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Article Excerpt
Research has revealed that almost half of relationships will end in divorce or separation when one member experiences a head injury. Many patients are not diagnosed initially, or for several months or years after their injury. Persons dealing with the numerous long-term cognitive and physical problems accompanying mild traumatic brain injury (MTBI) may develop a profound sense of "loss of self." This loss of self, manifest as identity ambiguity on the part of the MTBI subject may be strongly correlated with perceptions of boundary ambiguity on the part of the subject and family resulting from the situation of ambiguous loss. Early recognition and intervention may prevent relational and marital breakdown as well as unnecessary distress to family members. This article discusses the theoretical foundations of our research, preliminary findings of our ongoing qualitative study, and implications for future research and clinical intervention.
Keywords: ambiguous loss, boundary ambiguity, head injury, loss of self, mild traumatic brain injury (MTBI), MTBI and relational breakdown
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Sara was a 31-year-old intelligent, hardworking speech and language therapist, who had been happily married for several years. While sitting at a stoplight one afternoon, Sara was rear-ended. Treated only for whiplash in the emergency room, she was sent home unaware that any long-term damage had occurred. In the weeks following the accident, Sara began feeling depressed and anxious. She was unable to concentrate and function at work; while at home she was prone to emotional outbursts. Suffering from severe back and shoulder pain during the day, she would also wake in the night with clenched jaw and fists, and severe cramping in her feet and arms. Sara and her husband David were finding it impossible to communicate as they once had and marital stress increased. By the time she sought treatment for posttraumatic stress disorder (PTSD), the relationship with her husband had drastically deteriorated. Seeing that she was having problems, Sara's parents attempted to help and became increasingly involved in her daily life. Subsequently diagnosed with mild traumatic brain injury (MTBI) as a result of the car accident, Sara began to overcompensate by working more and sleeping less. Feelings of guilt, anger, and resentment intensified in the marriage. As well, Sara and her father would have bitter arguments about her failing marriage while she and her mother would have fights that generally ended in violence. Sara and David were silent about their own feelings surrounding the marriage for fear of hurting or offending each other, or of being rejected. As Sara became more aware of the ways in which the MTBI had affected her life, she began to set more realistic goals for rehabilitation and was hopeful that her marriage could be salvaged. After years of strain and feeling that Sara had become a completely different person, David was unwilling to continue marriage counseling and filed for divorce. Sara and her parents continued to fight and are now struggling to forgive one another and rebuild their family connections.
THEORETICAL UNDERPINNINGS
A number of researchers have explored the effect of traumatic brain injury (TBI) on family relationships (Florian, Katz, & Lahav, 1989; Kreutzer, Kolakowsky-Hayner, Demm, & Meade, 2002; Laroi, 2003; Perlesz & O'Loughlan, 1998; Resnick, 1993; Tyerman & Booth, 2001; Willer, Allen, Liss, & Zicht, 1991). TBI is commonly diagnosed by an extended period of loss of consciousness as opposed to mild traumatic brain injury (MTBI) where there is no loss of consciousness or the loss is brief. Unfortunately, there is as yet no other agreed upon distinction. There is also considerable coverage of the concept of "loss of self' as a consequence of TBI (Dann, 1984; Miller, 1993; Myles, 2004; Nochi, 1997, 1998, 2000; Persinger, 1993; Pollack, 1994).
However, a crucial gap still prevails. There have been no investigations into the combined impact of MTBI on loss of self and identity ambiguity in connection with what Boss (2002, 2004a) terms "boundary ambiguity and ambiguous loss" and their influence on relational breakdown. Ambiguous loss is described as "the most stressful kind of loss," in that it defies closure. Though the death of a family member is a stressful event, it is validated through sociocultural processes that allow families to move forward through their grief. Conversely, when a family member disappears, for instance by kidnapping (physical loss) or debilitating illness (psychological loss), remaining family members are thrown into uncertainty. Lacking verification of the loss and thus family membership or social processes, the ambiguous loss, if unresolved, creates the condition of boundary ambiguity within the family system. Families may find it impossible to work through their grief as they have been unable to renegotiate their new social boundaries. In such uncharted territory, a family may become paralyzed, unable to grieve and heal (Boss, 2006).
