Insight into mild brain injury from and Adlerian perspective.

Brain injury causes a multitude of changes that affect an individual's ability to perform vocationally and socially. Changes may occur in cognitive, emotional and behavioral functioning. Although the functional impact for clients with moderate to severe brain injury is well documented in the literature (e.g., Lynch, 1986), many people with injury on the mild end of the continuum may be misdiagnosed and/or the functional impact of the injury may be underestimated (Kay, 1986; Mateer, 1992; Sorenson & Kraus, 1991). Due to the frequency of misdiagnosis and lack of needed support, many individuals sustaining brain injury remain either unemployed or underemployed. Few can return to, and maintain, their former vocational performance Kosciulek, 1994; Mateer, 1992). Rehabilitation of an individual with any degree of brain injury should include cognitive treatment strategies, psychosocial counseling, and vocational rehabilitation (Mateer, 1992). This paper will address how these functions interrelate in the well being of the client. The principal aspects of brain injury and how they contribute to the psychological well-being of the client will be described. The primary goal of this paper is to examine the psychological sequelae of a mild brain injury and the impact of the sequelae on the client's ability to function productively. Demonstration of how an Adlerian counseling approach can be used to lessen the functional limitations will be presented.

Prevalence estimates of injury in the United States are between 1,125,000 and 1,600,000 per year for mild brain injuries caused by trauma alone (Koch, Merz & Lynch, 1995; Ruff, Wylie, & Tennant, 1993). This figure does not include estimates for those caused by other events. The figure is sufficient, however, to recognize that this is a condition that affects a substantial population. The peak incidence rate for these injuries occurs in the late teens and early twenties (Sorenson & Kraus, 1991). During this period many individuals are in the midst of training or launching their careers; therefore, essential job-related skills are not yet well established.

Brain injury is a significant concern to rehabilitation in both direct loss of income and the indirect loss of time from the work force (Rimel, Giordani, Barth, Boll & Jane, 1981). Another issue that may affect rehabilitation is a premature attempt to return to work (Mateer, 1992). Individuals pursuing this strategy are likely to experience deterioration of their employment status. Individuals may encounter discouragement, employment termination and a damaged reputation that may prejudice future opportunities (Fowler, 1981). Many of these individuals are likely to present themselves to rehabilitation counseling for assistance in reestablishing work options.

Definition

Brain injury is described as an induced physiological disruption. The disruption can be caused by a variety of events. Examples of such events could include the head being struck, stroke, fall or drugs (Kay, 1986). The medical model criterion for diagnosing mild brain injury is that the patient may exhibit any of the following behaviors: alteration of consciousness, loss of memory for events immediately before or after an accident, confusion or disorientation, or perceptual deficits that may or may not be transient (Acimovic, Lemmon & Keatley, 1993; Kay, 1986; Mateer, 1992). Any one of these conditions may indicate that brain functioning has been disrupted. The severity of the injury should not exceed certain criteria to be considered "mild." The loss of consciousness should not exceed 30 minutes. At the end of a 30 minute observation period, the patient should be able to respond to the Glasgow Coma Scale well enough to obtain a score of 13-15. In addition, any existing anterograde or retrograde amnesia should not be greater than 24 hours (Mateer, 1992; Sorenson & Kraus, 1991). While this model is a starting point in the assessment of this problem, it does not address the impact that the injury has on normal functioning for the survivors (Kay, 1986). Due to the tendency of service providers to base their decisions for selection on the medical model (e.g., length of loss of consciousness), many individuals are denied services. In addition, traditional conceptualizations of clients with mild brain injury clients are those of exaggerated symptoms for secondary gain (i.e., avoid work or responsibility, get attention, or monetary benefit from litigation) (Mateer, 1992; Vamey, 1990). The medical definition is giving way to a new understanding of the needs of the client, on of which is appropriate assessment addressing the functional limitations of the client in real world situations (Mateer, 1992; Ruff, et al., 1988). Although some clients report some difficulty in daily living skills, the functional limitations are more evident when the client attempts returning to work (Kay, 1986; Mateer, 1992; Sorenson & Kraus, 1993). The appearance of limitations upon return to work may be due to more objective standards of behavior and performance in the workplace. It may be also due to the client's unconscious manipulation of his or her social and home environment, which is not feasible at work.

