Tag Archives: traumatic brain injury

Rebuilding after brain injury

By Bethany Bray May 31, 2022

“I just want to feel useful again, like I have some purpose.”

“I just want to know is there anything I can do?”

“I just want to know I’m not going crazy.”

“I want to be happy again, have friends again and feel satisfied in relationships.”

These are among the heartbreaking responses Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist, receives from clients who have experienced a traumatic brain injury (TBI) when he asks what they want and need from counseling.

Individuals who have experienced a TBI often find themselves facing change and challenge in nearly every aspect of life. Depending on the severity of the injury and their recovery trajectory, TBI survivors can experience memory loss, personality changes and difficulty with language, comprehension, impulsivity, anger and decision-making. This is in addition to physical issues such as having challenges with balance, coordination and mobility. Individuals with a TBI may no longer be able to work in the field or job they once had. They may lose the independence to do things such as drive a car, and their friends and loved ones may struggle — or even give up on — maintaining a relationship with this new, changed person.

These clients might come to counseling after experiencing a hospitalization and lengthy rehabilitation process involving countless appointments with a variety of medical specialists. Brain injury survivors “are so steeped in the medical environment,” Lukow says, that they’re used to practitioners telling them what to do. Professional counselors can be the first to flip that narrative and ask the client what they want and need.

Lukow, who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s (VCU’s) Traumatic Brain Injury Model System program, says he has had clients break down in tears because he was the first professional to ask them about their wants and needs since their injury.

A professional counselor can be the one to “honor what they want and empathize with them and help them understand this huge shift in their life that has occurred in a blink of an eye,” Lukow says. “This work takes a lot of patience, a lot of reframing. But some of my most appreciative clients have been TBI survivors.” In counseling, “they’ve finally found someone who doesn’t make them feel like a burden or judged.”

A difficult road

The Centers for Disease Control and Prevention estimates that on any given day, roughly 176 people die and 611 people are hospitalized in the United States because of a TBI.

The Brain Injury Association of America (biausa.org) defines TBI as an “alteration in brain function, or other evidence of brain pathology, caused by an external force.” One of the most common causes is falls, but TBI can also result from motor vehicle accidents, sports/recreation or workplace injuries, child abuse or intimate partner violence, blast injuries during war or disaster, or acts of violence such as assault or gunshot wounds. Nontraumatic (or acquired) brain injury can occur from a stroke, seizure, meningitis, lack of oxygen, exposure to toxins, pressure from a tumor, drug overdose and other scenarios.

Research suggests that certain populations are more likely to be affected by TBI, including veterans and members of the military, racial and ethnic minorities, survivors of intimate partner violence, those who live in rural areas and people who have experienced incarceration or homelessness. According to a recent article published in JAMA Network Open, it’s estimated that between 9% and 28% of U.S. soldiers who served in the conflicts in Iraq and Afghanistan experienced a TBI.

Not only do the causes and severity of brain injury vary, but each survivor will also have a different recovery trajectory and array of symptoms depending on which areas of the brain were affected, the person’s age, the support and treatment they received during recovery, and numerous other factors.

TBI “is anything but cookie-cutter,” stresses Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI.

Not only will these clients’ needs and presenting concerns differ, but their therapeutic expectations, outcomes and what can be counted as “successes” will also vary, says Bradham-Cousar, who has a private counseling practice in Tampa, Florida. For one client, success may be returning to work full time; for another, it may be learning to calm down to keep from getting into fights with other residents of their group home (as was the case for one of Bradham-Cousar’s TBI clients).

“Success needs to be measured differently for each client — and it won’t look the same as your last client” with TBI, she emphasizes.

Lukow agrees, noting that benchmarks or signs that counselors may associate with improvement or growth in their other clients may not be apparent — or appropriate — with clients who have experienced a brain injury. Also, what might seem to be resistant behavior in this client population is often not intentional, he stresses. They may miss sessions or be hard to contact, but this is more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance.

Bounce forward

People who have experienced a brain injury will often hear well-meaning friends, family members, caregivers and even medical and other practitioners reference “bouncing back” when talking about their recovery. Lukow urges counselors to avoid using the phrase “bounce back” with these clients because there is no way for them to fully return to the life they had before their brain injury. Not only is such language unhelpful, but it can also give the recipient a sense of false hope.

Lukow instead uses the phrase “bounce forward” with his TBI clients. “In many cases, they can’t go back; they can only bounce forward,” says Lukow, who lives in Tennessee and works remotely as a staff counselor at a private practice in Williamsburg, Virginia.

Although these clients can’t go back to the way things were prior to their injury, they can work to move forward and make the most of their life with impairments through the support they receive and the skills they learn in counseling, Lukow says.

And these clients don’t always want or need encouragement, Lukow adds. At times, TBI clients may feel that the work they’re doing in counseling sessions only emphasizes what they have lost.

“Don’t always be a cheerleader,” Lukow urges. “Sometimes they don’t need to hear ‘that’s alright, you’ll get through it’ [from a counselor], but instead, ‘that really sucks.’”

Lukow specializes in counseling clients who have experienced TBI. He estimates that 10% to 20% of his current client caseload is recovering from a brain injury. During his time as a researcher at VCU, he developed resilience-based interventions for mental health practitioners to use with couples and individuals after a TBI.

It’s not uncommon for individuals recovering from a brain injury to be told by medical personnel, rehabilitation specialists and others that recovery ceases after a few years. An often-repeated message is that the only gains a person will make after a TBI are those made in the first two years, he says.

Although that may be true for some of the physical aspects of TBI recovery, growth and progress in other arenas — especially the emotional and psychological aspects — can continue for years and even decades, Lukow says. He has seen TBI clients make strides many years after their injury, especially in coming to accept that they may never get some of their abilities back and will need to rely on aids, such as memory reminders, for the rest of their life. Learning and growth can also happen years later for clients related to their social skills and in responding to awkward questions and assumptions made by others. (Lukow explains that these situations occur because TBI is often an “invisible” injury and people misjudge or misunderstand the actions or challenges of survivors because they don’t look disabled.)

Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis, agrees that recovery can occur long after the period of intensive treatment TBI survivors receive immediately after their injury. Goldstein once counseled a client who developed aphasia (language difficulty) after a TBI. This client, with the help of a speech therapist, was still relearning and mastering new words 10 years after his injury, Goldstein recalls.

“The good news is that brain plasticity is much better than we once thought it was,” Goldstein says. “But people are still told that they have a year to improve or a limited time.”

Asking the right questions

Individuals can experience an array of symptoms and difficulties after a brain injury that dovetail with mental health or the client’s presenting concern in a wide variety of ways. Because brain injury varies from person to person and there is no one concise set of symptoms, professional counselors must know some of the more common symptoms (e.g., memory loss) and — perhaps, more importantly — how to ascertain whether a client may have experienced a brain injury in the past.

Brain injury is nuanced and complicated, and there is a good deal of misunderstanding about it among the general population, Lukow asserts. Clients may come into counseling without realizing that their presenting concern (such as trouble maintaining relationships) could be tied to an unacknowledged brain injury or one that happened in the past.

Lukow points out that a person wouldn’t necessarily have needed to be hospitalized or even received a blow to the head for a brain injury to have serious consequences. A car accident, for example, can cause a person’s head to move so forcefully that the brain impacts against the skull without the head touching any part of the car.

Or clients may not realize that brain injury can be cumulative (e.g., “I had a few concussions back when I played lacrosse …”) and affect them later in life, Lukow says. He advises counselors to ask clients not only if they have had any brain injuries but also whether they have experienced any related issues such as a loss of consciousness, cognitive difficulty, a head or sports injury, or a fall.

Bradham-Cousar, a clinical assistant professor in the Department of Counseling, Recreation and School Psychology at Florida International University, urges counselors to listen for client language that may indicate they have had head trauma, including phrases such as “concussion,” “woke up a little while later,” “unconscious,” “got stitches,” “car accident” and “slipped and fell.”

Past brain injury can cause behavior and other deficiencies that are hard to pinpoint or connect to a diagnosis or for which psychiatric medicine doesn’t seem to help. Bradham-Cousar provides examples such as a person who has trouble understanding social cues but does not have autism spectrum disorder, someone who has reading difficulties but does not have a learning disorder, and someone who struggles with attention span and focus but does not have attention-deficit/hyperactivity disorder. In other examples, an individual may struggle with anger, self-control, problem-solving, object recognition or articulating what they’re trying to say and not realize that a past brain injury could be the root cause, she adds.

Goldstein advises counselors not to overlook issues that the client feels are “minor,” such as a concussion, because these could be contributing to their mental health challenges. Counselors should also be aware that in some cases, TBI can cause violent behavior or the urge to self-medicate with alcohol or other substances. So, Goldstein says, practitioners need to be comfortable screening for substance use and be familiar with the reporting protocol for their state in case a client discloses violent behavior (including when the client is a spouse or a family member of a TBI survivor).

TBI survivors sometimes turn to alcohol or other substances to temporarily escape or “slow down” from impulsivity and other challenges, Goldstein notes. However, “one drink for someone with TBI is not the same as it is for someone without [a brain injury]. Their symptoms will be amplified by any substance use, including alcohol,” he explains. “Brain injury and substance use don’t mix. It’s one of the worst things they can do to themselves, but it’s commonly seen among those with TBI.”

Complicating factors

The counselors interviewed for this article note that TBI can co-occur with common challenges that bring clients into counseling, most notably depression, anxiety and issues that correspond with loss and relationship problems. And sometimes there can be a chicken-and-egg debate about which of these issues came first, which adds a layer of complication for practitioners trying to assess and plan treatment for a TBI survivor in counseling.

For example, isolation, loneliness, and a loss of meaning and purpose — the classic markers for depression — are common after TBI and the related challenges that come with it, Lukow says.

In these situations, Bradham-Cousar notes that depression is often a secondary diagnosis to a client’s TBI that becomes co-occurring.

At the same time, it’s not uncommon for TBI survivors to be misdiagnosed with a mental illness because some post-injury symptoms can mimic those associated with other disorders, Goldstein adds. Brain injury can cause people to experience hallucinations, hear voices or have severe personality changes, impulse control problems and erratic moods that can resemble mania. This can lead to diagnoses such as personality disorders, psychosis, bipolar disorder or even antisocial personality disorder, Goldstein says.

“I call it [TBI] the great imposter,” Goldstein says. “Mental health [symptoms] are only part of the story. Sometimes it’s the tip of the iceberg, and sometimes it’s not at all what’s going on.”

Because of this, Goldstein recommends that counselors begin work with each client by first ruling out brain injury as the root cause of their mental health challenges. He stresses not to automatically assume that a client’s symptoms are psychiatric in origin. When it comes to mental health diagnoses and TBI clients, false negatives and false positives are very common, he says.

This challenge can be compounded when a client doesn’t recognize or disclose that they’ve had a brain injury (e.g., a concussion that they weren’t hospitalized for), Goldstein says. It’s also likely that the practitioner who referred a client to counseling — whether a medical or mental health professional — hasn’t ruled out TBI as the root of the individual’s symptoms because the connection between brain injury and mental health is simply not on the radar of most professionals.

“Even if a client has a big fat DSM diagnosis, don’t assume, and keep an open mind,” Goldstein says. “I implore [counselors] to rule out brain injury, and even if you think you’ve ruled it out, revisit it. Don’t assume the person that you’re seeing, no matter how they were referred, has a mental health diagnosis.”

Goldstein recommends that in addition to conducting a thorough intake process, counselors screen clients for brain injury by asking for access to their medical records and the ability to confer with the other professionals they are being treated by, such as a neurologist.

“Keep your mind open, and consult, consult, consult with people who are experts in areas that can help you tease apart where these symptoms are coming from,” Goldstein says. “Don’t assume that what you’re seeing is due to a mental health disorder. Your default should be that their brain has been injured.”

