Marilyn Lash, M.S.W.

Coping styles vary within families after brain injury

Every family has an emotional reaction when a spouse, sibling, child, or other relative has a traumatic brain injury. Each family has learned ways of coping from previous experiences with stresses, losses and changes in their lives. Some methods of coping have been productive for families in the past and helped ease not only their levels of stress and anxiety, but helped them problem solve and prepare for the future. Other ways of coping may not have been as productive for families. Some may have learned from this and changed how they cope with stress or change, while others may be stuck repeating negative patterns.

Emotional trauma of brain injury

We all know that nothing prepares families for the emotional trauma of brain injury. But we do know most people, including families, often react and cope in ways that are familiar when facing a crisis. If a strategy has helped in the past, the hope is that it will help in this new crisis. If it has not worked in the past, hopefully a different strategy will be considered. This sounds simplistic but it makes sense and it is based on patterns of human behavior. 

So if you are a family member of someone with a brain injury, you might consider thinking about how you have coped with the many changes and losses in your life. Surveys of families with a member who had a traumatic brain injury grouped their responses into five categories of cognitive, psychological, spiritual, support systems, and physical coping (DePompei, 2011).

Cognitive coping

This person looks for and uses information. Searching the internet is a common example. There are lots of ways that “cognitive copers” gather information including reading books and articles, talking with other families, attending conferences and workshops and contacting experts.

Psychological coping  

This person’s coping style uses internal positive thoughts. Examples are individuals who count their blessings, take it one day at a time, and focus on improvements and hope. Some take up a cause for prevention or public awareness or finding a cure – it may be brain injury in this case. For others, it may be breast cancer, diabetes, or some other illness.

Spiritual coping

Belief in a higher power brings great comfort to many. Those who use spiritual coping strategies may talk with clergy, read religious books, inspirational stories, or meditate. 

Support systems for coping

These people cope by reaching out to others. It may be as simple and informal as talking with friends to joining formal support groups on brain injury to participating in community groups or activities. 

Physical coping

Many people find that exercise reduces their stress and tension – it may be walking, jogging or aerobics. Others clean house, eat, cook or listen to music. 

Find what works for you

Everyone is different so it’s important to know what works for you. Most of us use several coping styles depending on the circumstances and the types of stress we are facing. By better understanding how you cope, you can take the steps to a more positive future. 

References

DePompei, R (2011). Coping Styles of Individuals and Families after Traumatic Brain Injury. Brain Injury/Professional,  8(4), 26-27. 

Recommended Reading 

Brain Injury It is a Journey

Flora Hammond, M.D. and Tami Guerrier, B.S., Editors 

Life Changes: When a spouse or partner has a brain injury

By Marilyn Lash, MSW

Effects of brain injury on marriage

With nearly half of all marriages in the U.S. ending in divorce, it’s been widely reported for many years that the rate of divorce is even higher among couples when a spouse has a brain injury. Divorce rates ranging from 48% to 78% are comm.only given. 

The stresses and challenges for couples are well known – ranging from the physical demands of caregiving to the emotional stresses of living with a spouse whose behavior and personality have changed.  In addition to the physical, cognitive, and emotional consequences of brain injury, many couples deal with the stresses of lower income due to the survivor’s unemployment and social isolation as friends withdraw. 

New research on marriage and divorce after brain injury

Research conducted in 2007 by the Traumatic Brain Injury Model System at Virginia Commonwealth University has looked more closely at this belief and has reported new and more positive findings.  Their study included 120 people with mild, moderate and severe brain injuries who were married at the time of their injury.  Their average age was 41 and it had been 3 to 8 years since their injury.  The study found that 3 out of 4 or 90 out of 120 survivors were still married.  This starkly contrasts with the common belief that divorce is widespread among couples after brain injury. 

Additional findings from the researchers are:

• The overall rate of breakdown among couples was 25% (17% of survivors were divorced; 8% separated).
• There was no difference in marital breakdown rates between male and female survivors.
• The more serious the injury, the greater the likelihood of divorce.
• Age mattered; survivors who were older when injured were much more likely to stay married.
• Length of marriage mattered; those who had been married for more years before the injury were more likely to stay married after the injury.

The authors concluded that this study “…does not support the notion that divorce rates for persons with brain injury are higher than those for the general population.”

Source:

Kreutzer, J., Godwin, E., Marwitz, J. (2010). The Truth about Divorce after Brain Injury. TBI Challenge! Winter, 3.

For more information, see: 

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier, B.S., Editors

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Explaining Brain Injury, Blast Injury and PTSD to Children and Teens

By Marilyn Lash, M.S.W., Janelle Breese Biagioni and Tonya Hellard

When a parent is injured, sons and daughters often feel confused, scared, anxious and angry. This guide helps parents explain the physical, cognitive, behavioral, social and communicative changes that can follow a brain injury, blast injury or PTSD. Using examples from children of all ages, it helps them understand their emotional reactions to a parent’s injury or PTSD. Each chapter has an exercise for children and practical tips for children, parents and professionals.

By Dawn Neumann, Ph.D.

TBI changes communication in a marriage

The woman in my office was clearly a very successful woman, who for the most part, usually had it together.  But now it appeared she could fall apart at any second. She was there to talk to me about her husband who had a traumatic brain injury (TBI). She told me that since the accident, he had made terrific strides learning to walk again, improving his balance, and regaining most of his thinking skills. 

Despite these monumental improvements, there was still a terrific strain in their relationship.  She no longer felt “connected” with her husband. The wife was frustrated and perplexed. Prior to the injury, which was just months before they were married, he was an extremely compassionate person always in tune to her emotions. Now he was oblivious to her needs.  He never comforted her in times of sadness or worry. He was unresponsive to her frustrations.  He never participated in her joys, not even when their first child was born. Was this because he didn’t care?  Most people would assume so, but as you read on, you will see that this is because he just couldn’t tell how she was feeling.      

