must ask a relative or friend to make a phone call in order to be able to address a serious and stigmatizing problem. When the person arrives for an appointment, he or she can communicate only by passing notes back and forth or by tak- ing someone to interpret a conversation with a therapist about intensely personal and often embarrassing matters. Clinicians must understand the effects these conditions have on forming a strong therapeutic alliance and identify exactly what is needed to work productively with people who are hearing impaired. TRAUMATIC BRAIN INJURY Traumatic brain injury (TBI) is caused by a blow to the head. This injury can result from an accident, such as a fall or automobile crash, a deliberate violent attack, or a concussive injury caused by an explosion. No matter what the cause, TBIs often impact the prefrontal cortex, damaging an individual’s ability to function across multiple domains. The prefrontal cortex of the brain is where executive functions are mediated. Executive functions involve the making of decisions, planning, weighing options, delaying in acting on impulses, processing of both internal and external feedback on the appropriateness of activities, and regulating of behavior to maximize harmony with those around the individual. By damaging the prefrontal cortex, TBI leads to at least a partial loss or decrease in these vital functions. Consequently, individuals with TBI have dif- ficulty inhibiting their impulses, no matter how harmful or inappropriate they might be. These individuals have difficulty making decisions or even recognizing all of their options. They find it difficult to regulate their behavior in socially acceptable and beneficial ways. Additionally, the ability to learn from either one’s own behavior or the experience of others may be damaged. These deficits can easily leave the individual feel- ing misunderstood, vulnerable, socially isolated, suspicious, depressed, and anxious. Even if substance use did not precede the TBI, it is understandable that it might follow the injury. Traumatic brain injury can affect capacity for work, leisure activities, and relationships, and in the long term it can result in social isolation, depression, anxiety, and loss of self- esteem. Studies have suggested a high prevalence of substance
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