Helping clients adjust to loss and change

The crux of what many clients who have experienced a brain injury need in counseling is help adjusting to change and processing loss. Most professional counselors already have an array of tools that can help in this realm, from coping mechanisms and goal setting to the therapeutic relationship itself.

“Often, they need [empathic] listening from a counselor and a large amount of time just to talk about their situation, what they need and what they’re struggling with,” Lukow says.

Any counseling technique or method that builds coping skills or helps clients deal with life changes and loss would be appropriate and helpful to use with clients who have experienced TBI, Lukow notes. This population may also need grief counseling and help with managing emotions and improving communication and social skills. Seemingly small skills, such as being able to politely ask someone to slow down or repeat themselves when they are outpacing the client’s cognition abilities in a conversation, can go a long way to boost the person’s self-esteem, rebuild their relationships and, in turn, reduce isolation, Lukow says.

Stress recognition and management are also important skills for brain injury clients to learn, Lukow adds. Techniques such as diaphragmatic breathing, muscle relaxation, guided imagery and mindfulness, as well as activities such as walking or exercising, painting, coloring, and listening to white noise or ambient sounds, can help these clients learn to calm themselves.

“[Brain injury] survivors are ‘allergic’ to stress,” Lukow says. “When their stress gets worse, their impairments get worse.”

Occasionally involving a client’s spouse, partner or loved ones in individual counseling sessions can also be beneficial for both parties. They provide comfort and moral support to the client in session, Bradham-Cousar explains, and in turn are better able to understand the client’s needs and therapeutic goals. For TBI clients who struggle with memory challenges, having another person in session can also serve to provide them with reminders of what was said and what was assigned as homework.

TBI clients’ loved ones can also benefit from group counseling. The counselors interviewed for this article agree that the supportive environment that group counseling provides can be extremely helpful for this client population and their family/caregivers. (For more on this topic, read the article “Life after traumatic brain injury: Lessons from a support group.”)

Bradham-Cousar specializes in counseling clients who live with disabilities, including cognitive difficulties from a brain injury, stroke or dementia. A large part of what these clients need, she says, is therapeutic work to move them toward acceptance of the change in their lives, including the things they can no longer do. She often uses cognitive behavior therapy and a working

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alliance approach to foster trust with clients who are brain injury survivors and adjust their thought patterns and perspective. Counselors can also help the client see the opportunity to gain new skills; they’re not just losing things but gaining them as well, she says.

Grief counseling and psychoeducation about grief can also help this client population process the many losses they have experienced, including the loss of a part of themselves, Bradham-Cousar adds.

“Counselors can help these [clients] to grow and understand their regenerated self and look at it [through] the eyes of a new opportunity, a new chance. They still have a life to live,” says Bradham-Cousar, a past president of the Florida Counseling Association and the American Rehabilitation Counseling Association. “It’s a transformational process. … They need to move forward to accept that they’re not as they used to be.”

Similarly, Lukow finds that using a solution-focused approach, as well as equipping clients with coping mechanisms and skills that can boost their self-esteem and resiliency, is helpful for clients who have experienced brain injury. For instance, a counselor might suggest that a client who struggles with memory issues set up a “launch pad” — a spot in a visible area of the home, such as a kitchen counter, to keep their keys, wallet and other essential items they need when going out so that they’re less likely to forget or lose them.

Much of this work, Lukow says, is supporting clients as they navigate the learning curve of trying new skills, abandoning things that aren’t working for them and finding solutions and workarounds to live life.

For example, a TBI survivor who is unable to drive may struggle with this loss of independence and feel like a burden for having to ask for rides from others. A counselor can help the client process these feelings so that it’s easier for them to ask for help and find solutions that boost their self-worth.

One such solution could be supporting the client as they learn how to take the bus, Lukow suggests. “Help them find a [bus] schedule and look together, asking, ‘Which stop is closest to your house?’ ‘How much does it cost?’ etc. Something as little as looking up a bus schedule can be a success. And with it, a shift in thinking: ‘Yeah, I can’t drive anymore, but it doesn’t mean I can’t get around.’”

Goldstein notes that motivational interviewing can be useful in helping TBI clients to focus on adjusting to change. Influenced by Irvin Yalom and Viktor Frankl, Goldstein also uses an existential approach to guide clients to make meaning of their new circumstances.

This client population “is searching for new meaning in a hugely altered life. They need to construct new meaning, and it’s sometimes not the meaning that they were hoping to construct,” Goldstein says. “These folks need to adjust to ‘the new me.’ They’re forever changed. As with big changes in our lives that are negative, there’s grief, and if we don’t work through the grief, it metastasizes.”

Language workarounds

Brain injury often affects a person’s ability to speak. Counselors who work with this population must be knowledgeable of and comfortable using adaptive technology or creative workarounds to communicate with clients who may not be able to respond verbally.

Bradham-Cousar sometimes uses a speech-generating app such as UbiDuo 3 with clients because it allows them to type responses to counseling prompts on a smartphone or other device. She also has an extra keyboard linked to a computer monitor in her counseling office for clients to use to type and display their thoughts during sessions.

Bradham-Cousar suggests that counselors use a collaborative approach by asking clients (during the intake process) to identify adaptive tools or supports they are comfortable using. Counselors can also find information on meeting these clients’ adaptive needs by searching for “brain injury” on the Job Accommodation Network’s website at askjan.org.

In addition to specializing in psychotherapy for brain injury, Goldstein’s subspecialty is helping clients with aphasia. He says that counselors need to be comfortable not only with using different modalities and tools to communicate with TBI clients who struggle with speech but also with long periods of silence in counseling sessions. This can be hard for some practitioners.

Goldstein urges counselors to become sensitive to the wealth of information communicated through a client’s body language and leverage what skills a client does possess. Remember, he says, that these clients have the same range of needs and emotions that verbal clients have; they know what they want to say, but it just won’t come out.

Goldstein sometimes uses a method he calls “facilitated therapy.” He invites another professional who is working with the client (such as a speech and language pathologist) to consult or co-treat with him or come to counseling sessions to serve as a mediator/facilitator until he has forged a bond with the client and learned to “speak their language,” even if it’s nonverbal.

