Case Studies

Sarah sustained a brain injury at the age of five months old following a road traffic accident. She faced a range of challenges as a youngster but her need for neurorehabilitation was not identified until much later in her teen years; this scenario is all too often apparent when the brain injury has occurred so early on in childhood. Sarah was described as being increasingly vulnerable in her relationships with her peers in her local community. It was reported that there were increasing incidents of aggressive behaviour, both verbally and against objects. It was clear that Sarah required support to develop skills central to the role of the frontal lobes as well as a range of other areas. Sarah was admitted to TRU’s Chapel House pre-community residential rehabilitation unit at the age of 19 years; it was envisaged that she would transition to a more independent living space on site and perhaps to her own property in the local area with the final stage being a return to her home of origin.

During the admission process, Sarah was assessed across the multidisciplinary team and a structure of activity was developed with her based on her interests and recommendations. Sarah struggled to identify her likes and dislikes but was able to commit to exploring options and learning to develop her own process of weighing up if she would like to continue with the activity or not drawing upon practising self-monitoring and self-rating. Sarah attended most of the vocational placements available at TRU, from wood shop to mechanics to craft and design to kitchens. All of these placements were ran by skilled vocational instructors who were able to support her and her rehabilitation coach to identify tasks at a level of challenge that she was able to cope with and thrive upon. By developing structure in this way, based on Sarah experiencing having meaningful roles and the development of skills, sense of mastery and increased self-esteem, she was able to build upon her successes. Sarah was able to develop and utilise compensatory external aids and systems (CEAS) that were meaningful to her – this way, they became useful and over time she was able to take more and more of a lead role in self-structuring leading to steady reductions in the need for one to one direct coaching.

Throughout her rehabilitation pathway at TRU, Sarah attended individual and group psychotherapeutic sessions. She was supported to increase her awareness of emotions both in herself and others. With time and positive experience, she was able to collaboratively begin to develop a range of goals to pursue. For example, she wanted to increase her confidence in a range of areas as this was a barrier at times to achieving her main long term goal. She was also supported to develop a Wellness Recovery Action Plan (WRAP), a document which focuses on increasing wellness by assessing and action planning for triggers and unhelpful early warning signs. This also proved helpful as she was able to access this whether a coach was present or not and as this is an evolving document, it is something she can choose to access following discharge.

Sarah successfully transitioned to living in one of the four independent living flats on the Chapel House site. She had achieved a range of goals to ensure that she could do so safely and was keen to remain grounded and identify further goals in order to move towards renting a property in the local area. The process from admission to discharge to TRU’s community outreach team was eighteen months. She had become increasingly skilled in self structuring, appropriate help seeking, increased independence in completion of CEAS and ADL’s. Initially, there were some challenges and she was supported to develop checklists for using new equipment and appliances and also had a coaching outreach package at key times to ensure successful transition. She was supported to increase her use of public transport and autonomy in accessing vocational placements, in line with her goal to maximise independence. Sarah set goals around pursuing voluntary work as she was keen to further develop her skills in real world settings. She secured a role that held personal meaning to her and she was able to integrate this into her structure and routine with minimal support, again drawing upon pre-learnt strategies. Sarah’s programme became increasingly focused on community based activities to promote independence. These transitions were collaboratively planned with her and she remained successful. At times, situations occurred that in the past may have had a negative impact on her day to day functioning; however, Sarah was able to respond to periods of lows by seeking support that she found helpful and reconnected with the ‘basics’ of taking time to process what was going on, problem solving and re-engaging with her structure and plans. She discharged successfully to a support package managed by her case manager. Sarah continues to enjoy her voluntary placement and has increased her hours spent there; she continues to ensure her weekly structure is meaningful and enjoyable to her.

