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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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)
Department of Physical Medicine and RehabilitationHarvard Medical School
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)
Department of Physical Medicine and RehabilitationHarvard Medical School
Substance abuse
RelationshipHistory
Pre- Mental Health
Age of relationship
Kids
Marital Satisfaction
Stage of Development
Pre-injuryRelationship
Department of Physical Medicine and RehabilitationHarvard Medical School
Pre-injury Factors Affecting Adjustment
Stages of Development
Unattached
New Marriage
Young children
Adolescence
“Empty Nest” Older
Life
Department of Physical Medicine and RehabilitationHarvard Medical School
Carter GA, McGoldrick M., 1980
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
Injury Factors Affecting Adjustment
Stage of recovery
Self esteem
Persistent deficits
Alexithymia
Sexual Dysfunction
Aggression
Anger
Mood Swings
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
Relationship DynamicsAffecting Adjustment
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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?
Department of Physical Medicine and RehabilitationHarvard Medical School
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?
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
Spouse Survivor
Brain Injury
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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)
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
Skills to teach
• Interpersonal skills• Effective communication• Emotional regulation skills• Problem solving skillsBackhaus, et al
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
Elements of Effective Communication
Thinking
Listening
Nonverbal
Speaking
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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/
Department of Physical Medicine and RehabilitationHarvard Medical School
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/
Department of Physical Medicine and RehabilitationHarvard Medical School
Tips for Good Communication
• Timely communication• Marital manners• Feeling talk
– I feel X when you do Y in Z situation• Mind reading
Bornstein and Bornstein 1986
Department of Physical Medicine and RehabilitationHarvard Medical School
Tips for Good Communication
• Avoid 4 horsemen of the Apocolypse– Criticism– Defensiveness– Contempt– StonewallingGottman and Silver 1999
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Bornstein and Bornstein 1986
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Bornstein and Bornstein 1986
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
Department of Physical Medicine and RehabilitationHarvard Medical School
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
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