The Great Before and After

Cathy Crimmins (Knopf, 2000)

"We thought we had experienced crummy vacations before the disaster
on the lake in Canada." So begins Cathy Crimmins' story about the
lakeside holiday that ended when her husband, Alan, was hit by a runaway
speedboat. That accident severely damaged Alan's brain and divided their
lives into "the great before and after." Before the accident, Alan was
bright, witty, intense, and life was normal. But after the accident,
everything changed.

In Where `Is the Mango Princess?, Crimmins describes the
frightening aftermath of traumatic brain injury and the agony of living
with the desperate question, "Will he live?" and then moves on to Alan's
rehabilitation and the more mundane yet horrific question, "Live for
what?"

As is common in head injury, Alan suffers speech and motor
difficulties. But more alarming than these are the behavioral changes. He
tires quickly, quarrels childishly and competes with his 7-year-old
daughter Kelly, and is markedly uninhibited--he swears in public, makes
gauche remarks, and laughs and angers quickly. (In the first few weeks
after the injury, he openly masturbated.)

Yet Alan is one of the luckier victims of serious head injury. His
education, motivation, family support, and intelligence are in his favor,
and in the brief time frame of the book, he exhibits a remarkable degree
of recovery. With the use of a paid assistant, he returns part-time to
his work as a trust officer at a bank within months of his injury. But he
is unquestionably changed. The complicated Alan has been replaced by a
simple, impulsive guy who yells at his daughter.

The book is filled with telling anecdotes about Alan's
inappropriate behavior and poor judgment. These are the stories shared in
caregivers' support groups, the gritty day-in, day-out incidents that can
erode the most resilient of family relationships, and that lead to
divorce in 95% of cases.

The early months following head injury are a painful, emotionally
and physically exhausting period for the victim's family. Crimmins takes
us into this stress-filled arena. She ably captures the kaleidoscope of
intense emotions felt by a spouse confronted with a beloved person who
looks the same but who is now someone else. We share her fear for their
future, her anger at the interloper (who now calls himself Al), her grief
at the loss of her absent husband, her fragile hope that the missing Alan
will return, and the grim despair during those moments when she is sure
he won't.

Crimmins (author of When Parents Were My Age, They Were Old and
Newt Gingrich's Bedtime Stories for Orphans) is a skillful storyteller.
Her book is a compelling chronicle of her struggles immediately following
the accident, throughout the acute recovery phase, and into the early
stages of rehabilitation. Readers will gain an appreciation of the
devastating effects brain injury has on the victim and the victim's loved
ones. They will also feel the frustration and anger of a woman who must
now add spousal caretaker to her role as a mother with a successful
career.

Regrettably, Crimmins' book tells us only about the first several
months of recovery, and inevitably leaves us with the impression that
there is little basis for hope. Brain injury rehabilitation is a slow,
repetitive, boring process that plays out over many years of dedicated
effort. Yet there is reason to hope: The injured can continue to improve
for years; there are programs that can teach strategies to manage
impulsive behavior; there are support groups for families; and there are
methods to improve family dynamics. If this story had been written after
Alan had had more time to progress, readers overwhelmed by the burden of
chronic caretaking might feel more encouraged.

Even so, the book has much to recommend it. Crimmins highlights two
important problems facing the brain injured: First, most insurance plans
and HMOs do not provide full rehabilitation coverage, so victims do not
progress as rapidly as they could. Second, the brain-injured have great
difficulty in returning to employment. Most need to be trained for new
work, and others need special accommodations at their old jobs. Although
Alan made an enormous effort to return to work part-time at his bank, he
ultimately lost the job because he could not work full-time. Ironically,
he could have received disability income for staying home and not trying
so hard.

Where Is the Mango Princess? is an intimate view of a family
struggling through the aftermath of a serious brain injury. This story is
not only well told, but also compelling and memorable.

Adapted by D.O.

Claudia Osborn, D.O., is the author 0f Over My Head: A Doctor's Own
Story of Head Injury from the Inside Out (Peripatetic, 1998), and is an
associate clinical professor of medicine at Michigan State
University.