TBI in Service Members – Real-life effects & the need for Empathetic, Compassionate & Trauma-informed Care: Acquired Neurdivergence Series, Article 1, by Jenah Nugent-Fullam, M.A., CCC-SLP
In January 2020, after U.S. military personnel were injured on bases in Afghanistan from Iranian missiles, tweets by President Trump incorrectly and harmfully labeled mild traumatic brain injuries as “headaches.” 1
These news reports focused our nation’s collective attention on a very misunderstood and misrepresented population of individuals-military service members with traumatic brain injury. The number of United States Uniformed Services members living with traumatic brain injury (TBI) is estimated to be upwards of 400,000 since the year 2000. The Defense and Veterans Brain Injury Center (DVBIC) estimates that approximately 1.7 million people sustain TBI’s annually (civilian and military), with around 3 million visits to emergency rooms to assess suspected traumatic brain injuries. 2
Traumatic brain injury is defined as “a traumatically induced structural injury and/or disruption of brain function as a result of an external force”.6 Most cases of TBI (both civilian and service-related) are considered mild. Approximately 83% of all service-related TBIs were classified as mild, around 10% were classified as moderate.2 Someone with a TBI can exhibit any of the following associated symptoms, which may present immediately, or can manifest months after injury:
- persistent headaches,
- cognitive impairments (short term memory loss, trouble concentrating)
- executive functioning problems (difficulty multitasking, organizing, planning, and decision making)
- behavioral changes (impulsiveness, poor insight), emotional changes (such as flat affect, anxiety and/or depressed mood)
- sensory problems (dizziness, impaired hand-eye coordination).6
Along with the physical and cognitive changes associated with TBI, survivors are also subject to Post Traumatic Stress Disorder (PTSD), depression and anxiety. Some numbers estimate that 34% of service members who have been affected by even mild TBI experience depression co-morbid with PTSD.7 Most notably, these patients demonstrate up to a 75% increase risk of suicide in the first six months after injury, compared to individuals in their age range that did not have a brain injury.8
To further complicate their situation, these emotional changes when coupled with an injury to areas such as the frontal lobe (which controls executive functioning) or the amygdala (which processes emotions such as fear, anxiety, and aggression), can lead to the inability to regulate themselves, sometimes resulting in physical and verbal outbursts, anxiety and confusion.
Beginning in around the year 2000, the field of Applied Behavior Analysis (ABA) has included Traumatic Brain Injury (TBI) among their ever-increasing scope of practice, claiming that ABA is “one of the most effective treatments for managing mood, behavioral and other mental disorders associated with brain damage”.3 ABA, in its simplest form, treats the behavior associated with TBI, rather than treating the underlying neurological reasons for that behavior.
The public may be shocked and surprised to know that Board Certified Applied Behavior Analysts (BCBAs) have no formal training in the neurological framework in which they claim to be experts,4 and they certainly do not apply a neurological approach to their therapy. We as rehabilitation professionals know that there is likely an underlying injury to the neurological mechanism responsible (emotional, sensory or physical impairment issue) that is directly related to the resulting behavior of a person with a brain injury. Instead, behavior modification (compliance training) mandates training a patient through a system of rewards and punishments, to respond exactly in the manner the ABA therapist has determined to be “appropriate,” rather than helping the patient understand why they responded the way they did, and how to utilize therapeutic techniques to overcome or adapt for their brain injury and related co-morbidities. In conjunction with memory impairments, or word-finding issues, depression, and anxiety, it is inhumane to expect a traumatically brain-injured patient to respond on command, similar to a robot. 5
When rehabilitation professionals examine these behavioral changes associated with TBI for what they are – attempts to communicate frustration or distress – we not only gain insight into the challenges these patients are facing but also harness the opportunity to build a stronger therapeutic relationship with our patients. By demanding compliance or utilizing compliance-based therapy techniques, we are taking away the autonomy of our patients over their bodies and their minds. We are conveying harmful messaging that being frustrated, angry or upset is not an acceptable way to feel or that our patient does not have the right to express their negative feelings. We are invalidating them as self-autonomous human beings. There is no such thing as positive reinforcement that demands compliance above self-determination and body-autonomy from your patient. Studies have shown that patients with a higher rate of self-efficacy – or a person’s confidence in their own ability to control over behavior, motivation or their social interactions/situations-increases their chances to be successful in treatment for psychological distress.9
For service members and their families, the DVBIC has generated a wealth of resources for providers, patients and families ranging from a concussion evaluation tool, headache management tool for physicians, Clinical Practice Guidelines for OT/SLP/PT, to Quality of Life scales.10 These resources have been compiled and are based on the most up-to-date research and evidence-based practices (EBP), and include rational and links to research supporting each individual guideline or tool.
