Relationships After Brain Injury:
In celebration of Valentine’s Day, we’re posting articles that  may shed some insight into relationships, post brain injury.

Emotions alter Relationships after Brain Injury

By Dawn Neumann, Ph.D.

TBI changes communication in a marriage

The woman in my office was clearly a very successful woman, who for the most part, usually had it together.  But now it appeared she could fall apart at any second. She was there to talk to me about her husband who had a traumatic brain injury (TBI). She told me that since the accident, he had made terrific strides learning to walk again, improving his balance, and regaining most of his thinking skills.

Hold onto hope.Despite these monumental improvements, there was still a terrific strain in their relationship.  She no longer felt “connected” with her husband. The wife was frustrated and perplexed. Prior to the injury, which was just months before they were married, he was an extremely compassionate person always in tune to her emotions. Now he was oblivious to her needs.  He never comforted her in times of sadness or worry. He was unresponsive to her frustrations.  He never participated in her joys, not even when their first child was born. Was this because he didn’t care?  Most people would assume so, but as you read on, you will see that this is because he just couldn’t tell how she was feeling.

Brain injury can affect relationships with everyone

We all know relationships can be very challenging. This does not just refer to relationships with spouses, but relationships with family, friends, coworkers, and even acquaintances. Add a brain injury into the mix, and these relationships can become even more stressed. In fact, relationship problems are one of the most frequently reported long-term and devastating consequences after brain injury. They often cause families who have been touched by a brain injury to become fairly isolated and have dwindling support networks.

In the last decade or so, researchers have slowly started to realize the impact of social challenges on an individual’s quality of life and well-being. Scientists are trying to understand the different sources of relationship problems after brain injury and figure out ways to address them.

What changes after a brain injury?

Why does it become more difficult for many persons with brain injury to develop and maintain relationships? Well, a lot of things change, but an area that researchers are very interested in now is emotion. This is not simply referring to people who have trouble controlling their emotions, which often makes social interactions uncomfortable. It’s much more complicated than that.

Reading and responding to needs and emotions of other people

What is the key to good relationships and social interactions? How well we interact depends a lot on being able to read and respond to other people’s needs and emotions, while effectively communicating our own. Let’s review why this is trickier than it sounds.

For the most part, people don’t always tell us what they need or how they are feeling. Instead, this information is subtly expressed through facial expressions (for example, knitted eyebrows), tone of voice, or body language. Believe it or not, recent studies show that as many as fifty percent of people with a brain injury have a harder time correctly “reading” other people’s needs and emotions. They may not pick up on these subtle cues or inferences, and only pay attention to the words that the person actually says – which is only half the picture.

Missing or mistaking emotions

Research has shown us that after a brain injury, people may tend to see no emotion when there is one, or mistake one emotion for another. Both errors have significant consequences. If a person sees no emotion when there actually is one, the person won’t respond to another person’s emotional need because it is not recognized. For example, if the person doesn’t realize that a spouse is sad or a boss is annoyed, there is no reason to offer comfort or to take action to solve the problem. If the person mistakes one emotion for another, such as assuming someone is angry when someone is actually sad, the interaction is more likely to be confrontational rather than supportive. This behavior would obviously be a problem.

Expressing too much emotion

It’s not only important to be able to read the emotions of others, but it’s also important that we accurately and appropriately express our emotions to others. After brain injury, we often see exaggerated expressions of anger or sadness. The pitfall with expressing these emotions is that this might not be what a person is actually feeling. People who express a lot of anger are often feeling other emotions, such as fear or sadness. However, they may act angry because they are not aware of their other emotions, or because they don’t know how to express or deal with their sadness or fear.

In cases where the person is feeling angry or sad, they may “take out” these emotions on people who were not responsible for causing these emotions. In instances when they are angry with the person they are interacting with, they may be verbally or physically aggressive because they may not be able to handle their emotions rationally and/or not know how to communicate these feelings in a calm way.

Language and cognitive problems can present an even greater challenge. Nonetheless, inappropriate expressions of anger are likely to receive an undesirable response, such as pushing people away or inflicting anger, when what is really needed is support and understanding.

Showing too little emotion

In contrast to those who are overly expressive with their emotions, there are people who show very little emotion after a brain injury. This will also be a problem for relationships and social interactions. When we talk with people, we try to get an idea of how they are feeling so that we know how to respond to them. If we can’t tell how they are feeling, it creates a lot of questions. Do they enjoy spending time with me? Does this person care about me or how I feel?  What do they think of me? When people are not emotionally expressive, social interactions can be confusing and unsatisfying.

