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Community Transition and the Fine and Performing Arts

Community Transition and the Fine and Performing Arts
[Northeast Center For Special Care] [Community Transition & The Fine & Performing Arts] Do you feel really happy that we're going to sing your song and record your song and Eric is going to film it on his camera? Yeah. >>Yeah. He said yeah. We're going to sing it good. Jimmy, will you come sing it with me, man? >>Yeah. All right, brother. He said that's cool. Yeah. That's my man right here. [♪mellow song in minor key♪] [all] Broken brain, broken again, don't light a fire. Fire, fire, fire, fire, fire, fire, fire, fire, fire, fire, fire, fire. We're getting ready for another show tonight, a very special show at the Colony Cafe in Woodstock. I have a brain injury on this side of my head. It's a bitch. [laughter] It's a bitch to be poetic. I sometimes can't find doors. You know what I mean. Lives that are so intensely lived are lives that absolutely require expression. It's God's world. Everything is alive and so am I. In God's universe there are many blessed and living things. God comes to me in my dreams and lets me know it will be okay. Eventually it will. He does. Yeah. I want to know when. [laughter] I'm impatient. [laughter] I'm impatient. I'm not a patient woman. I am not. Right, right? [laughter] [female speaker] Thank you so much. [applause] May the Lord be with everybody that has a brain injury. It's the worst thing that ever happened to me in my life. Adam is a neighbor at Northeast Center who came in, and he clearly had some musical talent. He was a drummer. We could see he had good ability to drum. But he never sang before. He didn't know he could sing. And just through fooling around in various musical situations, we discovered this amazing talent. I had no idea, not at all. [singing] Some people take walking for granted, some people talk trash all day. [♪band playing blues♪] But for me life's an everyday struggle, wish I could fly away. [♪band continues♪] I started painting about three years ago, since I came here. My whole attitude changed as far as my happiness and not being so mean and not just wanting to do nothing but lay in bed. I can actually say I'm happy when I'm down here working, and it brings up my self-esteem. I think with my painting my story is in the paintings, the happy side of me that I never got to see. Having one of your poems published is like having someone tell you you did a good job. It's very encouraging. It makes me want to get out and experience life and write about it. It's a little like the feeling you get on Christmas morning and you wonder what kind of presents you're going to get. [Thomas M.] Like the son of Atlas I bear the beams of love on my shoulders. It's not easy because I don't know what to do with love. But I am learning. [♪rock music♪] [Adam J. singing] Alive, alive, alive, alive. Only to be alive. Alive, alive, alive, alive, alive. Oh oh, oh oh oh. [♪music continues♪] Oh oh oh, oh oh oh. Oh oh oh. Alive, baby. [cheering and applause]

See the power of creative arts therapy and TBI.

How to Succeed in Biz-Ness by Really Trying (Logan's Story)

How to Succeed in Biz-Ness by Really Trying (Logan's Story)
[Logan and her mom] This is my daughter, Logan. >>And I'm a Biz kid. In 2001, Logan had a heart attack. She fell into a coma. She sustained a traumatic brain injury. >>A bad one. It took about a year before she could stand. >>About a year. Life was going to be different, but it wasn't over. We did therapy at home, and she was getting bored to death hanging out with her mom every day, and for fun we decided to do a mock-up magazine. And then her school teacher saw it, and they thought, "Wow, Logan! You should do this idea." They hooked us up with different people that showed us how to do it. I've created a magazine for people like me. We thought we could feature products we love that have helped Logan. This is a pencil grip that I use for my eyeliner. From a mom that e-mailed Logan and says, "Thank you for being such an inspiration." If you're going to start a fashion magazine, you need a design firm, and that's me. Producing a magazine is pretty complicated, but it's also a blast. The cool thing about Logan is that she dived into the project unknowingly really of what they were getting into. It really didn't matter what it took. It's really amazing. It's really complicated. We did go to people that knew how to do it, and they shared with us the tips and advice that we needed. Well, they came in totally green. It was fun to see them go through the process and the learning curve because it's super complicated and there's a lot to it--a lot more than people realize. You have to figure out the flow of a magazine. You have to hire a photographer. There's budgets and printing and bids and-- It's hundreds of hours,and people just don't have a clue really. In this business, persistence equals success. On this Logan project, there's a lot of action. I mean things are actually happening. All right, here are some new spreads for the current issue. This is actually using Bethany Hamilton who was the surfer in Hawaii who had her arm bit off by a shark. It feels good to be helping people that need it. One of the things that Logan has is tenacity, and you can really see that she sticks with it and she gets it done. I have never met anyone with more drive and inspiration than Logan. They're bound and determined that they're going to help these kids with disabilities.

