Two Clinicians’ Personal Story of TBI Recovery An SLP shows the true grit required to come back from a serious brain injury—she and a friend share lessons learned. Features
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Features  |   December 01, 2015
Two Clinicians’ Personal Story of TBI Recovery
Author Notes
  • Laura Morgan, MS, CF-SLP, lives in based in Bethesda, Maryland, where shares observations from her TBI experiences in educational and medical settings and serves as a research assistant for the Speech-Language Pathology Department of the Walter Reed National Military Medical Center. She plans to return to practicing speech-language pathology. lauramorgan88@gmail.com
    Laura Morgan, MS, CF-SLP, lives in based in Bethesda, Maryland, where shares observations from her TBI experiences in educational and medical settings and serves as a research assistant for the Speech-Language Pathology Department of the Walter Reed National Military Medical Center. She plans to return to practicing speech-language pathology. lauramorgan88@gmail.com×
  • Anna Miller, MA, CCC-SLP, is a speech-language pathologist and certified brain injury specialist at Adventist HealthCare Physical Health & Rehabilitation Hospital in Rockville, Maryland. She participates in the Brain Injury Support Group in Montgomery County, Maryland. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech & Language Disorders; and 12, Swallowing and Swallowing Disorders. ar5miller@gmail.com
    Anna Miller, MA, CCC-SLP, is a speech-language pathologist and certified brain injury specialist at Adventist HealthCare Physical Health & Rehabilitation Hospital in Rockville, Maryland. She participates in the Brain Injury Support Group in Montgomery County, Maryland. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech & Language Disorders; and 12, Swallowing and Swallowing Disorders. ar5miller@gmail.com×
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Attention, Memory & Executive Functions / Traumatic Brain Injury / Features
Features   |   December 01, 2015
Two Clinicians’ Personal Story of TBI Recovery
The ASHA Leader, December 2015, Vol. 20, online only. doi:10.1044/leader.FTR4.20122015.np
The ASHA Leader, December 2015, Vol. 20, online only. doi:10.1044/leader.FTR4.20122015.np
A near-fatal car accident during her clinical fellowship left SLP Laura Morgan with a serious traumatic brain injury. She’s had moments of despair, but she has drawn on her own strength—and the support of family and friends like fellow SLP Anna Miller—to mount a remarkable recovery.
Here, Morgan and Miller describe their own perspectives on Morgan’s journey. They also share first-hand advice for clinicians on supporting people through TBI rehabilitation.
Laura Morgan, TBI Survivor, Tells Her Story of Recovery
A car crash changed her life. The rehabilitation she received for a traumatic brain injury changed her approach to speech-language treatment.
After graduating from the University of Tennessee in 2012 with a master’s in speech-language pathology, I accepted a fellowship in a long-term care and rehabilitation facility. There I became fast friends with Anna, another speech-language pathology fellow.
About four and a half months into the fellowship, my grandmother passed away. My parents and I put our Christmas holiday preparations and other obligations on hold to attend my grandmother’s out-of-state funeral. I was going to play my cello in the service, so the instrument joined us in our vehicle.
The van was neatly packed full of pictures of my grandmother to be displayed at her service, along with all our fresh, raw grief. I was buckled in the back of our very safe van, traveling on the interstate, when it collided with an 18-wheel semi-truck. At the time, two off-duty emergency room nurses were traveling in the opposite direction. The nurses saw the whole incident occur, called 911 and quickly intervened with life-saving assistance.
I was taken by ambulance to the nearest hospital where I was stabilized, then flown by helicopter to a larger hospital equipped to handle my very serious injuries. I had a moderate-to-severe diffuse axonal traumatic brain injury, a broken jaw, several broken ribs and complete fractures of spinal vertebrae C1 and C2. Given the gravity of my injuries, my family was warned that I might be ventilator-dependent, paralyzed and cognitively unable to hold a job for the rest of my life.
I spent 72 days in several hospitals, a recipient of top-of-the-line medical care and the advocacy of vigilant family members and friends. Through these invaluable sources of support and much personal determination, I was able to advance fairly quickly to breathing on my own and communicating. During my final inpatient hospitalization, my physical needs were ready to be addressed, but I was still mostly restricted to wheelchair.
