Question

Describe the key psychological, somatic, cognitive, neurological and behavioral issues counselors must be aware of when counseling a client with trauma.

Answer 1

Traumatic brain injury (TBI) has been defined as an insult to the brain caused by an external force that may produce diminished or altered states of consciousness, which results in impaired cognitive abilities or physical functioning. Brain injured people present with a variety of problems and the nature of which depends in part on the site, extent, and severity of the damage and the age at which it occurred. Behavioral, motor, sensory, emotional, social, and cognitive problems are common after many kinds of brain injury. Some people may demonstrate all of these problems while others demonstrate just one or two. Neuropsychologists can be involved in the treatment of any and all of these different problems.

Although motor problems are most likely to be treated by physiotherapists, who are trained to prevent deformities and contractures and to understand how to reteach motor skills, neuropsychologists can assist physiotherapists in encouraging success in rehabilitation in several ways. Brain stem damage can lead to difficulty controlling fine movements. Damage to the cerebellum may lead to gross tremor and a staggering gait. Frontal lobe damage may cause difficulty in initiating movements or may result in the poor sequencing of motor movements involved in such tasks as making a cup of coffee or changing bed linen. Focal lesions may lead to permanent and intractable motor impairments.Behavioral assessment and task analysis can be used to measure and understand motor disorders. The Premack principle (i.e., using a desired activity to reward an undesired activity) cab be employed together with shaping and positive reinforcement for patients refusing to do prescribed exercises in their physiotherapy sessions. A number of head injured people show good motor recovery if this is measured by functional mobility .

Sensory impairments are also common after CNS damage. Hemiplegic stroke patients frequently lose sensation in their paralyzed limbs and may, as a consequence, damage themselves by trapping a leg in the spokes of a wheelchair or by burning an arm as a result of leaving it too close to a radiator. Visual sensory deficits are common following stroke, head injury, tumor, and other kinds of brain damage. Hemianopic patients can be taught to compensate for their visual field loss through, for example, improved scanning. It is even possible to reduce other visual deficits such as myopia through treatment procedures. Auditory sensory problems are less frequently encountered, although occasionally head injured people become deaf as a result of the accident. It is sometimes possible to teach these people sign language or another alternative communication system. These programs are implemented by speech and language therapists, although neuropsychologists may also take on such treatment, either alone or working together with the speech and language therapists. Principles from learning theory and other branches of psychology can enhance learning.

Emotional and social difficulties, including fear, anxiety, depression, and social isolation, are faced by the majority of brain injured people. Depression and anxiety can be expected in about two thirds of patients with TBI . TBI patients are also likely to face social isolation . Emotional changes are also seen frequently in stroke patients. Left and right hemisphere strokes tend to cause different emotional problems. Those with right hemi- sphere lesions are likely to show denial or indifference to their problems , while those with left hemisphere lesions are more likely show a catastrophic reaction. Patients with brain stem strokes may well show extreme emotional lability. There are three main factors that cause emotional and psychological problems after brain injury. First are neurological factors that provoke disturbances by the disruption of the specific neural mechanisms subserving the regulation and control of emotional and social behavior. Second are psychological or psychodynamic factors involving attitudes towards the disability arising from awareness of the disability and its implications for the patient's quality of life. Third are the consequences of the functional impairment on the patient's social network and social activities. Anxiety management procedures, cognitive therapy, and other methods for dealing with depression, family therapy, and social skills training can all be applied to brain injured people as well as to those whose mental health problems arise from psychiatric causes.

Behavior problems, frequently seen at some stage in people with severe head injury, may worsen over time if not treated properly. Common problems associated with severe head injury include yelling and swearing. Less common but more difficult to manage are physical violence and sexually offensive behaviors. Such problems may result in patients being admitted to long-term psychiatric care. Even very severe behavioral disturbance may respond to behavior modification regimes.

Cognitive, emotional, and behavior problems are far more likely to impede return to work or independent living than the more obvious physical problems. Disorders of learning and memory, information processing, planning and organizational problems, slowness of intellectual activity, and communication are all common after TBI . Less common are the agnosias, apraxias, and aphasias although these are often found after stroke, hypoxic brain damage, and some tumors. People with cognitive handicaps can have impaired judgment and be slow to learn new things; they may be unable to remember what they were doing a few minutes ago, and be very slow to process information. As a consequence, they may remain permanently dependent on their families. Many of these are unaware of the extent of their problems and may think they can do things just as well and just as quickly as they were able to do before the brain injury. Such lack of insight is likely to impede rehabilitation efforts. Behavior problems can exacerbate the situation as people with tantrums and poor self-control are not readily tolerated in society. Apathy and indifference reduce the chances of obtaining and holding down a job. Personality changes, mood swings, inappropriate social behavior, concrete thinking, and loss of sense of humor all reduce the chances of successful reintegration into society. Cognitive rehabilitation strategies can be employed to enable brain injured people and their families to live with, manage, by-pass, reduce, or come to terms with cognitive deficits resulting from an insult to the brain . This can be achieved through a process in which brain injured people work together with health service professionals to remediate or alleviate cognitive deficits.