Multiple studies of neuropsychological impairment among substance-abusing patients entering treatment suggest that more than 50 percent may suffer from measurable cerebral dysfunction (Butters & Cermak, 1980; Grant et al., 1978). With certain notable exceptions (e.g., Wernicke-Korsakoff Syndrome, alcohol-related dementia) cognitive impairment in substance dependent individuals has been shown to have a period of recovery following abstinence. Conventional treatment for substance abuse, however, is often completed before the individual has recovered the skills necessary to integrate information for posttreatment success. Posttreatment functioning, including abstinence, may be negatively impacted by this treatment mismatch. This article will provide a brief overview of the common neuropsychological impairment profile of patients treated for substance abuse, the impact of neuropsychological impairment on substance abuse treatment and posttreatment functioning, and findings in recent research using cognitive rehabilitation as an adjunctive treatment to standard therapies to decrease the risk of posttreatment relapse.

Neuropsychological impairment and recovery
Much of the research examining neuropsychological impairment in substance abusers has focused on alcohol abuse. Across studies, long-term alcohol abuse has been negatively associated most consistently with two areas of cognitive performance: executive functioning and visuospatial functioning. Executive functioning can be thought of as the combined set of skills that your brain uses to initiate, maintain, and appropriately shift responses to the environment (Ayd, 1995). These skills are very important in order to maintain independent living. Visuospatial skills help you coordinate movements with an appreciation of your physical surroundings (Heilman & Valenstein, 1993). Both measured and apparent impairment in these areas include problems with recent memory, abstraction and problem solving, cognitive flexibility, response inhibition, visuospatial abstracting, planning, and perceptual motor skills (Bates et al., 2002). Neuropsychological profiles of poly-substance abusers have also suggested that they have deficits in both executive functioning and visuospatial functioning (Fals-Stewart et al., 1994). These deficits are especially apparent in recovering substance abusers when a rapid response is called for (Bates et al., 2002), as is often the case in daily life (e.g., when driving a car).

Recovery of impaired neuropsychological functioning is thought to be based on two processes: time-dependent recovery and experience-dependent recovery (Goldman, 1986). Time-dependent recovery is the spontaneous improvement in neuropsychological functioning thought to occur simply by remaining abstinent from substances. Among alcoholics, the greatest amount of recovery occurs during the first two weeks of abstinence and is most notable in measures of general intellectual functioning, verbal skills, and recent memory (Cocchi & Chiavarini, 1997a, 1997b; Goldman, 1987). This improvement, however, is relative, and deficits continue to persist in many individuals. After the first four to seven weeks of abstinence, which is when many inpatient and outpatient treatment programs have concluded, impairments continue to be evident in problem solving (Nixon & Parsons, 1991; Sullivan et al., 1993), recent memory (Becker et al., 1983a, 1983b), visuospatial abilities (Beatty et al., 1996), and perceptual motor skills (York & Biederman, 1991). Although neuropsychological improvement continues throughout the first year of abstinence, some studies have shown that deficits persist 13 months after abstinence on tests of problem solving and perceptual motor abilities (Yohman et al., 1985) and even years following abstinence (Bowden et al., 1995; Parsons, 1998; Sullivan et al., 2000).

Relationship of neuropsychological deficits to treatment
One of the primary reasons neuropsychological impairment may negatively impact treatment response is that many of the current treatment models for substance abuse are verbally mediated (e.g., AA 12-Step, motivational interviewing, cognitive behavioral therapy) and require a great amount of cognitive processing to facilitate change (Goldman, 1990). A typical group therapy session in these programs may appear to have a simple and clear agenda; however, the patient is required to utilize a complex system of attention, memory, problem solving, and abstraction, in order to profit from the treatment (McCrady & Smith, 1986). Even in the best of current therapy groups, the neuropsychologically impaired individual is often asked to exercise both sustained and selective attention in a 45-minute verbally based treatment session, retain information (often without the aid of written materials), and apply what is learned in the session to life outside the treatment room. This is an immense task for neuropsychologically impaired individuals, and thus cognitive impairment may be one of the factors contributing to the high recidivism rate in many programs (Fals-Stewart, 1996).

