Brain Injury Journey Magazine-august-2013-vol-1-

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Brain Injury Journey Magazine-august-2013-vol-1-

  1. 1. A m agazine for the brain injury communit y August / September 2013Issue #3 Concussion: FromthePlaying FieldtotheClassroom Concussion: FromthePlaying FieldtotheClassroom
  2. 2. 2 “Our goal is to provide the highest quality, individualized transitional and long term care for persons with acquired brain injury.” Nathan D. Zasler, MD Founder, CEO & Medical Director Tree of Life Services, Inc. www.Tree-of-Life.com 1-888-886-5462 • Fax 804-346-1956 Administrative Offices 3721 Westerre Parkway, Suite B • Richmond, Virginia 23233 Chief Editor Nathan D. Zasler, MD
  3. 3. 3 Mission Statement Brain Injury Journey - Hope, Help, Healing helps persons with brain injury, families, and providers successfully navigate challenges and live a full and satisfying life. We offer empowering personal stories, inter- views with experts, and clinical updates and research findings. Above all, we provide a community to enhance hope and foster healing after brain trauma or disease. Publisher Lash & Associates Publishing/Training, Inc. 100 Boardwalk Drive, Ste. 150,Youngsville, NC 27596 Tel 919-556-0300 Fax 919-556-0900 www.lapublishing.com E-mail: orders@lapublishing.com President Marilyn Lash, MSW CEO Bob Cluett Brain Injury Journey Editor-in-Chief Barbara Stahura Graphic Design Bill Herrin Advertising Bob Cluett, Nick Vidal Subscriptions Nick Vidal Editorial Inquiries Marilyn Lash Editorial Policy Brain Injury Journey is published six issues per year. Lash & Associ- ates Publishing/Training Inc. does not endorse, support, or recommend any specific method, facility, treatment, program, or group for persons with brain injury. Any inquiries or concerns about an individual’s health, treatment, and recovery cannot be addressed and should be discussed with a health care practitioner. Advertising rates Please call 919-556-0300 for information on rates and distribution. Distribution and Subscription Brain Injury Journey is available electronically and in print. Sign up for free online subscriptions or paid print annual $48 subscription for six issues at: www.lapublishing.com/brain-injury-journey-magazine Letter to the Editor Policy We welcome comments and feedback, but please limit letters to 300 words. Published letters may be edited for spelling, grammar, and length. The writer must include name, address, email, and/or phone number for contact. Lash & Associates reserves the right to refuse let- ters for publication, and submission does not guarantee publication due to space limitations. Opinions in Letters to the Editor are solely those of the author and do not represent Lash & Associates. Brain Injury Journey©2013, is published six times a year by Lash & Associates Publishing / Training. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without written permission from the publisher. For reprint requests, please email orders@lapublishing.com Back issues can be ordered at http://www.lapublishing.com/brain-injury-magazine/ Issue #3 - August / Septermber 2013 Table of Contents Publisher’s Letter by Marilyn Lash, MSW…………………………………......4 Editor’s Letter by Barbara Stahura, CJF..………...................................4 Letters to the Editor....................................5 Play Safe Youth Sports and Young Brains Need Time to Develop by Phil Hossler, ATC.......................................................6 My New Normal After Concussion by Madeline Uretsky.......................................................7 Family Matters What Do You Expect? by Rosemary Rawlins…………………………………........8 Caregiver’s Compass Take the Danger Out of Caregiver Anger by Janet M. Cromer, RN, MA, LMHC………......….10 Stepping Stones The Journey of Grief by Janelle Breese Biagioni, RPC..………......................12 Legal Link Runaway Spending by Thomas Henson, Jr., JD and Carol Svec..…………14 New Horizons Can Anybody Hear Me? by Kim Jefferson Justus………....……..…..…………16 HBOT: A Way to Heal the Inured Brain? by Barbara Stahura, CJF...............................................18 Telling Your Story The Healing Power of the Mind by Barbara Stahura, CJF……………………………...21 Veteran Voices Why Are So Many Veterans Homeless? by Shad Meshad............................................................23 Clinical Corner Behavior – Help for Families and Caregivers by April Groff, PhD ........…...………………............25 Kids’ Club Behavior Management in School by Katherine A. Kimes, EdD, CBIS..............................28 Reading Room & Resources Book Reviews.……………………..............................30 Resource Page & Advertisers........................................31 A m agazine for the brain injury communit y
  4. 4. Letter from Lash & Associates by Marilyn Lash, MSW With each issue of our magazine, I learn something new. Personally, I think that’s the sign of a good magazine and a great team of writers. No matter how long you’ve been in this world of brain injury, there is always new knowledge to be gained. One of my favorite tasks is to read the final proofs and each time I come away thinking, “This is great!” I hope you, our readers, think so too. The brain is such a complex organ that an injury is literally like the stone thrown into the pond with ripples extending outward in all directions. However, unlike the pond that returns to its previous state of calm waters, the lives of the individuals who have been injured and their families are anything but calm. With each issue, I am constantly impressed and awed by the ripples that represent so many challenges and changes in people’s lives. I am honored to feature writers who are individuals with brain injuries and family members who speak frankly and valiantly about not only the struggles and losses in their lives, but who also remind us of the rewards and pleasures – small and large – that come with survival and reshaping the future. I also commend the clinicians and educators who are our authors for their recognition that rehabilitation and recovery are life-long journeys for survivors and their families. While insurers and funding sources increasingly control not only access to treatment but the duration of care and services, their articles recognize that the struggle to “live life fully” after an injury is more than a catch phrase. It is their intent to provide the necessary information and support to reach this goal. So…please put your feet up, relax, and read – who- ever you are, and wherever you are in your journey. As our masthead says, it’s about hope, help, and healing. From the Editor-in-Chief by Barbara Stahura, CJF Thousands of former NFL players and their families have filed lawsuits claiming dementia and other neurological diseases due to undiagnosed, untreated multiple concussions. Brain injury is the “signature injury” of wars in Afghanistan and Iraq with hundreds of thousands of service members exposed to powerful blasts that damaged their brains. Thousands of youth athletes who sustain concussions are put back into play far too early, causing more and often lasting harm to young brains. A huge proportion of prison inmates have had a brain injury that was never diagnosed or treated. Yet, we are still amazingly ignorant about brain injury—what it is, how to accurately diagnose it, how to treat it, and often whether a person actually has sustained one. Even the medical profession frequently fails in this regard. That’s not so surprising—after all, the brain is immensely complex and our understanding of it is still in its infancy. But it’s crucial that we vastly improve our knowledge in order to save lives from being needlessly damaged, even destroyed, by brain injury. When a hit-and-run left my husband with a terrible brain injury nearly a decade ago, he received immediate medical care, and later rehab, because he was obviously severely injured; even so, his imaging scans showed no visible damage. Yet for many people who do not appear to be injured from a blow to the head or whiplash or a fall, symptoms may not appear for days, weeks, or months. By then, they may not make the connection to the incident that caused the injury. Many times they are simply told they must be imagining what’s happening to them and sent home with no treatment. As they continue to deteriorate cognitively and otherwise, they lose hope. This situation is improving, but far too slowly. Millions of lives are affected by brain injury every year—not only the people with the brain injury but their families, employers, and other acquaintances—and our society suffers as a result. Here at Brain Injury Journey, our goal is to build and enlarge awareness not only within the brain injury community but far beyond. 4
  5. 5. 5 Letters to the Editor A m agazine for the brain injury communit y C’mon, give us a piece of your mind! Brain Injury Journey would love to have input from our readers! We look forward to your thoughts, comments and suggestions. E-mail us at: bijmagazine@lapublishing.com Brain Injury Journey has been getting some very positive feedback, and we thought that we’d share some of it with you! Here are some letters that we’ve received about our first two issues... Your new magazine is great! Many very helpful articles for survivors and family caregivers! – Steven D. Wade, Executive Director Brain Injury Association of New Hampshire The new magazine is awesome. I’m really excited reading it because it’s a great mix of different types of stories, techniques, and concepts. At the same time, the individual pieces tie together nicely by focusing on similar themes or approaches. I’ve already passed it on to some clinicians and advocates and plan to post the link to it on my own website. – Cheryl Green Congratulations on the first issue of Brain Injury Journey magazine! I got my electronic copy today, read some of the articles, skimmed over some, and will likely have to review it a few times to get it to ‘stick.’ I try not to overdo it, however, that isn’t easy. I’m a Marine and trained to push mentally and physically until we pass out or are dead. lol. Recovering from a brain injury, I want to find all the information I can to accelerate my recovery if possible. I really like your definition of healing in the first issue. Thank you for putting it together, and all the other things you do to help brain injury survivors! – Rodney Noll, USMC, Cpl, 1985-1989 “I took a look at your new magazine and I immediately signed up for the email subscription. The theme ‘Help, Hope, Healing’ ... what an appropriate title. It captures so much.” – Dennis Radman ANewWayofSpreading theNews-JoinourTeam! You can help fund the continued success of Brain Injury Journey magazine by advertising or becoming a preferred distributor. Benefits of advertising… • Distribution to over 90,000 readers • Affordable advertising rates • Free personalized printed magazines • Free postings on your website • Hyperlinks directly to your website • Request a Media Kit for rates from bcluett@lapublishing.com Benefits of being a preferred distributor… • Your personalized magazine to post on your website • Dedicated urls for search engine optimization • Increased website traffic • Back links from other preferred distributors • Permission for electronic distribution • Listing as a preferred distributor • 12 printed personalized magazines with each issue • Timely and relevant content for constituencies • Cost is only $250/issue; back issues for half price Benefits of being a FREE distributor… • Receive a file with magazine cover and link to Lash website for each issue at no charge • Increased website traffic • Improved search engine optimization with back links from other distributors • Printed acknowledgement in magazine as distributor • Timely and relevant content for constituencies • Special pricing discounts for custom printing of magazines Pleasecallusifyouhaveanyquestionsorcomments. w w w. l a p u b l i s h i n g. c o m Tel: 919-556-0300
