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Use of Family Focused Therapy in Rehabilitation for Veterans With Traumatic Brain Injury

Barbara M. Dausch Eastern Colorado Health Care System, Denver Veterans Affairs Medical Center, and University of Colorado Denver and Health

Sciences Center

Sheila Saliman Eastern Colorado Health Care System, Denver Veterans Affairs

Medical Center

Objective: Military personnel returning from Iraq and Afghanistan with traumatic brain injury (TBI) present with a complex array of stressors encountered during combat as well as upon re-entry, often with additional physical and mental health comorbidities. This requires an intensive approach to treatment that includes family intervention as a part of rehabilitation. There is a small but growing literature addressing the needs of families when a family member has sustained a TBI. An established treatment intervention for individuals with serious mental illness, such as family focused therapy (FFT), is uniquely suited to address the complexity of issues presented by returning military personnel, and may be adapted for moderate to severe TBI populations. In this article, we discuss the rationale for adapting this family intervention for this population and present a case vignette illustrating adaptations for TBI. Conclusions: The adaptation of an existing family intervention for a chronic condition that focuses on enhancing both individual and family functioning is a useful starting point. With further research to modify FFT for this unique population and establish feasibility, this approach may supplement existing models of family intervention.

Keywords: family therapy, TBI, rehabilitation, veterans, Iraq

Military personnel returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) present for services with a complex array of physical and psychological injuries, particu- larly traumatic brain injury (TBI; Hoge, Auchterlonie, & Milliken, 2006; Terrio et al., 2009). Families appear to play a pivotal role in facilitating reintegration of veterans into civilian life (Doyle & Peterson, 2005) and aid in the long-term functional outcomes for those with TBI (e.g., Sander et al., 2002). Stresses on families inherent in deployment to Iraq or Afghanistan, however, impact a family’s ability to serve as a resource, and a returning veteran who sustains a TBI can further negatively impact family functioning (McFarlane, 2009). Veterans who sustain a TBI in the context of severe and varied stressors that may include multiple medical and mental health comorbidities warrant an intervention that targets both the well-being of the family and the functional outcomes of the veteran with TBI. Models of psychological treatment in reha- bilitation psychology and psychosocial recovery for serious mental illness emphasize the centrality of the family’s role in facilitating individual adjustment and functioning. We propose an approach to improving individual outcomes that includes the individual with

moderate to severe TBI in the treatment and is focused on enhanc- ing systems (individual and family) function through providing information about the injury and the rehabilitation process along with skill training to enhance relational functioning. One type of family intervention, originally designed for individuals with bipo- lar disorder, family focused therapy (FFT; Miklowitz & Goldstein, 1997), lends itself to the multifaceted needs encountered in this population. Adapting an established treatment like FFT to the TBI population may supplement the existing models of intervention for persons with TBI and their families. In the following paper, we discuss current issues faced by military personnel returning from OEF/OIF with a TBI; the importance of the family in rehabilitation and reintegration of the military personnel member with TBI; models within rehabilitation psychology and psychosocial recov- ery for serious mental illness that enhance individual and family functioning; specific outcomes of family approaches, such as FFT, with modifications of FFT for TBI; and an illustrative case exam- ple of FFT for TBI.

TBI and OEF/OIF

Recent data suggest that significant numbers of OEF/OIF mili- tary personnel are sustaining TBIs of all severity levels during their deployment (Lew, Cifu, Sigford, Sayer, & Jaffee, 2007; Warden, 2006). TBI has been described as a “signature injury” of the current conflict (Stein & McAllister, 2009, p. 3). As many as 12% (Schneiderman, Braver, & Kang, 2008) to 22% (Terrio et al., 2009) of military personnel may be returning from deployment with a TBI.

In civilian populations, it is well known that TBI can have a substantial deleterious effect on family functioning (Boschen, Gar- garo, Gan, Gerber, & Brandys, 2007; Perlesz, Kinsella, & Crowe,

Barbara M. Dausch, Eastern Colorado Health Care System, Denver Veterans Affairs Medical Center, School of Medicine, University of Col- orado Denver and Health Sciences Center; Sheila Saliman, Eastern Colo- rado Health Care System, Denver Veterans Affairs Medical Center.

Dr. Dausch would like to acknowledge the ongoing mentorship of David J. Miklowitz whose skilled supervision and support has been instrumental in the development and application of this treatment to diverse clinical populations.

