i) The family

The family becomes an important part of the management and can be a tremendous protective factor in the management of the patient

While we often think families want to help their individual family members one of the challenges can be the family in its own right.

Expressed emotion

In psychiatry the concept of expressed emotion is used to describe how family dynamics can affect mental health outcome, particularly for schizophrenia.

Expressed emotion is a measure of the amount of emotional intensity that occurs within a family. Families that have high expressed emotion, be it positive or negative, can influence the relapse rate of people with schizophrenia.

There has not been any work on expressed emotion in families where a person has  traumatic brain injury. If a person with a traumatic brain injury has a mental illness and comes from a high expressed emotion family then it is likely there will be significant problems. Therefore the family needs to be treated as well as the patient.

Enforcing compliance

We also need to get the family to enforce compliance with treatment. That can be very difficult if the person with the traumatic brain injury was the dominant member of the family. Other family members might find it very hard to enforce treatment and to ensure that the person is participating.

Certain cultural factors will also prohibit family members from making decisions with regard to treatment and ensuring that the person complies.

Hidden agendas

There are also hidden agendas within the family that can have a significant impact on management.

In many cases the person with a dual diagnosis of traumatic brain injury and mental illness is further disempowered.

If you have a family where previously they felt they had lost control, for example, with their child, and the traumatic brain injury and the mental illness increases the amount of control they have on the child, they may not necessarily be keen for the person to get better because they will lose control again.

This is an incredibly sensitive area, it needs to be managed and dealt with because the family's hidden agendas, whether it is obstruction for treatment, or wanting to prolong symptomatology, will have a profound impact on the benefits of the therapy that you are offering.

Carer’s mental health can suffer

Because of the burden of care and the stress caused by the changes in the injured person’s abilities, behaviour, earning capacity, status and so on, there is a heavy stress placed on carers.  Often couples that did not spend much time together are now with each other all day every day.  Families are at risk of burnout.  If family members are unable to cope this reduces the potential for the patient’s recovery and long term management.

Working with families

Despite all of the challenges of working with the family it can be a tremendous asset for the person with a TBI when they have an understanding and supportive family.  The rehabilitation process is a collaborative one and needs to take into account the needs of the patient’s key support people.

 

ii) Questions