ABI – The Challenge

ABI can have substantial and lasting effects on cognition, emotion, behaviour, and identity and can affect the ability to cope with everyday life, work, education and relationships. As counsellors we may encounter clients with ABI or their family members in our practice, but are we adequately prepared to meet their needs and challenges?

In this article, I suggest that counselling awareness about ABI deserves more of our attention and easier access to training resources in the UK. 

 

ABI – A Growing Public Health Issue

I spent many years working for a leading neurological charity that supports people affected by brain injury. According to the latest statistics from Headway UK for 2019-20², there were:

• 356,699 UK admissions to hospital with acquired brain injury in 2019-20. This is a 12% increase since 2005-6.
• There were approximately 977 ABI admissions per day to UK hospitals in 2019-20. This is one person every 90 seconds!
• Males were 1.5 times more likely than females to be admitted for a head injury.
• Female head injuries were up 28% since 2005-6.
• There were 137,403 admissions for stroke – a 14% increase since 2005-6.

 

ABI is clearly an important and growing public health issue in the UK

Everyone of these statistics has a story. I think of Eric who told me so matter-of-factly how, following a bicycle accident he lost his job, his marriage, his family, his home and standing in his community.

Or Paul who remained living in a “loveless marriage” and dependant on his wife for food and laundry. He was unable to live independently and was too young for a residential care home. Paul was physically neglected, lonely, angry and losing his faculties. He expressed feelings of hopelessness and despair, unable to end his life due to his “feeble hands”. Using an electric wheelchair gave him some freedom but also afforded the opportunity “to end it all” at a rail station. This became his “safety net”. To leave this world on his terms.

 

ABI – Counselling Challenges

In my experience not all people with ABI receive adequate or timely access to psychological services.  There is of course the hurdle of stigma, shame and embarrassment. Jenny took months after a whiplash injury to ask for help because of her shame. She cried for the first few months of our sessions. Like Jenny, sometimes there are no visible signs of injury. The ABI sufferer often fears being judged or discriminated by others who do not understand, if they disclose their injury or seek help.  Jenny eventually lost her job in the health sector after months of sick leave followed by a job change that was beyond her abilities.

A lack of awareness, support availability, affordability, motivation, compatibility are also barriers to psychological wellbeing.  The NHS and some UK charities have budgets for counselling but these funds are constantly under pressure. Moreover, there is a lack of evidence-based guidelines and standards for counselling for ABI in the UK.  

Before Covid-19 hit the UK, when I was working with clients with ABI or their family members, I found a distinct lack of locally available specialised training and supervision. With easier access to online training and supervision this has somewhat progressed but there is still room for improvement.

As part of an ABI Multidisciplinary Team (MDT) we created our own group courses, discovering what worked well and what needed to improve. At one point there were so many male clients, I started a men’s group which literally became a “life saver” to some; a safe place, with tea and biscuits, to air their problems with others who “got them”. The men wrote their own group-rules with confidentiality as rule #1! We discussed topics such as, anger, sex, impotency, identity, suicide ideation, infidelity, loss and many more.  At first I wondered how they would manage with a female counsellor but I was bestowed the honour by Richard of being the “honourary bloke” for each session! Despite the severity of the topics we had many laughs together.

 

ABI – Relationship Challenges

One of the most common and distressing consequences of ABI is the impact on relationships. The emotional, behavioural, physical and cognitive changes after ABI can often have an effect on existing and future relationships. Harry stated he “lost” his wife to another man. This interloper became “a replacement father” to his children. Due to his ABI severity Harry had to watch another man cuddle and play with his children. Not only was his wife “stolen” from him, he also felt “robbed” of his identity as a dad. His level of anger and despair was palpable when working with him. 

The ripples of ABI reach far and wide, not just for the injured person. Terry’s wife said “my husband looks the same on the outside but has completely changed on the inside, I have lost my life partner”. Family members can lose friendships and social standing, often becoming isolated and alone in their grief of ‘life-after brain injury’. When I spoke with Bobby’s daughter she confided that her loving, caring father was now miserable and unpredictable, lashing out sometimes at loved ones. She often expressed in therapy how she felt ill-equipped to know how to help and care for him.

Some relationships may strengthen, but in my experience most struggle and become strained over time or even completely break down. This is supported by research;

• A study by Kreutzer et al.³ found that 25% of couples who had experienced a TBI reported marital dissatisfaction within the first year after injury.
• Godwin et al.⁴ found that the divorce rate among couples who had experienced a TBI was 17%, compared to the national average of 12%.
• Marital Stability and Quality of Couple Relationships after Acquired Brain Injury⁵ found that couples who had experienced an ABI reported lower levels of marital quality and satisfaction than couples who had not.

 

These studies suggest that counselling for ABI should include a strong focus on relationship issues and interventions.

Counselling can help those affected to understand, manage, and overcome the impact of their injury on their relationships. It can also help with adjusting to their new situation, rebuild their sense of self and identity, and enhance their quality of life. We often speak about acceptance within the counselling setting, to help a client grieve and process emotions. Journeying with them to a place of acceptance and hope is a privilege and requires skill. 

 

ABI – Unique Opportunities

Counselling for ABI requires specific knowledge and skills that may not be covered in general counselling training. For example, being aware of the cognitive impairments that ABI may affect communication and comprehension.

We also need to be familiar with emotional and behavioural changes that may occur after ABI, such as mood swings, aggression, impulsivity, apathy, loss of libido etc.

Therapists also need to be sensitive to the role changes and challenges that may arise in the relationships, such as dependency, caregiving, loss of intimacy, etc.

At an initial assessment Bill was reluctant to attend with his wife Pat who had suffered a stroke 3 years previously. Both were angry and depressed at the way retirement had treated them. Their hopes and dreams had been dashed with each subsequent year ‘post stroke’. With therapy came an understanding of tolerating the changes and a rekindled hope of the future. They made little day trips out, sometimes just for a “cuppa and short walk”, all within Pat’s framework of pacing herself. At the end of therapy Bill disclosed that a “load had fallen off”, that he “enjoyed” helping with household chores and Pat said she was more able to remain quiet when they were “not up to scratch”.  They ended therapy with a recommitment to each other for the “rest of our lives”.

In conclusion, I believe counselling for ABI is a vital area of training that deserves more attention and recognition.  It can provide valuable and beneficial support for people with ABI and their partners who face complex and difficult issues and decisions in their relationships after injury.  However, counselling for ABI requires specialised knowledge and skills that may not be attained in general counselling training.

Therefore, I propose that counselling for ABI should be included as an optional or mandatory module in counselling training courses. I also suggest that counsellors who work with clients with ABI or their partners should seek regular supervision and CPD in this area.

Before Covid-19, finding an appropriate ABI experienced supervisor was a dilemma for myself and my colleagues, both with cost and availability.  We would often have short peer supervision sessions to share our own reflections and expertise over a situation.   Post-Covid with online availability of resources I believe we have the opportunity to improve our competence and confidence in providing high-quality and effective counselling services for people with ABI and their partners by including this aspect of counselling in our training courses or in CPD sessions.