TRAUMATIC BRAIN INJURY TBI COPING WITH LOSS AND GRIEF

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					                                   TECHNICAL ASSISTANCE and CONTINUING
                                        EDUCATION SOUTHEAST TACE

                                  A Project of the Burton Blatt Institute at Syracuse University
                                        in collaboration with the DBTAC: Southeast ADA



   TRAUMATIC BRAIN INJURY TBI COPING WITH LOSS AND
               GRIEF VR IMPLICATIONS
                                   July 30, 2012
                                ROUGH EDITED COPY

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Well, welcome to the 2012 southeast TASE webinar, our topic is Traumatic Brain Injury
and Coping with Loss and Grief, VR Implications This webinar is actually the third for
those of you that have been following this series in a four part series. Focused on
improving employment out comes for individuals with traumatic brain injuries. This
webinar series was is being hosted by the southeast regional TASE but developed in
partnership with South Carolina state University. As well as a network that TASE has
been running focused on improving services to individuals with the most significant
disabilities. I'm Jill Houghten and I'm the facilitator today. And for those of you not
from with the southeast region TASE our mission is to improve the quality and
effectiveness of vocational rehabilitation services and enhance employment out comes
for individuals with disabilities in the southeastern states, specifically focusing on
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, Tennessee and South
Carolina. We are a collaborative effort with our southeast ADA center and we are
managed by the Burton Blatt Institute in New York.

Just a couple of housekeeping things before we get started. For those of you that are
not familiar with the southeast regional TASE, we host webinars on a regular basis
throughout the year and would highly encourage you to go to our website at
www.tacesoutheast.org and you can get information on up coming webinars as well as
get instructions and materials for each of the webinars that are posted on our website
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



You should know that the technology that we're using today should be fully accessible
to everyone regardless of your disability and our assistive technology you might use.
But you know there is always things that are inherent in all of our computers that are
beyond our control and that is why it's really important that you check your system in
advance of the session and just know that through TASE we have a staff on our team
that are always available to work with you in advance of webinars to help you trouble
shoot So I'm letting you know that. We are going to take questions at the end of our
session today. And on the left hand side of your computer screen you should see a
chat box and so we will just invite you to type your questions in that box and then I'll
read them out and our speaker will respond to your questions.

And I wanted to remind you if you have any kind of systems running in the background
on your computer, any kind of applications that would be helpful if you turned them off
so they do not interfere with your webinar and you want to remind yourself to hit your
space bar a couple times to just keep your computer awake and make sure it doesn't
shutdown.

But with all that in mind, we are ready to begin. I'm really privileged to introduce you
to our speaker today, her name is Tammara Thomas and she currently works for the
department of veteran affairs in Iowa city as a vocation rehabilitation Counselor. I
think you will find her incredibly interesting. She works collaboratively with the
transition clinic at the Veterans administration. Medical center and recovery and action
task force committee. And the mission of the transition clinic is to address traumatic
brain injury and post traumatic brain injury PTSD and common post deployment issues
of Veterans of Iraq Freedom and New Dawn and Enduring Freedom with a particular
focus on comorbidity that exists in combination with TBI and PTSD.

Tammara is originally from Chicago. She is a doctoral candidate at the University of
Iowa and is looking forward to finishing up here real soon. And I want to turn it over to
Tammara. So thank you so much, Tammara and take it away.

Thank you, Jill. I would like to take the time out to say thank you for everyone who
joined us today so we can examine the impacts of traumatic brain injury for people and
caregivers. The impact of TBI is not only devastating for the survivor but also the loved
ones. I want to give attention to how we can navigate the process as vocational
rehabilitation professionals. When I speak about the caregiver, I am speaking to that
person or those individuals who are non paid. Who are providing support of services
and care to individuals who are experiencing post traumatic injuries that they sustained
during deployment. At the beginning of this I want to apologize If you hear me
referring to our Veterans, Veterans, Veterans it's because I work for the Department of
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         2
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



Affairs and the Department of Affairs and it's not that I don't want to acknowledge all
the different disciplines we have joining the webinar. So keeping that in mind I'm very
excited to talk about the issues and there is so much to cover. I'm going to do the best
I can to try to give a lot of information without and still be able to connect the dots so
that we have the take away message from the entire webinar. So I want to read a
briefly a very short scenario of some of the things that or situations that here at the VA
that we see on a daily basis. I several Veterans who are actually in need of vocational
rehabilitation And it's not often times as simple as just going in and vocationally
rehabilitating them. There is a million issues we have to address. So if you would bear
with me briefly I will read this to put you in the mind frame of just a small issue that we
see, but it's pretty common throughout.

So Mary and Franklin have been married for 12 years, he is a 30 year old man deployed
to Afghanistan but recently was discharged from the U.S. Army. He served well in
armed forces but their family was very happy when he finally returned home. Mary
loved her husband very much and knew him before they got married and Franklin had
lots of friends and loved family time and a wonderful provider and responsible and
dependable. The family would call him superman, if there was a problem, Franklin
could solve it. Mary always wished she had his coping skills.

However, it was not long after Franklin returned home from the hospital that Mary
noticed some changes in him that were beyond the physical. She always knew that war
impacted people in many ways that forever changed them, but she was not expecting
her husband to be so different. He told Mary he had seen enough destruction to last a
lifetime and did not want to discuss his experiences. He just wanted to have a normal
life.