I do not remember anything from the 72 days I spent as an inpatient. I was unable to recall what had happened and why I was even in a medical facility. My family set up photos and memorabilia in the hospital rooms to try to ease my disorientation. “Why am I here? What happened?” I’d implore. Minutes later, I would forget the answers and tearfully ask the same questions. I was mourning a profound loss that kept repeating itself, making the grief raw again with each uncovering.
Anna, a welcome visitor, put a fun calendar on my hospital wall that served both as an orientation device and a source of cheer. Since my mind and body had suffered such a dramatic, life-changing event, I needed such creativity to provide me with encouragement and enjoyment. I am grateful I did not experience the personality change that is possible following severe head injury, as that would surely have complicated my recovery.
Though I was facing new limitations and stresses, I subconsciously still had the same self-perception and aspirations as before the accident. Time had stopped in my mind at a phase when I had been busy working as a speech-language pathologist and participating in many extracurricular and service activities. I automatically recalled what I could do before the accident, so any performance that did not match those abilities was an inexplicable defeat. I was not automatically proud of the hard work that was influencing the rate of my recovery. By necessity, I was living in the moment, because the here and now were all I could be sure of.
As a result, I couldn’t gauge how far I had come, and it was also very difficult to celebrate any of my gains. I had to intentionally form an accurate picture of my progress so that these improvements were not overlooked. Further, “living in the moment” meant that any happiness had to be gained through moment-to-moment experiences. No monetary compensation was given in exchange for my current “job” propelling my own rehabilitation, but it required endurance that would rival any of my prior endeavors.
Over the next several years, I completed weekly outpatient therapy sessions, including occupational, physical and speech-language therapy. This treatment provided a rare and valuable opportunity to observe from the speech-language patient’s perspective and gain insight that I believe will greatly benefit my future clinical practice.
What SLP Anna Miller Learned About TBI From Her Friend’s Recovery
When a fellow SLP and close friend sustained a traumatic brain injury, she saw rehabilitation in a whole new light.
There we were—walking the halls at the ASHA 2014 Convention in Orlando discussing the best approaches to cognitive rehabilitation after a TBI. It’s a walk I could not have imagined two years before. Two years before, this young woman walking next to me was in a coma and the future was very uncertain.
I met Laura on her first day at the skilled nursing facility where I was doing my clinical fellowship. She was joining me as a fellow, and it was my job to “show her the ropes.” Within minutes of meeting, I could already tell how sweet, smart and sensitive Laura was. She exuded a positive energy that brought smiles to patients’ faces. We decided to carpool to and from work.
So it began—two fresh-faced, naive new grads ready to take on the speech-language pathology world! Unfortunately, it didn’t take long for Laura to also discover the challenges of the job. Our car rides often turned into counseling sessions, but also provided us with the chance to discuss patients and learn from one another. We laughed about some of the humorous situations we found ourselves in each day and cried about the upsetting ones. We listened to motivational music and sometimes stopped at the fudge shop on the way home as a reward for making it through the day.
Everything changed that December when Laura and her parents were in a terrible car accident on the way to her grandmother’s funeral. Laura was the most seriously injured, suffering a moderate-to-severe TBI, fractures to her cervical spine, and a broken jaw. She was airlifted to a trauma center where she was put into an induced coma.
Laura and I had many times discussed how we couldn’t imagine what life must be like for our patients—those on vents, with tracheostomy tubes, unable to walk, unable to talk. But now, this was Laura.
After her accident, I was constantly reminded of her. I worked with one timid patient for whom Laura had made a memory aid. At the bottom, Laura had added a personal note: “Don’t feel bad about asking for help! Everyone is here to help you and they’re happy to do so!” Just one example of the empathy and compassion Laura brought to her job. Two weeks after the accident, I visited Laura just as she was starting to wake up from the coma. She opened her eyes and tracked me a bit throughout the room and lightly squeezed my hand. At that point, the doctors weren’t sure how much function Laura would regain.
Over the next several months Laura beat many odds: her tracheostomy tube was removed quickly, she began communicating, her physical movements improved, and she began eating by mouth (even helping to analyze her own swallow study results!). Finally, almost two and a half months after the accident, she was back home. There she continued with occupational, physical and speech therapy with home health care.
