1. This is the point at which you graduate up from keeping a simple list of your head-injured moments into doing full-fledged self-therapy by analyzing them.
2. To analyze a head-injured moment, you have to identify which kind of error you made, determine what kind of situation brought it on, and work out how to prevent it from happening again. You do this using the Analysis Form printed on the next page.
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3. First, number the forms you do in the order in which you do them. Then explain what went wrong in the section called “my mistake.” Make sure that you are only talking about one particular head injured moment that happened at a specific time, not a KIND of head-injured moment.
4. Then identify when the mistake started. Most mistakes don’t start when things begin to go wrong. Most of them start when you failed to prepare or to organize what you were doing. For example, if you brought up a difficult topic with an important friend on the spur of the moment, then the mistake probably began the night before, when you should have planned to have the conversation and put it on your daily schedule. That would have given you a chance to work out what you wanted to say. If you bought a last-minute gift for a powerful person that was poorly chosen and not appreciated, then the problem didn’t begin when they opened the gift, but instead when you should have gone shopping well ahead of time to give yourself enough time to pick a proper gift. If your car blew up because it ran out of oil, the problem didn’t begin when the car began to make funny noises, but rather when your car was scheduled to have its last oil change. Another way to think of it: If you could get into a time machine and go back and fix the whole problem, what is the first thing you would need to change? That’s when the problem began.
5. Now you want to figure out what got you to choose the wrong course of action. Was it your state of mind (your attitude, your emotions, or your physical condition)? Was it a case of overload? Did you make enough effort for the kind of task you were doing? Carefully analyze your state of mind when the mistake began, and circle as many of the descriptions as apply. Write down everyone you were with, as it often turns out that being around certain people brings out head-injured moments when you are doing certain tasks.
6. When you analyze the task, check off the category “Was I trying to do something new?” if you were trying a new or unfamiliar task, or trying to use a new strategy or techniq ue, or trying to use new equipment or new partners, or working in a new situation. This category does not apply only to tasks in which every aspect is familiar.
7. The category “Was I trying to do something hard?” asks you to make a judgment. Is this a task which is not easy for you to do? Is it a task that is not easy for most people to do? Is it a task where the results are judged by high standards? Mark it off if any of those conditions applies. This category does not apply on to task which are easy for you to do well.
8. Process factors: Survivors almost never have head-injured moments if they have just warned themselves that “I think I’m about to have a head-injured moment.” When you sound that warning to yourself, it is natural to raise your level of effort, think hard about what you are going to do, make sure you are not overloaded, get mentally prepared, and act carefully. The warning basically cures the problem. So when you DO have a head-injured moment, it almost always occurs BECAUSE you didn’t warn yourself. Be careful not to overlook this extremely important category, as it plays an important role in all aspects of self-therapy.
9. If this head-injured moment is a repeat of one you have already written up on an Analysis Form, that requires some extra thinking. I already made a plan to fix this problem—why didn’t it work? Did I forget to do something I intended to do? If so, I need to set a better trigger to remind myself of what I need to do. Or did I do everything I planned to do, and it still didn’t work? In that case, my plan was not effective, and I need a stronger solution. It is important to become MORE aggressive in your self-therapy any time an analysis fails, because you are trying to prove that you can overcome all of your head-injured moments.
10. The category “I was trying to do something the way I did it before my injury.” is another major source of head-injured moments. Most important tasks have to be re-programmed to work well after a head injury. Doing things the old way i inviting head-injured moments. It is important to never forget that you are working with a new brain, and that your old ways of doing things are not appropriate for this new brain.
11. If you are not planning to do a task, then you are not able to prepare properly for it. The element of surprise also disorganizes your brain. So if the task was not on your daily planner, it is important to recognize that fact. That is something you want to fix for next time if possible.
12. The last two process factors have to do with mental effort. They are keys to fixing yourself.
13. What is the main cause? This is probably the most difficult question on the form. If you could fix only one thing, which fix would be most likely to prevent the head-injured mom ent? Be sure to ask your selftherapy helper (family member or friend) if they agree with your choice.
14. Make a plan that will prevent the head-injured moment from becoming a problem the next time you are in that situation. First, you need to figure out how to get yourself to break your pattern and start using a fix it routine. How can you “trigger” yourself to put a new plan into effect ? “I’ll just remember” is not good enough. What will trigger you to remember? Will you put up a sign to remind yourself? Will you have someone remind you? Will you put a note in your daily schedule to remind yourself? Will you work hard enough to focus your mind on a danger sign to force yourself to remember? If your trigger isn’t effective, your plan will fail, and you’ll repeat your mistake.
15. When the trigger goes off, what are you going to say to yourself to warn yourself that you are about to create a head-injured moment? How you talk to yourself will determine how much effort you make and how much control you get. “I’m about to screw up!” or “Danger!” or “Head Injury Zone!” or whatever gets you to stop and think HARD, that is what you want to say to yourself.
