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Article Excerpt
Traumatic brain injury (TBI) can cause irreparable harm to individuals and have profound effects on families and communities. In addition to the physical and neurological effects, brain injury creates an intense boundary experience for clients that forces them to confront the existential givens o f freedom, death, isolation, and meaninglessness. This article provides an overview of TBI and its existential implications for clients, emphasizing interventions and clinical considerations for mental health counselors working with clients who have experienced TBI.
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According to the Brain Injury Association of America (2007), every 23 seconds someone in the U.S. sustains a traumatic brain injury (TBI), and more than 5.3 million people in the U.S. need long-term or lifelong help as a result (National Center for Injury Prevention and Control, 2006). After hospitalization and rehabilitation, many of these clients seek counseling, either to help with readjustment to life after the injury or to ameliorate mental health issues. These numbers are guaranteed to increase, in some instances dramatically, as Iraq War veterans return to the U.S. In fact, part of the $900 million the U.S. Congress has added to the Department of Defense budget for the 2007/2008 fiscal year is designated specifically to support research on brain injury and treatments for TBI (Munsey, 2007). Research by the Rand Corporation (Tanielian & Jaycox, 2008) has also revealed that PTSD, depression, and TBI among U.S. troop members are serious health concerns, and that TBI in particular is not well understood. The Rand study emphasized the need to train more mental health counselors to respond to these concerns.
Counseling clients who have experienced TBI can be compelling work. In addition to the physical and neurological effects, experiencing a brain injury immediately creates a boundary experience (Yalom, 1980) that forces clients to confront the existential givens of freedom, death, isolation, and meaninglessness. Although mental health counselors may feel underprepared to respond to their clients' physical and cognitive deficits, most would acknowledge that creating meaning amid chaos and fear is well within their expertise. However, some counselors may need additional training and support to understand the unique characteristics of clients who have experienced TBI. This article provides a brief overview of TBI and its existential implications for clients and concludes with recommendations for counselors.
OVERVIEW OF TBI
TBI occurs when a blow to the head impairs brain functioning (National Center for Injury Prevention and Control, 2006). According to the Brain Injury Association of America (2007), the leading causes of TBI are falls, motor vehicle accidents, and assaults. The head injuries that accompany TBI are usually categorized as either open or closed. An open head injury occurs when the skull is penetrated and brain tissue exposed. However, a closed head injury, in which the skull remains intact, can actually cause more damage because the force of the trauma goes directly to the brain instead of being partially deflected by the brain tissue (Miller, 1993). The brain injury resulting from either type of head trauma is classified as mild, moderate, severe, or catastrophic. All these classifications can encompass physical, cognitive, behavioral, and psychological symptoms, which vary depending on the area of the brain that is injured.
With a mild head injury the person may appear to be unimpaired. However, physical symptoms may include migraines, nausea, vomiting, blurred vision, fatigue, and numbness in the hands and feet. Cognitive problems include difficulty concentrating, increased distractibility, difficulty reading, and an inability to pay attention or solve problems. Behavioral and psychological problems associated with mild brain injury include depression, increased anxiety, mood swings, sleep disturbances, irritability, and loss of libido (Senelick & Dougherty, 2001).
A moderate brain injury occurs when a person is unconscious from 15 minutes to 24 hours. In addition to the symptoms listed above, a person with moderate brain injury may experience tremors, balance problems, paralysis, memory deficits, lack of coordination, language problems, perceptual difficulties, and difficulties with emotional expression. A person with a moderate brain injury is likely to spend time in a rehabilitation center after hospitalization (Senelick & Dougherty, 2001).
A severe brain injury occurs when the person is poorly responsive for at least one day, meaning he or she cannot react in a typical manner to external stimuli (Brain Injury Association of America, 2007). The injured person may have the same problems as those with mild and moderate brain injuries but with increased severity. A person with a severe brain injury will have a physical disability, such as muscle coordination problems, spasticity, or paralysis. Many of these people will need assistance with daily activities.
Catastrophic brain injury results in a coma that can last an undeterminable length of time. A person in a coma cannot speak, does not exhibit awareness of his or her surroundings, and may display only primitive reflexes (Brain Injury Association of America, 2007). Some people do emerge from coma, but their lives are usually dramatically affected, and most will require substantial assistance with daily living.
EXISTENTIAL IMPLICATIONS OF TBI FOR CLIENTS
It is important for mental health counselors not to assume that any two individuals within the same TBI category have the same limitations in function or the same emotional problems. All clients with brain injury do not react in the same way; many have extensive capacity for insight and are able to engage in rich clinical dialogue (Miller, 1993). Further, in addition to the psychological stages of adjustment that clients with TBI experience, they also face a range of behavioral, cognitive, and affective implications. The particular ramifications of TBI therefore vary tremendously, depending on the client's injury, personality, and environmental context (Prigatano, Borgaro, & Caples, 2003). However, in general, one...
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