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Michael Paul Mason is a brain injury Case Manager in the United States, and his book Head Cases is a part-autobiographical account of the nature of his role in working with clients with brain injury, in trying to secure the right health care provision for them as part of their care and recovery. As a support worker at the London Brain Injury Centre in the UK, it is interesting for me to read about the state of care provision for people with brain injury in the United States, in comparison with the UK. The most obvious differences would be firstly in the general healthcare system, with the Medicare and Medicaid systems in the US compared to the NHS in the UK, and secondly in the role of private healthcare insurance on access to services, which would both clearly impact on the pressures afforded to somebody whose main role is to secure funding and health care provision for brain injury survivors.
These pressures are made apparent in the frustration described when funding is made unavailable, a fact which the author describes accurately and is very honest about. The fall-out of this is poor emergency treatment for brain injury ('Portrait of an Injury'), lack of access to adequate treatment ('The Hermit of Hollywood Boulevard') and patients getting shifted from psychiatric hospitals, day centers and other care settings, amongst other things. We get an insight into the life of a Case Manager, travelling around the United States and even as far as Iraq ('The Hospital in the Desert') as new cases emerge constantly, demanding immediate attention. The cases can be diverse as people with diffuse axonal injury ('The Prisoner of the Present'), epilepsy and seizure disorders ('The Hermit of Hollywood Boulevard'), someone unable to produce tears due to damage to the cranial nerve ('Rob Rabe Cannot Cry'), a high-achieving, young, female artist with volatile outbursts ('Portrait of an Injury'), violent and challenging behaviors ('Ultraviolent Bryan', 'The Only Thing that Works' and 'Wood of the Suicides'), amnesia ('Fugue of the Pony Soldier' and 'In all Earnestness') and Cotard's syndrome ('The Resurrection of Doug Bearden'). The etiology and diagnosis in each of these cases, is, however, only the beginning of the line for each person's story of their ongoing battle for healthcare and recovery from brain injury.
At times, it seem that figurative descriptions are given precedence over straightforward ones, for example, from reading 'The Resurrection of Doug Bearden', on a brain injury survivor who believes he is dead, it becomes apparent that the client might be suffering from Cotard's syndrome. This explanation, however, is only demoted to endnotes, whilst the main text is dedicated to a far more ruminative discussion on the Tibetan Book of the Dead. Whilst parallels could well be drawn in terms of descriptive experience between the two, I would have preferred the straightforward explanation of how the original cause (HSV-1, or herpes-simplex type 1, virus) led to symptoms of Cotard's delusion before leading in to the discussion on the Tibetan Book of the Dead. The only connection which is explained is that the HSV-1 virus can often implant itself into the cranium, leading to symptoms of cognitive distortions, impairments and hallucinations (p. 132), from which it must be inferred, from the endnotes, that in this case these symptoms must also include Cotard's syndrome. It may be, however, that the author is trying to avoid overly-technical language in the text by placing it in the endnotes, which, for those who are interested in finding out further, are worth reading.
Similarly with 'Fugue of the Pony Soldier', a great deal is devoted to describing the author's experience of the inipi, the Native American sweat lodge which is used as part of a purification ceremony. It is, at first, not entirely clear why the case manager is participating in this ceremony apart from the fact that the client has suggested it to him, and the reason for writing about it in depth is perhaps revealed much later when it is stated that "in his [the client's] words, the condition had 'taken him far from his inipi circle', meaning that his injury had pulled him away from his spiritual practice, and he hoped that soon he would be able to return" (p. 198). So my reading of this can only be that the author is somehow trying to engage with the meaning of this practice for the client through his own participation in the ceremony. The author makes an interesting comment about the problems of classification; this client in particular might be diagnosed with dissociative fugue, since his symptoms involved amnesia, dissociation and fugue, although this is normally a psychiatric classification given for psychologically-induced states (e.g. trauma) rather than neurological ones (in this case an amnesic state caused by head injury).
A dedicated reader might try to sift through the chapters in order to discern the name, age, nature of accident, type of injury and corresponding symptoms for each case. This is, however, quite a challenging task, as this information is more revealed to the reader through shifting time frames and perspectives, at varying points in the text. The merit of this approach is perhaps that it reflects the often more piecemeal and impressionistic way in which a person's difficulties are presented to healthcare workers. Often it is simply not possible to know the exact cause or etiology of a person's difficulties (why they feel and behave as they do), and workers therefore have to be considerably imaginative in dealing with the more obvious, pragmatic and everyday. This aspect of writing about brain injury, might, however, confound anyone looking for straightforward explanations.
On the philosophical aspects of the text, I feel that the author delves into two areas. Firstly, it might be expected that working in an area as complex as brain injury might naturally lead to thoughts of a philosophical nature, for example on the relationship between mind, brain and behavior, and on notions of personal identity (especially the endurance of personal identity throughout time). It might also be expected that, having to be confronted on a daily basis with the material and political barriers in this area, both client and case manager might equally become enormously frustrated with the general order of things, divine, political, natural or otherwise.
A couple of the author's central questions are "What are we other than our brains [mind-brain identity]? Is there a part of me that can't be changed by brain injury [personal identity]?" (p. 11). At times, even the author's faith seems to dwindle as he exclaims "I'd like to hear His excuse" on the notion of one patient confronting God about her injury (p. 64). This could, it might be thought, relate to questions about the problem of evil and suffering; even though brain injury can often lead some to be more open to religious experience and faith (which is discussed earlier on pages 14-16), it is important to avoid unnecessary romanticism over this point and seems difficult to justify the suffering of brain injury on theistic grounds. His faith in his own situation as Case Manager also seems to dwindle on page 203 as he seems to almost give up on the state of affairs. The author's faith, however, seems restored by page 278, when he experiences the birth of his own child, a story which he manages to neatly weave into the rest of the narrative. I see the author's philosophical enquiries as an attempt to resolve the two areas of difficulty mentioned above, the first (concerning mind-brain and personal identity) being more within the realm of metaphysics and the second (concerning spirituality and morality) being within the realm of moral philosophy, regarding notions of social justice, fairness and equality. There is, unfortunately, not enough room to go beyond the initial conception of these ideas in Head Cases, although I would be interested in any future work should the author explore these ideas more fully.
© 2008 Alice Gee
Alice Gee, Support Worker, Rehab UK London Brain Injury Centre, MSc Philosophy of Mental Disorder, BA (Hons) Philosophy and Psychology, firstname.lastname@example.org