Correspondence concerning this article should be addressed to Barbara M. Dausch, Ph.D., Eastern Colorado Health Care System, 1055 Clermont Street/116, Denver, CO 80220. E-mail: [email protected]

Rehabilitation Psychology 2009, Vol. 54, No. 3, 279 –287

In the public domain DOI: 10.1037/a0016809

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1999). For veterans, the impact on the family of their TBI is complicated by the likelihood that they are returning to families that may have already been strained by their deployment. McFarlane (2009) discusses a variety of ways in which parental deployment challenges the spouses and children who are left behind, both during the deployment itself and after the veteran returns home. Deployments that are repeated and unprecedented in length disrupt the family system for extended periods of time; families have legitimate worry for their loved one’s physical well-being while s/he is overseas; children may not have ready access to the deployed parent’s support and care; and the family must reorganize family boundaries and roles when the parent leaves, and again upon return. Perhaps not surprisingly, therefore, relational problems are one of the main mental health issues identified among postdeployment military personnel (Milliken, Auchterlonie, & Hoge, 2007).

The evidence that families may be significantly affected by a military personnel member’s deployment to combat and by inju- ries sustained while deployed, is concerning, given that families appear to play a key role in facilitating the successful reintegration of the veteran into civilian life (Doyle & Peterson, 2005). The veteran of OEF/OIF with TBI faces many challenges in reentering home, work, and community life. For example, French and Par- kinson (2008) suggest that a TBI sustained during service in Iraq or Afghanistan is distinct from civilian-suffered TBI in several important ways, including frequent comorbid psychological and physical injuries, the unique and still little-understood mechanism of injury by blast, and the severe stressors associated with the deployment environment. Deploying to Iraq and Afghanistan ex- poses military personnel to a situation with no front line, so that anyone anywhere could be an adversary; with ambiguous rules of engagement that make it difficult to know when a situation is dangerous; with extensive use of difficult-to-detect threats in the form of improvised explosive devices; with decentralized, urban combat environments; and with frequent exposure to atrocities (La Bash, Vogt, King, & King, 2009). The lengthy and repeated deployments that characterize this conflict also take a toll on the well-being of military personnel (Polusny et al., 2009).

Other authors have noted that there is a high level of comor- bidity between TBI and mental health issues in returning OEF/OIF military personnel, including symptoms of posttraumatic stress disorder (PTSD; Hoge et al., 2006; Smith et al., 2008), extreme levels of state anxiety (McNulty, 2005), suicidality (Hoge et al., 2006; McNulty, 2005), and substance abuse (Jacobson et al., 2008). Military personnel exposed to blast and other injury mech- anisms have the added burden of coping with acute and chronic pain (Clark, Scholten, Walker, & Gironda, 2009). The Department of Veterans Affairs has established a Polytrauma System of Care designed to address the multifaceted needs of returning military personnel with TBI who present with comorbid medical and men- tal health issues. The impression of those caring for these military personnel is that many of them will cope with enduring sequelae from their deployment experiences and that they may require lifelong health care follow-up (Sayer et al., 2008). Thus, clinicians are faced with the task of identifying ways to facilitate positive long-term outcomes for military personnel who sustain a TBI.

There is some civilian data that suggests that the quality of family functioning can impact outcomes for those with TBI. Sander et al. (2002) found that TBI individuals in families with

unhealthy functioning made less progress in the postacute phase of rehabilitation than those with healthy functioning families. Testa, Malec, Moessner, and Brown (2006) concluded that individuals with family dysfunction at the time of discharge were at greater risk for distress and behavior problems at follow-up.

Furthermore, the evidence that family members themselves can benefit from intervention suggests that family-based treatments are a worthwhile area for further exploration. For example, a recent ran- domized controlled trial of PST with individuals caring for a person with TBI revealed that caregiver depression, health complaints, and ineffective problem solving all decreased as a result of the interven- tion (Rivera, Elliott, Berry, & Grant, 2008). Similar benefit has been demonstrated with caregivers of stroke survivors (Grant, Elliot, Weaver, Bartolucci, & Giger, 2002); improvement in problem solving but not caregiver depression was demonstrated in a randomized controlled trial of brief PST for caregivers of individuals with spinal cord injury (SCI; Elliott & Berry, 2009). Some clinical case study and anecdotal reports of adults with TBI also seem to support the efficacy of family interventions (Johnson, Crane, & Tatekawa, 2004; Laroi, 2000). Tyerman and Booth (2001) described their experiences with 7 years of community-based support for families in the post-acute phase of TBI, noting that families reacted very positively to this support. An earlier study of community-based education and support yielded sim- ilar findings regarding family appreciation for these efforts (Acorn, 1995). In a promising study of multiple-family group treatment for individuals with TBI and their families, Rodgers and colleagues (2007) found that after 12–18 months of psychoeducation, individuals with TBI were less depressed and more satisfied with life. Improve- ment in function or activity participation, however, was not measured.

