The Problem With the Word “Should”

The word “should” may be one of the most dangerous words for a brain injury survivor.  It tends to appear in sentences such as “I should be walking already” or “I should have been back at my job by now.”  The word puts a tremendous amount of expectation on the survivor and implies that somehow the survivor is a failure since he or she did not achieve what he or she “should” have achieved.  Often, this word begins a series of statements in which survivors verbally punish themselves.  “I should have been able to walk without a wheelchair but I instead I fell.  I should be doing better with my mobility.  I am letting down my whole family!”  These “should” statements can lead to depression, stress and low self-esteem.

The reality is that each brain injury heals at its own rate and that each person is left with his or her own challenges to deal with.  After a serious brain injury, it often takes a survivor considerably longer than he or she may expect to reach goals due to the severity of the injury.  An injured brain is not like a broken arm.  You cannot put a brain in a cast as you would put an arm, expecting that in a relatively brief period of time the brain will be healed.  Brain injury rehabilitation is a process that takes time and patience.  The only applicable “should” is that the survivor should give full effort in his or her therapies.  That is all anyone, including the survivor, can reasonably ask for.  As long as the survivor is giving his or her best effort, the survivor is doing everything in their power to get better.  The rest of the process will depend on time, practicing/learning skills and how the brain heals following the injury.  Recovery cannot be rushed or forced.  “Should” statements that imply that somehow recovery ought to have gone differently are simply emotional snares that are best avoided.

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Why Are We “Suddenly” Hearing About Brain Injuries

Brain injuries are a hot topic in today’s media.  Whether it be football players with lasting damage due to concussions, soldiers suffering from brain injuries due to overseas conflicts or the latest youth sports concussion protocols, it seems that there are suddenly many news stories on brain injury that simply were not around just five or ten years ago.  Some individuals may be cynical and wonder whether brain injuries are simply the “diagnosis of the moment”, one of the many diagnoses that are suddenly “hot” but will disappear over time.  To those individuals, I would like to offer several rational reasons why brain injury stories have become more prominent over the last few years.

First, many people are now living with brain injuries who would have died from their injuries in previous eras.  The medical world has advanced significantly over the years and now doctors are able to save the lives of people who would have otherwise died. However, just because their lives were saved does not mean they emerged from their health emergency unscathed.  These survivors often have brain injuries which require treatment.  Please allow me to give an example of this change over time.  I once was talking over lunch with an older rabbi about Transitional Learning Center.  He relayed a story about his time at a synagogue many decades ago in Indiana.  A young man in his community had a serious motorcycle accident and as his rabbi, he visited the young man in the hospital.  After conversing for a while and finishing his visit, the rabbi exited the room.  As he left, the doctor pulled him aside and said “You know he will be dead in three days”.  The rabbi was shocked, having just had a full conversation with the young man.  But the doctor was correct.  The hospital had no means to manage his brain injury.  Due to either brain swelling, bleeding or both (the rabbi did not know the details), the young man passed three days later.  Today, a person with a similar motorcycle accident would have a surgery and other potential procedures to manage his injury and would stand a good chance of living, albeit with a brain injury.  Similarly, improvements in military field medicine are allowing many soldiers to survive blasts and other dangers that would have killed them in previous battles.  Thankfully, these soldiers still have their lives, but often struggle with long-lasting brain injuries suffered in their military service.

Second, it is important to acknowledge the active suppression of information regarding brain injuries in certain circles that is only recently coming to light.  Most famously, the NFL actively denied and hid data on the long-term brain injury effects of concussions to former football players.  Through a series of lawsuits, the NFL opened up about brain injuries and is now acknowledging the long-term injuries that many former players have suffered.  This has led to a complex $1 billion settlement for players with long-term effects of brain injuries.  Following these court cases, many other lawsuits have been filed against other professional and amateur sports, leading to further agreements and new safety protocols.  The suppression in the past contributed to an artificial perception that brain injuries were less common than they actually were.

Third, we are in an age of information so it is much easier to learn about what is happening to people across the country, and even across the world.  Just think about how often you hear or read stories about a robbery or kidnapping occurring hundreds of miles from where you live.  Until the age of the internet, most of those stories would be confined to local media.  Now, stories can go “viral” and suddenly everyone knows the details.  This phenomenon is equally true in the realm of brain injuries.  A simple keyword search of “brain injury” will bring up a plethora of local stories that prior to the age of the internet would have been hidden from most of the world.  These local stories existed in the past but only now d0 we have so much access to them.