Dealing With Sleep Problems
1. Many survivors have sleep problems because they are inactive and living a new lifestyle.
2. Survivors who take a nap because they have nothing to do may be unable to sleep through the night. Other survivors may need to take a nap because they become so exhausted during the day.
3. Some survivors have chronic sleep problems because they injured the sleep-wake control center in the brainstem. If you have an injury of this kind, one of the symptoms that is easy to notice is waking up very slowly in the morning. If you sit around half-awake for half and hour or more before getting going, you probably have this problem. Damage to this system produces permanent changes in the sleeping and waking, so you may not be able to restore your pre-injury patterns.
4. If you are having problems going to sleep, make sure you limit or cut out your intake of stimulants like caffeine and nicotine in the pm hours of the day.
5. Getting vigorous physical exercise as part of your daily routine can help you to sleep better.
6. Many sleeping pills actually interfere with the quality of sleep, as does alcohol.
7. If you give yourself the opportunity to do entertaining things at night while you are waiting to go to sleep, that may strengthen the pattern of staying up late. It is a good idea to do boring, repetitive things at the end of the evening.
8. If you do exciting things late at night just before you get in bed, that is likely to make it harder to get to sleep. Watching murder mysteries or action shows or comedy just before turning in is not a good idea.
Watching documentaries about making paper or the history of salt will help you to go to sleep.
9. Some people tend to lie awake and think about things, and this keeps them up. If you notice this problem, there are two ways to handle it. First, give yourself an hour to sit in a room by yourself with no TV and no computer and no music, just thinking about things, before you go to bed. That way you can get your thinking done then. Second, if you get some idea that worries you when you are in bed, write it down on a tablet so that you can deal with it tomorrow, and then you can forget it for the night.
10. Some survivors wake up in the middle of the night because of apnea, a problem with breathing while asleep. One sign of apnea is loud, uneven snoring. If you suspect apnea, ask your family doctor to refer you to a sleep lab where you can be tested for apnea.
Booze, Dope, Nicotine, Caffeine and Other Drugs
1. One effect of head injury that most people notice is feeling low in energy, kind of like a person feels when getting over a cold or the flu. Many drugs make the survivor feel more energetic or more normal, and this makes them very attractive. However, there are specific problems that come from the use of these drugs.
2. The drug most often used by most people is caffeine. Caffeine is in coffee, tea, cola and most other soft drinks, and chocolate. It is a stimulant which produces a rush of body energy that makes many survivors feel normal for an hour or two. However, caffeine causes the body to quickly unload its energy reserves for the day. After a brief period of energy, caffeine leaves the person more exhausted for most of the day than they would feel if they did not drink any at all. If the person keeps drinking it to fight off the fatigue, it prevents sleep. Many survivors find that they cannot sleep properly if they have any caffeine after lunch or any later in the day. Survivors who stop using caffeine altogether usually report that they function better without it.
However, if you have a long habit of drinking a lot of caffeine, don’t stop suddenly. Taper off gradually. Stopping suddenly can produce extreme headaches.
3. Nicotine in cigarettes, cigars, and chewing tobacco has a similar effect. The tobacco also stresses the body.
4. Survivors often feel like they have lost some of the hobbies and activities they enjoy most, and they appreciate having a drink, a glass of wine, or a beer to relax. Others like to get completely trashed. Alcohol produces three problems. First, by numbing the brain, it increases the risk of falling or otherwise hurting yourself. Second, it kills brain cells. Third, survivors are more prone to becoming addicted, so what was moderate drinking before the injury can easily turn into alcoholism. Most cognitive rehabilitation specialists advise people to stop drinking altogether.
5. Marijuana is another source of pleasure some people are reluctant to give up. But it slows the reflexes and weakens memory for information for about 24 hours after smoking it. So if someone smokes one blunt every day, their brain is always impaired by the temporary effects of smoking.
6. Stimulants such as meth are even more tempting, because they provide a jolt of energy and enjoyment. But they also produce impulsive, out-of-control behavior and are extremely addictive. Cocaine is even more pleasurable, and more addictive. It also destroys brain cells.
7. Ecstasy appears to be a particularly harmful drug, as it seems to cause a lasti ng disruption of brain chemistry.
8. Pharmaceutical drugs that help you to go to sleep or narcotics prescribed for severe pain also dull the mind. Since these drugs are habit forming, and they gradually lose their effectiveness, requiring the user to take more and more, they are not a good answer to long-lasting sleep and pain problems. Your brain has already gone through enough. Give it a break!
9. If you are taking prescription drugs, don’t reduce your dosage or stop taking them without first discussing your desire with the physician who prescribed them. It can be dangerous, and in some cases, even fatal, to stop taking prescription drugs suddenly without a physician’s guidance.
Better Living Habits to Help My Brain Work Better
1. You can get away with treating your brain pretty badly and it still works okay, as long as you don’t have a head injury. That rule changes dramatically after a head injury. The brain malfunctions under any kind of unfavorable operating conditions.
2. For example, if you skip breakfast and eat fast food for lunch, expect your brain to get sluggish. Having a healthy breakfast, including some kind of meat or other protein, is strongly recommended.