To date there has been limited peer-reviewed, published inves- tigation of the impact of the family on the re-entry of a veteran with TBI into community life. Although limited research has been conducted to investigate whether adults with TBI have improved functional outcomes when families are the targets of intervention, literatures from other populations provide support for this asser- tion. For example, Elliott, Brossart, Berry, and Fine (2008) found that caregiver intervention with problem-solving training (PST) via teleconferencing led persons with spinal cord injury to have improved social functioning. Wade, Michaud, and Brown (2006) found that seven sessions of problem-solving and skill-building training for families of children with a moderate or severe TBI was successful in reducing child behavior problems.

While the importance of promoting healthy family functioning for improving individual outcomes in those with TBI is being increasingly recognized, there is room for additional development and investigation of evidence-based interventions targeting both family caregiver well-being and individual functioning. Further- more, as Boschen et al. (2007) note, continued development of interventions involving the family system is indicated. In the population of returning military personnel with TBI, such treat- ments may aid in a military personnel member’s readjustment from deployment to civilian life as well as educate and facilitate adjustment to a new way of functioning after injury.

Exploring Family Interventions for those with TBI

In the absence of extensive empirical evidence, it is warranted to turn to expert consensus, which would support that improving family functioning may lead to improved outcomes for those with

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TBI. The World Health Organization’s (WHO) International Clas- sification of Functioning, Disability and Health (ICF; WHO, 2001), can be a useful model for thinking about the relationship between family functioning and successful outcomes for military personnel with TBI. The ICF conceptualizes disability as “occur- ring at the intersection of person and environment” (Pledger, 2003, p. 281). According to this model, the extent to which a person may be considered disabled is determined by both the individual’s physical or mental impairment and the environment in which the individual is functioning. Thus, the individual’s ability to partici- pate in valued life roles and activities changes from one environ- ment to another. Within this model, rehabilitation efforts must look beyond the individual who suffered the injury or illness to also consider the role and nature of the physical and social situations within which the individual must function. The family is one such environment, and an individual with TBI in a family that is actively engaged, supportive, and assisting may have a very dif- ferent level of participation in life activities than an individual in a family that is not responsive and engaged in this manner. Additionally, a person with TBI is not a static entity; as new life stages are encountered, previously functional adaptations of the person with TBI and the family may no longer be useful (Cavallo & Kay, 2005). This requires a family system to again shift to accommodate the new phase. For example, as an individual is able to achieve independence in a particular domain, such as managing simple financial transactions, others in the family will need to accommodate by allowing for this independence and finding a way to help monitor this situation from a distance. If it is true that family functioning plays a role in outcomes for persons with TBI, then this model suggests that maximizing healthy family function- ing and facilitating periodic renegotiations of what is adaptive for the family may ameliorate the extent to which the individual with TBI is disabled. In turn, an individual who is more able to partic- ipate in social roles and re-integrate into the community has an enhanced quality of life and presents less social and economic strain on already over-burdened medical and social services sys- tems.

Similarly, psychologists in the field of psychiatric rehabilitation and recovery focus on psychological intervention that improves quality of life and functioning, in this case, within the context of the time after an acute psychiatric hospitalization. A core under- lying assumption guiding treatment is that an individual’s envi- ronment heavily influences to what extent that individual adjusts to and manages his or her illness (Miklowitz, Biuckians, & Richards, 2006). The family is considered to be a central aspect of many individuals’ environments and, as such, has been a focus of the development of intervention for individuals with serious mental illness. Over 25 years of scientific research on family treatments for individuals with serious mental illness have yielded an estab- lished literature on family psychoeducational treatments. These treatments optimize individual functioning through minimizing relapse and rehospitalization, among other outcomes (McFarlane, Dixon, Lukens, & Lucksted, 2003; Murray-Swank & Dixon, 2004).

Thus, models of psychological treatment in both rehabilitation psychology and psychosocial recovery for serious mental illness emphasize the impact of the individual’s injury or illness on the family as well as the centrality of the family’s role in facilitating individual adjustment to the injury or illness. Based upon similar-

ities in the conceptualization of approaches in these two areas, it would follow that the well-developed psychosocial interventions used to treat individuals with serious mental illness and their families may be adapted for those with TBI. Additionally, serious mental illness and TBI have some similar characteristics. They both are chronic, ongoing potentially disabling conditions with immediate family or supports often called upon as informal and untrained caregivers. The onset of these conditions represents a change from prior functioning (e.g. injury or first episode) and have social stigma associated with the diagnosis and with seeking mental health services.