Dizziness, headaches, poor memory, fatigue, loss of behavioral control and loss of concentration are commonly recognized as acute post-trauma experiences of individuals with mild brain injury (Kay, 1986; Mateer, 1992). It is becoming evident to more researchers and professionals that symptoms do not always resolve in individuals soon after the precipitating event (Acimovic, et al., 1993; Kay, 1986; Mateer, 1992). Present estimates are that about 25% of persons sustaining mild brain injury will continue to experience symptoms which interfere with their normal functioning indefinitely (Koch, et al., 1995; Kosciulek, 1994; Mateer, 1992). The cognitive sequelae which impact on an individual's normal functioning are the result of the organic damage Kay, 1986). Psychological and behavior maladaptions can also occur when diagnosis and treatment are unavailable. They may be the result of direct organic damage, or they may be the result of the pergon struggling to regain his or her preinjury manner of functioning (Kay, 1986; Mateer, 1992). In addition to the brain injury, depending on the mechanism of injury, the client may be experiencing post-traumatic reaction symptoms. Therefore, attention should be shifted from description of typical recovery to early identification and rehabilitation of affected individuals (Mateer, 1992; Sorenson & Kraus, 1991).

Psychosocial Impact of Brain Injury

Rehabilitation interventions should begin soon after diagnosis (Mateer, 1992). Returning to work too early in the recovery phase may cause difficulties. A sensitive counselor can allay some of the secondary psychological symptoms found in individuals who have experienced a traumatic injury but whose injury is considered "mild." Anxiety, frustration and depression, which can follow an injury, could significantly affect work adjustment upon return to work. Identification of lifestyle, recognition of residual strengths, and planning for remediation and compensation of recognized limitations are important for a client to claim responsibility and control of his or her life.

Without a diagnosis, but where the possibility of brain injury exists, counselors may find it expedient to conduct screening procedures as early as possible. Subjective complaints about changes in functioning previously overlooked by medical assessments should be explored for appropriate vocational planning (Koch. et al., 1995).

Adaptation to any traumatic injury is a dynamic process of stages which can typically include shock, anxiety, denial, depression, internalized anger, externalized hostility, acknowledgment and adjustment (Livneh & Sherwood, 1991). The client with a brain injury could present him or herself to the rehabilitation counseling setting in any one of the stages. While organic depression is recognized as a possible effect of the brain injury, often the psychological problems seen with brain injury are secondary to the injury (Mateer, 1992). The emotional impact of brain injury does not necessarily cause psychological problems. Instead, it causes anxiety, which is not a pathological response to a traumatic event. Anxiety is a normal response to the uncertainty faced by an individual who suddenly realizes the perceptions of self and environment built over the lifetime are no longer valid (Kay, 1986; Mateer, 1992). Unresolved anxiety can be an indication of the individual's lack of ability to adjust and accept the changes in circumstances. Coping mechanisms are crucial to adapting and adjusting to the changes. Lack of flexibility may be due to a lost ability to cope, or to an innate deficiency in coping skills. Each circumstance will affect the direction of counseling in different ways.

To more fully understand anxiety in a client with a brain injury, it is necessary to examine how individuals typically react to the losses. Loss of the cognitive ability to process and organize information affects an individual's vocational and social functioning. The same is true of the loss of the ability to pay attention to details, and of faulty error recognition. In addition, most clients will exhibit some degree of short term memory loss (Kay, 1986). Although many of these problems may become more evident when the client attempts to return to employment, these abilities are crucial in all categories of functioning (Kay, 1986). When these abilities are compromised, the person's confidence to perform effectively in cognitive functions can be shaken (Kay, 1986; Mateer, 1992). The emotional reaction to these limitations can be extremely anxious; thus, the need for early intervention. Anxiety can further compromise the client's ability to utilize cognitive abilities. If the client's anxiety is allowed to progress to depression, rehabilitation counseling will be more extended than it would have been had education and information been available initially (Mateer, 1992). Education and information for the client, the client's family, and co-workers are the most universally recommended treatments for preventing exacerbation of the client's cognitive status. Mateer (I 992) recommends handling both denial and social withdrawal with cognitive-behavioral procedures.

