Understanding Executive Skills

  • Introduction
  • The Captain of Your Ship
  • Managing Expectations
  • Description of the ‘Inside’
  • The Energy Expended is Enormous
  • How Things Should Feel and Work
  • Interrupted Harmony
  • How it Feels
  • Divergent Outcomes
  • Intention remains intact
  • Brain Injury – a Personal Experience
  • The Knock-on Effect
  • From the Outside
  • The Stress Can be Unbearable
  • The Thick Layer of Disability
  • Things that Can Help
  • Practical Tips

Introduction

There are a whole range of skills that the brain performs, which fall under the umbrella of ‘executive skills.’ 

The impairment of other, but related skills, such as communication and memory, often get a lot more attention than the role the ‘director’ of the brain plays, and yet it is often the absence of this ‘overseeing’ intelligence that causes the difficulties people have with performing tasks after brain injury.

Imagine the director of a movie or play.

He has to be able to tell everyone what to do, how to do it, and when. He is a multi-tasker and orchestrator of great things.

He knows everything, including every detail of the script, the cast, the sets, the mood, the meaning, and importantly, can visualise his goal or the end product.

He can manage and instruct a whole cacophony of dynamically changing scenes and information, and he can do all of this faster than we can blink.

As the overseer, he has the visual capacity to be able to hold the goal in mind and is then able to break it down into pieces, order them, make modifications where needed, and turn the intention or desire into an achievement.

Disruptions to the application and distribution of directive intelligence are typical following trauma to the brain. It is as though the director has gone AWOL, or is persistently absent.

Both the primary and secondary causes of brain injury can affect the way the executive works.

Historically it has been thought that the location of our management systems of the brain is in the frontal lobes. However, there is now a broader understanding that many alterations in brain function can contribute to difficulties in coordinating skills.

Lifestyle habits, such as the consumption of alcohol and drugs or a poor diet, poor sleep, lack of fresh air and daylight, and also stress and imbalances in gut flora, can contribute to increased difficulties in functioning.

Even those people who have never had a brain injury can struggle with executive thinking, mental clarity and flexibility, and performing tasks, simply because their overall health isn’t what it could be.

The captain of your ship

Imagine being the captain standing on the bridge of your ship. 

Down in the engine room, and throughout the rest of the ship, the crew are busy performing many functions making sure all your orders are carried out.

It is the first mate who takes on the burden of making sure all the details and orders and being carried out by the right crew members at the right time. This is relatable to the way your executive systems respond to your metacognition.

You, the captain are the decision maker. You decide what the crew will be fed, and how much rest time and sleep they get. You know if you work them hard, then you have to treat them well.

This is similar to how you treat your body at a cellular level following brain injury. If the crew are pushed too far, they will need more care to keep them going, than they do under general duties.

Just as the damage to the ship affects the working of the whole crew, the trauma and injury to your brain, affects your whole body. 

How well you treat your body post-injury, will affect your brain environment, and therefore the bio-chemical function of your brain. You have to make adjustments when pandemonium breaks out, otherwise your ship will list and become dead in the water.

On top of the crew, you have many tools at your disposal but if one thing goes wrong, it can create a domino effect.

This is exactly what it is like inside your brain following trauma and injury.

A chain of events starts, and the only person who can get things working again is you. You might call in outside help and have specialists brought in to assess the damage to the ship, meaning you have extra support and help. Understanding that others have the expertise to help you find what is malfunctioning, is a great idea!,

We can all see how changing your normal routines and habits, is not only necessary, but vital. It is a good idea to seek expert opinion when you are dealing with chaos and disorder – especially when the damage you are dealing with is tremendously complex.

It is the Captain who directs the director of the play or the conductor of the orchestra. He knows the chosen destination, and he also knows precisely how he wants to get there. 

He is reliant on his first mate, his executive systems, to help him accomplish what he wants.

When the changes and overload bring the captain down, he goes on autopilot. Under great duress and pressure he might be unable to make decisions in the same way he did before – he has to adjust.  

Before the damage occurred the Captain could give an order and someone down in the engine room turns the steering wheel or changes the speed. Despite the fact that the ship’s engineer can’t see out – he knows that if he does exactly what the Captain orders, then everything will work exactly as it should do. 