This spunky young woman persevered after a TBI to inspire others to achieve their dreams and goals.

Michael Paul Mason Talks About Brain Injury Case Management

Michael Paul Mason
As a brain injury case manager what I do is I travel all around the country evaluating people with moderate to severe injuries who have developed a pretty severe behavioral problem as a result of those injuries. And my job is to try to help them find a rehabilitation center that will accept them and provide treatment to them. And most of the time I fail at this job. It's an impossibility practically. There are a tiny number of beds in all of America. There really aren't enough beds to go around, and there are waiting lists at almost every facility. But the person is in genuine need, and they are benefited by simply sometimes being given a direction to go in as opposed to no direction. In many cases, by the time they get to me, a lot of times they're very close to giving up hope that there's anything at all. My hospital assigns me the task of finding some kind of loophole somewhere that they can grab onto to maybe give them that little bit of hope. So when the rare event does happen that I'm able to find a rehab that will accept someone or even get them into the hospital that I work for, there's often a lot of tears on the other line of happiness and of joy because they've managed to overcome such great odds. In most hospital settings a case manager facilitates discharges. So they will actually be assigned to a particular patient and look for the next stage of treatment. So in the case of a brain injury case manager, that case manager would typically say, "Okay, after we're done treating him, "this person maybe will be able to return home, "and they will need to contact this physician and work with this therapist "and do this kind of thing." I worked in a reverse kind of role in the sense that I worked at the front end helping patients to get admitted to places that they hadn't found. So in many instances I was filling a void that existed just because there simply aren't services to go around. What happens in many cases is that the person simply is not able to access the care that they need, and so they will tend to stay at wherever they're at. Sometimes this is at home, and so the burden of care is placed on the family. And at an average lifetime cost of something like $4 to $6 million per injury, you can imagine the kinds of financial strain that this puts on family members. They may have to quit their jobs in order to care for the person. And then once they quit the job, they may have to sell the home in order to afford getting by. And so many people with brain injuries make tremendous sacrifices just to sustain life, not necessarily to improve but just to get by. This is a very aggravating thing about our healthcare system that a lot of individuals are actively trying to advocate for greater reform and understanding. I became a brain injury case manager through a series of mistakes basically. What I did is I began working in mental health, and I became very interested in people's psychological conditions and the troubles that they were having. Eventually I was hired on by a hospital that had a brain injury unit on it, and they needed someone who could understand mental health issues but also felt comfortable in settings talking about neurological conditions, being able to read medical records and then writing reports based on these evaluations in hopes of getting individuals treatment. And so I had this skill set of being able to write as well as being able to navigate medical records, and that proved to be a good fit for them. I had been a freelance writer for many years in Tulsa. And the more I began writing for the advertising industry, the more disinterested I became in copyrighting, and so I wanted to leave that field and go into a field where I felt that I could do a little bit of writing. And so that at the time was purely mental health. I didn't know that there was even an industry involving brain injury, and I had not really heard the term much prior to working in mental health. But as I began to experience different scenarios in which people were in mental health settings with obvious neurological problems, then I began to look at those stories a little bit more closely because it just didn't make sense to me why a person with a physical injury was being placed in a mental health unit. It seemed unjust. I've had a lot of memorable experiences. But one that really stands out to me is that I had one family member come up to me after I had met their loved one with a brain injury, and the person--she kind of sat down right next to me, and I had been working this case for about a year and a half, and she said, "I don't know how often you get told this, but thank you." [off camera speaker] How often do you get told that? Not often because people are so much buried in their own-- Oh, yeah. I mean, I don't look for thanks, but it's nice when it happens.