We propose an approach to improving individual outcomes that includes the individual with moderate to severe TBI in the treat- ment and is focused on enhancing systems (individual and family) function through providing information about the injury and the rehabilitation process along with skill training to enhance rela- tional functioning. By adapting an established treatment, such as Family Focused Therapy (FFT; Miklowitz & Goldstein, 1997), to the TBI population, we supplement the existing models of inter- vention for persons with TBI and their families. The FFT model comes from a philosophic background similar to studies address- ing family caregivers of individuals with TBI. That is, both inter- ventions are rooted in a behavior therapy orientation with an emphasis on recovery/rehabilitation or enhancing individual and environmental function over simply the relief of symptoms. In addition to being a family intervention inclusive of the individual that is suited for long-term follow up and episodic care, this model has rendered impressive outcomes related to individual function- ing, such as increases in relationship functioning and life satisfac- tion as well as decreases in relapses and hospitalizations when compared to a control group (e.g., Miklowitz, George, Richards, Simoneau, & Suddath, 2003; Miklowitz et al., 2007).

History and Evolution of the Psychosocial Rehabilitation Into Recovery Movement

Family psychoeducational interventions such as FFT have their origins in theory-driven research on serious and persistent mental illness. Early investigators were interested in understanding factors that predicted conditions under which individuals would relapse shortly after returning home from a psychiatric hospitalization as compared with those who did not relapse. These early investigators identified aspects of the family environment that predicted relapse (for review see Falloon, 1985) and this was termed expressed emotion or EE. When interviewed individually, relatives who reported high levels of attitudinal criticism, hostility, and over involvement toward their loved one with a serious mental illness as measured by a semistructured interview, the Camberwell Family Interview (Vaughn & Leff, 1976), were labeled as “high EE.” This can be best understood by thinking broadly about the larger con- text of how family members may struggle to make sense of discrete episodes (i.e., mania, depression, psychosis) in their loved one. A reasonable attribution a family member may make in the absence of information about mental illness is that a specific behavior is personal and controllable (e.g., Wendel, Miklowitz, Richards, & George, 2000). Exacerbating these mistaken attribu- tions is the reciprocity of interactions. For example, if an individ- ual is irritable, impulsive, or exhibiting cognitive and/or behavioral

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disorganization characteristic of mania, they will likely elicit re- sponses from their relatives that are negative (e.g., “Sometimes my son just isn’t nice, he snaps at me when he wants to.”). Within this context, family members may be struggling themselves; the burden of caring for a loved one with a serious mental illness can be overwhelming and is well documented (e.g., Perlick et al., 2007).

Related to expressed emotion is the stress-vulnerability model of serious psychiatric illness (Nuechterlein & Dawson, 1984). That is, an individual’s illness, which is biologically and genetically based, makes one more vulnerable to stress, and, as one’s experi- ence of stress increases in the environment, the probability of manifesting symptoms of the illness increases. Family psychoedu- cational interventions were designed with this model in mind so that stress is minimized by modifying the environment. This in- volves educating the family and/or support system about the illness and symptom management so that realistic expectations can be set. Additionally, communication and problem-solving skills are taught to individuals and family members together in order to enhance functioning in these realms. Family psychoeducation is a package of education and skill training and involves cultivating a collaborative partnership among individuals, family members, cli- nicians, and the treatment team.

More recently, the psychosocial rehabilitation and recovery movement represents a shift from the traditional medical model to an individually focused model of care. It is centered on the experience of individuals with mental illness, or consumers, and is based on empowerment, hope, and self-determination (Anthony, 1993). It is the acknowledgment that in spite of and in the midst of psychiatric illness; individuals can live meaningful lives. The concept behind recovery is, in fact, borrowed from physical illness and rehabilitation (Anthony, 1993). The growth of this movement comes from advocacy within a number of co-occurring political, social, and economic trends, movements, and events. It began with de-institutionalization, followed by psychiatric rehabilitation (community-based support) and family advocacy, leading up to the recent President’s New Freedom Commission on Mental Health (2003) which directly recommends a recovery focus in the provi- sion of mental health services. Evidence-based practices, such as family psychoeducational interventions, are a part of recovery, as they can promote collaborative and positive relationships, bolster hope, teach real-world skills, and promote goals and help individ- uals and families move forward together (Anthony, 2003). Accord- ing to Glynn, Cohen, Dixon, and Niv (2006), family psychoedu- cation involves individually directed goals, education about the illness, and promotes life satisfaction. Family psychoeducation is an adjunct to psychopharmacological treatment and supports the ongoing use of medication through education and problem solving around this and many other issues. While these interventions target the family, outcomes studied in a large number of research studies (meta-analyses; Pilling et al. 2002; Pitschel-Walz, Leucht, Bauml, Kissling, & Engel, 2001) report significant individual effects, such as symptom improvement, relapse prevention, and delayed re- hospitalization.

