Psychosocial consequences of brain injury are well documented and frequently include difficulties with coping, loss of relationships and social support, and inability to participate in or fulfill meaningful roles.1 These changes and losses negatively impact quality of life and life satisfaction, and can influence rehabilitation outcomes, particularly community integration.
Epidemiologic studies demonstrate that a large percentage of individuals that sustain traumatic brain injury (TBI) are between the ages of 15 and 24.2 Many young people at this stage of life are establishing intimate relationships, entering the workforce, and may be living independently for the first time. A brain injury can create psychosocial consequences that can persist and become long-term problems. Some researchers suggest that long-term psychosocial consequences may be the greatest challenge facing individuals with brain injury. Health care and rehabilitation professionals should prioritize these as targets for early and aggressive intervention.3
The Institute of Medicine (IOM) recognized the importance of the interaction between the individual and the environment in the expression of disability. According to the IOM, environments can be physical (ie, architectural), social (ie, culture, economic, political, etc), and psychological (ie, personal resources, personality traits, and cognition). The interaction between the individual and the environment can either enable (restore function; expand access to the environment), or disable (limit performance in activities and roles).4 The psychological or attitudinal environment—that is, how a person perceives, experiences, and reacts to his current situation and circumstances—can be as enabling or as limiting as the physical/architectural environment.
For example, individuals that view their illness or injury as a challenge to overcome, believe they can exert some degree of control to change their situation, seek information and ask for assistance, and are more optimistic about their future; they are more likely to exert effort and work hard, and less likely to give up when setbacks occur. They are more likely to have a better outcome than the individual who harbors a “victim” mentality, perceives they have little control to change their situation, and withdraws or blames others for their situation or circumstances.5 Variables that influence positive psychosocial outcomes following brain injury include: focusing on strengths, facing the future with hope and optimism, resilience, identity strength, and positive coping.
According to the American Psychological Association, resilience is defined as, “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility, and adjustment to external and internal demands.”6 Studies demonstrate that individuals with TBI are at risk for low resilience, and low resilience following TBI is associated with psychological distress and decreased psychosocial adjustment.7,8
However, research has also demonstrated that resilience is dynamic and modifiable, and specific skills can be practiced to improve an individual’s ability to adapt to adversity.9,10 Among these skills are: managing emotions, optimism/maintaining a positive outlook, engaging in adaptive problem-solving, use of approach-oriented coping strategies, effective communication, and asking for and accepting assistance.
According to Sarbin, self-identity is shaped by a complex interplay of personal, social, and temporal factors.11 Personal identity includes preferences, unique personality traits, values, and goals. Social identity is a person’s sense of self based on memberships and identification with certain social groups. Temporal factors involve the aging process and the experience of life events over time. Self-identity, then, is a dynamic and evolving process. As we age and experience significant life events, we continuously construct and reconstruct our identity.
According to Levack and colleagues, following a brain injury, individuals desire to have a complete, satisfying, and coherent sense of self.12 Additionally, those with a brain injury want to experience acceptance, validation, and respect from others. Jones and colleagues suggest that whether an individual experiences positive or negative outcomes following TBI is dependent, in part, on changes in personal and social identity.13 For clinicians to develop meaningful goals and deliver relevant treatment, an understanding of the individual in the context of their life circumstances, both pre- and postinjury, is necessary.
In addition to positive personal and situational appraisals, and narrative therapy techniques to construct a positive self-narrative and providing opportunities to strengthen personal relationships, Villa and colleagues identified a number of themes that serve to guide clinical interventions to strengthen self-identity.14
Awareness of change in functioning: Following a brain injury, awareness of functional change and loss of function, triggered by struggling to complete tasks, can challenge the sense of self. Therapies that restore function—particularly in daily life activities, routine, and orderliness—may help restore a sense of self. Additionally, allowing the individual to come to terms with a few changes at a time allows them focus on remaining strengths rather than a collection of clinical problems, and provides continuity between the preinjury and postinjury self.
Autobiographical memory loss: Loss or disruption of accurate self-history and a continuous life story can impact a sense of personhood and knowing how to approach life and daily challenges. Assisting the individual in “filling gaps” through interviews with family, friends, and coworkers can recreate an accurate life story. Interventions that assist the person to return to meaningful activities and roles can strengthen a sense of self. Particularly helpful is assisting the individual to identify personal values and what is of value to the person.
Loss of autonomy: Following brain injury, individuals are often deprived of the opportunity to make personal decisions. Lack of decision-making and treatment delivered by a traditional medical model of care where practitioners are viewed as “experts” that may encourage an individual with brain injury to take on a “sick role.” Delivering person-centered care, encouraging informed choices, including individuals with brain injury in decision-making where appropriate, and treating them with dignity and respect, can strengthen self-identity.