After Franklin recovered from his physical injuries they were hopeful and optimistic that
things would return to normal and so much changed in how he is perceived by those
around him and sometimes he does not recognize himself but he returned home with
many physical conditions, a TBI, shattered pelvis, he could no longer return to work in
construction as he previously had before. He received a disability rating for PTSD, post
traumatic stress disorder and there were adjustments to be made upon his return so
the first two years were very difficult. Franklin had several doctors appointments at the
hospital and he knows Mary and his family, hope he will assume his former role in the
household after recovery but saying recovery was an on going circumstance, although
he was home, Mary was still the primary decision maker, additionally she also had most
of the financial and family responsibilities. Franklin was irritable, moody, experiencing
sleepless ness and isolating and forgetful. He was unable to solve problems well. And
he dealt with anxiety. He hated that he was different in so many ways Franklin
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         3
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



experienced depression because he feels like he has lost everything and is only a shell
of his former self and Mary is frustrated because she does not recognize Franklin her
husband nor does she know how to help him and she does not know how much longer
she can remain in the marriage.

That was a very colorful scenario of the issues that people deal with, once they are out
of the services, when they have all these issues, it's very, very common for there to be
a lot of confusion about what is this all about. So briefly going over the objective, our
goal is to review the traumatic brain injury symptoms, explore the veteran and TBI,
gain an understanding of the impact that TBI has on caregivers and the entire family
system. Also giving attention to the perspective of grief and loss and how it can impact
this process of rehabilitation. I want to introduce the conceptual model of health
related quality of life and also talk about strategies for families and rehabilitation
professionals to assist individuals with TBI.

Okay, so I know a lot of you, I know with me as I started as avocational rehabilitation
Counselor I have a case load of 189 200 Veterans at any given time. That is a lot. I
often times refer to my position as that I would say I'm running triage and sometimes
difficult and most times is difficult to address all the needs of our Veterans, you are one
person and the resources are limited and right now we are experiencing, we are down
three Counselors due to retirement. Right now they are not interested in replacing the
Counselors. So right now those cases are in the process of being divided up among the
remaining Counselors. Three total for out base in the eastern region. And so it can be
overwhelming. As I present this webinar, I take into account I'm sure that the case
loads out there are probably very difficult and probably have a lot of people that you
also attend to. So it's already so much to do. So I keep it in mind and mind and there
is no cookie cutter or pie in the sky approach to servicing all the people that we have to
service. However, I think having some information regarding the process of it and what
role that we can play and the role that we have would be very helpful to the veteran.
It's a daily challenge to meet the needs of the Veterans we serve but we are doing the
best to do it with the recognition that it's a daily process and we have to be creative in
how we approach it.

So with that said, I'm going to move on to the traumatic brain injury. The Department
of Defense and department of veteran affairs defines it as any traumatically induced
structural injury or physiological disruption of the brain function as a result of an
external force that is indicated by a new on set or worsening of at least one of the
following clinical signs So a period of loss decreased level of consciousness, loss of
memory event, any alteration in mental state at the time of the injury, neurological
deficits, and intercranial lesions.
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         4
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



A traumatic brain injury can significantly disrupt a person's life, but also the lives of the
family members. And caregivers. So it's really essential that we understand the needs
that result from the traumatic brain injury And this really includes knowledge of having
knowledge of who is the Veterans, support system, having knowledge regarding the
role within the family system, and assessing a level of understanding, a lot of times
when family members come in they don't really understand what is going on, okay, you
said that our loved one has a TBI, what does this really mean? They hear a lot of
medical jargon and have no clue as to how this is really going to impact the person they
will be responsible for caring for. Also as a professional you want to have an
understanding of the health of the family as a whole.

So, for example, if there is already a stress within the family system, before they
actually experience the TBI, then the TBI is certainly going to impact that system even
more so. So it's good to know what that is like initially. So keeping that in mind, you
want to also involve the family as early as possible. So once the diagnosis and they are
stabilized, there may be a period where the individual is hospitalized to address physical
issues and this could be a very long process and it may be a while before they get, in
fact, it will be a while before they enter rehabilitation services. But involving the family
on the front end of things as early as you possibly can and this is usually done with a
collaborative effort starting with the medical team for stabilization and just getting them
back to the point where they are ready to enter the rehab process. There should be
some educating because additionally the person who is going to be responsible or the
people or the family they are going to be key to helping daily living with transportation
needs and independent living skills, social activities, transitioning into the community,
reintegration. So ultimately, although the process is all about the individual, it really is
a group effort. And it's a very collaborative effort among all parties.

There are two different types of TBI injuries. One being an open injury. Meaning that
from the direct blow to the head that is penetrating it's what it is The skull can be
fractured, when this type of injury takes place, normally that person is going through
surgeries, reconstruction issues, the medical journey is a long haul because it's so
physically devastating. Which, you know, is not uncommon especially when we are
talking about people who have been deployed. Or and they have come back and have
been medically released or discharged from the military. So it's a long, long journey. A
lot of questions, they have not began to think about rehabilitation at that point At that
point they are trying to figure out how they will survive from one day to the next
possibly

Also, a second type is a closed injury and results from a blow or shifting of the brain,
the skull is not broken but the brain tissue can suffer lesions Again, this may not be an
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         5
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



open wound but because of the nature of the particular war we have been in, there is a
lot of these closed injuries due to operating heavy artillery, it has been very combative,
the previous war. So people are experiencing a lot of these closed head injuries and it's
starting to be very common next to PTSD, we are seeing a lot of it in the VA at least.

And also there are so many changes depending on the area in which the lesion takes
place or the tear or the sheering of the brain, it can impact just a full gambit, learning
and memory and interactions with other people. Even a desire or will to live depending
on where the injury takes place

To give you an example, so if the injury takes place in the cerebral cortex, the
characteristic of the symptoms that person may experience is loss of simple movement,
persistence of a single thought, inability to focus on a task and difficulty problem solve
and personality changes. In the temporal lobe you may have problems with irritability
and increased aggressiveness and difficulty recognizing faces and understanding spoken
words, memory loss. They may have persistent talking, I got a message here about
being muted, hopefully everyone can still hear me.

We are not muted.

Okay.