As one form of family psychoeducation, FFT was designed for individuals with bipolar disorder and their families. Randomized studies of FFT combined with pharmacotherapy (Miklowitz et al., 2003; Miklowitz et al., 2007; Rea et al., 2003) revealed outcomes, such as decreases in relapse rates and hospitalizations, enhanced mood stability and increases in adherence to medications relative

to control groups and comparison treatments among bipolar adults. One of these studies (Miklowitz et al., 2007) conducted in practice settings indicated that FFT, as an intensive psychosocial treatment provided to individuals with bipolar disorder and combined with pharmacotherapy, led to better total functioning, relationship func- tioning, and life satisfaction. FFT has also been provided success- fully over live interactive videoconferencing in a case study of a veteran with serious mental illness and holds promise for rural populations or families that have transportation or mobility issues (Dausch, Miklowitz, Nagamoto, Adler, & Shore, 2009). Addition- ally, a 12-session version of FFT has been adapted for this popu- lation of returning Veterans from OEF/OIF to address the preva- lence of PTSD as well as adjustment issues faced by families of Veterans returning from OEF/OIF (Dausch, Wahlberg, Miklowitz, Adler, & Nagamoto, 2007).

What is FFT?

In the traditional FFT protocol, a therapist meets with an indi- vidual and his or her designated family members or supports together for 21 sessions in a 9-month period with a titrating schedule from weekly to biweekly to monthly sessions. Despite this ideal structure, FFT can be delivered within any number of variations and session frequency is usually based on family avail- ability. Additionally, there are booster sessions available after all treatment modules are presented to review skills taught or deal with episodes of care that may be a result of life events and any new developmental challenges. Like other treatments disseminated into clinic settings, specific goals are established and treatment is delivered in coordination with these goals. For example, if family members prioritize communication as an issue, then communica- tion enhancement training may be presented in early sessions.

Treatment includes psychoeducation about bipolar disorder, communication enhancement training, and problem-solving skill training. The psychoeducational module consists of providing ed- ucation within an individualized dialogue surrounding the follow- ing topics: symptoms, life events impacting symptoms, the stress- vulnerability model of mental illness (etiology), risk and protective factors impacting the illness, medications and other treatment, ways the family can help, and, finally, development of a relapse plan based on prior discussions. Communication enhancement training consists of teaching the following skills to all family members: expressing positive feelings, active listening, making a positive request for change, and expressing negative feelings about specific behaviors. Other skills may be taught depending on the needs of families (e.g., timeouts). Problem solving is taught in a structured format (defining problem, listing solutions, listing ad- vantages/disadvantages, choosing best solutions, plan how to carry it out etc.) with the dual goal of teaching families to facilitate this important skill and to address specific problems impacting the family (Table 1). Skills are taught by first presenting the rationale for the skill, then modeling the skill, facilitating behavioral re- hearsal of the skill among all members of the family present, coaching family members on the skill, and finally discussing and assigning practice of the skill for homework.

The goals of FFT include the following: integrating the family’s experiences of the mood disorder, understanding vulnerability to future episodes, accepting the necessity of psychotropic medica- tion, distinguishing the individual’s personality from the disorder,

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recognizing and coping with stressful events that may trigger recurrences, and reestablishing functional family relationships af- ter an episode. While FFT is structured in its approach, there is flexibility to address unexpected issues that arise and an integra- tion of a systemic framework in implementing skill training. Built into FFT is acknowledgment and anticipation of denial, resis- tances, and dynamics that may keep families stuck in nonproduc- tive communication and problem-solving patterns. Techniques, such as predicting and reframing denial, “spreading the afflic- tion” or acknowledging that all family members face chal- lenges, and acknowledging underlying dynamics that may pre- vent progress towards stated goals, are a part of FFT. For example, if family members have different perceptions of the illness leading to family conflict (an individual may overiden- tify with it while a family member underidentifies with it), this is addressed directly as it surfaces in a session. This represents a dual focus of skill training as well as identifying and modifying ineffective interactional patterns. Both aspects address the ultimate goal of building family cohesion and support around coping with the illness as they also increase interpersonal satisfaction.

