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A secondary diagnosis following severe brain injury

The original diagnosis might be severe brain injury, but many years later there needs to be a secondary diagnosis, from the conditions arising from the injury. This is the basis of the need for occupation described here as alienation.

The idea of alienation is one which is peculiarly meaningful in our society today. There are huge movements of people away from the place of their origins, for all kinds of reasons. The idea of alienation is also pertinent to the person who has sustained a brain injury.

SOED From the Latin alienus, belonging to another person or place.
Belonging to another person, place or family: foreign in nature, character or origin: far removed from, inconsistent with: repugnant or opposed to.
A stranger, a foreigner: a resident foreign in origin and not naturalized: one excluded from (citizenship, privileges, etc).
To convert into an alien, to estrange: to transfer the property or ownership of anything.

The action of estranging, or the state of estrangement: the action of transferring ownership to another: diversion of anything to a different purpose: the state of being alienated: loss or derangement of mental faculties, insanity.

It would be hard to find another word which decribes so well the loss of ‘occupation’ of both mind and place as the word alienation. It connects an precise sense of loss which is the condition of the person with brain injury. This condition brings about an estrangement from all that they have been prior to their injury. In the worst case they are unrecognisable to both themselves and their loved ones, but even when this is not the case they are a stranger to themselves and others. The state of cognitive disability, in a society which is based on cognitive ability, is one which creates the conditions for loss of privilege and alienation from all the ‘natural’ rights of a citizen.

We recognise this state of alienation in some of our common sayings and these are drawn on as a resources which focus some of the education about occupation which is provided at the school of Occupational Therapy:

I just don’t know what to do.
I can’t go on.
There’s no place for me.
I just don’t fit in.
I’m so bored.

It is possible to look forward from these expressions to ways in which the need for occupation might be met, but that would be to pre-empt the next section.

Severe Brain Injury is not completely unique in the suffering which it brings.

Of course, it is not only the person with brain injury who becomes alienated in our society. Karl Marx’s (1886) well known theory of the alienation of the worker from the products of his labour , described a condition which has come to exemplify the human condition in the nineteenth and twentieth centuries. Obviously, not every human being will be miserable because they are suffering from this form of alienation, but it is definitely the case that the vulnerable will have the greatest tendency to suffer from inherent conditions within a society. Just producing a means of subsistence seems an inadequate solution to the problems of alienation, when one has returned from a confrontation with death. That which was once familiar and recognisable, is familiar no longer. Returning from hospital with a mind which seems to belong to another person, which does not work in the way that it did yesterday or last year, means that there is no ‘home’. There is no place and there is no mind which evokes that shared reality which is the meaning of home.

In attempting to understand some of the ‘bad’ effects of occupation, I turned to the work of Arendt (1958). She clarifies the concepts of work and labour, both of which deal with the material universe and with our relationship with the natural environment. In labour there is a performance with or on the materials, whereas in work the relationship is one of production of, or with the materials. She talks about the effects of both labour and work on the individual and these effects are very different.

According to Arendt, labour can a hard thing, full of pain. The effort of labour never frees the labourer from repeating it all over again and it remains therefore an eternal necessity imposed by nature. The daily fight in which the human body is engaged to keep the world clean and prevent its decay bears little resemblance to heroic deed; the endurance it needs to repair everyday anew the waste of yesterday is not courage, and what makes the effort painful is not danger but its endless repetition.
Labour becomes dysfunctional when the balance gets tipped too far toward pain. In poverty there is exhaustion which leads to wretchedness, which is soulless. On the other end of the scale, the wealthy face the perils of boredom when they are free to endlessly consume without the necessity to create an appetite through engaging in the process of production. The danger of a society which has too great an imbalance toward labour is that the earth herself will be consumed and inundated with waste products as the cycle of labour becomes ever faster, aided by machines. The loneliness of the labourer is usually overlooked because social conditions demand the simultaneous presence of many labourers for any given task.

The dangers of work are those of losing sight of the whole, of creating things for their own sake. These things can then rise up and destroy the worker, or the whole world. The dangers are those of challenging god at god’s own game and creating things which have no way of fitting into the world. The dilemma is one of futility and senselessness. The Greeks saw this danger and called the utilitarian a philistine, even if he was making the most beautiful statue, because of the essentially violent relationship with the earth which was presupposed.

Depression following severe brain injury

There pain described above is caused by the negative side of occupation, but at least it assumes that there is still some movement within the condition and therefore there is hope. Even worse than this is the suffering that is caused by having nothing at all to do, where life is pervaded by a sense of pointlessness. This is the common condition of many people with head injury with whom the clinician will be familiar.

The works of Primo Levi, Alexander Solzshenitzen, Victor Frankl in their writing about concentration camps make the effects of extreme idleness horribly and distressingly clear. Robert Burton (1638 in Caulton 1998a) tells us that it is not just melancholy which brings about idleness, but that idleness brings about melancholy.