This was the case for one client whose speech was severely limited after his brain injury. However, the client was a gifted artist and would draw pictures during sessions to communicate. When Goldstein began working with this client, he involved the client’s vocational rehabilitation counselor in sessions because she had been working with him for a while and understood the nuances in the way he expressed himself.

“He had his own language,” Goldstein recalls. “He communicated wonderfully; it was just not via speech.”

Once Goldstein established a relationship with this client, they were able to communicate and do one-on-one sessions without the other professional. In addition to drawing and art, the client would play songs he had saved in an extensive library on his phone to express how he was feeling.

“Counselors may have to get creative because these clients [can] have speech limitations and cannot do traditional talk therapy,” Goldstein says. “Look for the gifts they have and use it, use it, use it.”

Team approach

Counselors working with clients who have experienced TBI also need to be comfortable reaching out to, consulting with and co-treating with a number of professionals in different fields. Depending on the severity of their injury, TBI survivors may be treated by surgeons, neurologists, speech and language pathologists, occupational and physical therapists, social workers and vocational/career professionals, among others.

Goldstein recommends counselors build connections with a base of these types of professionals in their local area so they can consult and ask questions when facing a challenge or sticking point with a TBI client. When treating clients who have experienced TBI, “don’t fly solo,” Goldstein urges. “In this work, it’s not a two-way street [with other practitioners]; it’s a superhighway.”

The counselors interviewed for this article emphasize that counselors should resist the urge to refer TBI clients to a specialist right away. Counseling this client population can be complicated and challenging and it requires lots of patience, but the empathic listening and supportive relationship that a counselor provides can make a world of difference for these individuals and their families.

Goldstein encourages those counselors who are interested in this client population or who thrive working in multidisciplinary teams to think about specializing in counseling TBI clients. “Brain injury is scary, and it puts a lot of therapists off,” he says. “If you see someone with a brain injury and you’re baffled, pat yourself on the back, because you should be. And if you’re intrigued and interested [in this topic], consider it as a specialty.”

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Contact the counselors interviewed in this article:

Michelle Bradham-Cousar: info@adhamwellness.com
Hillel Goldstein: goldstein.psyd@bifstl.org
Herman Lukow: hermanlukow@williamsburgcounseling.com

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Related reading, from Counseling Today:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling after brain injury: Do’s and don’ts

By Bethany Bray May 20, 2022

Traumatic brain injury (TBI) is complicated.

Counseling practitioners may work with brain injury survivors who struggle with impulsivity, anger, despair, personality changes, memory loss, language or cognitive difficulties and a range of other symptoms. Not only do post-injury symptoms and recovery differ from person to person but the way these challenges dovetail with their mental health, relationships and overall wellness also varies.

Here are 12 important do’s and don’ts for mental health practitioners to keep in mind when counseling clients who have experienced a brain injury:

1) Do devote a lot of time to listening. One of the most important and beneficial things a counselor can offer a brain injury survivor is empathic and nonjudgmental listening. Having a space to talk about what they’re going through and struggling with and what they need without feeling like a burden can make a world of difference for these clients, says Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s Traumatic Brain Injury Model System program.

2) Don’t equate struggle with resistance. What might seem to be resistant behavior in this client population is often not intentional. They may miss sessions or be hard to contact, but it’s more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance, Lukow says.

3) Do be comfortable with silence in counseling sessions. Brain injury survivors may struggle with speaking or finding the right words to express themselves. Practitioners need to resist the urge to fill periods of silence, and they may also need to get creative to find other nonverbal methods or adaptive tools to communicate with these clients, notes Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis.

4) Don’t go it alone. Counselors can best treat these clients by collaborating, co-treating and consulting with professionals from a range of other disciplines who have expertise in helping brain injury survivors, including speech and language pathologists, occupational therapists, rehabilitation specialists and others, says Goldstein.

5) Do adjust your pace and expectations of progress. The therapeutic expectations, outcomes and what can be counted as a “success” will vary with clients who are TBI survivors, notes Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI. The benchmarks or signs that counselors may associate with improvement or growth in clients may not be apparent — or appropriate — with clients who have experienced brain injury.

6) Don’t be a cheerleader. Life after a brain injury is hard, and survivors may feel that conversations in counseling only emphasize what they’ve lost, says Lukow. A constant stream of positivity or messages such as “you’ll get through this” from a counselor may turn these clients off; instead, they need honesty from a practitioner and validation that what they’re going through is rough.

7) Do ask clients if they’ve ever had a brain injury or related issues such as falls, sports injuries or loss of consciousness. Clients may not disclose past brain injury or realize that it can be connected to their mental health or presenting concern, so it’s important to ask at intake. It’s equally important for counselors to realize that a past brain injury — even if a client doesn’t think it was serious — can lead to or exacerbate mental health symptoms, Lukow adds.

8) Don’t forget these clients’ loved ones and caretakers. The mental and emotional burden that comes with caring for a brain injury survivor is heavy, yet caretakers often put themselves last, Goldstein notes. The loved ones of TBI survivors can also benefit from therapy, particularly the supporting environment that group counseling can provide.

9) Do dig deep into your counseling toolbox. The crux of what brain injury survivors need in counseling is help dealing with loss and change, says Lukow. And counselors already have an arsenal of tools and methods to help in this realm, from cognitive behavior therapy to the therapeutic relationship itself.

10) Don’t think of life after brain injury only in terms of loss. Post-injury recovery is also an opportunity to gain new skills and find new ways of doing things. A client may not be able to work in a job or field they used to, for example, but a counselor can help them reframe this loss as a chance to look for a new occupation that fits with the skills they do have, notes Bradham-Cousar.

11) Do consider this as a specialty. There are not many professional counselors who specialize in psychotherapy for brain injury, but it’s an important and much-needed expertise, says Goldstein. It could be a good fit for counselors who are interested in this client population or who thrive working in multidisciplinary teams.

12) Don’t assume that recovery ceases within a few years of a brain injury. Survivors can still make gains with emotional, social and psychological challenges long after — even decades after — brain injury, says Lukow, especially when supported by helping professionals who provide patient, empathic care.

