Podcasting, rehab progress and post-injury purpose

Cognitive Rehabilitation Therapist, Natalie Mackenzie, and Neuro Occupational Therapist, Dr Sally Martin-Young illustrate how a top-down therapeutic approach and collaborative working using Podcasting as a therapeutic vehicle helped to build brain injury awareness, post-traumatic growth, and vocational opportunities for a gentleman with anosognosia 5 years post-accident.

“Bye now, nice to meet you”, our new client cheerily waved us off as he shut the front floor behind us. Dressed smartly, sat at the kitchen table with his laptop and phone, he had assured us how well he had recovered from the road traffic accident he had been involved in five years ago. He thanked us for our concerns but politely declined our rehabilitation services.

On the surface, our joint assessment interview had seemingly gone well; he presented as remarkedly unimpaired with no challenges or needs. He described how he had made an excellent recovery and was functioning on all cylinders once again at home, at work, in sport and within his social circles, and had been doing so for quite some time.

However, armed with the knowledge from his case manager and others assessments and reports, we left the property a bit stumped. This gentleman had anosognosia. He had absolutely no awareness of his brain injury needs; something very common in this severity of injury. 

This phenomenon is described in the neurology literature as the ‘frontal lobe paradox’.

Our client was able to mask his brain injury impairments well on a superficial level and he had good face validity during our assessment interview. Fundamentally, he ‘talked the talked’ but was not ‘walking the walk’. 

Neuropsychologist Dr Tracey Ryan-Morgan outlines the full extent of frontal lobe paradox behaviours in her conference presentation, ‘Decisions, Decisions, Decisions – Where the Frontal Lobes Meet the Mental Capacity Act’ (2019):

• Full of promises with no follow through.
• Difficulty translating intentions into actions.
• Challenges with initiating, planning and organising activities. 
• Schedules and diaries back-to-back; forever changing appointments with deadlines being constantly shifted. 
• Impulsivity.
• Jobs being started but not finished. 
• Challenges with flexible or abstract thinking. 
• A dichotomous style of thinking - everything being seen as black or white.
• Difficultly monitoring and evaluating actions or behaviours.

The brain’s frontal lobe is involved in regulating higher level executive function, i.e. abstraction, conceptualisation, judgement, problem solving, planning, organisation, time management, impulsivity, inhibition, emotional intelligence, self-motivation, initiation and insight. Furthermore, executive function underpins social cognitive communication, social intelligence, flexibility and behaviour.

Our client’s vocational roles pre-accident were undoubtedly cognitively demanding and required a high degree of executive functional ability. Many of his roles were also likely to demand sophisticated executive skills such as multi-tasking, creative and critical thinking and reasoning, adaptability and metacognition (i.e. self-monitoring, self-evaluation and self-regulation).

Hoffman (2013) describes a greater or lesser degree of the presence of frontal lobe paradox follow brain injury despite the location of brain lesion. Hence, the damage to his frontal lobe would without doubt impact upon these higher level functions somewhat. 

So where on earth do you start with someone who has absolutely no insight into their brain injury needs this many years post injury?

We both concurred a 'top-down’ therapeutic approach was required in this instance. This client-centred, holistic approach focuses foremost upon abilities and strengths as opposed to a 'bottom-up’ approach based on the bio-medical, impairment focused model that tends to highlight what a person cannot do.

We did not want to point out our client’s needs at this stage and risk him feeling despondent, disempowered, and demotivated to engage with us.

Considering occupational science principles, we pondered what would be the most appealing and meaningful occupation (or activity) to our client that would likely have the most impact upon his motivation and engagement in the therapeutic process as whole.

What occupation would be congruent or ‘match fit’ (Law et al, 1996) with his self-interests, values, volition, and capabilities?

Occupations are an umbrella term for all the everyday things, tasks, and activities that we do that occupy our self-care, domestic, work, educational, social, leisure and relaxation time during the day and throughout our week.

Essentially people are ‘occupational beings’ who have an innate need to fill and balance their time and live their life in purposeful and meaningful ways despite any health or environmental barriers. Once engaged in meaningful occupation, a person’s functional skills and abilities may develop and grow or can be restored or maintained. Positive health and well-being thus ensue (Wilcock, 2007). 

As therapists, we identify what is important to our clients, and embrace their previous identities, habits, roles, and routines which provides stronger therapeutic relationships with the client and their family. The client's most meaningful occupations are then analysed for therapeutic application. Once the client is successfully and happily engaged (often with some modifications and adaptations, the use of compensatory strategies or through scaffolded environments) they are likely to respond more positively to rehabilitation.

This positive 'I can' attitude then promotes opportunities to introduce the building of functional skills (motor, sensory, cognitive, psychological and social), healthier habits, structures and routines in other life domains and environments. A sense of purpose, meaning, happiness and self-identity emerges which ultimately enables the person to adjust and come to terms with their injury, disabilities and life changing circumstances over time.

