Marriage After ABI Putting the relationship back together conference/Annual... · • Post stroke-...

Department of Physical Medicine and RehabilitationHarvard Medical School

Christopher Carter, Psy.D. CBISTDirector of Continuity for Brain Injury and Spinal Cord InjurySpaulding Rehabilitation NetworkInstructor, Harvard Medical [email protected]

Marriage After ABI Putting the relationship

back together

Disclosures

Presenter has no conflicts of interest to report


Objectives

Following this presentation, participants will be able to:• Identify stressors placed on marriage by

ABI• Distinguish between pre-injury and post-

injury relationship problems• Identify strategies for helping couples

repairing their relationship following ABI


Brain Injury is a Family AffairMuriel Lezak

• Change in roles• Loss of partnership• Burden of decision-

making• Diminished resources• Family trauma• Change in supports

• Change in routines• Grief, ambiguous loss

and adjustment• Developing new skill sets• Large learning curve• Interrupts normal

developmental work


Stress on the Marriage

Divorce Rates

• 40-50% of married couples in the US divorce. • Higher rate for subsequent marriages

APA website

• Divorce rates following TBI range from 15%-78%Godwin, Kreutzer, Arango-Lasprilla, Lehan 2011

• Self described as less cohesive, less expressive, have more conflict, less active socially, more external locus of control, less like the ideal family, have increased enmeshment with rest of family

Tyerman and Booth 2001

• Higher spousal rates of dissatisfaction with post injury relationship compared with pre-injury relationship

Gosling and Oddy 1999


Predicting marital stability 2 yrspost injury

• 85% stable marital status, 15% separated or divorced• Instability associated with

– Age• 4.03 x’s greater for younger (36.2 yo) vs. older survivors (57.3 yo)

– Level of injury severity• 2.27 x’s greater for moderate GCS vs. severe GCS scores

– Cause of injury• 2.99 x’s greater for violent injury vs. non-violent injury

– Gender• 1.95 x’s greater for males with TBI than females with TBI

– Ethnicity• Caucasians: Increase in DRS increases instability• Minorities: Increase in DRS decreases instability

Arango-Lasprilla, et al. (2008)


Impact on Marital Relationship• Post stroke- Parent/child relationship, disturbance in equity, decreased

communication, Diminished intimacy• Survivors’ satisfaction tended to be higher than spouse• Couples engaged in finding a balance between giving and receiving

assistance agreeable to both• Tension between spouse’s views of care roles and survivor’s views of their

independence• Rethinking marriage:

– Reconfirmed around pre-stroke marriage, • Reciprocity and mutuality, working together, resolving conflicts, feeling each mattered to

their partner– Recalibrated around care,

• Reconciliation of differences in contribution, role of care-giver/recipient, power differential

– Parallel relationship• Mismatch in how relationship viewed, impact of deficits, loss of common interests,

activity task-focused around careAnderson, Keating and Wilson, (2017)


Substance abuse

RelationshipHistory

Pre- Mental Health

Age of relationship

Kids

Marital Satisfaction

Stage of Development

Pre-injuryRelationship


Pre-injury Factors Affecting Adjustment

Stages of Development

Unattached

New Marriage

Young children

Adolescence

“Empty Nest” Older

Life


Carter GA, McGoldrick M., 1980


Financial Resources

Family Supports

Coping resources

Shared Interest/activities

Social Supports

SpiritualResources

Extra-marital relationships

Relationship Resources Affecting Adjustment

Grief work

Post- Mental Health

Sourceof Injury

Spousal Trauma

Role Changes

Understanding of Impact of BI

Understanding of BI


Injury Factors Affecting Adjustment

Stage of recovery

Self esteem

Persistent deficits

Alexithymia

Sexual Dysfunction

Aggression

Anger

Mood Swings


Injury Factors Affecting Adjustment

Age Genderof Survivor

Empathic Capacity

Age Of Survivor

Self awareness

Communication Style

ResilienceCohesion

Relational Flexibility

Dyadic Consensus

AffectionalExpression

Communication Skills

Conflict Management

Conflict Tolerance

Problem Solving


Relationship DynamicsAffecting Adjustment

Presentation Assumptions

• Survivor has achieved sufficient recovery to be independent in self-care

• Survivor has capacity for self-reflection and insight

• Absence of active substance misuse and violence


Things the clinician needs to know• What is the story of the injury?