Due to the great variability in severity of organic damage, even in those clients who have been diagnosed with a mild brain injury, some clients can rely on retained social skills and other nonintellectual characteristics to do repetitive tasks (Parker. 1987). The client may also have highly developed verbal skills that mask recognition of brain injury symptoms (Koch, et al., 1995). However, organizational changes and learning new information can present challenges (Parker, 1987). In addition, diminished insight, lowered ability to problem solve and perceive situations correctly may lead to unrealistic vocational expectations (Chandler, Czerlinsky, Moore, Rutman, & Shumacher, 1993). If the client is pressured by others who believe the client to be malingering for secondary gain Ruff, et al., 1988), the unrealistic expectations and the anxiety are likely to be more exaggerated. Evidence points to a clear link between vocational status and self-esteem (Chandler, et al., 1993). Thus, the loss of these functions can significantly affect a person's self-esteem. Adlerian counseling has constructs that can be beneficial in helping clients with mild brain injury to reorient themselves to a healthy lifestyle.

Adlerian Theory and Perspectives

Several major constructs of Adlerian theory have application to counseling persons with mild brain injury in a rehabilitation setting: the lifestyle and holistic nature of humans; the importance of love, work and friendship; and the responsibility of the individual for his or her own well being (Rule, 1984). The client's current and past functioning can be examined through establishing a relationship with the client, investigating the client's lifestyle, interpreting the lifestyle, and helping the client toward reorientation (Rule, 1984).

Relationship

Establishment of a trusting relationship is crucial with clients from the brain-injured population. Respect, trust, and genuineness are key elements of the relationship (Rule, 1984). These factors may have been missing in other relationships with service providers. By the time clients with mild brain injury enter rehabilitation counseling, they may have seen doctors who falsely assured them of a good prognosis, lawyers that may accuse them of malingering, and/or psychologists who diagnose them with pathological disorders. These types of experiences can cause further confusion, discouragement and frustration at not having the "real" problem properly addressed. Thus, the client with brain injury often enters rehabilitation with expectations of having their subjective complaints about changes in functioning ignored. By treating clients with respect and listening to their troubles with genuine interest, the rehabilitation counselor can establish a trusting relationship. Goals established between the client and counselor for counseling are important to both the rehabilitation process and to the brain-injured client. A treatment contract (Scott, 1984) with the goals clearly defined allows for assessment at the end of the process to detect whether the desired outcome has been reached. In addition, it provides structure and focus for the client experiencing memory problems. This aspect will become important when the client questions why certain techniques are used. A cooperatively constructed treatment contract also helps to further rapport between the client and counselor. The goals defined in the treatment contract will be different for each individual depending on his or her needs. Possible goals include: return to work, independent living, personal health care, financial independence and/or healthy maintenance of interpersonal relationships (Lynch & Lynch, 1991). In addition, both the client's role and the counselor's role should be clearly defined in the treatment contract. Realizing that the responsibility for feelings, thoughts and behaviors rests with the client is important for both the counselor and the client (Rule, 1984; Livneh & Sherwood, 1991). The counselor's role is to guide the client through therapy toward emotional and functional adaptation to the post-injury self (Lynch & Lynch, 1991).

Lifestyle investigation and interpretation

Adlerian theory recognizes the client as a whole system; not as component parts. The interrelatedness of the holistic human and goals is an especially important concept to embrace when considering the invasive nature of brain injury on the functioning of an individual. Loss of cognitive skills is not isolated from loss of emotional control or inability to organize and moderate thinking and behavior. The all-encompassing nature of the disability is an important concept for the therapist to understand. A brain injury affects not only vocational ability but every other aspect of the client's life. The disability is not a separate part of the person, but becomes integrated into his or her personality. Adlerian theory assumes that one of the goals individuals innately pursue is that of finding a place of significance for themselves in their particular social environment (Rule, 1984). This holistic assumption of humans would indicate that these goals are not idle aspirations, but that all behavior is directed toward this goal. However, individuals are not always aware that their behavior is directed toward any specific goal. They may not even be able to articulate why they behave in a specific way at a designated time. This aspect of human nature becomes especially evident in people struggling to recover from brain injury. Individuals continue to strive toward the same lifestyle goals, both recognized and unrecognized, as they did before they were injured. The frustration stems from their inability to accomplish those goals or fathom changing the goals even when they recognize that their functioning is changed.

Rule (1984) contends that only unhealthy persons do not recognize and accept their limitations. Lack of recognition and acceptance of limitations may also be true of clients who were undiagnosed or given a psychiatric diagnosis because they continued to insist "something is wrong" despite negative medical findings. Often clients with brain injury recognize their own limitations but have difficulty articulating how it affects them. The basic premise of integrated functioning, which is a cornerstone of Adlerian thinking, can facilitate therapists understanding of what the client cannot explain.

