Friday, 29 May 2009

Tuesday 26th May.

Ohio State University (OSU), Columbus, Ohio. The biggest campus in the United States. Some people tell me there are 50,000 students, some say 70,000. The town is consumed, with every house for streets around being rented out to accommodate the legions. The faculty includes every subject you can imagine. The sports stadium has 90,000 seats. Apparently they get filled pretty often. The OSU sports budget is a hundred million dollars a year. There is a five star hotel. I am here to meet John Corrigan and the TBI Network team at the Medical Centre here on Campus. I will spend two days with them. I meet Debbie and April first and explain myself to them. They tell me how the Network functions. An hour later we sit down with John and I get further details. The Network began eighteen years ago. It covers Franklin County (Columbus and surrounds) with a population of somewhere over a million people. There are six Case Managers. They try to keep it to around twenty-five to thirty active cases at any one time, but over all they have approximately 150 clients. They receive around sixty referrals per quarter. Although brain injury is one of their inclusion criteria for clients, the Network is primarily funded as a drug rehab programme. I ask John why. 'Becuase it's easier. When you look at these people and the problems they have, drugs and alcohol are high on the list. When we started out we were finding a high proportion of our clients had these dependencies. We were making referrals to other rehab programmes but finding they had people with TBI they wanted us to take off their hands. We would take one person along and they would give us three in return.' John has also led some significant research into the co-morbidity of TBI and mental health problems. He says up to 60% have depression, schizophrenia, bi-polar or other significant psychiatric problems.
There is a relatively high rate of re-referral to the team (about 13%). Often it's individuals who have previously completed the programme but have fallen on hard times again. The courts also make the programme a parole condition for a lot of people. One person has come back eight times. They try to work with people as long as they are need support. They find other agencies often lack understanding of brain injury. Traditional drug programme are often too rigidly structured, not allowing enough time for people to get hold of each step before moving on to the next. The Network runs a series of support and education groups, but they don't ask people move on until they're ready. They can stay in each group as long as it takes.
They also offer vocational assistance based on IPS (Individual Placement and Support). 'All are eligible,' says Debbie, 'not all get work.' She says other programmes take too long over getting people into placements. People with TBI lose track or go off the radar if they're left hanging around too long. At the TBI Network they do their best to get people into placements within two weeks of signing up. 'During groups here at the centre, we get them to work out their own hypothetical businesses. We ask them who they would want to employ. It gets them thinking about job interviews and applications from the position of the employer.'
I meet Peter, one of the Team's clients. He tells me the Buckeyes are the best. He's proud to be a Buckeye. 'I'm American by brith, but a Buckeye by choice.' He tells me about Eddie George, who won the Heisman Trophy in 1995. His wife was on Survivor. Troy Smith won the Heisman Trophy too. And Vic Janowicz. And Hopalong Cassady in '55. OSU has more winners of the Heisman than anywhere else. Apart from Notre Dame, maybe. David has a problem with crack. He started smoking after his head injury. He says he's lost everything. He has to sell his house. He can work but every time he earns some money he just blows it on crack. 'It's a wicked drug,' he says. He's been through the TBI Network programme here at the OSU medical centre before. At first he didn't want to do it again because the court told him he had to. He doesn't like being told what to do. But now he's finished his probation and he's coming by choice. He want's to get clean. He's working with Max, one of the Network Case Managers. The three of us - Peter, Max and I - go along to an appointment at the clinic. Peter tells the doctor that he won't take pills. 'I only smoke things, I won't take any pills. There's nothing wrong with my mind. What are pills going to do? You can't fix my brain with pills.' The Dr says he might be able to get Peter onto an inpatient drug programme here at OSU. Peter seems happy about that.
Mirror lake, on campus. John tells me has tried to raise awareness about it. Students often throw each other in, not realising how shallow it is. 'We have about one spinal injury every five years.' We go for lunch at the Faculty Club on campus. The food is good.
John is circumspect about his achievements.
'My only regret is that in twenty-six years of working in the field I can't point to a single major breakthrough, a single significant step forward in helping people with TBI.' I ask him if he's talking about treatment. I say that treatment per se seems like a distant prospect to me. I talk vaguely about stem cell technology, about how hard it is to imagine anything like this working. (It's something I've thought about: even if you could get tissue to grow in the right places, how would the new cell populations integrate themselves with the existing brain - how would they organise themselves into something useful, something that approximated the function of the missing tissue? How long would this take?) I say perhaps real breakthrough could come in the form of social innovation, of political and cultural action of the kind proposed by Edgar Cahn. 'I'd take either,' says John. I don't care where the progress comes from or what form it takes.'