Coordinating care for people with brain injury is challenging.

Learning from Wounded Warriors

Neuropsychologist Maria Mouratidis Talks About the Heroes She Meets Every Day
Our returning warriors have been tremendous teachers, tremendous teachers not just about brain injury or psychological injuries but about resilience, about how to keep going even when something has happened, something as devastating as a severe physical or brain or psychological injury, about courage and the courage to try again, try harder, the courage to share and to reach out, the courage to overcome and be victorious despite circumstances or obstacles that might be in our way. And serving our returning warriors and their families causes profound changes in, I can say, myself and those with whom I serve as a person, that not to be affected and changed by the witnessing of the power of the human spirit and the body and the mind to heal and to continue against often some very severe consequences and odds. There have been patients that really no one thought would live and somehow have made remarkable recoveries, have been steadfast in their commitment to healing and growth. When I asked a young servicemember, a young Marine, how he was dealing with giving his left eye he said, "Well, ma'am, my right eye is getting stronger all the time." That power of expectation and of hope has been a tremendous gift. And we continue to learn by listening to our patients and their family members of what they are going through, what they need, what they have learned and sharing with them in that hope and in those struggles. And it has in some ways been more powerful than all the science in the world, all the education in the world, and it is something that if we take the time to listen is there and to step up to the plate as a person.

This neuropsychologist talks about the heroes she works with on a daily basis.

Navigating Cultural Barriers in Brain Injury Rehabilitation

Navigating Cultural Barriers in Brain Injury Rehabilitation
So how do I get a family or someone with a traumatic brain injury to buy into rehabilitation, if there are cultural barriers? Well, I start by buying into the family. I look at it the other way around. We're here collaboratively, and so that's why I start with their priorities and their goals and then look at how I can facilitate their goals and then perhaps add on ones that I've thought of that didn't occur to them or that they didn't notice yet, but I buy into them. That's the way I look at working on that. That's on a personal working-with-people level, but that's a much bigger issue, in terms of society as a whole. We have a lot of disparities in rehabilitation. That is to say that within the United States, people of various minority status generally receive fewer rehabilitation services than majority culture people. The barriers to that--probably the most important is healthcare funding, is that we have such a crazy quilt of healthcare funding that does not reach everybody, by any means, 46 million people without coverage and so on. And that's certainly a very important factor. Other factors are institutional barriers-- lack of awareness in the community of the services that may be available, lack of faith in those services, lack of appropriate outreach and language accessibility and so on. Fortunately, there is a government agency that has addressed all of those issues and has some very good guidelines. It's Cultural and Linguist Access to Services--I believe it's called CLASS. In the slides that accompany this interview, I'll list out some of those things of ways that institutions can look at making themselves more accessible to the ethnic minority communities that are in their catch-man area in their neighborhoods. There are a lot of things that keep people from even arriving at the office or the clinic or the rehabilitation facility or whatever it is. But once they've arrived, then other things having to do with those barriers are buying into them, working with their goals, finding out about their background, and those kinds of things. Again, as I said before, not just tolerance, but valuing and respecting that. Most of the things that I talk about, most of the things that I teach come from the people that I've worked with. They don't come so much from what I learned in graduate school or what I learned from the scientific literature.

Professional advice about getting buy-in from patients and families when cultural barriers are in the way.

