As you might expect, as a brain-injured speech-language pathologist (SLP) I look for accounts of SLP encounters with persons with brain injury in the social media I follow. I’ve seen a couple of posts lately that ask colleagues for help because the patient with brain injury is angry and mad and non-compliant! Patients with brain injury show them their middle finger, they sneer, they throw things, they yell or do some non-verbal equivalent, like ripping their clothes off! What should the poor SLP do? Call in the psych ward!
My brain-injured side understand the anger. I used to get mad a lot. I was so frustrated, but I didn’t understand that I had cognitive problems and I thought it was the other person’s fault for not understanding me! Since I’ve become an SLP, I can understand why persons with brain injury get mad at SLPs. SLPs tend to be so darned haughty while they flip through their cards and questions at a clip. I know an SLP who dropped out of the profession after her brain injury because of the haughtiness she perceived in her peers when they treated her as a patient. SLPs are hard to tolerate sometimes, what with their confrontational naming and questioning that makes the cognitively-impaired patient feel so frustrated and “dumb.”
While patients who have suffered a stroke or who have Parkinson’s Disease might be upset about their cognitive inabilities, they are usually able to understand what the SLP is doing and they often appreciate the help. They don’t usually take it out on the SLP. However the typical sequelae of brain injury, with its incredibly frustrating layers of thinking problems like disinhibition, working memory impairment, and slowed processing, send the person with brain injury right over that fine line into rage against the healthcare worker machine. For the most part, we, speaking from my brain-injured side, don’t know that we have a problem. Do you, the SLP, think we have a problem? Huh? Get out of here with your stupid pictures and dots and word problems.
Thankfully, I know some SLPs who understand persons with brain injury and I’ve calmed down a bit. The more enlightened SLP knows that it’s a confusing and unacceptable situation the person with brain-injury finds himself in. My hat’s off to the SLPs who patiently write back to the bewildered SLP on social media, telling them to take it easy. Don’t start flipping cards and asking questions until you take time to get to know the person. Build rapport first.
In the case of brain-injury, it takes more than goal-writing, data-collecting knowledge to get the job done. In the case of brain injury, the SLP should first put on her communication counselor hat and understand behaviors that will make or break a rehabilitation treatment plan.
outlines strategies to enhance patient buy in. I haven’t read the book yet, only read about it in Solhberg and Turkstra’s Optimizing Cognitive Rehabilitation. It sounds like one I need to read from cover to cover though. (Recommendations out there? Did anyone use this text for a course in a Communication Sciences and Disorders classes?) The strategies are right on, I think, and so I will annotate them here.
First of all, let the patient feel that he is in control. Explain what you are doing and why, that some mental processes may have been injured and you know some tricks that will help. Let the patient participate so that therapy targets fit his world view and interest. Fit your helpful therapies to the patient, who does not yet understand that he has a problem. Let him know that he can use these strategies on his own or come back to an SLP for more help later on, after he feels better, and has had a chance to get back into the swing of things. He might want the help of an SLP more at that time. Encourage self-efficacy.
Discourage the patient from thinking about recovering to his old level of abilities. Just focus on getting better based upon where he is now. This one is hard. The sooner the patient figures out that his life has changed permanently, in some ways, the better, but I can’t think of any words or activities that can help you do this. Anyway, it’s a strategy in the list, so have at it. (Maybe I’d understand how to facilitate these thought processes better if I read the full book rather than just this list!)
Introduce your client to others, if possible, who have overcome issues surrounding brain injury. I facilitate two brain injury survivor support groups and some of the members tell me joining the group turned their lives around. They no longer feel sorry for themselves because now they know others with brain injury. They can understand each other and laugh about their foibles together. No one understands what it’s like unless it’s another person with brain injury. A support group provides a new network of friends when the old network may have drifted away.
Use a lot of verbal rewards and incentives. Find out what motivates the person with brain injury to want to work with you. Healthcare providers may not be as in touch with this simple strategy as school-based SLPs.
Keep on reminding the patient that the thinking strategies you are telling him about are going to make a difference. You guarantee it. Don’t forget to say that if it’s not working for him now because he hurts too much to think, he can see an SLP later! Make sure your patient knows who to ask for later when he recognizes that he’s not thinking as effectively as he used to.
Teach thinking strategies and teach alternatives to strategies in case the first line of defense doesn’t work.
Reduce anxiety by talking about his symptoms. It’s a muddle to him and he can’t separate the pain from the brain drain. Help him write a list of his symptoms. He will have to manage many of these symptoms for the rest of his life. Personally, this was a big leap of positive understanding for me, to unravel my aches and pains and anxieties and to learn that there isn’t a pill or an operation that would take them away. I had to and could learn to manage the symptoms for the rest of my life with a mixture of medications, friends, green tea, yoga, and more.
Conduct a thorough cognitive assessment and, as far as is possible, explain it to the patient. Give him a copy. Tell him to put it in a safe place and, if he decides to see another SLP in a couple of years, share it with that person.
Variety is the spice of life and learning. Switch up those modalities to keep things interesting and to improve the odds of success. Work indoors and outdoors and all around to vary the environment too.
I predict that SLPs will be seeing more patients with brain injury in the years ahead as awareness increases. Hone up on your skills by taking a course online or, better yet, attending your state Brain Injury Association conference.