Applicability of FFT to TBI

While FFT was developed for use with individuals who suffer from serious mental illness, the gap between someone who suffers from a severe TBI and an individual struggling with bipolar disorder may be less broad than it might first appear. In both cases, challenging behaviors on the part of the individual can be a significant source of stress for families, particularly if the family assumes the behavior is volitional and within the individual’s control. It is easy for families to develop a set of expectations for the individual’s functioning and behavior that may not be well grounded in the actual deficits the individual is experiencing. In

both situations, the family is faced with an illness or injury that is permanent and also variable over time, so that once-effective means of coping with a given challenge may need to be adapted as the individual encounters new environments and as certain devel- opmental milestones pass without being met. More broadly, clini- cians working with both types of individuals recognize that the presence of a physical or mental impairment does not preclude them from living a meaningful life. Both rehabilitation and FFT therapists have as an overarching goal the improvement of the individual’s ability to participate in meaningful life activities and valued roles. This is achieved through enhancing an individual’s natural environment.

Modifications of FFT for TBI

Modifications of FFT for TBI occur in a few main areas. Information provided to individuals and families within the psy- choeducation module is modified to cover such topics as a review of the injury, typical family responses to injury, rehabilitation activities, acceptance of a new level of functioning, and corre- sponding changes in expectations, routines, and any adaptations of the environment, or tasks (Table 1). T is flexibility to address the multitude of problems presented by returning veterans (e.g., rein- tegration into civilian society, responses to stress from military service, PTSD, financial challenges). There may be sessions de- voted to discussing and normalizing such transitional issues. It may also be necessary to meet with the individual with TBI alone intermittently as well as connect with the larger treatment team to integrate information regarding ongoing rehabilitation needs as they arise. Additionally, flexibility in accommodating injury phase is taken into account for planning the content, structure, and course of treatment. For example, there will be differences in these three domains when working with families immediately after an injury

Table 1 FFT Modules with Modifications for TBI

FFT modules Topics addressed in FFT Modifications for TBI

Psychoeducation Symptoms (patient and family perspectives) Review of injury (patient and family responses to injury) Life events Role of life events Etiology and course Course of rehabilitation Risk and protective factors Changes in expectations and routines Treatment options and medications Treatment/rehabilitation activities and medications Relapse drill Working together around functional challenges and abilities

Communication enhancement training

Expressing positive feelings Expressing positive feelings Active listening Active listening Making positive requests for change Making positive requests for change Expressing negative feelings about specific behaviors Expressing negative feelings about specific behaviors

Problem solving Defining problem Defining problem Listing solutions Listing solutions Evaluating pros and cons Evaluating pros and cons Choosing best solutions Choosing best solutions Planning how to carry it out Planning how to carry it out

Goals Integrating family experiences of illness Integrating family experiences of injury/rehabilitation Understanding vulnerability to future episodes Understanding and accepting new level of functioning Accepting the necessity of treatment Accepting the necessity of ongoing rehabilitation Distinguishing one’s personality from illness Distinguishing one’s personality from injury Recognizing stressful events that trigger recurrences Recognizing stressful events that trigger reactions Reestablishing functional family relationships Reestablishing functional family relationships

Note. FFT � family focused therapy; TBI � traumatic brain injury.

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compared with those further along in rehabilitation. The former may require specific educational information, caregiver support and problem solving, and more frequent meetings or interface with medical and rehabilitation providers. Additional flexibility regard- ing scheduling sessions (frequency over time) and ongoing contact may increase or decrease depending on specific needs of rehabil- itation. There may be a need for more frequent sessions immedi- ately after an injury or around a specific developmental event (e.g., a missed graduation).

Illustrative Case Example

John is a 25-year-old combat Operation Iraqi Freedom veteran with multiple deployments who was referred to FFT by his pro- viders in order to facilitate education, communication, and prob- lem solving surrounding his rehabilitation. Potential FFT goals as applied to TBI included reviewing John’s injury and subsequent TBI; discussing John’s functional challenges and abilities; accept- ing the necessity of ongoing treatment; distinguishing who John is from his TBI; recognizing, adapting, and coping with stressful life events that impact John’s functioning; and reestablishing func- tional family relationships (see goals in Table 1). Specific goals identified by John and his family during the first session included effective communication around specific aspects of his functioning (e.g., attending rehabilitation appointments), increasing John’s sense of independence from his family despite his dependence on them for care (e.g., finances), and problem solving about when and how his parents can help him with his ADLs. John shared that he found it particularly difficult to have his parents step in to help him when he was in the presence of other military personnel from his unit visiting him. He also described difficulties he had with nego- tiating financial matters in the family.

