Drink, drugs and sex – a causation cocktail headache?

Considering brain injury client issues with alcohol, drugs and sex in the sphere of rehab and brain injury litigation.

I was asked to speak on this area for Rehabilitate Therapy Ltd. at their inaugural team conference away day last year. It’s an area which requires delicate handling, from a client/lawyer angle, but also to those in a therapeutic position with the client.

How do you then approach such a sensitive topic with the client? Sometimes it can be obvious, whereas sometimes it can be well disguised by the client.

In this article, I’ll attempt to explore certain topics from my experience and how those working with the individual can help.

Alcohol

It’s safe to say that alcohol doesn’t mix well with a brain injury. It’s widely known that an individual’s previous tolerance to alcohol is diminished following a brain injury.

However, despite best advice and guidance, clients may persist in unhealthy behaviours. Where it can be more troublesome is where it was an addiction to begin with.

Where a client has a previous dependency on alcohol, and lived a functional life to a degree, they will have developed methods of being able to disguise that addiction/dependency. Some will drink particular beverages which are not strong smelling or tasting, amongst other strategies. After their brain injury, they will carry those strategies over.

Where a client has had a previous dependency and ends up in ICU following the brain injury sustained in the accident, there can be occasions where the body reacts to the immediate withdrawal from alcohol. This can lead to seizures in some situations, which could in turn be conflated with the brain injury.

Clients with a historic dependency alcohol, may resort to their old coping mechanism following trauma. This may occur even though early private rehabilitation has been implemented through the claim. They will try to hide their dependency but more often than not, it cannot escape the detection of trained clinicians and therapists working with them.

If the therapist/clinician working on a private rehab basis, suspects alcohol issues, what do they then do?

If the therapy has been commissioned on a unilateral/single instruction, it’s often easier to have a discussion with the client’s solicitor initially. You can agree a way forward and approach with the client on the subject and ultimately map out a way to tackling the problem with them.

On a joint instruction, where therapy/case management is funded pursuant to the Rehab Code/Serious Injury Guide, there is simultaneous dialogue with the Defendant Insurer and the client’s solicitor. There are differing schools of thought as to situations like this but my view, for what is worth, is where there is something sensitive to discuss (such as this) the case manager should feel encouraged to call the client solicitor. I’ve had this before and it can be readily managed by a call in the first instance. Defendant Insurers I’ve come across are often understanding in those situations. After all, the case manager’s duties are to the injured client.

Drugs

It’s not unusual to come across clients who have a longstanding relationship and use of cannabis. It can be challenging to break that relationship and help educate the client as to the effects of cannabis, not just generally, but now with an injured brain in the mix.

Assuming the client has mental capacity on health and welfare, as a team (legal, rehab and experts), all you can do is try to educate and guide them through. Clients will often talk of the calming effect it has on them in reducing anxiety, which is a big symptom of brain injury. That being said, there are safer and more effective ways of combatting such symptoms and these are the options the client should be provided with and educated on.

Sadly, in some other cases you may come up against clients with heroin addiction, which were either long-standing, or even started post-accident. These situations require more immediate attention.

The primary challenge the client’s solicitor and therapy team may face, is trying to secure the requisite funding for the drug detox and tailored rehabilitation. That might be due to the size of the funds needed, balanced against causation challenges/queries from the Defendant. In situations where you have costly intervention, it’s important to lay out different options where available. It might be that you can have a programme which covers everything as an inpatient, or there may be a hybrid option where the client (following detox programme which does require staying as inpatient) can receive the tailored drug programme as an “outpatient”, alongside a structured community therapy and support package. As for the causation arguments, that will be case specific, however, it’s worth bearing in mind age old legal principles, such as the “thin skull/egg shell” one in that regard.

Sex

I’m not going to say too much on this subject mainly because there is an expert out there who can do a much better and detailed job, in explaining this area when it comes to brain injury. So, I am going to plug Dr Catriona McIntosh who is one of the leading experts when it comes to sexual relations capacity after brain injury. Catriona regularly speaks on this topic, so if you are not connected with her already on Linkedin, then do so!

What I will say on this area though, is by having a case manager and therapy team ready to be on call for whatever comes (who most often are in fairness). I’ve known clients find themselves in difficult situations, criminally speaking, because of increased sexual desire post injury and their subsequent use of the internet to that effect and chatting with others. I’ve known case managers supporting their client down at the police station to that effect.

It’s not just capacity on sexual relations which comes into focus here either. Often the precursor to arranging sexual relations, is by using the internet or apps to engage with others. What can then come under scrutiny are the safeguards in place regarding the client’s use of the internet. It’s a very difficult area and one that requires the MDT approach.

Sometimes safeguarding strategies can be implemented through technology. Another plug here to Jeff Goodright at Cyber Spider LTD , who I’ve heard speak before on this area and the fascinating work he has done to protect clients, as part of the MDT approach.

Final comments

Clients come with a constellation of problems following a brain injury; as to be expected. However, substance misuse or challenging sexual behaviours can add a different dimension to matters. Regular and clear communication is key between those acting in the interests of the injured client. Gathering as much information and data as to the nature of the problem will help determine the plan between the legal and therapy team. Don’t shy away from it – tackle the problems head on.

I hope in reading this it has given some insight, or given confidence in how to deal with a situation you may be handling this respect.

Finally, I would welcome any anecdotes and advice from others who have had experience and challenges in this area and which might be of help to others.