Thank you. An inability to characterize objects may be an issue. If it takes place
central or in the frontal areas there may be lack of vitality and loss of insight and
awareness. There are a full gambit areas of where there can be damaged areas in the
brain But as a rehabilitation professional it's really important to get to kind of know
where the location of their damage took place so that as you are going through the
process the rehabilitation process and you are experiencing some symptoms of
disconnect, if the person doesn't, this is very common, I have so many people on my
case load right now that just don't seem very motivated to get this rehabilitation thing
off the ground. It can be very frustrating, but often times if I go back and refresh
myself on the injuries and the disabilities that they have incurred then it begins to make
more sense as to why I have to work on their focus, why they are not following through
with things I asked them to do and why they seem like they are un motivated or
uninterested. It may not be a thing of a behavioral issue. It may purely be a direct
result of the injury that they incurred and it's outside of their control. So very helpful to
understand what is going on with the person that you're serving and what symptoms
you can I'm specific and impacting the rehabilitation process.



                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         6
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



I'm going to move on. So here are some facts, the disease control in 2007 indicated
that TBIs were the leading cause of death in disability in the U.S. and said 5.3 million
people have disabilities as a direct result of TBI and the estimated cost of for care and
loss of productivity whether they are no longer part of the job market and cannot
contribute is $60 billion. This is significant For a majority of survivors, although their
physical issues may heal and on the outside physically, they seem to have resolved the
issues, the brain doesn't heal that way. So the concept of recovery is relative.
Depending on how you look at it, what is really recovery. A lot of times people who
face these issues, they are un aware these changes have taken place so it may take
time for them to realize they are having problems processing new information. These
things may have been brought to their attention by their loved ones and it takes and it's
a very disabling consequence of TBI so you expect them to resolve themselves at some
point but a lot of times the caregivers or the person who has the disability, they are not
aware of the on going residual effects like behavioral issues, psychosocial issues and
cognitive issues so people are trying to make sense of what is happening

Military TBI, it's the significant injury of operation Enduring Freedom and operation Iraq
Freedom. They began calling this around when we started war on September 11, 2001
up to present, it's presenting itself more so now than anything As I mentioned before,
it's the result of the heavy artillery and weapons we are using now, the jarring, the
combat, that is just impacting a lot of Veterans who are serving or who were serving.
So in 2009 there were 13 1313 Veterans who received hospitalization to care for TBI
and 33 percent of patients with combat related injuries and 60% of the patients had
blast related injuries and sustained a TBI

So these numbers I don't believe are true estimates because individuals with mild TBI
may not seek medical care. Additionally these figures do not include the physical, the
emotional and social costs to the injured person and their family. Who experience TBI
related injuries. So mild TBI is one that actually one of the most common forms of
combat related injury Excuse me Okay. So in discussion the severity of traumatic brain
injury, TBI is measured on a continuum and they designate if a person has mild,
moderate or severe TBI. Most TBIs are classified as mild. So and the classification
system is arbitrary because we are not able to predict the person's likelihood that there
will be functional recovery The benefit of the categorization is that it provides a base
line, so we know at least know where the person started out on the continuum. The
severity grades, they are defined by using four and one is the Glasgow Coma Scale and
the length of coma and the length of period of altered consciousness, the mental status
and the length of post traumatic amnesia, PTA is a time interval from when the person
regains consciousness until he or she is able to consistently form memories of on going
events.
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         7
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



So we mentioned earlier closed head injury and open head injury. And both closed and
open head injury they basically both of them run the risk of having the same symptoms.
So it's good to note that open head injuries run the risk of the same symptoms but
additionally they there is concerns there may be fragments that could cause a
problem or further injury to the brain.

So the brain injury measurement of severity of classification, the Glasgow scale is an
instrument that is widely used and known of for measuring the seriousness of brain
injury. And I think I have, yeah, I do, a slide of the Glasgow coma scale. The longer
the person is unconscious the more the severe the injury to the brain and the greater
the residual effects. So with mild TBI because there are few objective signs of brain
damage in mild cases they may be accused of making up issues that really don't exist
However, the symptoms can still effect the emotional well being and social and
occupational outcomes on functioning of the person who endured the TBI. So it can be
very well debilitating If you look at the Glasgow Coma Scale there is a total score of
15, but that is actually measured, the total score is taken into account and based on the
person that the where they are in terms of TBI so it assesses the level of
consciousness from alert to coma, scores are assigned to the level of responding in
each of the three areas, so eyes opening, look at a score, the eyes do not open, if they
open to pain, do they open to verbal stimuli, spontaneously and a score is assigned to
it. The lower score, the lower the score the deeper the level of unconsciousness and
the greater the functional consequences. Again, the scale is used to establish a base
line to check out the change in the neurological functioning.

Okay. So a score of 13 or higher would indicate that an individual has a mild TBI. And
it occurs post concussion, months later after the injury. So there may be subtle
disruptive symptoms.

As I mentioned earlier, the symptoms may not manifest right away. And even though
the person is un aware of these changes, maybe others around them notice these
changes. But often times it takes a while for, say, for veteran affairs for a veteran to
come in, they often times go through a rating, changing of the rating or trying to get
assessed for a rating change and the rating is given based on a strange formula that I
have yet to understand. But they may find that when they go in for an assessment that
they are being diagnosed with a TBI and some are just clueless and when you begin to
explain what that is, they have some clarity like, oh, so disruptive are vertigo or
depression or irritability, memory impairment. If there is one symptoms that results
from disruption they can be considered mild TBI. And 70% of all TBIs are considered
mild. So it can go for a long time being un diagnosed. In moderate TBI, if you have a
score of 9 12 is characterized by loss of consciousness for a few minutes or several
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         8
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



hours. There may be disorientation, confusion that lasts for a few days or hours and it
could be physical deficits, he may experience vertigo, an inability to walk, due to
dizziness.