John sustained a TBI in a motorcycle accident while on leave from the Army. He was unhelmeted when his motorcycle collided with the back of a truck, and he was thrown approximately 50 feet off the road. He was unresponsive when emergency personnel arrived. He had a Glasgow Coma Scale score of 6 when admitted to the acute hospital. He had sustained multiple injuries, including a fractured femur and pelvis, rib fractures, and a fractured right forearm. An MRI performed at 1 week after injury revealed bilateral frontal subdural hematomas, along with diffuse damage indicative of a severe TBI. John had a complicated hospital course in which he developed pneumonia, required intubation, and be- came severely deconditioned. He experienced 6 weeks of posttrau- matic amnesia. At four weeks after injury, he was transferred to an inpatient rehabilitation medicine service, where at admission he was at a Rancho Level IV, and dependent with most self-care due to confusion, weakness, spasticity, and apraxia. By the time of his discharge home at 12 weeks after injury, John relied upon a wheelchair for mobility and was able to propel this independently; he was independent for most self-care but required assistance with bathing and toileting, and he struggled to complete higher-level activities of daily living (ADL), such as cooking, financial man- agement, and driving. He currently lives with his mother and father, who relocated to be able to take care of him. John was initially financially dependent upon his parents until he was med- ically boarded out of the military and received service connected disability from the VA. John expressed disappointment that he

could no longer serve in the military, the only profession he had known as an adult.

Treatment began with the identification and discussion of the above-stated goals, his injury and rehabilitation, and their current communication patterns. Part of what was highlighted in these discussions was John’s tendency to express anger and frustration, which resulted in a tense home environment. At the same time, the therapist noted that the family did not include a great deal of expression of positive feelings in their communication. Along with identifying areas where John needed assistance with ADLs and discussing general rehabilitation expectations, experiences, and goals (psychoeducation), the skill of expressing positive emotion was introduced in an early session (communication enhancement training). After practicing this skill at home, John and his parents realized the primary role it plays in bolstering support as well as giving each other feedback as to what was helpful. This skill was useful as they negotiated ways that John could receive support from his parents without intrusion when his military personnel from his unit would visit. The FFT clinician introduced active listening where each family member took a turn in the listener role. John and his family members noted how restricted they were with respect to the feelings and issues that were discussed. John realized that he could express anger and frustration, but that he often found himself shielding his parents from his pain by using humor; it was more difficult to express other emotions, such as sadness. It also became apparent that John’s mother and father related to John differently, in that his mother would assume that John needed help with most things (i.e., ADLs), while his father would ask him first if he needed help before getting involved. Psychoeducation around this as well as the introduction and practice of “making positive requests for change” where John could practice asking his parents for help and John’s parents could talk about how best to respect John’s independence around his needs. The family was able to recognize John’s particular sensitivity about requiring help for personal needs and with financial issues.

Through the practice of each of these communication skills, the therapist identified a dynamic in which John’s mother would take control of a situation where she felt John needed help (e.g., push his wheelchair up a particularly steep ramp at a local store) and at the same time would speak in a catastrophizing way about the situation (“What are we going to do when it’s winter and it’s too icy for me to push you? How are you going to ever do this on your own?”). This, in part, was anxiety about how to best be helpful and do the best thing for John’s recovery. John’s response to his mother’s anxiety and attempt to take control was to underestimate his abilities and potentially underfunction, resulting in his feeling a lack of independence. At other times, John’s mother would insist that he could do something (e.g., stand up for a period of time) and he would disagree. Psychoeducation about expectations and func- tional abilities was important to these discussions followed by simple problem solving to facilitate the exchange of their perspec- tives and needs. For John, this meant expressing negative feelings about specific behaviors towards his mother. For example, he became more willing to let her know that when she would state a lack of confidence about his functioning, he felt insecure about his true abilities. For his mother, this meant expressing her desire to care for him and not see him get let down or further hurt. By communicating in this way and moving forward to problem solv- ing around how to handle future situations, they were better able to

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understand and support one another. Problem solving was intro- duced and there were several issues that were addressed. These included the following: finances and John’s contribution as he began to receive disability payments through his VA service connection, how John’s parents could encourage independence without being intrusive, John’s transition from military life to civilian life (e.g., identity as military personnel and decrease in contact with his military friends), and the eventual transition from “being taken care of” to “moving on with life” (problem solving).

