Q. Psychosocial / Adaptation Issues

There is broad consensus that rehabilitation goals should be individualized and meaningful to patients and take into consideration their unique strengths and challenges. This includes determining the appropriate environment for the patients and helping them define meaningful activities and productivity for themselves. Accordingly, treatment programs should reflect the person’s individuality and the uniqueness of their situation. In the psychosocial realm, this includes addressing the issues that change intimacy and other aspects of the individual’s sexuality, which has significant implications for behaviour and relationships. 

Traumatic brain injury (TBI) in adulthood often disrupts an individual’s sense of self, roles and belonging. TBI is a complex condition to adapt to, and this needs to be supported through ongoing rehabilitation aimed at improving activities of daily living, satisfaction, and productivity. Positive psychosocial adaptation is essential to an individual’s sense of control and quality of life. Improved coping mechanisms are associated with improved psychosocial functioning and can lessen anxiety. Research has demonstrated a positive association between life satisfaction, employment/productivity, and relationships. Since TBI is a chronic disorder that affects individuals throughout their lifetime, individuals need to be supported in reducing isolation, having positive social relationships and engaging in productive and meaningful activities. In turn, this improves the psychosocial health and quality of life of the individual with TBI and those around them. The biopsychosocial effects of TBI can significantly impact sexuality. Attention to holistically addressing this is essential to strengthening the individual’s sense of self and relationships.

Integrated and individualized rehabilitation often requires the input of system navigators who have knowledge about local resources and can assist in making appropriate referrals to providers and facilities.  Rehabilitation teams should include specialists in psychosocial adjustment counselling. 

Interventions and approaches that will enhance and improve their patients’/clients’ participation and emotional well-being should be built into the rehabilitation program early on, to set goals and get the individual involved in meaningful and productive activities. Rehabilitation program managers should ensure access to appropriately trained clinicians on their team or that appropriate referrals are made for discussion and education regarding sexuality, sexual health and relationships. Planners should understand the importance of continuing programs that increase participation and well-being in the community long after an individual has sustained their TBI. Improving the quality of life, adaptation, and productivity of the individual with TBI can also positively impact on those around them, thus reducing caregiver burden, and improving the family’s socio-economic productivity. 

Indicators exemples

• Proportion of individuals with TBI for whom a discussion about sexuality, covering physical and psychological aspects, was carried out and documented in the person’s chart. 
• Proportion of individuals with TBI for whom personally relevant and meaningful productive activities are clearly documented in the treatment plan within the first six weeks after admission to rehabilitation. 

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Patients who engage in rehabilitation, whether it be community-based, in-home care, or residential transitional living programs, have all been found to experience improvements in productivity, social integration and activities of daily living (Hopman, Tate, & McCluskey, 2012). Goverover et al. (2007) found that an individual’s ability to perform instrumental activities of daily living (IADL) was stronger, and they had greater self-regulation, when self-awareness training was provided compared to conventional therapeutic interventions. In terms of improving an individual’s satisfaction with life, social relationships are important (Jacobsson & Lexell, 2013; Vandiver, 2000). The findings from Armengol (1999) suggest that social support groups which focus on education, coping skills training, and goal setting result in positive changes in measures of hopelessness leading to a greater sense of control and empowerment. Social interaction through brain injury support groups can also provide individuals with a sense of belonging and reduce feelings of isolation. McLean, Jarus, Hubley, and Jongbloed (2012) studied patients at a brain injury drop-in center and found that over a third of patients’ social and leisure activities occurred there.  

Learning productive coping mechanisms is also crucial. Individuals with TBI who used non-productive coping styles were found to have lower psychosocial functioning and increased anxiety. The former is concerning because the use of non-productive coping styles has been shown to increase to equal or higher levels than pre-injury (Gregorio, Gould, Spitz, van Heugten, & Ponsford, 2014). A study by Cicerone et al. (2008) found that participants in an intensive cognitive rehabilitation program which involved cognitive, emotional, interpersonal and functional interventions, had higher perceived quality of life scale scores than those receiving standard neurorehabilitation (p=0.0004).  

