Dr. Rebecca C. Villar joined the Lakeview Health team as Director of Neuropsychology. What follows are insights into Dr. Villar’s background, a few lessons and a deeper understanding of how neuropsychology and addiction intertwine, and how neuropsychological testing is used at Lakeview Health’s Florida dual diagnosis rehab.
Tell us about your background and what brought you to working in neuropsychology.
I initially studied the broader field of clinical psychology, but as I progressed through graduate school I developed a deep appreciation for neuropsychology. Understanding the neurological correlates for behavior, thoughts, and emotions gives a much richer perspective and context for developing and applying treatment. Once I was exposed to the field through coursework, I switched within my doctoral program to have a specialization in neuropsychology, which became the primary focus of my research, training, and work both during and after graduate school.
What is neuropsychology?
That’s a good question. Most of the time when clients come for an evaluation, they have no idea what neuropsychology actually is. Simply stated, it is the study of the relationship between the brain and human behavior, thought, and emotion. In years past, people often would treat the mind and brain as separate entities, but everything is ultimately dependent on the functioning of the brain. By examining and more thoroughly understanding different brain processes, we can make better assessments, predictions, and treatments than we could by ignoring the neurological aspects.
What does a neuropsychologist do?
We complete evaluations that assess many different brain functions, including intelligence, impulse control, reasoning, problem-solving, memory, learning, mood, personality, speech, and other areas in order to have a clearer sense of diagnoses, prognosis, strengths, and weaknesses. This information allows us to make individualized mental health treatment programs based on the client’s full cognitive and psychological profiles. It really gives a more thorough understanding of the person at a much deeper level than can be gained through an interview or early stages of therapy alone.
What does neuropsychological testing involve?
Neuropsychological testing starts off with a comprehensive interview, which includes discussing the client’s goals, background information, concerns, treatment history, a pattern of alcohol and substance use, medical history, personality traits, and so on. The interview is incredibly important because we need to have a good context for test selection and interpretation of the results. We also use the interview to ensure that we’re addressing all of the areas that are especially important to the individual with greater depth. Once we have all of the information from the interview, the testing is very much one-on-one and task-based.
For example, if I were assessing your reasoning or problem-solving skills, I would actually set up different problems and see not only if you can solve the problems, but how do you solve them. How do you approach each task? Are you planning ahead? Do you work slowly? Do you become frustrated or give up easily? So, it’s very interactive and gives us insight not only into how well you perform on these tests but also into the reasons that you’re coming to that answer or conclusion. All of the test data is interpreted through both individual domains and as a cohesive whole. It is very functional.
Fascinating. So, the test shows problem-solving skills as well as the cognitive reasoning that somebody has for doing it in a particular way?
Yes, the behavioral observations during the testing are just as important as the data. Let’s say someone is given a complex visual-constructional task and they were very organized, efficient, and accurate in their final answer. Someone else may have the same final score due to having ultimately constructed it correctly despite having approached it in a very unorganized, impulsive, haphazard way. Or someone else may have taken significantly longer to finish the task due to being highly meticulous or changing their answer frequently. These observations help give a sense of how each person is processing information and reacting to relatively novel demands.
What is a neuropsychological impairment?
A neuropsychological impairment is a brain-based area of weakness that is preventing the person from functioning effectively in a certain area. For example, if someone has an impairment related to impulse control, they might make the same mistakes over and over again no matter how bad the consequences are. Someone who already has an impairment related to impulse control or decision-making may be more risk-taking, need greater behavioral interventions, or require additional external supports to aid them in the recovery process than someone without that difficulty.
How do you take the neuropsychological testing information and use it for addiction treatment planning?
There are so many different facets to addiction because it involves very complex interactions regarding motivations, genetic or biological vulnerabilities, behaviors, environmental factors, emotions, relationships, cognitive style, and so on. The field of addiction treatment previously used a purely disease-based model with relatively generic treatments that ignored all of the individual aspects for each person. This often does not lead to long-term success. So if we were, for example, to find continued symptoms from trauma, with addiction as a form of self-medicating, the person should have a different treatment approach than someone who began using due to an impulse-control issue or thrill-seeking personality.