Brain injury can affect relationships with everyone

We all know relationships can be very challenging. This does not just refer to relationships with spouses, but relationships with family, friends, coworkers, and even acquaintances. Add a brain injury into the mix, and these relationships can become even more stressed. In fact, relationship problems are one of the most frequently reported long-term and devastating consequences after brain injury. They often cause families who have been touched by a brain injury to become fairly isolated and have dwindling support networks.  

In the last decade or so, researchers have slowly started to realize the impact of social challenges on an individual’s quality of life and well-being. Scientists are trying to understand the different sources of relationship problems after brain injury and figure out ways to address them.  

What changes after a brain injury?

Why does it become more difficult for many persons with brain injury to develop and maintain relationships? Well, a lot of things change, but an area that researchers are very interested in now is emotion. This is not simply referring to people who have trouble controlling their emotions, which often makes social interactions uncomfortable. It’s much more complicated than that.  

Reading and responding to needs and emotions of other people

What is the key to good relationships and social interactions? How well we interact depends a lot on being able to read and respond to other people’s needs and emotions, while effectively communicating our own. Let’s review why this is trickier than it sounds.  

For the most part, people don’t always tell us what they need or how they are feeling. Instead, this information is subtly expressed through facial expressions (for example, knitted eyebrows), tone of voice, or body language. Believe it or not, recent studies show that as many as fifty percent of people with a brain injury have a harder time correctly “reading” other people’s needs and emotions. They may not pick up on these subtle cues or inferences, and only pay attention to the words that the person actually says – which is only half the picture. 

Missing or mistaking emotions

Research has shown us that after a brain injury, people may tend to see no emotion when there is one, or mistake one emotion for another. Both errors have significant consequences. If a person sees no emotion when there actually is one, the person won’t respond to another person’s emotional need because it is not recognized. For example, if the person doesn’t realize that a spouse is sad or a boss is annoyed, there is no reason to offer comfort or to take action to solve the problem. If the person mistakes one emotion for another, such as assuming someone is angry when someone is actually sad, the interaction is more likely to be confrontational rather than supportive. This behavior would obviously be a problem.  

Expressing too much emotion

It’s not only important to be able to read the emotions of others, but it’s also important that we accurately and appropriately express our emotions to others. After brain injury, we often see exaggerated expressions of anger or sadness. The pitfall with expressing these emotions is that this might not be what a person is actually feeling. People who express a lot of anger are often feeling other emotions, such as fear or sadness. However, they may act angry because they are not aware of their other emotions, or because they don’t know how to express or deal with their sadness or fear. 

In cases where the person is feeling angry or sad, they may “take out” these emotions on people who were not responsible for causing these emotions. In instances when they are angry with the person they are interacting with, they may be verbally or physically aggressive because they may not be able to handle their emotions rationally and/or not know how to communicate these feelings in a calm way. 

Language and cognitive problems can present an even greater challenge. Nonetheless, inappropriate expressions of anger are likely to receive an undesirable response, such as pushing people away or inflicting anger, when what is really needed is support and understanding. 

Showing too little emotion

In contrast to those who are overly expressive with their emotions, there are people who show very little emotion after a brain injury. This will also be a problem for relationships and social interactions. When we talk with people, we try to get an idea of how they are feeling so that we know how to respond to them. If we can’t tell how they are feeling, it creates a lot of questions. Do they enjoy spending time with me? Does this person care about me or how I feel?  What do they think of me? When people are not emotionally expressive, social interactions can be confusing and unsatisfying.    

Sharing emotions builds relationships

The bottom line is that relationships are built on emotional exchanges that result in shared emotional experiences and the understanding of one another’s feelings. We must tune into the emotions of others and make sure we are kindly expressing our own. These are skills that often become more challenging for individuals after brain injury. The good news is that it appears to be a skill that can improve with treatment.

References:

Radice-Neumann D, Zupan B, Babbage D, and Willer B (2007). Overview of impaired facial affect recognition in persons with traumatic brain injury.  Brain Injury: 21(8): 807–816.

Radice-Neumann D, Zupan B, Tomita M, Willer B (2009). Training emotional processing in persons with brain injury.  Journal of Head Trauma and Rehabilitation: 24(5):313–323.

About the author:

Dawn Neumann is a Postdoctoral Research Fellow at Carolinas Rehabilitation in Charlotte, NC.

Reading recommendations

OOPS! Social Skills after Brain Injury

By Harvey E. Jacobs, Ph.D.

Procedure for Assessing Awareness and Adjustment Following Brain Injury

By Kit Malia and Anne Brannagan

Brain injury rehabilitation manual on assessing awareness and adjustment in adolescents and adults with brain injury in rehabilitation and community programs.

By Patricia Jackson, C.B.I.S. and Michael Davis, C.B.I.S. – C.E.

Case management over time

Since the 1960′s, the case manager has been a key organizer of services in traditional rehabilitative settings.  Case management has evolved over the years from a simple cost containment focus to a well-coordinated, systematic, comprehensive approach to quality cost-effective care.  Case managers today are routinely and almost universally involved in organizing and coordinating rehabilitative services and resources to maximize a person’s functional recovery after an injury.   

Most recently, the case manager has been recognized as a catalyst in the field of forensic or medical-legal rehabilitation.  Therefore neurolawyers are increasingly using professional case management services to ensure that their clients receive well-coordinated, quality care and treatment during the often lengthy process of litigation. Lawyers have a duty to provide comprehensive legal services, but they typically do not have the time to oversee the medical and rehabilitative aspects of a personal injury case. The provision of case management can have a direct positive impact on addressing the myriad of needs in a serious injury case.

Case managers, attorneys and personal injury claims

As more case managers are being employed by attorneys to oversee their clients’ case, it is important to clarify the role of a case manager in this specialty field of medical-legal rehabilitation.  A case manager is capable of wearing many hats.  This article describes how case management may be involved in a personal injury claim.   