Sharing emotions builds relationships

The bottom line is that relationships are built on emotional exchanges that result in shared emotional experiences and the understanding of one another’s feelings. We must tune into the emotions of others and make sure we are kindly expressing our own. These are skills that often become more challenging for individuals after brain injury. The good news is that it appears to be a skill that can improve with treatment.

References:

Radice-Neumann D, Zupan B, Babbage D, and Willer B (2007). Overview of impaired facial affect recognition in persons with traumatic brain injury.  Brain Injury: 21(8): 807–816.

Radice-Neumann D, Zupan B, Tomita M, Willer B (2009). Training emotional processing in persons with brain injury.  Journal of Head Trauma and Rehabilitation: 24(5):313–323.

About the author:

Dawn Neumann is a Postdoctoral Research Fellow at Carolinas Rehabilitation in Charlotte, NC.

Lash Blog Permission

 

Couples’ Relationships After Traumatic Brain Injury
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After traumatic brain injury, many couples find that their relationship with each other changes dramatically. These changes are very personal and can be very emotional for both people in the relationship. This factsheet will help couples understand some of the common changes they may notice in their relationship after TBI. Also, suggestions are given for ways that couples can address some of the more difficult changes they are experiencing.

Although some of the relationship changes after TBI are difficult and can be painful, there are many things that couples can do in order to enjoy each other and their relationship in new, positive, and meaningful ways.

Couples’ Relationships and TBI

A TBI can significantly change a couple’s relationship. There are different degrees of brain injury severity, and milder injuries such as concussions do not always result in significant or long-term relationship changes. However, after severe, moderate, or complicated-mild brain injury, both survivors and their spouses or partners must often change many parts of their lives. The following life changes typically affect intimate relationships:

  • Changes in responsibilities
  • Changes in relationship roles
  • Changes and challenges in communication

Brain injury survivors often have new personality traits, challenges, fears, and limitations. Survivors are often surprised by how these changes also mean that they will feel and behave differently in their relationships. These changes have led many spouses to say they feel like they are “married to a stranger.”

The intimate partners of survivors may have new concerns or fears related to both the incident that caused the injury and the new behavior traits of the survivor. Also, partners often change the focus in their lives in order to manage the multiple challenges that arise for their family after an injury.

These changes in the survivor’s personality and the life focus of both partners often result in a feeling that partners do not know what to expect from one another. Uncertainty can increase stress and anxiety within the home.

How Are Relationships Typically Affected?

Responsibilities

After a TBI, survivors must focus their energy on getting better and developing new skills. As a result, the assignment of responsibilities in the home must change. This means that everyone in the family is involved in learning new skills and taking on new jobs.

How do responsibilities typically change?

  • Survivors often give up many responsibilities, including work expectations and household chores, while they focus on getting better.
  • Partners often must take on many responsibilities formerly managed by the survivor, such as:
    • Yard work and physically maintaining their home through chores and repairs
    • Managing household finances
    • Planning and organizing activities for the family
  • There are also new tasks for both survivors and their partners, such as managing the health care of the survivor.

What happens when responsibilities change?

  • Any time people have to take on new responsibilities and learn how to handle new tasks, they will also experience more stress.
  • In addition to the stress of injury and recovery, the stress of changes in responsibilities can increase tension between partners.
  • Partners who have significantly more responsibilities will also have less time for other things. In contrast, survivors who are focusing on getting better may feel like they have more time. This can result in different expectations about how much time partners have to spend together.

Tips to improve relationship issues related to responsibility changes

  • Be understanding about each other’s new responsibilities. This can have a positive impact on a relationship. Although it is natural to focus on oneself when a person is overwhelmed, partners must take time and effort to note all of the new responsibilities their partner is managing. Noticing and talking about these challenges can reduce tension within your relationship.
  • Say “thank you.” Make a commitment to yourself to thank your partner at least once a day for attempting to manage new responsibilities.
  • Schedule opportunities to take breaks from responsibility. These breaks may be short and may not be as frequent as desired. However, when couples and families schedule time off for each adult family member and honor that commitment both practically and emotionally, thankfulness and respect are more likely to grow in the relationship.

Relationship Roles

In all families, people take on roles that often define how they behave. After brain injury, the challenge of recovery nearly always results in some changes to the roles within a family. While the person with TBI is in the hospital, their partner may need to make decisions that are usually made by the survivor. For example, a husband may make decisions about child care that his wife usually makes, or a wife may calm the family when everyone is upset, although that is something her husband has always done.

How do relationship roles change?

