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SEX AND REHAB – Tinder, escorts and an age-old taboo

The professionals helping to make sure sex is not forgotten in the drive to improve life quality after severe injury.

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Sex workers can play an important, if controversial, role in boosting confidence and quality of life for people with profound disabilities. Here pioneering sex therapist Tuppy Owens tells Andrew Mernin why it’s time to stop running away from the issue.

“Just because people are disabled, doesn’t mean they don’t have sexual urges,” says Tuppy Owens, who has spent decades helping people with disabilities enjoy sex and find love.

Owens is a sex therapist, campaigner, published author and former adult model. She is also founder of the TLC Trust, which helps disabled people to access sex workers safely.

Users visiting the site can browse a database of sex workers who have been vetted by TLC to check they can provide a safe and understanding experience for people with a range of disabilities; including those related to brain and spinal injury and neurological disease.

Tuppy Owens

TLC is closely linked to the Outsiders Club, also founded by Owens to help people with social and physical disabilities find partners, make friends and enjoy “peer support”.

After “helping a couple of disabled guys get laid” in 1978, she formulated plans for a club run by and for disabled people looking for friendship, romance and support.

The link between experiencing sex – via TLC – and finding love, possibly through the Outsiders Club, is absolutely intrinsic, believes Owens.

Crucially, sexual services can help to build the self-esteem and confidence needed to enter a loving, intimate relationship.

“If a disabled person feels nervous about starting a sexual relationship because they don’t really know what their bodies are capable of, they could go to a sex worker a couple of times so that they could be a better lover when they do find a partner.

“We don’t know how many sex workers are hired, how many disabled people use them or how they find them. Often their assistants or healthcare professionals will organise it for them because they are better [technically].

We vet both the sex workers and the people who want to join Outsiders to make sure the disabled people are safe.”

The legal aspect of helping disabled clients access sex workers is fraught with risks. At a very basic level, the individual must have capacity to make a choice about consenting to sex. But professionals looking to help clients visit a sex worker must of course consider a range of legal and other implications (as case manager John Walker explains below).

Owens’ mantra on the issue of legality is that: “It is illegal not to support disabled people to enjoy the same pleasures as others enjoy in the privacy of their own homes, under the Equality Act 2010 and the Human Rights Act 1998.

“This is great because when someone complains that they aren’t allowed to have sex, I can quote those laws and they have to go back to the person who won’t allow them to do it and say that’s illegal to stop them.”

TLC-vetted sex workers may visit the client’s house, offer services at their own accessible property or at a hotel.

In a residential care setting, Owens says, “there is usually someone running the home” that wouldn’t allow this sort of thing to happen on site.

“Care homes are becoming more interested but whether they would actually allow sex workers in the home is another thing.”

In terms of criminal law, the exchange of sexual services for money is legal in England, Wales and Scotland. A number of related activities are illegal, however, including soliciting in a public place, kerb crawling, owning or managing a brothel and pimping. Prostitution is illegal in Northern Ireland, meanwhile.

“People think sex work is still illegal in this country – even people who should know better,” says Owens.

Once the legal minefield is navigated, other challenges may arise, including the potential threat of emotional attachment issues.

Owens says: “If a person gets too keen on just one sex worker, we might suggest that they find another one because we don’t want them to fall in love. Obviously, a sex worker may have lots of other clients so there’s no point in getting too attached.”

Aside from mere pleasure, there are many other reasons why a person would choose to visit a sex worker. According to TLC, a common motivation for site visitors is to be taught what their bodies are capable of and how to please a potential partner.

Some users seek a “girlfriend or boyfriend” experience – pretending to be partners either in public in a non-sexual way or in the bedroom – or wish to lose their virginity. Others may be unable to achieve an orgasm alone, while acceptance is also an important factor.

TLC says: “Sexual expression may mean many things, and disabled people need to know that you will not be judged by your requests, however embarrassing you find them. People who provide sexual services have heard it all before, and are totally discreet.

“For many disabled people, just being in a warm set of arms, and having their bodies accepted, is incredibly powerful and helps to build your sexual confidence and walk tall ,or wheel tall, in the world

“Having your sexuality taken seriously without stigma or disapproval can be liberating and life-changing. For some, actually enjoying an orgasm at last can bring your life into balance.”

While male users may instigate the use of one of TLC’s vetted providers, women are advised to contact TLC first as it can be easy for them to “be lured by unprofessional guys”.