We talk a little about the Americans with Disabilities Act. 'Frontal problems in particular have to be better accommodated by the Act,' says John. 'The ability to make decisions about things outside of the present moment is essential in our society. I like to say that people with frontal brain injury have 20/20 hindsight, but not 20/20 foresight. The emphasis is so often placed on cognitive regulation, the ability to inhibit impulses, to act with restraint. But what we realize about high achievers in our culture is that they have both cognitive and emotional influences on their decision making - they are equipped to defer reward and to inhibit themselves but they also have passion, a genuine emotional intensity that drives them. The frontal systems are about the fine regulation of these competing but equally important processes.' I tell John what I've heard about civil rights - how people with cognitive impairment have been excluded so far from disability movements. I say that the general means of effecting political change (lobbying, litigation) are, by their nature, cognitively demanding and thereby inaccessible to people with brain injury. I tell him my theory that people with cognitive and learning impairments represent a challenge to Western values: we say that all people are born equal, that our societies are inclusive, but continue to set functional minima in terms of reason and intellect, to believe, as Thomas Jefferson did, in steady progress for all, towards perfection. People who acquire impairments through sickness or injury, people who get less able, do so in direct contradiction with this mission. ‘It’s true,’ says John. ‘If you look at the great political movements in American history, they have all been made with reference to that same project. If you look at Lincoln – when he took on slavery, he argued it in terms of the Declaration of Independence, of equality of opportunity. FDR did the same thing during the Great Depression. It’s what’s become known as the American Dream – to go out on your own and achieve things by your own merits, without the help of others. But that Dream is inaccessible to people with brain injury because they have so much trouble thinking and behaving strategically.’ John continues: ‘If you think about the way immigration has happened during America’s history, you also see a selection bias towards pioneers. People who come to America do so because they buy into the Dream. What you have here is a nation of people who believe in the independence and freedom of the individual – in individual responsibility and reward. And we are obsessed with work. Achievement is too often mistaken for happiness. There are many ways to be happy and proving yourself through achievement is not necessarily the quickest or most reliable. We’re not good at valuing people who need support doing things for themselves. We’ve put more effort into valuing returning soldiers lately, but I don’t know how good a job we’re doing.’
There is one prospect on the horizon, one possible breakthrough of the kind John is looking for. ‘But given the foregoing proclivities,' he says, 'you may think it monstrous…’ He's talking about Deep Brain Stimulation (DBS). It’s the technique of correcting neural activity by inserting stimulating electrodes into deregulated cortical areas, used with some success for Parkinsonism and other tremor disorders. John explains that this exact process is now being perfected for frontal brain lesions. ‘They’re working on it right here. The key discovery is that cortical tissue relies heavily on local inhibitory activity – the cell populations regulating their neighbours.' A lot of neurological problems are related to the loss of regulatory action that balances activity. By inserting a stimulatory electrode with a steady current, the ‘noise’ – the excitatory peaks and troughs that impair function – is cleared up. In the case of Parkinsonism, DBS is astonishingly effective in canceling out the condition's disabling tremors. If the technique is used for other cortical regions, the functional implications are something altogether different. John describes an experimental case involving a woman with chronic depression. ‘They had the frontal electrodes in and conducted an interview with her about her life. During the interview they steadily increased the regulatory stimulation and it was amazing – you could clearly see her answers becoming more positive.' This technology is coming, he says. ‘It will be with us in the next five years.’