  • Although people often take on many different roles in their relationships over the course of a lifetime, TBI results in dramatic role changes that occur instantly, and without preparation.
  • Early on in recovery, it may seem to couples that role changes are temporary. However, as time progresses, couples often find that these role changes may last for years or even be permanent.
  • Commonly, partners take on more leadership roles in the relationship. Depending upon who is hurt and how the family did things before the injury, this may mean some small shifts for the couple, or it may mean drastic changes.

What happens when relationship roles change?

  • The more role changes that occur, and the more dramatic the changes are, the harder it may be for a couple to adjust to the changes.
  • Certain family dynamics may also make the role changes more challenging:
    • Couples who keep tasks separate instead of alternating who does what may find it more challenging to adjust to new roles.
    • Couples who have just recently begun a new phase of their relationship, such as being newly married, having children, or being a new “empty nest” couple, may have a more difficult time with changes in roles.
  • As each partner learns how to operate in his or her new role, there will be a period of adjustment for both people. Uncertainty and frustration during this time can result in increased criticism between partners.
  • People close to the couple may not understand the need for role changes and sometimes incorrectly believe that such changes slow recovery. For example, family members may say “Let her talk to the kids’ teachers. She will never get back to her old self if you don’t let her do her job.” This can cause tension between the couple and their family and/or friends.

Tips to improve relationships when roles have changed

  • Identify where role changes occur and talk about these changes openly. Partners should try to be sensitive to the feelings of survivors. For example, the survivor may have felt pride in his or her role before the TBI and may feel sad or frustrated when asked to step aside.
  • Partners can serve as mentors and consultants for one another. Couples can ask one another, “What works best for you when you are in this situation?” Although survivors may not be able to manage a former role, such as being the financial decision maker, they can share their knowledge with their spouse. Both partners will benefit when this approach is taken.
  • Couples must be conscious of not criticizing the partner who is taking on a new role. For example, it is unlikely that a girlfriend will handle a challenge in the same way her boyfriend would have handled it. Partners should work hard to support one another in their new roles. This includes being patient with the time it takes for everyone to feel comfortable in their new roles.
  • Family and friends may need to be taught about brain injury and the changes it brings. Children who live at home will also benefit from direct discussions about these changes: “I know mom used to be the person who checked your homework every day, but she and I have decided that it will be better for now if I do it.” Without open communication about role changes, others may not understand why things feel so different and why supporting those differences can help the whole family to heal.

Communication

Communication is the foundation of a relationship. Many people think only of talking when they hear the word “communication,” but couples are actually communicating through gestures, facial expressions, emotional reactions, and physical interactions as well. In studies on relationships after brain injury, communication is often reported as the biggest change people notice.

For spouses:

  • Additional responsibilities and the uncertainty of recovery can cause spouses to feel very overwhelmed. When overwhelmed, people often change their communication styles. Some common changes can include talking less, talking more, and/or communicating more intensely or urgently than before.
  • Spouses may be unsure how best to communicate with their partner after injury. This discomfort may cause spouses not to communicate as often or as openly with the survivor.

For both people:

  • Increased stress levels often affect communication for both partners.
  • Both people may be afraid that sharing their negative thoughts or feelings will burden their partner.
  • When either person in a relationship changes how he or she communicates, both people will behave differently.

What happens when communication styles and patterns change?

  • Changes in communication between partners can result in both people feeling alone and isolated. Couples may feel they no longer understand what their partner is thinking or feeling.
  • Difficulty communicating can sometimes cause people to pull away from their relationship, choosing instead to handle challenges with friends or other family members. Sometimes, people choose not to communicate their feelings with anyone at all.
  • Communication struggles can impact all other parts of a relationship, including responsibilities and roles, and make it difficult to adjust to changes together.

Tips on improving a couple’s communication

  • Both partners should make a commitment to improve communication.
  • Listen patiently to what your partner is saying.
  • Listen for points where you can agree rather than focusing on disagreement.
  • When you do disagree, think about what you might say before you say it.
  • Remember that survivors will likely need more time to think about what their partner is saying, or about how they want to communicate again, patience is key.
  • Take notes on your thoughts during conversations rather than immediately saying what comes to mind. Come back to these points later, after you have had time to reflect.
  • Exchange bulleted lists of important points for big discussions. When you have something you would like to say, write it down before a discussion and use it as a guide. Trading these lists after a conversation helps with memory and allows more time to digest and think about the information.
  • When a topic is likely to cause a disagreement, practice what you would like to say before you start the conversation.
  • Practice in front of a mirror. Look at facial expressions, gestures, and body language, while also choosing your words carefully. When you talk, try to stick to what you practiced.