Owens says: “There tends to be more men looking for sex workers than women. With TLC I always tell women to ring me first so I can walk them through it. I want to be absolutely sure that they have a nice time – and that always works.”

An anonymous female user of services promoted on the site says: “Due to a combination of ill health and traumatic personal experiences, I had spent a long period of time avoiding physical contact and intimacy, but had reached a point where I felt confident enough to address the situation.

“I had many concerns, about safety especially, but I liked the way the website gave no- nonsense information and everything seemed very open…I was keen to work with ‘professionals’, as I thought that after all they knew what they were doing and also working with people with all kind of issues, disabilities and health issues meant they had experience of dealing with situations that might not be easy/ obvious for others to deal with.”

The woman was initially advised to meet a practitioner who offered a full body massage to help her to reconnect with herself physically; before considering taking the next step.

She says: “I was extremely nervous but the gentleman providing the service was kind, professional and at all times made it clear that I was able to stop anything that I did not like. In the end, everything went well and was far less difficult then I expected.

“Having taken this first step I then corresponded briefly with the second person I had been put in touch with and set up a booking. Again, the practitioner was lovely, caring, very open and had a great sense of humour and he made me feel safe at all time.

“Both experiences have been really helpful and, in some way, much less of a big deal than I thought they were going to be, in setting me back onto the path of being ‘physical’ again.”

Owens founded the TLC Trust in 2000 with the support of a disabled man who had reached his mid-40s without losing his virginity. Since then, scores of sex workers have been vetted and joined, with many happy customers along the way.

Among them was the young lady who wanted to buy herself a “birthday shag” for her 21st, and a man whose parents sought out a sex worker to help him have his first sexual experience at 38.

Owens would like to see disabled people’s desire to experience sex and love being taken more seriously by the professionals around them and society in general.

“Things haven’t really moved on in recent years, in fact I think they’ve gotten worse. Often people come to the Outsiders because they have been very lonely.

“Not only do they not have a good sex life, but they may have few friends, which is terrible. Even if they don’t end up finding a relationship they’ve been given the confidence to flirt and do other things that help to form relationships.”

Owens, who won a UNESCO award in 2015 for her innovative approach to sexual health and human rights, sees sexual services as empowering and positive to people with severe injuries – not shameful or something to be embarrassed about.

Could their costs therefore be factored into an individual’s care package? Owens would like to see this, although she is doubtful it will happen anytime soon.

“When you think about how much compensation a brain injured person requires, how much would they need to hire a sex worker [regularly] from when they were injured?

Obviously when they are younger, they would have a sex worker more often, maybe twice a month, then a bit less when they are 50 or so and less again when they are 80. It could be quite expensive overall.”

The prospect of sex workers becoming just another intervention on the rehab journey seems somewhat remote.

However, as Owens has long argued, sex is an integral part of the human experience and simply ignoring it under a cloud of taboo benefits no-one.


Sexual services and rehab – a case manager’s view

When a client asks to visit a sex worker, professionals must navigate a tricky terrain with no manual to guide the way, writes brain injury case manager John Walker.

The matter of clients using sex workers predisposes that they have the mental capacity to engage in that relationship. Having the capacity to have sex is a different question from having the capacity to utilise a sex worker however; and from a legal point of view, this is a foremost consideration.

Another consideration is the notion of the law of unforeseen consequences, in that embarking on the arrangement could result in all sorts of unexpected results.

It is therefore incumbent on a professional such as a case manager to risk assess the whole process as best they can.

There is also the potentially complex situation that surrounds the client’s family. The adult brain injured person rarely exists in isolation, but rather in the context of their family.

Understandably, families affected by severe injury tend to be more risk averse and protective, although sometimes, for example, parents who you may expect to be antagonistic towards the idea of sex workers, can actually be very liberal about it.

But overall, the case manager may be faced with very divergent views from the various people in the client’s life. Even after these challenges have been addressed, there are some relevant legal barriers that must be overcome before you consider putting a client in touch with a sex worker.

One part of the law determines how the process is driven along. Any practitioner in the area must be very clear that they are not, in any way, causing or inciting the process to take place.

Sections of the Sexual Offences Act 2003 ensure that the individual with whom the client would engage, for example, is not underage and is operating in the UK freely of their own volition.

