In our latest instalment of the Week in the Life of a Rehab Assistant series, Horatio Price, cognitive rehab assistant with BIS Services, discusses the ongoing process of learning the best ways to support clients through specialist tailored rehab, and the three main factors he believes lie at the heart of achieving that
I have been a rehabilitation assistant (RA) with The Brain Injury Service for four months now and thought it would be helpful for readers to gain insight into what that involves and what learnings I’ve uncovered to date. In my experience, there are three main factors at the heart of this role: Planning, Negotiation, and Building Rapport. I will outline what each of these factors involve and key lessons I’ve learnt in relation to them. I currently work with four clients (ages 25-60+) who have huge variation in their support needs, and thus I shall do my utmost to cater to the variation along each aspect I’ll be covering.
- Planning
Planning a session begins at the end of the previous session as I write up my notes and consider the development of the client across specific metrics such as cognition, memory, mood, impulsivity and more. Often the focus of the next session comes in three main forms: building on areas where positive momentum was identified, considering new approaches to areas where the client seemed to particularly struggle, and theorising ways of including an element of novelty or change such that, alongside the benefits of building consistency and habit, the client continues to be exposed to new stimuli.
Once I’ve determined these focuses, the next step is developing a plan for the session. RAs would be best advised not to get too attached to plans, as they are rarely actualised but can function as a helpful template which the RA attempts to gravitate the session towards. A common session plan will normally involve a combination of common daily activities (in order to facilitate the building of strong habits) and particular activities and tasks in relation to the rehabilitation aims that have been identified. Some examples of these might be: creating a shopping list and then going to the supermarket and purchasing items on the list, or searching up cafés and deciding which one to attend. A well calculated plan can subtly smuggle in countless tasks that relate to both cognitive rehabilitation goals and building positive lifestyle habits.
Whilst in some cases it is necessary for a plan to be prescribed by the RA, in my experience, despite the utility of creating a plan beforehand, it is optimal, when possible, to include the client in the planning component. This offers clients the opportunity to use cognitive functions, such as those involved in thinking ahead, considering the cost and benefit of different options, reflecting on previous experiences etc. This also adjusts the dynamic such that the client is in a decision-making position and places the client as a teammate of the RA working to achieve a common goal.
In my experience, clients have a more favourable inclination to tasks they have selected for themselves, as opposed to tasks that have been prescribed for them. Not involving the client in the decision-making process can also lead to a heightened awareness of the RA being in a position of cognitive authority, and reinforces the client’s lack of autonomy and independence, subtly nudging them into a passive role in their rehabilitation journey and reducing their agency. Planning a session can often place disproportionate emphasis on what tasks or activities are attempted and completed. As an RA I’ve learned the salience of the client’s posture towards, and relationship with, a given task is often more important and informative than the completion of the task itself.
Plans for a session are of course dependent on the specific rehabilitation goals of the client. For one of my clients, goals include: improving their capacity to plan their time, managing overstimulation in public spaces through gradual exposure, and partaking in light physical exercise (walking, for example).
I’ve identified that this client is a huge fan of cafés and has a particular appreciation for coffee and sweet treats. As a result, I identify several options for places we can go that have cafés in public areas as well as quieter back-up options should the client begin to struggle mid-session. Once I arrive, I start by initiating a discussion around what the client would like to do that day. Depending on their response, I reveal the options I’ve come up with and discuss which one suits best. Giving the client options often helps prevent the client saying they don’t want to do any of them, which I’ve had to learn the hard way having previously asked ‘would you like to go to X’ and then been stuck for ideas after the client said no to all eight options I had offered. It’s these kinds of learnings on the job that make it much easier after a few months, as well as making use of members of the MDT or my line manager for support.
- Negotiation and chunking
Planning is only as good as one’s capacity to negotiate a middle ground between the plan and what the client wants to do. So many clients struggle with motivation, fatigue and other factors, that the RA must find a balance between ushering the client towards goals and showing sufficient empathy towards the client and their struggles. As much as progress is the aim of our work, if some positive momentum is paired with mounting resentment from the client as they feel they’re not being heard and stripped of their say in the decision-making process, progress will swiftly u-turn into regression.