I say there’s something creepy about it. He says ‘yes.’ I ask what it represents. He says he doesn’t know. We speculate on how it will work. DBS equipment is generally controlled in same manner as a pacemaker (in fact this is exactly what it is) – a box implanted somewhere in the torso that allows the physician to calibrate the level of stimulation. Will patients eventually be given remote controls? How will we know what a ‘normal’ mood is? Or ‘normal’ frontal function? John says policy has already been passed against the use of the technology for ‘tune-up’ purposes, for healthy subjects who want to dial up their level of function (it’s not even clear to me how this would work). This topic seems to bring an end to our discussion. The implications of DBS are transformative, alien. The practicalities are hard to speculate on. There are many unanswered questions. I wonder how likely the prospect of eradicating cognitive impairment through this (or any other) method can be. If it proves a significant and affordable treatment for frontal disorders, it raises a significant question, as John implies: by eradicating the dysfunction, would we remove the need for social accommodation, for political and cultural change? The two agendas - treatment versus accommodation - do appear to stand in opposition to one another. In some respects this is the same argument currently being provoked by research into congenital conditions like autism and Downs: about the morality of removing people with these conditions from the population by means of genetic screening and abortion (now increasingly feasible). Though not treatable, these conditions may soon be preempt-able. But should they be? For me the answer is very plainly no because I believe people with these conditions are valuable. The same can be applied to psychiatric conditions. I may well be wrong, but I hold the conviction that a great number of people can live with mental illness successfully and that the need to 'treat ' it with medication (as well of the effectiveness of doing so) is typically overstated (see, for example, the work of Joanna Moncrieff). A world without mad people would, to me, be a strange and pitiable one. Due to my connection with the people at Headway, my instinct is to be suspicious of the idea of treatment for brain injury also. Perhaps it seems counter-intuitive, but in order to be a good advocate for the people I work with, I have to argue for the intrinsic value of their injuries. I have to say that having a brain injury is not necessarily a bad thing. That to have impairments, however profound, is not inherently negative, that being strange or difficult or ridiculous or impossible to understand might be, in some way, an important and valuable thing. To be someone who cannot function in our society as it is presently arranged has to be, for me, something worth being.
But if you ask me how many of the people I work with would share this view, how many of them would turn down a magical 'cure', the chance to return to life before injury if it were offered, I would not be able to answer you.

Monday 25th May.
Sunday 24th May.
Galaxy Hut, Arlington VA. The Sons of Guns. They are very bad. The vocalist only makes one noise, which is somewhere between yelling and clearing his throat, and still manages to sound off key with his backing singer. It's weird. It's a mess. He really ruins it for everybody. The audience clap politely but I feel bad for the rest of the band. I feel like probably the lead singer started the band and they can't get rid of him. I feel like they are the kind of band that either has six songs or several hundred. It doesn't make any difference. They all sound the same. At the end of their set I am behind the bassist in the line for the bar. The drummer comes up and hands him a roll of cash - the takings from the night. I feel like asking him if I could get $2.50 back: half the entry price. 

The Two Tears. They are better. One of their songs is called 'Sh*t F*cking Job'. The vocalist can sing, and does. She is noisy but in a good way, unlike the vocalist in The Sons of Guns. I would go to see The Two Tears again, if they were down the street, and if they somehow shook off The Sons.
Saturday 23rd May.

Tuesday, 26 May 2009

Friday 22nd May.
2:20pm. I am late for my meeting with Edgar Cahn. I am relying on him being nice enough to forgive me. Time is, after all, quite precious to Edgar. In a number of ways. He is credited with inventing the concept of Timebanking and the alternative currency, Timedollars, during the 1980s - both of which are tools for the revaluing of time, and the revaluing of people. He has spent a good portion of his life thinking about how time and money work, how people put a price on their time, about what an hour is worth and what can be achieved with it. When I finally get there, I quickly see that his home is a testament to the central role these innovations have played in his life. The front door is wide open. The ground floor is divided into an office on the right and a large sitting/conference room on the left. The walls are lined with books and hung with artefacts and paintings. A clockwork wooden sculpture clicks in perpetual motion in the background. Edgar explains that the three people at the desks in the office are the staff that keep the Timebanks organisation running. Edgar's wife, Christine, appears from upstairs. She is also an employee of the organisation. Upstairs are more offices - piled high with papers and books, computers humming quietly. 'In 1980 I suffered a massive heart attack that blew away sixty per cent of my heart,' says Edgar in measured tones, 'thirty years later my heart is eighty per cent healed. This is life-giving work.' At 74 Edgar is not a young man. But he speaks with palpable energy about the agendas that have formed his life's work since that near-death experience. I first saw him speak last summer at the Fink Club, an evening event in London hosted by the New Economics Foundation. I remember his address clearly because the ideas it contained were new and radical to me. What stood out more than anything was what he said about value: 'Capitalism is a value system based upon scarcity. We value things only that are rare. And in so doing we de-value what is common: parenting, friendships, the ability to care and empathise, the work of creating and sustaining the social infrastructure we all depend upon and without which nothing else would be possible.' This infrastructure is what Cahn calls the Core Economy - the system of interpersonal transactions that underlies and brings into being the mechanisms of the Fiscal Economy, the money economy we measure and analyze and panic over and to the support of which our governments have come to lend so much of their thought and energy in recent years. It is the Core Economy in which children are raised, in which friends and loved ones care for each other, in which nurturing and learning take place: who's transactions simultaneously make possible those of the Fiscal Economy and give them their meaning. Were it not for our relations with one another, the earning of money and the production of goods would be motiveless. 'I like to say that if the Money Economy is the software on a computer,' says Edgar, 'then the Core Economy is the operating system.' He explains that we have for too long taken the Core Economy for granted, believing that it will function without our direct support, that it will continue regardless of our attentions. 'We are now realising that the Core Economy does require our attention, that in the long term it will fall apart if we continue to devalue the talents and efforts that make it possible.'