The brain works like this. Different executive functions know they can each rely on each other to create a whole, to achieve set objectives, wishes and desires. 

If the mechanics and systems aren’t working, the Captain needs to address this. He has to create new plans to manage the changes. 

Living with a brain injury is just like this. You have to employ new strategies and tactics to keep the ship afloat until you have repaired the damage and have all cylinders in all the engines firing again. 

You are the Captain of your ship.

Your ability to hear yourself think, monitor your progress, and perform multilevel and complex tasks is down to who you are; your preferences, values, beliefs and personality. 

If you can no longer hear yourself think because your brain is injured, then you can no longer monitor and clearly direct your actions, communications and behaviours. 

Your underlying assets are still there – they just can’t be reached or function the same way because of mechanical failure or damage that requires repair. 

It is this thinking voice, or metacognition, that drives the executive functions which in turn, make your ship head where you want to go. With the crew and mechanics in a mess you have to develop new strategies to support the ship until you can hear yourself think again.

Managing expectations

For those who are living with the outcomes of brain injury, it is essential to release self-expectation. 

Although this may sound scary,  it doesn’t mean that you don’t retain your determination to rewire and heal your brain. What it means is that you shift your focus to acknowledging the tool you use is broken, and from here you create the acceptance that your reality has changed, and you will need to do a lot of work to get it back.

Things never change back to exactly how they were because we are all in a state of dynamic evolution and change, brain injury or not.

What you can aim for is to feel like yourself again, and to be able to carry out daily tasks in a way that supports your life. Many people return to education or to work. It is also best to release any temptation to set limitations or fall into negative thinking patterns – you will only exacerbate all the symptoms you are already struggling to manage.

Focus on increasing understanding of your impairments and re-evaluate expectations through introspection and self-education. A positive and practical approach can help prevent run-ins, disappointment, and resentment.

Remember, change is happening to everyone, and we can either acknowledge this change, accept it, and start working constructively towards a better future, or we can drown under fear, stress and self-pity. It is time to be practical.

It can also be difficult for family and friends to shift their expectations – especially when there are no outward visible signs of injury. 

Any neurological expert should be able to help you understand the changes, and what has happened to your brain.

Learning to ‘extract’ you from personal embroilment with impairments is crucial. Everyone should speak to you in terms of the differences in brain function. If you are struggling to make this divide, Cognitive Behavioural Therapy from a professional with proven experience of working with people who are living with brain injury, can help.

Description of what is happening on the inside

Imagine trying to play a complex piece of music without a conductor, making a movie without a director or running a ship without a first mate. 

This scenario makes living with a brain injury very tough, but it can be even tougher when you have a loss of insight and self-awareness as well. These losses effectively mean the Captain of the ship or the Producer of the concert, play or movie, has gone AWOL.

Now you not only have a missing crew, first mate and mechanical failure – i.e. executive function – but you also have no captain to come to the rescue – i.e. metacognitive function.

We can all understand how chaos can quickly and easily ensue. This turmoil is a precise example of what it is like to live with a brain injury; with the disorder being inside your head in every moment of every day.

When the brain dysfunctions following trauma or injury, it can be impossible to pinpoint, understand, or describe what is going on. It feels a bit like trying to catch a goldfish with soapy hands.

When the executive systems work, the ‘ conductor,’ is always unnoticed and is generally taken for granted.

Executive functions happen or work so fast that we have no reason to be consciously aware of them. This ‘conductor,’ or director, gains his position through years of trial and error – it is an unconscious facet of the brain.

The energy expended is enormous

Trying to ‘force’ a thought after a brain injury is like sending a probe into space with no instructions. 

The effort invested in attempting to find a direction or starting point is enormous, and the return of data can often take very long periods using copious amounts of energy.

What we have to remember, and be aware of or acknowledge, is that a lot of our learned experiences and memories that existed pre-injury are damaged, and the pathways to them are missing or obliterated. It is harder to work things out and the more effort we have to make, the more energy we use.

For those living with brain injury just being awake is energetically draining because there is always ‘incoming’ information that has to be filtered and sorted because the automatic systems of are no longer doing this automatically.

The injured brain really is working on overdrive.