Physical Intimacy/Sexual Relationships

Most couples notice significant changes in their sexual relationship after TBI. There are many reasons for these differences, including changes in:

  • Hormone levels due to injury
  • Roles in the sexual relationship
  • Appearance, self-confidence, and or attraction
  • Areas of sexual interest

*For more information on physical intimacy and sex after TBI, see the MSKTC factsheet on BrainLine “TBI & Sexuality.”

Tips for Improving Intimate Relationships

Find a therapist

Therapy can give couples support and ideas to improve their specific situations. Different types of counseling are available, including individual counseling for either the survivor or partner, couples counseling, or family therapy.

Seek out a counselor or psychotherapist who has expertise in brain injuries. If there are no therapists locally with brain injury experience, couples should provide their therapist with information about injury and common relationship challenges that can accompany injury. The Web sites on this factsheet can be a good place to start.

Try a support group

Many communities have support groups for both survivors and caregivers/partners, which are often listed in the newspaper or advertised by State brain injury associations. These groups can help couples establish new friendships, find local information and resources, and provide time apart from their partner for reflection.

When local support groups are unavailable, try Web-based chat groups and support communities. These groups are an excellent option when in-person groups are either too far away or when transportation is a challenge.

Finding a therapist or a support group

*Editor’s Note:
Please visit the Brain Injury Alliance of Montana web page list for Montana Brain Injury Support Groups.

Changing the relationship environment

At home, make a commitment to establish a positive environment. Looking for progress in recovery instead of ways in which a relationship is not succeeding can improve how people feel about each other. Additionally, part of having a positive home life comes from the opportunity for fun as a couple.

Scheduling a “date” on the calendar to take a walk, watch a movie on television, or play a game like cards can be an inexpensive strategy that may make a big difference in reducing tension. When fun time is scheduled, consider it to be as important as a doctor’s appointment—something that cannot be ignored or rescheduled.

Considerations in new relationships

If you are in a new relationship, the process of recovery can be more complicated. For example, if an individual is injured while he or she is in the early stages of a relationship, the couple may not know what their roles are yet. This can result in confusion and uncertainty and may lead some people to ask, “Who am I in this relationship?” or “Who are we together?”

Any couples who are new to their relationships can work to take a positive approach to recovery. Although role uncertainty may be a challenge, it also provides the couple more freedom by not being tied to old ways of doing things.

Considerations in nontraditional relationships

There are also a growing number of adults who choose to live in unmarried monogamous relationships. For cultural, financial, social, or other reasons, these couples may not be in a “traditional marriage.” Individuals who identify as gay, bisexual, lesbian, or transgender, as well as people who identify as heterosexual and in an unmarried relationship may have more complicated issues to deal with.

For example, they may not have access to their unmarried partner’s insurance, bereavement, pension, or other benefits. Other challenges can include the inability to be represented in health care decisions, lack of recognized family leave from work, or even having to choose to “come out” as a result of the injury. In addition, the lack of acceptance or awareness in their community with regard to nontraditional relationships may impact a couple’s ability even to seek or obtain care. These complications can influence a couple’s success or failure in a relationship.

Tips for nontraditional couples to manage challenges

  • For caregiving partners, building relationships with the survivor’s family members who are supportive can be very helpful. Partners may want to make working on these relationships a top priority as a way to stay involved in a survivor’s care.
  • Psychotherapy or counseling is likely an important component of recovery for nontraditional couples. Because partners may have even less support than couples in traditional relationships, finding a therapist who can provide this support and guidance is an important part of healing.

Concerns About Divorce or Separation

You may have heard that divorce or separation is likely after TBI. Although no one knows for sure what will happen in any relationship, some studies suggest that divorce and separation rates may actually be lower after brain injury than for the rest of the population. Rather than focusing on the possibility of divorce or separation, couples do best by focusing on improving the quality of their relationship with one another.

Recommended Reading

  • Healing Your Marriage After Brain Injury. Published in “The Challenge,” a Brain Injury Association of America publication. Written by Jeffrey S. Kreutzer, Ph.D., and Emilie E. Godwin, Ph.D.
  • Learning by Accident. Written by Rosemary Rawlins
  • Brain Injury Survivor’s Guide: Welcome to Our World. Written by Larry Jameson and Beth Jameson
  • Blog: Starting Marriage Over After a Brain Injury (survivor and caregiver stories). Available at http://www.marriagemissions.com/starting-marriage-over-after-a-brain-injury/

Couples’ Relationships After Traumatic Brain Injury was developed by Emilie Godwin, PhD, Jeffrey Kreutzer, PhD, and Stephanie Kolakowsky-Hayner, PhD in collaboration with the Model System Knowledge Translation Center. This health information content is based on research evidence and approved by experts from the TBI Model Systems.

Please check the MSKTC site for any recent updates on this article.

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