In the process of treatment, it may become clear that the client has impaired or poor functioning in one or many areas of cognition, such as verbal or non-verbal memory, information processing, problem-solving, reasoning, attention and concentration, decision-making, planning, sequencing, response inhibition and emotional regulation. Sometimes these cognitive impairments can result in behaviour that is mistakenly interpreted as the result of poor motivation or lack of effort, with impairments in executive functioning and goal-directed behaviour often the most commonly observed cognitive impairments in AOD settings [389].
Cognitive difficulties often bear no relation to mental illness and are sometimes the result of heavy AOD use or intoxication, or as a consequence of traumatic/acquired brain injury [1577]. There can, however, be a tendency for cognitive difficulties to be misattributed or minimised as being exclusively related to AOD use, leading to lack of further investigation, treatment, and subsequently further harm. While cognitive impairment is common among clients of AOD services, there are a multitude of medical, social, and neurodevelopmental factors that may contribute to its development, many of which are undiagnosed at service entry [1578]. Prescription medications and polypharmacy can also contribute to cognitive impairment. Appendix I contains information on a screening measure that AOD workers may find useful in identifying clients who may be at risk of cognitive impairment, and it is recommended that workers consult with neuropsychologists where appropriate.
AOD workers may find the recently released Turning Point guidelines on managing cognitive impairment in AOD treatment settings useful, which are available from: https://www.turningpoint.org.au/treatment/clinicians/Managing-Cognitive-Impairment-in-AOD-Treatment-Guidelines
When a client is experiencing some level of cognitive impairment, the effectiveness of therapeutic approaches can be diminished unless care is taken to adapt the approach to address these difficulties. Table 56 presents some simple techniques which can be useful in overcoming cognitive impairment [389].
Table 56: Techniques for managing cognitive impairment
| General techniques to address cognitive impairment |
- Integrate strategies such as repetition, writing things down, and cues to recall important information, into counselling.
- Provide structure during sessions, reduce the pace of sessions, and avoid overloading clients with information.
- Encourage healthy behaviours such as social and leisure activities.
- Encourage or incorporate stress reduction strategies such as mindfulness.
- Support motivation and realistic hope by informing clients that cognitive impairment from AOD use can improve with AOD reduction and targeted interventions.
|
| Techniques to address attention problems |
- Have a clear structure for each session.
- Consider shorter but more frequent sessions.
- Avoid overloading by limiting the content of each session.
- Keep sessions focused on relevant topics.
- Reduce session pace and provide breaks.
- Conduct sessions in a quiet, non-distracting environment.
- Provide written handouts of important information.
|
| Techniques to address learning and memory problems |
- Present information to be remembered both verbally and visually (e.g., draw diagrams).
- Repeat and summarise key information.
- Ask client to recall information from previous sessions, and suggest techniques to improve recall (e.g., writing things down, using memory aids).
- Review key points from previous sessions at the start of each session to compensate for poor memory.
- Remind client of appointment times and keep appointments at routine times.
|
| Techniques to address difficulties with mental flexibility, problem-solving, planning, and organising |
- Encourage routines and daily planning.
- Explain step-by-step problem solving and how to break goals into smaller, more manageable tasks.
- Discuss and practice responding to high-risk situations.
- For impulsive clients, encourage self-monitoring and use of cue cards with strategies to use.
|
Adapted from Stone et al. [389].
Preliminary research suggests that psychological interventions focusing on cognitive training, such as cognitive enhancement and remediation, can improve cognitive functioning among clients in AOD treatment settings [961, 1579, 1580]. Both cognitive remediation and cognitive enhancement therapies utilise computerised games and tasks to enhance domains of cognitive functioning (e.g., attention, memory), but cognitive enhancement therapy additionally targets holistic factors such as social skills and vocational capabilities to improve overall functioning [1581].
However, training for a specific cognitive impairment may have limited transference to other cognitive domains [1582]. There is preliminary evidence to suggest that pharmacotherapies such as galantamine (an acetylcholinesterase inhibitor) and modafinil may be effective in improving working memory among people with cocaine dependence [1583, 1584].