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Read more on counseling clients who have experienced a brain injury in an in-depth feature article in Counseling Today’s June magazine.

arloo/Shutterstock.com

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

From Combat to Counseling: Comprehensive mental health in the military-affiliated population

By Duane France October 17, 2019

Often, when talking about mental health in the military-affiliated population, the first thing that comes to many people’s minds is posttraumatic stress disorder (PTSD). This is true of mental health professionals as well.

Once, a colleague asked me how many deployments I had in my military career. When I told her that I had five combat and operational deployments, she said, “Well, of course you have PTSD!” In reality, the number of deployments doesn’t dictate the level of traumatic events to which a service member has been exposed. A client could have multiple deployments and not have experienced anything worse than separation from family, whereas another client could have experienced only one very serious and traumatic deployment.

It is important to understand what we are talking about when we discuss mental health in the military-affiliated population. It is critical to understand the culture of the military and to understand who we are talking about. However, as mental health professionals, it is equally important to understand the potential psychological impacts that our clients have experienced.

PTSD

Although PTSD is not representative of everything that service members deal with after the military, it is a condition that any counselor working with the military population must understand. It has been described in a number of different ways throughout history, including “soldier’s heart” in the Civil War, “shell shock” in World War I, and “battle fatigue” in World War II and the Korean War. After the Vietnam War, the symptoms that would come to signify PTSD were called “post-Vietnam syndrome.” It wasn’t until the third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, that PTSD became an official diagnosis.

There are a number of PTSD diagnostic criteria outlined in the DSM-5, the most significant of which is that the service member must have been exposed to an event that resulted in death, threatened death, actual or threatened serious injury, or sexual violence. The service member or veteran must have been exposed either through direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to such trauma, or experiencing indirect exposure to details of the trauma in the course of professional duties. This is significant. Just because a service member was deployed to a combat zone does not mean that the service member was exposed to an event that meets this criterion; this was certainly true for three of my five deployments. Being able to differentiate between PTSD and other psychological conditions is critical to supporting the client.

TBI

Another condition emerging as an important consideration is traumatic brain injury (TBI), which is also known as a concussion or mild, moderate, or severe TBI. Military equipment and medical response have improved significantly over the past 50 years, resulting in greater survivability on the battlefield. Injuries that previously might have been fatal are now being treated quickly and effectively. While this development has reduced the mortality rate in recent conflicts, it has led to an increase in the number and severity of catastrophic injuries.

Further complicating TBI is the fact that many of its symptoms overlap with those of PTSD, and many of the conditions that could cause TBI also meet criterion A for PTSD. Whether it is a blunt force trauma concussion from a direct blow to the head or a diffuse TBI caused by blast overpressure from an explosion, the causes of TBI could also be causes for PTSD (and vice versa).

Addiction

Addiction is another important mental health consideration in the military-affiliated population. This of course includes substance use. Many of us who served know that the military is a drinking culture. Drinking is normalized and used to relax, to celebrate, to memorialize. Regardless of rank or branch of service, alcohol is acceptable and available.

It is problematic, however, when the reason for alcohol use changes from celebration to self-medication, or using alcohol to reduce discomfort from psychological concerns. Additionally, the opioid epidemic in the veteran population typically begins during active duty. Because of the extreme chronic pain that results from multiple injuries, pain management is a necessary consideration, and painkillers are readily available.

In addition to substance use, it is also imperative to explore process addictions in the military-affiliated population. Whether it involves gambling, viewing pornography, compulsive eating or shopping, compulsive and addictive behaviors can cover the veteran’s or service member’s underlying concerns.

Photo by U.S. Army Sgt. Victor Perez Vargas/defense.gov

Emotional dysregulation

Difficulty tolerating and managing emotions is another significant aspect of mental health for the military-affiliated population. While there are certainly emotional components to PTSD, TBI and addiction, it is also possible for emotional challenges to exist apart from substance use, trauma exposure or physical injury. For many service members and veterans, the typical dysregulated emotions are depression, anxiety and anger.

Among the nontraumatic causes for an inability to manage these emotions are toxic leadership and systemic harassment. An inability to escape from an adverse situation can lead to feelings of helplessness and hopelessness. I will emphasize again that there are many situations in the military that could cause anger, anxiety and depression that have nothing to do with exposure to traumatic events. It is necessary to determine whether emotional dysregulation or substance use is the result of traumatic exposure or another cause.

These aspects of mental health are not unique to the military of course. Combat trauma is not the only cause of PTSD, and any significant blow to the head can cause TBI. Addiction is not a problem just for the military population, and emotional concerns such as depression and anxiety are widespread. Additionally, these conditions follow the medical model of mental health; there is a diagnosis for each of them and corresponding medications for each of them. Although these conditions can be debilitating in and of themselves, there are other factors unique to the military population that can complicate attempts to treat service members, veterans and their families.

Meaning and purpose

Although service in or affiliation with the military can be difficult, it can also be extremely satisfying. There is a collective effort toward a common goal, a sense of shared culture and community, and a feeling that the work you’re doing is important. Many veterans, upon leaving the service, struggle to find the same satisfaction in their post-military careers. Many are able to build a meaningful life after the military, but it is not automatic.

There is also the challenge of navigating an identity shift. Whether it’s for four years, 14 years or 24 years, the service member’s identity is closely tied to the military. We were Soldiers, Airmen, Sailors, Marines, or Coast Guardsmen literally 24 hours a day. Even if not serving full time, as is the case in the National Guard or Reserve components, service members are always aware of a type of double life. When we leave the service, many of us ask ourselves, “Who am I if I’m not a soldier?” A friend of mine, a medically retired Green Beret, expressed this quite well when he stated, “The Army said I couldn’t be me anymore. What do I do now?

