Neuro OT in action: ‘Anger management’ after brain injury
Helping brain injury survivors to manage angry or aggressive verbal or physical outbursts takes a neuro occupational therapy approach, often as complex as their client’s challenges.
Such was the case with Krysalis client Claire who was 48 years old when she experienced a brain injury due to encephalitis (inflammation of the brain). For our Neuro OT, however, there was a bigger hurdle to leap first.
And it would take all her clinical experience and knowledge of Claire’s layered diagnoses, her commitment to helping her, and every ounce of creativity she could summon to secure life-changing progress for this particular client.
Claire’s case demonstrates that, even with complex challenges, gains can be made that benefit not only the client but also their family and support team…
In the beginning, we did not know how to manage her behaviours. She used to do some strange things like wash her clothes in the toilet. She could be very physical if you upset her in any way. You had to be careful about how you said things in case this upset her. Even your tone of voice could make things worse. 
Member of Claire’s Companion Team
Claire had already learned to overcome many barriers to independence in her life. She was born with physical disabilities due to Thalidomide, a drug prescribed for morning sickness in pregnant women in the late 1950s and early 1960s [1].
She was proud of her academic ability and achievements in education and work. At the time of her brain injury, she was working full-time. She also cherished her role as a mother and valued her ability to look after her children when they were younger.
Claire enjoyed showing others what she could do independently, despite her disabilities. Her interests were varied and included gardening, cooking and crafts.
But her brain injury significantly impaired her cognitive abilities, largely her memory. She could not plan, organise, remember information, or even new faces. She was living much of her life in the here and now.
To make matters worse, Claire behaved in detrimental ways to her health and well-being.
She would withdraw to her room and refuse to go out into the community. She let her personal hygiene activities slip, such as washing herself, changing her clothes, and brushing her teeth.
She declined offers to wash her clothes or bed linen but would repeatedly wash her clothes in the toilet. Claire also began hoarding food and over-eating to excess.
Other negative behaviours impacted the people who cared most about Claire - her family and support team.
For example, Claire would repeatedly seek a response or reassurance to her verbal statements by adding, “I’m right, aren’t I?” or “I know everything, don’t I?”
She could erupt in anger, displayed through body blows, head pushing, kicking, or shouting. And she would throw items and intrude on other people’s personal space.
Conflict resolution
Through her clinical assessments, it became clear to our Neuro OT that Claire was experiencing conflict between her long-held values, especially self-reliance, and her new-found limitations. This influenced her responses to the people around her.
With very poor memory and other cognitive challenges, Claire could no longer rely on her hard-wired coping systems, triggering her behavioural outbursts.
But Claire needed to accept support to organise herself and her daily routine to raise her quality of life.
So, the initial stages of Claire’s neurorehabilitation focused on understanding her and her ‘view of her world’ and gathering other people’s views of Claire and her behavioural patterns.
Our Neuro OT discovered it was essential to Claire that she was seen as self-reliant and just as able to do things as anyone else. It was a long-established belief that was central to her self-image.
Claire was a determined person who had overcome many barriers to independence due to her Thalidomide-linked disabilities. It offended her when, even in her best interests, people tried to help her complete tasks. It made her feel more anxious and could trigger aggressive behaviour.
Our Neuro OT also noted, however, that Claire valued spending time showing others how she could do tasks independently. This would prove a key motivator in Claire’s neurorehabilitation - and a vital pointer for our Neuro OT to select strategies that supported Claire’s sense of empowerment.
Using the evidence-based ‘Active Environment’ OT model, which features structured documentation and goal setting, Claire was encouraged to engage with her daily routine.
Strategies included a clock with a date display, a weekly planner board, and - to replace verbal prompts, which Claire found confrontational - sensors were fitted instead to operate her toilet and body dryer.
Initially, all activities were planned indoors within Claire’s comfort zone. As she made progress, they were moved outdoors into her garden until, eventually, she was taking part in meaningful, community-based activities.
Creative righting
Creatively making things ‘right’ for a client can take time. The focus of Claire’s neuro occupational therapy was to influence her participation in activities, either independently or with the help of her support team, and to reduce her detrimental behaviours.
But our Neuro OT needed specific strategies to engage Claire and keep her engaged during her neurorehabilitation. Here are some of the ways she achieved this:
- Doing activities ‘with’ and not ‘for’ Claire
- Choosing activities linked to Claire’s history and valued roles and skills
- Identifying activities that explore Claire’s strengths and affirm her achievements
- Challenging her physical abilities
- Creating opportunities for her to show others her capabilities
Our Neuro OT also educated Claire’s family and support team regarding their expectations of her, the importance of pacing activities, routine, and consistency, and ensuring a safe and familiar base from which Claire could progress.
As a result of our Neuro OT’s intervention, Claire now maintains her personal hygiene, and her anger outbursts stopped. Other negative behaviours lessened.
She enjoys various activities at home, and, with support, she regularly accesses her community to take a walk or for shopping or leisure trips.
Claire’s experience of participating in activities was significantly altered by her neuro occupational therapy, allowing her again to feel independent and in control of her environment.
The OT's support and drive have helped the companions confront obstacles creatively. There is immense value to them as lone workers in receiving outside professional and therapeutic support.
Case Manager
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Krysalis Clinical Director, Jo Throp
Read on here: The tapestry of life with brain injury
