Hidden head injuries are challenging for professionals because, while the individual may appear well, they often have residual cognitive problems affecting their memory, emotions or behaviour, writes Mark Drinkwater.
PRACTITIONER Patti Simonson, head of social work at the Royal Hospital for Neuro-disability.
FIELD Hospital social work.
LOCATION Putney, south-west London.
CLIENT George*, a 56-year-old man who has sustained a traumatic brain injury.
CASE HISTORY George’s injury has left him with impaired brain function. However, after eight months of hospital rehabilitation he is ready to move back to community accommodation, although he has little in the way of family support.
DILEMMA He wants to move to the inner-city area where he rented a room, but ambiguity over his last permanent residence means he is not deemed to be in priority need for housing in that borough. George becomes very agitated when told information he doesn’t want to hear.
RISK FACTOR George is impatient and impulsive. The risk is that he might discharge himself from hospital before he is ready and before suitable community services are put in place to support him.
OUTCOME George reluctantly accepts private rented accommodation after he is helped to lodge a legal challenge. This enables him to live in the area of his choosing, and with support he is able to live independently in his own flat.
* Not his real name
(Picture: Tom Parkes)
Patti Simonson, head of the social work team at the Royal Hospital for Neuro-disability (RHN), recently worked with a complex case involving the rehabilitation of George*, who had sustained an injury to his frontal lobe in an assault.
George had spent a month in a general hospital before being transferred to the RHN for rehabilitation. Initial work at the RHN focused on helping George to become physically fit. “After formal physiotherapy treatment we encouraged him to go to the gym to continue to work on his fitness and maintain the gains he had made. He needed to get his strength up as he was weakened by the brain injury and had been in a coma for a month,” says Simonson.
However, while his physical health improved, it soon became clear that George had difficulty coping with bad news or uncertainty. Like many with frontal lobe injuries, he became agitated easily. “You have to temper how you give information to someone with George’s injuries, particularly if it’s information they don’t want to hear,” Simonson says. “He was very impatient and at times could appear to be threatening because of this. He was a real character. But hard work.”
George’s hidden head injury impaired his cognitive skills. His inability to see the other person’s point of view would invariably result in quarrels with others. Even a simple trip to the corner shop could end in a confrontation with the shopkeeper.
Simonson’s role focused on following up accommodation options, sorting out his financial situation, planning for the future with him and contacting external agencies to access resources on discharge.
Alongside these social work interventions, other professionals at the RHN worked on his therapeutic recovery. She recognises the importance of partnership working on a complex case like this, most notably with her psychology colleagues, who helped George with anger management techniques. This was no simple task, she says, because of George’s rigid thinking.
Despite his impairments, George made significant progress and developed enough awareness to realise he was vulnerable.
“His hidden head injury and the residual cognitive problems put a limit on his understanding. It’s this that makes him vulnerable,” says Simonson.
George did, however, express some worrying responses to coping with his condition. For instance, he said he felt like carrying a weapon for self-defence – something staff at the hospital managed to dissuade him from doing.
The most challenging aspect of the case was helping George find suitable move-on accommodation in the area he desired. He had been adamant that he only wanted to live in council housing in the inner city area that he had lived in prior to his accident. However, Simonson discovered George was not registered as living in that borough, as he had only ever had an unofficial cash-in-hand arrangement which his former landlord subsequently denied being involved in.
Ambiguity over his last place of residence caused problems because, in spite of his cognitive disabilities, it meant he did not meet that local authority’s criteria for priority-need housing.
Temporary hostel accommodation was one option the housing team suggested. Such a potentially hostile environment was likely to have resulted in altercations with other residents and Simonson was very much against this option. She managed to convince George – who was very impatient – to wait for more suitable accommodation. She helped him obtain legal representation and, following a legal challenge, he was offered a tenancy in his chosen area under the local authority’s private rental scheme.
While something of a compromise for George, the private housing offer was by far the best option available. With permanent housing secured, Simonson was then able to engage with the community physical disability team.
“It was a successful outcome,” she says. “He was independent. He had purpose. He was living where he wanted to be and he had improved in terms of his understanding of his problems and had more insight.”
Reflecting on the case, Simonson acknowledges George would have been vulnerable in temporary hostel accommodation. “If he had gone to temporary accommodation, I think he could have been in big trouble. He would have got in a fight there with someone and hit them. That’s the big danger with this client group. There are significant numbers of people with brain injuries that end up in the criminal justice system because they do not have the right support or live in the right environment to help them cope with their ongoing needs.”
Weighing up the risks
Arguments for taking the risk
● Expectations managed
The social worker managed George’s expectations concerning his housing choices. Without this support, he could have left hospital to live in inappropriate temporary hostel accommodation where he would have been exposed to many more risks.
● Suitable housing found
While he did not get the council housing he wanted, George was supported in his wish to live in one particular district and eventually gained a private rental tenancy in that area.
● Legal representation secured
Helping him find legal representation ensured that he got a more secure housing option
Arguments against taking the risk
● Still vulnerable
Despite his progress, George is still vulnerable living in the community on his own. While he looks physically well, this was deceptive. His hidden head injury puts a limit on his understanding and cognitive skills and this put him at some risk in the community.
● Little family support
George has little in the way of family support and will be reliant on those services provided by the local physical disability team. Will they have the specialist knowledge of his condition in order to support him appropriately?
● Uncertainty over future
It is uncertain whether George will stay out of confrontations when he returns to live in the community. While he wants to live in that area, he will be returning to an area where he was previously assaulted.
Lance Carver, service manager, Herefordshire
This case appears to have been highly successful in that George has achieved the result that was of primary importance to him in finding accommodation in the area that he wanted. Although he initially wanted council housing he may well find the experience of private sector more positive.
Managing risk for this client group can be extremely complex as, unlike many others, there is usually an apparent absence of any motive for the high-risk behaviour. For George, the risk lies in the new brittle personality trait that can lead so easily to anger.
The other unfortunate factor is that these new personality features can be difficult for families and associates to understand. It is not like mental health where there is an apparent illness that is the root cause. It often appears in those who have had a brain injury that they are somehow choosing to behave in this way. This also makes their mental capacity difficult to assess.
The case does highlight the limited specialist support available to such individuals in the community as it appears that the case was transferred to the physical disability team at the point of discharge. The service user is likely to benefit from further specialist support from those who really understand his condition and associated behaviours.
This article is published in the 26 August issue of Community Care magazine under the heading Should he stay or go?
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