– Is it a shared story or is the survivor’s version different from the spouse’s?

• What has been the impact of the injury on the survivor?– Does the survivor have the same appreciation for the impact that

the spouse does?

• What has been the impact of the injury on the spouse?– Is this a shared view?

• What has been the impact of the injury on the marriage?– Dyadic consensus?

• What has remained the same?


Things the clinician needs to know• What is the story of the marriage?

– How did they meet?– Pre-injury functioning?– Pre-injury satisfaction?

• Who else is involved in the marriage?– Children– F of O, In-laws– Community

• What are the stressors facing the marriage?• How committed are you to staying in the marriage?


Assessment Tools• Family Needs Questionnaire• Family Assessment Device• Ways of Coping Questionnaire• Interpersonal Communication Skills Inventory• Social Problem-Solving Inventory-Revised• Marital Adjustment Test• Dyadic Adjustment Scale• Quality of Marriage Index


Spouse Survivor

Brain Injury


What is the interface between the survivor, the spouse and the injury?

9 Psychological tasks for a good marriage

1. Separate emotionally from the family you grew up in2. Build togetherness through shared intimacy and identity3. Establish a rich and satisfying sexual relationship4. Embrace parenting while maintaining space for the marital

relationship5. Confront and master the crises of life6. Maintain the strength of the marital bond in the face of adversity7. Use humor and laughter to keep things in perspective and to avoid

boredom and isolation8. Nurture and comfort each other9. Keep the early romance alive

– Judith Wallerstein APA website


Format• Couple together• Individual meetings• Couples Groups: Backhaus, et al,

Rehab Hosp of Indiana• Manualized trainings

– BIFI Brain Injury Family Intervention Kreutzer, et al Virginia Commonwealth University

– Backhaus (2016)


Themes to address

• Is it the TBI?• Competing perceptions of TBI and its effects• Role changes and survivor dependency• Unpredictability after TBI• Encouraging continued recovery• Impoverished communication between the couple• Restricted leisure and social life for the couple• Reduced sexual relationship• Reduced emotional intimacy


Themes to Address

• Encouraging self-care, asking for assistance• Building emotional empathy

– Appreciating impact of injury on both parties– Addressing shame, guilt, anger, fear,

ambiguous loss• Extending recovery

– Identifying and managing risk– Balancing support with independence– Balancing care-taking with independence


Skills to teach• Marital satisfaction linked with

– Positive perception of spouse’s communication skills– Positive perception of one’s own communication skills– An effective attitude towards problems– Use of problem-solving/positive reappraisal coping

strategies– Strategic use of avoidance coping strategies

• Recommend training in dyadic communication skills and problem solving skills

Blais and Boisvert 2007


Tasks for Therapy

• Consensus development• Behavioral change• Communication skill building• Problem solving• Conflict/Crisis Management• Negotiating the new normal• Symptom management including disruptive behavior• Stress management and positive coping strategies for

both participants


Skills to teach

• Interpersonal skills• Effective communication• Emotional regulation skills• Problem solving skillsBackhaus, et al


Effective Communication

• Respect– Partners hold each other in high regard, consider one another

unique and worthwhile

• Understanding– The ability to know and comprehend what it is one’s partner is

experiencing– Seeing things from the partner’s point of view– Not the same as agreeing with

• Sensitivity– Being aware of partner’s needs

Bornstein and Bornstein 1986


Elements of Effective Communication

Thinking

Listening

Nonverbal

Speaking


What I intend to say

What I actually say

What I actually hear

What I think I hear

What I think about what I think I heard


Good communication is complicated

Tone, volume,Word choice,

Body language

Communication Tips

• Listen actively/Use feedback• Edit criticism• Be gentle• Seek first to understand vs. Being understood• Ask open-ended questions• Stay calm• Use “I” statements• Self-soothing• Accept influence from the Other• Share appreciations

https://healthypsych.com/18-communication-tips-for-couples/


https://healthypsych.com/18-communication-tips-for-couples/

Strategies for Ending Arguments• Validate and apologize• Change the topic of conversation in a gentle, sensitive manner• Use humor (not sarcasm)• Yield to the other• Make gentle physical contact• Take a break and re-approach later• Acknowledge common ground• Set a timerhttps://healthypsych.com/18-communication-tips-for-couples/