3. You should not subject your brain to any kind of nutritional deficiency. That means drinking plenty of water, and avoiding starving yourself.
4. There are many theories about nutritional effects on brain function that recommend avoiding sugar, white flour, or both. These are major ingredients in fast food. Although science has not reached agreement that eating a diet which is heavy in fruits and vegetables, whole grain bread, and healthy sources of protein (fish and chicken) helps your brain to work better, enough nutritionists suggest this kind of diet to make it worth considering.
5. Lack of sleep is a major source of reduced brain ability, especially in people who have had head injuries. To the extent that you can do so, you should make sure to get enough sleep. If you have difficulty in sleeping, this topic will be discussed in an advanced chapter.
6. If your injury makes you prone to getting tired, there are “energy management” techniques that allow you to make best use of the capacity you have.
7. Try to do your most difficult and important work early in the day.
8. Try to avoid working under tension as much as possible, as that burns extra energy.
9. Try not to do one kind of activity for long periods of time. Switch off from one activity to a completely different kind. For example, after reading something difficult for half an hour, switch to doing dishes or gardening. When you do this, you stop draining the last chemicals out of the reading systems of your brain and start using other, different systems. Switching activities like this can allow you to get a great deal done without getting completely exhausted.
10. If there are stresses where you live or spend time, work on reducing those stresses. For example, after living or hanging out in a messy room for a long time, some people find that it actually reduces stress to straighten it up. If your living area is infested with bugs, and that bothers you, take steps to get rid of them. Any reduction in stress is likely to make everything work better.
11. Getting some physical exercise every day seems to help the brain to work better.
CHAPTER FIFTEEN: Step Four: Increasing Mental Effort
1. The second major source of head-injured moments is actions that are not backed up by enough mental effort. This is a “stealth” problem that is particularly likely to be hidden from the survivor. Normally, the survivor feels like the amount of mental effort was appropriate, although after looking at the moment carefully, it is possible to see that it was actually insufficient.
2. The problem of insufficient mental effort shows itself in many ways. In a few instances, there is an actual lack of physical effort—not enough “oomph” when tossing a possession onto a dresser top, a soiled piece of clothing into the hamper, throwing keys to a partner, and so on.
3. In other situations, effort peters out before a task is finished. You can see this when a person leaves the front door or the car trunk open after unloading groceries, or leaves the stove on after cooking, or leaves the refrigerator door open after getting food, or forgets to flush the toilet. Tasks with more steps are even more likely to be left incomplete. Thus survivors commonly forget to turn the computer off after using it, to gas up the car after packing for a trip, or to put the newly arrived mail away after looking through it.
4. When a survivor regrets doing or saying something, it almost always means that when that action was planned, it was not thought through. “If I had only thought about it a little harder, I wouldn’t have done it, or I would have done it in a different way.” is a classic effort-related head-injured moment.
5. Whenever a survivor goes into a situation unprepared, having left needed supplies behind, or having failed to make necessary decisions, or having failed to prepare for all reasonable possibilities, this lack of advance planning indicates the effort problem.
6. Any time something is done a little carelessly, or a bit sloppily, it indicates a lack of effort to get it right.
7. Many so-called memory errors are actually problems caused by a lack of effort. A patient once told me that he did his laundry but “forgot” to put the detergent in. On thinking about it, he realized that he had tossed the clothes in casually, and then started the washer without even trying to think about what he was doing. If you don’t think, you’re not going to remember.
8. Survivors often do or say things that offend other people, or give them the wrong impression. These are actions that could have been avoided if they had been planned with careful effort.
9. Situations that are new or risky can sometimes be handled carelessly. In hindsight, the survivor often admits that he or she should have been more careful.
10. Many problems come from rushing. Rushing is simply a kind of carelessness. For example, many survivors with a little trouble pronouncing words talk way too quickly to be understood.
11. This is the easiest problem to solve: Make more effort. Stop and think. Figure out what you’re are going to do before you start to do it. Treat it like it’s really important to get it right. Double check your plan. Act slowly and carefully. Do it this way and there is no head-injured moment.
12. What makes this instruction hard to use is that you simply can’t do EVERYTHING this way. If you were super-careful about everything, things would take far too long and you would be exhausted from cranking up your powers of concentration. The trick is to know WHEN you need to make the extra effort. The question of when will be covered a few chapters later.
13. Whenever you have a head-injured moment, if it’s possible, try to do the task again, only this time do it the right way, and then pay close attention to the difference. How much more effort does it take to make your brain work properly? Keep asking yourself, how can I get myself to start getting these things right the first time? This topic gets discussed at length in the Rodger Wood, Kurt Goldstein, M. Mesulam, and Stuss and Benson books, and in the papers from our group called “Adaptive Effort and Traumatic Brain Injury” and “Exceptional Effort in Adaptive Recovery from Traumatic Brain Injury—A Case Series.” There are also a number of good papers that give examples of this problem written by Harvey Jacobs and Muriel Lezak.