Reflecting on the recent ‘Recovery and Rehabilitation in The Community: Alcohol Related Brain Injury in Ireland’ event, senior clinical psychologist Dr Nichola Robson shares her analysis for NR Times
It was a pleasure to listen to some of the leading professionals talk about alcohol related brain injury (ARBI), a condition arguably encountered in most areas of clinical practice.
The theme of ‘hope’ ran throughout the event, which was hosted remotely by Leonard Cheshire, with the central message that recovery from alcohol related brain damage (ARBD) is the norm, not the exception.
With the right kind of specialist intervention (including the provision of long-term residential placements), an estimated 75 per cent of individuals with ARBD experience a degree of recovery, with complete recovery possible for the remaining 25 per cent.
The day consisted of presentations from experts, interspersed with video anecdotes from service users’ family members and staff from Leonard Cheshire ARBI unit, ending with an interactive discussion between the audience and expert panel members.
Dr Jenny Svanberg (consultant clinical psychologist), clinical expert and author in the field, kicked off the day with an excellent summary of the available evidence regarding alcohol and the brain. She provided stark prevalence data and discussed the impact ARBD has on utilisation of non-specialist treatment services.
She also explained mechanisms through which alcohol damages the brain (both transient and more longstanding effects), the neurological structures affected, and how this maps onto the neuropsychological symptoms and clinical presentation.
Dr Svanberg outlined inherent diagnostic complexities due to subtle initial impairments often being masked by intoxication and chaotic lifestyle. She also highlighted issues of stigma faced by those with ARBD, and how their difficulties are often at least in part, often attributed to free choice.
However, she explained that due to the neurological impact of alcohol, specifically on the frontal areas of the brain, and associated cognitive impairment later in progression, reasoning and subsequently choice, is significantly impaired, as is the ability to engage with treatment.
Next, Professor Ken Wilson (Professor of Old age Psychiatry, Liverpool University), delivered a captivating talk on the clinical characteristics and experience of individuals with a diagnosis of ARBD. He used illustrative excerpts from clinical sessions to demonstrate the how these individuals present in clinical practice.
He discussed how intact working memory can mean that individuals present plausibly in conversation, however due to short term and longer term (episodic) memory impairment, they experience significant retention and functional difficulties. Due to their cognitive profile these individuals present with reduced insight, a high degree of confabulation and suggestibility, and are therefore exceptionally vulnerable. He discussed the implications of this for assessment of risk and mental capacity.
Prof. Wilson too emphasised the need to better understand the complexities surrounding this condition, including typical neuropsychological impairments, in order to challenge stigma and support engagement with treatment services (where available). In the absence of any specialist service pathway, individuals with ARBI tend to experience repeated relapse and readmission, with significant human and economic cost.
Following on from Prof. Wilson, Grant Brad (team leader, Glasgow Addiction Services’ ARBD Team) discussed the process of setting up and securing funding for specialist ARBD services. He talked through the service pathway in Glasgow, which covers acute and community settings (including assertive outreach), and offers holistic treatment provided by a specialist multidisciplinary team.
Grant emphasised the need for a lead care group to support diagnosis and navigation of treatment pathways. He also presented evidence of significant cost savings (primarily due to reduced service utilisations) and reduced mortality associated with the service. He addressed the complexities of assessment and suggested that in absence of formal cognitive testing (contraindicated due to ongoing alcohol use), assessment should involve establishing a timeline of issues, consulting medical records, assessing functional ability through observational methods, assessing and managing risk.
Grant’s team in the process of developing an audit tool to be piloted in the near future, to evaluate the effectiveness of the treatment provided. He is also keen to see the development of a professional network to facilitate the sharing of good practice.
Next, Diane Watson (ARBI clinical lead, Leonard Cheshire) provided an overview of the recently opened specialist fourteen bed alcohol related brain injury unit, which offers rehabilitation and residential placements (of up to three years). Diane discussed the service pathway, referral criteria, team configuration, and treatment approaches. She also provided some reflections on the journey so far, detailing substantial successes and some challenges, the latter mainly related to COVID restrictions.
Dr Anne Campbell (senior lecturer) and Dr Sharon Millen (research Fellow) from Queens University Belfast outlined their mixed method evaluation of the Leonard Cheshire intervention. They aim to measure outcomes relating to psychological wellbeing, functional abilities, relationships, and community participation as well as capturing the lived experience of service users, family members and staff. Preliminary findings suggested an improvement on measures of anxiety, depression, cognition, and function.
The final session was co-chaired by Dr Shield Gilheany (CEO, Alcohol Action Ireland) and Dr Helen McMonagle (Rehabilitation Coordinator, Alcohol Forum), and involved an interactive discussion regarding “the way forward”. Expert panel members included Dr Marie Goss (Consultant Clinical Neuropsychologist), Prof John Ryan (Consultant Hepatologist, Beaumont Hospital), Dr Kieran O’Driscoll (Consultant Psychiatrist, Bloomfield Mental Health Services) and Grant Brand. Discussions centred on the development of specialist treatment pathways (spanning acute and community settings) as well as the use of legislation to protect vulnerable individuals with ARBD.
To summarise key messages from the day: the impact of ARBD often goes under-recognised and there is a lack of specialist treatment pathways across the UK. Increased education (both public and professional) is needed to improve awareness and understanding of underlying pathology, pattern of impairment, presentation, and treatment needs.
Dr Nichola Robson
Undoubtedly there is a way to go, but this conference provided a valuable opportunity to showcase innovative service provision models supported by high quality data demonstrating effective outcomes, and in doing so sees us one step closer to meeting complex needs of this population.
One can only hope that these service provision models (or similar) can eventually be commissioned and rolled out across the UK.
* Written for NR Times by Dr Nichola Robson, senior clinical psychologist (neuropsychology) at Sunderland & Gateshead Community Acquired Brain Injury Service (CABIS), Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
