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CHAPTER FOUR: Learning Where to Look to Find Head-Injured Moments

For those survivors who are making progress in step two, they can begin to become more effective and wiser in watching their own behavior by starting to learn when their head-injured moments occur. Head-injured moments are not random at all. They occur at the times when the brain needs to shift into overdrive (that is, when the central executive network needs to do thoughtful problem-solving rather than just react by old habits and automatic pilot) but doesn’t do so. The situations in which this occurs have been mapped out very well in general terms.

1. Novelty. The survivor functions like a fish out of water in any foreign or strange or new setting, or in any familiar setting where life has changed a great deal. This includes moving to a new home in a different neighborhood or town. It includes functioning on a vacation to see the sights. It includes living in a family whose membership has changed (for example, with a new baby, with elderly parents having moved in, with a new step-parent, daughter-in-law, or son-in law, or with an important person having died or moved away). It includes trying to live without the driving privilege after becoming accustomed to driving. It includes a new job, or an old job in a new workplace. In any of these situations, the survivor relies on old ways of doing things, forcing them into the new situation. There is very little learning of new rules, new conditions, new expectations, or new ways of doing things. Reactions tend to be more impulsive, less thought-through, and more emotional than in familiar situations. Real problems can spring up due to the ways others are treated. The survivor develops a bad attitude over time, because it seems like nothing he or she can do is appreciated or right. Whenever the survivor has to deal with one of these changed situations, head-injured moments become much more likely.

The second kind of novelty that brings on head-injured moments is learning new behaviors or skills. For example, many survivors who are accustomed to the role of breadwinner have to adjust to the role of home-maker or caregiving parent. Obviously, a whole new set of skills is involved. The difficulty the survivor shows in making this adjustment is often written off as a psychological problem, but it is mainly a brain problem–a problem of frequent head-injuredmoments. Similarly, head-injured moments happen more often during and after training to perform a new job. If the survivor becomes ill or receives another injury, and has to make adjustments to some physical disability, head-injured moments occur around the disabilities. For example, survivors who must learn to use a wheelchair several years after an accident can have a

great deal of trouble working it, aiming it, parking it, carrying things in it, leaving it in public places, and so on.

2. Overload.

When the brain gets too much stimulation, input, pressure, stress, or emotion, it begins to malfunction. This produces more head-injured moments than any other factor. For example, situations with loud, harsh noises (babies crying, dogs barking, children’s high-pitched chatter and banging around, construction noises, the din of public waiting areas, and certain kinds of music) easily produce overload. Situations with bright or flickering lights, or lots of visual chaos and confusion produce overload. Situations that require dealing with too many things at one time produce overload. Pressure produces overload, particularly pressure to hurry but also to decide correctly, even if it comes from inside the person. Any strong emotion can produce overload, even the positive emotions like joy, enthusiasm, and excitement. People who have always had temper problems often have special difficulties with anger and the related emotions like irritation, resentment, annoyance, and rage. Being put on the spot, whether it’s being asked to remember something or to explain something, can sometimes overload a survivor. During overload, the problems, and the kind of head-injured moments the person has, depend on how much overload there is. At the lowest level, overload just overtaxes the brain, causing it to think slower and at the same time to react more impulsively. As overload gets worse, it begins to affect memory and awareness, eventually causing the mind to blank out. People forget what they were talking about. They forget everything they normally know. They become confused and bewildered. And at the most extreme level, they panic. Overload can bring on a full-fledged anxiety attack. Nothing can be done properly under overload–it is a sure cause of head-injured moments.

