A brain injury is a devastating event. It affects not just the injured person, but the lives of everyone they are connected to. Until about 30 years ago, treatment for brain-injured individuals was very limited. Most brain-injury survivors were never expected to return to a normal life, and (to a degree, due to such expectations) they would be consigned to a limited existence. Today, thanks partially to new operating procedures, but owing mostly to a better understanding of neuroplasticity (the brain’s ability to reorganize and adapt) and the psychology of recovery, survivors often bounce back and are able to live fulfilling lives.
Yehuda Ben-Yishay, Ph.D. is the director of the Rusk Brain Injury Rehabilitation Program in New York City. In 1973, he was sent to Israel to develop a recovery program for brain injured soldiers after the Israeli-Egyptian war. There he developed “Milieu therapy,” the first holistic approach to brain recovery. His program stressed the importance of a survivor’s emotional state and connections to family and society. The innovative techniques developed by Dr. Ben-Yishay have since impacted recovery programs worldwide. He sat down with us recently to discuss his insights from over three decades of experience with brain injury therapy.
Brain World: Tell us about your approach in treating brain injury survivors.
Yehuda Ben-Yishay: We help brain-injured individuals to improve their functional, vocational, and interpersonal life, including the state of their ego-identity and self esteem. Thirty years ago, if somebody suffered a major brain injury, it was felt there was nothing that could be done to restore that individual to a functional life. Now we take people who are moderately or severely brain injured, and — depending on certain factors, such as their personality — over a year of intensive rehabilitation, restore quite a number of them to functional status: living in a home environment, working, or studying.
BW: How does personality affect an individual’s chance for recovery?
YBY: Your temperament, intelligence, and education affect how you react to the world and respond to different interpersonal situations and challenges. Under what conditions do you succumb, and what conditions do you persist? We find that some brain-injured individuals will have a tendency to give up faster than others. Other individuals will persist and try.
You cannot really separate behavioral, personality components and cognitive components. Each one influences another. Although there are similarities in the kind of syndromes that can result from frontal lobe injuries, in memory functions or perceptions, how they express themselves in an individual’s symptoms is unique. Some individuals will be amenable and malleable to intervention, while others who are equally impaired neurologically are not. Personality, will, malleability, and accepting the influence and coaching of others, cannot be separated from the individual. If three individuals have similar injuries, each will have different rehabilitation trajectories, and one will come to the top.
We just finished a study of individuals who have achieved the greatest success in our program. We asked ourselves, which personality attributes would dispose a normal individual, before his brain injury, to become successful at rehabilitation? Sure enough, we showed the influence of personality is very important to determining who is successful in rehabilitation.
BW: Is saying you need a positive attitude too simplistic?
YBY: No, actually personality characteristics like positive thinking, the ability to take charge and the desire to be involved are some that we have identified. People who are optimistic and benevolent are more malleable to treatment and will probably emerge more successful, as will people who have a tendency to persist in what they do, and who are willing to work hard to accomplish their objectives.
We found out that those who we labeled the “examined self” — who are introspective about themselves — achieved greater success vocationally, greater integration into society, and felt much better about their accomplishments. That surprised us, because we felt that introspection was for philosophers. But it turns out people who lived the examined life were more successful in recovery.
BW: What about a grumpy couch-potato who is brain-injured? Is there hope for him?
YBY: The grumpy couch-potato, or the person who is lazy, or surrenders at the first shot is a combination of what he was endowed with genetically, his education, and his upbringing. If you compare a person who surrenders and goes to pieces under stress to a person with ego-resilience, the ego-resilient person will do better.
But we do try to strengthen people. The James-Lange theory says, act boldly and you may become bold. The psychoanalytic system would say, let’s analyze why you are scared and maybe you’ll stop running. The James-Lange theory says, stop running, and you will become less scared. How did the samurai become brave? Acting bravely. I have a friend who was one of the biggest cowards in the world. He ended up an Israeli parachute sergeant with 3,000 jumps. He said the more he jumped, the braver he got. Behavioral therapies say if you act right, you will think right.
BW: Are you able to apply this to improve an individual who, because of his psychology, is not a good candidate for rehabilitation?
YBY: I don’t want to rush into saying absolutely yes, but that is what we are working on. We practice how to act dignified so that we feel dignified. We have a young woman who had a brain tumor — who had behavioral problems all her life. She couldn’t hold a job. She always wanted to be recognized as bright, but she didn’t know how to behave. We told her, stop being defiant, impulsive, and aggressive. Let’s practice how to act dignified, learn when to keep your mouth shut and stop being impulsive. She has been in therapy for a year, and she is changing. We have been telling her, “All your life you were rebelling against everybody because you felt they were rejecting you. All you were looking for was respect. We respect you. Now you start respecting yourself.” If a person has that kernel in themselves, they can overcome.