Gary sustained his first brain injury at the age of 13 years due to falling from the roof of a house. He recovered well from this and completed school and a range of other courses, becoming highly skilled in the area of information technology. However, Gary later sustained a second brain injury due to seizure activity whilst driving at the age of 27 years. Prior to being admitted to TRU, Gary had spent time in a number of inpatient facilities sectioned under the Mental Health Act; primarily due to aggressive behaviour and paranoid ideation. At the time of Gary’s referral, it was reported that his presentation was largely underpinned by the complex array of neuropsychological difficulties he suffered due to the brain injury and this had culminated in deterioration in his mental health. He was admitted under 117 Aftercare to a psychiatric ward informally whilst attempting to identify a service that could meet his identified needs. His local services reported that they were no longer able to meet his needs and requested an assessment from TRU even though our service was many miles away.

At this time, Gary presented with aggressive behaviour directed towards others (which was most prevalent following seizure activity) and paranoid thinking patterns. He was described as having a range of cognitive impairments as a consequence of the acquired brain injury including impairments in memory functioning, attention and across areas of higher executive functioning. He also reported high levels of fatigue and difficulties in motivation leading to a lack of ability to initiate and follow through with basic or more complex activities of daily living.

Gary was admitted to TRU’s ABI Centre Newton locked rehabilitation facility on an informal basis. He was assessed by various clinical disciplines including neuropsychiatry, neuropsychology, speech and language therapy, and physiotherapy. From each of these assessments, collaborative goals were generated with Gary to inform his rehabilitation programme. Comprehensive plans were developed to achieve these and monitoring systems were in place.

Gary commenced medication changes supervised by the consultant clinical neuropsychiatrist in order to establish a stable seizure management medication regime. He was also introduced to various compensatory external aids and systems (CEAS) to support his cognitive impairments. These systems aimed to help him to manage his day to day activities over the week, plan for specific activities such as shopping and develop problem solving strategies for difficulties that may arise. Gary began to engage in psychology sessions in order to develop a greater understanding of his presentation and develop long term goals for his future.

Following his transition to the pre-community unit Chapel House, Gary was supported to fine tune daily living skills and further develop adaptive strategies and compensatory aids in order to prepare him for successful community re-integration. Throughout his neuro rehabilitation pathway, Gary showed skill and pride in individualising compensatory systems and this was an important driving force in him becoming more dependant upon himself to self-structure. Gary’s most recent transition was to an independent flat in an area local to TRU, supported by our community outreach team. During this time, Gary achieved a high level of independence; successfully managing to obtain his driving licence, maintaining the routines he had established through residential rehabilitation and increasing his independent community access for activities such as grocery shopping, social and leisure activities and medication management. He was also supported through psychology sessions to explore and challenge the problematic and negative thoughts he experienced which impacted on his psychological well-being and subsequent behaviour.

Since admission, Gary’s primary goal was to develop and maintain his psychological wellness and independence to a level compatible to being able to return to his home area and feel confident in this being successful.

At the time of writing, Gary is currently preparing for discharge back to his local area through collaborative planning with his team at TRU and professionals back home – Gary has approached this with positivity and has taken a lead role. To support him to achieve success, Gary has been involved in the development of risk assessment and management plans and extensive planning around maintaining his psychological well-being; this has included the development of management plans to support him to draw upon should he identify the presence of any trigger factors that may trigger a decline. Gary has been able to test out the helpfulness of these plans at times when he has noticed difficulties that have arisen – he has been pleased with his ability to get back on track by using strategies he has developed to be individualised to him.

