Lyons Davidson’s Head Injury team attended the British Association of Brain Injury Case Managers (BABICM) AGM and Summer Conference in Bristol on 28 June. The focus of the meeting this year was ‘Relationships After Head Injury’.
The day began with an interesting presentation from Jeffrey S Kreutzer, Professor of Physical Medicine and Rehabilitation, and Professor of Neurosurgery and Psychiatry at Virginia Commonwealth University. He outlined the importance of working with the families of brain-injured people.
Head injury management
A patient’s behaviour is the best indicator of how the family is affected and Professor Kreutzer once overheard a patient say to his neurologist: “You saved my life, but it is not a life worth living.” He emphasised the need for more research and counselling to turn this around. Professor Kreutzer explained his treatment methods. He is particularly keen on developing coping strategies for couples and the wider family. He noted the difficulties they experience living with a characterlogically altered brain-injured patient: research shows that common problems include feeling trapped and isolated, and even those family members who maintain outside social contacts may feel alone, since so few people understand their plight.
Normalisation process
Counselling goals include helping family members readjust expectations and providing practical management advice, letting them know that anger, frustration and sorrow are natural emotions, part of the ‘normalisation process’. Particularly interesting was research in the Journal of Neurology, Neurosurgery and Psychiatry, which looked at five-year outcomes of severe blunt head injury from a relative’s point of view. It found that relatives were under greater strain later (compared to one year after injury) and the best predictor of that strain was the magnitude of behavioural and personality change in the patient. It found that most survivors lived with their families, did not work or attend school and were dependent on others for skills, finances and services outside the home. Families most frequently assumed major responsibility for the survivor’s long-term care, despite having no training. Most families reported that the traumatic episode continued to have a variety of adverse effects on them years after injury.
Brain injury education for families
Clearly, noted Professor Kreutzer, when someone is injured, the whole family is affected and this can have serious implications for relationships. To assist them, he implements the six-point Brain Injury Family Intervention Goals, which:
Provide patients, families and carers with information about common symptoms and challenges they will face after brain injury;
Help families better understand how brain injury has affected them individually and as a unit;
Teach patients, families and carers effective problem-solving strategies, enabling them to achieve personal goals;
Teach coping strategies that facilitate emotional recovery, helping families feel better about themselves, their lives and relationships;
Instil hope in family members by identifying progress and personal strengths and facilitating access to community resources;
Teach families effective communication skills, helping them develop strong, long-term support systems.
Managing challenging behaviour
The next speaker was Hugh Jones of Pannone LLP, who discussed practical issues of relationship breakdown for brain-injured clients and the role of the Financial Deputy. He noted that protective families may not want the injured person to have a relationship, for fear of the partner being a ‘gold digger’, and they may also be concerned about whether they are in ‘real’ relationships at all. Older children are likely to notice the difference in behaviour post-injury, which can lead to a breakdown in relationships, with some children seeing the injured parent as a source of money. Partners who take on other people’s children can experience issues with looking after them and may need to consider if carers, nannies or case managers are required. Ultimately, it can end with children being taken into care.
Beneficial interest
A Financial Deputy works in the best interests of the client, but this can involve a balancing act between what clients want and what they need. Deputies must apply the principles set out in Section 1 of the Mental Capacity Act 2005, and may need to make provision for the needs of anyone who is related to or connected with the client. After a brain injury, relationships are under a considerable amount of strain, and while married couples have financial claims as of right, cohabitees do not. If a property is in joint names there is an assumption of a 50/50 share, however if it is in one name, the non-owning party must establish a beneficial interest (which is not easy to do).
If the brain-injured client has received a personal injury award, this may also be taken into account in divorce proceedings. In two contrasting cases, Wagstaff in the Court of Appeal [1992] essentially gave no award from compensation to the non-injured spouse; whereas in the recent case of Mansfield [2011], the Court of Appeal awarded over half the compensation to the non-injured spouse.
Safeguarding authority
Matthew Stockwell, Barrister at St John’s Buildings, gave a talk on ‘Sex, Contraception and Marriage’ in the context of head injury. The issue of sexual capacity is of practical significance (as well as acute sensitivity) for injured people and those supporting them. It is also, he noted, an area where the state should exercise particular caution in safeguarding authorities and the courts. The law relating to sexual capacity is presently in a lamentably uncertain state, and he outlined current tensions and offered practical advice to case managers when dealing with clients with increased or decreased sexualised behaviour following acquired brain injury.
He was followed by Claire Wilson, Neuropsychologist at the Rookwood Hospital in Cardiff, who addressed sexuality and relations after a traumatic brain injury, looking at the clinical issues, sexual dysfunction, and medical and psychological factors.
Head injury and depression
The World Health Organisation recognises the importance of interpersonal relations and many studies highlight the health benefits associated with a sexual life, although the effect of a traumatic brain injury on sexual function is often overlooked in rehabilitation by professionals and family members. Clare Wilson explored studies which have shown that traumatic brain-injured patients experience a variety of obstacles, not just physical symptoms but also decreased opportunities and frequency of physical relationships, decreased confidence and depressive symptoms. There can also be subtle differences with expression of affection, misunderstanding and frustration or embarrassment. She then looked at the effects of this in the context of close relations and, again, it was noted that there were high rates of marital difficulties and divorce stemming from lack of empathy or expression of affection, feeling rejected, a partner’s loss of attraction and issues with disfigurement and ongoing medical involvement. In order to help patients and their partners, discussions are required about sexual difficulties in a relaxed, trusting, comfortable and confidential environment.
Enhancing self-esteem
There next followed a role play from sex and relationship coach, hypnotherapist and NLP Master Practitioner Hardeep Tassell, Dr Tuppy Owens, sex therapist and sex and disability pioneer, and case manager Carol Milne. This explored enabling safe sexual expression, underlined the importance of relationships after an acquired brain injury and examined the ways in which self-esteem can be enhanced, leading to a feeling of being ‘normal’.
European Convention on Human Rights
This session was followed by Claire de Than of City University, whose presentation was entitled ‘Legal Issues of Consent, Sexual Autonomy and Human Rights’. The European Convention on Human Rights provides the right to respect for private life, the right to marry and the right to information about sex and contraception. There is a duty on the state and public authorities to allow disabled people to create and maintain sexual relations as part of a private life and expression. Everyone has the right to such relationships, she maintained, and nobody should interfere with these rights or discriminate – but she also placed a strong emphasis on the duty to protect vulnerable people.
Lord Justice Munby concluded the day’s talks. He said that the welfare of the individual must be looked after, but highlighted the need to hold a balance between the safety and dignity of that individual, and posed the questions: what good is making someone safe if it makes them miserable? It is a human right to have a sex life? He noted that while much is available to disabled and disadvantaged people, there needs to be protection against exploitation.
Lyons Davidson’s Head Injury Team specialises in all types of head and brain injury claims on behalf of the injured party. For more information contact: 0117 904 5829.