There are symptoms that can occur that can physically be disruptive for the veteran.
Cognitive veteran, cognitive deficits not being able to think or problem solve,
negotiating issues, simple things they may they were able to workout without
problem, they may experience difficulty in that. And then psychosocial deficits if they
are working at that time or if they are in their household inappropriately dealing with
people inappropriately behaving in public and not communicating well with those
around them, getting into arguments, just being generally difficult You will see these
signs. A lot of times the vet because it's so hard to for them to identify there is
changes, it could be miss construed they are being assholes, sorry for that, being very
difficult. It may just be a symptom that they are experiencing. The symptoms can be
resolved in a few weeks, it may take months or may never be resolved.

So it just it's very individualized and it depends on each person. And how they recover.
And then we have a severity rating. For the severe TBI. And that is Glasgow is 8 or
less So this person was in a coma for an extended period of time They may have been
in a vegetative state. This is a touch and go person. A lot of times when they are at
this state the deficits can definitely be permanent. So this is these people normally in
terms of rehabilitation specifically when we talk about vocational rehabilitation, may not
join the workforce again. And at this point that focus shifts from not necessarily
vocational rehabilitation but quality of life and we will discuss that later on in the
webinar. So here are points to remember

TBI is a signature injury of our last war TBI may resolve quickly but may be
permanent. Symptoms of TBI usually fall into three categories, physical, cognitive or
emotional.

So we are moving on. Here are more points. Brain injuries, severity is classified by
signs and symptoms at the time of the original injury A lot of times Veterans come in
for a rating change and they are talking about new symptoms and they attribute it to
the TBI but they make the rating decisions and they are focused on and looking at the
symptoms at the time of the original injury and not new manifesting injuries. So that is
something to remember. And that the majority of TBIs are mild. So when we look at,
if we take all of this into account, often times we don't know who this person is, you
know, not only do they have they experienced physical changes, you know, problems
in their walking, talking, control of muscles, vision, hearing, speaking, all can be


                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                         9
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



effected physically, we are looking at emotional and behavior and personality changes.
It's hard on families and caregivers because they may not know who this person is.

Now, there was a couple of incidents where I had caregivers come in with Veterans and
we talk about these emotional and behavioral and personality changes. And in some
circumstances the caregiver may like the person that is before them now post injury as
compared to when they, you know, when they didn't have the TBI.

So I mean, in some cases, the caregiver is saying actually this person is a much more
decent person. On the other hand, there are issues where the caregiver comes in and
they can be very enabling and a barrier sometimes because they may shoot for the
stars as to how this person is having a debilitating issue as a result and their account of
the issues may not line up medically, you know, so it's always a concern either way it
goes. But for the most part, the person has changed a lot and the changes are the
result of the head injury. So this is something to consider, changes of personality
implies that there is an alteration in the person's attitude, patterns of behavior, their
reactions to events may actually be different than it was before The changes
sometimes they are very often times they are very apparent to those around the
person. So the caregiver and the family, they can pick it up quickly. There was
research done on family stress following a TBI indicating behavior and personality
changes in an individual who experienced a TBI is stressful for caregivers more so than
the physical disability And this is because, you know, in part of the duration, of the
emotional and behavioral change, at some point physically, hopefully a person gets
better, but when we are talking about differences in personality and emotional changes
and cognition, this there is no way of gauging how long this is going to be present, is
this permanently who we have now as a family member? And this can have such a
great impact on the family system. They found that caregivers who report high levels
of cognitive and behavioral problems, they found that they tend to have, I'm sorry, they
tend to have higher levels of unhealthy family functioning.

So this family function may be it was healthy prior to but now they are dealing with the
emotional and the behavioral cognitive differences in their loved ones and the family
function changes. So again there are no absolutes in all cases and they are actually all
cases are individualized and there is really no cookie cutter way of identifying who is
going to be like what.

Now, I mentioned before that or mentioning earlier on I work for polytrauma.
Polytrauma is a word used to describe, and I will move to a slide, describe multiple or a
combination of wounds that impact more than one physical regular region or organ
system. When we have Veterans come in, their issues are poly traumatic so we will see
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                        10
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



TBI and see PTSD and we see a lot of musculoskeletal issues. If they were exposed to
agent orange we find a lot of so many issues that result from the agent orange. So for
us and in this area it's important for us to have a collaborative relationship with
polytrauma, the unit, mental health This is the message that I really ultimately would
like to send to all of you out there, that collaborate, collaborate. We found in this area
the eastern region that a lot of our Veterans, we were sharing, there was a lot of
overlap. And because, you know, trying to connect the dots and trying to provide the
most wholistic treatment possible, it's important you understand all the services that
your person, the person that you're serving is reserving and find out if there is overlap.

On the front end of things when they come in I have them sign a release of information
for each entity I think that I may need to communicate with. And this is an extra step.
Who has the time for all of this? I don't know. I don't know how I have the time. But
because everyone is committed to providing wrap around services we communicate
regularly and have a formal meeting once a week or once a month to actually staff all
of those and find out who is overlapping. It has helped to save so much time and give
us much more positive out comes when it comes to helping a veteran become
rehabilitated

We are actually piloting this with TBI patients right now where we have a wrap around
service with their careers, not just jobs but careers and I'm happy to say it's working.
It takes time but it's actually working. So back to polytrauma, it describes the multiple
conditions that may arise. So a person who may have TBI is not unlikely they won't
have a couple with post traumatic stress disorder, anxiety, depression, mental health
issues and multiple skeletal issues. So due to the increased likelihood of exposure to
high energy blast and explosion, most Veterans returning have issues and we have to
address them in conjunction with the vocational rehabilitation because if they do not
manage the issue it's difficult for us to go into avocational rehabilitation goal

At this point it's also important for us to look at what the veteran or what the person
needs. The caregiver may need to structure an environment that would enhance the
recovery process, the responsibilities may include teaching self control and self
structure to assist with the inhibition the person may exhibit. Teaching new skills and
provide over learning and repetitive teaching of practices, help to anticipate future
events. So there are a lot that the person has to take into account when they are
assisting.

