By Marilyn Lash, MSW

Effects of brain injury on marriage

With nearly half of all marriages in the U.S. ending in divorce, it’s been widely reported for many years that the rate of divorce is even higher among couples when a spouse has a brain injury. Divorce rates ranging from 48% to 78% are comm.only given. 

The stresses and challenges for couples are well known – ranging from the physical demands of caregiving to the emotional stresses of living with a spouse whose behavior and personality have changed.  In addition to the physical, cognitive, and emotional consequences of brain injury, many couples deal with the stresses of lower income due to the survivor’s unemployment and social isolation as friends withdraw. 

New research on marriage and divorce after brain injury

Research conducted in 2007 by the Traumatic Brain Injury Model System at Virginia Commonwealth University has looked more closely at this belief and has reported new and more positive findings.  Their study included 120 people with mild, moderate and severe brain injuries who were married at the time of their injury.  Their average age was 41 and it had been 3 to 8 years since their injury.  The study found that 3 out of 4 or 90 out of 120 survivors were still married.  This starkly contrasts with the common belief that divorce is widespread among couples after brain injury. 

Additional findings from the researchers are:

• The overall rate of breakdown among couples was 25% (17% of survivors were divorced; 8% separated).
• There was no difference in marital breakdown rates between male and female survivors.
• The more serious the injury, the greater the likelihood of divorce.
• Age mattered; survivors who were older when injured were much more likely to stay married.
• Length of marriage mattered; those who had been married for more years before the injury were more likely to stay married after the injury.

The authors concluded that this study “…does not support the notion that divorce rates for persons with brain injury are higher than those for the general population.”

Source:

Kreutzer, J., Godwin, E., Marwitz, J. (2010). The Truth about Divorce after Brain Injury. TBI Challenge! Winter, 3.

For more information, see: 

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier, B.S., Editors

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Explaining Brain Injury, Blast Injury and PTSD to Children and Teens

By Marilyn Lash, M.S.W., Janelle Breese Biagioni and Tonya Hellard

When a parent is injured, sons and daughters often feel confused, scared, anxious and angry. This guide helps parents explain the physical, cognitive, behavioral, social and communicative changes that can follow a brain injury, blast injury or PTSD. Using examples from children of all ages, it helps them understand their emotional reactions to a parent’s injury or PTSD. Each chapter has an exercise for children and practical tips for children, parents and professionals.

By Patricia Jackson, C.B.I.S. and Michael Davis, C.B.I.S. – C.E.

Case management over time

Since the 1960′s, the case manager has been a key organizer of services in traditional rehabilitative settings.  Case management has evolved over the years from a simple cost containment focus to a well-coordinated, systematic, comprehensive approach to quality cost-effective care.  Case managers today are routinely and almost universally involved in organizing and coordinating rehabilitative services and resources to maximize a person’s functional recovery after an injury.   

Most recently, the case manager has been recognized as a catalyst in the field of forensic or medical-legal rehabilitation.  Therefore neurolawyers are increasingly using professional case management services to ensure that their clients receive well-coordinated, quality care and treatment during the often lengthy process of litigation. Lawyers have a duty to provide comprehensive legal services, but they typically do not have the time to oversee the medical and rehabilitative aspects of a personal injury case. The provision of case management can have a direct positive impact on addressing the myriad of needs in a serious injury case.

Case managers, attorneys and personal injury claims

As more case managers are being employed by attorneys to oversee their clients’ case, it is important to clarify the role of a case manager in this specialty field of medical-legal rehabilitation.  A case manager is capable of wearing many hats.  This article describes how case management may be involved in a personal injury claim.   

The attorney weighs the benefits of involving a case manager right from the start.  Time is typically of the essence in catastrophic injury claims.  By using professional case management services to coordinate care that will maximize the client’s physical, cognitive and emotional functioning, the attorney can focus on the litigation process. 

The many roles of case managers

Case management assumes various roles throughout the different stages of a client’s recovery from an illness or injury. 

Hospital

In the acute medical arena, the case manager serves as a discharge planner and helps move an individual from the hospital to rehabilitation, home health care or outpatient therapies.  

Insurance Company

The insurance case manager serves mostly as a cost monitor to ensure that health care dollars are expended wisely.

Rehabilitation Program

Facility-based rehabilitation case managers usually serve on a team within that facility to guide therapies toward maximum potential recovery for the patient within the confines of their facility.