The first hurdle often requires effort multiple times that of the hurdles thereafter. If the RA can get the client to put their shoes on and walk out of the door, whether they walk for two minutes or 20, a huge milestone has been reached. I try to remind myself of this as I seek to plan sessions and rehabilitation protocols. If the client is putting in the effort necessary to find out whether they can manage in the context of going for a walk, rather than not trying in the first place, that is a huge win. With the variation in clients’ symptoms, outcome-based goals can often risk underappreciating a client’s effort. This is why I often try to set goals in relation to intent rather than outcome ie. Put shoes on and clothes appropriate for going for a walk, leave the house, and walk for at least three minutes.
In instances where I have arrived at the client’s house and they have agreed to a particular plan for the day but are delaying the execution of the plan, and are clearly hesitant to get going, it can be helpful to chunk the task for the client so that they can confront it in smaller, more manageable steps. A single moment of uncertainty, combined with the underlying struggles with common ABI symptoms such as fatigue and motivation, can be sufficient for the client to disengage with a plan or idea. Hence, it is often crucial to pre-emptively lay out the upcoming steps the client will need to tackle chronologically and outline these in a manner that doesn’t frame the overall task as complex.
I experienced a particular scenario this past December that perfectly illustrated the importance of negotiation and subtly using a chunking approach by emphasizing just the next step in the thought process or behaviour. Christmas was coming up, and I thought it could be a worthwhile activity to do some Christmas shopping with a client. Initially they were adamant that it wasn’t the kind of thing they did. When pushed to explain why this was they expressed that they ‘wouldn’t know what to get anyway’. After resisting the idea that we consider it for a period and go into a few shops, they eventually started to let their guard down and agreed to look in some shops, brainstorming what kind of present their partner might like. By the end of the session, they had gift wrapped the exceptional present, planned a card to write and had another card for their daughters to write for their mother.
The client had resisted my suggestions at every step of the way, particularly the gift wrapping, though perhaps for good reason we joked, after regrettably viewing the outcome of our labour. Yet, they overcame their resistance as I continuously negotiated a smaller, more manageable goal, offering the target of just writing one line of a card, rather than being expected to complete the whole thing, for example. I was fortunate, in this instance, that the client only required minimal chunking before being caught up in the excitement of surprising their unsuspecting partner with a present. This was a perfect example of determining where there is opportunity for the RA to push the client, leveraging the rapport that’s been built, and negotiating with them throughout the process to accumulate small wins.
- Building rapport
A few weeks ago while I was discussing a client’s lack of social life with the MDT, I realised that I may well be their best friend (the client’s that is, much as I’d like to think of myself in the eyes of the MDT). Biased by the professional angle with which I approach the job, up until that point, I was yet to consider the many hats I may wear in the client’s life aside from being an RA. This has enabled me to consider the space I occupy in the client’s life in a more holistic manner, and reflect on how broad the goal of cognitive rehabilitation can be. I had thought of it initially through a scientific lens, and though I felt strongly about building rapport and a good relationship, I viewed this as crucial to the extent that it created a petri dish for cognitive rehabilitation, as opposed to being an aspect of the rehabilitation itself.
I pondered how I could facilitate cognitive rehabilitation through avenues other than purely focusing on aspects of cognition as an objective science. By this I mean, once sufficient rapport is built, being prepared to speak in broader terms about life and one’s relationship with it, finding humour when it is available, and speaking in a more philosophical sense, which, since this realisation, I’ve noticed my clients enjoy doing.
Recognising the many hats I wear for the client has caused me to reflect on the space I hold and the things I represent to the client. If I am one of the only people they interact with each week, what impact do my small gestures have on their wellbeing?
I had noticed one of my clients was very appreciative of my work with them, and had on several occasions mentioned feeling guilty and undeserving of the amount of support they receive. After the aforementioned realisation, I made a point of highlighting the many ways I’d benefitted from the client, and more specifically, the numerous things they had taught me about cultural differences, the importance of one’s presentation, and appreciating detail in quality when it comes to things like coffee, food, art, cars, and more. Highlighting this to the client seemed to have a significant positive impact on them including remedying their concerns of being unworthy and brought us closer together as two individuals who reciprocally teach each other about life.
To conclude, I recently had a meeting with the psychologist for one of my clients, in which they introduced me to the analogy of ‘rock climbing in the dark’, referring to the unpredictable nature of working with clients who have ABIs. To further the analogy (in a subtly adjusted format of climbing), I propose that RAs are sherpas, attempting to follow a particular trail, guiding the client, we urge them along each day, battling unpredictable weather in the form of mood, motivation, and fatigue, and ignoring the top of the mountain, through focusing on taking a few steps at a time.