  6. 6. 6 Youth Sports and Young Brains Need Time to Develop by Phil Hossler, ATC It is said that youth is wasted on those so young. That was probably said by an adult who was “not so young” anymore. While it is true that youth are and probably always have been emotionally and socially underdeveloped, neither of these can cause the problems that physically immature brain tissue can cause when impacted. As adult caregivers, especially in athletic healthcare, it is important for us to remember that while a teen’s sprained ankle or pulled muscle may heal faster than ours, their brain tissue holds onto insult longer. So don’t rush them! Youth sports are taking their lead from professional and collegiate lessons. Rule changes, practice time on and off, concussion legislation, and education are more common now than in any time previously. Since not every school-aged concussion is sport-related, supervision for school personnel can be difficult or missing completely. While football is still the leading cause of sport concussion in males, and soccer is the leading one for females, don’t forget about skateboarding, bicycle falls, backyard hijinks, and playground mishaps. The Centers for Disease Control and Prevention (CDC, 2007) estimates 1.7 million people obtain a traumatic brain injury (TBI) annually, with 75 percent of these being concussions. Children up to 14 years account for almost a half a million of the emergency room visits. While the CDC estimates that youth from 5-18 years account for 135,000 sports and recreation TBIs, since many concussive episodes go untreated and unreported, Langlois, Rutland-Brown, and Thomas (2006) suggest that the number of concussions may actually approach 3.8 million for youth and adults. Recovery time doubles for each concussion A recent study reported in the American Academy of Pediatrics stated that recovery time is doubled for each concussion after the first one. The study found that it took up to 35 days for full recovery with no signs or symptoms if this was the second concussion in the past twelve months (Pediatrics. Jan, 2013). Matthew A. Eisenberg, MD, lead investigator, admits that relying on the self-reporting of symptoms by youth may have limitations. However, he states that “even after symptoms have improved and even after these neuropsychological tests have returned to normal, there’s still a vulnerability that can lead to a much more severe second concussion.” As a certified athletic trainer on the high school level, I spend more time teaching my athletes, coaches, parents, and teachers about concussion than I ever have before. Youth athletes need to understand the foolishness of not reporting symptoms such as headache, dizziness, and nausea. They need to understand that one to two weeks’ recovery now is preferable to four to six weeks later if they ignore signs and symptoms. Brain tissue that receives a second—even a mild second—impact may have lingering, prolonged, serious, and even life- threatening consequences if not given the additional recovery time that multiple episodes require. Mild brain injuries such as concussion are called the “invisible injury.” Professional football players have played on national television and not remembered the game due to a concussion suffered in the game. Youth sports and young students need to understand the impact that head trauma may have on their social, emotional, and physical, as well as school performances. In general, concussion affects mental stamina more than intellectual ability because the injured brain must work harder to accomplish anything, and so the student gets tired more easily. So all adult caregivers in the youth’s “neighborhood” such as teachers, parents, coaches, school nurses, physicians, and athletic trainers must be involved in the process and insist on “take your time!” Phil Hossler is a certified athletic trainer at a large high school in New Jersey. He is the author of four books and 35 professional articles on athletic healthcare topics. Play Safe
  7. 7. 7 Play Safe My New Normal After Concussion by Madeline Uretsky On October 13, 2011, I sustained a severe concussion while playing in my high school soccer game. Almost two years later, I still suffer from symptoms 24/7; I could never have imagined my life turning out this way. I am often asked what it is like to live with a brain injury. It’s difficult, but I have learned to live with this “new normal” and face the fact that living with a brain injury is a new life. Often times, I cannot do things that normal teenagers do, like going to the mall, movies, concerts, sporting events, stores, restaurants, or crowded places. I have slowly integrated myself into going to these places again on a limited basis, but I plan my days according to my pain. I live with a constant dull headache, sharp head pains, an endless state of fogginess, fatigue, balance problems, memory loss, neck pain, inability to concentrate and carry on a conversation, and sensitivity to light and noise. In terms of visual stimulation, things like sunlight, flashing lights, revolving doors, swaying trees, bright colors, and disorganized rooms are all daily occurrences that increase my headaches. In terms of noises, things like bells, high- pitched barking, baby and toddler voices, shopping carts, and clanging utensils also increase my headaches. School is exhausting After missing three months of school while on brain rest, I was nervous to return. I wondered if people would think I’m faking—after all, I look fine. School is exhausting, and one of the worst places for people with concussions—slamming lockers, bells, fire drills, commotion between classes, AND having to use my brain! Although I have maintained my grades, it is with more difficulty, and with learning issues that need to be accommodated. I now read at a slower pace and have trouble comprehending orally. I spend more time doing homework, I have extended time on tests, and I can take tests outside of the classroom. Patterned carpets, shiny floors, bright rooms, open windows, small desks, and crowded classrooms create more headaches, fatigue, and make taking tests difficult. Certain subjects like math are challenging because of graphing: the boxes on the paper and following the lines create more headaches due to the extra effort involved in concentrating. But I am healing Currently, I spend several days a week attending various appointments to help myself heal. Eating healthy has also improved my quality of life and decreased my fogginess as well. It has been a difficult journey over the past two years, but with a great support system at home, my medical team, and my positive attitude, I have managed to navigate my “new normal.” I know my limits, I listen to the doctors’ orders, and I live my life in constant caution. Concussions are often perceived as a sign of weakness because they are invisible, but they are not to be taken lightly, because they can have devastating short- term and long-term effects. Recovery can be slow, but there are many resources and plenty of support, as I have found, and there is improvement over time. Madeline Uretsky, currently a senior in high school, and once a four-sport student athlete, has become a prominent voice in concussion education. She was the subject of a Boston Globe feature story on concussions and has been featured in other articles. She has been a featured speaker at the Boston Acquired Brain Injury Support (BABIS) Walk and the Pediatric Brain Injury Conference in Massachusetts, and is an ambassador for the Brain Injury Association of Massachusetts. Read more of her work on the Lash & Associates blog at http://www.lapublishing.com/blog/?s=uretsky It’s difficult, but I have learned to live with this “new normal” and face the fact that living with a brain injury is a new life. Often times, I cannot do things that normal teenagers do, like going to the mall, movies, concerts, sporting events, stores, restaurants, or crowded places.
  8. 8. 8 What Do You Expect? by Rosemary Rawlins Did you ever expect one thing and get the exact opposite? Anyone who experiences or cares for someone with a brain injury will most likely answer, “Yes!” At some point in our young adult lives, we create a life plan. This plan may include starting a career or vocation, volunteering, or getting married and starting a family. Many of us eventually fall into a routine. We know the plan and go with it day by day. I married Hugh when I was twenty-two years old, and I’ve always expected to grow old with him. I was working full time as a human resource administrator for an engineering company on Long Island, NY, when we got married. We grew up together, continued our educations together, and moved to Vermont where Hugh became a CPA and I gave birth to twin daughters. When the girls were two years old, we moved to Virginia and have been there ever since. Life in Virginia was solid. We had a life plan. I worked part-time running a small business of my own, and Hugh worked full time providing us with benefits. We were saving money for the future and all our activities revolved around our daughters. Then, at the end of Mary and Anna’s eighth-grade year in middle school, Hugh was struck by a car and nearly died of a severe traumatic brain injury. Life stopped. All expectations were erased. The future was unclear. Uncertainty after brain injury One of the hardest things to accept after a family member sustains a brain injury is uncertainty—hundreds of questions with no answers. “Will he live? Will he be able to walk? Will he be able to speak? Is his memory impaired? Will he ever work again?” Doctors cannot make promises in the early days after a brain injury because every person and each individual brain injury is unique. All of our life expectations changed. They changed so drastically that Mary and Anna couldn’t even expect me to pick them up from school or get them to an appointment on time. I had always been a very attentive mother, but here I was completely preoccupied and emotionally wrung out. Could my kids expect me to comfort them? I tried, but they sensed my dread. I’ll always be grateful to those who stepped in and comforted them, and me. As Hugh slowly recovered, we felt more optimistic and new expectations came into play. Five months after his crash, his company asked him if he could return to work and he wanted to try. It took only a short time for his company to realize he was not able to work at that level anymore. When he lost his job, our expectations were once again smashed and we both fell into a pit of despair. When we saw Dr. Jeff Kreutzer, a neuropsychologist, he gently suggested we “take some time to grieve for our old life, and start a new one.” How do you do that after 46 years? Starting over with a new life plan With counseling, support, thoughtful discussion, reflection, education, meditation, exercise, guided imagery, dark chocolate, and a long list of family and friends, Hugh and I were able to form a new life plan that suited us both and created stability for our family. Here is some of the advice we followed: • Take a realistic inventory of your strengths, skills, and what you enjoy doing. • Revisit dreams you may have put on the back burner and see if you can make them work now that you have a clean slate. • Support and encourage each other. • Meet each other where you are today. (Don’t try to communicate as if nothing has changed. Use communications strategies that work now.) • Don’t get stuck in the past. • Try new things together and apart and share your experiences. Family Matters