The attorney weighs the benefits of involving a case manager right from the start.  Time is typically of the essence in catastrophic injury claims.  By using professional case management services to coordinate care that will maximize the client’s physical, cognitive and emotional functioning, the attorney can focus on the litigation process. 

The many roles of case managers

Case management assumes various roles throughout the different stages of a client’s recovery from an illness or injury. 

Hospital

In the acute medical arena, the case manager serves as a discharge planner and helps move an individual from the hospital to rehabilitation, home health care or outpatient therapies.  

Insurance Company

The insurance case manager serves mostly as a cost monitor to ensure that health care dollars are expended wisely.

Rehabilitation Program

Facility-based rehabilitation case managers usually serve on a team within that facility to guide therapies toward maximum potential recovery for the patient within the confines of their facility.

Forensic case manager

None of the case managers above are typically involved in the legal aspects of a patient’s case. The forensic case manager is concerned with every aspect of the above.  At the same time, the forensic case manager assures that the legal perspective is being addressed to maximize client recovery.  The personal injury attorney who utilizes the services of an experienced case manager is in fact assuring the client’s access to quality treatment and medical care.

Case manager as liaison

The weeks and months immediately following a traumatic injury are full of day-to-day stressors.  As a result, families usually are overwhelmed with information and decisions they may not be equipped to handle.  All too often, families do not feel fully informed or supported by many of the medical professionals whose expertise has preserved the life of their loved one in trauma.

If the attorney who has been retained in a personal injury case involves a case manager immediately, the family will benefit.  By using the expertise of an experienced rehabilitation professional, the case manager can assume a guiding role in the care of their loved one.

The attorney also benefits by identifying the case manager as the primary contact person for the family.  The case manager is able to field numerous questions and run interference.  This gives the attorney valuable time to proceed with the intricacies of the litigation process.

Families in trauma have special needs.  They can appear to be demanding at times.  But they may simply need someone to listen to their concerns, their ideas or even more importantly, their fears.  So first and foremost a case manager is a liaison for not only the client, but for the family, the rehabilitation team and the attorney, as well.

Case manager as advocate

Once given the opportunity to review medical records, discuss the case with all parties involved, and determine the priorities, the case manager can oversee a treatment plan, monitor progress, advocate as necessary and create a clear pathway through the rehabilitation maze.

The forensic case manager can objectively oversee the provision of services from a more holistic and client-centered approach.  The forensic case manager works in conjunction with the clinical case manager and the insurance case manager, but does not have their internal pressures or external financial obligations.

Attorneys who assign a case manager to their personal injury cases are assured that the:

• appropriateness and effectiveness of therapies and programming will be monitored, and

• care will be coordinated in the best interest of their clients’ long term needs.

If long term rehabilitation is necessary, the involved case manager has the ability to explore and identify possible funding sources early on.  Through their experience, case managers are familiar with federal, state and local resource systems available to the client.  The attorney may be a novice or have limited experience in that particular arena. Understanding the systems of Medicaid, Social Security, vocational rehabilitation, workers compensation, and the public schools is complex.  Gaining access to their services is a time-consuming process.  Rather than assume that task and breaking new ground, the attorney can rely on the case manager to fulfill this area of responsibility.

Case manager as negotiator

It is important for the client and family to have a skilled negotiator throughout the course of recovery.  The case manager is capable of creatively negotiating a proposed plan of care, length of stay, rates of service and when necessary, identifying appropriate vendors.  Negotiating services to develop a continuum of quality care is crucial as well as time consuming.  Whether it is acute care, outpatient rehabilitation or in-home care, the involvement of a case manager can make a difference.

Taking the long view or seeing the big picture

Where expert life care planning is necessary, identifying service providers and ensuring the implementation of the life care plan is a long term commitment.  The attorney who utilizes the expertise of a case manager is cognizant of the fact that a client’s needs continue long after the litigation process has ended.

There is no easy road to recovery following a catastrophic injury.  Recovery from traumatic injury can be a long arduous process, not only for the injured party but for the family as well. The family’s emotional needs can frequently be overlooked unintentionally while professionals focus on rehabilitation of the client.  The case manager functions as a support system for the family and as an educator and guide through the maze of rehabilitation.  

One of the most valuable tools a case manager brings to the table is the ability to listen.  A skilled case manager listens to concerns from all parties involved, pulls the information together, develops a plan and ultimately directs the implementation of that plan.  The case manager works closely with the rehabilitation team, medical consultants and the family.  By bringing forth the clinical perspective, the case manager helps the attorney strategize throughout the litigation process.

It is the attorney’s duty and obligation to provide clients with the best possible means available to ensure successful resolution to their case.  Financial recovery is only one aspect of a case.  Personal injury attorneys should also concern themselves with the more critical aspects of a case, i.e., emotional and physical well- being.  

An experienced forensic case manager is an asset to the plaintiff attorney’s case for many reasons, some of which have been described here.  Each personal injury case presents itself with a unique situation, specific needs and a vast range of priorities.  In collaboration with the attorney, the list of priorities can be defined, responsibilities delineated and an initial plan set in motion by the case manager.

Whether acting as liaison, advocate, negotiator or educator, the role of a forensic case manager is key in litigating personal injury claims in today’s legal arena.  Ethics dictate diligence by the plaintiff counsel.  Morally speaking, this diligence would serve the client equally as well in the pursuit of quality services, thus facilitating improved quality of the life for the client.

Bee, C.M.(1996) Damages/Running The Gauntlet From Soft Tissue to Head Injuries/From Chiropractor to Neurosurgeon. A non-published presentation.

Burke, W.H. (1995). The Rehabilitation Expert: Analysis and Management of Brain Injury and Other Neurologic Disorders. In Burke, W.H. (Ed.) The Handbook of Forensic Rehabilitation, Houston, TX: HDI Publishers.