3. Extra Effort.

When adults and adolescents have to do things that are difficult, they naturally make more effort. A task can be difficult because the behaviors themselves are hard to do, like learning to play the violin or to steer a hang glider. Or it can be difficult because it has to be performed very well to be acceptable. In this way, competitive activities (sports, other contests, the performing arts, public debates, dares) are always difficult to learn, and they remain difficult for everyone except for the talented few who can easily dominate everyone else. Building or making things may need to be done perfectly to be acceptable, as in heart surgery, sculpture, or diamond cutting, and to a lesser extent, in more ordinary crafts, repair work, home remodeling, and so on. Other activities are difficult because an error can kill, including driving a car, piloting a plane or boat, using various machinery, firing a weapon, handling dangerous animals, getting around in high places like mountain tops, using potentially deadly drugs like heroin or morphine, and so on. Still other activities are dangerous because a mistake is unacceptable, for example, driving in front of a highway patrol car, doing your job while the boss is watching, handling valuable items borrowed from others, or being asked to show that your skills in front of a crowd. In addition, the situation in which a normal activity is performed may make it difficult–like trying to fly a kite on a very windy day, or surf in storm breakers, or even walk across a rocking boat or a moving bus. Finally, some people feel it necessary to do everything well and cannot tolerate any kind of defective performance out of themselves–the more active they get, the more they risk headinjured moments. When doing things that require extra effort, survivors tend not to raise their level of effort. By effort, I am referring first to mental preparation, focusing the mind, concentrating, hinking through what you are going to do, and working out the fine details. I am also referring to summoning up both mental and physical effort to gain maximum control of your thoughts and movements. Survivors behave according to their well-established habits. If they are in the habit of making a lot of effort, they still do that. But whenever something unique to the moment calls for extra effort, they don’t do that. Any activity that involves dealing with unexpected surges of difficulty can be expected to produce head-injured moments.

4. Mixed Feelings.

Everyone has difficulty with performing adequately when their heart is not completely into what they are doing. If you are doing a task for your boss or teacher, and you hate him, it is hard to do your best. If you are trying to do something well but struggling with the desire to quit and go home, it is equally tough to do well. If you know what you should do, but you are tempted to do something you shouldn’t (drugs, alcohol, sex, and so on), that temptation can either distract you from what you are trying to do, or you can give in to it, and abandon what you are supposed to do. However, a person with a factory-fresh brain, recognizing the conflict, can summon up enough mental effort to fight off the temptation, quell the mixed feelings, and finish the task well. In head injury, this extra effort is not summoned. Situations of mixed feelings are ripe for head-injured moments.

5. Fatigue:

You probably have a good idea of what fatigue does to your loved one. The fatigue that comes of a lack of sleep makes everything the brain does less effective. In fact, fatigue makes the person act more like he or she did earlier in recovery. Fatigue produces more impulsivity, more safety problems, poorer self-control, disorganization–it is the enemy!

Your loved one may well resist the idea of living a lifestyle that preserves adequate rest– going to bed as early as a school child, avoiding caffeine, and avoiding arousing activities before bed. If so, this of course gets handled through the self-therapy system, by keeping track of all the ability problems that occur on days of too little sleep. It is even a good idea to make up a graph, comparing performance on a day of good sleep with that on a day of short sleep. The person will be shocked at how strong the fatigue effect is. But if your efforts to work the program don’t produce instant agreement and habit change, stick to the program and keep collecting the evidence that fatigue needs to be managed better.

The second kind of fatigue, short-term tiredness from repeated or sustained effort, is more difficult simply because the survivor often does not realize that he or she is tired. How quickly this fatigue can hit is shocking. After a severe injury or a focal frontal or brainstem injury, fatigue can set in after less than a minute of full-bore concentrating. It comes on even faster if the person is working under tension or worry. Even after a milder injury, fatigue effects can appear after a few minutes of full concentration. The survivor needs to learn to recognize the symptoms of effort-related fatigue, and to anticipate them, so that activities can be staged with enough rest breaks. Often in doing training exercises I find that early trainees refuse the rest breaks they need. I let them refuse, but before we resume I mention that they will probably regret not taking a rest, and then come back to that point after the next action if fatigue has degraded it.

6. Other Body State Problems:

In the same way that the mind misfires when tired or overloaded, it also misfires when the body is in bad shape from not being taken care of in other ways. During illnesses, headinjured moments become more likely, especially when there is a high fever. It has also become apparent that allergies tend to distract the person’s mind and produce more head-injured moments. Malnutrition is a problem which is easy to fall into because the survivor does not always feel as hungry or notice the feelings of hunger when busy with something else. The same goes for dehydration. Some health food nuts claim that eating a bad diet of junk food, sugar, and soft drinks takes more of a toll after a head injury than it did before. Although there is no body of research on this question, my observations of patients in rehab suggest that these concerns are probably legitimate. Eating a well-balanced, healthy diet, including a good breakfast, and avoiding junk food, probably has some mental benefits.

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