Studies that have included populations with a high degree of impairment have provided the strongest support for the negative association between neuropsychological impairment and substance abuse treatment gains (Parsons et al., 1990). More specifically, when impaired substance abusers are compared to their cognitively intact peers they have been found to have greater dropout rates from residential programs (Fals-Stewart & Lucente, 1994a; Fals-Stewart & Schafer, 1992), faster relapse rates, and poorer long-term outcomes (Fals-Stewart, 1993; Yohman et al., 1985). These individuals also perform significantly worse than cognitively intact peers on measures of recall and recognition when information is presented either in a film format (Becker & Jaffee, 1984) or in the general treatment program (Godding et al., 1992; Sanchez-Craig & Walker, 1982). Neuropsychologically impaired patients have also been found to have a more difficult time acquiring drink refusal skills (Smith & McCrady, 1991).

Although a few studies have failed to support this link (Eckardt et al., 1988; Morgenstern & Bates, 1999) these inconsistent findings are likely due, at least in part, to methodological differences (e.g., sensitivity of the neuropsychological measures, lack of ecological validity in measures, length of abstinence when tested; Goldman, 1990). Bates, Bowden, and Barry (2002) proposed that these differences also may exist between studies because the link between neuropsychological performance and treatment outcomes is more complex than previously tested, and future research should consider other variables related to this functioning. Factors to consider, and that have been found to have a deleterious effect on either neuropsychological functioning or recovery, include older age (Bates et al., 2002; Fals-Stewart & Bates, 2003; Oscar-Berman et al., 1997); vitamin B deficiency (Tarter et al., 1990); presence of health disorders such as cirrhosis, hepatic encephalopathy, and traumatic brain injury (Arria et al., 1991); positive familial history of alcoholism (Garland et al., 1993; Yohman & Parson, 1987); and lower levels of education (Bates et al., in press). Finally, recent research exploring neuropsychological impairments in alcoholic women has found a similar impairment pattern to men (Glenn & Parsons, 1991; Nixon & Glenn, 1995; Sullivan et al., 2002). Women, however, seem to be more sensitive to the effects of alcohol because they attain equal levels of impairment with less chronic and lower amounts of ethanol consumption (Nixon, 1994; Nixon & Glenn, 1995).

Impact of neurocognitive impairment on treatment programs
Treatment provider perceptions of neuropsychologically impaired patients are often less accurate than their perceptions of cognitively intact patients, and impairment is often mistaken for motivational and behavioral problems characterized as a lack of goal directed behavior, non-compliance, unwillingness to participate during groups, and inability to adhere to inpatient rules (Fals-Stewart, 1997; Fals-Stewart et al., 1993). More generally, the patients are viewed as socially insensitive and appear uninterested in learning the skills necessary for treatment success, despite patient statements to the contrary. Fals-Stewart and Lucente (1994b) conducted a study examining clinicians’ abilities to accurately identify cognitive impairment based on information collected during the standard screening and evaluation process and found that, compared with patient performance on a neuropsychological battery, clinicians’ perceptions were highly inaccurate. Perhaps most concerning, these mistaken assumptions have been associated with a poorer prognosis for patients in the recovery period (Leber et al., 1985).

Unfortunately, treatment programs do not routinely provide screenings for patients and instead rely on treatment provider perceptions, which as described above are often inaccurate. Furthermore, many clinicians have found that when impairments are identified it is often difficult, if not impossible, to alter the treatment program to meet the patient’s needs. For example, time and resources are not necessarily available, in the current programs, to move more than 50 percent of the patient population out of groups and into an equivalent number of individual sessions. In addition, it would not be considered reasonable to wait a month or more for patients to recover their neuropsychological abilities before commencing treatment. One alternative is to address neuropsychological impairments in specialized and adjunctive cognitive rehabilitation early in treatment so that patients may more fully profit from the standard treatment program.

Neuropsychological impairment, rehabilitation, and relapse
Although disagreement remains in the research regarding the relationship between cognitive impairment and posttreatment functioning, there is evidence that impairment on neuropsychological batteries is predictive of drinking status following discharge (Abbott & Gregson, 1981; Walker et al., 1983). This is especially true when ecologically valid measures are used (Sussman et al., 1986). Neuropsy-chologically impaired substance abusers are also less likely to attend aftercare treatment following discharge (Abbott & Gregson, 1981) and are less likely to be employed (Goldman, 1990). Failure of this population to maintain employment is consistent with research of other disorders (e.g., following traumatic brain injuries) that has found cognitive impairment, especially in the form of memory dysfunction, is a major obstacle when regaining and maintaining employment (Weddell et al., 1980).