Burke, W.H. (1995). The Forensic Analysis of Costs in Head Injury Claims. A non-published presentation. Insurance Defense network, Las Vegas, NV.

Evans, R. & Watke, M. (1995). Catastrophic Neurologic Injury: Improving Outcomes Through Case Management: The Case Manger, July/August / Sept. 83-88.

Fawber,H.& Zorger Orstein B. (1995). Case Management in Forensic Rehabilitation. In Burke, W.H. (Ed.) The Handbook Of Forensic Rehabilitation. Houston, TX: HDI Publishers.

Howe, R. (Ed.) Inside Case Management. 1 (11), 1 (12), 2 (6). 1995.

Mullahy, C. (1995). The Case Manager Is the Catalytic Collaborator in Managed Care. The Journal of Care Management. 1(1), June 7-9.

For more information from Lash and Associates Publishing/Training, Inc., see:

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Head Cases

By Michael Paul Mason

Book on brain injury, blast injury and PTSD features chapters on adults, children and veterans discussing changes in memory, self-image, violence, suicide, family stress and war in Iraq.

By Patricia L. Jackson, B.S., C.B.I.S. and Michael W. Davis, C.B.I.S.- C.E.T

Is it really happily ever after? 

The Life Care Plan is designed to identify long term needs through a comprehensive assessment of the client’s medical, physical, behavioral and emotional status.  Once the data is evaluated, a Life Care Plan outlines what services the client will need over the course of a lifetime to maintain physical health and emotional well being.  Contrary to popular belief, after a Life Care Plan is deemed necessary and finalized, the client, a.k.a. the subject of the Life Care Plan, is not set for life. 

In reality, it is after a Life Care Plan is finalized that the real work begins.  The Life Care Plan is a necessary map to direct the client’s way along the path of life.  If it is taken at its worth, the client will have access to the supports that were identified to facilitate successful care over the long run.  Unfortunately in a majority of cases, the Life Care Plan simply finds its way into a file cabinet and is stored along with other medical and legal documents.  

Who are the players in the plan? 

Somewhere along the way a major component is overlooked.  The medical and rehabilitation specialists do their jobs by identifying the needs of the client.  The family hires legal representation to help them do the best they can for their loved one.  The attorney’s obligation is fulfilled by presentation of a comprehensive Life Care Plan in court.  The judge (and perhaps jury) recognize the severity of the injury and find in favor of the client.  The decision is made about a financial settlement that will ensure access to whatever services had been deemed necessary for care over the client’s lifetime.  And then, everyone goes home.

Money doesn’t guarantee services 

Although life care planning focuses on caring for the needs of the injured person, a financial award in itself does nothing to guarantee client services.  There is a huge gap in the system.  The family is not always aware of the how-to’s in the rehabilitation community, yet they are most often the ones left holding the “plan” so-to-speak.  Even experts within the system find that it can be difficult to access services.  It is a grave disservice to expect that a client’s family members will know how to work through the complexities of a system, including as the maze of rehabilitation services. 

The case manager is the missing link  

A case manager who specializes in the implementation of Life Care Plans can fill that void.  Working with the family, a case manager takes charge of the Life Care Plan to access and arrange the services identified for the client.  

The role of each person involved in the Life Care Plan process is defined and is important.  Each specialist is responsible for their area of expertise.  However, the reality is that every individual involved in the case has an ethical responsibility to see that what they recommend is in fact carried out.  

It is not enough to identify, acknowledge and provide financial resources to help the client.  The care the client deserves and is entitled to should not be compromised simply because no one is identified to assume responsibility for implementing the Life Care Plan.  A case manager assures that the finances are utilized in the way that they were designated, rather than leaving follow-up client care to chance.  The Case Manager doesn’t have all the answers, but will find the resources to get the answers that the client and family deserve.

Case managers can help fulfill the intent of a life care plan

Surely it is the intent of the judge and our legal system as a whole to provide financial support by way of a settlement when they find in favor of a client.  When utilized properly, a financial award will provide support and services for the client who has sustained a serious injury.  A financial award that is misused or used improperly not only doesn’t help or support the client, but it also causes greater harm by decreasing the client’s chance for success and an improved quality of life.  Misuse will also most likely create a host of secondary problems resulting from lack of proper medical and psychological care. 

A case manager can be the critical missing link.  By monitoring the client’s status and maintaining communication amongst all the parties involved, the client’s care will remain in the forefront as the true priority.  After all, quality client care is the true intent of any financial settlement. 

Patricia Jackson is a Case Manager and Michael Davis is the President and Senior Case Manager with Neurological Case Management Associates, specializing in the field of neurological rehabilitation, in Charleston, WV.

For more information from Lash and Associates Publishing/Training, Inc., see:

Adult Mini Tool Kit on Traumatic Brain Injury for Families

This Adult Mini Tool Kit is designed for lawyers and life care planners to give to families with information on traumatic brain injury. 

Ketchup on the Baseboard: Rebuilding Life After Brain Injury

By Carolyn Rocchio

By Marilyn Lash, M.S.W.
Lash and Associates Publishing/Training, Inc.

Signs of stress and PTSD in the military 

As service members and veterans come home from Iraq and Afghanistan, many have psychological issues related to traumatic stress and post traumatic stress disorder (PTSD).  