Rewiring the brain is perpetual and enormous amounts of effort are being put in. As such, the brain is always on ‘red alert’ watching for errors and learning, which again, uses vast amounts of energy. It is, therefore, imperative that we provide our bodies with essential micronutrients and quality restorative sleep.

The toxic biological and chemical cascade that happens following the initial insult doesn’t help, so it is also imperative that we use nutrition and supportive supplements to improve the brain environment.

How things should feel and work

When ‘the conductor’ is working, we have clarity and feel brilliant.

All our cognitive and perceptual skills are integrated by the executive systems. This activity happens at a high level compared to other tasks the brain undertakes. 

We feel as though we can find out everything we need to know, and we live in a routine where most of our actions are carried out on an unconscious but competent basis.

We are readily able to absorb, understand, and learn new information. In many ways, people can ‘feel’ as though they already know everything they need to know for daily life. It is only when change happens that we have to make conscious adjustments to our plans and so on.

Unless we sit down and give it some serious consideration, we are unaware of the higher level activities of the executive systems because they are so spontaneous. 

It is the executive system which works out what data we need, and what preferences, values or beliefs are needed to create a predictable and familiar outcome. 

The brain can’t do this after it is injured because the routes to the data and our personal information are damaged. The areas of the brain that help us to be flexible, adaptable, aware of consequences and are monitoring what we are up to can also be damaged so they often fail making it even harder to be like our normal selves. 

We are usually more aware of executive functions when something changes or we are problem solving. This is when we have to put in the conscious effort to create new plans and goals. 

Our executive functions are involved in helping us understand what we need to do and how we will do it, and this can and will only happen if your brain is able to interact with your self-awareness and ability to reflect, practice, consider and learn which are cognitive skills associated with insight or recognition. 

When people lose insight and self-awareness they are left working on auto-pilot which is where so many things go wrong because this autopilot is only able to do what it remembers about the past, and it can’t take into account any ‘new’ information.

It feels as though everything you are trying to do throughout the day is the first time you ever did it – hence another reason why so much energy is being expended. 

 Where there are attentional problems, there are also executive ones. We need to be able to pay attention to control non-routine activities and the behaviours associated with managing something that is effectively starting from scratch each time.

In the main, ‘good thinking’ and the feeling of clarity happens when the ‘conductor’ is orchestrating our thinking and beliefs about the events in our lives. The ‘healthier’ the conductor,’ the better we feel. 

A working orchestra is a harmony in motion. The conductor can define every movement of every musician.

There is a fluidity that makes us want to get up in the morning and makes us look forward to every day. Brain injury can take this away.

Interrupted harmony

Information in the brain ‘resonates’ like a bow being pulled or pushed over a stringed instrument. 

When the neurological structure is damaged, this ceases to happen; when the brain is hurt, damaged, or dysfunctional – the ‘harmony’ is interrupted.

Instead of following a ‘set’ path, thought discords and gets lost or entangled making it hard for information to flow.

Effectively, outcomes lose their unique impetus.

Thoughts no longer know where they started, or where they should go to – the conductor has gone AWOL – leaving chaos and profound confusion in the aftermath.

When it comes down to ‘living’ with these outcomes, it takes the utmost of determination and brute force to correct things – if you are able to notice what went wrong.

Recovery can take years, or even decades, and at some level is ongoing for a lifetime. For many, these struggles can be continuous without them ever fully realising the cause. 

People living with brain injuries usually instinctively understand, at some level, that there are at least some, if not very, very many aspects of their injury, that are beyond the perspectives and understanding of most people.

How it feels

Imagine each thought you have is a balloon. 

When they work well, they make you happy; you have a sense of understanding and achievement.

When things go wrong with your thinking, you can fall to the ground very quickly, and if this happens a lot, which it does, it becomes harder and harder to pick yourself up.

Every thought, and having an awareness of each of them, is vital to our state of mind and general well-being. Our inner confidence and self-esteem rely on how well we know ourselves. The last thing any of us want is to know how it feels when our balloons have popped.

When the brain is injured, it can feel as though everything is happening ‘to you’ without any chance of being able to choose anything – not even the thoughts you have. It is like a perpetual tsunami going off in your head, and no matter how hard you try, constant flooding and fogs pervade the mind.

Divergent outcomes

Living with brain injury – you think you have plugged one hole, only to find there are so many leaks you are in danger of drowning. 