Throughout the treatment, important family dynamics were identified. One result of acknowledging family dynamics and their role in the complexity of issues John faced was the realization that there was unacknowledged grief among all family members around accepting what had happened. The grief in this case in not unlike the grief felt by individuals with serious mental illness and their families as they “grieve over the lost healthy self” (Miklowitz & Goldstein, 1997, p. 169). This grieving process occurred once the family was able to communicate more effectively and John was able to understand how his behavior (i.e., humor) functioned to protect his parents as well as himself from these feelings. As treatment progressed, he was also able to acknowledge the role of this humor, which was to shield him from traumas he experienced as a part of his combat experience. John acknowledged that he had suffered losses of friends during his deployments and “seen things that no one should see.” He was able to admit to feelings of guilt around his own actions in combat, and John’s parents were able to understand how important visits with fellow military personnel were. In this case, the FFT therapist was also able to engage the family around an educational discussion of PTSD, and the impor- tance of screening to determine treatment needs. John reported that he had been screened for PTSD and did not carry this diagnosis, which was helpful for his parents to know.

Throughout this process, John and his family stated that they appreciated the opportunity to fine-tune the way in which they communicated about and coped with the drastic change in their family life due to John’s TBI. John was appreciative of the opportunity to communicate his needs as well as to work together with his parents around the issues that were compounded by military service, his accident, and subsequent TBI.

In this case as well as others receiving FFT for TBI, treatment can consist of 20� sessions followed by booster sessions every month or so. Treatment typically begins with a consistent schedule and then is negotiated in an ongoing manner with frequent revis- iting of goals and review of accomplishments. Although the mod- ules are distinct in the FFT protocol, there is flexibility to address what is most pressing, and, often, psychoeducation is ongoing and mixed with skill training. This ensures that the family is engaged and feeling as if they are best able to build upon education around TBI with skills to communicate and move beyond problems as they work towards their goals.

Conclusions and Future Directions

The case of John and his family illustrates the overlap between the needs of a returning OEF/OIF veteran with TBI in the post- acute phase of recovery, along with his family, and one approach to improving individual outcomes via a family based intervention embodied in FFT. The substantial number of military personnel returning with TBI, coupled with the medical and mental health

co-morbidities on top of the complexity of stressors encountered during combat as well as upon re-entry, necessitates an intensive approach to treatment that includes systematic family intervention. Although the importance of supporting healthy family functioning for veterans with TBI is recognized, as yet there is a small albeit growing literature addressing needed family intervention for this population. While it is promising that current interventions with families of adults with TBI (e.g., PST; Rivera et al., 2008) show impressive results in caregiver status (e.g., depression, problem solving ability), it is important to build upon the foundation of this approach due to the complexity of issues presented by this specific population of returning military personnel. Involving the military personnel member in the family intervention is promising as a way of impacting individual functioning outcomes during a difficult transition and amidst potential co-occurring psychological disor- ders. Adaptation of already existing models of family intervention that share similar illness characteristics (i.e., chronic and function- ally disabling) as well as overarching conceptual philosophy (i.e., recovery) is a prudent first step in the long process of establishing an intervention. One such model is FFT, originally designed for individuals with bipolar disorder and, with adaptation noted in this paper, shows potential.

Despite the need for family services to meet the acute and complex problems of OEF/OIF military personnel sustaining a TBI, there are many steps needed before FFT can be seen as a recommended intervention. This includes extending the current knowledge of individual and family functioning where an OEF/ OIF military personnel member has sustained a TBI. Descriptive studies outlining various domains of individual and family func- tioning, within the complex picture of a returning military person- nel member’s physical and psychological profile, would be an important first step. In order to gain a contextual understanding of individual and family or relational functioning, it would be impor- tant to obtain data from different informants (individual and family members) as well as via different methodological approaches (observational, other report, and self-report). Because of the com- plexity of physical and psychological challenges facing military personnel, collaborations between psychologists from rehabilita- tion medicine and psychiatric rehabilitation are vital in moving this line of research forward. In order to further explore FFT for TBI, a treatment manual or protocol would need to be written and guided by understanding the needs of this population. It would likely include optional information about other psychological dis- orders, such as PTSD, and require systematic investigation to establish feasibility and simple outcomes. In order to extend this as a viable option for those populations at a distance or to disabled to attend sessions, this treatment would need to be tested via live interactive videoconferencing.

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Received May 12, 2009 Accepted June 17, 2009 �

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