• More than 90% of soldiers and Marines returning from Iraq reported stressors of…
  • roadside bombs
  • length of deployment
  • handling human remains
  • killing an enemy
  • seeing dead or injured comrades
  • being unable to stop a violent situation. 
• 30% of troops returning home from Iraq reported some type of mental health problem, including
  • anxiety
  • depression http://www.lapublishing.com/depression–brain-injury-family/
  • nightmares
  • anger
  • difficulty concentrating. 
• 15-17% of troops returning from Iraq in 2004 experienced acute stress or post traumatic stress disorder (PTSD).  http://www.lapublishing.com/PTSD-blast-brain-injury/

The stigma of mental health

Mental health treatment has always been carried more stigma or “baggage” than treatment for physical conditions in the U.S.  Common misperceptions in the general population are that seeking therapy, counseling or even medication for emotional help is a sign of weakness.  Even most private health insurers have strict limits on the scope and number of mental health services allowed.  There is a general belief among the public that those who seek mental health treatment are unstable, disturbed, and mentally ill.  This stereotype leads to patterns of avoidance by friends, neighbors and coworkers.  It contributes to denial by individuals and delays seeking treatment.   

This stigma makes it even more difficult for soldiers and service members to ask for help in a military culture that stresses being strong and avoiding signs of vulnerability or weakness. 

PTSD screening in the military

 The military has made a serious effort to address psychological issues among troops.  Despite this, there is still a lag of soldiers actually seeking help.  Before returning to their home stations, all soldiers undergo mandatory psychological and medical screening.  Based on the results of the psychological questionnaire to assess PTSD, depression and alcohol abuse, soldiers may be required to have an interview with a mental health professional.  Those who indicate medical symptoms are referred to medical professionals. 

Soldiers are more reluctant to report psychological problems, especially when returning with their units.  The findings are striking… 

• Only 38-45% of troops newly diagnosed with mental health problems were interested in receiving help.
• Fear of stigmatization and concern about barriers to getting psychological help was twice as likely among troops who scored positively compared to those who did not.
• Only 23-40% of troops who reported interest in seeking help during the previous year had actually received professional treatment.

Beliefs about mental health and mental illness

Beliefs that psychological distress is a sign of weakness are also linked to the perception that individuals are responsible for their problems.  There is a common belief among civilians and service members that individuals should be able to control their psychological symptoms through choice, determination, and sheer will power. 

Consequently, it is easy to see why service members fear exclusion by comrades if they report symptoms of PTSD or other emotional distress.  Seeking treatment may be avoided or delayed due to apprehension about its stigma and reactions of comrades. 

Interventions for reducing stigma in the military 

Organizational policies and programs directly impact whether service members seek mental health support.  Concerns about losing a job or security clearance are barriers to seeking mental health treatment.  Anonymity and confidentiality are other concerns reported by soldiers. 

Leaders and supervisors have a critical role in identifying and helping soldiers receive mental health support and treatment.  If leaders emphasize the importance of early mental health treatment, service members are more likely to seek help because it has less negative associations.  Leaders are instrumental for creating a climate where mental health problems such as PTSD are recognized and early treatment encouraged and supported.

References:

Greene-Shortridge, TM, Britt, TW, and Castro, CA. (2007). The Stigma of Mental Health Problems in the Military. Military Medicine, 172, 2:157.

For more information, see:

Understanding the Effects of Brain Injury, Blast Injury, Concussion and PTSD

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

Healing Together

By Suzanne Phillips, Psy.D and Dianne Kane, D.S.W.

Book for couples coping with effects of trauma and post-traumatic stress disorder (PTSD) from war, brain injury, violence, accidents, crime or health problems.

By Katherine H. Taber, Ph.D. and Robin A. Hurley, M.D.

More veterans have brain injuries and concussions

Brain injuries are becoming increasingly more common with changes in modern warfare. Returning combat veterans may not know they have suffered such a wound. That is why VA doctors want returning soldiers and their families to have this information.

If the head is hit or shaken severely, a “concussion” or “closed head injury” can result. Many types of forces can cause a brain injury. Examples include being hit on the head, being near an explosion, and being in a motor vehicle accident. A brain injury can happen in the absence of any external injury. However, it is important to remember that presence of external injury does not mean the brain has been injured.

Concussion is seldom life threatening, so doctors often use the term “mild” when the person is only dazed or confused or loses consciousness for a short time. However, concussion can result in serious symptoms. People who survive multiple concussions may have more serious problems. Here are some of the more common symptoms of brain injury.

Common symptoms of brain injury concussion

• “I just don’t feel like myself.”
• Feeling light-headed or dizzy
• Difficulty organizing daily tasks
• Blurred vision or ringing in the ears
• Feeling sad, anxious or listless
• Easily irritated or angered
• Feeling tired all the time
• Trouble with memory, attention or concentration
• More sensitive to sounds, lights or distractions
• Impaired decision making or problem solving
• Difficulty inhibiting behavior – impulsive
• Slowed thinking, moving, speaking or reading
• Easily confused, feeling easily overwhelmed
• Change in sleep – much more or much less
• Change in sexual interest or behavior
• People who have had a concussion may say that they are “fine” although their behavior or personality has changed. Changes such as these in a family member or friend suggest the need for medical help.

Recovery following brain injury

Some symptoms may be present immediately. Others may appear much later. People experience brain injuries differently. Speed of recovery varies from person to person. Most people with mild brain injuries recover fully, but it can take time. Here are some things that can be done to promote healing, and to make symptoms easier to manage.

Promote healing and manage symptoms of concussion

Things that can help

• Get plenty of rest and sleep
• Increase activity slowly
• Carry a notebook – write things down if you have trouble remembering
• Establish a regular daily routine to structure activities
• Do only one thing at a time if you are easily distracted – turn off the TV or radio while you work
• Check with someone you trust when making decisions

Things that can hurt

• Avoid activities that could lead to another brain injury – examples include contact sports, motorcycles, skiing
• Avoid alcohol as it may slow healing of the injury
• Avoid caffeine or “energy enhancing” products as they may increase symptoms – check the labels on cough, cold, and allergy medicines
• Avoid excessive use of over-the-counter sleeping aids – they can slow thinking and memory
• In general, recovery is slower in older persons. People with a previous brain injury may find that it takes longer to recover from their current injury. Some symptoms can last for days, weeks, or longer. Talk to your health care provider about any troubling symptoms or problems.