I'm going to kind of start zooming along a little faster because the time is running short
quickly.


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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



Okay. So let's look at cognitive impairments. Cognitive, it's intellectual and mental
process of information. You see this in the inability to remember, there may be
adjustment difficulties There may be depression. Interpersonal conflicts and issues
with PTSD. And as the result of the overlap of the cognitive and emotional systems,
coupled with the un awareness they are exhibiting these behaviors, it can negatively
impact the rehabilitation process.

Here are some other cognitive symptoms. Attention, memory, we talked about that,
executive functioning, there may be a problem in decreased ability to shift from task to
task, problem in terms of planning, decision making, they may not be able to function
as independently as they once had before.

The thing with cognitive recovery is that the relationship focuses on managing the key
factors that contribute to the over all picture of the disability. So for example, the initial
stabilization of pain and sleep issues may improve with the individual's ability to
concentrate on cognitive interventions. So many patients with moderate injuries can
and for the most part can return to work and resume their responsibilities However,
they may require some assistance, assistive technology is one way to help and combat
cognitive recovery issues. Right now it's a big thing where we get into purchasing
iPads. For some it's not a luxury We are good at getting out if it's a luxury item being
requested or if it's an item that is needed. Again, that collaboration between
polytrauma, neuro psyche, mental health can help us determine whether an iPad is
something that would actually help them with their cognitive issues. But the key to it
all is that early education is really important. Kind of giving a person some ideas of
what they can expect when they are looking at recovery out comes They may never
recover to the points where they were when they did not have any of these issues at
all. But they can get to a point where through intervention that they are able to
function in a way that is not debilitating of life and not interfering with their quality of
life

So we have already talked about that and we can return to work at any time So with
the physical impairments, as I mentioned, they are prominent on the front end of
things. They are early part of the recovery process and they tend to slow down at least
one to two years post injury. But there is increasing evidence that functional cognitive
improves may continue 5 10 years post injury. So it's no absolute definite that it will
come to a screeching halt and that is it.

So points to remember, concussions can cause mild cognitive symptoms while more
severe injuries may have persistent and pervasive consequences. In the first few
months rapid improvements is the rule Compared to patients with mild to moderate
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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



TBI, fewer patients with several injuries return to work or independent living. Here are
facts about emotional difficulties, adjustment and behavioral problems.

Take note that pre morbid problems of previously before they had the injury had issues
with impulse control and substance abuse and family problems they are at risk for more
emotional I'm sorry for a traumatic brain injury. So following the brain injury one has
to deal with both pre injury characteristics as well as new and post injury behavioral
problems

For example, just being able to tolerate frustration can lead to agitation, use of
profanity, an inability to generally cope and you have to be mindful of possible
destructive behaviors that follows the inability to cope. And I'm going to go ahead and
give you guys, you can check out the rest of these kind of informative kind of tips a
little later.

I'm going to go ahead and skip on ahead.

So we are looking at what is the so what of all of this. What does this have to do with
anything? Well, besides the fact that these issues are debilitated to the veteran,
caregivers also experience issues. It may be very difficult if you don't take into account
they do experience displacement and isolation. For example, you know, our whole
purpose is to continue to keep the person integrated and transition well into society and
keep them active and social. But those people who take care of them as a result of
those disabilities that they are dealing with, they may fine that they are isolating and
they are spending so much time caring for their loved one that they are not really
taking care of their own needs and this is counter productive because we need them to
be healthy so they can better assist their loved ones.

So with the caregiver population it's not uncommon for people to feel alone or people
around them to describe it because they cannot hang out or cannot go They isolate
themselves because maybe they don't know how to deal with the behavioral problems
or the cognitive issues of the person they are caring for with a TBI So it may be an
issue where they are taking it upon themselves to not engage. So the changes that
occur physically, emotionally and cognitively and survivors of TBI can be overwhelming
for the veteran or the person who incurred the injury and also the caregiver

Also, as I mentioned earlier, it's essential to understand the dynamics that take place
before the actual injury. If the health of the family was precarious before the injury it
will be more volatile, there are adjustments the caregivers have to endure like
preexisting factors, relationship factors, this can have a major impact on how they

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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



adjust to the post injury issues. There may also which is common issues of financial
burden. Maybe the hospital bills are such and they are not able to really handle that
and healthy relationships, finances and life circumstances can actually impact any
relationship. So a couple with health issues like TBI it becomes even more of a
detriment to that family system. I want to take time to introduce these acts, 1986
theory of emotional reaction. Everybody re acts to things in a different way and I want
to introduce this to you because when we looked at people's reaction, to especially
health related issues, they go through a stage that is also almost like the process, the
grief process, stage one, 0 to 3 month, the expectation for the family members is that
there should be full recovery within one year.

So there is relief, shock, denial, depression, avoidance can take place during this. They
are hoping full recovery by one year. In stage to, you know, the recovery, the patient
at this point do not understand why have they not gotten better yet, what is going on.
If they try a little harder they would be all right. So this becomes a problem. And they
progress through the stages and get impatient and feel trapped possibly. Experience
sadness and mourning once they realize it has been a while and nothing has changed,
and reorganization of the family system has to take place. If the family makes it There
is no absolute and no one goes through all of the steps, that I may go through all of
them or skip one and go to the next. But it's to be aware that throughout this process
there are stages that the person with experience of TBI goes through but especially the
family when they are on the outskirts or not on the outskirts but when they are
experiencing this whole experience, they go through these stages And then as a result
they may have guilty feelings and feel like they should feel better or resentment. Like
all you put me through before you were de played and all you put me through and now
I have an issue where, you know, now I have to take care of you. So just FYI being
aware of this.