The Fiscal Economy presently runs on a value system that is contradictory to that necessary for a healthy Core Economy. We tend to value qualities that are scarce amongst the population, things that few of us possess: tenacity, reason, artistry, abstraction, creativity, leadership; and for good reason. But in our obsession with these scarce things, we risk losing sight of those qualities we do have in abundance, those things we truly rely on for our well being.
'There are domains of endeavour that are best executed outside the market economy,' explains Edgar. 'If you contracted out brushing your teeth you wouldn't be able to afford it - you'd have to pay some specialist with insurance and guild membership and years of expensive training.' There are also domains that simply can't be accommodated in terms of money changing hands: you can't pay someone to care about you. You can pay someone to perform the actions associated with care, but you cannot make them experience the underlying emotions that inform the quality of those actions, that might provoke them to take interest in your well being beyond the letter of their contract.
People who have acquired disabilities are often victims of the scarcity economy. Many loose those things for which they have previously been valued, the skills they have sold on the competitive market, and find themselves then without value. In the scarcity economy, the fact that they may retain many central human capacities makes no difference because those central capacities are viewed as being abundant and therefore of little value. This is why mothers and fathers are not formally rewarded for their roles. And why nurses are paid less than doctors. The problem begins when these roles are actively undermined by policy decisions. People take intrinsic reward from doing the jobs of the Core Economy, or jobs that involve the same kinds of activities, but this reward is not invulnerable in the face of attack. If these roles are made too difficult or unpleasant, people will do them less effectively and, eventually, stop doing them.
According to Edgar the solution is to plug in a new value system that is supplementary to that promoted by capitalism. 'Money is a fantastic system for dealing with a lot of things, things we need and want. But it's not the only way of doing things and we have to have systems for recognising and rewarding the work taking place outside paid employment. We need alternative systems of exchange.' This is where Timebanking comes in. The theory is that by bringing people together to exchange time and effort without money changing hands, people outside the competitive job market can be reengaged and revalued. Edgar breaks down five principles:
1. Acknowledge that everybody has capacity
2. Define the value of currently undervalued labour (record and reward)
3. Ensure reciprocity in individual acts (pay it forward)
4. Invest in community and promote interdependence
5. Hellraising (lobbying, raising awareness)
These principles aren't limited to the Timebanking network. I have heard about food distribution networks and housing projects that operate on similar grounds. Even TV Chef Jamie Oliver's recent Pass It On project has elements in common. (Absurdly) I have yet to visit a working Timebank but one project I am excited to see is the Youth Court going on here in DC. In this system, young offenders are tried and sentenced by their peers (usually to community service), and can then enroll as members of the Court, taking up roles they are proud of. I fix a date to see the Court in action next month.
There remains one hard question: What happens when a person loses not only the skills valued by the scarcity market, but also those abilities that define them as a member of the Core Economy? What happens if a brain injury (or other circumstance) leaves a person unable to care, to reciprocate socially, to participate in friendships? How do we advocate for their value then? 'I would argue that most of your people can listen to someone, that most of them can work in a garden or watch someone's pet. But even those that can't do these things still have a critical function in teaching the most fundamental values of tolerance.' He describes projects in which young offenders are required to care for children with learning disabilities. 'I've seen even the most troubled of youngsters change their attitudes quite suddenly when confronted by people with greater problems than their own.'
This all fits well with my earlier thoughts on the value of problems - the symbiosis between difficulty and innovation. It also brings to mind something Harvey Jacobs said about his clinical work. He said this: 'I work with people who want to create opportunity from challenge.'
Edgar describes himself as a 'pathological optimist'. He says that human history has taken us through various phases - of nomadism and agriculture, to our current industrial times. He believes we reaching the end of this phase and that we are about to move into a new 'ecological era' - where we redefine and reorganize our resources. He is convinced that there is enough food and energy and water to go around, and that, with a new value system, the Western World can rebalance itself with its neighbours and arrive at a sustainable mode of existence. The ideology is vital to this shift, he explains, because values are central to behaviour.