Katherine Taber, Ph.D. and Robin Hurley, M.D. are at the Mid-Atlantic Mental Illness Research, Education and Clinical Center located at the W.G. “Bill” Hefner VA Medical Center in Salisbury, NC.

For more information on blast injuries and concussion, see the manual:

Understanding the Effects of Concussion, Blast and Brain Injuries:

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

By Carolyn Rocchio

Mild brain injury is a real problem for families

Many service members and veterans have returned from war with undiagnosed mild brain injuries or concussion.  Greater emphasis is now being placed on case management and coordination of services for service members and veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom after sustaining traumatic brain injury in response to the July 12, 2006 report from the Department of Veterans Affairs Office of Inspector General (1). This need was reinforced by testimony before the House Veteran’s Affairs Subcommittee on September 28, 2006 with the presentation of alarming data about the large numbers of blast injuries resulting in changes in neurosensory deficits (2).

Traumatic brain injury has become the “signature” injury of Operation Enduring Freedom and Operation Iraqi Freedom. As of January 2006, the Department of Defense reported more than 11,852 returning wounded had exposure to blast injuries (2). It is reasonable to conclude that many additional service members/veterans who have been exposed to blasts without bodily injury are later experiencing classic signs of mild brain injury.

Mild brain injury is a significant problem in the general population in this country as well. According to data from the Centers for Disease Control and Prevention 1.1 million Americans are seen annually in emergency departments with mild brain injury and countless numbers are never screened or diagnosed.(3)

Coming home isn’t always easy

Many service members/veterans return home with the expectation that their lives will resume as they were prior to deployment. Such is not the case for many who have been exposed to blasts. Without information and resources to guide and support the service member/veteran and family, a “mild” brain injury can take a serious toll on the family. It is critical that service members/veterans be screened for a mild brain injury when exposed to blast injury and given appropriate follow up and treatment. Equally important is educating the family members who will ultimately become the support team once the veteran completes treatment. Families must be made aware of the nature and consequences of mild brain injury and provided with tools to provide support in the months and possibly years to follow.

Social workers should be aware of informational resources to assist families being seen in VA facilities, both inpatient and outpatient. Many educational resources and publications exist to educate families. In turn, families must be taught how to access community resources and be prepared for changes and characteristics common to mild brain injury. Some of the more common characteristics that may be present on discharge or develop later include:

• headache
• fatigue
• dizziness
• memory problems
• sleep disorders
• problems concentrating
• ringing in ears
• irritability
• visual changes
• sexual dysfunction
• sensitivity to light, sound and odors

Even though some or many of the characteristics above may exist, the overall appearance of the individual can still be unchanged unless there are other physical injuries. This appearance of well-being can be misleading for family members, friends, and others. Even the service member/veteran is not always aware of the less visible cognitive changes. This can lead to frustration when the family is not patient and supportive.

A mild brain injury can be tricky to diagnose

Mild brain injury is often difficult to diagnose as changes in brain structure are seldom captured by CT or MRI scanning. This lack of physical evidence of an injury can result in labeling the individual as “faking” or malingering, when in fact there have been molecular changes in the brain that affect how the individual thinks and acts. A neuropsychological assessment is the key piece of information that can explain how the injury has affected the individual’s functional capabilities. Ideally the service member/veteran, family members and the neuropsychologist should meet to discuss the findings and establish ways the family can support and promote emotional well being of the service member/veteran and other family members.

All members of the family undergo a difficult adjustment once the service member/veteran returns home. There may have been many role reversals with family members assuming new responsibilities while the service member was deployed. After a brief honeymoon period, when everyone is delighted that the service member has returned, things can go down hill very rapidly. This can happen when others see the subtle changes, but do not understand the cause. At this point, it is not uncommon for the service member/veteran to develop a secondary emotional response to these changes. This can create new problems, that without professional intervention, may escalate into family dysfunction and even violent behaviors. This secondary emotional response often becomes even more disabling than the original insult when support is not available. This can lead to a psychiatric referral that further exacerbates this issue. Persons with mild brain injury often describe themselves as feeling “crazy” because they do not understand the changes they are experiencing.

Risks at home

Families need to be extremely vigilant when there are small children in the home. Irritability and impaired behavioral control can result in children becoming the target of the service member/veteran’s temper when seemingly minor interactions become emotionally charged. Older children may need help understanding why the parent who was once loving and supportive becomes moody and irritable for no apparent reason.

Trying to return to work can be fraught with problems. While the initial return to a job may be met with exhilaration and a sense of camaraderie with old colleagues, problems may surface over time. The service member/veteran may find things that were once easy are now far more difficult. The pace of work is slower. Fatigue is a major factor. Interaction with coworkers can become argumentative and problematic.

Seizure activity can develop some months or even years after a blow to the head. Often these seizures are not convulsive, but more likely to be partial complex temporal lobe seizures which manifest as a change in behavior. The service member/veteran may complain about foul odors, become more sensitive to light or sound, pace the floor and even have hallucinations. Any symptoms should be reported with a follow up evaluation to determine if seizure activity is present.

What can be done to lessen these problems?

Structure is important for reestablishing a daily routine. Military personnel have one advantage in that they are very disciplined and used to taking orders from others. Until the routine is going smoothly at home, the spouse, parent or significant other may need to be the authority figure and help set up a structure. It is not uncommon for a brain injury to affect a person’s ability to initiate a daily routine. This can be particularly difficult when moving from the highly structured military regime back to a more relaxed home setting.