Fourth, we are now having a more honest conversation about brain injuries.  In the past, people generally did not talk about brain injuries.  Athletes and soldiers rarely mentioned their deficits due to fear of sounding “weak”.  Individuals with brain injury deficits from car accidents, strokes or other methods were often afraid of negative views and discrimination if others knew about their deficits.  We are now coming to an age of sharing without fear.  It may be hard to believe but the Americans With Disabilities Act (ADA), the civil rights legislation that has allowed for a greater involvement of people with disabilities in the workplace without fear of discrimination, was only passed in 1990.  In comparison, the Civil Rights Act, which blocked discrimination due to issues such as race, gender, and religion, was passed in 1964.

Fifth, we are much more able to diagnose and treat brain injuries than in the past.  Technology such as MRI and CT exams to scan the brain and locate injuries are relatively new.  Moreover until fairly recently many people, even health professionals, did not even know the right questions to ask to identify a potential brain injury.  For instance, if a high school athlete is concussed in a game today, the coach and athletic trainer often have a protocol to follow to ensure proper health management.  Twenty years ago, the player would likely have been just given smelling salts, asked if he or she felt “okay” and sent back into the game.  In fact, many states now have mandatory concussion training for coaches and athletic trainers.  This was unheard of just a few years ago.  In the past, people with brain injuries were forced to suffer in the silence of unrecognized deficits.  Now, these brain injuries and their concomitant deficits are more likely to be accurately diagnosed.

Overall, there are many rational reasons why we are “suddenly” hearing about brain injuries in the media, despite these injuries having been an issue in the past.

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Just Be Grateful

“Just be grateful you are alive”

“Just be thankful you didn’t die”

“You should just focus on the fact you survived”

Brain injury survivors hear these types of well-meaning lines all the time.  They are used by family members and friends to help survivors see the “brighter side” during their recovery period.  And the statements are true; traumatic brain injuries, strokes and other forms of acquired brain injuries lead to death for millions of people worldwide every year.  It is worthwhile to be thankful for life.  But these lines can be double-edged swords.

Taking a step back for a moment, most survivors are truly thankful to be alive following their near-death experiences.  But that does not mean that they have not suffered real, painful losses.  At the same time as you want to encourage and support survivors, it is also important to allow them to mourn these losses.  There is nothing inherently wrong with lamenting loss of arm function or fluid speech, as long as this does not lead to a serious decline in mood or performance.  For instance, wouldn’t any person be upset if after decades of normal walking, he or she would have to learn how to walk all over again because of a stroke?  A balance has to be struck between fostering positive mood and allowing for reasonable mourning of loss.  “Just be grateful you are alive” is not an inherently bad statement as long as it is not being overused and preventing healthy adjustment to change.  However, using this line repeatedly often causes survivors to be frustrated and feel as if they cannot express their feelings.  Though it may be difficult for a family member or friend to see the survivors experience sadness or anger, this is often one of the steps necessary to make a successful transition to post-injury life.

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Give Yourself Permission

Brain injury survivors and their loved ones often try to approach life after an injury as if it is a fight.  Battle hard, stay strong and never let your enemy see your weaknesses.  But in truth, though there are some similarities in this analogy that are appropriate, life after an injury is not an actual fight.  In fact, by treating it as a real fight, sometimes survivors and their loved ones hurt themselves but not allowing themselves to feel and process certain emotions in a healthy manner.  By not processing emotions, individuals may allow these emotions to fester inside and come out at the wrong time or in the wrong situation.  Not processing emotions can lead to difficulties such as depression, anxiety and relationship stress.  I would like to encourage you to give yourself permission to feel these emotions.

Give yourself permission to get angry at the injury.  It truly is a frustrating and unpleasant experience.

Give yourself permission to cry.  There is no weakness in crying.  This is an appropriate reaction to a painful situation.

Give yourself permission to mourn.  There may be parts of you from the past that will no longer be part of your post-injury future.  It is okay to mourn their passing.

Give yourself permission to laugh.  Laugh at the moments of oddity.  Laughter , in measured amounts, is a reasonable coping technique during times of distress.

Most of all, give yourself permission to experience and value the full range of your emotions.  After all, our emotions are important aspects of who we are as people.  They are a central part of simply being human.  So please, give yourself permission to be the complete person that you are, despite your injury.

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Doing It Best

Jahvid Best appeared to be on the road to football stardom.  Drafted in the first round by the Detroit Lions, Best possessed blazing speed that was the envy of other running backs.  Unfortunately, his professional football career was ended prematurely during it’s second year due to the effects of concussions.  Best put forth great effort to get back into the NFL but doctors ruled against his return.  For many people, this would be the end of the story.  But for Jahvid Best, it was the start of something new.