Edgar gives me a print-out to take with me, a page of excerpts from a book called Mothers and Others by Anthropologist Sarah Blaffer Hrdy:
Psychologists know that there is a heritable component to emotional capacity and that this affects the development of compassion among individuals. By fourteen months of age, identical twins (who share all genes) are more alike in how they react to an experimenter who pretends to painfully pinch her finger on a clipboard than are fraternal twins (who share only half their genes). But empathy also has a learned component, which has more to do with analytical skills. During the first years of life, within the context of early relationships with mothers and other committed caretakers, each individual learns to look at the world from someone else's perspective.
And this is why I get so worried. Just because humans have evolved to be smart enough to chronicle our species' histories, to speculate about its origins, and to figure out that we have about 30,000 genes in our genome is no reason to assume that evolution has come to a standstill. As gene frequencies change, natural selection acts on the outcome, the expression of those genes. No one doubts, for instance, that fish benefit from being able to see. Yet species reared in total darkness--as are the small, cave-dwelling characin of Mexico--fail to develop their visual capacity. Through evolutionary time, traits that are unexpressed are eventually lost. If populations of these fish are isolated in caves long enough, youngsters descended from those original populations will no longer be able to develop eyesight at all, even if reared in sunlight.
If human compassion develops only under particular rearing conditions, and if an increasing proportion of the species survives to breeding age without developing compassion, it won't make any difference how useful this trait was among our ancestors. It will become like sight in cave-dwelling fish.
No doubt our descendants thousands of years from now (should our species survive) will still be bipedal, symbol-generating apes. Most likely they will be adept at using sophisticated technologies. But will they still be human in the way we, shaped by a long heritage of cooperative breeding, currently define ourselves?
Hrdy's ideas seem to add a greater urgency to Edgar's ideological discourse: a kind of use-it-or-lose-it biological imperative. If we don't nurture our ability to nurture, it may yet disappear, sink into dormancy, become no more than silt at the bottom of the gene pool, join the ranks of inert sequences down the twisting stairs of the human genome.
I have thought this: our future necessarily holds revolution (however sudden or gradual) in terms of energy and resource. Without unlocking new technologies for sustainable energy, food, water, we stand little chance of survival in the longer term. I have thought: social innovation is a side show, something that will happen along side or as consequence of these grander scientific narratives. But Edgar has provoked a different idea: that social and ideological evolution may be the decider in humanity's direction. People seem to me to be capable of almost anything. Crude determinations about human nature ('genetic' selfishness, religious altruism or somewhere in between) seem always to fall short. It seems to me that we are almost infinitely adaptable. And that what guides our adaptation is what we believe. The limits of our existence are those of what we can imagine and accept. There are constraints on our behaviour. Time is of the essence. Things may not work out as we expect.
DC Metro is Accessible
It says so on the posters. And it's true. DC's subway system is newer than those of many major cities. There is no need to Mind the Gap. There are lifts in every station. The platforms are nice and wide. In addition, the Metro is actually a pretty nice place to spend time. It's cool (but not cold), the lighting is restful, the sounds and voices that alert you to doors closing and stations arriving are reassuring (rather than ear-splitting), overcrowding seems to be the exception rather than the rule and the architecture has a pleasant retro-Jetsons modernist vibe, a sort of concrete honey-comb styling that puts me in mind of a great big friendly bee hive.

Friday, 22 May 2009

Thursday 21st May.
ADAPT Clubhouse, Arlington Virginia (just south of Washington DC). I get a tour from Chuck. He shows me the computer room, the kitchen, the meeting room, the office. He shows me the maintenance room where they fix things and build things. There are bird feeders lined up, getting mended. He says the squirrels climb up and knock them off. He takes me outside and shows me the garden at the front. He says he likes gardening. At home he built a deck on the back of his house. He isn't that great at building things but his father in law is and he told him what to do. He likes cooking too. That's what he does here at the clubhouse most days - works in the kitchen. When he was in hospital he worried what was going to happen to him - wondered what he was going to do with himself. But just about right after he left hospital he found out about the Clubhouse. Its good because otherwise he would just be sitting at home.