Dr. Tedd Judd Talks About Brain Injury and Setting Family-Centered Goals

Dr. Tedd Judd Talks About Setting Family-Centered Goals
It's important to be family-centered when you're setting goals for somebody who has had a traumatic brain injury because, while it's important to do that for anybody with a significant illness, in that the family is going to be involved in one way or another, with how the person copes perhaps with aspects of the treatment. Even if it's not a brain injury, they may have a change in diet or in exercise or what they can and can't do, and the family is going to be able to make that easier or harder to the extent that they understand it. And they're going to have some ideas of where that fits in. That's double or triple when it comes to traumatic brain injury, because not only is it a matter of the routines of the household and the way you interrelate and the risks and so on, but with any significant brain injury, the person with the injury has changed in their ability to do things, their ability to understand and make good choices and decisions and take responsibility. They may no longer be fully responsible for their own choices, or at least temporarily, during the course of their rehabilitation. The family may need to be taking over significant functions for them. A family will do that anyhow, when they observe that there are problems going on, but it's better if they're involved with the team, so that they can collaboratively arrange a way to do that that respects the autonomy and dignity of the person with the brain injury, that moves them along towards recovery, so that they're not holding them back by doing everything for them, but rather that they're letting them do what they can do, but making sure they're safe and doing it in a way that doesn't create problems for people. And so what you want to do is to develop goals, develop a direction to go that is going to be meaningful for the person and for their family and is going to fit and work.

What makes family-centered care so effective?

Dr. Tedd Judd Talks About Brain Injury Professionals and Cultural Competence

The mistakes that professionals can make in working with an Hispanic family or an Hispanic client, well, they're varied. They are as varied as Hispanics are varied. And Hispanics are very varied ethnically, in education, in culture, in country of origin, even in language within Spanish and outside of Spanish. In my part of the country, we have a lot of Mexicans from the area of Oaxaca whose first language is Mixteco, which is an indigenous language. And so you see an Hispanic name and you hear they're from Mexico, and you think it's going to be Spanish and it turns out not Spanish. There are of course lots of different forms of Spanish, and I find that although I do reasonably well with Mexican Spanish, I have a harder time with Puerto Rican and Cuban Spanish. So there's variability in language. And assuming that everybody is the same in that regard isn't going to work. In addition to the great cultural variability that there is across Latin America, we probably have a greater variability of levels of education than we have within the United States. Most of the time with people in the U.S. who grew up here, we can count on them having primary and often some high school education, often much more than that. There are large numbers of people who come to the U.S. from countries in Latin America who have no education. And of those who have no education, some are illiterate, some are quite literate because they've learned by other means, and you can't assume that because they haven't been to school that they're illiterate. So there's a whole lot of variability that we need to find out who do we have and not stereotype. That's one starting place. And then how acculturated they are to here, how they view their relationship to majority culture and so on. And then there are other things that have to do with interpersonal style. If you get in there and say, "Hello, how are you, let's get right to work," that's not going to work. [laughs] You need to spend some time working on the relationship and establishing some kind of sense of connection before you're ready to move ahead and work. And I think that may even be more true when you're working across culture than when you are within culture. So you can have that camaraderie and that connection a lot faster if you can recognize and give those signals that you're from a common background. I fall somewhere in between often because in speaking Spanish I put a lot of people who speak Spanish more at ease, sometimes even if they're better at English than Spanish and we just drop a few words in Spanish here and there and make a few references, and there's kind of a little bit of settling in. But of course I'm not Hispanic in origin and Spanish is my second language, and they can sense that, so it'll take me longer perhaps than someone else. But you have to spend some time establishing that credibility, and you don't know when you arrive what's going to establish that credibility. Sometimes it's the diplomas on the wall, what we call the ego wall--all the diplomas. Sometimes that does it. Sometimes it's how warm and friendly you are. Sometimes it's whether you have some knowledge or background in understanding their culture. Sometimes it's just whether you're open to finding that out and that you can convey that openness. I work with a lot of different cultures, and I know some reasonably well; others I don't know very well at all. And when I'm with someone that I don't know their culture very well, which may include some Latinos, depending on where they're from, I'll say that up front, and I'll say, "I don't know that much about where you're from." "Please help me out here. I'll try to do my best to understand." "And if you find that I'm missing something, please let me know." That may help or it may not, depending on who it is. But certainly spending that time to make sure that you have a foundation from which you can work is very important. We as North Americans tend to work with the individual, so much so that our funding for rehabilitation and healthcare services are very individually oriented as well. But if we're going to be effective, we have to work with the person's context and with family members. And sometimes that takes figuring out which ones and how to get in touch with them and how to make that work. That might mean going out, as I said before. It might mean making some phone calls, inviting people in. There are a variety of ways. And you may not even know at the first. It's not necessarily the formal closest relative, and it may be extended family that are most important. You need to kind of hear out and wait until you figure out who are the people that are important here, who hold influence, who are they going to believe, who are they going to trust. You may or may not be able to work directly with that person. That person might be a few thousand miles away, but you may have to call them up or say, "Well, what would Tia Tita say about that?" "Can you call her and ask her what she thinks?" And so you need to just try to figure it out.