Practitioners have to be very mindful of the legal context and make sure they are operating within criminal law. They must also navigate the fact that lots of bits of legislation can have contradictory effects in the UK.

Of course, as Tuppy Owens mentions in her interview, there are also relevant elements of the Equalities and Human Rights acts, which help to make a strong case for access to sexual services by disabled individuals.

It is important to stress that the majority of brain injured adults who express an interest in visiting a sex worker never go on to do so.

From a rehab perspective, the issue may be approached as a problem-solving exercise. The client might tell you “I want this” but because of their brain injury may not be aware of the range of different factors in achieving it.

Working through the barriers to fulfilling this aim doesn’t mean the client will necessarily achieve it; but the process of pursuing it can serve as good cognitive, psychological and emotional practice that might better equip them to deal with life in the future.

At the same time, taking a client’s sexual requirements seriously is important and can positively influence their rehabilitation.

While most sex-related issues that occur after a brain injury are those that affect existing intimate relationships, some clients will indeed seek a sex worker visit. They may see the process as a stepping stone towards having the skills and confidence to pursue a loving relationship.

Sex is a very basic human need and without it people can become frustrated. After a
brain injury, what wasn’t necessarily a driver towards behavioural problems could become a contributing factor to the overall difficulties the client has.

Obviously, sex is also closely linked with self-esteem and self-worth. There is certainly anecdotal evidence that young men with brain injuries can benefit from a safe, carefully arranged sexual encounter.

For various reasons, including greater frequency of brain injury prevalence, this client group seems to be the most likely to seek sexual services after injury.

If clients have difficulties with inhibitory control caused by the brain injury, addressing their sexual frustrations could help to reduce possible behavioural problems in the community.

There are a number of different agencies who deploy sex workers with experience of working with clients with neurological impairment.

Clearly there is no prescribed method to helping clients narrow this field. Instead, the process involves conversations with agencies to work out whether there is someone with the adequate experience conveniently located for the client.

In the entire management of this tricky issue, case managers can find themselves operating from two very different positions. One is from the perspective of care and nurture and a commitment to introducing new experiences where possible.

The other is slightly opposing in nature, with a remit of control, risk management and consideration of the law. Always being aware of your position on this spectrum can help to manage the situation in the interest of the client’s wellbeing.

In summary, there is no guide book on this topic for brain injury professionals and each case must be considered in its own context. Based on my own experience I would strongly recommend discussing the issue as a multidisciplinary group – and definitely do not ignore any sexual concerns your client has, however awkward the topic may seem.

John Walker is a brain injury case manager who runs Education and Case Management Services with his wife Judith James.


From marital faux pas to dating game pitfalls

How occupational therapists play a key role in unlocking the power of sex in rehab.

Occupational therapy, as defined by the NHS, is supporting people whose health prevents them from doing the activities that matter to them.

When the slightest mention of the activity provokes mass embarrassment among clients and their families, however, the field becomes particularly challenging.

But such awkwardness must be overcome because sex really does matter and can have a huge influence on an individual’s life after brain injury.

So says Rachel Lees, a specialist occupational therapist (OT) at Neural Pathways, which provides therapy and rehab services for people with neurological conditions.

“It’s so important. Sex is a massive thing but as soon as you get to the topic, everyone panics and shys away from it. But it’s an important human need and part of helping people get back their quality of life.

“As OTs we look at everything holistically. We have a duty of care to support the client if they want to get into a new relationship or need help with an existing one as it’s such a huge part of anyone’s life.”

The impact of sex and intimate relationships on any individual extends far beyond the bedroom walls; for brain-injured adults in rehab, failing to meet these basic desires can be hugely disruptive to their recovery.

Lees says: “I had a client who was getting really down because he wanted companionship – a relationship and everything that comes along with that.

“It was impacting on his performance in other areas of his rehab. Because he was feeling low and had self-esteem issues, he was getting frustrated and agitated.

“Not having sexual and relationship needs met might increase frustration and anxiety and affect self-esteem. It really can affect everything.”

As well as helping clients address sexual and relationship needs, OTs in multidisciplinary teams are key in assessing whether they have capacity to consent to relationships.

Part of this involves considering how sex or a relationship would impact on the rest of
their rehab.

As an OT, Lees has never been involved in facilitating a brain-injured client’s visit to a sex worker or escort. She has, however, helped them to overcome the anxiety that might precede a planned sexual encounter.