Common sense would dictate that, in addition to cognitive and physical impairment, MTBI can cause severe disruption in self-image and interpersonal relationships. Unfortunately, this is frequently not taken into consideration during treatment planning or by third-party payers. For many individuals with MTBI, neglect of the emotional and relational aspects of the injury will result in inadequate treatment and considerable, unnecessary suffering.
Long-term presence of psychiatric symptoms is frequently found in subjects who have experienced TBI (Arciniegas, Harris, & Brousseau, 2003; Brooks, Campsie, Symington, Beattie, & Mckinlay, 1986; Fujii, 2002; Koponen et al., 2002; van Reekum, Bolago, Finlayson, Garner, & Links, 1996). Psychiatric conditions commonly observed following MTBI include depression, anxiety, and dissociative disorder (Busch & Alpern, 1998; Mooney & Speed, 2001). Depending on the circumstances of the injury, people with MTBI may develop acute stress disorder and PTSD (Harvey & Bryant, 2000; Hibbard, Uysal, Kepler, Bogdany, & Silver, 1998; Hiott & Labbate, 2002; Ohry, Rattok, & Solomon, 1996). This will invariably catalyze relational problems such as marital distress, disintegration of parenting skills, and workplace conflicts. Even when PTSD as a diagnosis is not present, the serious symptoms of MTBI frequently act as major stressors in their own right. These include: cognitive deficits, auditory and visual problems, spatial disorientation, vertigo, balance problems, chronic pain, sleep disturbance, fatigue, headache, toothache, dislocated jaw, endocrinal and neurotransmitter imbalance, depression, anger management problems, unpredictable emotional outbursts, and numerous other physical challenges.
There is clear evidence that the symptoms of chronic illness or pain, such as those listed above, will change the way people relate to themselves and those closest to them (Campbell, 2003; McDaniel & Doherty, 2003; Rolland, 1994). Similar to Seaburn's description of cancer as the unwelcome guest (1990), families dealing with MTBI may struggle with the realization that the injury has left a stranger in their midst who has become the predominant presence in every conversation and major decision. However, despite the centrality of the topic, many families refrain from talking about their most important issues for fear that discussion will create alienation, blame, guilt and/or rejection. In cases of families dealing with MTBI, MTBI subjects frequently try to hide their deficits while the family "walks on egg shells." The family members may share their concerns and observations with one another, but not with the MTBI subject. This combination of ambiguity and secrecy compounds the problem and is particularly evident in couple relationships.
Our extensive clinical experience with the impact of MTBI suggests that subjects with MTBI frequently develop a sense of loss of self. This loss of self can be attributed to their new physical and emotional deficits that profoundly alter their family and social interactions. As the case of Sara and David demonstrates, this loss can cause a devastating ripple effect not only in couple relationships but within the family system. The sense of loss of self and resulting identity ambiguity experienced by a family member with MTBI creates a sense of boundary ambiguity in both the couple and the family. The boundary ambiguity may manifest as loss of the injured person as the family knew her or him, as well as loss of the family system as it once was. With such ambiguous loss, the boundary ambiguity is left unresolved. These effects clinically appear to be associated with considerable stress, and may correlate with the breakdown of couples, parental and family relationships.
Ambiguous loss has been closely studied in cases of Alzheimer's disease, missing persons in New York after September 11, 2001 (Boss, Beaulieu, Wieling, Turner, & Cruz 2003), and cases of the "disappeared" following political dissension in countries like Argentina and Cambodia (Boss, 1999). In addition, disconnectedness, disruption, and disintegration of family relationships following trauma have been studied extensively (Calhoun & Tendeschi, 1999; Eisenbruch, 1991; Horwitz, 2001; Landau, 2005; Landau & Saul, 2004). Nevertheless, the far-reaching implications of loss of self, identity ambiguity, boundary ambiguity, and ambiguous loss on the family following MTBI have gone largely undocumented. This is an area in which early assessment and intervention could prevent major lifelong personal and relational difficulties. Therapy following MTBI must include the family and all intimate relationships. Long-term cognitive, physical, emotional, and relational losses must be treated in order for the individual to resume personal, family, social, and work functions. It is also of utmost importance that in considering the biopsychosocial aspects of care, the cultural and spiritual components of healing be addressed.
BACKGROUND
The occurrence of relational breakdown due to brain injury is not...
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