Given that identity (and identity reconstruction) evolves over time, and recovery from brain injury can take months or even years, Villa and colleagues suggest giving attention to the timing of interventions and meeting the individual “where he is” in the recovery process. For example, awareness of changes in function may occur early in recovery, whereas a sense of loss of autonomy may occur later in the recovery process.
Positive Psychology Practices
It has been suggested that positive emotional states and psychological well-being, and negative emotional states and ill-being, are distinct and separate systems, not extreme ends of a single continuum.15 Therefore, treatment programs that focus on impairments, problem identification, and decreasing the experience of negative emotions versus focusing on strengths and facilitating the experience of positive emotions, may undermine psychosocial outcomes.16 Focusing on deficits and weaknesses may result in psychological distress and inadvertently promote a “victim mentality” or adoption of “sick role.” During rehabilitation, greater attention should be placed on identifying and building upon individual strengths, providing opportunities for experiencing positive emotions, and delivering interventions that foster personal growth.17
Lai and colleagues18 conducted a systematic review of the efficacy of positive psychology intervention in neurological populations. Their review examined the literature between 1980 and 2017 and identified 6 positive psychology therapy techniques: mindfulness-based approaches, positive savoring, life summary, expressive-based interventions, hope-based interventions, and character strengths.
Mindfulness-based approaches targeted stress reduction through nonjudgmental awareness in the present moment, mindful movements, or structured breathing exercises. In addition to reducing stress, mindfulness-based approaches increased self-efficacy, knowledge, and skills to manage symptoms, as well as improvements in some cognitive functions (ie, attention and processing speed).
Positive savoring involved focusing attention on pleasurable and/or appreciable experiences in life. Savoring techniques instilled gratitude, promoted altruism, and strengthened social connections.
Life summary techniques included a “lifeline” exercise in which participants narrated past successes or meaningful events to solidify a sense of purpose in life. Life summary exercises decreased levels of depression and promoted optimism.
Expressive-based interventions like music, drawing, poetry, or dance engaged the mind-body connection, promoted positive affect, and improved interpersonal communication.
Hope-based interventions focused on positive beliefs and expectations about current and future health status in spite of current barriers. Hope interventions increased positive expectancy and decreased perceived stress.
Character strength interventions focused on developing personal strengths and talents and assisted participants to reconnect with values and promote self-conceptualization. The authors concluded that these interventions improved quality of life, reduced distress, and lowered depressive symptoms.
The methods individuals use to cope with change following injury can influence rehabilitation outcomes. Coping refers to the thoughts and behaviors individuals use to manage situations that are appraised as stressful, or that exceed available resources.19 Coping strategies are generally categorized as either adaptive (also referred to as productive, problem-focused, or approach-oriented), or maladaptive (also referred to as passive, emotion-focused, or avoidant-oriented). Adaptive or problem-focused strategies seek to actively address or confront the problem and include gathering information, asking for and accepting help, planning and problem-solving, or reappraising the situation. Maladaptive or emotion-focused strategies involve regulating emotions rather than taking action to change the stressful situation and involve denial, wishful thinking, minimization, blaming, or avoiding by using drugs and/or alcohol.20 Following brain injury, adaptive coping is associated with better self-esteem, greater perceived self-efficacy, increased problem-solving, reduction in anxiety and depressive symptoms, and higher quality of life.21,22
Cognitive behavioral therapy (CBT) interventions focusing on the development of specific coping skills (ie, problem-solving), or reappraising situations accurately or more positively, resulted in improvements in coping for individuals with brain injury. Backhaus and colleagues22 describe a randomized controlled trial that involved a 12-session, manualized CBT group in which participants received psychoeducation, social support, and coping skills training. When compared to a wait list control group, the participants showed greater perceived self-efficacy immediately after treatment and at follow-up. Though not statistically significant, participants in the treatment group also showed better emotional functioning and less emotional distress.
Anson and Ponsford21 enrolled individuals with TBI in a CBT-based group intervention (Coping Skills Group) to improve adaptive coping. Following the 10-session intervention, improvements in adaptive coping were noted. Coping that involved problem-solving, using humor, and engaging in pleasurable activities to manage stress was associated with higher self-esteem. The intervention did not appear to impact maladaptive coping. Coping that involved wishful thinking, self-blame, worry, avoidance or using drugs/alcohol was associated with anxiety, depression, and lower self-esteem.
Dr Seale is the Regional Director of Clinical Services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a chemical dependency counselor and psychological associate with independent practice. He also holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.
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