I finished my clinical fellowship in May 2013 and began working soon after at a rehabilitation hospital closer to my home. Last year, Laura and her family decided to continue her outpatient therapies at my facility, and I watched her improving the strength of her left arm and increasing her balance, among other gains.
Today, almost three years after the accident, Laura is walking (and sometimes running!) without any assistive device. She is also driving, and making her way back into the speech-language pathology world. Her sweet personality and unending care for others is as it was before the accident. She continues to have mild cognitive and physical deficits, but I notice progress every time I see her.
Throughout her recovery, Laura has been incredibly introspective, writing beautifully about the healing process. I have worked to incorporate her advice into my clinical work, and believe I have become a better SLP because of it.
Just a walk down the hall with Laura at the ASHA convention meant so much to me. I knew Laura was special the day I met her, but I could never have predicted that she would walk so tall in the face of such a challenge. Observing Laura’s journey has helped remind me that those we treat are people’s daughters and sons, sisters and brothers, friends and co-workers, and maybe even someone’s SLP.
Five Pointers for Working With Clients With TBI
When treating this population, what you do matters less than how you do it.
Based on both of our experiences as clinicians, Laura’s experience as a patient, and Anna’s experience as a close friend of a person with a TBI, we offer some take-away points for working with people with brain injuries.
First, develop rapport.
“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
This quote, attributed to Maya Angelou, nicely sums up the importance of rapport in therapy. This sentiment has been supported by psychotherapy research, which finds that a client’s relationship with the clinician frequently contributes more to outcomes than does type of treatment used (see sources below). In other words, it matters less what you do than how you do it.
Laura found this to be true during her treatment. She often recalled only the most emotionally impactful events from a session, which, unfortunately, were frequently the most negative. If she had a meeting with a clinician in which nine items were listed as fabulous gains, but one was mentioned as needing more work, guess which one she would remember? To counter this tendency, Laura created a “Journal of Successes” in which she records and celebrates emotional, cognitive and physical accomplishments.
It is also important to recognize and respect that negative feelings are a normal part of the TBI aftermath. Chemical changes can lead to emotional dysregulation (see sources below). What deserves equal recognition, however, is that there are justifiable reasons for the patient to be upset, including disruptions to interpersonal, physical, financial and occupational areas. Additionally, a patient may not be able to rely on pre-injury coping mechanisms. For example, a person who used exercise for stress relief may no longer be able to do so if the person is experiencing physical deficits.
By recognizing and validating these changes in our clients’ lives, we can help foster critical rapport that can be overtaken by pressures of data-taking, documentation and lack of time. Laura appreciated when a therapist sought to learn more about her. A box of “get to know you” questions on your desk could help spark these types of discussions. You might disclose appropriate information about yourself and acknowledge when you learn from the patient (for example, “That was a great way to describe what aphasia feels like. I may use that when I’m explaining aphasia to other patients.”).
Recognize the effects of head injury are a hidden disability.
Like psychiatric and learning disabilities, TBI is not apparent to the untrained eye. Consider these points about hidden disabilities in your work with clients.
  • Don’t be fooled. Visible progress is great and deserves acknowledgment, but that doesn’t mean the person is feeling as celebratory as you might think.

  • Celebrate hard work, but also respect for the client not being fully satisfied with results.

  • Don’t put words in a client’s mouth (“You must be so, so happy and pleased with your progress!”). Instead, offer a statement that includes ongoing emotional support such as, “It sounds like this is still a painful process and it is important that you express your desires for help, but wow—I can see that your hard work is making a huge difference! Do you want to hear how I’ve seen you progress?”

  • If you can’t personally relate to the client’s experience, don’t try.

  • Use real or possible situations relevant to the client’s life to instruct and rehearse self-advocacy and appropriate self-disclosure about this hidden disability.

Acknowledge and respect your patient’s goals
We can never truly predict a TBI patient’s long-term outcome, so even if a patient’s long-term goals seem unrealistic, this may change. In the inpatient rehabilitation setting, having hope early on has been shown to correlate with better functional outcomes (see sources below). SLPs can provide hope without making any promises with statements such as, “We cannot predict the future, but that sounds like a great goal. Let’s give it a shot!”
