Couples Therapy Following Aphasia & Acquired Couples Therapy Following Aphasia & Acquired Brain InjuryBrain Injury

Dr Giles YeatesDr Giles YeatesCommunity Head Injury Service, AylesburyCommunity Head Injury Service, Aylesbury

Giles.Yeates@buckspct.nhs.uk

Reflecting on Our Own Aphasia within Reflecting on Our Own Aphasia within Our RelationshipsOur Relationships

In Our Intimate Relationships:In Our Intimate Relationships: When it no longer feels worthwhile to say more, to try to reach When it no longer feels worthwhile to say more, to try to reach

out and reconnect, hopelessnessout and reconnect, hopelessness When it doesn’t feel safe to try and risk reconnecting, for fear of When it doesn’t feel safe to try and risk reconnecting, for fear of

getting it wrong againgetting it wrong again

In Our Therapeutic Relationships:In Our Therapeutic Relationships: When communication with clients with aphasia feels so effortful, When communication with clients with aphasia feels so effortful,

against the odds, that meaningful conversations are not against the odds, that meaningful conversations are not attempted attempted

In Our Professional Team Communications:In Our Professional Team Communications: When therapeutic opportunities are not explored in team When therapeutic opportunities are not explored in team

thinking-through-conversation, due to assumptions of clients’ thinking-through-conversation, due to assumptions of clients’ abilityability

The Elephant in the Room in The Elephant in the Room in Neuro-Rehab sessions….Neuro-Rehab sessions….

Loss of empathic connection between survivors of Loss of empathic connection between survivors of brain injury and those around thembrain injury and those around them

Withdrawal, disconnection, and/or intrusion, Withdrawal, disconnection, and/or intrusion, insensitivity insensitivity

A distressing priority for relatives, mostly likely A distressing priority for relatives, mostly likely resulting in resigned, impotent responses by cliniciansresulting in resigned, impotent responses by clinicians

Juxtapose the need for an ‘interdependence’ rehab Juxtapose the need for an ‘interdependence’ rehab goal in contrast to typical goals for independence goal in contrast to typical goals for independence

Aphasia as Identity & Aphasia as Identity & Relationship TheftRelationship Theft

Aphasia as Identity Theft Aphasia as Identity Theft (Shadden, 2005 )(Shadden, 2005 ) Robbing cherished selves from partnersRobbing cherished selves from partners This loss disturbing sense of self in non-This loss disturbing sense of self in non-

injured partner (Yeates, 2013)injured partner (Yeates, 2013) Sabat & Harré (1992) Discourse analysis of Sabat & Harré (1992) Discourse analysis of

interactional loss of social self following interactional loss of social self following dementia language difficultiesdementia language difficulties

Aphasia & Couples Outcomes:Aphasia & Couples Outcomes: Association between post-stroke aphasia and Association between post-stroke aphasia and

marital satisfaction of partner, the latter marital satisfaction of partner, the latter lower than wives of non-aphasic stroke lower than wives of non-aphasic stroke survivors (survivors (Łapkiewicz et al., 2008; Williams, Williams, 1993; Williams & Freer, 1986)1993; Williams & Freer, 1986)

But mixed evidence on association between But mixed evidence on association between aphasia severity and marital satisfactionaphasia severity and marital satisfaction

Wives’ perception of aphasia severity a key Wives’ perception of aphasia severity a key moderator, related to level of nurturance moderator, related to level of nurturance provided & independent of survivor provided & independent of survivor communication performance (Buxbaum, communication performance (Buxbaum, 1967)1967)

Aphasia & CouplesAphasia & Couples

Difficulties in Social Cognition/Pragmatic Difficulties in Social Cognition/Pragmatic Communication & Couples Relationships Communication & Couples Relationships

(Yeates, 2013)(Yeates, 2013)

Perspectival Intersubjective Space: Predicting/Decoding the

mental states of others & appreciating

different perspectives….

