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Whatever It Takes (WIT)


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Helping a person who has had a life-changing brain injury often calls for creative problem-solving to address complex needs with fragmented services and inconsistent funding mechanisms. Persons with traumatic brain injury present unique challenges for professionals in healthcare, human service agencies, and vocational rehabilitation because their abilities have changed and the person with a brain injury may or may not understand the differences caused by the injury. Meeting these goals calls for a strategy that Willer and Corrigan called "Whatever It Takes" (WIT). The following are 10 WIT principles to help guide professionals from various disciplines as they work with persons who have experienced serious brain injury.

WIT Principles

  1. No two individuals with acquired brain injuries are alike.
  2. Skills are more likely to generalize when taught in the environment where they will be used.
  3. Environments are easier to change than people.
  4. Community integration should be holistic.
  5. Life is a "place and train" venture.
  6. Natural supports last longer than professionals.
  7. Interventions must not do more harm than good.
  8. Service delivery systems present many of the barriers to community integration.
  9. Respect for the individual is paramount.
  10. Needs of individuals with brain injuries last a lifetime: so should their resources.

 

1. No two individuals with acquired brain injuries are alike.

There is a tendency to talk of brain injury as a singular impairment, but experience quickly reveals vast differences from person to person. People were different before they were hurt. After injury, individual differences are compounded by the injury severity and location of the damage to the brain, secondary medical complications, and how the individual adjusts to motor, cognitive, and emotional effects. The lifestyle and living environment that each person hopes to re-establish will call for different abilities and adaptations. And to make things more complicated, most of these issues continue to change in the months and years after injury. Because needs will differ greatly, services must be both individualized and flexible. Treatment plans must be developed for each person &emdash; one size doesn't fit all. Standardized programming or group activities may need to be adapted to be useful for the person with traumatic brain injury.

2. Skills are more likely to generalize when taught in the environment where they will be used.

An injury to the brain may cause difficulty transferring learning from one situation to another –"generalizability." Problems of generalizability may arise for routine skills like preparing a meal and are even more likely for complex social skills like those needed to refuse a drink of alcohol. The practical approach to "generalizability" problems is to teach skills in the specific situation in which they will be used. For instance, cooking skills should be taught in the kitchen where they will be used. Social skills may have to be learned in a person's own community with actual family, friends, and acquaintances. Certainly, it can never be taken for granted that a skill or behavior learned in one setting will automatically be applied in another. Treatment planning should always address how a learning will be generalized to a person's everyday life.

3. Environments are easier to change than people.

Ameliorating deficits is an important part of the medical model of rehabilitation, but in some cases it may be more practical to adapt a person's environment than to push skill acquisition to the point of frustration. For example, within months of injury it is more practical to teach someone with memory problems to use written reminders than to continue to work directly on improving the ability to recall. It may be more effective to help people change who they live with than to teach them not to drink when house mates are partying. Environmental changes like these lead to quick results and allow more time and energy for other tasks.

4. Community integration should be holistic.

Though professionals usually define their relationship with a client in terms of specific problems or needs, it is particularly important to maintain a holistic view of a person with serious brain injury. Problems in one area of life easily undermine treatment of another. The person starting a new job may not be successful if distracted by worries about their living situation. At the same time, a desired change in one domain; "I want to get a job";can be turned into motivation for another goal; "I'm going to stop drinking." Not only should each professional maintain a holistic perspective, but all the service providers working with an individual with brain injury should coordinate and collaborate.

5. Life is a "place and train" venture.

Supported employment is a proven strategy in vocational rehabilitation, both for persons with traumatic brain injury and others. In this strategy, skills needed to perform a job are trained by a job coach or other support person after placement. The worker is placed, then trained. In contrast, the more traditional model of vocational rehabilitation first trains to do a type of job then places in an actual work setting. A "place and train" approach may be more effective because of problems in generalizability, described above, as well as the frequent necessity to address both obvious and subtle demands of a work situation. As with the workplace, "place and train" may be a successful strategy for other skills that have to be acquired after brain injury--independent living, use of public transportation, or leisure pursuits. "Place and train" also provides more immediate reinforcement for the individual and is often a more efficient use of resources.

6. Natural supports last longer than professionals.

Members of a person's social and natural environment will be involved with them longer than any professionals. Professional involvement is temporary and limited by time, financial constraints, professional ethics, changes in professional duties,retirement, or other reasons. But support from friends and families may also pose a problem for persons with brain injury. Research has demonstrated that friends before the injury often do not continue as friends after. Therefore, the role of the community professional often is to help identify and facilitate new friends and unpaid social supports. A rule of thumb is that interventions involving natural (unpaid) supports should be encouraged over paid supports because they are more likely to assist the individual for intrinsic reasons.

7. Interventions must not do more harm than good.

There is a natural assumption that all professional intervention is helpful; however, there is ample evidence that unintended side effects may cause harm. For example, a living environment that provides for all of a person's needs without their participation can be a barrier to developing independent living skills. For persons with a substance abuse problem, getting back to work may give them the financial resources to resume use of alcohol or other drugs. For this reason, each and every intervention must be examined to be certain that the benefits outweigh the harm and that unintended side effects have not resulted.

8. Service delivery systems present many of the barriers to community integration.

Service systems and funding sources present many of the biggest challenges to community integration for persons with brain injury. For example, if a health insurer refuses to reimburse for a certain useful service but will pay for another, professionals and family members may find themselves encouraging the less appropriate, but funded, alternative. More often than not, the financial barrier to services is that nothing is covered, a service is not available, or the individual with a brain injury does not quite fit eligibility requirements. For services that are available, an equally destructive barrier is the fragmentation of responsibility among multiple service providers. Community professionals will often find themselves acting as advocates, exploring ways to reduce barriers and improve services.

9. Respect for the individual is paramount.

Everyone accepts that an individual's dignity and self respect is important, but, in the rush to rehabilitate, it is easy to bypass normal courtesies. Normal infringements on dignity are inadvertent but still important to avoid. Every individual deserves: the right to privacy, the right to courteous, person-first language, and the right to make personal decisions. Community professionals must be always on guard against short-cuts or staff conveniences which rob the individual of dignity and self-respect.

10. Needs of individuals with brain injuries last a lifetime: so should their resources.

Sometimes health insurance benefits and social programs settlements from lawsuits have lifetime limits or income in lump sums. Service providers do not do an individual a favor by suggesting treatment that consumes significant portions of such limited funds in a relatively short period of time. After serious brain injury, disabling effects will be with individuals for a lifetime, regardless of compensatory strategies learned to reduce the effects. Resources to assist individuals should also last a lifetime. Future needs may not always be obvious, but assistance for independent living may be needed if family support changes. In addition, even if initial vocational rehabilitation is successful, it may be needed again if an employer goes out of business.

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This website has been funded with financial assistance from Grant #H133A120086 awarded by the U.S. Department of Education, National Institute on Disability Rehabilitation Research (NIDRR) to the Ohio Valley Center for Brain Injury Prevention and Rehabilitation for the current funding period of 10/01/2012 - 09/30/2017.