Ray sustained his brain injury at 28 years of age – he was stood on a path and hit by a van with a set of ladders on the roof which struck him on the front right temple penetrating the skull and brain. He underwent surgery and it was reported that 8cm of his temporal lobe was removed. A CT scan showed substantial brain contusions on the right side and swelling to his brain. Within several days of the accident, he also suffered a stroke which left him with left sided hemiparesis. The events in Ray’s life after the accident are unclear; however we know that social services were involved due to him having experienced physical and financial abuse. This resulted in him being removed from the environment and his children being placed in care and adopted – as can be imagined, this was a traumatic and distressing time for Ray. We understand that at some point, Ray lived alone with a care package where someone visited him a few times a week. He was unable to look after himself to an acceptable level resulting in him struggling with basics of self and domestic hygiene and eating enough to keep healthy. He had also sold all of his furniture so his house was derelict. Ray found himself placed in services that were inappropriate to his needs, including a mental health service, a community package and a residential package. None of these services were experienced in supporting individuals with complex needs after brain injury and all were unsuccessful in meeting Ray’s identified needs. It was reported that since the brain injury, Ray had become increasingly aggressive and anxious. He attempted to cope by drinking alcohol excessively, but this frequently led to him being barred from local pubs and he did not want to be alone so he would invite local youths into his home. The risks escalated and culminated in a series of events that resulted in Ray being arrested and sentenced to prison following a fire arms offence. It appeared that he had pointed a gun at his landlord, but then asked the landlord to ring the police and report him for the offence. It was understood that Ray was not coping well at this time and had hoped that the police would shoot him when they arrived. It was at this stage that the need for Ray to have the opportunity for neurorehabilitation was identified, as it was acknowledged that serving a prison sentence was not an appropriate outcome for him. Therefore, some 16 years after his brain injury, Ray was referred for an admission assessment for a residential neurorehabilitation package to TRU Ltd.

Ray had a forensic history prior to his brain injury – however this did not exclude him from being a candidate for neurorehabilitation, nor did the time frame from injury. In terms of early history, Ray’s was one of eight children and there were a range of challenges in the home and social environment. His criminal activity started to be recorded at about 10 years of age and he was sentenced to a detention centre for robbery aged 15 years. He went on to serve several prison sentences as an adult including a three and a half year sentence for burglary.

TRU’s admission assessment acknowledged a role for residential neurorehabilitation and put forward a plan of care. Following liaison with the courts, Ray was transferred to TRU’s Lyme House neurobehavioural unit – this was sanctioned by a court order, with conditions to ensure there was monitoring and review of his progress. The court recognised that Ray had never had access to specialist rehabilitation services, that he was unsafe within the community due to his vulnerability and supported his right to specialist brain injury rehabilitation. Ray’s pre-morbid presentation including anti-social behaviour was considered; however, it was agreed that his brain injury and cognitive impairments had impacted as such to exacerbate pre-morbid characteristics.

When Ray was admitted to his residential neurorehabilitation programme, his main presenting difficulties were with regards to verbal aggression and physical aggression against objects. Aggression against others was not prominent due to his lack of confidence in himself physically. He had limited control of his emotions and attempted to ‘control’ those around him. Ray’s programme was largely psychology led and team support, supervision and development of strategies to manage difficult behaviour was key. At the outset, there were a range of barriers to Ray engaging in his rehabilitation programme and the primary identified factor was severe anxiety which was manifesting as aggression. In addition, Ray was territorial and very much aimed to be the ‘top dog’ as he called it – reminiscent of his background in correctional and prison facilities. Ray was intolerant of others and very concrete in his thinking style; he often referred to his court order and rehabilitation as ‘serving time’ and perceived this as a prison sentence with little focus on the potential for positive gains.

Ray’s brain injury had resulted in generalised impairment with regard to his verbal and non-verbal intellect. He had significant memory difficulties and suffered from a range of executive functioning impairments; Ray found it difficult to plan, organise, problem solve, think consequentially and had a rigid thinking style demonstrating impairment with regards to cognitive flexibility.

Ray’s heightened emotional arousal was a dominant factor that contributed to his presenting difficulties. A key area was his fear of having a seizure. It appeared that after his accident he had suffered seizures which had resulted in him feeling vulnerable and out of control. He therefore became anxious when he experienced emotional arousal and started to misinterpret the symptomology of anxiety as the onset of a seizure. He over-estimated the risks and underestimated his ability to cope. He therefore attempted to control others around him to feel safe and developed a wide array of safety behaviours. He did not like to be alone and would not leave the unit grounds. He also had anxiety regarding travelling in vehicles which again contributed to him refusing to leave the unit to attend activities. He was low in mood, had low self esteem and was very distrusting of others.