The construct of lifestyle is particularly important to understand when working with clients who have sustained mild brain injury. Lifestyle is formed in early childhood and influences the developing person's perceptions of self and environment. By adulthood, a coherently organized system of perceiving events and situations is a directing force of a person (Scott, 1984). This system includes both the tendency toward stability and the creative ability to change. Scott (1984) describes this dichotomy as the need to preserve the coherence of the system through homeostasis. The creativity to change is explained as adaptations to disruption of the homeostasis. Individuals who experience brain injury do not lose the innate nature of being human. They experience a major disruption in the coherence of their lifestyle. Natural reactions to such a disruption involve attempts at preservation of the lifestyle with the individual's personal goals intact. Such attempts can be observed in individuals who resist recognizing they have sustained brain injury. The client is likely to resist changing concepts of the lifestyle that make them who they are. A client with brain injury experiences an incongruence between those perceptions of self and his or her current ability to interact with their environment. Perceptions of self become disorganized and confused, especially if an individual has been mistakenly told they have no brain injury and are attempting to act on that premise. Individuals do not relinquish the essence of the lifestyle, even in the presence of evidence that they have lost the ability to pursue the same lifestyle. Scott (1984) recognized that while resistance impedes communication, it should be viewed as the innate nature of the individual, not as a conflict between the goals of the counselor and those of the client. This idea of resistance makes sense when the coherence of the lifestyle is accepted. Before the injury, the person's lifestyle was reinforced by his or her perceptions of interactions in any given situation. Those perceptions of self influenced their goals and behavior with others (Rule, 1984).

Understanding the lifestyle will allow the counselor to comprehend the personal meaning brain injury has for the individual. For some individuals, certain limitations will be more devastating to their sense of being than it will be to other individuals. For an individual whose pre-injury life was complex, with friends, family and demanding work, the loss of the ability to organize information and remember details may be more devastating than for the individual whose life is simple with undemanding work, few friends and no family. In all adults with brain injury, the nature of their injuries limits their creativity to adapt. Limited creative adaptation is evident in those who persevere to solve problems in ways that are no longer effective. Embedded in the construct of lifestyle are concepts of striving toward a sense of significance, feeling complete and being fulfilled (Livneh & Sherwood, 1991). These aspects may be threatened in an individual with mild brain-injury.

An exploration of the family environment and expectations is important. In the case of brain injury, the current family situation may be more relevant than the psychological birth order and development of the individual. The counselor can learn these details by attending to statements about change in the family functioning and how the client perceives family members-reactions to the changes. Depending on whether the client is a parent or an adult child, brain injury will have different impacts on family functioning.

Compensation

Some maladaptive responses seen in adults with mild brain injury are more easily understood if viewed from the Adlerian concept of compensation. Compensation is the mechanism used to overcome perceived and/or real deficits. The client with brain injury may struggle to compensate for deficits by hiding or denying problems or withdrawing socially. This reaction may be a maladaptive striving for superiority. The client may respond in this mariner due to a loss of self-esteem or a lack of energy left to attend to concerns of others Livneh & Sherwood, 1991). The client is likely to be investing a lot of energy into preserving the integrity of self. which may seem self-centered to others (Kay, 1986). Whatever the underlying cause, this type of reaction has potential to further strain social relationships. The client may have been aware of change in others' attitudes or may have become unaware of their own preoccupation. Guidance toward social interest and recognition of other people's needs could be accomplished by explaining what effect this type of behavior has on the attitudes of others. In addition, the client, the client's family and/or co-workers may need to be educated about the client's need for graded cognitive stimulation. Novack, et al. (1988) propose a structured plan be created for helping the client regain the ability to handle multiple and complex pieces of information.

Although most constructs of Adlerian therapy are appropriate in interpreting lifestyle, the concept of "all behavior is purposeful" should be used with caution. The client's maladaptive striving for superiority could be interpreted as serving a hidden purpose. This interpretation could cause more harm than good in clients lacking the ability to direct their behavior in productive ways. A more helpful interpretation would be directed toward the need for psychological support with identification and remediation of acquired deficits.