Professionals need to be culturally savvy to work most effectively with people of different ethnicities.

Dr. Tedd Judd Talks About Brain Injury and Cultural Background

There are certain senses and broad theoretical senses in which cultural differences don't make a big difference in how I teach rehab to home kinds of things, in the sense of certain principles. The sort of thing of the zone of recovery that I talked about before, the idea that we're working on the person gradually learning how to do things. Some cultures and some families are more readily oriented to that sort of thing than others, and we may have to go back to first principles and explain and work that through with people earlier, for more time. Also, people from certain cultures will have different explanations or different ideas as to what might have caused this problem and what is going to be helpful. And so we have to spend a lot of time, first learning about the culture in general that the person is coming from, and then understanding where that person and their family is, with respect to that culture of origin because many such people are immigrants in our country, and they're in a process. They're somewhere from in between their culture of origin and our host culture here. And where they are and what their goals are, in terms of their process of being here, is very different from one family to another, even within families. You may have a very common kind of thing, for instance, is that the parents have come too late to learn English very well, but the kids are picking up English quite easily. And so they're in two different positions with regard to their language, and acculturation and their understanding of how we do things here and so on, and maybe even in their own goals. We try find that out about each family member and where they are, so that what we do can be respectful of that and respectful of their understanding. Then we take that to see what their goals are going to be and where they want to-- what they're looking for in rehabilitation and try to tailor what we know how to do to help them arrive at what they want to arrive at. There are times when we might have to nudge that or massage that a bit to say to participate in that process acculturation, to say, "Well, yeah, we could do it this way, but that's not going to work here very well." (laughs) We may, to some small extent, be agents of cultural change when that is kind of part of the overall process of helping towards their goals that they may not be aware of. But that's not our job overall, only as it pertains to our rehabilitation goals. Certainly, we want to try to not just be respectful or tolerate of other cultures or perspectives, but to make use of and include and celebrate that in what we do. It's important for us to understand what are the community organizations, what are the activities that are really important to someone, and to work with them towards their goals of reincorporating into that. Now, that may include not only what they do to be able to fit in, but how they can understand how they fit there, and it may well include a reaching out to that community in a certain sort of way, so that setting, that can make a place for the person and allow them to function there. It may involve making a visit to the church, having a gathering of friends, going to the person's home and bringing other people around. Let me tell a story. I was working in the national rehabilitation hospital in Costa Rica, and a woman in the hospital who had an episode of anoxia, loss of oxygen, and she had 5 children, one of whom was a baby. She had returned home. She had a severe amnesia, and she had a severe lack of initiation. She just couldn't get herself going at things, which damage to a certain part of the brain can produce that. It wasn't depression. It wasn't that she didn't want to. It's that the starter was broken in the brain. It's like a car with a dead battery. What you can do with them is you can roll start them if you've got a standard transmission. You know--put it in gear, push it a little, and then pop the clutch, and then you get going, and that's the metaphor we often use for doing that. It's a kind of hard thing to grasp. We made a trip from the hospital, hospital bus, whole rehab team, 4-hour drive to her home, twice across the continental divide, and arrived at the home, and it was a kind of semi-rural neighborhood. Of course, they knew we were coming, when we got there. There was also a small rehab facility in the local town. We brought them over because they were going to do follow-up. There were about 15 or 20 of us professionals, and then the family and the neighbors started showing up. We had 30 people come, all squeezed into this living room. Everybody was part of the action. The extended family came from more of a distance and all of the neighbors who were going to be around. We gave explanations about this initiation and so on, and talked about what they could do to facilitate her being more active. Quite reasonably, in such a circumstance, they had hired someone to help out in the home. The person who was hired to help out in the home was on the model of--you know-- I'm a domestic servant. I'm here to do as much of the cooking and cleaning that I can to relieve her. We had to explain, "The more you can get her to do, the better," which is very much away from the model of what she thought she was hired to do, but, of course, her husband and the older kids were going to comment on this and the other family members had to know that we were talking about that, so that they didn't think that she was a bad employee. We demonstrated ways of doing that and what sorts of things would facilitate. Then we had local people that could follow-up with that instruction. But--you know--we got 30 people, a big community who were there, able to support her in that and those kinds of things. We never would've gotten 30 people to come 4 hours over the mountains to the hospital to learn all of those things. We might have tried to educate her husband and one or two other family members, so that they could say that, but it would've have come across with the same kind of authority for them and the same kind of impact for that family. Go there. Look at the context. See who you've got. When we were over there, we also learned some things that we might not have learned in the hospital, such as she would be sitting around all day doing nothing, and one day, there was thunder and a rainstorm starting to come. Suddenly, she jumped up out of the chair, ran outside to bring the laundry in off the line. We wouldn't learn that in the hospital, but their right stimulus was enough to get her moving and doing things. When you look at the context, when you go out and look at the context, you can learn things. You can collaborate until you arrive at something that is going to be more useful Take our knowledge, their knowledge, put it together.

