A Christmas Party

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.