The reasons for substance use are endless, so if we treat each case exactly the same, we are not giving the person the best opportunity for a successful recovery. By ignoring those factors, addiction treatment can perhaps temporarily influence behavior, but it will be much more likely that the underlying problem will either manifest itself in a different way or lead to a relapse. If instead we take the test data and focus on building off of strengths to improve areas of weakness and address the underlying issues, we will be much more likely to lead to long-term success and well-being.
Do different substances, like an opiate versus alcohol, change the brain in different ways?
That’s a great question. The answer is both yes and no. While each substance affects the brain a little bit differently, which causes the differences in sensation and pattern of use, they all impact the brain’s reward, motivation, and pleasure centers. So, both alcohol and opioids affect dopamine levels, similar to what would be involved in other substance abuse, food addiction, gambling addiction, compulsive behaviors, and so on. These different forms of addiction each tap into the brain’s dopamine system in addition to stimulating or suppressing other neurotransmitters within the brain. So it’s affecting the brain the same way in one regard, but affecting the brain very differently in other regards.
How are you going to be using the neuropsychological testing, neuropsychological basic intervention within Lakeview Health treatment?
Clients at Lakeview go through rigorous assessments through the initial intake and treatment process. There is also an initial brief neuropsychological screen that gives a nice snapshot in terms of cognitive functioning, including memory, attention, problem-solving, and other areas. A full neuropsychological evaluation can take 6-8 hours, so we do not want to subject every person to that more intensive testing unless we need additional information beyond those earlier assessments.
Both the screens and more comprehensive testing are incredibly important for a variety of reasons. One is the treatment planning that we’ve discussed before. Another is that substance use in and of itself can cause neurological difficulties. It also makes you more likely to have an anoxic brain injury or traumatic brain injury- for example, through falls or an accident due to driving under the influence. There are many comorbidities or premorbid factors that may have led to substance use in the first place. There are many different reasons that someone may have neuropsychological difficulties- both related to and unrelated to substance use.
If there’s a neurological issue that we need to target, we want to have that data. It can lead to important adjustments medically, to individual therapies, to group interventions, or for post-discharge planning. We need to target all of the areas that are driving or fueling the addiction in order to foster the best long-term outcome. We make sure that we’re addressing whatever personality traits, environmental issues, or cognitive concerns there may be, that are maintaining those unhealthy habits and behaviors. Also, we want to focus on overall well-being.
The purpose of being in a facility like Lakeview is not only to stop substance use. That’s obviously our primary goal, but it’s also to grow as a person. This is a really good opportunity for patients to invest in themselves and grow as human beings, reassess some of the things that maybe they are unsatisfied with in their lives, and find ways of growing and moving forward.
If neuropsychological testing were deemed appropriate for an individual, wherein the treatment process could they expect to have this assessment?
Lakeview greatly values thorough assessments, so neuropsychological testing would not be completed until after the intake and assessments from other disciplines. Testing would also not be completed until after detox, as we want to ensure that their performance is not negatively impacted by withdrawal and lingering effects from substance use.
Thank you for taking the time to discuss your role, background, and neuropsychology. Any parting words of wisdom?
Understanding the driving forces behind each person’s addiction is vital. The reasons each person uses are going to be unique to them. Addiction can affect anyone, absolutely anyone, and so everyone has a different reason for using. Unless we have a really good grasp of what each individual’s reasons are, we’re not really going to have the most effective treatment.
Neuropsychological testing can help as far as identifying the cognitive, behavioral, and emotional components of each person’s addiction so that the rest of the treatment team can apply their expertise to the same end. It makes all the difference in the world to have everyone working together. It is unfortunate when treatment takes a more piecemeal approach when different disciplines are working too independently and not communicating effectively. But, in a setting like Lakeview Health, it works beautifully. Everyone can collaborate and support each other to make sure that we’re all working toward the same goal with complementary approaches.
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