- TOOL KITS
- A. The NEXT Step
- B. Promoting Independence
- C. Phone Apps
- D. Return to Work
- E. Motivational Interviewing
- F. Paediatric Brain Injury Rehabilitation Resources
- a) Introduction
- 0. Introduction
- 1. Working together promoting independence
- 2 . Using this kit
- b) Issues, goals, action
- 3. Identifying issues W
- 4. Setting goals W
- 5. Making goals happen W
- 6. Monitoring progress W
- c) Strategies Myself and my relationships
- 7. My behaviour's changed W
- 8. Thinking
- 9. Relationships W
- Managing memory, money and time
- 11. Remembering information and messages
- 12. Finances and handling money W
- 13. Managing time W
- Household tasks
- 14. Food and shopping W
- 15. Food and meals W
- 16. House keeping
- 17. Laundry
- Getting around
- 18. Public transport W
- 19. Accessing the community
- Life tasks
- 20. Self care
- 21. Fitness
- 22. Leisure
- 23. Employment
- 24. Continue learning
- 25. Health and well-being
- 26. Emergencies
8. Thinking processes
Speed of information
Why has my thinking changed? I can't think things through like I used to.
After a brain injury you may notice changes in how you think things through. The different thinking processes you use in different situations may not work as they used to. Even though no one experiences exactly the same set of problems, there are some changes that occur more frequently than others. These can include:
2.3 Speed of Information Processing
2.4 Problem Solving
2.5 Planning and Organising
2.6 Concrete Thinking
2.7 Self Monitoring
Why is it so difficult to remember things that people tell me? Why am I so forgetful?
For a memory system to work well there are three important things that it must do which includes:
1. Learning new information, or getting the information into the memory system
2. Storing, or keeping, information within memory
3. Remembering, or getting the information back out of memory when it is needed. For example, finding the correct answer to the question, "What is your doctor's name?"
Memory problems can occur when one or all of these three stages are not working properly. Assessments completed by a neuropsychologist can help find out what the memory problem is and then decide what the best strategies are to help with that problem.
1. Learning new information
If information (like names, faces, instructions, directions, etc.) is going to be remembered properly it needs to get into the memory system properly.
The following suggestions can assist learning:
- Pay attention - focus attention on what it is that you want to remember, listen carefully to what people tell you, and focus on one thing at a time. So don't try to read a book while watching television if you want to remember what the book was about later.
- Understand - make sure you understand the information you want to remember and ask questions if you don't.
- Short and simple - if there is a lot of information you want to remember then pick out what is most important and focus on smaller amounts first, trying to learn a little bit at a time. Make sure information is kept simple and to the point so it doesn't contain lots of unnecessary or complicated things that you don't understand.
- Organisation - by learning information in a way that is organised it will be easier to remember later on. Try to arrange things in a way that makes sense to you.
- Repetition - repeating information over and over again helps to keep it in memory. It is better to learn a little bit at a time and then repeat it as often as you can.
2. Keeping information in memory
There can be times when someone will tell you something and you will be able to repeat back straight away exactly what he or she has told you. However, there can be other times where after only half an hour, you have forgotten all that you were told. Forgetting may happen if information isn't stored properly or if there are difficulties getting information out of memory storage.
3. Remembering information
Sometimes it can still be very difficult to get the information that you want out of memory when you need it, such as times when you might question, "what is her name?" or, "what did my wife ask me to do at 4.00pm today?"
Ways to help you remember things include:
- using the memory aids mentioned before EVERY DAY to check what you have to do for the day.
- cues and prompts can provide just enough of a hint to help remember ...
- verbal prompts like the first letter of a person's name could be enough to help you remember their full name.
- coloured stickers/post-it notes - put in an obvious place, on the fridge or on the front door, can become a prompt to check that you have completed a specific task, for example "put the rubbish outside" and "feed the pets".
- watch alarms can also be a cue that reminds you to do something, for example, if you have to take medication regularly an alarm could be set to go at certain times which reminds you to take your medicine.
More helpful hints
If there are problems with keeping information in memory and then remembering it, it is often useful to use what are called compensatory memory aids. The information is recorded somewhere that you can frequently refer to. These aids include:
- a diary
- shopping lists
- memo boards
When using such aids they should always:
- be kept organised and tidy
- contain necessary information only
- notebooks and diaries should always be bound because loose pieces of paper can easily be lost
- kept in a specific place so that they can be easily found and looked at every single day.
See Section 13 Managing Your Time, for practical advice in using these compensatory aids.