A crucial part of her role is helping clients deal with behavioural changes that can affect relationships.

“After a brain injury, sexual and social disinhibitions rise quite commonly and people can become more inappropriate. They may have never said anything inappropriate before their injury but now they just can’t filter it out.”

This can cause obvious problems in marriages and other relationships that pre-dated the injury.

“Their partner could be embarrassed by their behaviour. For example, I had a client who was out with his wife and paid attention to, and made a comment about, another woman’s breasts. So it can be a bit embarrassing.”

Similar challenges occur when single clients attempt to navigate the dating game in an age of Tinder and other instantly accessible apps.

“They may need support workers to act as the filter they no longer have or be that person looking over their shoulder who says: ‘Do you think that’s an appropriate thing to say? How can we make it more appropriate?’”

While sex and relationships influence an individual’s overall wellbeing, they can also be a useful area in which to hone problem- solving skills.

Even the mere process of going on a date can involve numerous tasks that may be highly challenging for a person with cognitive difficulties. Overcoming them with the help of the OT can be an important part of rehab.

“A lot of clients don’t have the skills to use computers because of their cognitive impairments. They go online and struggle to write information about themselves – so they struggle in terms of putting a dating profile together and we can work on their computer skills.

“Then, if they are going out for a date, do they need support to attend it? How do they budget for the date? What would they wear? There is a whole list of things we could get involved in as an OT as part of their rehab programme. We often look at pros and cons of different options and then seek a solution to each problem.”

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Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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Stepping up the fight against alcohol-related brain injury

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Alcohol-related brain injury (ARBI) is becoming more widely recognised, but specific rehab services for the condition are surprisingly rare.

With few dedicated units for patients with ARBI, many patients in need of specialist care instead find themselves in a hospital or even an elderly care home.

ARBI is characterised by prolonged cognitive impairment and changes in the brain due to chronic alcohol consumption.

The average age of diagnosis in men is 55, and only 45 for women – following at least five years of excessive alcohol consumption, of around 50 units per week in men and 35 for women.

ARBI is not a degenerative condition, with up to 75 per cent of patients recovering to some degree with the correct support; and the first three months following diagnosis are recognised as key in a person’s recovery. Access to appropriate provision, therefore, is even more crucial at this time.

In February, UK-wide charity Leonard Cheshire opened a residential unit in Northern Ireland to help some of the many patients in need in the country. It is the first facility of its kind on the island of Ireland. 

The 14-bed unit, near Belfast, opened inconveniently – after years of planning – just as the COVID-19 crisis was emerging.

Its work goes on, however, with the centre taking patients from across the country, though initially from the capital and surrounding areas.

The residential centre aims to support residents over a two to three-year period, although that can be shorter for some patients. It helps them to live independently, by building the life skills and confidence to do so. 

Naomi Brown, clinical lead at the centre, joined Leonard Cheshire late last year to oversee the opening of the facility, following an extensive career in brain injury work and in being part of multidisciplinary teams.  

She says: “The background here in Northern Ireland is that the acquired brain injury (ABI) service is really well structured and established but for ARBI, often the person wouldn’t meet the criteria for addiction services, but their needs would not be such that they needed to be admitted to hospital, or even fulfil the criteria for ABI services, so they would fall through the cracks.

“The provision they receive would often come from the care sector, but to end up in a care home at what could be a very young age is not appropriate either.

“There is a real lack of options. Their care managers recognise they aren’t in the appropriate setting for them, but through a lack of alternatives, it is very difficult.

“A lot of symptoms are very similar to those under the influence of alcohol, difficulty with balance and memory for example, which can make ARBI difficult to diagnose.

“Often it can be something like liver failure that gets them into hospital, but then it becomes obvious there are cognitive issues there too.

“Our centre only has 14 beds, which we don’t pretend is going to answer the scale of the problem, but the decision to restrict it to that number is that we don’t want quantity over quality. To try and accommodate huge numbers would risk the patient-centred approach that we are really proud of, so we wanted to keep it on a small scale.

“But there are 14 places here at any one time for people to get access to the specialist rehabilitation they need, so we are really pleased to be able to offer this.”

With the centre’s goal being the independent living of its patients, a resident-led rehab plan is created for each individual, based around their individual goals and aspirations.

It is delivered by Leonard Cheshire’s team of rehab assistants, supported by clinicians, occupational therapists, physiotherapists, speech and language therapists and neuropsychologists who come in to hold sessions with the residents, and overseen by Naomi. 