Moral injury

Another concept that has emerged over the past 25 years is moral injury. PTSD, at a very basic level, is an injury of the behavior. It is classic conditioning: When a triggering event occurs, a certain reaction is initiated. It is, of course, more complicated than that, but a significant aspect of PTSD is stimulus response. TBI, on the other hand, is a physical injury of the brain. Moral injury can be described as an injury of the soul: What a service member believes to be right and wrong with the world has been fundamentally changed.

In one of the first articles to fully develop an explanation of moral injury, Brett Litz and colleagues described moral injury as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” There is some disagreement as to whether moral injury is an aspect of PTSD or its own distinct condition. the fact is that one can have a morally injurious event that is not traumatic, and there are a number of traumatic events that are not morally injurious. Regardless, it is beneficial for anyone interested in working with the military population to familiarize themselves with moral injury and to at least explore the concept with these clients.

Needs fulfillment

The military is a highly connected communal society where tasks are divided among its members. When I was in Iraq and Afghanistan, I didn’t have to worry about where my food and water would come from because there were other service members or contractors who provided that. When my family and I arrived at a new duty station, we were provided housing, and there were people on base who gave us guidance on schools for our children.

Of course, when service members leave the military, those same needs still have to be fulfilled, but now it must be done in different ways. This isn’t to suggest that service members aren’t capable on their own, but challenges related to employment and housing — those lowest levels of Maslow’s hierarchy of needs — are widely known in the veteran population. Even our psychological needs, such as belongingness and esteem, are part of the military framework. Our peer group is provided for us; like them or love them, the people you serve with are your family. Your effort is recognized with rank or reward. Outside of the military, however, we have to learn how to meet those old needs in new ways … and for some service members, that can be difficult.

Relationships

The final aspect of mental health in the military-affiliated population that I’ll discuss is relationships. Our mental health affects our interactions with others, and our interactions with others affects our relationships. Whether it is frequent separation, moving households every three or four years, or relationships with people who are literally on the other side of the world, the relationships of those in the military population are necessarily different from those who have never served.

When considering how military service impacts relationships and vice versa, it is important to understand that this doesn’t just refer to intimate relationships such as spouses and children, or even parents and siblings. This also includes peer relationships (friends and acquaintances) and work relationships. Understanding how to integrate into a community that has a different cultural orientation than you do is difficult. Even if none of the other psychological concerns mentioned in this article are prominent, adapting relationships to a new lifestyle can be challenging.

Considering all aspects of psychological wellness

It can be daunting to consider how these various aspects may interact to provide an almost never-ending combination of circumstances for members of the military-affiliated population. One thing is clear though: The more of these areas that the service member, veteran, or military family member has difficulty in, the more at risk they are.

As professional counselors, we need to be able to understand the complexity of our clients’ conditions. We need to ensure that we have a full picture of their needs and then address those needs if possible. If an area is outside of our expertise — if we are not trained in an evidence-based practice for PTSD, for example — then we have an ethical responsibility to refer that client to someone who can meet their needs.

In this way, we are providing the best possible care for those who serve, those who have served, and those who care for them.

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Life after traumatic brain injury: Lessons from a support group

By Judy A. Schmidt October 8, 2018

Support groups are wonderful opportunities for people with similar life experiences to meet each other, share their stories and encourage one another. Group members benefit from learning coping strategies and everyday tips for dealing with various experiences. For people with traumatic brain injury (TBI), support groups offer informal opportunities for understanding a shared experience that greatly changed their lives, often within a few seconds’ or minutes’ time. They are left with physical, cognitive and emotional outcomes that impact their relationships, work and independence, often leading to loneliness and isolation.

As noted by the Brain Injury Association of America, more than 2.5 million adults and children experience a TBI in the United States each year, and support groups play a vital role in their continued recovery and re-entry to everyday life. A TBI dramatically interrupts life for these individuals and their families. Extended hospitalizations for physical recovery and long-term cognitive training for rewiring the brain alter all aspects of life, with treatment continuing for up to a year after the incident.

Effects of TBI

The effects of TBI are varied and highly individualized. The extent of the physical and psychosocial impacts depends on the type of injury (closed, open or acquired) and the severity of the injury. Thus, depending on the area of injury, people with TBI may deal with deficits in memory, executive functioning issues and poor judgment.

Frontal lobe injuries may lead to changes in mood and personality, difficulty making decisions and difficulty with expressive language, all of which are executive functions.

Injuries to the parietal lobe, which helps with perceptual abilities, may lead to difficulties naming words (anomia), finding words (agraphia) or reading (alexia), as well as problems with perceptual abilities that integrate sensory information. The ability to distinguish right from left may also be affected.

Damage to the temporal lobe may involve hearing loss, Wernicke’s aphasia (difficulty grasping the meaning of spoken language), problems categorizing information such as objects and short-term memory problems.

Brain injuries to the occipital lobe, which controls our vision, may lead to visual field problems, distorted perception and difficulty with reading, writing and word recognition.

Injury to the base of the skull at the site of the cerebellum creates difficulties with balance, equilibrium and coordination, as well as slurred speech.

Acute and long-term rehabilitation from TBI involves physical, occupational and speech therapy, as well as cognitive neuropsychological evaluations. As individuals recover from the physical damage, it is important for counselors to be a part of the rehabilitation team to manage adjustment to the physical injuries, acute stress and cognitive disability. In addition, the psychosocial aspects of TBI are very disruptive. They can be long-lasting as these individuals and their families begin to adapt to everyday life. Counselors are needed to provide individual and family counseling, as well as psychoeducation about TBI and recovery.

Psychosocial aspects of TBI

The psychosocial aspects of TBI are also related to the area of brain damage. People with frontal lobe damage may have difficulty making decisions, maintaining attention to tasks and controlling impulsive behaviors.

When the parietal lobe is damaged, difficulties occur with eye-hand coordination, reading, math and writing.

Temporal lobe damage interferes with communication skills, learning and memory. Learning difficulties due to recognition and visual field problems may result from occipital lobe damage.