It can also be useful to have a special place for important items so that you know where to go and look for them when they are needed. Such items might include a handbag, wallet, mobile phone, car keys, house keys, diary, medication, or reading glasses. These might be items that you need every day and really need to know where they are before you can go out anywhere. Having a special place for certain items will mean that the item has to be put in that special place every day when it is not in use.
After Justin had his brain injury he had a lot of difficulty with his memory. Justin tried several of these strategies and with practice used several of them independently. Justin received support from his family as he trialed different strategies.
He decided he most wanted to remember what was going on during the day, where he had put his mobile phone, car keys and sunglasses and remember to take his medication. Justin used a large diary to write down what was going on during the day. He used the diary to know what appointments he had on and wrote in everything else he did during the day in the order he did it. This provided him with a written record that he said he could look at if necessary.
He identified one spot in his bedroom where he always puts his keys, sunglasses and mobile phone. Justin stated this took practice and he needed reminding from his family at first.
To remember to take his medication, Justin programmed his wristwatch alarm. When it went off in the morning, Justin would stop what he was doing and take his medication. He would then tick it off in his diary that he had taken his morning medication. He would then set the alarm for his evening medication. He would repeat the same procedure as for the morning when the alarm went off in the evening. The cycle continued.
By just trying these three different strategies, Justin increased his independence by achieving three goals aimed at improving his memory.
An alarm could be set to go at certain times which reminds you to take your medicine.
I find it really hard to take in what people are saying and when I try to follow a conversation I lose track of what is going on. Why can't I play my favourite computer game for more than 20 minutes? I used to sit in front of the computer for two hours.
It can be very difficult to be involved in an activity, such as playing computer games, reading a book or magazine, watching a movie, or having a conversation with people if you have problems with attention. You might find that you don't remember much of what you have read, seen, or heard, that it is difficult to follow or doesn't make much sense.
When you have difficulties with attention you might notice that:
- it's difficult to cope with anything but a very small amount of information at a time
- you can only cope with one thing at a time
- you lose track of what you are doing or saying
- you might leave things out or miss pieces of information
- you are easily distracted
- you can only pay attention for a very short amount of time
- it is hard to finish things that you have started.
Some things you can do to assist with attentional difficulties are:
- don't try to do too much and do only one thing at a time
- write important information down immediately
- keep activities really short - so that you can complete a task
- if it is a large project you want to undertake then break it down into smaller parts that you know you can cope with one day at a time
- take regular breaks if you are going to be working on something for quite a while
- if it is becoming too difficult to maintain attention do something different, change activities and try something else for a while. Come back to the task later
- try and limit distractions if you want to read, find somewhere quiet away from the television or phone if talking with a friend in a social setting, find somewhere away from the crowd, maybe at the edge of the room where it will be easier to focus on just one voice if studying, try to keep your study space quiet. Try not to have music playing while studying. Ask family members not to interrupt you for a certain period of time.
- if you don't understand what someone has said then ask questions or ask them if they can repeat what they have told you. It may be that you have lost track of what they were saying or you were distracted and missed something. Write the information down if there is a lot to remember.
Danny had his brain injury when he was twenty; His employer was really keen to have him return to work and Danny wanted to return also. A work visit was conducted and Danny found that some aspects of his job had changed. He was required to remember information that someone else gave him to complete one aspect of the job, that led to another part of the same job. Danny's work environment was noisy and lots of different people were talking at the one time. Danny found that he would get distracted and found it difficult to focus his attention on what he was meant to do.
The occupational therapist and Danny decided to try and work out some strategies to make it easier to remember what he had to do and when. Danny found out the information he was given verbally was the same type of information each time. They gave him the name of a customer, address and type of parcel sticker it was to be labeled with.
Danny developed a sheet with this information on it as a template. He then wrote it down whenever he had to pick up this information. He could then complete it independently. It didn't matter if he became distracted because he crossed off each step as he went and he could work out where he was up to by looking at the package. Danny learnt to check the information with the supervisor before leaving to do the next part of the job. When everything was really busy at peak times, Danny used earplugs to stop him from being distracted.
Why does it seem to take me forever to get things done?
Sometimes the way that you process, or think about, information has not changed, but the speed at which you can do things like answer a question, write something down, or complete a math calculation has slowed down.
This can also mean that when people are speaking to you, you are not processing, or thinking about, what the person is saying as quickly as they are saying it. Then you may lose track of what was said or misunderstand information. This can be known as 'slowed speed of information processing'.
