Providing Psychotherapy Services on a Traumatic Brain Injury Service

August 21, 2014

Hello, I’d like to take a brief moment to introduce myself as I have not yet had the pleasure of meeting all of you. My name is Jessica Redis and I am a Licensed Clinical Social Worker providing psychotherapy to patients and families on the Traumatic Brain Injury (TBI) unit. I work closely not only with the nursing, therapy and medical staff, but also as part of the team of psychological services at Helen Hayes which includes psychiatrist Dr. Hornstein, psychologists Dr. Quail and Dr. Lowenstein, and Licensed Mental Health Counselor Sarah White. My clinical experience includes inpatient psychiatric settings as well as home and community based services with individuals of all ages. My practice is eclectic, pulling not only from my schooling and clinical work, but also from my own personal experiences caring for loved ones after their own major medical events.

Working closely with Dr. Seliger, I can mainly be found on the Traumatic Brain Injury Unit. This is a rewarding yet challenging place to work, primarily because of the often life-changing and sudden injuries and illnesses of our patients. Also, the wide array of reactions of our patients’ loved ones. For many of our patients and families, the time in acute care immediately following the injury or illness is a time of shock, disbelief, heightened fear and worry about survival of their loved ones. At first, the worry is hour to hour, then day by day, until survival seems assured and the patient is medically stable. The patient is then deemed appropriate for rehabilitation and is transferred to our care.

When patients and families arrive at our doors, they are often exhausted and running on empty–emotionally, physically and cognitively. It is at this moment that I make my first contact and begin to lay the groundwork for ensuring patient and family comfort and building rapport. I check in about basic needs, encourage families to take a deep breath and am often given the feedback that once in our care, families feel like they can begin to relax and regroup.

Once the patient settles into the milieu, families begin thinking about “the rest of our lives”–not only the patient’s life, but also how the family will manage the patient’s “new normal.” The patient and families share their hopes and expectations, which are not simply for survival, but also for recovery and a return to the life they enjoyed before the brain insult occurred. The start of rehabilitation is, for many, the time when expectations and hopes are challenged by the realities of the patient’s different abilities and needs. Patients and families begin to understand what neurological recovery looks like, the open ended timeline of recovery and, often, the incompleteness of that recovery. Many patients’ families find themselves facing a long period of recovery with an unclear end-point and an uncertain outcome. This is, understandably, unsettling (to say the least) for all involved.

The terms “counseling” and “psychotherapy” are interchangeable and the practice can be confusing in this setting. My role typically requires that a patient have a level of alertness and awareness and a reasonably good day-to-day memory that not all patients possess upon admission. Often when a patient remains confused, I check in with them on a basic level–reorienting them, inquiring about pain, assessing emotional state and extending kindness and comfort as memory improves. It is in building this relationship that I am also able to assist in the early phases of a patient who is becoming increasingly agitated.

It is more common that in the early days of a patient’s stay at Helen Hayes, my focus is on the family; their adjustment to the rehabilitation unit, their worries and fears, and their grief over what has happened. I model and encourage good self-care and advocacy for their loved one. Family members may be surprised and even upset over the range of emotional reactions they are having–emotions that seem very much like grieving a death. Family members may also react to the changes in behavior and personality of their loved one. Just as all individuals are different, so, too, are families and how they react and respond to crisis. These are all issues that I work with on a daily basis.

When a patient is awake and alert, is able to communicate, remember and retain things with some consistency and has developed some insight into their current level of functioning, they may become a candidate for counseling and psychotherapy. People who were verbal, who were able to talk about their emotions and who were thoughtful about the people and the world around them prior to their injury or illness are more likely to accept and engage in counseling than those who coped with life’s stresses solely or primarily through physical activity, risk taking and substance abuse. In situations where a patient is agitated and confused and their ability to make sense out of their environment and experiences is impaired, they are not yet able to benefit from counseling or psychotherapy.

The final aspect of my role on the TBI unit is as a support to the treatment team as they go about their work. Sometimes this is accomplished by explaining what is happening with a given family, or by providing some history about a patient that is relevant to their care to the staff. At other times, it is acknowledging the staff member’s own reactions, views and emotions with a goal of ensuring that person is providing the very best care that they can. Good rehabilitative care involves collaboration between not only the patient and the family, but also the entire treatment team: nursing, therapy, case management and medical staff. It truly is a team effort with the patient and family’s strengths and needs at the center of planning and implementation. It requires a joint commitment to work hard, to share goals that are realistic and achievable, to develop relationships that are respectful of the history, culture and knowledge of the patient and family and of the expertise and experience of the staff in an environment that is professional and healing.

The work is, as I said earlier, quite challenging, but it is important work. I am honored to be a part of such a professional TBI team and for the opportunity to work with patients and families at a time of great need.

-Jessica Redis, LCSW
in collaboration with Dr. Bruce Lowenstein
Traumatic Brain Injury Service