Empirical investigations of cognitive rehabilitation have indicated that some neuropsychological deficits are remediable (Allen et al., 1997) and those that do not repair themselves with time potentially may be improved with the use of experience-dependent processes, which relies on active rehabilitation and/or repetition of neuropsychological skills to increase the level and speed of recovery. The bulk of these studies have been conducted by Goldman and his colleagues, in alcoholic populations, using a time lag design, in which one group is tested shortly after discontinuing alcohol consumption and a comparison group is tested following a longer period of abstinence. Over the course of their studies, they have found that psychomotor and executive functioning deficits were remediated with test- specific practice (Goldman et al., 1985). Remediated abilities were generalizable to novel situations that require similar abilities (Goldman et al., 1985). Remediation of basic and specific skills generalized to complex tasks that required utilization of all the skills (Goldman & Goldman, 1987). Remediation of skills could be attained from simple repetition tasks just as well as more time-taxing processes that required practicing the underlying skills (Forsberg & Goldman, 1987). Simple practice efforts from one task generalized to other tasks that theoretically required the same skill (Forsberg & Goldman, 1987). Not all studies support simple repetition in the recovery process, but instead found that improvement was gained only through more intensive rehabilitation processes (Hannon et al., 1989; Wetzig & Hardin, 1990). Although, these studies provide evidence of the utility of neuropsychological retraining in treatment, the ecological validity of such treatment has not been established. Namely, how does the rehabilitation translate to day-to-day and post-treatment functioning as measured by abstinence, employment, and psychosocial abilities?

Few studies to date have considered the effect of neuropsychological rehabilitation on the treatment process. One study, by Fals-Stewart and Lucente (1994b), examined the effect of a systematic two-month long course of computerized neuropsychological rehabilitation (Psychological Software Services, 1989, 1990) on the neuropsychological impairment and treatment process in a sample of mandated substance abuse patients in residential treatment. The neuropsychological rehabilitation group was compared to three control groups: relaxation training, computer typing, and treatment as usual. They found that the group that underwent neuropsychological rehabilitation improved to a greater extent than controls on follow-up measures of neuropsychological functioning. The treatment group was also given higher ratings by treating therapists on a measure of psychosocial functioning (e.g., patient participation during groups, compliance with rules) during treatment. The authors surmised that earlier cognitive improvement allowed the treated patients to participate more fully in the treatment program and to synthesize treatment relevant information to a greater extent than patients in the other groups.

Preliminary follow-up to this study provides the first data to consider posttreatment functioning as it is related to neuropsychological rehabilitation (Grohman et al., 2002) We found that patients in the rehabilitation group had a significantly greater percentage of days abstinent during the posttreatment period. These patients were also more likely to participate in self-help groups and any type of formal substance abuse treatment during the posttreatment period. These data broaden the implications of cognitive rehabilitation with evidence that significant and positive changes are greater in those who participate in a neurocognitive rehabilitation program throughout the one-year post-treatment period in the forms of abstinence and post-discharge substance abuse treatment participation. These findings provide a starting point for understanding long-term outcomes of treated individuals, and further exploration will provide a greater understanding of the mechanisms by which this process occurs.

The bottom line
Neuropsychological impairment, in the forms of executive and visuospatial dysfunction, is a common phenomenon in patients treated for substance abuse. Its manifestation and time-dependent recovery may vary based on numerous historical and current health factors. Measurable impairments have been found to be negatively associated with treatment factors such as compliance, attendance, and absorption of material. Yet, neuropsychological impairments often go unrecognized in patients, or worse, are mistaken for behavioral problems. Cognitive rehabilitation of these patients is at its early stages of investigation but shows promise for improving cognitive functioning in impaired patients in the early stages of treatment, when it is most needed. Preliminary analyses have shown that these gains have positive long-term implications in patient functioning, but further research is required to examine just how and under what circumstances these gains are best realized.

Kerry Grohman, PhD, is a Research Associate at the Research Institute on Addictions, The University at Buffalo, State University of New York. Trained in Counseling Psychology, Dr. Grohman has focused her work on neuropsychological functioning, cognitive rehabilitation, and
neuroimaging in substance abuse. She can be reached via email at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

William Fals-Stewart, PhD, is a Senior Research Scientist at the Research Institute on Addictions, The Univer-sity at Buffalo, State University of New York. His internationally recognized work focuses on marital/family therapy with drug-abusing patients, the relationship of substance use and intimate partner violence, longitudinal outcome of substance abuse treatment, psychological and neuropsychological assessment with drug-abusing patients, and substance use and workplace violence. He can be reached via email at
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This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, p. 12-17.

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