March is Brain Injury Awareness Month, and the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Service Members, Veterans, and their Families Technical Assistance (SMVF TA) Center has invited our partners at the National Association of State Head Injury Administrators (NASHIA) to share some key insights and information on brain injuries and their implications for the SMVF community. Highlights from our conversation include the need to screen for lifetime exposure to brain injury, the prevalence of co-occurring conditions among service members and Veterans, and psychoeducation as a key component in supporting individuals with brain injuries. They also discuss new programs and provide studies, tools, and resources available to the behavioral health community.

As we observe Brain Injury Awareness Month, what message would you like to convey to SMVF dealing with the impacts of traumatic brain injury (TBI)?

It is OK to talk about the challenges you are facing; you are not alone. Just because a person has a brain injury does not mean they are a “broken” person. There are compensatory strategies and resources available to help you achieve your goals and to experience successful outcomes in life!

What are the most critical gaps in our current understanding of and/or support systems for TBI among service members and Veterans? How can they be addressed?

One of the important gaps is first knowing a person has sustained a brain injury. Often, those who have experienced a mild (or multiple mild) brain injury, known as a concussion, go undiagnosed and, therefore, do not understand why they struggle. If providers are not aware, they often attribute the challenges to behavioral causes versus understanding the underlying brain injury deficits a person is experiencing. A solution to this gap is to conduct a screening for lifetime exposure to brain injury and a screening for challenges related to brain injury. This is typically done using self-report tools such as the Online Brain Injury Screening and Support System (OBISSS). OBISSS incorporates an evidence-based screen for lifetime exposure, the Ohio State University Brain Injury Identification Method, and the Symptoms Questionnaire for Brain Injury, which identifies specific areas of neurocognitive challenge. Once these areas are identified, compensatory strategies are recommended to address the challenges. If a person continues to struggle despite the implementation of compensatory strategies, it is recommended that the individual undergo neuropsychological screening to determine if there are other factors contributing to their challenges.

Another issue faced by service members and Veterans with brain injury is the increased prevalence of co-occurring conditions such as spinal cord injury, post-traumatic stress disorder, mental health conditions, and substance use disorders. Also, Veterans with brain injury are more likely to have engagement with the criminal legal system. Without addressing the underlying challenges associated with brain injury, Veterans may experience serious challenges in their day-to-day lives. Training providers about brain injury can ensure that the appropriate adjustments are made and that support is provided so that the Veteran experiences better outcomes in treatment.

NASHIA has partnered with the Mid-America and Mountain Plains Addiction Technology Transfer Centers (ATTCs), TA providers for SAMHSA, to develop toolkits to assist behavioral health providers to better support those with brain injury. While this resource is not specific to Veterans, the approach to support is still applicable. To address the needs of Veterans with brain injury engaged in the justice system, NASHIA developed a Veteran Treatment Court (VTC) Toolkit for state brain injury programs and for VTCs.

NASHIA also collaborated with the U.S. Department of Veterans Affairs (VA) TBI Model Systems on the Improved Understanding of Medical and Psychological Needs in Veterans and Service members with TBI (IMaP) study. The goals of IMaP are to examine types of long-term physical and psychological health conditions in persons with TBI, the impact of those health conditions on recovery, and chronic rehabilitation needs, including accessibility of needed services.

In the IMaP study, service members and Veterans identified these initial challenges to addressing their rehabilitation needs:

  • Lack of transportation: to get to appointments
  • Limited access to services: difficulty in getting referrals and scheduling appointments
  • Need for caregiver support: to help with scheduling, transportation, help with instructions, etc.
  • Health disparity due to race: poorer health outcomes due to race
  • Distance to healthcare services: live far from where services are offered
  • Scheduling: difficulty scheduling appointments, wait times

This study provides us with a better understanding of SMVF needs that can inform the development of a road map for states to address. Additionally, this project identified a resource that includes information on brain injury, mental health, and other co-occurring conditions.

In your experience, what steps can providers, peers, and families take to support resilience and recovery in individuals with TBI and co-occurring mental health conditions and substance use disorders?

The first step is to become educated on brain injury. Learn about the prevalence, causes, and consequences of brain injury. Also, learn about compensatory strategies that can help to mitigate the effects of brain injury and improve outcomes for individuals with brain injury. There are a variety of resources that can assist with this learning. First, almost every state has a lead state agency on brain injury or an advocacy agency focused on brain injury. These can be great resources for providing training. Second, there are a variety of web-based resources where providers, peers, and families can learn more about brain injury. For example, BrainLine has extensive information on brain injury and specific information on brain injury related to Veterans. The Brain Injury Association of America (BIAA) has educational resources on its website. The Center for Brain Injury Research and Training has a learning series called Skill Builder that provides basic information on how to support someone with a brain injury. NASHIA has a resource library that provides a variety of resources designed to provide education on brain injury (the website is listed below). The TBI Model Systems Knowledge Translation Center has factsheets and information on brain injury, as well as information specific to Veterans and brain injury. Finally, the Ohio Valley Center on Brain Injury Prevention and Rehabilitation has many training videos related to brain injury on its website.

Psychoeducation is a key component of support for individuals with brain injury. Helping individuals understand what brain injury is, how it might be affecting them, and, most importantly, strategies to compensate for their brain injury is critical. The TBI Model Systems Knowledge Translation Center and the Ohio Valley Center on Brain Injury Prevention and Rehabilitation provide fact sheets and infographic resources written for individuals with brain injury and their family members that can be good sources for psychoeducation. The BrainLine website is also an excellent resource for psychoeducation materials. Finally, MINDSOURCE-Brain Injury Network developed a psychoeducation curriculum called AHEAD (Achieving Healing through Education, Accountability, and Determination). AHEAD has seven modules: understanding brain injury and symptom recognition, memory skills and goal setting, emotional regulation, communication mastery, brain injury and anger management, “stop and think” strategies, and grieving and brain injury. Knowledge truly is power. Once an individual with brain injury understands their injury and what they need to be successful, they can become successful self-advocates.

Support groups and community-based brain injury resources can be helpful to reduce the stigma of brain injury and to obtain the support needed to navigate the resources needed to be successful with a brain injury. Most states have information and referral or resource facilitation support available for people with brain injury and their families and caregivers. To find these resources in your state, visit any of the following: NASHIA, the BIAA, and the United States Brain Injury Alliance.

SAMHSA’s SMVF TA Center is honored to provide TA to states, territories, and communities seeking to strengthen their behavioral health support for those who have served in the armed forces. For TA inquiries, please email smvftacenter@prainc.com. For more information about the SMVF TA Center and the resources offered, please visit SAMHSA’s SMVF TA Center’s web pages.

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