The effects of brain injury

The effects of brain injury are by and large not understood by the world. The person who manifests symptoms of lack of motivation is more than likely going to be accused of laziness. In a world which is a cultural construction, the person with cognitive deficits is more likely to have their behaviour interpreted in cultural terms. The fact that so many people with brain injury end up in prison is one of the most obvious pieces of evidence of this fact. A good neuropsychology assessment is critical in identifying the origin and extent of cognitive changes for the person with brain injury, but it is not possible to force the world to read these reports and have any kind of understanding of their implications. It is worth drawing attention to the similarity of the words used to describe the deficits which are of biological origin and those which have a cultural basis to appreciate why the work of the neuropsychologist is so important for promoting a real understanding of what the person with brain injury has to live with.

There are…… signs of a defective capacity for self-control or self-direction such as emotional lability or flattening, a heightened tendency to irritability and excitability, impulsivity, erratic carelessness, rigidity and difficulty in making shifts in attention and in ongoing behaviour. Deterioration in personal grooming and cleanliness may also distinguish these patients…..there is impaired capacity to initiate activity, decreased or absent motivation (anergia), and defects in planning and carrying out the activity sequences that make up goal directed behaviours. Patients without significant impairment of receptive or expressive functions who suffer primarily from these kinds of control defects are often mistakenly judged to be malingering, lazy or spoiled, psychiatrically disturbed, or - if this kind of defect appears following a legally compensable brain injury - exhibiting a 'compensation neurosis' that some interested persons may believe will disappear when the patient's legal claim has been settled. (Lezak 1995).

The neuropsychologist is the person best placed to give an accurate diagnosis and possible prognosis for the brain disorder. The prognosis should include some idea of the time scale over which neurologic recovery can be expected, together with an eventual outcome, where the level of recovery is likely to reach a plateau (Mills, Cassidy, Katz 1997). A diagnosis of traumatic head injury is not enough to give this kind of information, and it needs further elaboration of the kind provided in the report quoted above in the Introduction to this thesis:

Mr Williams was admitted to Rathnew Hospital in a deeply unconscious state after a motorcycle accident in 27 December 1991. At admission his Glasgow Coma score was 5/15 and a CT head scan showed brain swelling and diffuse brain injury with numerous small haemorrhages in the right hemisphere and in the left occipital lobe. He remained unconscious until about the 20th January. …On 12th February 1992 he uttered his first words. A CT scan in February 1992 showed mild cortical atrophy and this picture has been present in subsequent scans. He received a very severe closed head injury as indicated by the duration of coma and his period of post-traumatic amnesia which was estimated by clinical staff as up to 3 months.

This level of diagnosis allows one to predict the kinds of outcomes that will ensue and these can be summarised (Mills, Cassidy, Katz 1997):

Cognitive problems involve deficits in attention, memory, and higher-level regulatory or executive processes. Even after the basic elements of attention resolve with the passage of the confusional state, more complex attentional problems remain. Patients usually have a slowed rate of mental processing, increased susceptibility to distracting interference, and difficulty dividing attention among tow or more tasks. The functional implications of these problems include slowed completion of more complex everyday activities (eg meal preparation) and difficulty concentrating on more than one thing at a time (eg talking and driving).

Although dense amnesia is not usually seen in uncomplicated injuries, memory problems remain. Patients are often forgetful, have trouble with ‘automatic,’ passive memory and have less effective learning strategies. Even when tests of general intellectual function have normalized, higher cognitive processes such as those associated with the frontal systems remain dysfunctional. These so-called executive problems present during tasks that require flexible thinking, deviation from routine, and self-reflection. Due to such problems, planning an alternate route when encountering heavy traffic or efficiently organizing a number of errands may become overwhelming. Frontal system dysfunction also leads to the emotional and behavioral problems that are so common following brain injury. With the loss of orbital frontal supervisory control over emotions and appetitive drive states, impulsivity, disinhibition, and personality changes occur. However, when lateral frontal dysfunction predominates, patients are apathetic, unconcerned (abulic), and unmotivated.

Limbic disconnection syndromes produce mood disorders, irritability, and on occasion, outright aggression.

This description gives many of the expected outcomes for someone with a severe diffuse traumatic brain injury at the end of the recovery stage. The timeline for recovery for patients with severe diffuse injury extends over years, however there comes a point where they are ready for community re-entry. The most well known description of the epochs of recovery for this type of injury is the Los Ranchos scale (Hagen et al 1972). At this point, which equates to levels VII and VIII on the Los Ranchos scale, there are other factors which become more important and neurology simply becomes one factor among many which needs to be considered -

This final stage of recovery is better delineated by psychosocial criteria than by specific neurologic milestones. As such, the impact of the underlying neurology on recovery lessens and an individual’s premorbid personality and social resources become increasingly important in predicting outcome. Premorbid developmental, medical or psychiatric disorders and the support of the person’s social network all play increasingly important roles in determining how fast and how far he or she will progress (Mills, Cassidy, Katz 1997).