Jonsson et al. (2001) propose a healthy and ‘engaging occupation’:

• is infused with meaning and purpose  
• involves intense participation 
• is structured and performed routinely and over time 
• consists of a set of activities all connected to each other 
• is performed beyond personal pleasure  
• involves a community of people who share a common commitment

One thing that had stood out during our initial assessment, was our client’s ambition to create a Podcast. He had previous experience of radio presenting in a voluntary capacity so had some foundational skills upon which to build.

From our knowledge and research, we determined that Podcasting would be congruent with his self-interests, values, and volition, and was within his capabilities with external scaffolding and support. More importantly, Podcasting had the potential to embrace all the principles of a healthy and engaging occupation, outlined by Jonnson et al. (2001).

We set to work with the rest of our multidisciplinary team and, together, with the aid of a Podcast producer, we supported our client to compile a series of Podcasts about his accident and recovery as a truly client centred rehabilitation goal over the course of a year.

The Podcast evolved into an ‘engaging occupation’ which not only became a therapeutic vehicle for brain injury education, awareness building and self-discovery in action, but also as a means for vocational re-direction.

Engaging in the Podcast has helped our client to learn about his acquired brain injury and to start to develop an awareness of the impact of his brain injury and the strategies that can help improve his functional capabilities. The process has adopted a whole team approach and has provided valuable opportunities for brain injury education, the introduction of compensatory strategies, aids and cognitive assistive technology.

He marvels over the fact that he had not realised he even had a brain injury and has become so enthused to share his learning and experiences with others who have also sustained a traumatic brain injury, their friends and families and the wider public.

Moreover, his overarching goal is to now raise awareness of this hidden injury and help improve service provision on a national level by sharing his lived experiences. 

The Podcast series has involved interviews with healthcare professionals and doctors, staff from a brain injury charity, other brain injury survivors, as well as self-reflections from our client himself.

Subjects have focused upon vestibular function, executive function, fatigue, emotions, cognitive communication, the impact on others, hidden injury and service provision. 

Our therapeutic interventions within the Podcast studio have included:

• Exploration of different learning styles: visual, kinaesthetic, linguistic, interpersonal – examples include making visual collages to think in pictures; discussions and debate with ‘homework tasks’ to consult others and gather alternative views; use of music to alter mood and create distractions; use of scripts and topic lists; use of pictorial flowcharts to maintain focus to task.
• Allocating set time at the beginning of the sessions for our client to offload and to share news, stories and updates.
• Introduction of a wall mounted ‘parking board’ to capture and park flights of ideas, with time allocated at the end of the session to review any of these if still relevant.
• Working from a Podcast planner booklet.  
• Use of a white board and flip charts – to display a pre-prepared plan for the session that is ticked off as we work through the agenda points.
• Use of Otter.ai for real time automated notes and audio transcription.
• Links to a digital Trello board with action tasks.
• Prompts/reminders for task completion throughout the week via text and email.

One significant development was that our client started to develop intellectual awareness into his brain injury needs.

Crosson et al. (1989) devised a Pyramid Model of Self-Awareness that outlines three layers of self-awareness: intellectual awareness (the acknowledgment that a particular function is impaired), emergent awareness (the ability to monitor performance and recognise problems as they occur and implement strategies in action) and anticipatory awareness (being able to anticipate when an impairment will affect performance and independently implement strategies in preparation).

Insight is the ability to recognise one’s situation and act accordingly having planned for one’s limitations, whereas intellectual awareness, for example, is simply a verbal exercise where a person is able to state their problems but not plan in advance and act accordingly with the consequences of those problems. 

As an example, our client talks about the consequences of his brain injury and the helpful tools and strategies that can support his challenges within his acquired brain injury Podcast series. This is because of the intensive multidisciplinary neuro-rehabilitation programme he has received surrounding the Podcast thus far and is remarkable progress from where he started. 

Another area of development is his ability to self-reflect and there is progress in terms of his emotional blunting. For example, when listening back to some of his recordings and hearing himself articulate and describe the challenges he has faced, particularly in relation to the episode on emotions, he had tears in his eyes.

Equally, Podcasting has also provided opportunity for our client to re-learn and further develop his previous radio presenting and interview skills in terms of active listening, being articulate and expressive, and improving the cadence, diction and timing of his voice.

He has practiced various methods of interview, i.e. within the sound booth in the studio, via video links, and has hosted both individual and group interviews whilst out on location. When he is well-prepared and he is rehearsed, there is a marked improvement in his confidence, self-esteem and his interviewing skill set. 

He is now able to generate conversation and questions from a list of themes and topics which is what he did pre-injury on the radio. He is becoming less reliant upon scripts. He is a visual learner and has found the use of pictorial theme boards and collages particularly helpful. 

Furthermore, our client has begun to re-build his sense of self-identity as a ‘Podcaster’ and there is now the potential to establish new roles and goals. The Podcast has become a vehicle for future occupational interests and vocational prospects. It has become an important mitigating factor in reducing the negative effects of the debilitating process the brain injury has caused in stripping back his roles, self-identity, self-control and independence.

Due to his success in creating a series of Podcasts around acquired brain injury with plans afoot to broadcast his work in the public domain, we have been exploring the potential for our client to host his own regular Podcast Show. We have encouraged him to think about his Unique Selling Point (USP) and branding. 