It's a busy day. Brian, the director, and Keith, one of the unit coordinators are out for the morning, but there are visitors coming (in addition to me) and a barbeque lunch to cook. I help Chuck out in the kitchen. I break up the lettuce. I peel the sweet potatoes and cut them into chips. I chop the onion. I help form patties from the pink mush in the bowl. The Clubhouse is low on members today - a lot of them are on holiday. It's Chuck and Steve and Kimberly and Marshall and Elmo and Kevin. They seem to work together well, even if they get a bit confused at times. At lunch I talk to Anna, Marshall's personal aide. She is from El Salvador. We talk about how many Spanish people are in America. She calls them 'Spanish', making me think of people from Spain, but I know she means people from Mexico and Central and Southern America, people like her. She had a visa and flew to DC, where she now lives. She said her mother told her not to go through Mexico. It's too dangerous. If she was going through Mexico, she wasn't allowed to go. We talk about all the work Hispanics do in America, all the work nobody else wants to do. And how they helped elect Obama. We talk about how the powerful people in America don't want minorities getting power. She says perhaps next will be a Spanish president. I ask if she knows someone who would be good. She laughs and says perhaps one of her children. Elmo is sitting nearby. Elmo is from Bolivia. He tells me he came to America through Mexico, the way Anna's mother told her not to go. His English is poor and my Spanish is worse, but he makes it clear that he walked across the border. He makes a shuffling motion with his arms, to indicate crawling on his stomach. He also explains that he has had two head injuries: one caused by a fall when he was a child, the other more recent. In the US he has been working as a dishwasher. Sitting at the computer I show him Google Maps. I zoom slowly in on the house I have been living in in London. With the Street View we are able to see the front door, the trees and steps at the front. He wants to see his home in Cochabamba. We zoom out and in again on Bolivia. We get as close as we can but Street View has not been set up yet for his city. We can see the long road to Tiquipaya, where he lives, but no more. Anna shows us San Salvador, the capital of her country but, again no street view. She seems amazed at the satellite images none-the-less.
Brian appears and introduces himself. We sit and talk for a while. We seem to be on the same page about a number of things. He says he's excited about the idea of my trip. He wants to know what he can learn from me, what I think of the other Clubhouses. I point out that he is a man, and that his staff are both men too - and all of them are young (none of them much over 30). And they're good too. From what I have seen today they really get the point. Brian smiles and says he knows. He understands why I'm drawing attention to it. I ask how he managed it. Admittedly, ADAPT isn't huge, but for any organisation involved in social care (or something that looks like it) to have an all male staff team is good going. There is no magic spell. Brian admits that he wanted to have men on the team, but Keith and David were both the best candidates at the time they were employed. He didn't employ them because they're male. But he's glad to have them. 'If you don't have enough men on the team the dynamic is wrong for the client group' (brain injury through trauma is much more common among men and many of the Clubhouses, and Headway East London have predominantly male clients). We talk about the Clubhouse model as well. Brian says the members have been taking less of a lead lately. They need a few more people who can take initiative, he says. The model relies on having a diverse group, on having at least a few members who are good at forming plans and following through. It's hard though, he says, because those are the guys who are going to want to get back into work, and they're more often going to succeed, so they don't stick around. Brian seems to take the view that the Clubhouse model for brain injury is still very much in development. 'People talk about how this works and that doesn't and how this Clubhouse is better than that Clubhouse - but we all have things we do well and things we do less well. You make choices based on what's happening locally and where you can get money. But the big challenge is to make sure everyone is included. It's very easy to cherry-pick the best members, the ones that are going to get back to work, who have less severe injuries, but that leaves a whole lot of people out and that's no good.' I've heard this criticism leveled at programmes in the UK - and have leveled it myself on some occasions. It makes sense at a business level - by carefully screening out the more difficult clients you keep your success rates up. But ultimately this is a cynical practice, one based more on the perpetuation of careers and institutions than on the needs of the client group. Brian strikes me as being passionate about this stuff. He takes it seriously. He tells me about some of the other projects under the Brain Injury Services in Northern Virginia. One of them helps people with injuries learn public speaking skills. There will be a talk by one of them at a University in DC in June. I'd like to see it. Brian is shocked that I've never tried Hershey's Kisses. He shouts that they are the best chocolate. David is eating Trail Mix. He says Brian's obsessed. He has a box he keeps in the cupboard. Brian piles a handful in front of me, then another. Then he takes out a bag and fills it for me.
Dish: Ultimate Burro; Resaruant: Mexicali Blues, Arlington VA; Opinion: Extremely good.