Some helpful strategies for family caregivers include:

• Use day planners, post it notes, and written lists to minimize problems related to memory loss.
• Use watches with alarms, egg timers or electronic timers to keep track of time related tasks.
• Organize all possessions, shelves, drawers, etc with everything in an assigned place to prevent the frustration of locating lost or misplaced items.
• Build in time for relaxation, meditation and/or yoga and Tai Chi to reduce stress.
• Encourage social interaction, but make sure all friends, families and others are aware of the service member/veteran’s persistent problems and ways to interact more successfully.
• Find support groups. The assurance of others with similar residual affects of mild brain injury can be extremely important. Some VA centers with brain injury programs sponsor such groups. Information about community based support groups for individuals with brain injuries and their families can be obtained by contacting the Brain Injury Association of America at 800-444-6443 for referral to the group nearest the family.
• Plan time each day for rest or a nap to offset the effects of long term fatigue. Many will experience disrupted sleep and may require medication to insure restful sleep occurs.
• Model calm when things become emotionally charged. In the event that violence is an issue, make sure family members leave the area to avoid being injured until calm is restored.
• Seek professional help from a person familiar with mild brain injury in planning the work environment to ensure a successful return to work.
• Ask about the use of alcohol and nonprescription drugs before discharge. Alcohol and street drugs can have negative effects when medications are prescribed for conditions such as seizures. In general, any use of alcohol has an exaggerated affect on a person with brain injury. Use of alcohol and other substances is best reinforced if guidance is provided in discharge summaries so family members can rely on professional direction in written form.
• Ask about driving safety due to changes in perception, judgment, visual, and attention deficits. Driving should not be resumed until the service member/veteran is evaluated by a Certified Driving Educator, where emphasis is more on cognitive functions than the mechanical ability to operate a vehicle.

Summary

Mild brain injury can create significant disruption in the lives of the person with the injury as well as members of the family. To insure a more successful recovery, it is critical that there be a thorough assessment to determine what areas of the brain have been injured and the effects on everyday functioning. Additionally, once cognitive deficits have been identified, it is important that strategies to compensate for these deficits be developed. Lastly, family education and resources must be provided. A well informed and supportive family is the major component of successful community reentry.

References:

 (1) Health Status of and Services for Operation Enduring Freedom, Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation. Report Number 05-01818-165. VA Office Office of Inspector General. Washington, DC , July 12, 2006.

(2) Zamperi, Thomas. Chrm. Director Government Relations, The Blind Veterans Association. Testimony: The House Veterans Affairs Subcommittee. September 28, 2006.

(3) Langlois J, Rutland-Brown W, Thomas K. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.

Recommendation reading

Mild Traumatic Brain Injury Workbook

By Douglas J. Mason, Psy.D

Workbook for adults, veterans and families on mild traumatic brain injury and concussion symptoms with strategies and exercises for improving attention, memory and executive functions.

Brain LASH

By Gail Denton, Ph.D.

Book helps adults and families understand mild brain injury symptoms with strategies for physical, cognitive and emotional changes after concussion.

Changing Educational Systems

By Katherine Kimes, Ph.D.

Students with traumatic brain injury in school

Students returning to school with traumatic brain injuries may have a variety of physical, cognitive, behavioral, social and emotional challenges. Recovery of function is typically enhanced through exposure to enriched environments like the education provided at schools. Just as schools promote learning, recovery after a brain injury is a re-learning process. This is why it is important to provide students with brain injuries access to appropriate supports and services by educators within the school system.

Still under the radar screen

Unfortunately, brain injury has slipped under our educators’ radar. It has often gone unnoticed due to underreporting and/or misidentification. However, more and more children, adolescents, and young adults are surviving their injuries as medical technology advances. However, students with brain injury who return to school and require special accommodations, supports, and services are still too often at an unfair disadvantage because educators have little knowledge or training about teaching them. Without the necessary educational supports and programs, students with brain injuries are at greater risk for lower academic performance, failing grades, and dropping out prior to high school graduation. Important steps need to be taken in order to change our educational system across the nation if we are to meet the challenge of educating students with brain injuries.

It’s a messy problem

Currently, there are 5.3 million Americans living with the effects of a long-term disability as a result of brain injury with 1.5 million Americans sustaining a TBI annually. But just ask any educator (primary, secondary, or post secondary) and they will tell you that they do not know much about brain injury. They believe that they have not had any, or many, students in their classrooms who have sustained brain injuries. This, unfortunately, is an enormous misconception.

There are numerous problems that surround the epidemic of TBI in our nation’s youths. However, effectively educating these students is a predominant theme and one that needs immediate attention. The “messy problem” requiring a systemic change is that educators’ level of competency for educating, supporting, and transitioning students with brain injury needs to improve. Teachers in school systems across the country must be provided with adequate training in traumatic brain injury. When educators do not know how to best support these students, they are given inappropriate supports and transitional services which can ultimately inhibit their cognitive recovery. Educators’ inadequacy ultimately compounds the challenges faced by students in all grades and ultimately fails to prepare them for adulthood.

The SYSTEM needs to change

The mission of this “system change” is to increase teachers’ awareness of brain injury in order to provide effective, appropriate educational supports and transitional services for this unique population of students. With access to this information, educators will be able to provide these students with improved opportunities for their futures. These students require more than academic success. They must also be prepared for the transitions from high school into the community, business world, and/or post-secondary educational institutions to lay claim on their futures.

Level 1 change

Use professional development to increase the level of competency among educators by providing a foundation of knowledge about traumatic brain injury. This includes

educating teachers on the epidemic of brain injury, statistics, terminology, mechanisms of injury, and methods and strategies for accommodations and support services.

Level 2 change

Expand educators’ skills to include the identification and assessment of cognitive, physical, and psychosocial challenges including repercussions of the brain injury on a student’s overall quality of life.

Level 3 change

Train educators in the learning differences of students with brain injury compared to other disabilities.