  9. 9. 9 • Cherish old memories while making new ones. I’ll always be grateful to Dr. Kreutzer for being so direct. He gave us an ending, “Grieve for your old life,” but he gave us a beginning, too, when he said, “Start a new life with realistic expectations and move forward.” Hugh took the time he needed to heal. We developed new goals that we felt confident we could reach. In the struggle to learn more about ourselves as individuals and as a family, we grew closer. Mary and Anna were once again able to depend on us. I began to lean on Hugh again. Incredibly, he did return to work in an executive position. Expectations can be comforting if you don’t attach yourself to them too much! Now, when I expect something like a perfect holiday, I tell myself not to get caught in that trap. Just let it happen, roll with it, and life will go on as it was meant to be. You won’t be so disappointed with your failed expectations if you know they are sometimes no more than wishful thinking. Rosemary Rawlins is the author of Learning by Accident and a caregiving blogger with BrainLine.org. You can learn more about her by visiting her website: http://www.rosemaryrawlins.com MONTERO Law Center More Than 30 Years Serving Brain Injury Survivors ACCIDENTS Construction • Auto • Maritime Aviation • Railroad • Slips & Falls INADEQUATE SECURITY WORKERS COMPENSATION IMMIGRATION CRIMINAL DEFENSEWWW.MONTEROLAW.COM 954-767-6500 Fort Lauderdale 772-467-6565 Fort Pierce 888-459-0529 Toll Free montero2.indd 1 7/20/2012 11:40:46 AM Don’t make them wait any longer! order today! A m agazine for the brain injury communit y Do Your Patients Read About Cars, Gardening, & Hollywood Gossip In Your Waiting Room? Why entertain them when you can help them be informed? Brain Injury Journey magazine offers Hope,Help and Healing to people who deal with PTSD,concussion,traumatic brain injuries,blast injuries,and more.Encourage your patients by subscribing to six printed issues per year for just $48! Order online at: www.lapublishing.com/brain-injury-magazine-journey/
  10. 10. 10 Caregiver’s Compass Take the Danger Out of Caregiver Anger by Janet Cromer, RN, MA, LMHC Caregiver anger comes in every form and size. There’s the diffuse anger at the disease or injury that caused the brain injury. The anger towards family and friends who “don’t get it” and stop helping too soon. How about the anger towards the healthcare professionals who seem too rushed to care, and the easiest target of all—insurance companies who curtail benefits? Perhaps the hardest anger to admit is anger towards the person you care for. Specific consequences of brain injury can invoke a volatile mix of anger, sadness, and frustration. This article addresses three problems caregivers identify as interpersonal anger triggers: 1. Changes related to cognition and memory. 2. Changes in the relationship. 3. Changes in the ability of the person with brain injury to process and express anger constructively. Constant repetition of questions and lessons Even the most well-intentioned caregiver can get angry with the slow process of rebuilding skills. Sheila describes her husband Mark as a “bright, communicative engineer” before he sustained a traumatic brain injury (TBI) in a motorcycle accident. Sheila is a “get it done, no excuses” kind of person, and found herself getting angry when Mark asked the same question ten times or couldn’t follow a one-step command. Sheila says that when she couldn’t rally indefatigable patience, she would “blurt out the meanest thing that came to mind… and then feel horribly ashamed.” Many caregivers describe this cycle of anger, guilt about feeling angry, then anger about feeling guilty. Hazel had a pituitary tumor that was treated with surgery, radiation therapy to her brain, and hormonal supplements. The treatments took a toll on her executive functions and ability to express emotions. To complicate matters, she was later diagnosed with Hodgkin’s lymphoma. Her husband, Mike, says that a side effect of chemotherapy was the further dulling of cognitive functions known as “chemo brain.” Mike says, “My anger toward Hazel was so problematic that I couldn’t focus, and I felt that I could not address it with her. On one hand, Hazel’s flat affect made it hard to tell whether she was putting enough effort into engaging with me or her treatment.” He continues, “On the other hand, I didn’t know how capable of engaging she was, due to the nature of her illness.” Sometimes professionals can help clarify realistic expectations. From intimacy to isolation Personality changes, role readjustments, and ambiguous loss challenge every family’s dynamics and can be a source of anger. Marsha’s husband, Terrence, suffered a brain injury on the job when an engine carrier hit him on the head. Marsha says that Terrence went from being a “charismatic, non-worrying sportsman to a sedentary man whose face is always pinched with a frown even when he’s not angry.” Married for 46 years, the couple “always goofed around and did everything together.” Marsha sighs as she says, “We were one. Now I feel very, very lonely.” Mike says, “I was angry that the hard work Hazel and I had put into our relationship over many years did not result in the ‘golden years’ I felt we deserved. I was bitter about that, but did not express it to Hazel since she was blameless for her condition.” “With TBI you look at the person and initially you think he is the same because he looks essentially the same. It takes a long time for it to sink in that the person in front of you is only the outer shell of the person he was before the injury,” says Sheila. “He looks and smells like your husband, but he is a stranger in that body.” The urge to fight back When the person with the brain injury has trouble processing and expressing anger constructively, the caregiver often becomes a target. When Terrence became overwhelmed and confused by multiple therapy appointments, he swore at Marsha. “He actually cussed at me for the first time in our lives!” she exclaimed. “His words hurt me like a whip.”
  11. 11. 11 My husband, Alan, was prone to angry outbursts after his severe anoxic brain injury. When humiliated or frustrated by his losses, he screamed accusations at me. His memory was also impaired, so he forgot these incidents after a short nap. However, I resented the attacks, and distrusted Alan for awhile. Many times I longed to have a good argument like a “normal” couple, to clear the air, resolve the situation, apologize, and move forward. Alan’s cognitive limitations made that unrealistic, so we had to find less direct ways of restoring trust, control, and respect. When your head’s ready to explode The first step in managing anger constructively is to recognize the feeling and the bodily sensations that go along with it, preferably before acting on the anger. Anger inflames and then depletes body, mind, spirit, and relationships. Marsha sums up the caregiver’s perfect storm: “You feel fit to burst, like your head is going to explode, and your guts are hurting. You can take just so much, but you can’t take it out on the person.” Sound familiar? Sheila found herself becoming an angry person overall. “I lashed out a lot at Mark, I got an ulcer, I quit doing the things I enjoyed,” she says. “And all that only made things worse.” Sometimes she would sit in the shower and cry and scream out. Sheila admits, “I didn’t want anyone to know I was coming undone.” Take the danger out of anger 1. Step back, take a few breaths and plan how to respond, not react, to the situation. Respond with respect for both yourself and the survivor. 2. Identify interactions when tensions tend to be highest. That’s the advice of Barry Jacobs, PhD, in his book, The Emotional Survival Guide for Caregivers. Then define a specific plan to decrease those tensions or refrain from aggravating each other. Use a signal to stop before escalating. Marsha and Terrence devised a red flag/green flag system that helps them. Marsha says, “When Terrence starts to get agitated and scolds me, I say ‘Red flag!’ and he stops to take a quiet break.” Terrence likes to tease his wife, and if she’s not getting the joke he says “Green flag!” to signal that he’s kidding. The flags are direct, and a shared laugh can often defuse an argument. 3. Find a psychotherapist who specializes in caregiver concerns. Sheila processed her anger with a neuropsychologist who also validated her feelings. She says, “Therapy helped me put things into better perspective, forgive myself for not being perfect, which in turn, allowed me to forgive in all of the other areas of life in which I was angry.” Irritability and anger can also signal depression, so request screening. Alan and I benefited from couple’s counseling. Mike facilitated a support group, and in helping others, found comfort and relief. 4. Practice patience with mind-body practices. Mike practiced tai chi and meditation. He drew on the emotional self-knowledge developed in his spiritual community. 5. Immerse yourself in physical and creative outlets. Exercise, body work, gardening, hobbies, and sports can provide an outlet for angry energy. 6. Appreciate the unique strength, courage, and resilience of the family you are now, as you slowly adjust and put the “mosaic pieces” of a new life together. Many thanks to the caregivers who honestly shared their experiences for this article. Pseudonyms were used to protect privacy. Resources Jacobs, B. (2006). The Emotional Survival Guide for Caregivers. New York: The Guilford Press. Phillips, S. and Kane, D. (2009). Healing Together. New Harbinger Publications. Janet Cromer, RN, MA, LMHC is a psychiatric RN and the author of Professor Cromer Learns to Read: A Couple’s New Life after Brain Injury. Janet speaks nationally on family and professional caregiver issues including stress resilience, traumatic stress, compassion renewal, seasons of caregiving, and creativity and healing. See more at http://www.janetcromer.com My husband, Alan, was prone to angry outbursts after his severe anoxic brain injury. When humiliated or frustrated by his losses, he screamed accusations at me. His memory was also impaired, so he forgot these incidents after a short nap. However, I resented the attacks, and distrusted Alan for awhile.