To manage slowed speed of information processing:
- be aware that it takes you longer to do things and be honest about it
- set realistic time frames, so allow extra time to complete activities
- if people are presenting instructions ask if they could present information slowly
- do one thing at a time
- if you know that you have upcoming deadlines to meet, maybe through study or work, then plan ahead. Start preparation months in advance to avoid leaving things 'to the last minute'
- it is better to work at your own pace and be correct than to put additional time pressures on yourself and make mistakes.
Sam who was twenty had just spent some time at the Transitional Living Unit, which is part of the Brain Injury Rehabilitation Unit. Part of the program meant Sam had to cook the evening meal for the other residents. Sam was cooking one Tuesday night, which is Movie night. Sam had decided to cook spaghetti bolognaise. He had a written recipe to use. Sam thought it would only take one hour to prepare.
To humour the staff, he started when they suggested. This allowed two hours before the time they had to leave. Sam worked through the recipe and found that he would not have been ready to leave if he had only allowed himself one hour for cooking. However, by having two hours, Sam found that he did not have to rush and was able to work at his own pace. He realised he was not able to cook the pasta and prepare the sauce so he asked the staff to prepare the spaghetti for him. He was then able to focus on one step at a time. Sam knew he required more time to read the recipe and follow the steps. By seeing this practically he started to allow longer periods of time to complete activities he called simple such as making his breakfast so he would be ready for his physio appointments.
If someone asks me a question I have a lot of trouble trying to work out the answer.
If I try to make something the pieces don't seem to fit together the right way and I don't know what I am doing.
Finding the correct solution to a problem can be difficult for a lot of people but after a brain injury there can sometimes be changes to a person's problem solving skills. They can have problems thinking of new solutions and keep trying old methods of problem solving even though the old methods don't work. They can have problems with reasoning, or thinking through a problem, particularly when there are lots of different bits of information that need to be considered to get a correct answer.
To help improve problem solving skills:
- have a goal in mind - make sure you know exactly what it is you want to achieve
- make sure you have everything you need to complete a task before you start
- try to plan your approach before beginning a new task. If possible talk things through with someone else, write this plan down
- follow a plan or guidelines
- break a task down into smaller components
- approach a task in a step by step manner completing each step before moving onto the next one
- if you feel things are not working properly~ ask for some assistance from someone you trust
- if you feel that things just don't seem to be working at all, then take a break from what you are doing. Look at this as an opportunity to take time out to think of a different way to solve the problem.
Frank had decided he wanted to move into his own accommodation near his sister on the South Coast. Part of this process involved Frank finding a suitable house. Frank thought this would be easy. At the time he was living at Liverpool and was not medically fit to drive.
Frank thought the best way to find a house was to go out looking. He said he would know the house for him when he saw it. When Frank said this to the occupational therapist and his case manager they had concerns. They thought there were some other things Frank needed to consider. Frank was prompted to prepare a list. He was able to identify what his house should be like because of his difficulty walking up steps, and stepping over obstacles on the ground.
They used the Accommodation Kit "More Than One Way" to get some ideas and prepare a list. Also staff asked him to think about what his house would need to be near, as he did not have his driver's licence. They also asked Frank how he was going to be able to go and see the houses available. They asked him to think if there was anything he may need to plan for or that he could do before leaving to look at houses. When given these prompts, Frank could work out what he needed to do to live by himself in the community.
The things I do just don't seem to get finished properly. If I have several things to do in one day by the end of the day there is always something I haven't done, and I can't find where I have put things in my kitchen.
Keeping the activities that you do day to day well organised and well planned will help to make sure that they get done and are completed correctly.
You can organise your home so that items have a particular place where they belong and can always be found. If you are studying you can organise study notes by their subjects and even separate different topics under each subject heading. You can organise your workspace so that items, or files, or pens, can be found as soon as they are needed. Planning is thinking before you begin something. So you can plan your day by listing the things that you need to do, and checking them off once they are completed. You can plan how you might fix something that is broken, how you might solve a problem, how you might build a garden shed, or what is the best way from your home to the shopping centre.
To improve planning and organisational skills:
- take time to think about what you want to do before you begin a task
- develop a weekly timetable so that you get into a routine with regular activities
- plan ahead - use a diary, or calendar, to record upcoming events then make sure you check them daily
- work towards goals in a step by step way
- make use of plans, guidelines, written instructions, and models when starting new tasks.