If patients can no longer participate in previous activities, it is important to acknowledge their sense of loss. And suggestions to replace these activities may not always be helpful. Early on, for example, Laura found it difficult to accept that she was not able to play the cello. Well-intentioned suggestions to instead play other instruments often made her feel worse. However, totally separate activities (such as kayaking) were the most helpful. It was only later on in Laura’s recovery that she could open her mind to exploring other musical activities.
Help patients realize that they can ultimately achieve goals through creativity, flexibility and time. Also understand that what might seem like lack of motivation may actually be depression, cognitive deficits (such as forgetting to complete homework assignments due to memory impairments) or simply feeling overwhelmed (“I have so much to do. I’m just going to do nothing.”). You can help patients problem-solve through such situations. For example, make a goal for the patient to request breaks, repetitions and/or clarifications when needed.
A further complication may be the “good old days” bias, in which people often look back at their pre-injury period as better than it actually was (see sources below). SLPs can help educate patients about this phenomenon and share stories of their own cognitive imperfections (“I need to take notes during the session to help my own memory”).
Make therapy sessions as functional as possible.
Laura became most disengaged with a therapy task when she could not see its relevance to her own life. We suggest constantly checking in with the patient and caregivers about goals and tying treatment to them.
As patients transition to outpatient therapy, they may be overwhelmed by the amount of tasks they “should” be completing (physical therapy exercises, hand exercises, cognitive exercises). Laura used a daily checklist to help her better manage her tasks. We can help our clients organize and prioritize items on such lists and encourage them to push back when clinicians overwhelm them with information and tasks.
Involve family members/caregivers early and often.
Encourage caregivers to hang pictures of the patient’s family members and friends and information about the patient’s interests and hobbies on the wall. Encourage family and friends to incorporate humor into the recovery process.
Patients and caregivers are likely being bombarded by new information, so expect to repeat it many times. Let them know that it is normal to feel overwhelmed.
Because every person and every TBI is different, there is no guarantee that all these recommendations will benefit every patient. What is universal, however, is the helpfulness of an open, “team” approach to TBI care. We, as SLPs, may be “experts” on clinical aspects of recovery, but the patient is an “expert” on what will motivate or discourage him or her. Both patient and clinician “experts” are essential for achieving goals and success in recovery from traumatic brain injury.
Sources
Iverson, G. L., Lange, R. T., Brooks, B. L, & Rennison, V. L. (2010). “Good old days” bias following mild traumatic brain injury. Clinical Neuropsychology, 24, 17–37. [Article]
Iverson, G. L., Lange, R. T., Brooks, B. L, & Rennison, V. L. (2010). “Good old days” bias following mild traumatic brain injury. Clinical Neuropsychology, 24, 17–37. [Article] ×
Kortte, K. B., Stevenson, J. E., Hosey, M. M., Castillo, R., & Wegener, S. T. (2012). Hope predicts positive functional role outcomes in acute rehabilitation populations. Rehabilitation Psychology, 57, 248–255. [Article] [PubMed]
Kortte, K. B., Stevenson, J. E., Hosey, M. M., Castillo, R., & Wegener, S. T. (2012). Hope predicts positive functional role outcomes in acute rehabilitation populations. Rehabilitation Psychology, 57, 248–255. [Article] [PubMed]×
Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 357–361. [Article]
Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 357–361. [Article] ×
Turkstra, L. S. (2013). Inpatient cognitive rehabilitation: Is it time for a change? Journal of Head Trauma Rehabilitation, 28, 332–336. [Article] [PubMed]
Turkstra, L. S. (2013). Inpatient cognitive rehabilitation: Is it time for a change? Journal of Head Trauma Rehabilitation, 28, 332–336. [Article] [PubMed]×
Wampold, B. E. (2011). Qualities and actions of effective therapists. American Psychological Association Continuing Education Program. Retrieved from www.apa.org/education/ce/effective-therapists.pdf.
Wampold, B. E. (2011). Qualities and actions of effective therapists. American Psychological Association Continuing Education Program. Retrieved from www.apa.org/education/ce/effective-therapists.pdf.×
1 Comment
August 18, 2017
Kristdann Abad
Amazing!
Thank you for taking the time to share this. The strategies can be utilized with any patient grieving a loss.
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December 2015
Volume 20, Issue 12