Reflection on time with clients post-TBI

Our UPL Case Managers working with individuals with a Brain Injury:

• Have a minimum of 6 years Neuro clinical experience in statutory and/or private services.
• Have a holistic approach to their INAs and Case Management, ensuring that the multiple factors which may be influencing a client’s presentation, needs and any presenting risks are considered, addressed and reviewed.
• Adopt a collaborative Multi-Disciplinary Team (MDT) approach to supporting their clients and their support system.
• Support both their clients and their support system with navigating their rehabilitation journey and the possible challenges which may present during this time.
• Utilise UPL Clinical Supervision to discuss and review any complexities and/or risks which may present during an individual’s rehabilitation.
• Engage in peer support and reflective practice with other clinicians to support with problem solving, identifying solutions and peer learning
• Are supported and encouraged to attend training and courses to continue to
  enhance their clinical knowledge and further their understanding of available
  services (statutory, private and charitable)

An INA visit was completed promptly at the Josh’s home at the end of April 2024.

Goal areas established with Josh included:

• returning to meaningful employment
• talking therapies
• obtaining a UK car driving licence
• returning to previously enjoyed hobbies / interests

Presenting barriers at the time of the INA included:

• Josh did not believe that he had any residual impairments following the TBI
• Josh’s mobility had improved significantly, therefore he believed that he was back to his pre-admission baseline
• Josh presented with hospital and therapy fatigue
• Limitations of patients’ insight and awareness of their difficulties in particular, may impact on their ability to engage effectively in rehabilitation, and may therefore affect the timing of intervention (Rehabilitation following acquired brain injury, National Clinical Guideline, p18)

Positive attributes for rehabilitation at INA included:

• Josh was keen to engage in psychology input to talk about what he had been through
• Josh agreed to an Occupational Therapy and Physiotherapy assessment to obtain support with returning to meaningful employment and to further improve his mobility,
• Josh was receptive to CM input, taking CM calls and he would call the CM to discuss any issues or concerns that he was experiencing
• Josh was eager to resume his previous activities, return to employment and ‘normality’
• “The cognitive effects of brain injury may not be as obvious in the early days of injury
  and may be more apparent once the brain injury survivor has returned home or
  attempted a return to work. They may therefore take longer to understand and
  adjust to than some of the other effects of brain injury.” Headway

Rehabilitation:

• Weekly Neuropsychology input, focused on establishing a valued therapeutic relationship
• Specialist Neuro-Occupational Therapist completed initial assessment and 1 session, this input was terminated by Josh when he found temporary work believing that this was the sole purpose for the OT input
• Specialist Neuro-physiotherapist provided exercises and intermittent review of Josh’s progress, scheduling these sessions around his work became challenging
• Josh was deemed medically fit to drive by his GP, consultant and DVLA, passing his car driving test and obtaining his UK car licence
• Reviewed by the NHS Consultant Neuropsychiatrist who discharged Josh from their care
• Commenced employment at Kwik Fit

Discussion with Clinical Lead:

• Josh had made good progress returning to work and some meaningful activities
• Josh continued to communicate regularly with the CM, however, he was reluctant for any further rehabilitation intervention to continue other than psychology
• Potentially discharging the client
• “In some cases, it may be appropriate to keep the patient under review and defer intervention until s/he is ready to engage.” (Rehabilitation following acquired brain injury, National Clinical Guidelines P43)

Discussion with Josh February 2025:

• During a telephone call with the CM Josh reported an episode in work when working a different shift, reporting to a different manager
• Josh described that he had been given multiple verbal instructions, and he was unable to process, retain or prioritise the information / tasks appropriately.
• This lived experience allowed Josh to reflect on his recovery to date and how this could impact his future
• Rehabilitation after traumatic injury, NICE guidelines 2022 recommend guided self-managed rehabilitation to allow the person to engage in rehabilitation in their own time and by their own schedule.

Actions / events following lived experience at work:

• Continued discussion between CM, Neuropsychologist and physiotherapist
• Neuropsychology recommended ADHD assessment and Neuropsyatry assessment
• Neuropsychiatrist recommended medication which Josh started taking, reporting a positive change in his thinking, mood and impulsivity
• The Neuropsychiatrist and Neuropsychologist have completed joint sessions to plan ongoing intervention
• Recent visit by CM to Josh established that he continues to have difficulty with some elements of processing and multi-tasking. Josh has agreed to an Occupational Therapy assessment to assess this further to develop his understanding of how it could affect his daily life and potential strategies to manage this
• Through education and discussion, Josh has gained further understanding of the brain and the recovery process
• Josh is employed at a golf club and has taken up golf
• Josh has enrolled onto a plumbing and heating course at college

The Importance of time in recovery:

To allow the client to:

• develop a trusting, working relationship with the Case Manager and Psychologist where he felt safe to confide
• adjust to their situation, identifying what is important to them
• participate in rehabilitation at their own pace, at an appropriate time for them
• take a lead in their therapy and focus their goals on what is meaningful and important to them.
• Rehabilitation after traumatic injury NICE Guidelines 2022 recommend a tailored and personalised journey towards the person’s agreed goals, focusing on what is important to them, developed with the person

To allow the CM to:

• understand how important lived / real-life experiences are in rehabilitation, and to portray this to referring parties
• recognise the importance of reflection on events for the client, CM and MDT