  12. 12. Stepping Stones The Journey of Grief by Janelle Breese Biagioni, RPC As an individual travels the journey of grief, the magnitude and impact of loss is revealed in layers. Much like peeling an onion, the deeper the cut, the more tears shed. Why? Loss is incredibly painful, life-changing, chaotic, and strikes without choice. Traditional teachings state that loss results from death, divorce, and other life transitions. Today’s expanded list includes Alzheimer’s, chronic illness, and catastrophic injuries such as spinal cord and brain injury. A medical model, which is to assess, diagnose, and treat, was the typical approach to help the bereaved. It didn’t work. The pain and suffering resulting from loss is not time-specific, orderly, or predictable. Much more fitting is the Companioning Model, which is to be present for the person and walk alongside them for however long they need to explore and give expression to their feelings. Historically there was little else to offer those suffering from loss. Erroneously, society believed that keeping a stiff upper lip or not talking or dwelling on what happened were the proper ways to cope. The truth was, the outside world didn’t know how to help people work through the devastation they struggled with. Thankfully, in 1969, Dr. Elisabeth Kübler-Ross wrote On Death and Dying. This ground-breaking book was like taking water to the parched. Until then, social workers and others in the helping profession were not equipped to facilitate the conversation about loss. Kübler-Ross opened the doors for that dialogue. Having said that, her model, known as the Five Stages of Grief (Denial, Anger, Bargaining, Depression, and Acceptance), was interpreted as a list of emotions to be experienced in a specific order. Before her death, Kübler- Ross declared the model was not meant to be a list of absolutes but rather a list of potential responses. Dr. Alan Wolfelt, of the Centre for Loss & Life Transitions, offers a much more expansive range of responses which include shock, numbness, disbelief, disorganization, confusion, anxiety, panic, fear, physiological changes, explosive emotion, sadness, and more. He teaches that ultimately the person works towards reconciliation and healing. Don’t sidestep the journey of grief As the layers of loss are revealed, it is not unusual for the person to resist and/or suppress feelings. That’s okay for a while—it’s actually healthy to take a bit of a break from the sorrow. But when the pushing aside becomes an outright dismissal of the pain, then additional problems may set in. You cannot sidestep grief. There is no way to get to the other side of it except to go through it. Unresolved grief will take any opportunity to rear its ugly head. I like to use the analogy of a yard flush with bright yellow dandelions. You can mow the grass and cut every head off. But before the lawn mower is tucked away, you witness the lemon-colored petals of another head pop up from the ground. Why? Because you only skimmed the surface with a blade—you didn’t get the root. The work of grieving is the same. Unless you get to the root of how you feel and work through those feelings, grief will pop up again and again in your life. Much like the snowball effect, it will get bigger and bigger. Remember: the only wrong way to grieve is to not grieve. 12
  13. 13. As people grieve, their loss morphs into a multi- dimensional journey which requires an unknown length of time to reconcile. The reason is that loss isn’t an event, it’s a process. It is not time specific. As time passes, people discover how what has happened impacts them personally and in their daily life, thus revealing the layers. This applies to loss through death, divorce, and separation, as well as developmental losses (such as empty nest or retirement), loss of external objects (such as a house fire), and a loss of self. The latter—a loss of self—resonates the most for people with a brain injury. They are no longer the same person, and they no longer function in the same way as they had before being injured. This is painful and causes suffering. Brain injury means loss for the whole family The entire family experiences loss through their loved one’s brain injury. How can it be that the family suffers a loss when the person is alive and home with them? Isn’t it only the person who is living with physical and/or cognitive deficits who suffers? No, because often the roles and responsibilities shift in the family. For example, after my husband was injured he could not return to work. Given there was little community support in place 23 years ago, his care and supervision fell onto me. This meant that I could not work, as taking care of him was a full-time job. He was a police officer so we continued to receive his pay until he died. But I was self-employed, and if I wasn’t working there was no extra money coming in. This resulted in lifestyle changes for us. My children suffered as well. Not only was their father unable to engage with them as he had prior to being injured, I was also not functioning as the mother that I had been either. They were still fed and clothed and went to school, but I had no time for extras like reading, playing games, or just spending time with them. Everything went into getting their dad through the day. Our children, as other children do, assumed responsibilities that were not theirs. They became equal caregiver with me, often having to help out with their dad instead of being outside playing with their friends. It’s not fair, but it is the reality that many families live with. Each of us experienced a layer of loss and had to work through that. S.H.A.R.E. Individuals and families living with loss have special needs. When loss is escalated by the impact of brain injury, these needs are significant, and people need help. The S.H.A.R.E. list provides ways to help: Supports – people need short-term and long term supports from a variety of people. Hope – an effect of loss is hopelessness. They want to know happiness will return in their life; however, they have little capacity to hear it. Gentle reassurance is important. Acknowledge – help the person to express and acknowledge what it is he or she has lost. Don’t persuade, dissuade, or judge. Reflection – healing requires turning inward. Personal reflection facilitates the searching for meaning and understanding of what has happened and how one will survive. Engage in life – when the person reconnects with loved ones, friends, coworkers and community, it is a sign of healing. Extended family, friends, and colleagues are capable of providing supports; however, professional counseling can also help. Counseling provides a safe place for people to give expression to their pain. It will assist in exploring feelings about what has happened and provide guidance to reconcile those feelings. Remember, there is no sidestepping grief. You have to go through it to get to the other side. Doing the work will keep you safe from turning to drugs or alcohol, and it allows you to live the rest of your life to the fullest. Why? Because you deserve to … we all do! Janelle Breese, RPC, is an author, speaker, and counselor with expertise in grief, loss, life transitions, and brain injury. She resides with her family in Victoria, BC. She is the author of A Change of Mind: One Family’s Journey through Brain Injury and the upcoming book, Life Losses: Healing for a Broken Heart. Visit her website at www.lifelosses.com and follow her blog at www.janellebreese.blogspot.com. She can be contacted at Janelle@lifelosses.com 13 The journey of grief is not predictable or orderly. It’s not a concise five-step process but rather a twisted and windy road fraught with pebbles, boulders, and unseen hurdles set to throw you off course.
  14. 14. 14 Runaway Spending by Thomas Henson Jr. and Carol Svec The call from my sister started pleasant enough: “Could you send me an early birthday gift?” Ann’s voice sounded light, almost happy. “Sure,” I said. “What would you like?” There was an ominous pause. “What can you afford?” That was how our family learned about my sister’s financial disaster. Within days we were all sucked in, fighting to rebuild yet another aspect of her life. Ann’s brain injury was caused by a fist-sized meningioma and the surgery to remove it. She seemed to thrive until she got divorced five years ago. Then—on her own for the first time—Ann struggled to take over paying household bills. It wasn’t until the “birthday present” call that our family learned that this particular task was beyond her capabilities. We learned that Ann had maxed out seven credit cards. Collection agencies were hounding her. And scammers loved her—she gave the equivalent of six mortgage payments to a “matchmaker” who advertised with a homemade sign on the side of a highway. Financially, Ann had fallen as far as someone can go without ending up homeless (although she was on her way there, too). My family has become painfully aware of a sad truth: Ann’s brain injury took away her “money sense.” The magic of money Runaway spending and inability to manage money Legal Link are common among people with certain types of brain injury, especially with frontal lobe damage. That’s where the “executive functions” reside, including the abilities to plan, make decisions, process information, and control inappropriate behavior, such as spending a year’s salary on shoes or football tickets. Despite the sometimes staggering levels of debt, families often don’t see the problem. Unlike other behaviors, spending is almost magical—wave a plastic card, and “poof!” you’re now $20,000 deeper in debt. It’s quick and invisible (unless shopping bags start piling up). Plus, in many families, money is a taboo topic. But that attitude only fosters silence, secrets, and shame… followed by emergency calls begging for help. Here are solutions we have found helpful, some with specific notes for families and individuals with brain injury: • Open a dialog, and open the books. People with brain injury often feel embarrassed and frustrated about the abilities that were stolen from them, which can make it difficult to admit to yet another area of disability. Families: You’ll get more straight answers if you create an atmosphere of acceptance that is free of blame. Individual: The conversation will be difficult, but stick with it. Be honest. Only then can you put together a workable plan for getting you out of debt. • Define the problem. With investigation, patterns will emerge. Is the problem one of spending too much? Not writing checks in a timely manner? Poor record-keeping? From that understanding you can put processes in place to address the issues. • Get the family involved. Families: The problem of unfettered spending may require constant supervision. Consider appointing a family member to take over the checkbook and do monthly reviews of finances. Individuals: As difficult as it may be to relinquish control, SvecHenson
  15. 15. Bankruptcy Attorney. Under the best of circumstances, money problems are difficult, and brain injury compounds the strain. As you struggle to climb out of the financial trenches, keep family close—as a resource and as support. It’s easier to climb up when you have strong shoulders to stand on. Thomas Henson Jr. is a partner and head of the Complex Litigation Group at HensonFuerst Attorneys, based in Raleigh and Rocky Mount, NC. He serves on the board of directors of the Brain Injury Association of North Carolina (BIANC), and in 2012, Thomas was appointed by the governor to a four-year term on the North Carolina Traumatic Brain Injury Advisory Council. Thomas remains an active member of the Traumatic Brain Injury Litigation Group of the American Association for Justice. Carol Svec is the creative director at HensonFuerst Attorneys and an award-winning health and wellness writer. Her publications include The Inflammation Cure, The Body Shape Solution to Weight Loss and Wellness, and Joy Bauer’s Food Cures, which became a #1 New York Times bestseller. She is also a loving sister to Ann, whose story was told in this article. 15 the solution to your financial worries may require more hands-on help from your family. It may help to think of it as allowing your family to take over the stress of money. • Sign up for notifications. Banks and credit card companies can provide email notifications when bank account funds dip below a specified level, or when spending increases above a certain dollar amount. Sign up for these notifications so that there are no major surprises from month to month. • Assign a Limited Power of Attorney. Power of Attorney (POA) allows a specified family member to have access to an individual’s accounts and financial records to monitor spending and perform other financial activities. Finally, understand that you don’t have to go it alone. There are experts who can help. Ask your doctor or attorney for referrals to reputable experts who may be useful. For example, Life Care Planners provide guidance for the “big picture.” They can help assess current and future financial needs—throughout your entire lifetime— and formulate a plan to best maintain your quality of life. Case Managers deal with the nuts and bolts of daily living, such as learning how to set up procedures for remembering to pay bills, or arranging for transportation if necessary. And if the situation is truly dire, consider talking with a Hope ...comes in many forms Helping Brain Injury Victims and their Families Nationwide. 2501 Blue Ridge Road • Suite 390 • Raleigh, NC • 27607 • LawMed.com 1-800-452-9633 1-800-4LAW-MED Thomas Henson, Jr. Brain Injury Attorney and Advocate for over 20 Years THIS IS AN ADVERTISEMENT. Henson Fuerst Attorneys are licensed in NC, VA, GA, NY and DC, and will associate co-counsel in various jurisdictions to assist with these claims. Clients not accepted in states where unauthorized by state bar rules. SERVICES MAY BE PERFORMED BY OTHERS IN THE FIRM.