Forensic case manager

None of the case managers above are typically involved in the legal aspects of a patient’s case. The forensic case manager is concerned with every aspect of the above.  At the same time, the forensic case manager assures that the legal perspective is being addressed to maximize client recovery.  The personal injury attorney who utilizes the services of an experienced case manager is in fact assuring the client’s access to quality treatment and medical care.

Case manager as liaison

The weeks and months immediately following a traumatic injury are full of day-to-day stressors.  As a result, families usually are overwhelmed with information and decisions they may not be equipped to handle.  All too often, families do not feel fully informed or supported by many of the medical professionals whose expertise has preserved the life of their loved one in trauma.

If the attorney who has been retained in a personal injury case involves a case manager immediately, the family will benefit.  By using the expertise of an experienced rehabilitation professional, the case manager can assume a guiding role in the care of their loved one.

The attorney also benefits by identifying the case manager as the primary contact person for the family.  The case manager is able to field numerous questions and run interference.  This gives the attorney valuable time to proceed with the intricacies of the litigation process.

Families in trauma have special needs.  They can appear to be demanding at times.  But they may simply need someone to listen to their concerns, their ideas or even more importantly, their fears.  So first and foremost a case manager is a liaison for not only the client, but for the family, the rehabilitation team and the attorney, as well.

Case manager as advocate

Once given the opportunity to review medical records, discuss the case with all parties involved, and determine the priorities, the case manager can oversee a treatment plan, monitor progress, advocate as necessary and create a clear pathway through the rehabilitation maze.

The forensic case manager can objectively oversee the provision of services from a more holistic and client-centered approach.  The forensic case manager works in conjunction with the clinical case manager and the insurance case manager, but does not have their internal pressures or external financial obligations.

Attorneys who assign a case manager to their personal injury cases are assured that the:

• appropriateness and effectiveness of therapies and programming will be monitored, and

• care will be coordinated in the best interest of their clients’ long term needs.

If long term rehabilitation is necessary, the involved case manager has the ability to explore and identify possible funding sources early on.  Through their experience, case managers are familiar with federal, state and local resource systems available to the client.  The attorney may be a novice or have limited experience in that particular arena. Understanding the systems of Medicaid, Social Security, vocational rehabilitation, workers compensation, and the public schools is complex.  Gaining access to their services is a time-consuming process.  Rather than assume that task and breaking new ground, the attorney can rely on the case manager to fulfill this area of responsibility.

Case manager as negotiator

It is important for the client and family to have a skilled negotiator throughout the course of recovery.  The case manager is capable of creatively negotiating a proposed plan of care, length of stay, rates of service and when necessary, identifying appropriate vendors.  Negotiating services to develop a continuum of quality care is crucial as well as time consuming.  Whether it is acute care, outpatient rehabilitation or in-home care, the involvement of a case manager can make a difference.

Taking the long view or seeing the big picture

Where expert life care planning is necessary, identifying service providers and ensuring the implementation of the life care plan is a long term commitment.  The attorney who utilizes the expertise of a case manager is cognizant of the fact that a client’s needs continue long after the litigation process has ended.

There is no easy road to recovery following a catastrophic injury.  Recovery from traumatic injury can be a long arduous process, not only for the injured party but for the family as well. The family’s emotional needs can frequently be overlooked unintentionally while professionals focus on rehabilitation of the client.  The case manager functions as a support system for the family and as an educator and guide through the maze of rehabilitation.  

One of the most valuable tools a case manager brings to the table is the ability to listen.  A skilled case manager listens to concerns from all parties involved, pulls the information together, develops a plan and ultimately directs the implementation of that plan.  The case manager works closely with the rehabilitation team, medical consultants and the family.  By bringing forth the clinical perspective, the case manager helps the attorney strategize throughout the litigation process.

It is the attorney’s duty and obligation to provide clients with the best possible means available to ensure successful resolution to their case.  Financial recovery is only one aspect of a case.  Personal injury attorneys should also concern themselves with the more critical aspects of a case, i.e., emotional and physical well- being.  

An experienced forensic case manager is an asset to the plaintiff attorney’s case for many reasons, some of which have been described here.  Each personal injury case presents itself with a unique situation, specific needs and a vast range of priorities.  In collaboration with the attorney, the list of priorities can be defined, responsibilities delineated and an initial plan set in motion by the case manager.

Whether acting as liaison, advocate, negotiator or educator, the role of a forensic case manager is key in litigating personal injury claims in today’s legal arena.  Ethics dictate diligence by the plaintiff counsel.  Morally speaking, this diligence would serve the client equally as well in the pursuit of quality services, thus facilitating improved quality of the life for the client.

