Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
use problems in people being treated for TBI. A significant proportion of individuals who sustain a TBI test positive for alcohol or illicit drugs. For example, Scheenen and colleagues (2016) found that 30% to 50% of individuals presenting with mild TBI were intoxicated at the time of hospital admission. Furthermore, individuals with TBI engage in more alcohol use after the injury, with observed increases in alcohol use longitudinally (Pagulayan et al., 2016). Therefore, a recipro- cal association between substance use and TBI exists, in which substance use likely increases the risk of experiencing TBI and TBI increases the risk of engaging in substance use. Furthermore, a specific disorder called alcohol-related brain inju- ries ( ARBI ) describes cognitive impairments that are a direct result of alcohol use that are similar to those of TBI but do not result from a traumatic blow to the head. The impact of a TBI on cognitive abilities can be complicated by the cogni- tive effects of alcohol use or illicit drug use. Looking at the problem from another perspective, studies with samples drawn primarily from SUD treatment populations have found large percentages of individuals with various levels of head injury. Therefore, it is imperative to screen individuals with SUD for TBI and vice versa. Treatment for individuals with TBI and a SUD must take into account the executive functioning deficits associated with TBI, while also attempting to exercise those neural pathways that can supplement for the damage done to the prefrontal cortex. Interventions developed for use immediately after the TBI event have focused on psychoeducation to help individu- als understand that substance use is not in their best interest and will worsen the effects of the TBI and decrease the value of rehabilitative efforts (Tweedly et al., 2012). Interventions developed for a time beyond the immediate rehabilitation from TBI use motivational interviewing, intensive case management, or social skills training. Both motivational interviewing and social skills training exercise executive function and assist the individual in learning or developing the ability to make better judgments and interact in a more appropriate way. Intensive case management is directed at improving the living situation of the individual and facilitating access to other beneficial services in the community. MILITARY VETERANS Excessive use of alcohol, especially in the form of binge and heavy drinking, is not a new phenomenon in the military. In fact, it has in many ways become a part of military culture. Alcohol use disorders are the most common SUDs among military personnel and veterans (U.S. Department of the Army, 2022). Recent research has shown that military deployments and combat in Iraq and Afghanistan may also be associated with increases in alcohol consumption, binge and heavy drinking, and alcohol-related problems (U.S. Department of the Army, 2022). With binge and heavy drinking comes the significant risk of SUDs and all the concomitant problems affecting health and ability to function. Bray, Brown, and Williams (2013) found that combat exposure was significantly
related to excessive alcohol use. Military personnel with high combat exposure had significantly higher rates of heavy drinking, binge drinking, and harmful alcohol use than their counterparts with lower levels of combat exposure. More than one fourth of military personnel with high combat exposure drank heavily, and more than one half drank at binge levels (Bray et al., 2013). This binge and heavy drinking culture form the basis of what can be seen in veterans but is complicated by post deployment problems such as PTSD and TBI. Among veterans receiving treatment from the U.S. Department of Veterans Affairs, substance use disorders are associated with a significant increase in risk for suicide (U.S. Department of the Army, 2022). Among active-duty military personnel, alcohol use occurs in approximately one-fourth of all suicide attempts (U.S. Department of the Army, 2022). Importantly, fewer than half of combat veterans will seek out mental health treatment of any kind. This low number results in part from pervasive fears and stigma about receiving mental health care within the military or Veterans Affairs systems (U.S. Department of the Army, 2022). The need for appropriately trained professionals with specialized knowledge of service members’ experiences continues to grow as military person- nel and veterans make the transition home from deployment. Contributing to military personnel and veterans’ low rate of treatment seeking are a number of pervasive beliefs within the military community that directly interfere with treatment engagement. Specifically, service members routinely express concerns that seeking treatment would cause superiors to view and treat them differently and that peers would view them as weak and have less confidence in their abilities. The military culture values strength, mental toughness, self-reliance, and an expectation that its members will master stress while “shak- ing off” injury and illness. In contrast, the traditional mental health culture values emotional vulnerability and reliance on others for assistance and is typically couched within an injury- or deficiency-based perspective (e.g., signs and symptoms of disorders). From the military perspective, which is based on an identity of strength and elitism, it is easy to see how seeking out treatment could be viewed as a sign of “weakness.” In light of these beliefs, mental health professionals both within and external to the military invariably find themselves fighting against the stigmatization of mental health concerns and treatments, typically by attempting to change these perceptions and cultural norms so they align more closely with the perceptions and norms of the mental health system. Unfortunately, despite considerable investment in anti-stigma efforts over the past few years, these pervasive beliefs and mental health stigmas have not changed significantly (Joint Mental Health Advisory Team 7, 2011). This situation sug- gests that traditional approaches for reaching out to military and veteran populations have not been particularly effective. The problem of mental health stigma has stimulated consider- able professional discussion and thinking, with more recent conceptualizations incorporating multicultural perspectives on mental health treatment. The ability to understand the cultural
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