Below is some more information on Traumatic Brain Injuries such as Karen's. As you will see, Karen has some, but not all, of the possible symptoms. Different people with TBI can show very different symptoms.

Following the TBI Overview, there are some comments from Karen's VR Counselor, Jack, about her situation.

Traumatic brain injury happens when the brain is suddenly pushed against the skull and damaged. Anything that damages the brain can cause a traumatic brain injury, but the most common traumatic brain injuries happen when the head is suddenly slowed down, such as in car wrecks, falls, or diving accidents. Traumatic brain injury is a very complicated disability - people with similar accidents can show very different symptoms because the injury may happen at different parts on the brain.

In most TBI accidents, the person is unconscious for a while. Whether a person is unconscious for just a little while (minutes), or for a long time (weeks), after the person "recovers" they will almost always have some problems doing things. They may also have trouble keeping a job. Some problems are easy to see right away but others may not show up for a while (delayed onset). Generally, the longer a person is unconscious, the more serious the damage to their brain is and, therefore, the worse the person's problems will be.

However, even if a person remains conscious or is only unconscious for a few seconds, there can be a brain injury that causes small changes in the person's feelings, thoughts, and behavior. These small changes can sometimes cause problems for the person and their family.

Traumatic Brain Injuries are one type of brain injuries, but there are other ways the brain can be damaged, such as a stroke. A stroke happens when blood flow to part of the brain is blocked for a while by a clot. Without oxygen from the blood, part of the brain will be damaged. Other medical problems besides strokes can also cause brain injuries.

Because the brain is so complicated, an injury to the brain can cause many different types of problems. Sometimes it seems like almost any kind of problem could be caused by a traumatic brain injury. Here are some of the most common kinds of problems people have after a traumatic brain injury.

Memory Problems - TBI often causes problems with memory. A person with a TBI will forget things people tell them or forget where they put things. They may get overwhelmed easily if someone gives them a lot of instructions to remember at once. When they are tired, these problems may get worse. Because of this, someone with a TBI may get confused easily. In addition, people who have TBI may not remember skills that they had before the injury.

Speaking Problems -TBI also can cause problems with words and speaking, but the problems vary from person to person. For example, some people may not be able understand what someone is trying to say, and others may have trouble saying what they are thinking - they just can't "find" the words.

Personality Changes - Personality changes are also common in people with TBI. Families may feel that the injured person has become a "different person", as if the person who came home from the hospital is not the same person they used to know. Friends and families will notice that the person may get angry more often, may not be very organized anymore, may do things "on an impulse" all the time, may seem rude or inconsiderate, or many other things. When children experience a traumatic brain injury, the full effects of their disability may not show up until years later when they are teenagers. Some people get divorced after a TBI because of the personality changes.

Sexual Behavior - Some TBI survivors also show inappropriate sexual behavior. They may grab themselves or other people in sexual ways, or they may suddenly kiss someone in public. They may ask someone they hardly know to have sex with them. They may tell dirty jokes at the wrong time. In general, these kinds of problems are caused by trouble controlling their urges.

Impulse Control - Some of the TBI problems, like the sexual behavior problems, are caused by problems controlling impulses or urges. Most of us have impulses and urges to do things all the time that we don't act on. We may want to run away from a bad situation, or hit someone, or kiss someone, but we don't because we know it is not appropriate. Some TBI survivors do not realize what is not appropriate, or may not even think about it. They may just act on every urge they have.

Anger - After a TBI, people may get angry a lot and over what seem like minor incidents to other people. They may get mad about having to eat a salad, or the way someone looks at them, or the fact that people keep telling them they are different since their accident. Or they may cry a lot.

Future Accidents - After a TBI, many people are clumsy for a while and have to relearn some basic skills like walking and writing. This means that someone with a TBI is likely to have more accidents and possibly get a second TBI. In addition, the possible memory and thinking problems can increase the chance they will have more accidents.

Remember that these are possible effects and not everyone who experience TBI will demonstrate them. Also, each person will show some unique problems. For instance, Karen was right handed before her accident but was left handed for several months after the accident, then she became right handed again.