Rehabilitation Counseling Intervention

Insight into the direction of the client's lifestyle and goals can be gained by using earliest memories. These memories can serve as anchors that reveal the development of the lifestyle pattern, goals and expectations (Livneh & Sherwood, 1991). Wheeler (1987) proposed using those memories to identify and assess strengths of the individual. This valuable information can provide a basis for encouragement from the counselor to expand and use these strengths. The counselor may first have to convince the brain-injured client that although the client processes information differently, growth and change are still possible. Wheeler I 987) also suggested that the very strengths the client has may also be a source of difficulty. This is particularly applicable to the client with a brain injury. The very strengths that once contributed to the individual's sense of self-esteem may be compromised or less accessible. Creative options to correct, circumvent, or compensate for these hidden" strengths should be investigated by the counselor and client. It is possible that the client cannot organize options into a list alone but may recognize appropriate strategies when presented.

Strategies

Strategies proposed to overcome adjustment problems include humor, imagery, role playing and psychodrama (Scott, 1984). The purpose of these strategies, when used in interpretation of the lifestyle, is to integrate insight with application of information (Scott, 1984). Directing attention to this purpose focuses on a common problem for persons with brain injury.

Several advantages in using humor have been identified. It has the potential to relieve some tension and anxiety felt by the client (Rule, 1977). There is a greater chance the client will remember the incident to transfer the gained insight into functioning in the real world. It may also serve to increase the client's internal locus of control (Rule, 1979). In addition, Ellis (1976) recommended using humor to address inflexible patterns of thinking, acting and feeling. The counselor's insight into the client's lifestyle and stage of recovery will aid in deciding when and how to use humor as a therapeutic technique.

Imagery can be a useful tool in rebuilding a client's confidence in trusting his or her creative ability (Scott, 1984). The ,what if' technique could be useful in facilitating the client who has trouble in conjuring fanciful images and relaxation and meditation could aid the process. The purpose is to explore the client's feelings and sensations and to expand awareness and insight about options and choices. These techniques can be used to confirm that the client has an intuitive sense of what is best. The advantage of these techniques is the emotional distance created with fantasy between the client and the problem which allows the client to view the situation more objectively.

Role playing and psychodrama can provide structure in which to use imagery (Scott, 1984). These techniques have the advantage of having the client experience alternative ways to deal with conflict, new vocational choices, or ways to optimize residual strengths while in a safe environment.

Reorientation

Once clients have insight into primary goals and recognize their own limitations to fulfilling those goals in the manner in which they were directed pre-injury, it may be practical to reexamine the initial treatment contract. The client may decide that the goals are no longer appropriate and may need help in defining what may now be workable.

Lifestyle interpretation is used as a tool to show the primary goals of the client. Each step of Adlerian counseling is aimed at reorienting the client to acceptance and adjustment; the key ingredients of wellness. Several strategies suggested by Britzman & Henkin (1992) that could be useful in helping clients with brain injury accomplish reorientation are: 1) encouragement of self-awareness, 2) an individualized wellness plan, 3) reframing of wellness to increase its appeal, 4) focus on existing wellness strengths, 5) encouragement for effort rather than outcome, 6) facilitating of self-responsibility and internal motivation, and 7) promotion of individual ownership of wellness choices. With these underlying concepts and the lifestyle goals of the client defined, the client and the counselor can begin to explore the vocational opportunities open to the client. Examples may include job restructuring or job modification of pre-injury employment or investigation of other work opportunities in the community. Additional alternatives may involve retraining the client on previous social skills, enhancing memory with calendars and journals, or using work protocols with clearly defined structure to guide the client through specified tasks.

The rehabilitation counselor has a vast array of strategies to choose from in accomplishing both specific behavior changes and broader cognitive perceptions. Rule (1984) suggested using strategies from a number of different theoretical perspectives. These include RET, behavioral therapy, Gestalt counseling, and reality therapy. Considering the complexity of the challenges faced by the counselor and client in reorientation, using a variety of perspectives makes logical sense.

Summary

A rehabilitation counselor who can guide the client with brain injury toward responsibility and ownership of behavior and feeling has great potential for helping the client regain self-esteem and to find appropriate employment. Using the Adlerian constructs of lifestyle investigation and interpretation, the coherent nature of human personality, and reorientation in conjunction with rehabilitation concepts of changing maladaptive behavior, establishing goals, and assessing outcomes can provide the needed understanding and structure.

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