As a result of the Podcast, he has acknowledged that he is slowly coming to terms with the fact that brain injury is considered a disability, and he did not even realise he had a brain injury before embarking on the project. He has even decided this could be part of his USP, i.e. “I’ve had a life changing experience… what’s yours?” 

What is important, and what makes Podcasting safe, functional and productive, is that the producer is now able to recognise our client’s executive and cognitive challenges and anticipate his cognitive fatigue. The producer will skilfully and subtly intervene and adjust the demands of the session accordingly. Podcasting is safe in this respect in that it differs from live radio.

Podcast recordings can be re-recorded, and interviews edited. If cognitive fatigue kicks in, recordings can be used as ‘place holder’ and re-recorded on a different day when our client is more refreshed. Work can be undertaken in manageable chunks and adapted according to need. There is no is pressure to perform on the day.

It has become evident our client enjoys the presenting, interacting and interview aspects of Podcasting. He enjoys talking to people and networking. He likes listening to and sharing peoples’ narratives. He is always listening out for what would make good story.

Ultimately, Podcasting has enabled our client to replicate the meaning and values within his previous roles pre-brain injury. For him, Podcasting provides:

• A deep sense of purpose being able to facilitate innovative interviews and create debate amongst listeners.

• A sense of credibility and professional reputation
• Opportunities to continue charity work that he finds rewarding and fulfilling; it remains that he can contribute and make a positive impact in the community. 
• Opportunities to keep abreast of digital media.
• The freedom of non-traditional employment that encourages his creativity and innovation.

It is unclear at this stage whether Podcasting will result in remunerative opportunities. However, it is possible, that if successful, there could be opportunities to build subscribers, advertisers, and sponsors to generate income.

In order to help launch the Podcast series on acquired brain injury and to help build his potential new show, we have been supporting him to host an exhibition stand at The Podcast Show 2024, one of the biggest international Podcasting events being held in London in May, coincidently during Brain Injury Awareness Week.

As well as a launch platform to raise awareness on this important subject, The Podcast Show is an ideal venue to network within the Podcast arena with seasoned professionals and global industry brands to build knowledge on how to acquire followers, advertisers and sponsors. 

In order to support people like our client to fulfil their time with meaningful and productive occupation that embraces their knowledge and expertise, upholds their identify, status, and values, that positively impacts their mental health and well-being, a top-down therapeutic approach that is embraced by the multidisciplinary team is key.

Time needs to be afforded to sensitively explore and identify engaging occupations that match fit, to help guide neuro-rehabilitation principles to build awareness and insight in brain injury.

Natalie Mackenzie is a Cognitive Rehabilitation Therapist and director of the BIS Services. Dr Sally Martin-Young is a Consultant Neuro Occupational Therapist and director of independent occupational therapy services, Live Life. Paul Cheese, producer at Relium X has been instrumental in making this project a success. You can find out more about all services at www.thebiss.co.uk www.livelifegroup.co.uk and www.reliumx.co.uk Thanks also go to the other members of the team for their input.

The Podcast ‘Thinking Ahead’ is being launched on Friday 17^th May on all podcast channels. We will also be exhibiting at the Podcast Show 2024 in London on the 22^nd and 23^rd May during Brain Injury Awareness week – so come along to find out more. Follow the show on all social media platforms at @thinkingaheadpc

REFERENCES

Crosson, C., Barco, P.P., Velozo, C., Bolesta, M.M., Cooper, P.V., Werts, D., & Brobeck. T. (1989). Awareness and Compensation in Postacute Head Injury Rehabilitation. Journal of Head Trauma Rehabilitation (4) 46–54. DOI: 10.1097/00001199-198909000-00008.

Fisher, J. M. (2000). Creating the Future? In Scheer, J. W. (Ed), The Person in Society: Challenges to a Constructivist Theory. ISBN 3898060152.

Hoffmann, M. (2013). The Human Frontal Lobes & Frontal Network Systems: An Evolutionary, Clinical and Treatment Perspective. ISRN Neurol. 10.1155/892459. 

Jonsson, H., Josephsson, S. & Keilhofner, G. (2001). Narratives and Experience in an Occupational Transition. American Journal of Occupational Therapy, 55, 424-432. 

Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. & Letts, L. (1996). The Person Environment-Occupation Model: A Transactive Approach to Occupational Performance. Canadian Journal of Occupational Therapy: 63 (1) 9-23. 

Ryan-Morgan, T. (2019). Decisions, Decisions, Decisions – Where The Frontal Lobes Meet The Mental Capacity Act.  Accessed: 20th^th April 2024. Available at: https://projects.swan.ac.uk/sasnos/wp-content/uploads/2020/01/Dr-Tracey-Ryan-Morgan-Decisions-Decisions-Decisions-%E2%80%93-Where-theFrontal-Lobes-Meet-the-Mental-Capacity-Act.pdf 

Wilcock, A. (2007). An Occupational Perspective for Health (2^nd Ed.). New Jersey: Slack.