On the job, a person who has survived a TBI may not seem to fit in with other people. They are often not as self aware as other people - they may not realize how they are acting, what is going on around them, or when they are interfering with other people's jobs. They may also have trouble reading social situations, such as telling when they are annoying someone, or when someone else wants some time alone. These are things most people do not say directly, but show by "body language" and tone of voice, which TBI survivors can have a hard time interpreting.

Because many TBI survivors can have some trouble learning new tasks, a steady routine at work is often very important to them. They will generally feel most comfortable if they are doing the same type of thing every day, in the same place, at the same time. They may not deal well with jobs that involve a lot of changes and "thinking on your feet". This may make them appear clumsy or confused when they are trying to deal with changing situations.

TBI can also cause emotional problems for people. They may get depressed easily, feel isolated from other people, and not want to do anything. They may get angry and irritable easily and lash out at other people. On the job, a steady routine can often help them avoid these mood problems.

Jack Greene
Karen's VR Counselor

There is also a long version of these comments

I wasn't originally interested in rehabilitation. I was going to be a Nuclear Engineer, but I couldn't pass Calculus. I fell into VR counseling instead, but it fit for me. My personality is made for this. I enjoy the flexibility of being a VR Counselor.

A vocational rehabilitation counselor (VR Counselor) works for state government vocational rehabilitation agencies. He or she helps individuals who have mental and/or physical disabilities (clients) to find, get, and keep jobs. The counselor plans, organizes, and implements individualized rehabilitation services for the client. Usually, a VR counselor has a Master's Degree in Rehabilitation Counseling or a related field.

There are many types of counselors, and we work in many settings, like job service, crisis settings or hospitals. But VR counselors, I think, have more flexibility and can adjust our method to achieve employment outcomes. We are the most outcomes-based program I've seen, and it's because of language in the Rehab Act - which is very specific about what we are supposed to be doing.

Even our VR coding system - the numbers associated with progress through the VR system leading to successful employment - is designed to encourage effectiveness. And there's a certain independence for VR counselors - I determine where I go to get my job done.

I am a morning person so I try to come in early get all the paperwork out of the way (there's always paperwork!). I start seeing clients at 9:00 AM and continue for the rest of the day. And I see people in a variety of settings besides my office - different facilities, homes, jobs, where ever. Recently I became primary VR contact for a medical rehabilitation center working with people with spinal cord injuries, with strokes, or with general orthopedic disabilities. In addition I see people with traumatic brain injury and learning disabilities.

I've got to say Karen is a brave young woman. It takes a lot to do some of the things she has done, initiating change and such. She moved to Missouri on her own, she quit McDonald's when it didn't work out and found another job, and now she's willing to strike out in a completely new direction. Those are scary things for anyone.

I'm not too surprised that she's had some problems in fast food, given the problems people with TBI frequently have. There's an awful lot of social interaction working in fast food places, and that can be very distracting for someone with TBI. And, while there are routines, you also get moved around between job tasks a lot in those jobs. Plus, your work schedule and work hours change all the time in fast food - you may work morning shift and then find out you have to be there the next day at five p.m. That's not great for someone who needs routine like Karen does.

Looking over her last IWRP, I think we should do some more exploration of options with her than was done in the past. There is even a note in her psych eval (psychological evaluation) from '97 that she could be doing more than she would working at McDonald's. At the time, I think, everyone had already figured McJobs was what she should do, but now we might take some more time to rethink her options.

The psych eval also makes a point of mentioning how well she handled herself in the interview. Her social skills are there, no question. She presents herself well, understands the dynamics of social situations. These are things you always look at to estimate someone's potential for various jobs, and she has a lot of possibilities open to her with these skills.

I know she's interested in a clerical or secretarial job, and that could work. The psych eval mentions that she keeps her own check book, so her basic math skills are there as well. I think we should evaluate her on that, see how well it will work out. We might have her job shadow someone, for example, and see if she still wants to try that after a couple of days. And maybe that won't work, even then, but we'll keep looking. Karen seems real motivated to find something for herself and as long as she is willing to pursue it, we're going to keep exploring possibilities.

So Karen is ready to start some changes in her life, which is great. It's up to me to help guide her through her choices and decisions, and help her find a situation that she'll find rewarding.

End of content, navigation links follow