Excerpted from the novel On the Trail of Evil with Dick
Daring, Speech Therapist (out of print)
The upshot of this whole affair was contained in a statement
I had heard a colleague make in a case conference some years ago. His patient was
in the acute rehabilitation unit, in treatment after a traumatic brain injury.
The guy was giving his rationale for the patient to feel optimistic about her
recovery. He said this to her – “You are your neurons; but you are not just your neurons!” My colleague had
started his training with a liberal arts undergraduate degree, so I usually gave
him some slack for the unorthodox things he said and did in his practice. But –
he was right, and his soft and sweet aphorism helped me get my own patient
through her first Christmas after her own concussion.
You always have to take what the patient is willing to give you
was what kept running through my mind as I initially met with her. Married,
mid-50’s, and found dangling from atop the compartment of her flipped sedan, saved from a worse
fate by a stubborn seat/shoulder belt. Now in my office that mid-November, she
could give a history of her immediate past through conversation pocked by
pauses and nonverbal musings. The Boston Naming Test demonstrated mild-moderate
anomia (problems finding words). On the Ross Information Processing
Assessment, she had signs of mild global cognitive impairment, with
short-term memory and problem-solving being the most affected of all her skills.
Screening for anosmia, or impaired
smell, showed that she could not identify peanut butter when blindfolded. She did
pick up the smell of instant coffee. We had a brief rest-break segue’ from the
testing to interview. My patient told me then of her need to get back to
homemaking. Her hubby just expected it, and – and she – well, gosh, she said, I
feel like I can do it!
I knew better, but I also surmised from our initial
conversation that it would be my head banging the wall if I attempted to talk
her out of her homemaking routine. Our
twice-weekly sessions were made up of training, on the component skills that
were weak in testing (memory, problem solving). A few minutes of review and
warm-up preceded the skill training, and then a little cool-down, teaching and counseling
ended each hour. My patient faced the training very well, and seemed to make
steady progress with accessing words in conversation – and solving simple problems.
She regularly, though, needed a few extra minutes to talk about how hard it had
become at home to get her daily homemaking done.
I knew she needed to develop insight about who she is now.
When she was able to reveal how well she lived her life with her cognitive
challenges, then we could together find ways to get the best outcome she could
imagine. What could she imagine? Her
husband had reminded her one day that the family Christmas party was
coming up soon. She had already told me that, when making a casserole and a “Jell-O
salad” one evening, she had the casserole ready to plate but couldn’t find the
salad. Lifting the casserole dish cover, she reported feeling mortified that
the Jell-O box was looking back at her, baked into the casserole!
Therapy then grew from just the component skill training, which
we also call treatment of the impairment,
to work on the skills she needed to hone to pull off this party. That was
treatment at the activity level. Our
activities included assembling and arranging all the ingredients to make the
dishes my patient was serving (there were 5!); re-creating and stepping through
each recipe; and completing individual recipes in the accustomed time span. The
last activity took 2 weeks to reach criterion, where she could make a dip, bake
some cookies or – make a Jell-O salad as efficiently as possible in the
available time.
You take what your patient gives you, I reminded myself as I
got an apron almost saturated every session with flour and water. Finally, my patient was
ready for the big test. We simulated the party in the outpatient rehab lounge. In
the professional lingo, this is training at the participation (real life)
level. Our practice sessions allowed her to gradually recognize the real-life
context cues for starting baking for the cookies, and for making the salad! As
we did after each activity training session, we spent all the time my patient
needed to review the successes and her own need to ‘tighten up’ her control
over the session. Though she admitted she was tired and a little mindblown from
the work, she expressed confidence she could pull off the real party. And , a
week later, at our next-to-last scheduled session, she reported that –
exhaustion and an extra day required to reassemble the house afterwards – she did
just that!
She was her neurons, but not just her neurons - yep. Her love for her family, and her
strong desire to get back into life after her injury – that made her decision
to train her impaired central nervous system easier. As the training reached
its zenith with the simulated party in our shop, my patient had learned much
more about herself: how to get more rest; how to assert herself with hubby, so
that he did volunteer more assistance at the party than he initially might
have; how to plan her routines to get more done with the energy and focus she
felt each day – rather than to say Oh, I’ve
done that for years, no problem, she learned to say today, I’ll do that as well as I can with the skills I have.
I think she had a better-than-average Christmas that year.
