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Two intervention options to build trust and promote therapeutic engagement in a person with a Traumatic Brain Injury.

I met with a colleague the other day for lunch, who told me a story about one of her clients with a traumatic brain injury who did not want to engage in any therapy.  The clients only goal was to get back to work; however, her team of speech therapists in Toronto knew that she would fail given the extent of her injuries (i.e., loss of memory, executive function difficulties, verbal problem-solving difficulties, etc.).  The team did not want her to endure this type of failure and; therefore, offered multiple options in which she could participate aside from going back to work.  This client had little insight that she would fail at work, and felt that her whole therapeutic team was against her, trying to put up barriers to her achieving her ultimate goal.    

This story made me think of Tim Feeney, a psychologist who specializes in Traumatic Brain Injury and who lectured a couple years ago on the importance of aligning yourself as a therapist with the client’s goals even if you think they will fail.  The reason he said this, is because aligning yourself will build trust,  and with their trust, they might engage with you in therapy.  He gave the example of a guy that couldn’t save a penny to pay for rent or food, but wanted to take on the responsibility of getting a dog.  The therapists knew that this scenario was bound for failure and were trying to dissuade him from making this grave mistake.  Tim explained to the treating therapists to think of all the possible learning opportunities that could be harnessed with a guy motivated to get a dog.  He could learn budgeting, as he would need to save money to buy the dog, buy food, pay for veterinary expenses, etc.  In doing so, he would obviously have to pay his rent as he would have to house the dog somewhere.  He could improve his executive functions, as he would have to set a goal and make a plan to get this dog.  He would have to follow through on his plan, and of course, review how it was going.  Long story short, this guys’ team followed Tim Feeney’s advice and the result was a guy who learned how to budget, pay his rent, set goals, make plans and accomplish his goals and in doing so, was able to get a dog.  This accomplishment built his self worth, self confidence and  taught his team an invaluable lesson.   Lesson learned: Sometimes taking a risk with a client can lead to the client achieving their goals and great therapeutic success!

I am sure you are asking the question…what if it doesn’t lead to success?

I also told her about one of my clients who presented with the same difficulties as her client.  All of my clients’ therapists knew that given her cognitive and psychological difficulties she would likely be unsuccessful at reintegrating into the workplace.  We educated and found other therapeutic activities that would allow for success (e.g., volunteering); however, she was uninterested as her perception of success was getting back to her pre-accident life.  Her personal injury lawyer was excellent.  They encouraged the client’s therapy team to align themselves with her goal and support her to get back to work.  This allowed her team to establish trust.  This client went back to work and was unable to cope.  We provided countless strategies and worked with HR to make many work accommodations.  However, as hypothesized, her injuries were far too great.  The process of trying and failing with the team supporting her allowed the client to build a lot of insight around her areas of difficulty and she came to the conclusion on her own that it was not a great fit.  She was then engaged in finding other therapeutic options.  In addition, the lawyer was able to show how much the car accident and resulting injuries impacted her life.    Lesson learned: Sometimes, supporting a client in their goals, even if it results in failure, is a more efficient intervention than trying to find other therapeutic options in which the client is not interested.  

My colleague and I concluded our lunch and she walked away with two possible options:

1. Align the team with the clients goals, take a risk with the client, and with the teams support they will succeed in their goals and learn invaluable cognitive lessons along the way, or 

2.  Align the team with the clients goals, take a risk and provide the support needed for the client to achieve their goal.  If the natural consequence of failure takes place with the teams support, the client will begin to build insight that this goal may not be the best fit.  At this point, be present to support the client in problem-solving and planning steps to move forward.     

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