Tips for Good Communication

• Timely communication• Marital manners• Feeling talk

– I feel X when you do Y in Z situation• Mind reading



Tips for Good Communication

• Avoid 4 horsemen of the Apocolypse– Criticism– Defensiveness– Contempt– StonewallingGottman and Silver 1999


Tips for Good CommunicationWhat helps• Be positive• Be flexible• Be brief• Be assertive• Be nondefensive• Personalize remarks (I/U)• Voice appreciation• Express affection• Measured honesty

What hurts• Nagging• Interrupting• Catastrophizing• Arguing over trivia• Overgeneralizing• Sidetracking• Demanding/threatening• Insulting• Sarcasm



Tips for Problem Solving• Choose an appropriate time and place• Record the vitals of the session: problem-solution, who

does what• Be specific in defining the problem• Accept the problem and move to a solution• Specify the desired goal• Brainstorm• Choose a solution with compromise in mind• Try it out• Evaluate and revise, refine, renegotiate



Homework to Allow for Practice• Opportunities to apply problem solutions• Time together

– Shared tasks– Shared leisure activities

• Things I appreciate about …• Caring days (behaviors that show you care) requested

by recipient– Husband: Give me a backrub, feed the dog, kiss me, go for a

walk with me, go to bed the same time I do– Wife: Compliment my cooking, ask how my day went, put the

cap back on the toothpaste, take me to the movies


On-line resources

• Brainline.org Starting marriage over after a brain injury

• After Brain Injury: New Vows Reflect a Changed Marriage

• Marriage After TBI– See Godwin et al (2014) for more listings


Resources• Backhaus S, Neumann D, Parrot D, Hammond FM, Brownson C, Malec J

(2016) Examination of an intervention to enhance relationship satisfaction after brain injury: A feasibility study, Brain Injury, 30:8, 975-985

– https://doi.org?10.3109/02699052.2016.1147601

• Bornstein PH, Bornstein MT (1986) Marital Therapy: A behavioral-communications approach Pergamon Press, New York

• Godwin EE, Chappell B, Kreutzer J (2014) Relationships after TBI: A grounded research study, Brain Injury; 28(4):398-413

• Godwin EE, Kreutzer JS, Arango-Lasprilla JC, Lehan TJ (2011) Marriage After Brain Injury: Review, Analysis and Research Recommendations, Journal of Head Trauma Rehabilitation; 26(1), 43-55

• Gottman JM, Silver N (1999) The Seven Principles for Making Marriage Work, Three Rivers Press, New York

• Kreutzer J, Kolakowski-Hayner SA, Demm SR, Meade MA (2002) A Structured Approach to Family Intervention After Brain Injury, Journal of Head Trauma Rehabilitation, 17(4):349-367


https://doi.org?10.3109/02699052.2016.1147601

Slide Number 1DisclosuresObjectivesBrain Injury is a Family Affair�Muriel LezakDivorce RatesPredicting marital stability 2 yrs post injuryImpact on Marital RelationshipPre-injury Factors Affecting AdjustmentStages of DevelopmentRelationship Resources Affecting AdjustmentInjury Factors Affecting AdjustmentInjury Factors Affecting AdjustmentRelationship Dynamics�Affecting AdjustmentSlide Number 14Presentation AssumptionsThings the clinician needs to knowThings the clinician needs to knowAssessment ToolsWhat is the interface between the survivor, the spouse and the injury?9 Psychological tasks for a good marriageFormatThemes to addressThemes to AddressSkills to teachTasks for TherapySkills to teach�Effective CommunicationElements of Effective CommunicationGood communication is complicatedCommunication TipsStrategies for Ending ArgumentsTips for Good Communication�Tips for Good Communication�Tips for Good CommunicationTips for Problem SolvingHomework to Allow for PracticeOn-line resourcesResources

Marriage After ABI Putting the relationship back together conference/Annual... · • Post stroke-...

Documents

Transcript of Marriage After ABI Putting the relationship back together conference/Annual... · • Post stroke-...