The more doctors or therapists know about the background and traditions of their patients, the more effective they will be.

Guidelines for Using Brain Injury Rehabilitation Techniques at Home

Dr. Tedd Judd
When I'm working with families around incorporating rehabilitation techniques into the home setting, the first thing that I emphasize is that you're a family member first. And you need to maintain and respect your role as a family member and maintain the love and the other things that are most important in that way. If part of that can include doing rehab as well, great, but if not, and if trying to do rehab is going to get in the way, then let your role as a family member come first and let that be first. Okay, that being said, then if you are able to furthermore incorporate rehab in, what I would look for more than anything is finding ways to make everyday activities things that you want to do anyhow, things that will also facilitate movement towards goals that you have. How do you do that? Well, you do them at what we call the zone of recovery. The zone of recovery, just to understand historically, comes from a psychologist named Vygotsky from the Soviet Union from the 1930's. He called it the zone of proximal development and talked about it in children, but we've used it in rehabilitation. That's the activity that the person can do with a little bit of help, that it's a challenge, but they're able to accomplish it, that it's not so easy that they're bored by it. Now, life includes lots of things that are boring and all of us have to do, and even if you've mastered that thing, and you can do it okay, there may be something to be gained from doing it because it has to be done anyhow, and you get better at it and so forth. It's not to say that you're not allowed to do boring things or things that are too easy, but if you wanted to be helpful, and if you've got a complicated activity that the person can do part of, what you want to look for is not just giving them the parts that they can do easily. It's also including the parts that are a challenge, but that eventually they're going to be able to succeed at, and something that's not so hard that they get too frustrated at it. This idea of the zone of recovery includes not only how hard it is, but what the nature of the interaction is with the family member. It implies that the family member is guiding, that the family member is perhaps cuing, coaching, indicating, answering questions. The family member isn't just sitting back and letting the person do it all by themselves and struggle with it or whatever. And the family member isn't showing them every little step, every little part of the way. Rather, they're--so if you think of it physically, it's not like you're walking behind pushing. You're not walking ahead and pulling them along. You're walking next to them and indicating and guiding when that's needed. That's the zone of recovery. That's the kind of activity that yeah, I think--yeah, okay I can do that. I think--yeah, that one. That's another principle that helps. Another thing is that it's a moving target, that people recover, and that makes it a bit of an art. People who are good teachers, people who are good at parenting often have that knack. It's a knack, and so one of the things that I do too, is I look for the family members who have that knack, who like to do that, and who have the time and the ability to do so and are motivated to do so. You pick the right ones for that also. But it's a learn-able knack, so that idea of looking for that zone often helps people to figure out what they should be doing. Another thing I like to do along those lines is we'll pick an activity that the person wants to be able to do, that they're not quite able to do yet. We'll say, "Okay, well, what is getting in the way?" Well, how could we deal with that? How could we get around it? We'll do problem solving together, and often what I can do when we work through a half a dozen problems, the family, along with the person, may then have a notion of a way to go about things, and they can tackle new problems themselves. Let's do a little example. Suppose we've got somebody who has got a new brain injury-- or not a new brain injury--it's several months. They're home now. Let's say that