Complex People
Harvey E. Jacobs 1
Rehabilitation is a most intimate of enterprises. In the course of treatment, at least one party opens up details of his or her life and being, often involuntary, on a journey over an elusive path called recovery. Yet the rest of us also share more about ourselves than we may care to imagine.
After we throw away role distinctions, disciplinary differences, procedures, and approaches, some of the common denominators of this enterprise include: trust, caring, belief, hope, determination, feelings, faith, respect, friendship, love, spirituality, sharing, and vision. Rehabilitation is much more than treatment and although competent treatment is critical to a successful program, treatment alone is rarely sufficient. On many levels, rehabilitation involves matching people who need to be cared for with people who need to care, people in desperation with people who have vision, people who can both give and receive, and people who believe with people who believe.
These distinctions are not always dichotomous nor one sided -- from client to staff -- but occur in all different directions. Thus, faith is taught by the mother who knows that her son will survive when medical staff doubt that he will last the night. Perseverance and grace come from the person who was told she would never walk, yet alone work, who stops by to take her former counselor out to lunch at the new restaurant she just opened. Belief and vision comes from the nurse, who gently blots the tears of the individual who thinks that his life is over and angrily demands to know why people are even trying. Friendship comes from being there as someone lets go of something tightly held that they may never have again, discovers a new and unexpected treasure from the obvious, or faces the void of uncertainty. It is how we individually and collectively share in the experience. Although one team member may be identified as the client and the recipient of the principal focus of change, we all learn and grow with each person we meet.
The power of this journey also exposes many personal vulnerabilities and choices. It can represent the "yin" and "yang" of our existence and show how we may choose to balance our values on this perilous two-edged sword. It is the difference that we can make when we have a choice, however infrequently such choices may occur.
It is the difference between offering our compassion to help someone find their way, or feigning it for ulterior motives. It is the difference between acknowledging a person in time of need and discovery, or patronizing them. It is the difference between working with someone's trust, or feeding off his or her fears. It is whether each of us view our roles from a position of responsibility or privilege; not only those who provide services, but those who receive them. (It's funny though, how often we incorrectly assume which "side" we are on.) Not surprisingly, the more often we make the right decision, the more often we have the opportunity to do so, again.
It is how we represent ourselves to others, communicate our intent, and act on our words. It is acting on what is right, rather than on what is not wrong. It is when the words "I don't know" become the challenge to open new doors rather than an excuse to shut others. It is acknowledgment of personal limitations as well as abilities, not as a sign of weakness, but as a contributing member of a team. It is seeing others in the way that we hope we are seen, honestly, but with a strong appreciation for our gifts and a loving hand for our challenges. It can represent humanity in its most endearing light of sharing and nurturing, or its darkest shadows of deceit and degradation.
We deliberately make these choices every day whether or not we acknowledge them to others, or even ourselves. Our choices are reflected in our actions which communicate even more clearly than our words. They broadcast a sense of the value that we have for others and ourselves, how we identify and use our energy, and what is important. Though difficult to pin down, it represents the quality and earnestness of our efforts, and it has a major impact on how we serve others and how other people respond.
Despite all of the advancements in the field over the past decade, brain injury rehabilitation remains an art form, not a science. The complexity of variables with which we deal, the many unknowns, and the individualistic framework all contribute to this assessment. (In the grand scheme of things, it is not clear that science ranks higher on the evolutionary scale than art.)
A scientific approach is only one of the tools we use in rehabilitation, but it is an important tool because it helps us develop anchors and markers during this complex journey. Like a compass, these templates help us maintain perspective as we paddle through the swells and storms of this sea. There is simply so much to do and it is so easy to be affected by all the challenges that we need direction. Otherwise, we may continually change course to each newly perceived need and not realize that we are off course until we run out of time and resources, when it is simply too late.
Nevertheless, a compass alone cannot capture the wind nor keep us pointed in the right direction. It is only one means of telling us which direction we are headed. Its information is only as good as the quality of our destination. Going north or south is of little value unless there is something important to reach. Similarly, the process of rehabilitation is only as good as what it brings, and the singular activity of treatment can actually be meaningless unless we have greater goals. Thus, I have never met a person who solely needed physical therapy, but I have met people who wished to improve the pattern of their gait, especially if it meant being able to take a walk with their child. I have never met a person who just needed a social skills program, but I have met many people who wished to interact with others more effectively, especially if it allowed intimacy and sharing. Similarly, I have never met a person who only needed vocational rehabilitation, but I have met many people who wanted to go back to work to have a sense of self-respect, social contribution, and the resources to shape a little more of their destiny.