“From the minute someone is admitted to us, we are already planning for their discharge, even though that may be a long time and a lot of work away.

“From the very start, it’s about the individual, it’s absolutely not a generic approach, even though the ultimate outcome for everyone may be the same. Most people who move in do want to live independently, so if that’s their goal and we will do all we can to help them achieve that, with a plan individualised for them. 

“Some people will come to us and we realise they won’t be here very long as they do very well very quickly, but for others, they are going to be with us for two or three years.

“Some people arrive and love it here and say they don’t want to leave, which is a great reflection on the work we do and the centre we’ve created, but the ambition is that the point will come where they realise they don’t need us anymore.

“Through the work we do and our interventions, we can make very good progress. We’ve had some people here already who have been in quite an acute state but the progress they make brings joy into my heart.”

One such patient is David* who, despite only being with the centre for a matter of weeks, has made significant progress in his recovery.

Prior to moving to Leonard Cheshire, he lived in a nursing home for two years.

Before his arrival, Naomi remembers he had low mood, minimal spontaneous conversation and spent long periods of time in his bed sleeping.

He had no clear weekly routine and lacked any scheduled therapeutic or recreational activities.

Naomi says: “David initially required a significant amount of support to initiate activities, engage with others or even leave his room. He has slowly adjusted to the active therapeutic programme in the unit and his mood has improved significantly.

“His mobility and exercise tolerance has greatly increased, he participates in group activities, is now more spontaneous in conversation and has developed facial expressions. David has been able to self-identify rehabilitation goals and discovered a new love for playing the drums and guitar. 

“He is in the very early stages of his rehabilitation but having spent three months in the ARBI unit, the change is his quality of life is already dramatic.

“He engages in an individual, weekly timetable which includes activities of daily living, physical, cognitive and social activities, and is reportedly very happy in his current placement. Once the COVID-19 restrictions are lifted, we very much hope to begin reintegrating David to the local community and making future plans for his discharge.”

David’s experience is one which the unit is keen to replicate, by engaging patients from the earliest stages of their arrival at Leonard Cheshire in building a new and healthier daily routine.

“We are always keen to introduce routine, as that is so important in the longer-term. Where some people have maybe traditionally watched TV all night then get up into the afternoon, we try to create a new routine with lots of support services available in the morning. A healthy routine is what we want them to have when they go back home,” says Naomi.  

“We encourage people to do things for themselves – to get up, make yourself breakfast, maybe do some gardening or help with the cleaning, all things which promote the ability to do things independently.

“If they put the washer on, they’ll need to go back to it when it’s finished. We have rehab assistants on-hand to support them, but we do actively encourage independence.”

Everyone has an individual timetable for the week based on their own interests, combined with their clinical requirements, which centres on promoting reintegration into the community.

“It’s very individualised, so if someone wants to do an online course or learn how to cook for themselves, or learn a musical instrument, we’ll focus on that. We have a fantastic team here who will turn their hand to anything for the benefit of our residents,” says Naomi.

“As well as activities in the centre, we do a lot in the community, or rather we did before COVID-19, but that will resume when it’s safe to do so. We did sports activities, yoga classes, bowling, it’s not just your classic physio. We want people to be engaged and comfortable with the world outside. 

“We will always ensure residents have support once they leave us, and are setting that up long before they go.

“If there was someone who was with us who wasn’t from Belfast, we would use resources we knew were transferable to where they lived, so they didn’t leave us and not know how to access support.

“We build up these links with community services in the relevant discharge areas, so ideally the person will already be confident at being independent and will have the added assurance of knowing they continue to be supported.”

The Leonard Cheshire centre’s launch came amid changes to Northern Ireland’s legislative backdrop with the implementation of the Mental Capacity Act (NI) 2016. This has new deprivation of liberty regulations, a significant new introduction for the country and its approach to capacity and consent.

Naomi says: “When planning for the opening of a new centre, a global pandemic wasn’t on the radar, and for it also to coincide with the new mental capacity legislation meant it was a really busy time for us in the early stages, the COVID-19 aspect of which we could not have foreseen. 

“The pandemic did present challenges for our residents, many have a certain level of confusion so it’s difficult for them to always remember that they can’t be close to someone else, they have to regularly wash their hands. There is a lot of prompting which leads to a certain amount of frustration. While they are watching these things on TV about how COVID is affecting the world, it’s hard to relate that to everyday life.”