We as rehabilitation professionals and patient advocates must seek out and practice treatment techniques that are empathetic to our patients. Never should we withhold, coerce or force our patients to comply with a treatment plan or goal. Make sure that you include your patients, and their families, in the creation of your plan of care. It is important to collaborate with all professionals involved, from the neurologists, occupational and physical therapists, psychologists and psychiatrists, to ensure we are taking into account the whole person.
The Therapist Neurodiversity Collective includes patients with acquired neurological conditions such as traumatic brain injury, in the category of acquired neurodivergence. As the founding members of this Collective conduct continuing in-depth studies of the self-determination and self-advocacy violations that ABA present, and as we see more and more self-serving published research pushing the use of ABA into adult and geriatric settings such as skilled nursing homes, traumatic brain injury units, rehab hospitals, and outpatient clinics, we include these patients with acquired neurodivergence in our platform for both logical and empathetic reasons. Therapists treat acquired neurodivergence (TBI, post-stroke, brain bleed, etc.) as a medical condition. An acquired neurological condition requires prescribed rehabilitative therapy from skilled licensed speech, physical and occupational therapists.
1 Trump is Misinformed About Traumatic Brain Injury (2020, February 26) Retrieved from https://thehill.com/opinion/healthcare/480020-president-is-misinformed-about-traumatic-brain-injuries
2 DoD Worldwide Numbers for TBI. (2020, January 31). Retrieved from https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi
3 Applied Behavior Analysis in the Treatment of Traumatic Brain Injury. (n.d.). Retrieved from https://www.appliedbehavioranalysisprograms.com/specialties/applied-behavior-analysis-in-the-treatment-of-traumatic-brain-injury/
4 Coursework in Applied Behavior Analysis (BCBA). (n.d.). Retrieved from https://www.mercy.edu/degrees-programs/coursework-applied-behavior-analysis-bcba
5 Ricciardi, J. N. (2017, March 17). Applying Behavioral Principles in the Neurorehabilitation … Retrieved from http://www.biact.org/assets/uploads/files/Conference/Annual Conference Archives/Joseph Ricciardi – Behavioral Principles.pdf
6 Traumatic brain injury (TBI). American Speech-Language-Hearing Association. http://www.asha.org/public/speech/disorders/tbi/. Accessed 10 Feb 2020
7 Kennedy, J. E., Lu, L. H., Reid, M. W., Leal, F. O., & Cooper, D. B. (2019). Correlates of Depression in U.S. Military Service Members With a History of Mild Traumatic Brain Injury. Mil Med,184(Supplement_1), 148-154. doi:10.1093/milmed/usy321
8 Madsen, T., Erlangsen, A., Orlovska, S., Mofaddy, R., Nordentoft, M., & Benros, M. E. (2018, August 14). Association Between Traumatic Brain Injury and Risk of Suicide. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30120477
9 Belanger, H. G., Vanderploeg, R. D., Curtiss, G., Armistead-Jehle, P., Kennedy, J. E., Tate, D. F., … Cooper, D. B. (2019). Self-efficacy predicts response to cognitive rehabilitation in military service members with post-concussive symptoms. Neuropsychological Rehabilitation, 1–14. doi: 10.1080/09602011.2019.1575245
10 Cognitive Rehabilitation for Service Members and Veterans Following Mild to Moderate Traumatic Brain Injury Clinical Suite. Retrieved from https://dvbic.dcoe.mil/material/cognitive-rehabilitation-service-members-and-veterans-following-mild-moderate-traumatic-brain-injury-clinical-suite
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