A Journey Through Brain Injury, Identity, and Growth

In 2023, the client was diagnosed with epilepsy which came as a shock and posed a new challenge to the client and his family as it was some considerable time post injury.

The client presents as full of bravado and attitude and it took some work to get a glimpse of the person beneath the façade. The Case Manager used her coaching skills to get to know “the real client”. It was then that they were able to get an idea that he had clear aspirations of what he wanted to do with his life. Cognitively he had been significantly affected by his injury and his working memory, short term memory, attention, executive skills all had been significantly affected. He had a low threshold to managing his temper and would display signs of anger to those around with a “sharp tongue” which at times was difficult for the team members.

His parents had separated and he initially lived with his Mum but his Mum and Dad had very different parenting styles. The client’s Dad had a very soft and sensitive approach, his perspective was that he had been through a lot, he was aware of the opinions of the experts and so was aware of his future prognosis. Mum presented as a person with strong opinions of the way things should go and would argue with Dad and say that he was being too soft. As a result of this tension the client would align with Dad as he generally got what he wanted, and he would clash with Mum. The client had two older brothers and he looked up to them, they were influential in his life however they chose to use recreational cannabis which brought about its own challenges.

One of the regular challenges working with the client was that he had a really strong sense of entitlement about money. Initially Mum managed finances but a Deputy was brought on after a few months. The Case Manager worked with the Psychologist, Mum and Dad; to try to get everyone on same page with regards to finance, they tried to employ some common practices and agreements in place as the case was getting time heavy with requests from the client regarding large spends. Some of the challenges were that his brothers would sell him things, the client was inclined to impulsive spending and so the team would try to drip feed the money, ask for receipts, in an attempt to try to manage the spend. It was important to have safety systems in place to safeguard that there was no exploitation going on. The family were receptive to the psychologist intervention and the suggestions made.

Initially there was only a personal trainer and an OT involved in the case. The client had been through several MDT members including physios and support workers. He was disillusioned about therapy and he said he couldn’t see the point in it. When Joy became involved, she knew that she was a “fresh face” and it was an opportunity for him to reset. She noted that he wasn’t good at sitting and would pace a lot and so she made her attempts at engaging him in rehab again visual, she wanted to tune into what she thought would land with him, she took a few different constructs around journeys, goals, stairs, roads, aspirations with her. The road construct enabled him to share that he
wanted to explore buying a business to do up houses with his brother and to have his own place. He also shared that he was into golf and so they worked together progressing the independent living picture.

The client needed a support worker to work with him to provide structure and purpose to his day and he gave the case manager a brief of what that person would be like. He said that it needed to be a young male with the right personality fit for him and he needed to fit into his social group. There was always a “honeymoon period” when the support workers were introduced and a couple moved on. The client’s memory was significantly affected and whilst on this independent living journey there would be the occasional set back or disappointment and he would vent to whoever walked through the door. Joy became aware very quickly that they needed a tight team and so set up a WhatsApp group so that all communication was accurate and immediate and information didn’t get lost through translation.

When the client got triggered, it would be quite intense and someone in the team would be targeted with the negativity. Neuropsychologist worked for a long time to support the Deputy and the rest of the team when he was triggered as it was difficult to manage and was often in public. It was also used to celebrate in the moment and to keep the team solid and consistent in their approach.
As the rehab progressed towards independent living the team were of the view that he needed some structure and accountability. In the past he had not stuck to anything. To support him with this phase one was designed with specific targets and markers to progress to step two. Visual structures were provided at home where he could tick things off when they were achieved. The first month didn’t go so well with lots of push back and grumbling but then he realised what he needed to do and stepped up a bit. The client had a low threshold to boredom, and if it felt “samey” wouldn’t be in the game for long.
The therapists would arrive for their sessions with a developed plan for the day and would then need to work on what he was willing to do that day, often pulling on all of their creative resources as his engagement was key to success. A few rehab assistants were involved which worked well as they could pull in a new one when needed to present a new fresh face at any point.
Part of the success was to introduce an incentive system which was a round of golf. The incentive was that by Friday if the client had attended 75% of his therapy sessions he qualified for a round of golf on Monday. The Case Manager was tasked with delivering the news so that the relationships with the therapist were not affected.

The client reached a point where he had achieved phase 1 and phase 2 was looking at a property. An OT was sourced to assist with his quite specific request about where he wanted to live.

And then the client changed his mind, he decided that he didn’t want to live
independently. This decision was made by the client right near to settlement and so the Case Manager wanted to check that this was his informed decision. The client was no longer engaging with the Case Manager; it seemed that he simply wasn’t ready to live independently. He said that he can do it later on down the line when he was ready and when claim was settled. Joy used to be able to see him with Dad or the neuropsychologist, but then the client threatened to cancel his session if she turned up and so the MDT realised that they needed to move onto the next stage and instruct a fresh case manager with the settlement where they could have a fresh start without focusing on independent living.

The Case Manager was able to engage the client in his rehab journey through
spending time trialling what worked well for him specifically. Ultimately he was empowered to be able to verbalise that he had changed his mind and opted out of the independent living.