Gemma found that she had difficulty planning to move into her own home. She knew everything that needed to be done but just couldn't work out an order to do it in. For example, she knew she had to pack up her house, but she wasn't sure how she would get the boxes. Gemma sat down with staff from the Brain Injury Rehabilitation Unit and came up with a plan of action. Gemma and the social worker identified where she could get boxes. They worked out what would be a good size box for future lifting purposes. Once Gemma had the boxes she was able to pack her rooms up one at a time and be ready for the move. Gemma wrote what was in each box on a master list and wrote on each box which room it needed to be moved to.
When Gemma moved into her own house, she knew she had to find good places for everything. Gemma knew her memory would let her down if she didn't keep her new place organised, especially with everything being in new places. So Gemma decided before she unpacked she would work out where everything went in each room. For example, in the kitchen she used post-it notes to mark where she was putting different things. She worked out what things she used most and put these in places where she could most easily get to them. She put the saucepans she most used on a shelf higher than those she rarely used. She put her cutlery, bits and pieces, tea towels and wraps in a similar spot to where they were in her old house. She put the telephone books in the cupboard under the telephone. Gemma made a new spot to place her mobile phone, keys and sunglasses. To help keep these items together she bought a handbag. Gemma made sure her new house was set up in an organised way so that she could find everything as she needed it.
Other people complain that I don't listen to what they are saying and that I can't take another person's point of view.
When people make statements, or you are presented with a problem, it can be difficult to think of anything else but the information that you have in front of you.
This can mean that a lot of other information is ignored or not thought of just because you can't see it. Sometimes that other information can be important for your own understanding, to improve the way you get along with other people, and to help you develop new methods of problem solving when old methods don't work. This is really important if you need to cope with new situations.
To manage such difficulties you need to be aware that they are happening.
- if you encounter difficulties with any tasks that you are involved in ask for assistance from a friend, family member, therapist, to work out how to make the task less difficult
- keep activities that you do focused on an end goal - know what you are trying to do and how you are going to do it
- use terms that are simple. When talking with other people ask that they keep conversations simple and without any difficult words.
Tracey is twenty-eight. She wanted to get a job. Prior to having her accident Tracey worked in an office. She had completed some of a bookkeeping course at TAFE. Tracey had very definite views on what she wanted to do for work. She looked through the paper and applied for a secretarial position at a legal firm.
Tracey was very sure she was going to get the position even though she did not meet the requirements of the position. She was very upset and disappointed when she found out she was unsuccessful. She found it difficult to understand why she did not get it.
Tracey spoke to staff at the Brain Injury Rehabilitation Unit's Work Assessment Unit, who worked with her to identify a position that was more suited to her. Tracey worked with the occupational therapist at the Work Assessment Unit to identify a more suitable job, commence a work readiness program and to practise interview skills. It took Tracey a little while to see why she needed to work on these areas, however when she did she worked hard to find a suitable job that could use her unique and individual skills.
People are always complaining about my behaviour.
They say I talk too much, I swear too much, I try and do things too quickly, that I keep repeating myself, and that I don't listen when they try to help me do things in a better way.
After a brain injury people sometimes don't control their behaviour as well as they did before their injury.
Most of the time they don't know that their behaviour has changed, but other people do notice.
After a brain injury you might:
- rush at things or try to do tasks as fast as possible
- make hasty decisions without thinking through the consequences
- behave in a way that is silly, rude, or offensive to other people
- make mistakes but not realise
- talk about the same thing all the time
- talk too much so that others are no longer interested
- not be open to new ideas
- not be aware of the changes that have occurred to you.
To help improve these types of problems you will need a lot of support and assistance from either family, friends, carers or therapy staff. They will need to provide feedback and reminders to you about your behaviour so that you are able to learn how to improve your behaviour.
Charlie had his accident when he was twenty. One of the areas that was affected because of his brain injury was his ability to monitor or keep tabs on what he was doing and saying. Charlie was given a lot of feedback from staff about what he would say and do. He would sometimes become over familiar with staff and found it difficult to remember he was working with staff. He wanted to go for coffee and see them socially. Charlie knew he shouldn't be having these conversations with staff, but he just couldn't stop himself from asking. Staff suggested to Charlie he might benefit from working with the clinical psychologist to try to control this behaviour better. Charlie agreed and worked hard on his ability to watch what he was saying. Charlie can now talk appropriately to staff and does not ask to see them socially.
Is there anyone I can contact about my thinking processes?
Brain Injury Rehabilitation Unit staff who you can contact include:
- Medical Specialists
- Clinical Psychologist
- Occupational Therapist
- Speech Pathologist
Accommodation Kit - More Than One Way". If you would like to see this resource you can contact the Brain Injury Association or your local Brain Injury Service. Go to Appendix for an order form.