For many, it feels like your brain is drowning, and so you try diversion tactics.

While some people will withdraw, others will try to do something they consider routine, such as meeting a friend for lunch, only to find that all the background noise is swamping you, the bright lights are blinding you, and the general cacophony is ‘painful’ to your senses.

You try to relax with the TV, that should work! But you find that you can’t follow the programme, or even remember what you are watching or why.

There is no reprieve; there is no let-up. You try to sleep, and your brain won’t shut up. You are exhausted, and the general meaning of feeling overwhelmed doesn’t even begin to cut it.

Living with a brain injury is horrible. Brain injury doesn’t ‘let-up’ and never gives you an occasional hour or day off.

Depending on how severely the physical brain is damaged, and how severe the toxic chemical overload is, creates different experiences for each individual.

The enormity of the outcomes can be very divergent.

Intention remains intact

Think back to the explanation about a whole new dictionary being needed to explain how it feels to have a brain injury. 

When your executive systems ‘go down,’ it is beyond confusing.

It feels as though just trying to think switches the internal washing machine to a persistent ‘on’ position. Everything is tumbled around and mangled, so much so, that it can make you feel physically nauseous or desperately uncomfortable inside your own skin..

Thoughts should follow a linear pattern. This ‘thing’ should make sense because the last ‘thing’ seemed to make sense.

That the previous idea was unconnected or the gist misconstrued, is often immediately lost, and you carry on doing things badly regardless.  You may never realise your understanding needs updating.

It may ‘feel’ like a thought, or something you said should make sense, and yet it doesn’t because you can’t quite grasp it. It feels as though whatever happened was so fleeting that you can’t catch it – and you can’t because what you are trying to grasp is spontaneous executive dysfunction. 

Amongst the chaos, Intentions remain intact.

The innate personality or authentic self remains intact.

The impetus that starts any behaviour, communication or thought, is the same. It is when it passes through the broken brain that it all gets muddled and disjointed, and things come out differently to what we thought or wanted.

Intention happens at a quantum energy level; its’ matrix entangled in who we are. It isn’t dependent on the physical functionality of the brain even though neurological damage can disrupt our access to knowing this authentic self.

Whatever their source, thoughts should form a pattern and feel right, and this doesn’t happen after a brain injury. For those with less severe outcomes, things aren’t always this wired or weird – but they are ‘uncomfortable’ all the same.

Brain injury – a personal experience

In many ways it is almost impossible to explain what living with a brain injury is like because there are no accurate comparisons in everyday life. 

You can’t take the imagination of an uninjured person to ‘Neverland,’ and let the story unfold so that they can experience what it is like to live with a brain injury.

People have to rely on their knowledge and a host of other skills instead.

It is like not being able to imagine the ‘magic’ of fairy-dust – no picture or words can make you feel the experience of brain injury. The same kind of thing happens with understanding your brain injury, which is why so few people try to describe it.

No one can ‘make’ the root or foundation of your imagination ‘just be there.’ We all know this. We all know in our hearts that the best we can do is to gain as much knowledge and understanding as we can.

How long the perpetual confusion of brain injury will last for is dependent on many factors, and will strongly depend on the amount of help and support people get and from where.

When there is no clarity, it isn’t about being able to go back to point ‘A’ quickly to restart your thinking. Finding or re-finding point ‘A’ for someone living with a brain injury is like picking out one starling from a flock.

If you can no longer reason things through logically, then where do you start?

Executive dysfunction has a knock-on-affect.

The ‘conductor,’ or brain executive, should drive everything else.

When it isn’t, it is a bit like being the immobilised passenger in the back seat of a car when the driver is blindfolded, completely ‘tallyho,’ and has no care for how you feel or what you go through as a result.

It is as though someone else is in charge, and they are pulling you around on a gurney behind them so that you only get a glimpse of what is going on.

Your perspective of life alters inordinately.

Some part of you knows that what you are experiencing is wrong – but there is no other part of you that is functional enough to understand or put it right.

From the ‘outside’

While the ‘inside’ of brain injury is an inescapable labyrinth, looking at, or ‘observing’ someone who has lost their executive functionality from the ‘outside,’ can be like watching a master illusionist. 

