The knowledge that recent or long-term heavy drinking can affect the cognitive abilities of clients early in treatment is nothing new. Knowing this, many addiction counselors account for these contingencies and subsequently adjust their clinical judgments. Yet, many counselors under the pressure of managed care, or lacking the knowledge, sometimes don’t. They may expect more from early admissions or mistake client features for one thing when residual effects are the issue.

For example, clients have been accused of being in denial because they cannot recall important events of their drinking history. They’ve been accused of lacking motivation because did not compete a homework assignment, or were not able to integrate the components of a recent lecture into their recovery. In some cases, the denial and lack of motivation were real, but at other times, such behavior was the result of cognitive impairment caused by alcohol. Be it the pressure or unfamiliarity, many counselors tend to jump to conclusions about what on Earth is going on with new admissions.

Some new research has been completed on these early effects — and all addiction counselors need to know about it. This research centers on the effects of drinking on cognitive functioning, especially memory.

Initial clinical questions
When treatment begins, the basic question an addiction counselor needs to address is: how do I adapt my counseling direction based on early client information? More specifically, how do I distinguish between clinical features and memory impairment caused by drinking?

Distinguishing is the $64 question. We have looked, but have not found a reliable test instrument to help clarify that question. So, unless someone knows of such a test (please send it to me), we have to go with good ol’ fashioned hard work, obtaining the best information possible. Most intake assessments, coupled with a few standard tests and collateral contacts, acquire such information.

Through the intake phase, you are trying to determine if a client can complete certain assignments accurately, assess what is the best time to insert educational material to get the best retention, and assess if the client understands what is said in a group or individual session. More specifically, you want to know if the client will be able to comprehend the educational material to be given, the homework recommended, and the questionnaires to fill out regarding the client’s drinking history. To clarify parameters, we will not be talking about level of dementia that results in Wernicke-Korsakoff syndrome.

Knowing of no such instrument to answer these questions, we use the available intake data to make better clinical decisions. For example, if the client arrives at your facility from a detoxification facility that uses a lot of medications, or had been drinking within two days of admission, the intake information would warrant a strong suspicion that the client’s cognitive abilities may be compromised for awhile. Moreover, if the intake indicates that the new admission has been drinking heavily for years, that little piece of information also would warrant suspicions about impairment, particularly memory.

Memory problems
The memory impairment research indicates heavy alcohol use clearly damages retrospective memory (Ling et al., 2003). Retrospective memory has to do with learning material, preserving it, and reclaiming it. Much of this research data comes from laboratory studies, but it is still applicable to the field. For instance, the Ling research group (2003) found the heavy alcohol users made more errors in day-to-day memory function than those who consumed little or no alcohol. The typical heavy alcohol user reported over 30 percent more memory-related problems than those who did not drink.

In addition to the retrospective memory, we have prospective memory. This latter memory has to do with remembering things in the future, or the everyday type memory. According to the Ling study, heavy drinkers were prone to miss appointments, forget birthdays, or pay bills on time. Essentially, heavy drinkers have problems with remembering if they did something such as lock their doors, switch off lights, or forget where they put their house keys.

Research-to-practice key I
Individuals who enter treatment with a recent and or heavy drinking history are going to have a difficult time learning, retaining, and recalling information that the counselor gives them early on in the treatment process. This means that, until they clear up a little, it would be best not to assign complicated tasks often found in relapse prevention or counseling that has a lot of treatment objectives. The data suggest that clients may forget to do it. By the way, there’s a basic rule: heavy drinking is considered drinking more than 21 drinks per week, for about 10 years (NIAAA, 2001).

Some conflicting data
Clinical research sometimes presents contradictory results, and this seems to be true of general cognitive impairment caused by heavy drinking. For example, Alcohol Alert (NIAAA, 2001) published a whole edition on cognitive impairment. The publication noted that although reason says that heavy drinking and the resulting impairment may impede recovery from alcoholism, the overall findings did not predict poor outcomes. On the other hand, some evidence supports the possibility that the brain damage resulting from or predating alcohol use may contribute to the development and progression of alcoholism. In particular, Sullivan (2003) noted that the prefrontal cortex and cerebellum are particularly vulnerable to alcohol. The prefrontal cortex has been associated with high-order thinking and cerebellum with smooth movements (Czerner, 2001).

The evidence is pretty strong that most alcoholics exhibit mild-to-moderate problems in intellectual functioning. The most prevalent impairments are found to affect visuospatial abilities (e.g., locating objects in 2 or 3 dimensions). Certainly, higher cognitive functions such as abstract thinking are impacted.

Yet, as solid as this information seems to be, the research also indicates that alcoholics entering treatment perform as well as non-alcoholics on intelligence tests. But, alcoholics perform more poorly on neuropsychological tests of specific cognitive abilities. For example, alcoholics who have been abstinent can file office documents, but the same people will have difficulty devising a different filing system (NIAAA, 2001).

It is also no secret that many cognitive functions are reversible with abstinence and time. But, our concern is early treatment, i.e., the first few weeks of counseling. Alcohol-abuse induced cognitive deficits repeatedly have been said to affect treatment. This particularly holds true for understanding educational information and skill-development sessions given early in the treatment process (NIAAA, 2001).

Research-to-practice key II
It is essential that the counselor have the best information available concerning the dynamics of a new admission’s drinking history. If it has been heavy for years, if there was a recent use, or if the client came from a detoxification where extensive medications were used, then assigning complex homework assignments, lectures, or other educational material may be contraindicated right away.

The “try it yourself” section
Time to try an experiment (nothing fancy) to assess if clients (those who meet the pretreatment conditions mentioned in this column) would be compliant with homework assignments and general instructions. Randomly assign such individuals to two groups. The first group would be given assignments and instructions immediately upon admission. The second group would be given some time (say a few days to a week) between admission and the homework and/or other instructions. Simply count the compliance rates between the groups and note any differences.

For a different slant on this same experiment, conduct a short interview with a random sample of the two groups. Essentially, ask open-ended questions about how each group member felt toward the homework and/or instructions given at the time of their admission. This would be a qualitative piece of the research. The aim is to provoke each sample to simply talk about their early feelings, mental states, and ability to understand what was going on early in the treatment process. Certain trends might evolve like a picture in a jigsaw puzzle. The resulting information could prove invaluable to your program.

Good luck with your research, and as always, I would be interested in your results.

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai’i at Manoa. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
NIAAA. (July, 2001). Cognitive impairment and recovery from alcoholism. Alcohol Alert, 53.
Czerner, T.B. (2001). What makes you tick? The brain in plain English. New York: John Wiley & Sons.
Leroi, I., Sheppard, J.M. & Lyketsos, C.G. (2002). Cognitive function after 11.5 years of alcohol use: Relation to alcohol use. American Journal of Epidemiology, 156, 747-752.
Ling, J., Heffernan, T.M., Buchanan, T., Rodgers, J., Scholey, A.B., & Parrott, A.C. (2003). Effects of alcohol on subjective ratings of prospective and everyday memory deficits. Alcoholism: Clinical & Experimental Research, 27(6), 970-975.
Sullivan, E.V. (2003). Compromised pontocerebellar and cerebellothalamocortical systems: Speculation on their contributions to cognitive and motor impairment in nonamnesic alcoholism. Alcoholism: Clinical and Experimental Research, 27, 9, 1409-1419.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2004, v.5, n.1, pp. 76-77.

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