In assisting people with TBI and their families, it is important to understand how psychosocial areas of life are affected and how these areas impact the potential return to daily living. For example, an individual may not return to his or her pre-injury abilities and can experience problems returning to work or school. Difficulties with problem-solving, understanding others’ emotions and social cues, or just being able to carry on a conversation may isolate the person with the TBI and increase his or her feelings of loss. Other areas of life that may be affected include the ability to drive, participate in sports and exercise, which can create deficits in the person’s social life. Problems with executive functioning can lead to challenges making sound decisions. Because safety is a major concern, the individual with a TBI may need to be monitored consistently by family, which can lead to tensions and other problems.

These are all skills that most of us take for granted or complete without much planning and forethought. But for individuals with TBI, family and personal relationships can grow strained, and the ability to build new relationships is impacted. The person’s independence and self-esteem suffer greatly.

Lessons learned

As a rehabilitation counselor for an acute inpatient rehabilitation program, I work with individuals who have TBIs, as well as their families, to provide counseling for stabilization, adjustment to disability and assistance with developing coping strategies. Providing support to these patients and their families as they begin realizing the extent of the brain damage and start dealing with feelings of loss is a crucial part of recovery.

For three years, I facilitated a monthly outpatient support group for people with TBI and found the experience fascinating. Hearing stories of people having car accidents, motorcycle accidents, work accidents, anoxia (deprivation of oxygen) and other unexpected accidents was difficult and often heart-wrenching. Yet these shared experiences forged a bond among group members that was undeniable and very moving.

They shared what it was like to not remember exactly what had happened to cause their brain injury. They shared what it was like to lose track of time and details and to have to trust the information told to them by health care providers, family members and friends. The fact that they each had “lost a period of time” from their lives and hadn’t been the same since seemed to build a sense of trust and caring among the group.

I soon learned that as a rehabilitation counselor, I could understand the medical, cognitive, vocational and emotional results of their injuries, but I couldn’t fully appreciate the daily psychosocial impact that their injuries had taken and continued to take on their lives.

The time since being injured varied among the support group members — anywhere from two years to 18 years. Regardless, the psychosocial effects they experienced were extensive. They talked about their school and work being interrupted, about having to settle for less challenging options or not being able to pursue their goals at all. Some shared tales of broken marriages and relationships, of losing custody of their children.

Others talked about losing their sense of independence because they had to rely on their families for almost everything. Some could no longer live at home due to the need for constant supervision, so they had to learn to live in group homes. Pursuing sports or other recreation choices was hard because of physical limitations. Another significant loss was no longer being able to drive and depending on others for transportation. The lack of money for “extras” was particularly difficult for those group members with children.

Holidays posed another challenge for these support group members because of sensory issues with noise, lights and too many people talking at once. Others discussed experiencing the stigma of having a TBI and being considered “different now” by family members and friends. This was felt particularly strongly at social gatherings, where family and friends made infrequent contact with them. Isolation and loneliness were prevalent themes in their stories. Depression, anxiety and low self-esteem made daily life a struggle.

Research conducted by Jesse Fann and colleagues in 2009 and by Annemieke Scholten and colleagues in 2016 and subsequently published in the Journal of Neurotrauma shows that the rate of depression during the first year after a TBI is 50 percent. The rate is close to 60 percent within seven years after the TBI. So, it is crucial for counselors to have this awareness of serious mental health issues in people with TBI to properly assist them and their families in seeking appropriate treatment.

Members of the support group I facilitated discussed that being on medication was difficult due to the side effects and to the cost of the medication if they had little or no insurance. They felt that cognitive retraining programs and daily psychosocial programs modeled after those for people with serious and persistent mental illness helped tremendously. The aspects of these programs that they reported helping most were receiving cognitive behavior therapy and continuing to learn more about TBI. The psychosocial programs were highly regarded because of the increase in social activities, access to vocational rehabilitation and supported employment services, and integration back into the community.

At times, the support group was difficult to manage because of the cognitive and emotional deficits with which the individuals dealt. However, the members had their unique ways of helping each other and redirecting the conversations. It was very clear that they respected one another.

Our time together as a support group transformed us into a unique family, particularly because the group remained fairly constant in its membership. The members trusted each other and understood the struggles being discussed. However, they also felt safe in correcting each other and being bluntly honest (which people with TBI are). We did have some new members join along the way. They were welcomed with open arms, and veteran members exhibited an unabashed eagerness to help. It was always interesting to hear about the creative accommodations that our members developed to live life each day and how the professionals in their lives assisted them.

As the group grew stronger, the members felt it was important for me to record what they wanted others to know about TBI and people with TBI. Their primary messages were:

“Conversation and expressing one’s self can be difficult.”
“People with TBI may not like the same things as they previously did, so don’t force us.”
“Tasks may take longer for people with TBI, so wait for us.”
“Social situations can overload people with TBI.”
“TBI affects everyone around the person.”
“Those with TBI are still the same people they were before.”

During my time with the support group, I learned many lessons. First of all, I learned that life after a TBI requires constant adjustments that must be made each day to be productive and involved. I also came to understand that time does offer healing when abundant respect and empathy are present. But most important, I learned about living life as it happens from a wonderful group of resilient individuals.

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Judy A. Schmidt is a clinical assistant professor in the clinical rehabilitation and mental health counseling program in the Department of Allied Health Sciences, and an adjunct clinical assistant professor in the Department of Physical Medicine and Rehabilitation, School of Medicine, at the University of North Carolina (UNC) at Chapel Hill. She is the rehabilitation counselor for the acute inpatient rehabilitation unit for UNC Hospital, where she provides counseling services to patients and their families after traumatic brain injury, stroke, spinal cord injury and other neurological trauma. Contact her at judy_schmidt@med.unc.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

A counselor looks at football

By Kevin Doyle January 29, 2018

I have been a lifelong football fan. I remember playing outside in the snow, emulating the National Football League (NFL) stars of the 1960s and then going inside to watch some of the fabled rivalries of the time, like the Kansas City Chiefs versus the Oakland Raiders. I grew up on Joe Namath’s Super Bowl guarantee, Franco Harris’s “Immaculate Reception,” and the undefeated Miami Dolphins team of 1972. My beloved Washington football franchise (yes, that name is a problem — but that is for another story) owned the 1980s (along with the San Francisco 49ers), and my brother and I sported Charley Taylor (42) and Larry Brown (43) jerseys in the previous decade. My two sons played the game at the high school level, both excelling and taking much from the experience. In short, I was raised on football in many ways.