Level 4 change

Learn instructional strategies. While services need to be individualized, students with TBI often have some general common needs: structure, flexibility, supervision, and appropriate direct intervention

Level 5 change

Increase educators’ competency regarding awareness of how students’ learning environments and social interactions can change after brain injury and how educators’ use of interventions such as environmental modifications and positive behavioral support can help these students succeed.

Conclusion

Achieving any systemic change requires increasing the competency level of stakeholders. Therefore, not only should teachers be included in this change process, but also the communities of parents, administrators, allied professionals, and the students themselves.

References

Almli, C. & Finger S. (1992). Brain injury and recovery of function: Theories and mechanisms of functional reorganization. Journal of Head Trauma Rehabilitation, 7(2), 70-77.

American Council on Education (1989). Head Injury Survivor On Campus: Issues and Resources. HEATH Resource Center (pp.1-11). Washington, DC.

Brain Injury Association of America (2001). [Media Resource Kit].

Finger, S. (1999). Margaret Kennard on Sparing and Recovery of Function: A Tribute on The 100th anniversary of Her Birth. Journal of the History of Neurosciences, 8(3), 269-285.

Gray, D.S., (2002). Mechanisms of Brain Injury, Markers of Severity, Classification, Sequelae of Injury and Recovery from Injury. BIRPP. Retrieved October 20, 2002 from Internet.

Johnson DA, Ruston S. & Shaw J. (1996). Virtual reality enriched environments, physical
exercise and neuropsychological rehabilitation. Proc 1st Euro. Conf. Disability. Retrieved October 19, 2002 from Internet.

Perna, R. (2002). Brain Injury: Does Age Really Matter? Brain Injury Source 6(2), 32-34.

Savage, R.C. & Wolcott, G.F. (Eds.) (1994). Educational Dimensions of Acquired Brain Injury. Austin, TX: PRO-ED, Inc.

Wehman, P. (1996). Applications for youth with traumatic brain injury. Life beyond the classroom: Transition strategies for young people with disabilities (pp. 445-478). Baltimore: Paul H. Brookes Publishing Co.

Recommended Reading

Students with Brain Injury 

By Katherine Kimes, Ed.D., Marilyn Lash, M.S.W. and Ron Savage, Ed.D.

This TBI manual for educators and parents provides a foundation for understanding the educational needs and behavioral challenges of children with traumatic brain injuries. 

Signs and Strategies for Educating Students with Brain Injuries 

By Marilyn Lash, M.S.W., Gary Wolcott, M.Ed. and Sue Pearson, M.A.

Manual describes the consequences of brain injuries on a student’s learning, behavior, communication, cognition and adjustment in school and at home.

By Marilyn Lash, M.S.W.

Lash & Associates Publishing/Training, Inc

Each school year brings many changes for students, teachers and parents.

Fears, frustrations and uncertainties may accompany exciting changes when a student has a brain injury and goes to school. Will classmates treat me differently now? Will the teacher know how to help me? What if I can’t keep up?

Not only do classmates, teachers, room assignments and books change, but the content and type of school work changes with each grade. As schoolwork becomes more complex with each passing year, the brain is challenged in new ways. Recovery from the injury and ongoing brain development are occurring simultaneously for this student. It is over time that the long-term effects of a student’s brain injury become fully evident as learning becomes more complex and schoolwork is more challenging.

Begin with information

There is a lot going on and it’s not surprising that educators, students and parents often aren’t quite sure how to begin. The place to start is with information. Regardless of when the student was injured, information is the key to helping the educational team understand and meet the needs of this student. The following list helps parents and educators get started. Try to include the student in this process whenever possible.

Step 1.  Set up a meeting with parents and all teachers and staff involved with the student.

Step 2.  Review medical and rehabilitation information about the severity of the student’s injury, current medications and side effects, and ongoing therapies.

Step 3.  Review reports from specialists, including therapists and neuropsychologists, to understand which parts of the brain were injured and possible consequences for learning and behavior.

Step 4.  Have samples of the student’s work from the previous school year, including

• effective instructional strategies
• compensatory strategies for memory, organization, and planning
• techniques for managing behaviors
• adaptive devices
• schedule changes because of fatigue

Step 5.  Review what special services or supports were provided last year, what worked and what was not helpful. Make sure everyone has a clear understanding of this student’s strengths, difficulties and needs.

Step 6.  Set up a plan for regular feedback and communication between the educational team and parents. Don’t wait for problems to develop.

Step 7.  Identify resources within and outside the school who can provide in-services on brain injury and consultation.

Step 8.  Be flexible. Recovery is a continuous process, especially in the first 1-2 years after brain injury. Goals and objectives need to be continually revised as the student’s needs and abilities change. The educational plan needs to a flexible tool, not a fixed written document.

Step 9.  Prepare for transitions. Consistency and structure are very important for the student with a brain injury. Any change, not matter how small, needs careful preparation for the student to succeed.

Step 10.  Look ahead. Time passes and students grow up. The ultimate measure of a student’s education is preparation for adulthood. Don’t wait until senior year to think about what happens next. Transition planning under special education must begin when the student is age 14. A plan must be put into action by age 16.

Parents have a special role and perspective in gathering information. No one knows their child better. They not only have the comparison of their child before and after the injury, but they have seen their child progress through the various stages of medical care and rehabilitation. Parents are the link between various teachers, classes and schools. Use their experience to understand how to teach this student effectively and plan on involving parents in this process. If parents are to be able to help students with homework and support the efforts of teachers, they must be an integral part of the educational team. Only if parents and educators work together can there be an effective educational plan that will truly benefit this student.

Recommended reading 

Learning and Cognitive Communicative Challenges

By Roberta DePompei, Ph.D. and Janet Tyler, Ph.D.

Manual with teaching strategies for students with acquired brain injury and challenges with behavior, attention, cognition and language.

Educational Series on Teaching and Behavior after Brain Injury

Four manuals with information and strategies on teaching and addressing challenging .behaviors of students with brain injuries.