Quality of life is such an ephemeral but critical issue in what we do and how we do it. It can be so easily discounted or discarded as our hierarchy of needs and being are challenged by catastrophic injuries, their aftermath, or even the demands of daily life. We then tend to respond and think at a lower level of Maslow's (1968) hierarchy of being; about basic issues of survival rather than issues of affiliation, fulfillment, and actualization. We may be asked why we are even spending time worrying about someone's happiness when he or she cannot even hold a spoon, yet both are important. Although we cannot write a prescriptive program to increase chances for these higher order values, we can deliver them in our daily interaction.
A brain injury damages a brain, not a being, not a spirit, nor a person. No, it is not easy to define these terms, but it involves reaching through the twisted limbs, the tears, the humiliation, and the anguish to find common elements of sharing, trust, respect, communication, and the other common denominators of living. Thus, if you could learn to use all of the technical procedures that are available in rehabilitation and nothing else, we will have all failed. They are but templates and tools to be used in a much grander challenge.
This holistic appreciation is not counter-intuitive to the focused orientation of most therapeutic interventions. Precise definition and application of any intervention is very important. Yet, at the same time they are simply procedures, techniques of learning and direction that can be of benefit in given situations. The purpose, manner, intent, and competence with which of these techniques are used are equally critical. Each of us accepts a certain (but not total) level of responsibility for another person when we implement any type of treatment, and it is important to remember how seriously this responsibility should be acknowledged.
Similarly, "either - or" arguments between self and behavior, cognition vs. performance, nature vs. nurture, or equivalent "straw men" are all meaningless ruses in this context. Unfortunately, we often tend to polarize challenging situations or hide behind differences in roles, experiences, training, or dogma as a means of simplifying their presentation or apportioning liability. However, "we" are critical, complex, and encompass all of the above. It is how we balance the diversities and challenges of living that is so important. I have yet to find an "either - or" issue on any case on which I have worked. There are always options, alternatives, relative benefits and risks, short-term and long-term trade-offs, various outcome potentials, and other factors that must be respected. These are important and difficult issues that we implicitly assume by virtue of our work, and we cannot defer them because of their complexity or perceived ambiguity.
There are no absolute answers to these daily dilemmas and none of us has infinite wisdom. Those who claim otherwise must accept the burden and responsibility of their "unique power." Similarly, "I don't know" is not an excuse for inaction or continuing ineffective ways. Neither should it be an open door for assumption of liability by others. In an honest, supportive, and caring environment, we combine our diversities into a collective whole. In an age of specialization and polarization, we need to become comprehensivists (Fuller, 1979) and see both the forest and the trees.
How we address these challenges is determined in part by who actively participates in treatment process and direction. This is why client involvement is so important and must be considered the norm rather than the exception. It is also important to acknowledge what each person brings to the equation. Although team roles such as "client," "family member," "professional," "payer," and others may be relatively well defined, we still bring our own personal histories, biases, values, and challenges to the table, whether or not we acknowledge them. Each of us needs to be aware of these issues, how they affect us and others, and how they change over time. Staying in touch with our own lives and personal evolution is just as important as keeping abreast of our technical field, yet either alone is insufficient. In this vein, I can only provide personally relevant answers to these continually evolving questions.
As we sit around the table acknowledging each person's distinctions, remember the commonalties that bring all of us together. It is from here that we merge and begin to build a strong foundation.
Thank you for your time and consideration.
Footnote
1. Excerpted from:
Jacobs, H.E. (1993). Behavior Analysis Guidelines and Brain Injury Rehabilitation:
People, Principles and Programs. (Epilogue) Gaithersburg, Maryland: Aspen Publishing
Company. Now available from the Brain Injury Association, 105 North Alfred Street,
Alexandria, VA 22314. Phone (703) 236-6000; FAX (703) 236-6001
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References
Fuller, B.F. (1979). Synergistics 2. New York: McMillan Publishing Company.
Maslow, A.H. (1968). Toward a Psychology of Being: Second Edition. Princeton, New Jersey:
Van Nostrand.
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Contact Harvey Jacobs at:
9221 Forest Hill Avenue
Richmond, VA 23235
(804) 323-5560