Bee, C.M.(1996) Damages/Running The Gauntlet From Soft Tissue to Head Injuries/From Chiropractor to Neurosurgeon. A non-published presentation.

Burke, W.H. (1995). The Rehabilitation Expert: Analysis and Management of Brain Injury and Other Neurologic Disorders. In Burke, W.H. (Ed.) The Handbook of Forensic Rehabilitation, Houston, TX: HDI Publishers.

Burke, W.H. (1995). The Forensic Analysis of Costs in Head Injury Claims. A non-published presentation. Insurance Defense network, Las Vegas, NV.

Evans, R. & Watke, M. (1995). Catastrophic Neurologic Injury: Improving Outcomes Through Case Management: The Case Manger, July/August / Sept. 83-88.

Fawber,H.& Zorger Orstein B. (1995). Case Management in Forensic Rehabilitation. In Burke, W.H. (Ed.) The Handbook Of Forensic Rehabilitation. Houston, TX: HDI Publishers.

Howe, R. (Ed.) Inside Case Management. 1 (11), 1 (12), 2 (6). 1995.

Mullahy, C. (1995). The Case Manager Is the Catalytic Collaborator in Managed Care. The Journal of Care Management. 1(1), June 7-9.

For more information from Lash and Associates Publishing/Training, Inc., see:

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Head Cases

By Michael Paul Mason

Book on brain injury, blast injury and PTSD features chapters on adults, children and veterans discussing changes in memory, self-image, violence, suicide, family stress and war in Iraq.

By Patricia L. Jackson, B.S., C.B.I.S. and Michael W. Davis, C.B.I.S.- C.E.T

Is it really happily ever after? 

The Life Care Plan is designed to identify long term needs through a comprehensive assessment of the client’s medical, physical, behavioral and emotional status.  Once the data is evaluated, a Life Care Plan outlines what services the client will need over the course of a lifetime to maintain physical health and emotional well being.  Contrary to popular belief, after a Life Care Plan is deemed necessary and finalized, the client, a.k.a. the subject of the Life Care Plan, is not set for life. 

In reality, it is after a Life Care Plan is finalized that the real work begins.  The Life Care Plan is a necessary map to direct the client’s way along the path of life.  If it is taken at its worth, the client will have access to the supports that were identified to facilitate successful care over the long run.  Unfortunately in a majority of cases, the Life Care Plan simply finds its way into a file cabinet and is stored along with other medical and legal documents.  

Who are the players in the plan? 

Somewhere along the way a major component is overlooked.  The medical and rehabilitation specialists do their jobs by identifying the needs of the client.  The family hires legal representation to help them do the best they can for their loved one.  The attorney’s obligation is fulfilled by presentation of a comprehensive Life Care Plan in court.  The judge (and perhaps jury) recognize the severity of the injury and find in favor of the client.  The decision is made about a financial settlement that will ensure access to whatever services had been deemed necessary for care over the client’s lifetime.  And then, everyone goes home.

Money doesn’t guarantee services 

Although life care planning focuses on caring for the needs of the injured person, a financial award in itself does nothing to guarantee client services.  There is a huge gap in the system.  The family is not always aware of the how-to’s in the rehabilitation community, yet they are most often the ones left holding the “plan” so-to-speak.  Even experts within the system find that it can be difficult to access services.  It is a grave disservice to expect that a client’s family members will know how to work through the complexities of a system, including as the maze of rehabilitation services. 

The case manager is the missing link  

A case manager who specializes in the implementation of Life Care Plans can fill that void.  Working with the family, a case manager takes charge of the Life Care Plan to access and arrange the services identified for the client.  

The role of each person involved in the Life Care Plan process is defined and is important.  Each specialist is responsible for their area of expertise.  However, the reality is that every individual involved in the case has an ethical responsibility to see that what they recommend is in fact carried out.  

It is not enough to identify, acknowledge and provide financial resources to help the client.  The care the client deserves and is entitled to should not be compromised simply because no one is identified to assume responsibility for implementing the Life Care Plan.  A case manager assures that the finances are utilized in the way that they were designated, rather than leaving follow-up client care to chance.  The Case Manager doesn’t have all the answers, but will find the resources to get the answers that the client and family deserve.

Case managers can help fulfill the intent of a life care plan

Surely it is the intent of the judge and our legal system as a whole to provide financial support by way of a settlement when they find in favor of a client.  When utilized properly, a financial award will provide support and services for the client who has sustained a serious injury.  A financial award that is misused or used improperly not only doesn’t help or support the client, but it also causes greater harm by decreasing the client’s chance for success and an improved quality of life.  Misuse will also most likely create a host of secondary problems resulting from lack of proper medical and psychological care. 