One of the key tasks that brain injury survivors must navigate is to look at their retained abilities and identify what they can do best, in spite of their injury.  Best understood that his body was not ready to be tackled by 300 lb linemen, but he still had his speed.  Best worked tirelessly at his skills on the track.  The hard word paid off.  Best qualified for the Olympics in Rio.  He will be representing the island of nation of St. Lucia.  Best demonstrated how to thrive and succeed in spite of an injury!  Though he was not a TLC patient, we certainly think he is truly a hero for the brain injury community.  Identifying a survivor’s skills and choosing activities that match those skills is a key part of the rehabilitation process.  For more reading on Jahvid Best’s journey, click on the link below:

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When Michael Jordan is Smarter than the Media

As a brain injury rehabilitation therapist, it is can be painful to read the news.  Sometimes, the media simply do not appreciate the seriousness of brain injuries and the need to take reasonable actions to prevent injuries.  Today was one of those days.  Michael Jordan, arguably the greatest player in the history of basketball, decided to go jet skiing.  Being a smart man, Jordan wore a protective helmet.  It was not worn for fashion but for function.  For some reason, Pete Blackburn of Uproxx, as posted on Yahoo, decided to make fun of Jordan for wearing the helmet.  This is the offending article:

The article is just silly and encourages poor safety awareness.  The fact is that that people do get brain injuries and even die in jet ski accidents.  Jordan is entirely correct for wearing the helmet.  To put this issue in perspective, I would like to provide a few examples of people who have suffered brain injuries while jet skiing.  Duke University football player Blair Holliday nearly died due to a traumatic brain injury suffered in a jet ski accident (

Lisa Votaw suffered a brain injury in Minnesota when the jet ski she was on flipped over (

Firefighter Mike Yurchak of Pennsylvania suffered a serious brain injury in a jet ski accident (

Similarly, this past January, a woman in Miami received a brain injury when she was involved in a collision of two jet skis (

Jordan should be appreciated, not lambasted, for taking reasonable precautions by wearing a helmet on a jet ski.  There are already enough injuries out there.  We do not need to discourage anyone from being safe while having fun.

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Citizen Science

One of the big changes for brain injury survivors need to adjust to is that they often have a great deal more time to fill in their day once they return home from rehabilitation.  Whereas they previously may have spent most of their pre-injury days involved in work or school, those that are unable to return to these activities now have large holes in their schedule.  For instance, if a survivor spent 40 hours a week at a job and cannot return to work, he or she now has 40 hours of time to fill in their post-injury life.  One way of filling this time in a meaningful way is through citizen science projects.

Citizen science projects are based on the idea that scientists do not have enough time or ability to collect and analyze all of the information that they would like in order to conduct their research.  For instance, if a scientist was collecting information on trout migration, he or she cannot be at every single stream and river to collect data.  However, these scientists could ask fisherman who are at these waterways to spend 30 minutes counting the trout in a particular location.  This way, the scientists can get data from many more locations.  A second example is identifying galaxies.  There are billions of galaxies in our universe but scientists do not have the time to categorize all the photographs of galaxies that they have .  However, they can put up these pictures for regular people to look at on the web and ask these people to categorize galaxies based on shape.  As you can see in both examples, much of the information for research projects can be gathered and analyzed by individuals with little or no training but have a large impact on the quality and quantity of science.  The work of citizen science projects are often used to help make policy decisions, find new discoveries and help understand our environment in a more complete manner.

Just like the examples given above, there are many different types of citizen science projects.  Some involve going out of the home, such as to a forest or lake, while some can be done at home.  They are run by universities, museums, nonprofits and government agencies.  You can easily locate many citizen science projects by entering the keywords “citizen science” into  the search box of any web browser.  Here are a few helpful links to locate projects:

Scientific American:

Cornell University:


Hopefully, incorporating citizen science projects into a weekly activity schedule will help bring brain injury survivors enjoyment and meaning in their post-injury lives!

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Bubba Smith and CTE

The phrase “larger than life personality” could have been invented to describe Bubba Smith.  Looming at 6’7″ and almost 300 pounds, he was the first pick of the 1967 NFL draft and earned his ring at Superbowl V with the Baltimore Colts.  His extraordinary defensive skills on the football field left many a shell-shocked quarterback lying prostate in his wake.  Following his nine year professional football career, he parlayed his fame into a second career in film and television.  He is best known in the acting world as Captain Moses Hightower in the Police Academy movies and for his appearances in Miller Lite commercials.  After he passed in 2011, his estate allowed researchers to study his brain for evidence of Chronic Traumatic Encephalopathy (CTE).  It was discovered that he had been living under the effects of level three CTE (the scale runs from one to four).  Follow the link below to read more about these findings.

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But Are You Getting Help?

Following a brain injury, family members will often spend every possible moment dedicated to efforts in support of an injured loved one and devote special attention to helping that survivor get the best care possible.  They with rare exception will spend countless hours on the phone battling insurance companies and filling out forms.  These family members must deal not only with stressors directly related to worrying over a  loved one’s health, but must make peace with planning for a suddenly very different future and must manage (sometimes alone) a freshly revealed terrifying financial mine field.