Nothing you ‘see’ is real in terms of anything and everything you have ever experienced before.

For some people, especially those who haven’t been given any information or told what to expect, the role of caregiver can be tremendously stressful. In these cases, your assumptions are often just that – best guesses. Judgements become just as weak as you try one tactic after another. You are doing your utmost, giving your best, but nothing you do seems to be helping.

Sometimes it can feel like most everything you do or say to help is thrown back in your face. You can’t work out why. How can the best of intentions go so awry?

You may get frustrated with being told that you don’t understand. Efforts to be empathetic, compassionate, attempts to help, can feel like ammunition that fires back at you at a fast rate of knots. Changing the way you communicate may help; educating yourself certainly will.

You think, ‘just shut up then,’ and go about your business, and sometimes even this doesn’t work. You can’t win. You feel as though whatever you try, in some way every effort is thwarted.

Some people put this down to changes in the personality of the person they love and try and get on with things the best they can.

Others reach out for help or try to research the situation they are experiencing. Many answers are incomplete and leave people feeling isolated. A lot of people feel as though they, ‘didn’t sign up for this,’ and they may leave a relationship or withdraw from trying.

When everything is disjointed, there don’t seem to be any ‘complete’ answers. You have to keep trying because you believe there must be another way.

The stress can be unbearable

Leaving ‘comparison’ aside, living with, or being in the life of someone who can longer make thought ‘A’ connect to thought ‘B,’ can take a lot of patience.

What you see as uncharacteristic laziness is probably due to your loved one struggling with the fuzz or fog they feel when the director and captain are AWOL.

What you see as uncharacteristic moodiness, is perhaps due to your loved one feeling lost and frustrated that however hard they try, nothing forms a thought that gives them momentum.

All of the things that you see as being ‘out-of-character’ will be due to the impact an injury has had on the brain and the consequential dysfunction. Resist the temptation to put it down to a changed personality. The essence of a person remains the same; it is their behaviour that changes.

Some of the changes you see will also be down to the psychological trauma, and people must be referred for grief counselling to deal with feelings of loss.

The ‘why’ questions can spiral around for a long time, especially where there is a lack of expert help. Ambiguous loss and the resulting anger and distress need professional help to gain resolution, but, again, grief or sadness should be understood in context rather than becoming a one point of blame for changed behaviour.

Everyone needs to address their feelings about the changes a brain injury brings at some point. The effects of a brain injury, the initial trauma, these all ripple out and affect everyone.

Many people living with brain injury won’t be able to automatically see or understand that other people got ‘hurt’ too. They may need some gentle help understanding, and even with this, it may take time for them to realise and work things out for themselves.

Very often, people living with brain injury struggle to understand the needs and feelings of those around them. They may not be able to read or understand your reactions or pain the way they used to.

The thick layer of disability

The loss of function, the inability to have flowing thought, isn’t down to attitude, it is due to the ‘real’ person being ‘drowned, by the thick layer of disability.

The loss of executive functionality can feel as though you are a ping-pong ball forced beneath the surface of everyday life. You are never allowed up for air.

No one sets out to be self-centred; what families and friends see and feel is all the injured brain can actively manage.

No one wants to be unable to consider the feelings of others.  Much of the time, even when this is pointed out, it holds no meaning. If you can’t reflect on your own thoughts or feelings, you can’t process what is happening to other people either.

The reason for this lack of meaning is although the intentions are still happening precisely the same way as before – it is the inability to ‘see,’ and be self-objective, that is getting in the way. When there is no feedback happening it feels as though all you can do is try to get on with the next thing.

Much of this is down to the fact that the brain is no longer flowing the way it did. It can be impossible for someone to be able to understand what ‘normal’ people see from the ‘outside,’ and it can feel very much as though you are now trapped in an alien world far from the one you used to know.

It feels as though Scottie beamed you up when you weren’t looking, and now everyone else has remained in everyday life, and you are alienated from it entirely.

It feels as though you are hanging on to the periphery of everyday life by your fingernails. 

Things that can help improve executive function:

  • Positive Health – Eat for Nutrition
  • Getting professional help and therapy
  • Repetition
  • Learning to be self-objective
  • Supplements
  • Self-regulated learning

Practical tips

Ask your doctor for a referral to a neuropsychologist. 