it's somebody, a young man in his early twenties-- which would be fairly typical--and has perhaps returned home to live with his parents. One of the things that he would really like to do is to go to the neighborhood soccer games 4 or 5 blocks away, like he used to do, and watch the games and see his friends and all that. Several problems that are getting in the way-- He can walk, but he gets tired easily, and 4 or 5 blocks to walk, that's going to be a lot. He just kind of gets tired generally at any kind of activity and when he gets tired or when he gets over stimulated, and there is too much noise and light and activity, he gets irritable and he gets anxious. Okay, so we've got some problems. Conventional rehabilitation, "Oh, well, we'll give him physical therapy to improve his stamina, so that he can do that, and we'll give him cognitive rehabilitation with the speech pathologist or an occupational therapist who will improve his attention, so that he can handle more stimulation, and we'll give him psychotherapy to deal with his irritability and anxiety." Okay, that's great, but it's 4 or 5 months before he can get to go watch the soccer match that way. Instead, what we'll do is we'll say, "Hm-mm, let's see what we've already got that can deal with this." We could look at desensitizing to the over-stimulation. We could look at learning to handle all of that going on by practicing at home by watching soccer on TV. Now, most of the time, I don't think of the TV as a rehabilitation machine, but if we've got a particular goal like that, and something we're going towards, it could be. We could work on that some. We could say, "Okay, for now, we're going to drive to the soccer game, or we're going to take the bus, so that you have a little more energy. We know you get tired before too long, so we won't stay for the whole game when we start out. Because the crowds are worse when everybody is arriving and that's difficult to handle, we'll come a little late, and we'll leave early. On top of that, we know we've got a routine worked out for when you get angry or when you get anxious that we call is a time out." Or for this person, maybe it's take a break or relax. We use whatever language works best for them. We'll have a plan B, so that if you're there at the game, and things get a little too rough, you'll have somewhere you can go and something you can do, and we'll figure out in advance where would be a good place for that. You'll go with a family member who can help you monitor that because maybe you're not too good yet at monitoring and noticing when you're starting to get irritable or anxious, and so that family member will be watching what you're doing. Okay, now we've got a whole plan in place to go to your first game. Then you go to your first game, some things work, some things don't. We'll talk about it afterwards, what worked, what didn't, what are we going to do next time. Then with the zone of recovery, next time, okay, we go for a little longer. The next time, I'm going to leave you alone for a little while while you're there and see how you do. Then maybe a few weeks, a month later, we're ready to walk there or to get a ride there and walk back. Now, we'll add bits and pieces that way. Then we'll be ready to--well, we'll walk by your side, but you tell me where we turn. You tell me which route we take. We're doing rehabilitation. We're using everyday activities. We're doing an analysis of what is going on with that activity to find out where the problems are and how to approach them. We're doing some compensations of putting things in place that allow the person to function better, and we're doing some kind of restoring of function by exercising it and doing it over and over again to build up the habits that are needed to make it work better. That's one kind of activity. We could do the same thing for going shopping or for washing the dishes or for going out on a date or to a party or any kind of motivating activity. Well, washing the dishes might not be all that motivating for some people, but it needs doing anyhow. There are all kinds of ways that you can take everyday activities and analyze them. It's cognitive. It's physical. It's emotional. You're looking at the whole thing, and you're working with all of it.