Brain  injury survivors themselves also face an enormous number of stressors as they struggle to regain command of basic skills and learn different ways to perform common tasks.  However there is a major difference in this regard between the brain injury survivors and their family members, particularly while the survivors are in rehabilitation.  The brain injury survivors are surrounded throughout the day by professionals trained in the treatment of brain injury who can help with mood, education and adjustment.  Survivors merely need look to their immediate surroundings to find an abundance of professional help to address any difficulties.  Family members generally do not have anything approaching such a level of support so readily available.  With all this in mind, it becomes clear just how thoroughly brain injuries are in fact a family affair.  All members of a family are affected, not just the brain injury survivor.  Likewise, all family members are part of the team necessary for managing long-term effects of the injury.  It is important that all members of the team (not just the survivor) are receiving the help and support that they need in order to adjust to these major life changes.

At TLC, staff commonly ask survivors’ families, “Are you getting help?” and “How can we help you through this process?”  It is important that family members do not neglect themselves while giving all they can to aid injured loved ones.  Such care taken is in the best interests of both the personal health of the family members in question and the optimal well-being of the survivors they support.  Caregivers with high stress levels often find themselves more susceptible to physical illnesses than the average person.  A family member side-lined by illness can offer only a fraction of the aid and support he or she would wish to.  Further, family members deserve to be allowed to live their lives to the most complete level of happiness possible (just like the survivors deserve to).  Put simply, if these family members are struggling themselves then they are placed in a severely disadvantaged position from which to help the survivors in their lives.

Family members of survivors should consider personal therapy and support groups as aids for their own psychological and spiritual adjustment (Both the Brain Injury Association of America and the American Stroke Association offer listings of local support groups).  These family members can often benefit from reaching out to friends and community resources in order to better address the management of difficulties.  Seeking help is not a sign of weakness but is instead a common sense step taken in the interest of maximizing both individual and family success and happiness.  Brain injuries are complex and stressful.  Family members should not pretend to be super-humans capable of handling anything and everything.  They should actively ask doctors and therapists for information on brain injury prognoses, education resources and proven strategies helpful in planning for the future.  Overall, one of the most important ways that family members can contribute to the advancing well-being of survivors in their lives is to remain sufficiently mindful of their own.

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A Story About Adjustment and Meaning

I would like to tell a brief story about adjustment and meaning that I often share with our patients at TLC.  I believe it highlights many important aspects of healthy post-injury adjustment.  Many years ago, TLC had a patient who had suffered a severe stroke.  He had been hard-working in his life as a truck driver, and his dedication to determined effort did not decline after being injured.  This patient worked incredibly hard to get better and in fact, he did improve.  However, his injury was too severe to allow him to return to his job.  He had an arm that did not work, weakness in one leg which caused walking to be more difficult and he had left neglect (a condition which causes the brain to ignore items on the left side).  He simply could no longer safely fulfill all the requirements of his job due the effects of the stroke.  It was apparent pretty early on in his rehabilitation that he would not be able to return to work at his former job in the foreseeable future and his psychotherapist attempted to help him plan for a different but still meaningful life after discharge.  The patient initially insisted that he was going to be able to get back to work, but after several months he began to understand and accept the reality of his situation.  After this acceptance, the conversations he’d had with his psychotherapist really began to sink in.  What happened next was truly special.

One day, the patient walked into his psychotherapist’s office and stated that he had come to a decision.  He was not a young man but he had two young children.  He said that prior to his injury, he woke up before his children arose and came home after they had gone to sleep.  He never really saw his children except on Sundays.  Prior to his injury, he was a truck driver who was a good breadwinner for his family.  But now, his new job was going to be as a full-time dad who would be present for all of his children’s events and activities.  He was happy with his decision and found great meaning in being an active father.  By making this mental switch, his mood was brightened and he was excited for the future.  Seeing another potential opportunity, the therapist encouraged him to contact an adult daughter with whom he had not spoken in a long time (even prior to his stroke).  With a little encouragement, he made the call and was able to rekindle the relationship with his daughter.  She had two children, so he also was able to renew his relationship with his grandchildren.  He was truly happy.

Most of our patients at TLC are driven to return to their previous lives, and their visions for these restorations often include resuming previous occupations.  There is nothing wrong with this and our therapists work diligently to help patients reach these goals.  However, a brain injury may be too severe to allow a brain injury survivor to return to his or her old job.  Though this is sad, it does not mean an end to happiness and meaningfulness in the survivor’s life.  The survivor need only find a new or adjusted role that he or she can then embrace.  This adjusted role does not have to look the same for each survivor, it just has to bestow upon a given survivor’s life the sense of value that accompanies that recognized significance.


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