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Emotional changes following brain injury: psychological and neurological components of depression, denial and anxiety

Journal of Rehabilitation, April-June, 1991 by Carol Armstrong

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Studies have shown that manu ex-patients stay at home doing nothing after rehabilitation has ended with much distress accompanying the social isolation and lack of productive work (Ben-Yishay, Silver, Piasetsky, & Rattok, 1987, Prigatano, et al., 1984). Disturbances of motivation, the ability to cope flexibly, slowed fluency of thought or disturbed reasoning and judgment have neurological bases in the brain. These mental changes leave individuals with great difficulty in self-structuring, planning of activities, and organization of their lives. Long-term psychological and cognitive help as well as special work training opportunities are a great need.

Behavioral Management

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"I find the methods (of behavior modification) distasteful but they seem to work in head injury" (Gloag, 1985, p.913). Family members are often concerned about giving structured responses to patients which they fear will be just one more negative restriction on the patient. Correct use of behavior modification is motivating to patients, and behavior modification programming is often used with persons with head injury. The purpose of behavior modification plans is to structure the environment in a way that enhances the recovery process. Behavior modification plans are not primarily to control or punish, but to rehabilitate. They teach self-control to a disinhibited mind. They teach new skills and routines to one wit unstable motivation. They provide overlearning. They help the patients anticipate future events, an ability often impaired in patients with traumatic brain injury (Freedman, Bleiberg, & Freeland, 19876). Behavior modification plans also address the need for increased attention related to ego needs, by replacing negative attention with positive attention. The patient is shown what behavior will be rewarded. The psychologist provides structure which limits the cognitive field and thus decreases the patient's confusion while making choices.

If the structure is relevant to the impairment, then long-term change will result. Often the positive attention component is the most powerful, and plans will suffice simply if based on this factor. Patients have difficulty interpreting interactions with others because their integration of their perceptions is impaired and they cannot easily see alternative viewpoints. Their view of staff, from the vantage point of injured and overcontrolled hospital patients, is also tarnished by their frustration with their restrictions and with their many losses. They more often experience the environment as well as internal signals as negative, painful, punitive, or not worth the effort of compliance. They require a very empathetic environment which builds their ego resources. For example, a patient was recovering from a severe injury, and was not yet able to identify or express her thoughts and feelings adequately. She very much needed attention, and sought it in the only way she knew, which was to whistle, swear, and make other noises incessantly. By angering the other patients to whom her behavior was irritating, she elicited hostile reactions from them. This provided her with more negative attention which was apparently not really meeting her needs. The treating team tried several behavior modification methods with her such as withdrawing attention from her actions, isolating her so she was not reinforced by other patients, and rewarding her with favorite foods or activities. However, all these plans failed. Finally they tried "affection therapy". Affection therapy consisted of frequent and regular reminders to her that she was wanted and cared about, especially focusing on physical signs of affection. Thus, staff would give her a hug and a friendly comment before and after every interaction with her, regardless of her performance. The unconditional reward of affection very quickly caused her to cease her annoying behaviors, because she was receiving the kind of positive attention she really needed.

Health Care Industry

Emotional changes following brain injury: psychological and neurological components of depression, denial and anxiety

Journal of Rehabilitation, April-June, 1991 by Carol Armstrong

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