2021

Case Study Report for

A 25 Y/O MALE WITH A TBI (TRAUMATIC BRAIN INJURY).
JANELLE MEZA
Case Study
My client is a 25 y/o male veteran, recently discharged from the army and has a TBI. He is
currently 60% service connected for VA disability benefits. He is currently living at home with
his family and is attending a VA outpatient support group to address some of his emotional
issues. He is struggling with his relationship with his family. Prior to his service and his injury,
the client was an active young adult, engaging in regular leisure activities such as basketball,
hanging out at the local bar with his friends, bicycle riding and going to concerts. He hoped to go
to college on the GI Bill post discharge, but now does not feel that is a possibility. Since his
discharge from the army, this client has frequent angry outbursts, difficulty sleeping, lethargy
and poor motivation to participate in his past interests. He is isolative, has cut off contact with
his friends and spends most of his days drinking beer and watching TV. His family relationship
is strained, particularly with his father who frequently tells the client to do something and get on
with his life. His mother is more understanding and feels the client needs to address his issues.
He has one sister who lives out of state and is married with her own family and is not engaged
with the client.

Assessment Tool
The assessment tool that I will be using for this client is the symbols tool which includes the
Glascow Coma Scale. The Glascow Coma Scale is found to be the most common scoring system
when describing the levels of consciousness in a client with a TBI. This scale will help determine
the severity of the brain injury. Not only that, but this test is also reliable and objective when it
comes down to recording the initial level at which the client is at after their brain injury.

Primary Problem Areas

• Facing emotional issues
o Angry outbursts
• Struggling relationship with his family
o Sister lives out of state; not engaged with client.
o Father frequently bothered by lack of motivation from client.
• Difficulty sleeping
• Lethargy/Poor motivation to participate in past interests
• Isolative
• Creating bad habits like drinking beer and watching TV most of the days.

Strengths/Weaknesses of Client
Strengths:
 • Attending a VA outpatient support group to address some of his emotional issues
• Has a mother who is understanding and simply wants the client to address his issues
• 60% connected for VA disability benefits
Weaknesses:
• Poor motivation
• Isolative
• New bad habits

Goal 1.0: Uplift client’s motivation to participate in leisure activities.

Objective 1.0: Identify at least 3 leisure activities that the client enjoyed before the
injury.
Objective 1.1: Client will choose 1 leisure activity 3 days a week to participate in, for at
least an hour.

Goal 2.0: Address/shine a light on the client’s emotional issues.

Objective 2.0: Client will learn coping skills to control his emotions.
Objective 2.1: Client will start journaling at least twice a week until emotional progress
is shown.

Treatment Plan
In the client’s treatment plan, the goals/objectives I will be addressing first are, Goal/Obj. 1.0-
1.1, uplifting the client’s motivation to participate in leisure activities in which the client enjoyed
before the TBI. By doing so, the client is expected to participate in 1 leisure activity, 3 days out
of the week for at least an hour. This will get the client back to their past routines and interests.
Treatment interventions that I would recommend for this client in Recreation Therapy are audio
therapy, which can be done at any moment of the day/week. Therefore, the client is welcome to
practice this treatment on their own. Nutritional modifications to break bad habits is another
treatment intervention that the client will face. Changing one’s diet has shown to boost their
mood/energy. This will take place 5 days a week, for at least 2 weeks. At the end of the 2 weeks,
I will assess the clients progress by creating a survey that the client will complete before the 2
weeks start, and then when they end. This will help me measure, record, and compare the client’s
progress. If no change is shown, modifications will be made to improve client’s well-being.