Physical exercise and leisure activities should be encouraged during the rehabilitation process and in the community (Charrette et al., 2016; Quilico et al., 2023). A study by Driver, Rees, O'Connor, and Lox (2006) suggests that participation in group exercise should be encouraged as an adjunct of the rehabilitation process for patients with TBI as it can foster feelings of well-being and self-esteem which could have a positive impact upon other rehabilitation strategies (Driver et al., 2006). Any physical exercise is beneficial to patients post-TBI, which has been reinforced by Schwandt et al. (2012), who demonstrated that aerobic exercises (ergometer, treadmill, or recumbent step machine) all lead to a reduction in depressive symptoms, improved self-esteem, and improved aerobic capacity. Bellon and colleagues (2015) conducted an RCT in which participants were randomized into a walking group (treatment) or nutrition group (control). The home-based walking group was administered a pedometer to track steps taken weekly for 12 weeks, with a coaching call 3 days/week to encourage increase in weekly step count. The home-based nutrition group learned about healthy eating habits through coaching calls 3 days/week for 12 weeks. Depression on the Centre for Epidemiological Studies-Depression scale decreased significantly from baseline to 12 weeks and 24 weeks for all participants (p=0.007), but there was no significant difference between groups at 12 weeks or 24 weeks. Further, in a pre-post study by Damiano and colleagues (2016), participants completed a home-based, aerobic exercise program for 5 days/week over 8 weeks. Training included exercise of moderate intensity for 30 minutes on the elliptical machine. Measures were assessed at baseline, 8 weeks, and 16 weeks. Moderate intensity aerobic exercise program was noted to improve depression as a result of improved sleep quality in individuals with TBI. Similarly, moderate and high intensity aerobic exercise programs have also been found to reduce mood disturbances, and improve anxiety, tension, depression, anger, confusion, and psychological stress in individuals with TBI (Rzezak et al., 2015; Weinstein et al., 2017). 

Borgen et al. (2023) conducted a randomized controlled trial to examine the effectiveness of the Ontario Brain Injury Association Peer Support Program on community integration, mood, health-related quality of life, and self-efficacy. Participants were randomly allocated to either the peer support intervention or waitlist group. Those in the intervention group were matched with a peer mentor for 4 months. Outcomes were assessed at baseline, at 2 months, and 4 months. At 2 months, the intervention group experienced a nonsignificant worsening of mood, as measured by the PHQ-9, however their mood non significantly increased by the 4-month time point. The use of themes and/or topics for discussion each week should be encouraged to ensure outcome improvements for mentees, instead of flexible conversation with peer mentors only.  

In a scoping review conducted by Wasilewski et al. (2022), peer support was found to serve multiple functions throughout a person with TBI’s recovery. Several facilitators for developing and implementing peer support programs include: peer mentor skills, flexible intervention delivery, online support delivery, use of existing hospital resources to improve peer support services, and using existing hospital resources to improve peer support services.  

Life satisfaction following TBI seems to be directly related to employment and social integration (Corrigan, Bogner, Mysiw, Clinchot, & Fugate, 2001; Tennant, Macdermott, & Neary, 1995). This evidence demonstrates the importance of fostering the reintegration into meaningful, productive activity, which can be accomplished through vocational intervention. As suggested by the findings of Wall, Rosenthal, and Niemczura (1998), increased job success may be achieved through community based vocational training programs which combine the concepts of work adjustment and supported employment. Participants have shown to have increased employment success and satisfaction when techniques which foster self-confidence were used, instruction and adjustments were given for specific work tasks, and a job coach was available to minimize interpersonal problems (Wall et al., 1998).  

Sexuality is also closely connected to an individual’s identity, relationships, and self-esteem (Moreno, Arango Lasprilla, Gan, & McKerral, 2013; Fraser et al., 2022). Reduced self-esteem and a perceived decline in personal sex appeal have been reported as common personality changes following head injury (Kreuter, Dahllof, Gudjonsson, Sullivan, & Siosteen, 1998; Kreutzer & Zasler, 1989). Individuals who identified themselves as ‘impaired’ or inadequate in some way did not perceive themselves as confident or attractive and did not pursue or recognize safe opportunities for pair bonding or sexual activity. In approaching sexuality in a TBI population, a holistic perspective is necessary: neurophysiological and psychological effects, medical and physical issues, and relationship factors (Moreno et al., 2013). The complexity and interaction of these factors must be understood. 

Armengol, C. G. (1999). A multimodal support group with Hispanic traumatic brain injury survivors. J Head Trauma Rehabil, 14(3), 233-246. 

Borgen, I. M., Løvstad, M., Hauger, S. L., Forslund, M. V., Kleffelgård, I., Andelic, N., ... & Røe, C. (2023). Effect of an Individually Tailored and Home-Based Intervention in the Chronic Phase of Traumatic Brain Injury: A Randomized Clinical Trial. JAMA Network Open, 6(5), e2310821-e2310821.

Charrette, A. L., Lorenz, L. S., Fong, J., O’Neil-Pirozzi, T. M., Lamson, K., Demore-Taber, M., & Lilley, R. (2016). Pilot study of intensive exercise on endurance, advanced mobility and gait speed in adults with chronic severe acquired brain injury. Brain injury, 30(10), 1213-1219. 

Conejo-Ceron, S. (2015). Effectiveness of psychological and/or educational interventions to prevent the onset of episodes of depression: a systematic review of systematic reviews and meta-analyses. Preventive medicine, 76, S22-S32.