  16. 16. 16 New Horizons Can Anybody Hear Me? by Kim Jefferson Justus If you would have told me two years ago that I would become a published author and radio host with a worldwide reach, I would have laughed uproariously in your face. In 1995, I suffered a ruptured brain aneurysm that came very close to killing me. I was initially misdiagnosed, spent eleven days in a coma, and underwent a craniotomy. After that, no one ever suggested I do any follow-up testing, have any ongoing therapy, be referred to a support group, or do anything—except “give it time to heal.” I thought the doc meant the zipper head wound, the surgical pain, and disrupted brain tissue. There was never a head’s up, no pun intended, that it might not be as easy as that. No one said, “Your life changed forever the day your head exploded. It will take time to see what permanent deficits or challenges you’ll be facing down the road.” The support and validation just weren’t there. It was as if no one could hear me. I kept a journal in my initial year of recovery. It wasn’t too long before I “looked normal” and of course thought I could slip back into my previous life, so I tossed the journal into a plastic bin in the basement. Events happened in my life, which let me know it was finally time to write my brain injury story. When the book, In a Flash: Miracles Here and Beyond, was released at the beginning of 2012, the viral nature of the Internet had taken hold. I was shocked and humbled at the amount of email I received. I heard from survivors all over the world who could relate to my experience. At that point, I realized that in all of those years, I had never met another survivor. It took writing a book to be able to meet others who had suffered a similar experience. Becoming a radio host Several months later, I was contacted by Craig Sicilia, who had started a weekly Internet radio program three years before, called Brain Injury Radio. He was about to expand their platform to an every-night experience. He had heard me interviewed several times, read my book, and was now inviting me to be the Wednesday night host under their umbrella. I couldn’t believe the path my life had started down! My show is called Recovery Now. Brain Injury Radio Network (BIRN) has ten different hosts, each with their own style. The shows are on each night at the same time, running for three hours. We interview survivors and provide educational information on “life after brain injury” and issues related to caregiving. We discuss the problems we face as well as the solutions we’ve found. In the simultaneous chat room, some gather to discuss the subject at hand, and some use it as a means to bond with other survivors. We also take callers, so these shows are very interactive. We always invite fellow survivors to offer show ideas for subjects they’d like to hear more about. I’ve learned more from other people with brain injury in less than a year on BIRN than I had gleaned in the seventeen years before. No one ever needs to be so isolated in their experience again. BIRN fills a much needed gap for peer-to- peer support. As a radio host, I was catapulted into a world of awareness and advocacy. Few of us hosts had experience in radio before. Initially, we all struggled to learn the ropes. We hung in there, because we believed in Craig’s vision. Awareness needed to be created, which would proceed to advocacy, leading to more survivors being heard, lending itself to action compounded by the many. Voices in smaller numbers have fallen on deaf ears. We are now in a position to be heard, and not swept under the rug of healthcare. What I’ve learned As my show’s host, I have encountered several recurring themes among survivors. One is that regardless of the source of the brain injury, many of the remaining residuals are the same. These include issues such as becoming easily fatigued, short term memory problems, vision and sleep disturbances, frequent headaches, depression, anxiety, and many times PTSD. Additional residuals include what I call “sensory overload” and “full basket syndrome.” The traditional medical approach to treat these symptoms seems to be to throw pills at them. Alternative medical practices include EFT, acupuncture, Isuffered a ruptured brain aneurysm that came very close to killing me. I was initially misdiagnosed, spent eleven days in a coma, and underwent a craniotomy. After that, no one ever suggested I do any follow-up testing, have any ongoing therapy, be referred to a support group, or do anything—except “give it time to heal.”
  17. 17. 17 cranial sacral therapy, massage, and diet. One of the big factors in how far we recover often has to do with attitude. Another theme is that many brain injury conditions have been misdiagnosed the first time around, which I find rather alarming. This happened to me in 1995, but I find it incredulous that these incidences are still far too frequent. Too many survivors have not felt validated when they describe their aftereffects to doctors. Many guests and listeners I speak to have been relegated to what I call, not so affectionately, “the shrink bone yard.” Traditional medical practices saved most of our lives, but there seems to be a grossly inadequate understanding about what we go on to live with, many of us, for the rest of our lives. My hope is that shows like those on BIRN will help educate and validate both survivors and their caregivers. Then, armed with that newfound information, we will be better able to communicate with and help educate our practitioners. Kim Justus lives in Nebraska with her husband, Gary, four dogs, and a Sun Conure. She worked as a financial consultant for twenty-five years, until her brain injury took her out of the industry. Since then she has become a multi- published photographer, author and radio host. Her memoir is In a Flash: Miracles Here and Beyond www.inaflash.org and her radio show is Recovery Now www.braininjuryradio.com Lash & Associates Publishing/Training Inc. Dr. Stephen Hooper Helps Make Sense of It All... http://www.lapublishing.com/assessment-children-tbi-adolescent/ This in-depth examination and discussion of how to assess the impact of traumatic brain injury on children and adolescents has a special focus on reintegrating students to school and the community. It is a valuable resource for rehabilitation clinicians, educators, psychologists, neuropsychologists and counselors in hospitals, schools, and private practice. Dr. Hooper addresses the limitations of many assessment methods with particular attention to the develop- mental impact of childhood trauma on cognition, and examines specific assessment constructs and procedures for motor & sensory functions, at- tention, language, visual processing, memory, learning, executive func- tions, social and behavior functions. Each chapter has a special section on research findings and clinical practices for children and adolescents with traumatic brain injury (TBI) with recommendations for assessment procedures and measures with detailed tables for reference. PrePress Special - order now for 10% discount with coupon code HOOP when you order on the website. Book will become available in August 2013. Here is the link: Expanded ConsciousnessMore Meditations on Brain Injury By Mike Strand Lash & Associates Publishing/Training Inc. 100 Boardwalk Drive, Suite 150, Youngsville, NC 27596 Tel: (919) 556-0300 Fax: (919) 556-0900www.lapublishing.com http://mikesbigbrainbash.blogspot.com/       ExpandedConsciousness ByMikeStrand Lash & Associates Publishing/Training Inc. The Second Time Around ...He Enlightens Us Again! This second book by popular columnist Mike Strand (Expanded Consciousness: More Meditations on Brain Injury) delves into the mysteries and challeng- es of living with a brain injury. Using short essays to explore and express his personal thoughts and experiences, he offers insights, perspective, and support for survivors of brain injury, their families, and caregivers.With a mix of humor, grace, sensitivity and awareness he tackles the ever chang- ing challenges for survivors as they rebuild their lives.Topics covered are as diverse as climbing stairs to marriage to getting cable.This is a book that you will go back to over and over again no matter where you are in the journey of brain injury. Item: EXCO Price: $9.00 (100 pages) - 2013 Market price: $12.00 save 25% http://www.lapublishing.com/brain-injury-survivor-strand/
  18. 18. 18 Clinical Corner HBOT: A Way to Heal the Injured Brain? by Barbara Stahura, CJF When SCUBA divers ascend from the high atmospheric pressure of the depths, it’s important to come up slowly so their bodies adjust to the low pressure at the surface. If they ascend too quickly, they will become ill with the “bends,” or decompression sickness, and require some time in a hyperbaric oxygen (HBO) chamber receiving 100 percent oxygen under higher atmospheric pressure. Hyperbaric oxygen therapy (HBOT) has been found to also be helpful in a variety of other conditions, including crush injuries, acute carbon monoxide poisoning, and diabetic wounds. HBOT is also used to treat brain injury from trauma or another cause such as stroke. While the number of people who have used HBOT for brain injury is unknown, its popularity is growing. However, insurance generally does not cover it, nor has the FDA approved it for this use. Some older clinical studies do not demonstrate the effectiveness of HBOT with brain injury, but a growing number of more recent studies do. One study, from 2009, demonstrated that the patients with severe brain injury who received higher levels of oxygen in an HBO chamber had a positive increase in brain metabolism when compared to the control group and the group who received “normobaric” treatment, or treatment with pressure equivalent to sea level (Rockswald & Rockswald, 2010). A groundbreaking study of U.S. military veterans with blast-induced mild traumatic brain injury and PTSD, published in 2011, produced significant results. “Headaches, post-concussion symptoms, abnormal neurological exam findings, cognition, PTSD, depression suicidal ideation, quality of life and brain blood flow were significantly improved after a one-month course of HBOT.” Six months later, the great majority of veterans in the study sustained their improvements. www.prweb.com/releases/2011/12/prweb9011742.htm Bruce Gottlieb, MD, medical director of Hyperbaric Services of the Palm Beaches, LLC, http://palmbeachhyperbaric.com in Delray Beach, FL, is an enthusiastic supporter of HBOT. He says HBOT “is one of the simplest therapies around, but there is a lot of confusion around it. Lots of people claim to provide HBO therapy, but many of them in reality do not.” It is crucial to have close medical supervision in an accredited facility, he says. It should not be done at home. The basic guideline of his clinic, he says, is that “HBO is an adjunct therapy. It is not a primary therapy for brain injury. And it is not a panacea or a silver bullet. We stress that patients have to do other therapies—occupational, physical, speech, and even psychological—in conjunction with HBO.” He likens HBOT to a catalyst, “like Miracle-Gro for your lawn. The soil has to be good for it to work.” And with brain injury, the other therapies improve the condition of the brain to make it more receptive to HBOT. Treatment with HBOT Patients receive either one or two daily HBO sessions, depending on the time they have available, and brain injury requires a minimum of 40 to 80 sessions of one or two hours each—and often many more, according to Gottlieb and Sarah Crane, director of research. Treatment is cumulative, with more improvement occurring with more sessions. The cost of HBOT for brain injury varies among regions and the facilities where it is performed. According to Crane, the per-session fee across the country ranges from $500 to $1,500, which adds up quickly. However, most clinical studies do not charge fees to those enrolled in the studies. Hyperbaric Services of the Palm Beaches, one of about 500 HBOT centers in the U.S., is participating in a clinical trial of HBOT through the National Brain Injury Rescue and Rehabilitation (NBIRR) Clinical Trial. They are not charging fees to enrollees. For more information, see http://clinicaltrials.gov/show/ NCT01105962 How does it work? The brain uses oxygen at a “ferocious rate,” Gottlieb says, and can easily become starved. When a trauma occurs, the brain often swells, so the injured tissue does not receive enough oxygen. “So the area that needs the most oxygen gets the least,” he says. HBOT drives oxygen into the cerebrospinal fluid, which carries it to the brain and permits healing. Inflammation is another damaging result of a brain injury, acting much like a fire in its destructive power. But HBOT can put out that fire by sending 100 percent oxygen
