“Life is just one damn thing after another”, says Donal. For him, brain injury represents just another bump in the journey of life. His work commitments had led him to work longer and longer hours, and his marriage had spiraled towards breakdown. He was drinking in the evenings just to try to get some sleep. Life was becoming unmanageable long before the car accident that left him with memory loss, organizational difficulties, problems with impulse control and aggressive outbursts that have necessitated numerous police interventions, including three arrests.
For many people with acquired brain injury, the narrative they have established to account for their lives involves being a victim of life circumstances. Brain injury represents calamitous loss, and the journey of life is imagined as an attempt to regain or restore the former version of the self. In some cases, complete recovery is not possible, and the journey therefore appears doomed to frustration; either a resigned defeat by life’s circumstances, or an eternal quest for that version of the self that can no longer be.
The traditional treatment model is often designed to train people with brain injury to fit in with the world. Through attempting to build insight, or through skills teaching and contingency mananagement, or through use of medication, the aim often seems to be to help the person with brain injury blend back in to the world. This is increasingly at odds with a more mindfulness- based model, which emphasizes coming to understand and accept the self that you are. It can also contrast with a person-centred approach, which attempts to change the world to create a greater fit with the needs and impairments of the person. A comprehensive model of rehabilitation, then is one that combines all three approaches. It combines an understanding of survivor’s neuropsychological assets and impairments of the person with the psychological and social demands of the environment and seeks to create an individualized environment in which the person can achieve cognitive, emotional and behavioural success.
Neuropsychological assessment, interviewing the person about the impairments they experience and the demands they are facing, observing the person as he or she attempts to overcome those impairments, interviewing people who know the person well; each of these offer the clinician an insight into the world experience of the person, which is the stating point for any neuro-rehabilitation process.
Recovering from brain injury may mean discovering that other narratives are possible. Malia and Brannagan (2007) liken the process of adapting to a brain injury to a hero’s journey. The key components of a hero’s journey are having a real need for change or a more meaningful life, overcoming the challenges faced by departing from our normal state, the land of the known, encountering and embracing adventures along the way, and obtaining enormous benefit at the end of the journey, not from arriving but from having travelled. The person who perseveres and overcomes the challenges of the hero’s journey, who transcends limitations and reaches a new level of meaning, is transformed into something better. The hero becomes a role model for us all.
In Donal’s case, recovery from brain injury meant realizing that life had offered him a second chance. Donal might have been killed in the road traffic collision. Recovery involves realizing that progress is not only made by relearning old skills, but also
by organizing the environment to accommodate or compensate for difficulties now experienced. For example, Donal uses a range of daily and weekly schedules and calendars, to overcome many of the problems with memory he currently experiences. Recovery involves realizing that the person can still live a satisfying life, even though he or she has impairments as a result of the brain injury. With more time on his hands as a result of being out of work, Donal has been able to form friendships and develop the caring side to his nature that the business of his lifestyle before his injury prevented him from developing). Sometimes, there can even be positive consequences to a brain injury, which are worth amplifying. For Donal, recovery from brain injury means becoming comfortable with himself and his life. It means becoming grounded in what really matters.
It means learning to take breaks and to listen to the early signs of strain in the mind and in the body; and learning to sit with pockets of pain that his mind started to run from a long time ago.
In practice, Donal and his neurorehabilitation team have a multi-element plan. In includes adaptations to the environment (a whiteboard on his living room wall, a Google calendar which give him SMS reminders of his schedule; a Dictaphone and notebook for recording important conversations and events); a spreadsheet for organizing and managing complex tasks; a
weekly schedule of exercise to promote recovery and prevent depression; supports for budgeting and menu planning. It includes skills teaching (mindfulness; goal management; scheduling; assertiveness and conflict resolution). It includes focused strategies for avoiding or overcoming problem situations. And it involves knowing how and when to ask for help and rely on others. After a time, the Donal and his rehabilitation assistant develop this plan into a checklist, and gradually, Donal takes more responsibility for maintaining the supports he has learned keep him in a life of his choosing.
For many, a brain injury is experienced as a sudden and violent rupture in life’s journey, for which there appears to be no possible explanation. Sometimes, it seems, the only possible explanation is that there is no explanation; that we do not have the gift of writing the script for life, and that we all must at some stage accept suffering as a natural fact of human existence and face up to our challenges. It is not easy, but it is the first step on a truly heroic journey.