Family News and Views, A Monthly Publication of the Brain Injury Association
Vol. 6, No. 2 April 1999
By Carolyn Rocchio

Transition Into the Community

Reintegrating an individual with brain injury back into the community (school, work, family living) can be a difficult transition, particularly when rehabilitation is limited. Inadequate funding sources often limits rehabilitation to a set number of days, which may only allow for restoration of the most basic physical functions and provide little or no time to address cognitive recovery and behavioral control.

It is not surprising for individuals to find "getting back to real living" a major problem for which there was little or no preparation. For some, spontaneous recovery creates improved insight and awareness of ways things have changed, and depression, anger and frustration levels may be difficult to control. Due to damage affecting vital areas of the brain, others might have a lack of insight or awareness to the point of denial or believing nothing is wrong.

This scenario, coupled with lack of meaningful purpose for day-to-day existence, contributes to difficulties in harmony in the household. Without supportive guidance and cooperation, some problems escalate to the use of drugs and alcohol, violence, criminal activity and a downward spiral of dysfunction. It can be increasingly difficult for families to keep the atmosphere under control. Many with whom I have spoken describe their homes as virtual prisons in which they attempt to keep the family member "incarcerated" for their own protection. A mother told me of a situation in which her son is so volatile, the other family members are afraid to even speak to him and the sister has moved out to avoid her brother's verbal abuse. The mother quit her job to stay home and "guard" the son.

Many families seeking assistance are referred to psychiatrists and/or local Community Mental Health Centers. Families frequently end up using the Baker Act when things become so out-of- control that the family feels threatened. Baker-Acting an individual usually requires the individual be held in a psychiatric ward of a hospital or in a community mental health center for 72 hours, or until stabilized. Some community mental health centers may schedule psychiatric examinations, and medications are generally prescribed to reduce undesirable behavior. However, many psychiatric medications have a negative effect on individuals with brain injury and can further compromise cognition. With or without medication, a short-term hospitalization may provide relief for the family, and for the individual, the structure of the setting with no demands on them can have a very calming effect.

Another population frequently referred to Community Mental Health Centers are pubescent youngsters through young adults, as a result of behaviors bearing resemblance to schizophrenia. Ironically, this age group is also at high risk for TBI. Many youngsters, subjected to beatings, shaken baby syndrome and sports-related blows to the head, often suffer gradually diminishing cognitive abilities without realizing the underlying cause. Up to 15 percent of schizophrenics have had significant head injury that preceded the first psychotic episode. (Lishman) The IQ usually remains in a normal range, and CT scans can be negative; however, neuropsychological evaluation is more likely to determine the extent of focal deficits. Should there be evidence of brain damage resulting from trauma to the head, treatment options should evaluate the efficacy of rehabilitative efforts to improve cognitive and psychosocial skills versus/or concomitantly with a pharmacological and psychotherapeutic approach.

Community Mental Health Solutions

Community mental counselors have limited training in recognizing and treating individuals with TBI. Solutions are limited and costly; however, mental health counselors need to know how TBI differs from psychiatric disorders, possess good intuition and have the cooperation of the family. One of the first principles in working with individuals with brain injury is knowing that no two brain injuries are ever the same. Naturally there are commonalties, but each individual presents with his/her own strengths and weaknesses that must be determined before substantive gains can be made. Secondly, individuals with TBI know the person they were before the injury, and in many cases, lack awareness and insight about ways they have changed. Minor, moderate and severe TBIs each have classic residual sequelae.

Damage to the frontal and temporal lobes of the brain (most common to vehicular crashes) creates persistent cognitive difficulties which, without therapy to develop compensatory strategies, ultimately creates psychosocial dysfunction. The family is a very important support component, as clients cannot be treated in isolation. Family input about premorbid personality, characteristics and level of functioning is critical.

Some of the more common cognitive and psychosocial problems associated with traumatic brain injury include:

• confusion/disorientation
  
• egocentricity/self-centeredness
  
• disinhibition
  
• impulsivity
  
• poor judgment and reasoning skills
  
• lack of motivation
  
• depression
  
• emotional ability/instability
  
• outburst/aggressiveness
  
• restlessness and anxiety
  
• short attention span
  
• memory impairment
  
• fatigability/lack of endurance
  
• inappropriate social skills
  
• substance abuse
  
• inability to organize tasks and thoughts
  
• headaches (more common to minor brain injury)
  
• sleep disorders
  
• low self-esteem
  
• sexual dysfunction
  
• preservative behavior
  
• rigidity and inflexibility
  
• verbosity
  
• confabulation
  
  

Family Advocacy Can Make a Difference

Community Mental Health can be an appropriate resource for individuals with brain injury when counselors better understand TBI and its characteristic cognitive and behavioral components. Families can help educate centers in their communities by scheduling in-service training through BIA state associations, inviting mental health counselors to support group meetings and educational conferences, asking mental health personnel to be guest speakers at support group meetings and jointly working on a menu of appropriate services to benefit persons with brain injury. Services traditionally provided by community mental health agencies include: case management, evaluations and referral, group counseling and drug counseling. Many community mental health agencies also operate drop-in centers, where individuals can interact socially in a supportive and informal environment. Community services can serve effectively, but need the input of knowledgeable families about ways their services can be helpful to a broader population.

References
(1) Kwentus J A, Hart R P, Peck E T, Kornstein S: Psychiatric complications of closed head trauma. Psychosomatics 26(1):8-15.
(2) Lishman W A: Organic Psychiatry. London, Blackwell Scientific Publications, 1978.