The more professionals can teach caregivers, the more effective the rehab techniques will be at home.

Dr. Tedd Judd Talks About Understanding Behavior Changes with TBI

There are a lot of different ways that people understand or try to understand or think to themselves about what may be going on with some of the behavior changes we often see with traumatic brain injuries. And it's often handy to talk particularly about the example of impulsive anger. Maybe two examples will serve. The other one, the one I've mentioned before, is the lack of initiation. And I picked these two because they're enduring problems that tend to be very disruptive to someone's return to their usual role and they're very frequent problems. And they are also very treatable. They can be made better. There are lots of other problems too, but we'll pick those. When we consider the different-- I'm going to talk from a neuropsychological perspective first and then go on to some of the other cultural things that can go on. From a neuropsychological perspective, we can think of three major components of the personality of someone who's had a significant brain injury. There's the personality they already had before the injury, and an injury can happen to anybody, so there's the full range. There are the reactions they have to that, and I put that in two parts. One is the reaction to the experience of the injury itself. So you might be really angry at the driver or the person who assaulted you or you might feel really guilty because you were responsible for the accident, or you might have post-traumatic stress disorder from the ambulances coming and from seeing the car coming at you at the last moment, all kinds of reactive things to the accident itself. Then there's also a reaction to being disabled and to what life is like now-- the embarrassment, the fears of the future, the depression and so on. And there's a third component. So we've had personality prior to the injury, reactions to the injury which we can understand from the point of view of people with intact brains, and the third is the changes in personality and emotions that result from injury to the brain itself because the brain is the organ of emotion, it's the organ of personality. And so when it's changed, emotion and personality are changed. Impulsive anger comes in large part from that third component when we see it as a change, that the person who gets angry very suddenly out of proportion to whatever the event is that's triggering the anger and when they calm down suddenly afterwards and when it's out of character, often people say, "Why am I acting like this? I never used to be this way before." "Please help me get rid of this anger." I know we're talking about the organic impulsive anger of brain injury. When it has those kinds of components and when it doesn't serve a purpose very often, it doesn't get them anything. Anger serves a purpose in our lives much of the time. It can get you something, and there are times when it's appropriate to get angry. But the impulsive anger of brain injury often doesn't get you anything. So those are some of the characteristics of that. Most people, when they first see it, will tend to assume that either the person was like that before, if they didn't know them well and haven't seen it as a change, or perhaps that this is a reaction to either the injury, "Well, they're angry because they were in an auto accident," or "They're angry about being disabled." They'll see it as reactive to that. And that's a possibility, but much more often it's something else. Likewise, people will tend to see that lack of initiation, that dead battery in the car kind of experience, as, "Well, they must be depressed or they're unmotivated "or they don't really want to get better," rather than seeing it as a brain problem. Those are common interpretations to see in any culture. In addition to those interpretations, we may also see people who put a spiritual interpretation on it, who see it as fate or who see it as a punishment from God or from the gods or the ancestral spirits or various other sources for something that either they or someone in their family did or one of their ancestors did. There are people who may see it as something that's part of a past life of their own that's responsible for it or who may not attribute it to anything in particular, just chance and life happens this way. And one of the things that sometimes we have difficulty understanding from a Western perspective, even though we do it ourselves, is that many people hold several interpretations at the same time and it's not contradictory for them. Actually, that's true of us, although we don't recognize it. What caused the accident? Well, what caused the accident was that the car ran off the road. But what caused the accident was that the road wasn't well marked. But what caused the accident was that it was rainy that night or that the driver was drunk or that the person at the bar didn't recognize they were drunk and let them go out or that we have a society such that blah, blah, blah. Causality can have many different levels, and they can all be operating. And that person themselves may say, "Well, this is a punishment for my terrible ways," and that may also be another level of explanation that likewise applies. And that's okay, and we can work with all of those, and sometimes you just pick the one that's going to serve the purpose now as best you can.

Emotional and behavioral changes in a person after a TBI can be significant.

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