A case manager can be the critical missing link.  By monitoring the client’s status and maintaining communication amongst all the parties involved, the client’s care will remain in the forefront as the true priority.  After all, quality client care is the true intent of any financial settlement. 

Patricia Jackson is a Case Manager and Michael Davis is the President and Senior Case Manager with Neurological Case Management Associates, specializing in the field of neurological rehabilitation, in Charleston, WV.

For more information from Lash and Associates Publishing/Training, Inc., see:

Adult Mini Tool Kit on Traumatic Brain Injury for Families

This Adult Mini Tool Kit is designed for lawyers and life care planners to give to families with information on traumatic brain injury. 

Ketchup on the Baseboard: Rebuilding Life After Brain Injury

By Carolyn Rocchio

By Carolyn Rocchio

Mild brain injury is a real problem for families

Many service members and veterans have returned from war with undiagnosed mild brain injuries or concussion.  Greater emphasis is now being placed on case management and coordination of services for service members and veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom after sustaining traumatic brain injury in response to the July 12, 2006 report from the Department of Veterans Affairs Office of Inspector General (1). This need was reinforced by testimony before the House Veteran’s Affairs Subcommittee on September 28, 2006 with the presentation of alarming data about the large numbers of blast injuries resulting in changes in neurosensory deficits (2).

Traumatic brain injury has become the “signature” injury of Operation Enduring Freedom and Operation Iraqi Freedom. As of January 2006, the Department of Defense reported more than 11,852 returning wounded had exposure to blast injuries (2). It is reasonable to conclude that many additional service members/veterans who have been exposed to blasts without bodily injury are later experiencing classic signs of mild brain injury.

Mild brain injury is a significant problem in the general population in this country as well. According to data from the Centers for Disease Control and Prevention 1.1 million Americans are seen annually in emergency departments with mild brain injury and countless numbers are never screened or diagnosed.(3)

Coming home isn’t always easy

Many service members/veterans return home with the expectation that their lives will resume as they were prior to deployment. Such is not the case for many who have been exposed to blasts. Without information and resources to guide and support the service member/veteran and family, a “mild” brain injury can take a serious toll on the family. It is critical that service members/veterans be screened for a mild brain injury when exposed to blast injury and given appropriate follow up and treatment. Equally important is educating the family members who will ultimately become the support team once the veteran completes treatment. Families must be made aware of the nature and consequences of mild brain injury and provided with tools to provide support in the months and possibly years to follow.

Social workers should be aware of informational resources to assist families being seen in VA facilities, both inpatient and outpatient. Many educational resources and publications exist to educate families. In turn, families must be taught how to access community resources and be prepared for changes and characteristics common to mild brain injury. Some of the more common characteristics that may be present on discharge or develop later include:

• headache
• fatigue
• dizziness
• memory problems
• sleep disorders
• problems concentrating
• ringing in ears
• irritability
• visual changes
• sexual dysfunction
• sensitivity to light, sound and odors

Even though some or many of the characteristics above may exist, the overall appearance of the individual can still be unchanged unless there are other physical injuries. This appearance of well-being can be misleading for family members, friends, and others. Even the service member/veteran is not always aware of the less visible cognitive changes. This can lead to frustration when the family is not patient and supportive.

A mild brain injury can be tricky to diagnose

Mild brain injury is often difficult to diagnose as changes in brain structure are seldom captured by CT or MRI scanning. This lack of physical evidence of an injury can result in labeling the individual as “faking” or malingering, when in fact there have been molecular changes in the brain that affect how the individual thinks and acts. A neuropsychological assessment is the key piece of information that can explain how the injury has affected the individual’s functional capabilities. Ideally the service member/veteran, family members and the neuropsychologist should meet to discuss the findings and establish ways the family can support and promote emotional well being of the service member/veteran and other family members.

All members of the family undergo a difficult adjustment once the service member/veteran returns home. There may have been many role reversals with family members assuming new responsibilities while the service member was deployed. After a brief honeymoon period, when everyone is delighted that the service member has returned, things can go down hill very rapidly. This can happen when others see the subtle changes, but do not understand the cause. At this point, it is not uncommon for the service member/veteran to develop a secondary emotional response to these changes. This can create new problems, that without professional intervention, may escalate into family dysfunction and even violent behaviors. This secondary emotional response often becomes even more disabling than the original insult when support is not available. This can lead to a psychiatric referral that further exacerbates this issue. Persons with mild brain injury often describe themselves as feeling “crazy” because they do not understand the changes they are experiencing.