Once the person comes to the realization that my loved one is not doing well or the
person is realizing they are not going to be that same person they were, it's important
to start establishing quality of life. And I want to briefly introduce to you the health
related theory, conceptual theory of quality of life. So during the process of vocational
rehabilitation, helping people restore meaning to who they are or who they can be
professionally is really very important.

So restoring normalcy can take place through professional development. People have
meaning and establishing new meaning for their life. And maintaining a good quality of
life in spite of health issues So I would like to just talk a little bit about that because it's
very relative this model was revised and it was revised because they wanted to look at
rehabilitation from an ecological approach and there are layers when you are looking at
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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



the quality of life and the five they considered was biological functioning, which is the
actual functioning of the body, the cells, the organs, looking at the resilient and the
vulnerabilities and they look at the symptoms that result from the conditions that the
person has incurred They are interested in the functional status, can the person still
perform the task on several domains? The general health perception is looked at How
does the person view their health And then over all they are looking at the quality of
life. So from the person's perspective, they are interested in seeing how do they
perceive, the person who is experiencing the TBI, how do they perceive their quality of
life

So specifically in terms of relating to quality of life, the interesting is in how health and
illness and treatment effects the quality of life. So according to this in 2010, HR QOL
had a personal perception of quality of life and it's based on the individual aspirations
and expectations which is really filtered in terms of how that person who was
experiencing the TBI, how they view it. It's through their own world view that their
session is. So it's certainly an internal construct. I think that, just to give you more
information on why it's relative, I think that and but a person's quality of life is so
individualized. So what I think may be quality of life the next person may not think that
there is quality of life.

From a rehabilitation professional perspective, it's important to figure out what that
person was experiencing, the trauma considers to be quality of life. So there are two
ways to determine it, one is external assessment and this is usually evaluated by the
person who is giving the care to the veteran or the person who has TBI or the done by
the professional So and the rehabilitation context it's a measure of the degree of the
goodness of daily living.

Now it may be very important that this assessment takes place from a professional
perspective because often times it's needed to determine eligibility and benefits, so it
has to be done from that perspective and also the caregiver also has a perspective of
quality of life as compared to post TBI.

The second type of appraisal of HR QOL is internal assessment and focuses on the
individual's perception of quality of life and directly ask them, do they think they have
quality of life. And it takes into account their performance which is filtered through the
personal aspiration and own standards. So the point that rehabilitation professionals
have to be aware of is there are many factors that can come into play when assessing a
person's quality of life. For example, individual experiences with healthcare system. In
our from my example, what is experience like with VA. Some of our Veterans are


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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



angry with government and angry with circumstance so we look at environmental
issues when we are considering that.

And then there is the degree of economic and self sufficiency and opportunity and
quality of life. So you look at experiences and opportunity and can be key when we are
talking about the influence on perception. And it can color the rehabilitation process.

I bring all this up to say that when we are looking at quality of life, we have to consider
grief, loss and grief. So in an attempt to connect the dots, we understand how the
impact of cognitive behavioral and emotional issues, how they can affect the person
with the TBI and the caregiver. And the family system And we understand the
importance of addressing health related quality of life issues. However, as, you know,
all those who are attending you know the issue of rehabilitation can be very multi
faceted and as avocational rehabilitation professional, we have to take note that all
parties involved are experiencing some form of grief and loss. Those involved in this
recovery process will go through the process of trying to make sense of what is
happening. What now? This issue can certainly color that.

So historically there has been studies of loss and grief to understand an individual faced
with a disability but now we are getting to a point that it has to be attended to because
depending on the attitude and the perception of the disability, you know, do you see
this as have you accepted the disability? Do you feel like there is life after the
disability? Do you feel that it's over? If the attitude, regarding the disability, can affect
the approach to the recovery process, so, in essence, if we don't attend to it and we
don't look for it, not necessarily counsel because there is only so much we can do, but
attend to it and realize it has relevance and it does have a place in the rehabilitation
process Where am I on my time? Okay.

We will keep moving. Okay.

Hello.

Can you hear me?

Yes.

I was going to say it's 2:00 and we have until 2:30.

Okay. Thank you so much.

We want to allow time for questions at the end.
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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



Okay. So I need to go for about 15 more minutes.

Okay. All right. So, yeah, when we look at grief and loss, it's very important that we
take it into account. So from the perspective of the caregiver, let me I think I
skipped something going back a little bit. Sorry.

Okay. So from the perspective of the caregiver, quality of life can be complex and
difficult to define due to anxiety, depression and burden. Sometimes it's very hard to
even think in terms of grief and loss because you have this person still there, they are
not gone, they have not transitioned, but you're still feeling that they are not the
person that they once were. You are grieving the fact that, you know, this person is
lost and you have to get to know and understand the individual that is before you now.
And that is sad.

For the person experiencing the TBI, they lost a sense of purpose. They are trying to
gain their footing and they are often times managing physical issues Who they once
were doesn't exist Their roles have changed within the household. Perhaps the person
was a very astute and taking care of finances and a go getter and the rock and now
require assistance and from Veterans, the person went away for deployment and they
left and that person or the person or wives and husband's they left behind assume
responsibility for the day to day run of the household, the bills and making decisions, all
of these things but when they return they no longer have the responsibilities because
they cannot. They have to figure out what is their role within their family system. Now
their role cannot be the same, they are experiencing the loss of that. So, you know, I
want to briefly compare the stages of grief and I looked at the stages of grief and they
really truly did parallel the process. The stage process when recovery is taking place
That is denial, anger, bargaining, depression and acceptance They have to run the full
gambit because they have to figure out what am I going to do post TBI. They are
frustrated and angry and confused and seeking answers.