These authors then proceed to say that this progression will lead to further cognitive improvement, which will in turn lead to community integration and an new self awareness. They indicate a complex inter-relationship between cognitive functions and what the person goes on to do, without elucidating the details. I suspect that work could be done on this relationship between the brain and normal behaviour, but it would not be useful. We already have ways of describing degrees of competence in normal behaviour and we no longer need the neuropsychologist at this point. I return to Ryle (1949) for corroboration.

The classification and diagnosis of exhibitions of our mental impotences require specialized research methods. The explanation of the exhibitions of our mental competences often requires nothing but ordinary good sense, or it may require the specialized methods of economists, scholars, strategists, and examiners (p. 398)

The kind of knowledge that I need in order to ‘know how to go on’ does not require a degree in psychology. I do not need to know psychological theory and have an ability to apply it in order to understand whether a cupboard door has been hung competently, or a table made correctly. However, some rudimentary idea of carpentry might be useful if I am to judge his performance as successful or otherwise.

Understanding is a part of knowing how. The knowledge that is required for understanding intelligent performances of a specific kind is some degree of competence in performances of that kind. The competent critic of prose-style, experimental technique, or embroidery, must at least know how to write, experiment or sew. Whether or not he has also learned some psychology matters about as much as whether he has learned any chemistry, neurology or economics. These studies may in certain circumstances assist his appreciation of what he is criticizing; but the one necessary condition is that he has some mastery of the art or procedure, examples of which he is to appraise. For one person to see the jokes that another makes, the one thing he must have is a sense of humour and even that special brand of sense of humour of which those jokes are exercises. (Ryle 1949 p. 53)

The occupational therapist takes the effects of brain injury into account

Neurology is therefore extremely important in providing an understanding of the underlying deficits which the person with brain injury has to live with. It is particularly important that there should be an understanding of these deficits because they have so many cultural manifestations which would cause the person with brain injury to be condemned if they are not understood. Improvement in the underlying cognitive deficit can continue for years, especially after a severe diffuse injury. However there comes a time when this improvement is irrelevant in relation to all the other factors which are impacting on him. At this point, while the underlying deficit continue to be held in mind, the progression that he makes cannot be considered in neurological terms. His performance at this point needs to be described and judged in terms of competencies rather than in terms of deficits.

At this point one begins to reach for a concept of the mind which might accommodate this particular kind of knowing. Ryle provides this in one of his more controversial theories, which yet seems to exactly describe what I am trying to say.

The statement ‘the mind is its own place’, as theorists might construe it, is not true, for the mind is not even a metaphorical ‘place’. On the contrary, the chessboard, the platform, the scholar’s desk, the judge’s bench, the lorry-driver’s seat, the studio and the football field are among its places. These are where people work and play stupidly or intelligently. ‘Mind’ is not the name of another person, working or frolicking behind an impenetrable screen; it is not the name of another place where work is done or games are played; and it is not the name of another tool with which work is done, or another appliance with which games are played.

I find myself agreeing with Ryle’s notion that our mind exists in the places where it is engaged. It seems to echo Marx’s idea that of work that “the blacksmith forges and the product is a forging”. Neurology provides a way of looking at the mind/brain, but I find that it is not the way that I look at the mind of someone who is grasping at achieving the fullest expression of his humanity possible.

I start with a definition of occupation, and then look at literature which indicates that by acting on the external world man changes his nature. This world is something which we hold in common and I emphasise this commonality throughout. I then talk about alienation and idleness as two particular manifestations of the need for occupation.

The notion of being well occupied can best be described by describing actual engagement in particular activities. However, it is possible to outline some things which are common to most manifestations of being well occupied. It is a fact that we are well able and used to judging what people do already, we understand behaviour without needing any special qualification beyond belonging to a common culture. The predicament of needing occupation could be described as not ‘knowing how to go on’ and in this section I describe what form this ‘knowing might take. I say that it will take the form of the activity which is being done, whether that be playing a game of chess, or making a table. Some examples are given of how an activity might be analysed when using this framework. A critical part of any activity is the finishing of it and there are many things associated with a thing that is finished, compared to things which are not finished. I try to describe some of these differences and the associations that come from the satisfactory completion of some types of occupation. I move then to a theory which says that our task is to find our ‘real work’ and that we create a world of hope and a space for action. Within this space we can reflect back the meaning of what we have done, and our real individuality begins to take form. I give some small vignettes, which illustrate some of the ways that this framework has been described in the literature.

Then I explain they reasons why I have not focussed on the very extensive literature on neurology to answer my research questions. This point is touched on when I define what I mean by ‘common sense’ and how an exclusive focus on deficits can isolate the person with brain injury. I strongly believe that good diagnosis and prognosis is essential, but even in the neuropsychology literature it is said that psychosocial criteria are more important than specific neurologic milestones, in the longterm. I therefore conclude with a return to the idea that the kind of understanding that is needed here is an understanding of occupation. By keeping the focus on occupation it is possible to arrive at a theory of the mind which is congruent with it.

Next page: The need for occupation

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