Why social work is so important for brain injury survivors

Why do people who have suffered brain injury need social work support?

Many brain injured survivors experience cognitive, behavioural, psychological and physical disability and subsequently exhibit degrees of impaired social competence, including disinhibited speech, impulsivity, poor social skills and judgement. They can be egocentric, appearing (often unintentionally) selfish and self-centred. A scenario of vulnerable relationships and breakdown followed by the inability to forge new relationships is all to common. Consequently, many brain injury survivors experience social isolation, low mood/depression and poor quality of life. When combined with barriers to returning to work or gaining work, resulting in reduced income and/or reliance upon the benefits system, the outcome for many can be very poor indeed. Social work support can prevent or reduce the impact of this downward spiral.

What does a specialist brain injury social worker do?

The Sheffield brain injury social work team support survivors through the three main components of the brain injury care pathway: the acute stage, sub-acute stage (involving inpatient rehabilitation) and into the community.
 
Family members become incredibly distressed at the scale of impairment, disability, behaviour and personality change that emerge following brain injury. For many it will be catastrophic, others may downplay their loved one’s level of disability and will remain unrealistic in potential goal attainment and recovery. Mutual adjustment can be delayed in these cases and it is the brain injury social worker’s role to confront these issues, offering a solution-based empathic intervention.
 
Offering support to families is essential as, in many cases, they will be the brain injury survivor’s only lifelong support network following rehabilitation discharge. Social workers offer families brain injury education to aid adjustment by raising awareness and providing behavioural management strategies, supported by the appropriate multi-disciplinary team members.

The brain injury team provides information, emotional support, onward referrals, signposting and community care assessments of need. The psychosocial goals-focused intervention provided by Sheffield head injury rehabilitation centre works to maximise the brain injured survivor’s potential, whilst supporting ongoing adjustment. The brain injury social worker is an integral element of this process and represents a positive example of health and social care working together. 

How did you get into brain injury social work?

I had trained and qualified as a social worker in 1990 and gained work as a hospital social worker. I had always been intrigued by the workings of the brain – especially when ‘brains get broken’ (as a client described it). The interest grew as I was referred more clients with brain injury. I was aware that we had a well-established dedicated team at that time in Sheffield and would ask for their advice about cases I was working. Social workers often work with those who experience social disadvantage and marginalisation, but when working with brain injury survivors I became very aware of this and the effects of multiple loss, believing I could make a difference. When a position became vacant in the brain injury team in 1997 I applied and was successful. Fifteen years later I’m still here albeit in more of a management role.
 
What are the key skills required of a brain injury social worker?

• Good interpersonal skills and clear communication requiring flexibility in their application when meeting the wide and varied needs and presenting behaviours of brain injury survivors;
• Skills in managing difficult behaviour, including understanding its origins, responding appropriately and being assertive and clear regarding boundaries with survivors who can exhibit disinhibited, impulsive behaviour; 
• De-escalation skills – often brain injury survivors misinterpret information and react in a disproportionate way;
• Assessment and interviewing skills – many brain injury survivors lack insight and awareness and will subsequently understate their needs, and there is a real requirement for knowledge and tenacity in gaining detailed information about eligible need to formulate an in-depth assessment;
• Good coordination skills – brain injury survivors will often have many agencies working alongside, including health, social care, housing, substance misuse and police, and the brain injury social worker needs to be able to co-ordinate these services in establishing a robust support network.

What are the three biggest challenges of working with people who have had a brain injury?

1. There needs to be recognition that working with brain injury survivors can be intense and time consuming, particularly working with those who are isolated, vulnerable and have co-morbidity issues, such as mental health, substance misuse, or a history of violence or risk taking. Lack of insight increases vulnerability levels as brain injury survivors will put themselves repeatedly at risk. The social worker is often the only support available and will need to be proactive as many fall under eligibility criteria or refuse to engage with services.
 
2. Navigating and supporting brain injury survivors through the welfare rights system is challenging work as their disability can be largely hidden. Many brain injury survivors have difficulty in articulating the effects of their disability, they fail the employment and support allowance medical assessment and consequently get pushed back into the job market prematurely or inappropriately, causing anxiety, depression and anger. Without the support of a social worker many misrepresent or deny they have a disability due to poor awareness and insight problems. Others have reduced tolerance and refuse to fully co-operate, leading to benefit realignment or withdrawal.

3. Returning to work can be challenging for brain injury survivors. Often the issue is not to do with physical disability as work environments can usually be adapted, but more to do with adjustments that will satisfy the effects of cognitive impairment and psychological need. Employers need to be supported in recognising the need for a structured and organised day, alternative training methods, consistent work space, need for memory prompts and clear boundaries regarding appropriate office behaviour. When brain injury isn’t recognised as a unique disability by employers or the brain injury survivor doesn’t make their needs apparent, gaining and retaining employment becomes problematic.

 Simon Eggington is advanced practitioner in the Sheffield brain injury social work team

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