New referrals continue to arrive during the pandemic, from both hospital discharge and moving from a care home environment, although happily the Leonard Cheshire unit has remained COVID-19 free.

“We were keen to admit new residents and take referrals from hospitals and care homes, subject to extra measures being in place to protect ourselves and our residents.

“We wanted to continue to support hospitals and free up beds, but also to offer the appropriate care to people whose specific needs through their ARBI diagnosis meant they would be better in our centre than a hospital environment or care home.

“This has certainly been a challenging period in which to start our ARBI unit, but we have come through it well together so far and we look forward to continuing to develop ourselves as we come out of the pandemic and go into the future.”

*Name changed for anonymity.

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Neurobehavioural rehab in aggression management after TBI

Changes in personality following TBIs are often more problematic than neurocognitive, functional deficits or even physical disabilities. Dr Grzegorz Grzegorzak, consultant neuropsychiatrist at St Peter’s Hospital, South Wales, explains why taking a neurobehavioural approach to treating TBI can be highly effective.

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Personality changes are sometimes referred to as neurobehavioural disability (ND), especially when associated with social difficulties.

The concept of ND involves impairments of numerous aspects of functioning including the abilities to self- monitor and self-regulate, to control frustration, anger and aggression, to tolerate delay in gratification, and to self-motivate.

These impairments can lead to a sense of being overwhelmed when facing situations requiring control and management of internal impulses or coping with social situations or tasks.

Impulsivity, disinhibition and aggression all have significant potential to interfere with rehabilitation efforts, jeopardize recovery and become a major obstacle to successful functioning in social roles.

Research estimates the prevalence of aggression in survivors of TBI as being as high as 33.7 per cent.

Addressing aggression as soon as it arises is critical to the individual’s recovery.

Sometimes aggressive behaviour is so intense and frequent that its management takes priority over all other aspects of care and rehabilitation.

Neurobehavioural rehabilitation (NR) was introduced in the late 1970‘s as an attempt to improve functional abilities of TBI patients.

NR stems from recognising that people who survive TBI can still learn new skills to self-regulate and to modify their behaviour.

The basis of NR is embedded in learning theory and thus the success of NR is reliant on the patient’s ability to make use of new information and experiences.

Therefore, NR is only suitable for the post-acute phase of recovery from TBI, and in fact is intended as a medium to long term rehabilitation programme.

​NR interventions are composed of comprehensive and multidisciplinary efforts to create a user-friendly, supportive and encouraging social environment which facilitates therapeutic interactions and activities.

Specific goals and detailed routines are constructed for each patient individually, based on structured collection of data informed by behavioural analysis.

The process of designing and implementing the interventions puts emphasis on personal autonomy.

Clinical formulation is preferred over medical diagnosis. The attitude of the MDT should always be positive, embracing a strong belief in the patient’s ability to achieve their goals, improve and recover.

Carefully managed feedback and positive reinforcement are an essential part of NR.

Consistent interactions with every member of the team are of utmost importance, given that neurobehavioural intervention should not be limited to scheduled activities but in fact incorporated in every interaction.

Over the last forty years the model has been implemented by many neurorehabilitation services worldwide.

Several case studies describing recovery pathways through NR paint a very positive picture, and our own experience at St Peter’s of adopting a neurobehavioural approach has demonstrated it can produce real and measurable outcomes for both our patients andtheir families.

Case Study: Mehmet

On admission to St Peter’s Hospital, Mehmet presented with extreme challenging behaviours including serious assaults on staff, destruction of environment, verbal abuse and shouting.

Mehmet has frontal lobe dysfunction as a result of a head injury he sustained. For the previous 18 months he had been in a general hospital.

At St Peter’s a bespoke positive behaviour support plan and activity plan were developed with Mehmet’s input and reflecting his cultural needs which, under the supervision of his MDT, promoted positive changes to his social interactions, routines and activities.

Over nine months Mehmet’s challenging behaviours reduced significantly and he now enjoys a wide range of activities including regular community visits and has strengthened his relationship with his family.

Dr Grzegorz Grzegorzak is one of the consultant neuropsychiatrists at St Peter’s Hospital a specialist 39-bed Neuropsychiatric facility in Newport, South Wales run by the Ludlow Street Healthcare Group. www.saintpetershospital.co.uk

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