So in this case, in this case, the Ben Sira 1983 suggested the better control one has in
terms of resources the more likely they will experience successful coping. So the
message from this is that there has to be referral. We are in no way expected to
operate out of the side of the scope of our practice by providing grief counseling. I
mean, if that is part of the mental health is part of what you do also so be it. But for
those of us who are specifically working on rehabilitation out comes, it may not include
providing mental healthcare as well. Referral is key. Collaboration is key. Vocation
rehabilitation, professional rehabilitation and should utilize the referral resources and
assist the individual survivors and families navigate through emotional trauma because
emotional trauma is a byproduct of traumatic brain injury. So this is key. Moving on.
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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



Okay. So successful reintegration of a person with a history of TBI into the previous
family struck THUR structure is very essential. Do we have a roadmap to how it will
be accomplished? We don't. However, it will be accomplished through collaborating,
through appropriate referral systems and getting together with people who are also
responsible for transition. Because we can become so very tunnel vision when it comes
to our responsibility and our scope of practice we can kind of miss all of the other
pieces that can determine whether our rehabilitation process is going to be successful
or not. So you have to ensure that that person has all the wrap around services
necessary to negotiate reintegration in the family and community and professionally, all
the pieces, there is no one stop shot but understanding that you do have support
systems out there, so the big picture of why, why are we going through all this? What
are the implications for me as avocational rehabilitation professional? Well, just a cap,
responsibility for us, would be to involve the caregiver and the process as early as
possible.

It's important that you don't make this rehabilitation process, that you don't take the
focus off of the person that you are actually serving but that you integrate and you
recruit those family systems and that caregiver in that process earlier on so they
there is more clarity and there is more ownership and there is less convoluted systems
when they start on the front end and can be very helpful to the rehabilitation process.
Also, being aware of that they can harm it, you have to have your antennas to figure
out where the person fits and before you bring the person in the relationship it's good
to get feedback from the person that you're serving as to what they believe their
relationship is like with the caregiver It may be harmful to the process Maybe they
don't want to be part of the process. So it's important that you get a handle on that.

The other responsibility is to demonstrate empathy and acknowledge that not only the
veteran or the person with TBI not only are they experiencing issues of loss, grief,
confusion, anger, disenchantment, these feelings are normal.

Also, a lot of care givers work through feelings regarding this process. It may be
necessary for you to have a list of referrals for the caregiver. But allow them to talk
about that, you know. Educate them regarding the TBI as much as you can. And
certainly educate them regarding the rehabilitation process. Identify your wrap around
services, polytrauma, support groups, all of that, and you have to have a working
knowledge of that. I like to have handouts and I like to encourage them to participate
in support groups because it's really healthy to actually interact with people who are
actually experiencing the same thing. And they get to see that there are their
situation is normalized and they see themselves, you know, by looking at this is where

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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



the stage that I am but eventually maybe I will end up being in this stage So it actually
fosters hope.

Also identify other programs that the veteran is at or the person is engaged in. Where
are they getting their services, what are they working on currently Understand overlap
So you can maximize the rehabilitation experience. Overall the veteran and caregiver
family should be assisted in obtaining a realistic expectation and also pursuing realistic
goals.

So taking away, step one, validate and normalize. Step two, you want to educate and
step three collaborate. Thank you all for joining me. Are there any questions that I
have?

Wow, Tammara that was awesome. Thank you so much I think the first question we
have in the chat box is the Glasgow used throughout the U.S. and used for civilians as
well?

Yes, it's a commonly used scale. It is.

Okay, so inviting additional questions here. Can you address various cultural factors
that might be relevant?

That is an interesting perspective Culturally, you know, as you know cultural
competition is a very hot topic. I make no assumptions regarding cultural factors.
What I consider to be culturally relevant may not necessarily be what they believe is
culturally relevant. So I would ask, I'm an African/American person, culturally there are
certain issues that I would ascribe to me being an African/American and culturally in my
family with nursing care and it's inappropriate, you make accommodations at home,
that is out of my home, it's very community oriented So being able to address the issue
in a way you can speak openly. Sometimes you have issues where different cultures do
not believe you share your person business or burden on others and handle it from
within. So culturally I think is an issue where you ask them what is normal. And what
they are dealing with. I try not to ever make any assumptions regarding it. However, I
could make some inferences like if we know there is a certain culture or background
that has different has issues and substance abuse, you know, if this is prevalent, this
could impact a whole lot of the process because it's very hard to work rehabilitation
goals when you have issues where there is a drug abuse, alcoholism, even in terms of a
certain culture and minority populations financially They may have issues or situations
that require so much more on the front end of things before you can really approach


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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



avocational or rehabilitation goal. So I think it's important to figure out what they
consider to be a culture issue for them. Next question.

The next question is: Do you know the divorce rate of married couples following a
traumatic brain injury?

I don't but I know it can be high. I had a colleague who just did research on that.
Especially if the relationship was not healthy before the traumatic brain injury For
Veterans in general, the divorce rate is high Military has a very hard impact in general
on marriages. But the actual number I don't know. I apologize.

There was somebody that had their hand up and then now they don't. Does it mean
you got your question answered? Here is another question, do you see any trends in
occupations and we will come to Karen next after I answer this one, do you see trends
in occupations with people who have traumatic brain injuries, realizing that there are
many degrees of TBI just asking in general?

Let me see if I understand it. Are there any trends in people who have TBIs realizing
that there are many degrees.

Any trends in occupations, recognizing that, you know, every individual is different and
degrees of TBI and maybe there is not an answer to the question.

The degree in TBI, I am not sure how to answer it. When they get their assessment
usually and see the physician, they are notified of the degree of TBI that they have
when they come by the time they get there to see me, they know whether they have
a mild TBI or the degree. They are pretty much aware of it. They are actually pretty
well versed on their deficits and can verbalize and say, hay, I have problems with
memory. They are very versed on it. So I think that they are aware of it I'm not sure
if I'm answering that question appropriately. If I'm not

Okay. The no follow up with an additional question You're a technical person, and my
question is Celestia, Karen has her hand raised and I'm not sure how to acknowledge
her.