  19. 19. 19 to the injured areas, and slowly the areas heal. Gottlieb says there are no side effects or ill effects from HBOT, although some people experience increased pressure in the ear, similar to what happens in a plane. Some people should not do HBOT, including those with severe lung disease such as emphysema, uncontrolled seizure activity, or severe inner ear pain. Since the person undergoing treatment lies down and music can be piped in, HBOT can be very relaxing. Clinical studies of HBOT will continue for some time. Many people with brain injury and their families hope it will some day be a proven therapy covered by insurance. Reference: Rockswald, SB, Rockswald, GL, Zaun, DA, Zhang, X, Cerra, CE, Bergman, TA, Liu, J (2010). A prospective randomized clinical trial to compare the effect of hyperbaric to normobaric hyperoxia on cerebral metabolism, intracranial pressure, and oxygen toxicity in severe traumatic brain injury. Journal of Neurosurgery 112(5): 1080-1094. Bryan Gansner A blast from an improvised explosive device blew up the vehicle carrying Army SSgt. Bryan Gansner in Iraq in 2006. While he was originally diagnosed with a mild brain injury, later scans showed it to be moderate. He also had PTSD. Cheryl Gansner recalls that her husband had “behavioral problems, was very angry and forgetful. He was not performing well at work. He was kind of off, not himself.” For two years after he came home, he slept alone in the basement and remained removed and isolated. By 2009, “he hit rock bottom,” she says. The couple was close to divorce, and Bryan wanted to quit his job, move to his parents’ home, and do nothing. “He didn’t want kids because he thought he wouldn’t be a good enough father,” she says. But a friend whose husband had undergone HBOT for brain injury with good results recommended it for Bryan. He was able to enroll in a clinical trial studying HBOT for brain injury in veterans, in New Orleans, and began treatment with 40 sessions in October 2009. When the study was over, he did 40 more. And Cheryl, program director for Hearts of Valor http://www.heartsofvalor.org, a network of people caring for wounded, ill, or injured service members, created and maintained by Operation Two HBOT Success Stories Homefront, saw a huge difference in her husband. “His depression and PTSD are way down,” she says. “His IQ rose six points, his anxiety is down considerably, his auditory memory and verbal skills are much improved.” His sleep also improved dramatically, and his medication dosages have been lowered. The Gansners are now awaiting the birth of their first child. “I have my husband back,” says Cheryl. “We’re appreciative of the gains he made.” Johnny Torres Two weeks before his 21st birthday, Johnny Torres was struck by a vehicle near his home in Tucson. On active duty with the Army, he suffered a diffuse axonal injury to his brain, along with bleeding in his corpus callosum, leaving him in a coma for two weeks, and severely debilitated after that. He was bedridden, unable to swallow, talk, walk, or function independently in any way. His cognition was severely affected. He spent time at a local rehab hospital, then 90 days at the VA hospital in Palo Alto, Calif., and then another 90 at the Tucson VA hospital, says his mother, Diana Torres. “Then we brought him home.” Johnny required round- the-clock care, provided by Diana and paid caregivers. “He was combative, he would hit me and spit on me. Sometimes he would get me in a headlock and my husband would have to help me out,” she says. “I would pass out on the couch, I was so exhausted.”
  20. 20. 20 Diana heard about HBOT but originally declined to put Johnny into treatment because of the high cost. But she later spoke with Dr. Carol Henricks, a Tucson neurologist who does HBOT and who Diana calls “an angel,” and decided the cost was worth it. He has now had nearly 400 sessions. Diana says her son is vastly improved. “He is calmer and less combative,” she explains. “He eats everything, no longer drools. His cognition is good— he can watch TV and understand it. He’s started talking , and now says a new word nearly every day.” His pre-injury strength is returning, and he can push himself up and wrestle with his dad. How many more treatments will he have? “I’m not going to stop,” says Diana. “I see miracles happening here.” Barbara Stahura, certified journal facilitator, is co- author, along with Susan B. Schuster, MA, CCC-SLP, of After Brain Injury: Telling Your Story, the first journaling book for people with brain injury. Editor of Brain Injury Journey, she presents journaling workshops around the country to people with brain injury, family caregivers, and others, and is a member of the faculty of the Therapeutic Writing Institute and the Lash & Associates speakers bureau. She lives in Indiana with her husband, Ken Willingham, a survivor of TBI. http://www.barbarastahura.com YourBest Source forBrain Injury Products Speech Language Pathologists look to the AliMed catalog first for tools to work with clients with neurological injury. *Contact Sherry Davis at sdavis@AliMed.com or call 800-225-2610 ext. 496. Ask for the Speech Therapy Catalog #11102 Request our newest catalog now! It’s FREE!* Assessment and Therapy Products for: ● Problem-Solving ● Memory ● Cognition ● Communication ● Language ● Left-Visual ● Attention Processing 7080 BI Magazine Ad_final_7080 BI Magazine Ad 7/30/13 3:07 PM Page 1 5130 Linton Boulevard, Suite H3 & 4 Delray Beach, FL 33484 (561)819-6125•1-800-983-8582•www.PalmBeachHyperbaric.com•oxygen4u@bellsouth.net Hyperbaric Oxygen Effective & Specialized Treatment Program for Neuro Wellness foundation Our Simple Game Plan Is To Make A World of Difference. h t t p : / / w w w . j o e n i e k r o f o u n d a t i o n . c o m / Joe Niekro Foundation, PO Box 2876, Scottsdale, AZ 85252-2876, Office: 602-318-1013, Fax: 480-323-3876 The Joe Niekro Foundation was established in 2007 in honor of the founder’s father, Joe Niekro, who lost his life from a sudden cerebral brain aneurysm in 2006. The foundation is committed to aiding in the research and treatment of aneurysm patients and families, to raise awareness about aneurysm factors, causes, treatments and research. Funds are used to educate the public about brain aneurysms, Join Our Mission! to support patients and families, and to develop awareness programs and educational materials for hospitals, clinics, and other institutions worldwide. Every donation matters! The Joe Niekro Founda- tion is a registered 501 (c)(3) which means your donations are 100% tax deductible. Your donations are used to enhance the research and treatment of aneurysm patients and families. Just go to our website (shown below), or call us today!
  21. 21. The Healing Power of the Mind by Barbara Stahura, CJF When the Jeep flipped near Long Binh, South Vietnam, on February 25, 1968, Spec. 4th Class Bill Roper was thrown out and his head smashed against the hard ground. Inside his skull, his brain collided with bone and began to swell uncontrollably. Within minutes the swelling jeopardized the young soldier’s life; without quick action, parts of his brain would be damaged beyond repair and he would die. Fortunately, the accident happened near the 24th Evac Hospital, where neurosurgeon Floyd Robinson rapidly assessed the situation and performed a right subtemporal decompression—he drilled holes into the right side of Roper’s skull to relieve the intracranial pressure caused by the swelling. At first, Roper, who had been a clerk in the motor pool at Long Binh, clung to life in a deep coma. His condition was so bleak that the Army sent his family a telegram stating that he was not expected to recover. Later, he vacillated between a dim semi-awareness and the blankness of unconsciousness. Slowly, though, he became more aware, his memory and other cognitive processes began functioning again, and the slur in his speech lessened (and eventually disappeared). He was fortunate enough to have entered the frustrating, tedious process of recovering from a severe brain injury. The damage to the right side of his brain had paralyzed his left arm and leg. After being transferred to a military hospital in the States for rehabilitation, Roper received the news from his doctors that he likely would remain a hemiplegic (paralyzed on one side of his body). Forty-five years later, Roper can look back on that dismal time in his life and know with certainty that one Telling Your Story can outfox doctors’ predictions. Having decided that their prognosis for his non-recovery was simply not acceptable, he walked out of the hospital about three months later. True, he had a definite limp and could not move with any kind of grace, but he walked. He then worked hard to rebuild his body through heavy-duty body building and later gave that up to run marathons. He went on to run a successful computer business for many years and is now a motivational-inspirational speaker and author. While his recovery was satisfying and empowering, it didn’t really surprise him, although his physicians considered it “a miracle,” he says. “My recovery was all about the power within myself and being able to tap into it,” Roper says. “Everybody has this power. The power of all creation is within everyone. So, it’s not hopeless. You can be what you want to be and overcome your injury, but you must be willing to think you can. You must be willing to tap into that power.” Get up every time you fall down Roper tells his story in his first book, The Compassionate Warrior, detailing his use of the power of his mind to overcome his brain injury and its manifestations. (See a review on page 30.) His doctors warned him that his left side would always be paralyzed. But he refused to believe that. He knew in his deepest heart that he would recover. He believed that his injured brain still remembered how to move his left arm and leg, so all he had to do was keep reminding it. “I knew I had dominion over my body, and all I had to do was stick to the belief that deep down inside, all was well,” he says. While still in the hospital, he kept getting out of bed to try and stand, against doctor’s orders, and every time, he fell to the ground. But with each attempt, his determination only grew stronger, and he continued his battle against gravity. Finally, he could “shuffle around.” His doctors were amazed at his progress, but he wasn’t. “I knew everything was possible,” he says, and so he left the 21 “If you believe you’re going to be disabled, you will be,” he says. “Begin with baby steps, and trust that you have the power. You do have everything you need within yourself. So believe this. It’s the starting point for manifesting whatever you need.”