Some specialists will concentrate on functionality rather than overcoming symptoms or vice versa.

Your doctor may refer you to a neurologist, who, if he doesn’t think your life is in danger, might focus on prescribing drugs but will likely ignore the problems with functionality – it isn’t his ‘field.’

The type of help you get will very much depend on who you see, and you may get batted about from pillar to post as you try to find the right person. A general practitioner may not even be aware that your brain can be injured, or may not know that they need to refer you or know that services are available. It might help to take information with you – Brain Injury A Guide for General Practitioners – Click To Print / Download

You can try to get the ‘executive’ to work again through specialist treatments such as occupational therapy, and by using other therapies, but the truth is that until you alleviate the symptoms that erupt from the secondary outcomes of brain injury, you will be fighting an uphill battle. 

Alleviating the symptoms must, therefore, be the first port of call and a neuropsychologist is the best person to direct what you need.

For those who do not have access to further medical support, please see the ‘things that can help’ above.

The range of symptoms can be very varied, but, as regards executive functionality some of the biggest problems are neurological fatigue, the loss of clarity, loss of connection, and the overwhelming feeling of being ‘ fogged’ and unable connect your thoughts, along with losing those skills that help with daily living.

At the time of injury, the brain is subjected to a cascade of biochemicals, causing problems with understanding and executive function. There are known connections between executive dysfunction and neuroinflammation.

In a way, the impairments are protective because the slowing of the mind allows the automatic survival systems of the brain to take over. You don’t know what you don’t know so to begin with you may be oblivious to the problems you have and are therefore shielded from the worse aspects of brain injury.

This change interrupts the intellectual capacity to choose and to be consciously aware, so that the ‘reptilian brain,’ the centre of flight and flight, can focus on its’ primary objective – which is to sustain life.

Some outcomes relate to the brain being aware it is injured. It isn’t worried about how you feel – it is concerned about making sure you stay alive while your sense and senses are numbed and discordant because of the physical disruption that has occurred.

Once this cascade starts – the switch is in the ‘on position. The chemicals which flood the brain, in theory may allow your survival mechanisms to be in charge. The poor brain environment causes the common symptoms of brain injury.

This cascade is effectively both friend and foe. Inflammation is a biological healing response, and yet, when unaddressed, it can prolong symptoms for months or years.

This biochemical overload, as explained in what happens to the injured brain, and the dangers of stress and cortisol, can cause mayhem – headaches, dizziness, trouble interpreting and organising your world, and so on.

This ‘on-switch’ also exacerbates the influences of PTSD.

Symptoms are indicators of what is wrong; they are like ‘way-markers’ or signposts. Very often, people ignore the importance of these signs of underlying medical problems and most often the main aim is to get rid of them, usually with prescription medications. The synthetic chemical agents in these drugs often exacerbate symptoms – or cause others – because the injured brain can be more sensitive to prescription medications. Many people do find relief though, so it is essential to speak to your doctor, functional practitioner, or neuropsychologist.

A lot of people get frustrated because they know that medication is just masking the problem, but very often, people feel as though they have no other choice. It doesn’t matter whether you, or the person you love, is at the acute phase, or are years down the line of struggle, there are things you can do.

Services are available although it can be a minefield getting to them.

What you need for executive dysfunction is a neuropsychologist who can order a neurological assessment and will guide your treatment and the team of neuro therapists you need.

If you are having problems getting to these specialist services, local support groups can often help with advocacy or information. Type, ‘brain injury support group near me’ in your browser.

Things you can do to help yourself or your loved one.

We discuss most of the strategies for overcoming executive dysfunction under the individual outcomes, such as the specific cognitive and emotional/behavioural struggles that generally occur. We will come to these.

There are very few published tips for the actual thinking and understanding issues that arise. What you don’t want to do is spend months or years struggling with problems which you can alleviate by trying black seed oil and by using other strategies. See how much all this helps first.

Whatever you do think of solutions in terms of a whole-body-approach. 

Other ideas:

  • Practising Objective Observation to increase self-feedback
  • Play games – do puzzles, especially sudoku
  • Journaling – each day read back the previous day and repeat
  • Use positive feedback to help your brain understand when it is doing well – pat yourself on the back and tell your brain, ‘well done!’