Risks at home

Families need to be extremely vigilant when there are small children in the home. Irritability and impaired behavioral control can result in children becoming the target of the service member/veteran’s temper when seemingly minor interactions become emotionally charged. Older children may need help understanding why the parent who was once loving and supportive becomes moody and irritable for no apparent reason.

Trying to return to work can be fraught with problems. While the initial return to a job may be met with exhilaration and a sense of camaraderie with old colleagues, problems may surface over time. The service member/veteran may find things that were once easy are now far more difficult. The pace of work is slower. Fatigue is a major factor. Interaction with coworkers can become argumentative and problematic.

Seizure activity can develop some months or even years after a blow to the head. Often these seizures are not convulsive, but more likely to be partial complex temporal lobe seizures which manifest as a change in behavior. The service member/veteran may complain about foul odors, become more sensitive to light or sound, pace the floor and even have hallucinations. Any symptoms should be reported with a follow up evaluation to determine if seizure activity is present.

What can be done to lessen these problems?

Structure is important for reestablishing a daily routine. Military personnel have one advantage in that they are very disciplined and used to taking orders from others. Until the routine is going smoothly at home, the spouse, parent or significant other may need to be the authority figure and help set up a structure. It is not uncommon for a brain injury to affect a person’s ability to initiate a daily routine. This can be particularly difficult when moving from the highly structured military regime back to a more relaxed home setting.

Some helpful strategies for family caregivers include:

• Use day planners, post it notes, and written lists to minimize problems related to memory loss.
• Use watches with alarms, egg timers or electronic timers to keep track of time related tasks.
• Organize all possessions, shelves, drawers, etc with everything in an assigned place to prevent the frustration of locating lost or misplaced items.
• Build in time for relaxation, meditation and/or yoga and Tai Chi to reduce stress.
• Encourage social interaction, but make sure all friends, families and others are aware of the service member/veteran’s persistent problems and ways to interact more successfully.
• Find support groups. The assurance of others with similar residual affects of mild brain injury can be extremely important. Some VA centers with brain injury programs sponsor such groups. Information about community based support groups for individuals with brain injuries and their families can be obtained by contacting the Brain Injury Association of America at 800-444-6443 for referral to the group nearest the family.
• Plan time each day for rest or a nap to offset the effects of long term fatigue. Many will experience disrupted sleep and may require medication to insure restful sleep occurs.
• Model calm when things become emotionally charged. In the event that violence is an issue, make sure family members leave the area to avoid being injured until calm is restored.
• Seek professional help from a person familiar with mild brain injury in planning the work environment to ensure a successful return to work.
• Ask about the use of alcohol and nonprescription drugs before discharge. Alcohol and street drugs can have negative effects when medications are prescribed for conditions such as seizures. In general, any use of alcohol has an exaggerated affect on a person with brain injury. Use of alcohol and other substances is best reinforced if guidance is provided in discharge summaries so family members can rely on professional direction in written form.
• Ask about driving safety due to changes in perception, judgment, visual, and attention deficits. Driving should not be resumed until the service member/veteran is evaluated by a Certified Driving Educator, where emphasis is more on cognitive functions than the mechanical ability to operate a vehicle.

Summary

Mild brain injury can create significant disruption in the lives of the person with the injury as well as members of the family. To insure a more successful recovery, it is critical that there be a thorough assessment to determine what areas of the brain have been injured and the effects on everyday functioning. Additionally, once cognitive deficits have been identified, it is important that strategies to compensate for these deficits be developed. Lastly, family education and resources must be provided. A well informed and supportive family is the major component of successful community reentry.

References:

 (1) Health Status of and Services for Operation Enduring Freedom, Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation. Report Number 05-01818-165. VA Office Office of Inspector General. Washington, DC , July 12, 2006.

(2) Zamperi, Thomas. Chrm. Director Government Relations, The Blind Veterans Association. Testimony: The House Veterans Affairs Subcommittee. September 28, 2006.

(3) Langlois J, Rutland-Brown W, Thomas K. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.

Recommendation reading

Mild Traumatic Brain Injury Workbook

By Douglas J. Mason, Psy.D

Workbook for adults, veterans and families on mild traumatic brain injury and concussion symptoms with strategies and exercises for improving attention, memory and executive functions.

Brain LASH

By Gail Denton, Ph.D.

Book helps adults and families understand mild brain injury symptoms with strategies for physical, cognitive and emotional changes after concussion.