  22. 22. 22 hospital upright and under his own power. His walk then wasn’t graceful in the least, but he knew he would continue improving because he refused to give up on himself. Roper’s unshakable belief in himself came from several sources. His mother was the first. Whenever he asked for help with something as a child, she encouraged him— strongly—to do it himself. As a high school athlete, his strength and conditioning coach was Bill Curry, who had been a national weightlifting champ three years running, and Curry taught his athletes to give “150 percent” to everything they did, recalls Roper. So these positive influences, along with what he calls his “inner knowing” that had been part of him since childhood, inspired him to keep improving. Belief is the key Today, Roper believes that his “catastrophic experience had allowed me to discover this awesome power within me.” He stresses that this same power is available to everyone. “It’s really the power of all creation.” “If you believe you’re going to be disabled, you will be,” he says. “Begin with baby steps, and trust that you have the power. You do have everything you need within yourself. So believe this. It’s the starting point for manifesting whatever you need.” He further developed his inner power through meditation. Back in 1975, he heard it was a good way to reduce stress. And he was under great stress, including suffering from PTSD. So he learned Transcendental Meditation, and has practiced it twice daily ever since. It helped him to know that “I had the ability to overcome anything. And my stress melted away,” he recalls. “TM allowed my brain to let go of the traumatic events of war. They’re still there, but in the background.” When Roper meditates, he is able to “connect with the vision that is available to me when I commune with the great power of the universe,” he wrote on his blog http:// tbivet.com/ptsd-meditation-here-now. “I make myself open and available to the wonders of the universe that are available.” Roper stresses that he is not special in this regard; every human possesses this great power of the mind and spirit (and there are many other effective methods of meditation and mindfulness practice). “It’s your mindset,” he says. “If you think negatively about yourself or what you can or can’t do, that’s your reality. Your reality is a reflection of what you think, and that depends on your past experiences.” He does not claim that everyone with a brain injury can overcome every aspect of it. Yet, he says, “while you might not become your old self, you can come back better than you thought you could.” He also says that “gratitude is one of the most important functions in life. Maintain your sense of gratitude. I’m grateful that I’m here right now and for what I have, good and bad, and that there’s this great power that I have—that we all have.” While he once believed that the brain injury was the worst thing that could have happened to him, he now believes otherwise. That day in Vietnam, he “was in the right place at the right time,” and his experience opened him to an entirely new way of living his life. Most importantly, he learned that “there is meaning to everything that happens, and a purpose for my life.” See Roper’s website at tbivet.com Barbara Stahura, certified journal facilitator, is co- author, along with Susan B. Schuster, MA, CCC-SLP, of After Brain Injury: Telling Your Story, the first journaling book for people with brain injury. Editor of Brain Injury Journey, she presents journaling workshops around the country to people with brain injury, family caregivers, and others, and is a member of the faculty of the Therapeutic Writing Institute and the Lash & Associates speakers bureau. She lives in Indiana with her husband, Ken Willingham, a survivor of TBI. http://www.barbarastahura.com User Manual for a Computer Based Cognitive Rehabilitation Program Developed by James Japp, MA, MSc Dip Couns Neuropsychologists UK M e m o r y E x e r c i s e s AcquiredBrain Injury Lash & Associates Publishing/Training Inc. It’s Like Weightlifting... With Your Brain! Our Acquired Brain Injury Memory Exercises (ABIME) Is a Computer Based Cognitive Rehabilitation Program That Strengthens Memory and Cognition. Developed in the UK by James Japp, MA, MSc Dip Couns Neuropsychologists UK This software offers cognitive exercises for adolescents and adults with neurological impairments including traumatic brain injury and stroke. ABIME has six key components with exercises across a range of visual, verbal and spatial memory functions. They are 1) memory for numbers; 2) working visual memory; 3) short term visual memory; 4) visuo- spatial memory; 5) immediate verbal recall; and 6) delayed visual/verbal mem- ory. Responses are computer tracked and scored for clinical use in assessment, treatment planning, cognitive rehabilitation and research. Item: ABIME Pages: 30 page user manual - CD for use on XP/Vista/Windows 7 Year: 2013 Price: $120.00 FREE SHIPPING! - when you order on the website with coupon code SHIP Here is the link: www.lapublishing.com/brain-injury-memory-exercises Or call to order: 919-556-0300
  23. 23. 23 Veteran Voices Why are so many Veterans Homeless? by Shad Meshad I met my first homeless vets on the streets of Los Angeles in 1971. I’d just returned from Vietnam where I’d served as a psychiatric social worker in the Army. No more Captain’s bars for me. I had wild hair, a bushy mustache, and an attitude, so I fit right in. Initially I’d been asked to find out why veterans were not using the VA Center for their healthcare, but my interactions with these vets, all of us lost in one way or another, changed the course for me. Those were dark times, shadowed by what we’d seen and done in the war. Some vets brought all that horror home, re-living it episode by episode, riding that long escalator down into despair and chronic homelessness. It wasn’t until 1980 that PTSD, Post-Traumatic Stress Disorder, made it into the DSM manual. By then of course I’d been seeing and documenting its effects while trying to deal with them for over nine years. To this day our National Veterans Foundation (NVF) Outreach van still serves Vietnam veterans in communities of homeless under bridges, in abandoned lots, alongside riverbanks, any place we find them. Now we’re seeing more and more vets who served in Iraq and Afghanistan. These vets often have PTSD, but many have also had a TBI or traumatic brain injury. As you probably know, TBIs are so prevalent they’re called the signature wound of these two long- running wars. The VA is by now familiar with PTSD, its symptoms and its effects. However, because the symptoms of PTSD and TBI are similar and often overlap, PTSD can be the initial incorrect or incomplete diagnosis where TBI is present. Both these conditions can manifest as depression, anxiety, sleeplessness, irritability, aggression, and increasing social isolation. But TBI can also include memory loss, migraines, seizures, problems with language, and trouble making what might seem like simple decisions. Vets with brain injury need different treatment. Homelessness and brain injury What’s this got to do with homelessness? Just this: the VA’s first large-scale study of homeless veterans, released in 2012, found that over half of the newly homeless diagnosed with mental disorders had received that diagnosis before homelessness. The VA’s Inspector General (IG) said, “Presence of mental disorders (substance-related disorders and/or mental illness) is the strongest predictor of becoming homeless after discharge from active duty.” That’s from the horse’s mouth. Strongest predictor. It gets worse. Here’s the IG later in the same report: “…about half of the newly homeless occurred after 3 years discharged from active duty.” So what we’re looking at is vets returning home, trying to transition back into civilian life—jobs, school, families—while they’re dealing with the effects of PTSD and/or TBI. Say they give it three years. And then, for many, the wheels come off. It looks to me like homelessness is the last stop on this PTSD/TBI train ride, not the first. The NVF employs veterans as peer counselors on our crisis hotline. Three of our best counselors have had extensive combat experience: one has two combat tours in Iraq; the second, four combat tours in Iraq; and the third (who’s returned to military duty), four combat tours—two in Iraq and two in Afghanistan. A total of ten tours, all of them “outside the wire.” The first two counselors were diagnosed with PTSD and TBI; the third counselor’s PTSD was expressed in aggression. All of them found that when they came home, they couldn’t turn off the hypervigilance that had served them so well in the combat zone. The result: a quick-to-rise edginess, a dislike of crowds, sleeplessness, difficulty controlling emotion when they perceived a threat. Another side to the hypervigilance is the havoc it plays with the body, in a constant state of heightened alertness. I think a key factor in their successful transition back into civilian life was employment. See what I mean? A problem this size has many parts. Not only do we need to focus on getting our vets the correct diagnoses and then the right Not only do we need to focus on getting our vets the correct diagnoses and then the right treatment, we have to look at the larger picture, at all the elements that come together to build a life. Education is one of them; others are medical care, gainful employment, and meaningful social contact.