Causes of Melancholy – Idleness
Idleness of the mind is much worse than this of the body; wit without employment is a disease, the rust of the soul, a plague, a hell itself, Galen calls it. “As in a standing pool worms and filthy creepers increase” (the water putrifies, and air likewise, if it not be continually stirred by the wind), “so do evil and corrupt thoughts in an idle person,” (Seneca). The soul is contaminated. In a commonwealth, where there is no public enemy, there is, likely civil wars, and they rage upon themselves: this body of ours, when it is idle and knows not how to bestow itself, macerates and vexeth itself with cares, griefs, false fears, discontents, and suspicions; it tortures and preys upon its own bowels, and is never at rest. Thus much I dare boldly say: he or she that is idle, be they of what condition they will, never so rich, so well allied, fortunate, happy, let them have all things in abundance and felicity that heart can wish and desire, all contentment, so long as he or she or they are idle, they shall never be pleased, never well in body and mind, but weary still, sickly still, vexed still, loathing still, weeping , sighing, grieving, suspecting, offended with the world, with every object, wishing themselves gone or dead, or else carried away with some foolish phantasy or other…. As A. Gellius could observe; he that knows not how to spend his time, has more business, care, grief, anguish of mind than he that is most busy in the midst of all his business, an idle person (as he follows it) knows not when he is well, what he would have, or whither he would go (as soon as he comes to a place, he wants to leave it), he is tired out with everything, displeased with all, weary of his life; happy neither at home nor abroad, he wanders and lives beside himself

(First Partition, Particular Causes. Section 2: Of Head Melancholy, Outward).


The condition can be caused by all manner of things: losing ones driving licence, prison, school, unemployment, brain injury or retirement. These conditions can be incredibly difficult to circumvent once they have been entered into. Cowper describes the horrors of this state for the individual very well in his poem, when he describes the ‘toil’ involved in the condition of being retired.

From Retirement

Thus some retire to nourish hopeless woe,
Some seeking happiness not found below,
Some to comply with humour, and a mind
To social scenes by nature disinclined,
Some swayed by fashion, some by deep disgust,
Some self-impoverished, and because they must;
But few that court retirement are aware
Of half the toils they must encounter there.
Lucrative offices are seldom lost
For want of powers proportioned to the post:
Give even a dunce the employment he desires,
And he soon finds the talents it requires;
A business with income at its heels
Furnishes always oil for its own wheels.
But in his arduous enterprise to close
His active years with indolent repose,
He finds the labours of that state exceed
His utmost faculties; severe indeed.
‘Tis easy to resign a toilsome place,
But not to manage leisure with a grace;
Absence of occupation is not rest,
A mind quite vacant is a mind distressed.

William Cowper


From the outside the release from labour can seem like a great blessing, but actually the mind needs the engagement and without it can become clinically depressed. There is no greater torture for the mind than the boredom that comes with “indolent repose”. It is not something that affects only the cognitively challenged, even the man who has filled positions of employment with great competence will suffer in the same way. It is relatively easy to keep on going in a demanding job, than it is to find a way in a situation which makes no demands.

History can also speak about the destructive effects of a meaningless existence. The fall of the Roman Empire was preceded by a time when large numbers of the populace had no function but to amuse themselves. Collingwood (1938) describes this moment as part of his argument against art as amusement.

The critical moment was reached when Rome created an urban proletariat whose only function was to eat free bread and watch free shows. This meant the segregation of an entire class which had no work to do whatever; no positive function in society, whether economic or military or administrative or intellectual or religious; only the business of being supported and being amused. When that had been done it was only a question of time before Plato’s nightmare of a consumer’s society became true.

I have talked here about two of the ways in which occupation can begin to manifest itself as a problem. It is possible that alienation comes about through doing things which are somehow or other the wrong things to be doing in a particular situation. A profound moral echo begins to be felt when one explores the way that people become alienated through what they are doing. However, it is arguable that the greatest distress of all becomes manifest in the person who has nothing at all to do and I explore some of the things which can be said about the state of idleness.

Someone with all of his faculties intact, who has indeed demonstrated a high level of performance in his working life, can find the state of idleness brought on by retirement to be a huge challenge. It is a similar challenge faced by the young man with brain injury, who has not had the advantage of a life of worthwhile work behind him and who lacks the most basic resources with which to face this state. It could and should be perceived that instead of telling this person to ‘pull up their socks’, and instead of giving them counselling for the inevitable depression which they will be experiencing, it would be more helpful to provide the conditions for some kind of re-engagement in occupation. Most people will find a way out of the void themselves, or with the help of their loved ones. But there are others who do not have this kind of help available or whose need goes beyond anything which can be provided by family or friends. In this case, it would be useful to have a practitioner who had the skills and resources to enable the conditions for successful engagement in occupation. I attempt to describe in the next section what this successful engagement might look like.

Next page: Being well occupied




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