I’m back to reading the information over at Give Back LA — I seem to go in fits and starts, focusing on my recovery for a while, and then going off on my own, to see how it works out. What I find, time and time again, is that taking things for granted gets me in trouble. Taking for granted that my brain is always going to work the way I expect it to, gets me in trouble. Taking for granted that my body is always going to be “on” the way I need it to be, gets me in trouble. For some reason, a part of me thinks that I can exist without sleep and proper exercise and eating junk food to stay awake in the afternoon.
This is clearly false. And my difficulties with deadlines and getting my work done and communicating with people (in ways that match how I wish to be understood) are ample evidence.
So (and I know I’ve said this before), I need to get back to Increasing Mental Effort — doing it deliberately and mindfully, and not just bagging it when I get distracted by something else.
Give Back says the following, and I also have comments:
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.
BB: This is so true. Time and time again, I think that I’m handling things just fine, only to discover that it’s just not true. This can be incredibly demoralizing, as I think I’ve got this TBI business beat, and it comes back to haunt me. Only when I pay close attention to the outcomes of what I’m attempting to do, can I realize that things didn’t pan out like I expected.
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.
BB: True, too. I often find myself distracted, but I don’t think it make that big of a difference… until it does. I drop things because I’m not paying close enough attention. I over-shoot my targets. I under-perform in many little tiny ways that aren’t obvious to others, but which I notice — and I hate.
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.
BB: Yes, yes, and more yes. How many times have I really poured myself into my work, only to find at the last minute that I’ve missed something — and something really important. I end up undermining my own efforts, because I haven’t followed through… because I didn’t realize I needed to follow through.
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.
BB: Yeah, pretty much. There’s a part of me that likes to “wing it” and fly into things with just adrenaline to keep me going. This is a recipe for disaster, and I often get lucky when things don’t fall apart. I need to stop and think things through more often. I’ve gotten much better about doing that, but when I’m tired and really busy, I need to make the extra effort. It’s good to realize that before I start my activities.
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.
BB: Part of the problem of preparing for all reasonable possibilities, is that I sometimes get so overwhelmed by everything, that I just give up and end up “winging it” because I’m swamped by the options and choices. I have difficulty at times figuring out what “reasonable” possibilities are — my head runs away, and I don’t always realize it.
6. Any time something is done a little carelessly, or a bit sloppily, it indicates a lack of effort to get it right.
BB: Sounds familiar to me. From way back. How many times I’ve been told I’m “lazy” or “sloppy”… Geeze. If people would only encourage me a bit, it would help. But no, they have to start with the lectures. Story of my life for as long as I can remember. The thing is, the lack of effort is not intentional. It’s just my brain not realizing it needs to buckle down and focus in more.
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.
BB: Right again. So many times, we do things that we’ve done many, many times, and we don’t realize we’ve gotten out of the habit of thinking about them. I think this happens especially as we grow older, and we’re accustomed to doing things a certain way. If we’ve experienced a brain injury after we are fully grown (and a bit set in our ways), we don’t realize we need to make more effort to do the same things we did before, because we “know” how to do them, right? Yes, we DO know how to do them. But the process of doing them may be a bit clunkier than it was before. If we just give more thought to our activities, then we can often achieve what we set out to do, the way we have done them before. The difference is, we have to put more effort into things. And that can feel debilitating and annoying and defeating. It can make us feel like failures, when it’s just a different way of going about doing things.
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.
BB: Yes, but how do you plan your interactions with careful effort? This is a particularly hard one for me (and I believe many others). When I’m talking to someone, I just want to relax and not have to work at things. But that can backfire. Interestingly, I tend to have better quality interactions with strangers and people with whom I don’t have a strong rapport — probably because I feel I need to make more of an effort with them. The people I know and am used to, I don’t make as much of an effort with, so I get lax and don’t plan and pick my words as carefully. And things get messed up – more often than I’d like.
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.
BB: In my case, it’s the opposite. I handle them more carefully, so they go much better than some of my everyday experiences. On the other hand, I know someone who sustained an mTBI about 15 years ago, and they have since become less careful and more prone to just wade into situations without paying close attention. They get into trouble, and they spend a lot of time trying to get out of trouble. They put themself in tight situations, and they rely on adrenaline to get themself out. But it rarely works out, and they spend a lot of time being down on themself about how things went, like it was all their fault, they’re stupid, etc. But it was just them not paying close attention and giving the experience its due.
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.
BB: This happened to me when I was a kid. People had a lot of trouble understanding me, mainly because I was a “motor mouth” who just flew through conversations. I think part of me was nervous about not knowing how to pronounce things, and my anxiety made me go faster, to get it over with. Didn’t work out at all. It took years to chill out with that. And in the meantime, I acquired this attitude that I was alone, people didn’t/couldn’t understand me, and I was a total loser. What overall effect that had on my life in general, it’s hard to say, but I think it’s safe to assume that a kid with those kinds of uncorrected problems will make different choices as they grow up… just because of early lack of effort, and the inability to see that extra effort is required.
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.
BB: The friend I mentioned earlier thinks that doing this is a sign that they are “giving in” to their difficulties, and they make it mean that there is something wrong with them. So, they don’t do it. One of the issues around this — and Give Back doesn’t seem to recognize this — is that thinking things through can be overwhelming, demoralizing, and confusing. And that just adds to the distress. In a way, my friend who doesn’t think things through (but goes by “intuition”) is trying to have less stress in their life by avoiding that kind of struggle. But they introduce more, on down the line.
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.
BB: This is true. Knowing when you need to do this, is the big problem. They cover that later in their section on Self-Therapy, so I won’t go into it now.
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?
BB: At the start, this can be pretty draining, because everything feels like an effort, and it seems like every moment of the day is a head-injured moment. In a way, it is. But with time and practice, these things work themselves out.
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.
BB: I wish I could find these books and papers to read. But I have not had any luck finding them online. I believe they are available at the library, but I’ll have to check that out. I also wish I had more time to devote to this study, but I’ve got so much going on in my life, it’s about all I can do, to just keep this blog up, while going about my daily activities. Oh, well. I’m sure it will all work out…
Also read: SELF-THERAPY FOR TRAUMATIC BRAIN INJURY: TEACHING YOURSELF TO PREVENT HEAD-INJURED MOMENTS
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When you have become an expert Self-Therapist, you will be ready to give others the kind of help that made it easier for you to learn Self-Therapy. Don’t just be thankful for the blessings you got–pass them on!
Broken Brain - Brilliant Mind 
See I actually don’t totally agree with this; telling a person with a BI that if only they were better prepared they would not have problems just adds guilt and shame to the situation. In people with BI the feedback loops are broken, they literally don’t see things, don’t recognize the missing element – even with careful attentiveness. They can try to slow it down, they can relearn from mistakes but often they step back into the lives they had before which are fast paced, high demand. This is why many structured programs recommend that people slowly return to work loads IF THEY CAN. Unfortunately if you do not have the personal and financial means for this a person with a BI will put themselves back into the fray – and it can be costly. Not only are there mistakes in work, but relationships can be destroyed, and even their health and well being can be damaged – pushing themselves too hard, getting in a car and not recognizing the mental fatigue, attempting an activity that they are not in the position to do or not giving second thought to an impulse that is potentially dangerous. People with BI do not know that they are missing something – because it’s just one note in the concerto that is missing – but yet it will matter.
I actually think it takes a HUGE effort to redo task the ‘right way’ and to retrain yourself. It can be done but it is a long and arduous process. People tend to underestimate that – and I know of no workplace on the planet that will accommodate it.
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