  24. 24. treatment, we have to look at the larger picture, at all the elements that come together to build a life. Education is one of them; others are medical care, gainful employment, and meaningful social contact. The VA now has a special section targeting homeless vets that is staffed by previously homeless vets. That’s the model the NVF has used for decades because it works: vet to vet. Brain injuries require integrated care The injured brain takes time to adjust to the effects of the injury. And as for diagnosis and treatment, no one size fits all. Each traumatic brain injury is unique in itself, not to mention that no human is a copy of another. What’s needed is patience, and coordinated care. Maybe a better word is integrated care. There are many agencies for the homeless and community-based organizations for vets, all trying to re-invent the same wheel. Wouldn’t it make more sense to coordinate these efforts to make better use of our financial and human resources? The VA is a place to start and they’re trying, but their size and the overwhelming number of vets waiting for care makes me think we’d better start working on this from the ground up. A solution from the top down is likely to be further in our future. Homelessness is what’s in store for far too many of these veterans if we wait. It doesn’t make sense to squander all the talent that resides in these men and women. We need them as contributing members of our society. Allowing them to slip into homelessness or worse because we didn’t provide the care they need to heal from PTSD and TBI is just not an option. As a U.S. Army Medical Service Officer in Vietnam in 1970, Shad Meshad began pioneering treatment techniques for what would later become known as Post-Traumatic Stress Disorder. The founder and co-author of the VA’s Vet Center Program, Meshad founded the National Veterans Foundation www.nvf.org in 1985, an organization dedicated to serving Veterans in crisis and bettering the lives of all U.S. Veterans and their family members. The NVF operates a crisis hotline and live chat on their website for veterans of all wars including those on active duty in the current war, in addition to homeless outreach in the Los Angeles area. Final Salute Inc. Serves Homeless Women Veterans Among the homeless military veterans are an estimated 55,000 women, but we don’t often hear about them. According to a study conducted in 2009 on Veteran Homelessness by HUD and the VA: • Female veterans are more likely to be homeless than their male counterparts. • Female veterans are also 4 times more likely to be homeless when compared to female non-veterans in the U.S. and female non-veterans in the poverty population. Many of these forgotten heroes are disabled as a result of their service. Many of them have children. Yet there are few services specifically fashioned for them, and even fewer that accept children. Jaspen Boothe, a captain in the Army National Guard, deployed during Operation Iraqi Freedom/ Operation Enduring Freedom. As a single parent in the Army Reserves in New Orleans in 2005, she lost everything to Hurricane Katrina. The next month, she was diagnosed with an aggressive head, neck, and throat cancer. She was unable to deploy to Iraq and was facing discharge from the Army. She needed complex medical care, a job, and a place to live with her son. Yet when she searched for assistance, she learned there were no existing programs for female veterans with children and was told she should explore welfare and social services as an option, just like every other single mother. After she recovered, with lifelong side effects from the cancer treatment, she was able to stay in the Reserves and later was able to return to full-time duty. But she had not forgotten what she had learned and decided to do something about the desperate situation facing homeless female veterans. Boothe founded Final Salute Inc. www.finalsaluteinc.org in November 2010, which serves women veterans with housing and financial support. For an interview with Boothe, listen to the Kim Justus show on Blog Talk Radio here: http://www.blogtalkradio.com/ braininjuryradio/2013/06/27/recovery-now-with-kim- justusfinal-salute 24
  25. 25. 25 Clinical Corner Behavior – Help for Families and Caregivers? by April Groff, PhD Changes in behavior after a brain injury are common and particularly stressful for families and caregivers. “Why does he act that way? What can we do? She’s like a different person.” These are just a few comments repeatedly heard by clinicians when talking with families and caregivers. It’s not only the person with the brain injury who has changed. Family members now find they have to change their expectations and about the survivor’s behavior. They also learn to change how they respond to these new and often frustrating and challenging behaviors that they see at home and out in the community. Behavior and memory are connected Someone with a brain injury may have short or long- term problems with memory. This means that learning new information can be very difficult, and the person may become confused about how to act. A person with a brain injury may also do or say something over and over—like repeating a word, question, or activity. In most cases, repetitive behavior isn’t harmful. But it can be incredibly annoying and difficult for family members, who will need much patience and understanding while trying to figure out how to respond. Below are some tips that families and caregivers can use to prevent behavior difficulties associated with memory problems. There are also tips for responding to these behaviors. Prevention strategies • Establish a structured environment and daily routine. They are essential to reduce behavioral problems related to memory. Having a written daily schedule that is similar from day to day can make it easier for your loved one to remember what is expected and what to do next. • Keep household objects in the same designated places. Use the same route to walk to a specific location. • Keep distractions to a minimum and focus on one task at a time. • Use a memory aid system specific to the person’s needs. This may require writing down key information on a calendar, in a memory notebook, or in a smart phone. It may involve using visual reminders, alarms, or labels. • Have the person wear an ID bracelet with brain injury status, address, and emergency phone numbers. Tips for responding • If the person repeatedly asks a question, provide an answer. Repeat yourself. It’s easy to get frustrated or to feel like the person isn’t listening to you, but don’t take it personally. Remember that it is the brain injury causing the behavior, not the person. • Stay calm and be patient. Offer reassurance with a calm voice. Don’t argue or try to use logic to convince the person to behave differently. • Focus on the emotion, not the behavior. Rather than reacting to repetition, try to think about how the person is feeling and respond to the feeling. • Use memory aids. Refer to calendars, notebooks, smart phones, visual reminders, or other memory aids familiar to the person. • Engage the person in an activity. Provide structure and try to engage the person in a pleasant activity. • If the behavior isn’t harmful, try not to worry about it. Find ways to accept and work with it rather than trying to stop it or change it. Agitation A person with a brain injury may feel easily overwhelmed, which can lead to agitated behaviors. He may become restless, and pace, fidget, or move around. He may become unsettled or upset more easily than before or for reasons that aren’t readily apparent to family members or caregivers. Many factors can interfere with a person’s ability to think. A person with a brain injury has a lower threshold for interference, causing more sensitivity to anything that interferes with their ability to think and is more susceptible to cognitive overload. This often leads to agitation. Below are some tips for preventing agitation, as well as tips for responses.
  26. 26. physical discomfort. • Simplify the task at hand. • Provide an outlet to the situation that involves physical or focused activity. Offer to go for a walk or use art or music to divert attention away from anxiety. Aggression and anger • Angry outbursts and aggressive behaviors can occur when confusion and cognitive overload escalate. Or they can occur suddenly and unexpectedly. Aggressive behaviors can be either verbal or physical. They tend to be triggered by environmental factors like extreme overstimulation or internal factors like pain, physical discomfort, or inability to communicate effectively. Provided that the situation does not present a physical threat, various approaches can help prevent or diffuse anger outbursts and aggressive behavior. The above prevention strategies for agitation are also effective in reducing the likelihood of angry outbursts and aggression. Prevention strategies • Identify and talk about acceptable ways of expressing anger in the household. It’s important to acknowledge that anger will happen, and it can be helpful for a family to have a plan and agreement about how it can be safely expressed. • Try to establish consistent, non-confrontational responses from all family members. Role play and practice these responses to gain comfort. • Manage the environment to minimize triggers. • Be sure that pain management strategies are in place and minimize situations that are physically uncomfortable. How to respond • Assess the level of danger. Harm can often be avoided by stepping back and standing away from the person. Direct others in the immediate environment to do the same. • Avoid physical contact, guidance, holding, or restraint. 26 Prevention strategies • Keep the environment calm. Avoid noise, glare, and background distractions, such as having the television on or being in the same room where others are having conversations. If home is hectic, identify a safe zone. This can be a quiet area where the person can go during loud or busy times. In the community, try to target outings for days or times likely to be less crowded and noisy. If you begin to notice that an environment is becoming overwhelming in any way, offer an alternative such as going to a quieter location. • Support the person’s physical comfort. Make sure the room is a comfortable temperature. Factors such as pain, temperature, hunger, or toileting demands can overwhelm a person and lead to agitation. • Support opportunities for the person to get regular physical exercise as part of their routine. • Support your loved one in reducing or eliminating caffeine or other stimulating substances. • Identify a list of soothing rituals that are effective in calming the person when agitation does occur. Having a plan for what to do in case of agitation will reduce anxiety for both you and your loved one. How to respond • Reduce stimulation. Decrease noise and distractions or help the person move to a quieter place. Engage in pre-planned soothing rituals. • Use calm, positive, and reassuring statements. Say things like, “I will stay with you until you feel better” or “I’m sorry this is overwhelming.” Slow down your rate of speech. • Avoid asking questions or placing additional demands on the person. If you have to ask questions, avoid open-ended questions and instead offer the choice of options. Instead of asking “Where do you want to go?” try “We can go to the car or to the restroom.” • Consider whether pain, fatigue, hunger, thirst, temperature, or toileting demands could be causing
  27. 27. 27 • Remain as calm as you can. Try not to get upset or take the behavior personally. Speak slowly and in a soft tone. • Don’t challenge, confront, or criticize the person. Be positive and reassuring. Consider the feelings underlying the behavior. • Help the person regain a sense of control by asking if there is anything that would help him to feel better. • Think about what happened right before the reaction that may have triggered the behavior. Try to understand the source of the anger and address the unmet need if possible. • Rule out pain as a factor in the escalation in the behavior. Pain can cause a person with a brain injury to act aggressively. • Try to change the person’s mood by agreeing and avoiding an argument. Show extra affection and support to address underlying frustrations. • Validate the emotion by identifying the feelings and letting the person know these feelings are legitimate. “It makes sense that you are angry” can be an effective response. • Shift focus to another activity. The immediate situation or activity may have unintentionally caused the aggressive response. Try something different. • Treat each incident as an isolated occurrence since the person may not remember having acted this way before. April Groff, Ph.D., is a licensed clinical psychologist specializing in neuropsychology. She currently is the clinical director at Learning Services in North Carolina, where she oversees post-acute residential rehabilitation and supported living program for individuals with acquired brain injury. Her previous roles include director of the Polytrauma Transitional Rehabilitation Program and staff psychologist within the Polytrauma Rehabilitation Center at the VA Palo Alto Healthcare System. She has extensive experience working with active duty service members, veterans, and civilians with brain injury and their family members. www.learningservices.com Spread the News! Be a Distributor for Our Magazine There’s no hidden agendas, costs, or tricks. We simply want to reach as many readers as possible and need your help. We make it easy. Lash & Associates gives you graphics and links to post on your website, newsletters or social media sites like Facebook and Twitter. We can help you increase traffic to your website, too! Many Brain Injury Associations and Alliances in the US have already become distributors. The list is worldwide – here are some of our current distributors: State Brain Injury Organizations Brain Injury Alliance of Unites States http://usbia.org/ Brain Injury Alliance of Connecticut http://biact.homestead.com/ Brain Injury Alliance of Montana http://biamt.org/ Brain Injury Alliance of Oregon http://www.biaoregon.org/ Brain Injury Alliance of Utah http://info@biau.org Brain Injury Association of Indiana http://www.biai.org/ Brain InjuryAssociation of Kansas and Greater Kansas City http://biaks.org/ Brain Injury Association of Nebraska http://www.biane.org Brain Injury Association of New Hampshire http://www.bianh.org/ Brain Injury Association of New York http://www.bianys.org/ Brain Injury Association of South Carolina http://www.biausa.org/sc/ Brain Injury Association of Tennessee http://www.braininjurytn.org/ Brain Injury Association of Virginia http://www.biav.net/ International Distributors Gisborne Brain Injury Association http://www.brain- injury.org.nz/html/local_associations.html (New Zealand) Headway Ireland http://www.headway.ie/ (Ireland) Mobile Health Consult (Brain Dynamics) http://www. mobilehealthconsult.com (Niger) Brain Injury Association Central Districts Region http:// www.brain-injury.org.nz (New Zealand) Want to join us? Contact nick@lapublishing.com Lash & Associates Publishing/Training Inc. 100 Boardwalk Drive, Suite 150, Youngsville, NC 27596 Tel: (919) 556-0300 Fax: (919) 556-0900 www.lapublishing.com Lash & Associates Publishing/Training Inc. 100 Boardwalk Drive, Suite 150 Youngsville, NC 27596 Tel: (919) 556-0300 Fax: (919) 556-0900 www.lapublishing.com Lash & Associates Publishing/Training Inc. 100 Boardwalk Drive, Suite 150, Youngsville, NC 27596 Tel: (919) 556-0300 Fax: (919) 556-0900 www.lapublishing.com Leading Source of Information on Brain Injury in Children, Adolescents, Adults and Veterans A m agazine for the brain injury communit y

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