Ray was very reliant and controlling of his allocated coach and this was attributed to his anxieties. He reliably worked within his psychology sessions to a shared understanding of how things were for him and he was agreeable to this being discussed with his coaching team to help them understand and work with him better. Ray was introduced to some basic compensatory external aids and systems (CEAS) to support him to create a structure and to enable him to get through his day despite the impact of his cognitive impairments. He responded well to a cognitive behavioural therapy (CBT) model of working, adapted where necessary in consideration of his difficulties. It was important to have a coach he trusted present as a supporter both within session and to ensure carry over outside of session; be it reviewing information discussed, reminding to carry out tasks set for out of session, helping to recall details of events discussed. It was also agreed what bits of information would be beneficial to cascade to his wider team and which would remain fully confidential to those present – to maximise consistency of Ray’s support from a range of coaches. The staff team also worked with Ray on psycho-education around seizures and epilepsy and he created a pack of information for other clients. During this time, Ray gained greater emotional stability and there was a significant reduction of verbal aggression and increased collaboration with the team around him.

The gains Ray had made resulted in him transferring to one of TRU’s other units as a stepping stone toward achieving a successive further move to our pre-community/community re-entry unit. All of the systems and strategies he utilised at the neurobehavioural unit were transferred with him, as it was acknowledged that maintaining consistency in all other areas of his life at this time was essential. At this point Ray had gained greater control over his emotions and behavioural responses, so the focus shifted to support him to gain increased independence with his activities of daily living and community re-integration. He was supported to take small achievable steps towards developing his ability to self-structure. The team also supported him to work on developing his problem solving abilities which incorporated elements such as cognitive flexibility and consequential thinking. Continuing to explore Ray’s interests and values to develop a more adaptive social identity was central to identifying a meaningful role for him to enhance his self esteem and self worth. In line with his interests, he commenced a gardening role on the unit and encouraged other clients to participate with him. His sense of mastery, success and achievement steadily increased. Ray became increasingly confident and was able to find the inner resources to focus on engaging in a graded exposure programme regarding both travelling in a car and increased community access. He was successful in this and therefore was increasingly able to access off site vocational sessions to extend his structure and meaningful activity. Through the counselling therapy that Ray had been having, he decided that he wanted to write about his life to illustrate some of the struggles and successes he had achieved.

Following success here, Ray transitioned to our Chapel House unit. The aim was to socialise Ray to the environment with increased focus on developing self reliance and self-structuring. There was potential for Ray to further transition to an on site independent flat to assess his level of need of support; monitoring help seeking, problem solving and a range of other skills. This was the final stage before community re-entry and again with this transition, all the systems and coping strategies previously developed remained consistent. We therefore focused on maintenance of the achievements that he had already made. Psychology sessions moved on to focus on developing a wellness recovery action plan with Ray and again this was utilised and promoted by the core team around him. Also, now that Ray had gained more awareness around his anxieties and social judgement, the team worked collaboratively with him to create his own risk assessment for community living. This focused on areas of maintenance such as activities of daily living routines, but also included elements such as self neglect, vulnerability and exploitation which were clear factors of risk previously and Ray was keen to avoid recurrence. Ray used this risk assessment and the wellness recovery action plan to create a personalised document entitled ‘staying well’.

Ray’s court order came to an end but even so, he continued to work on his neurorehabilitation goals and successfully transitioned to the local community where he now resides in a bungalow. Upon discharge from active rehabilitation, all the systems and strategies transferred with him. Also due to the new environment, additional systems were implemented to maximise his success. At present, he has a significantly reduced support package when compared to his support needs upon admission at TRU. To Ray’s absolute credit, he has not been involved in the legal system since neurorehabilitation and he is mostly content with his life these days.