All of these things will stay with me, but recent events have conspired to lead me to question of whether the sport in its current form is morally defensible. Recently, coverage of the death by suicide of former New England Patriots player, and convicted murderer, Aaron Hernandez, noted that his brain had advanced chronic traumatic encephalopathy (CTE), and a study published in 2017 in JAMA found evidence of CTE in 110 of 111 former NFL players.

Former NFL player Antwaan Randle El, a nine-year NFL veteran who is now in his late 30s, recently spoke out about his memory problems. He became the latest in a series of both high- and low-profile professional players known or alleged to have had serious brain issues possibly due to their football careers. This includes well-known players such as Junior Seau, Dave Duerson, Mike Webster and Frank Gifford.

The national discourse has been stirred by Steve Almond’s searing Against Football: One Fan’s Reluctant Manifesto; the film Concussion, based on the work of forensic pathologist Bennet Omalu and the work of Jeanne Marie Laskas in her article for GQ titled Game Brain; as well as pro football works such as Gregg Easterbrook’s The Game’s Not Over: In Defense of Football and Mark Edmundson’s Why Football Matters: My Education in the Game.

What, then, is the role of the professional counselor in this debate — or is there one? I submit that counselors in a variety of settings have a responsibility to be aware of this issue that is currently facing our culture, and there are several reasons why.

First, this appears to be a significant safety issue for a segment of our population, namely those individuals who have either played football in the past or are currently playing. No less an authority than the Mayo Clinic has reported that symptoms such as aggression, motor impairment, tremor, memory loss, irritability and focusing problems are associated with CTE.

If an adult male were to report symptoms such as these in counseling, it could be prudent to check to see if the client was once a football player. Referral for additional medical assessment could be an appropriate course of action, although currently, no effective treatments for CTE-related symptoms seem to be available. In fact, a definitive diagnosis cannot be made until tests of the brain can be conducted after an individual’s death.

For players currently involved in football, repeated concussions could be placing those individuals at increased risk and should be monitored. Most levels of play, including the NFL and NCAA, have put so-called “concussion protocols” in place to prevent players from continuing to play until they have received medical clearance. Although counselors would likely not play a leading role in these determinations, it would be advisable for counselors working on college campuses, with professional football players or even at lower levels (high school, middle school, youth football) to be aware of them and to support efforts to protect player safety.

Second, the question of whether to allow children to play football has become an emotional and sometimes conflict-ridden debate within families. Participation rates in both high school and youth football have widely been reported to be declining and show no signs of changing in the near future, according to numerous sources.

Counselors routinely work with children and families, and reaching a decision about whether a child should play football can be difficult. An informed decision must balance the potential safety concerns associated with the sport and the potential benefits of playing the sport, including physical activity and learning about teamwork and discipline. In some families, football is seen as a rite of passage — something that adolescent males (and, in some cases, females) engage in as part of the maturation process. In some cases, it may be the child who desperately wants to play, while the parents are warier. In other cases, parental pressure on a child to participate may be the driving issue. In either instance, a counselor, whether school-based or community-based, may be in a position to help the family make this decision. Knowledge of some of the relevant issues is essential to any effort to be of assistance.

Third is the reality that any societal issue can make its way into a counseling session. This is not to imply that we as counselors need to be experts on any and all social and societal issues. However, we do have a responsibility to be aware of burgeoning issues facing our culture and to be ready to discuss or address them —or at least to listen to our clients do so.

Many of us no doubt had clients with opinions about the most recent presidential election. Their thoughts naturally made their way into counseling sessions. Our own personal feelings aside, we had a responsibility as counselors to listen, to consider our clients feelings and opinions, and to ponder what role, if any, these thoughts contributed to the stressors they were facing. Likewise, we must strive as counselors to stay informed about myriad issues of relevance to our clients. Societal question such as same-sex marriage, health care, immigration and employment barriers for those with criminal convictions, to name a few, play out in our clients’ lives on a daily basis.

Granted, the issue of football may pale in comparison to some of these, but we have a responsibility nonetheless to pay attention, to inform ourselves and to monitor the debate, because it may well come up in a counseling session with an individual or family. If we are unaware of this issue (or another one), we may need to do further research in between sessions or, in extreme cases, even consider referring our client to another provider with more knowledge of the issue he or she is facing.

Finally, there are social justice issues to be considered, consistent with the counseling profession’s recent emphasis in this area. One would have to have been living under the proverbial rock not to have noticed the emotional national dialogue around NFL players sitting or kneeling during the playing of the national anthem. Started by former San Francisco 49er quarterback Colin Kaepernick in 2016, this protest has spread to other players and teams and led to an increasingly hostile “conversation” about the form of the protest itself, overshadowing the issue of police brutality that Kaepernick sought to highlight.

The various authors I noted earlier identified numerous concerns more specifically related to football that are of a social justice nature. Approximately 68 percent of NFL players are African American, and the treatment of players has been criticized by some as evoking memories of slavery by the so-called “owners” of the franchises. Anyone who has ever watched the “meat market” known as the NFL Combine, which consists partly of athletes’ bodies being examined by prospective employers (owners), and which is now nationally televised, cannot help but notice this parallel. With the average NFL career lasting less than four years and contracts, even when lucrative, not being guaranteed in case of injury, discerning individuals can easily raise legitimate social justice questions.

In summary, a growing national conversation about football, its viability, its safety and its future is becoming difficult to ignore. Counselors at various levels and in various settings have a responsibility not only to be aware of this conversation, but also to consider its significance in relation to the clients with whom we work. Engaging in this conversation is consistent with current calls within the profession for social justice.

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Kevin Doyle is a licensed professional counselor in Virginia and an associate professor in the counselor education program at Longwood University. He has also coached youth, high school and adult sports for the past 30 years. Contact him at doyleks@longwood.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.