Hi, Jill, other than acknowledging her verbally, there is no way to acknowledge her.
Karen, if you have a question please type it in the chat room.

Excellent. I thought there was a trick I didn't know how to do. So while Karen is
typing, although I'm going to look really quick and see if she has, I have not seen her

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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



question come in yet, so the next question is are there specific treatment plans that the
VA uses to help people with TBI?

No, there are no specific treatment plans. We do have templates that we use to write
treatment plans. Again, because they are template I don't like to use them because
every one issue is different. Admittedly I don't believe that our treatment plans are as
individualized as they can be. It really is upon that vocational rehabilitation Counselor
to take the steps necessary. For me, when I know a person has a traumatic brain
injury, we have access to a system called Capris and the system allows us to look at the
medical records of the individuals because people sometimes are not as transparent as
they should be and we don't understand what is going on If I go into the record and I
see that there are issues and this person has not mentioned them to me I will bring
them out and I will address those issues. And if warranted, as a part of all of my
treatment plans, they have to be especially if they have a TBI they have to keep
medical appointments and be involved in counseling, regular counseling and it's hard
for them not to because they have so many behavioral issues that they need to be in
counseling or under some forms of medication. So there is no cookie cutter one. It's
just it depends how thorough each rehabilitation Counselor is.

Okay, the next question is: Do you know if group work is known to be helpful with
family members to address grief and loss?

From report of individuals, I found that those who have family member whose are
involved in group therapy who is wholeheartedly involved through the process, our
outcomes are much greater, much, much better And their account is they do help
From sometimes from the veteran's perspective, depending on where they are in
recovery, another disability they present like PTSD, there can and will be resistance
sometimes to group work. A lot of them hate to do it because they feel it's rehashing
everything all over again. I've heard more recent complaints has been with the V A
hospitals, we have Vietnamese people and they don't want to talk to them and all kinds
of reasons why perhaps they do not want to participate in group work and many of
them go and are not opposed to individual counseling but to be in a program from my
perspective and to be successful I make sure I make it a part as a requirement as they
go through vocation rehabilitation.

The next question is: In your experience, do you find the high rate of substance abuse
in the population of individuals with TBI?

No. I wouldn't say a high rate. Usually I have a red flag, I have an advantage over
most of my colleagues because I'm a certified substance abuse Counselor. So when I

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                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



go into treatment plans and vocational goals, I can quickly pick up that there is
something not quite right. So when I have individuals who I suspect, you know, and
it's very hard to tell because you don't see them very regularly and when you do see
them, you know, it's so infrequent that it's hard to get your base line together. But if
they are totally not compliant in their vocational rehabilitation goals and, you know, I'll
look and dig a little deeper. I would not say there is a high, most people who have
those issues, they usually do not have the where with all to pursue vocational
rehabilitation. They are like hanging out. Those who do come in and they have that
going on, then in my treatment plans they have to be at a place where they are
functional, meaning they have to have so much time actually before I pursue the
vocational goals because there is no way we can address vocational goals if they are
high or drunk. I have them resolve those issues. I like to deal with them when they
are on an outpatient basis now and maintaining sobriety. So I'm not saying there are
not very high number of Veterans with these issues, by the time they get to vocational
rehabilitation they try to be more focused.

Sure. The next question is: Are you aware of any studies in marriage involving a
spouse with TBI?

No, I'm not; but it would be a good research area.

What about are you aware of any correlation between Alzheimer's and TBI?

No, I'm not.

These are some tough questions.

I should be jotting them down and we could be taking notes.

When I graduate.

Any other questions? What about dementia, correlation between dementia and TBI?

For those severe.

Are you aware of any?

I'm not aware of any studies But I know on the front end of severe TBI dementia could
be there and resolve, it can resolve itself over time. But in terms of studies, no.

Here is another one: What type of resources can the Federal Government provide to
help with these clients?
                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                        22
                         073012 Webinar Transcript– Traumatic Brain Injury and Coping with Loss and Grief, VR Implications



Okay, well, I did attach a page of resources. The resources that I have,000 in from
the Federal Government are from avocational perspective and for Veterans and most of
the resources take place within the veteran affairs or veteran administration system.
But I can research that and e mail it to you and maybe you could e mail it out to all the
participants if they are interested in it.

Sure. Absolutely, yes Any additional questions before we move towards wrapping this
awesome webinar up? We always know when there are lots of questions like this, it
means it's been very helpful. So I'm going to move towards wrapping it up I want to
thank you so much, Tammara, and want to thank all of our participants as well. Just a
couple housekeeping things, so a transcript of this session along with all of the
handouts, it will be posted on the TASE website within two weeks and I belief,
believe, Celestia will provide you contact information for the TASE information. I want
to remind each of you to complete the evaluation of today's session, your feedback is
very important to us, and that is the only way we know how to make things better.
And it's also the only way that we know what you really liked and how we met your
needs. I'm also going to put the link to the evaluation form in the chat area which I
think is already up there So you can go directly to that and fill that out. I want to let
you know this session has been approved for CRCC credits and you should have
referred or should have received instructions in an e mail prior to this webinar, so follow
those instructions And most importantly remember that if your questions were not
answered today, please contact the southeast TASE center. Again, TASEsoutheast.org.
And, again, thanks to each of you for your participation today and Tammara for your
awesome presentation.

Thank you so much.

We have one more webinar in this series coming up, and it's actually on September 6.
And it is part four in the four part series. So if you are interested in this topic please
join us it's implications of working with the families of individuals with TBI. So thanks
again and everybody have a great day.




                      Phone: (866) 518-7750 [voice/tty] • Fax: (404) 541-9002
                     Web: TACEsoutheast.org | Email : tacesoutheast@law.syr.edu
                A Project of the Burton Blatt Institute (BBI) at Syracuse University | bbi.syr.edu
Funded by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Grant # H264A080021
                                                        23

				
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