Works in tandem with Works in tandem with attunement processattunement process

Depends on network of Depends on network of medial frontal cortex, medial frontal cortex, posterior superior temporal posterior superior temporal sulcus and temporal pole/?sulcus and temporal pole/?amygdalaamygdala

Theory of Mind/Mentalising & Theory of Mind/Mentalising & Perspective-Taking DeficitsPerspective-Taking Deficits post injurypost injury (e.g., Frith, 2006 ; Rowe et (e.g., Frith, 2006 ; Rowe et al., 2001; Samson et al., 2007)al., 2001; Samson et al., 2007)

“We-centric Intersubjective Space”:

Aligning/attuning to others’ affective states

•

• Emotion Recognition & Affective Emotion Recognition & Affective Communication:Communication:

• Simulation, Resonance or Contagion? Simulation, Resonance or Contagion?

•Involvement of anterior cingulate, Involvement of anterior cingulate, amygdala, insula & somatosensory cortexamygdala, insula & somatosensory cortex

• Emotion recognition Emotion recognition && experiential deficits experiential deficits post injury: post injury: Fear, Anger & DisgustFear, Anger & Disgust (see review by (see review by Goldman & Sripada, 2005)Goldman & Sripada, 2005)

Closing the social loop through appropriate responding….

- Mainly involves orbito- and medial frontal Mainly involves orbito- and medial frontal cortex, also insula, amygdala & temporal poles, cortex, also insula, amygdala & temporal poles, damage to which results in:damage to which results in:

- Accessing social knowledge- Accessing social knowledge (Channon & Crawford, (Channon & Crawford, 2000)2000)

- Making social judgements & using social normsMaking social judgements & using social norms (Milders et al., 2003)(Milders et al., 2003)

- Social ProxemicsSocial Proxemics (Morris et al., 2007)(Morris et al., 2007)

- Social ReasoningSocial Reasoning (Stone et al., 2002) (Stone et al., 2002)

- Social problem solvingSocial problem solving (Grafman et al., 1996)(Grafman et al., 1996)

- Affect regulationAffect regulation (Burgess & Wood, 1990)(Burgess & Wood, 1990)

- Interoceptive-based decision makingInteroceptive-based decision making (Bechara et al., (Bechara et al., 1994; Damasio, 1994)1994; Damasio, 1994)

Social Cognition Predictors of Couple Relationship Social Cognition Predictors of Couple Relationship Functioning Functioning

(preliminary findings, n= 55)(preliminary findings, n= 55)

Mentalising Mind in Eyes

Identification of Social Rule Violations

Soc Sit Violations

Emotion Recognition

TASIT EET

Carer StrainCSI

Dyadic AdjustmentDAS Total

Cohesion of Relationship

DAS COH

Demand-Withdraw Interactional Pattern

Comm Q D-W

-

-

+

+

.272

.219

.334

.152

-

Physical IntimacyDAS AE

Happiness Recognition

TASIT EET Happy+

.342

Survivor Neuropsychology

Partner Psychosocial

Variables

Partner -Rated Relationship Variables

How to Help? A Case for A Relational Approach to Aphasia Rehabilitation

‘‘Skull Seduction’ after ABI Skull Seduction’ after ABI (Yeates, 2007; (Yeates, 2007;

2011)2011):: Clinicians can perpetuate partition of clients & Clinicians can perpetuate partition of clients &

relatives in the literature by seeing couple relatives in the literature by seeing couple separately, focusing mostly on survivorseparately, focusing mostly on survivor

Acting exclusively as brain injury experts can Acting exclusively as brain injury experts can perpetuate the focus on the damaged brain as a perpetuate the focus on the damaged brain as a repository of all problems and only where the repository of all problems and only where the recovery takes place, limits the family’s options for recovery takes place, limits the family’s options for change togetherchange together

Skye McDonald (2000): call of “let’s get social” in Skye McDonald (2000): call of “let’s get social” in aphasiology, situated within relationships and aphasiology, situated within relationships and social contextsocial context

…….& fetishising independence & autonomy.& fetishising independence & autonomy

Feeling versus thinking in Feeling versus thinking in Romantic Love: Romantic Love: An opportunity in An opportunity in

the heat of emotion?the heat of emotion?

(Bartels & Zeki, 2004)

Emotionally-Focused Emotionally-Focused Couples Therapy (EFT)Couples Therapy (EFT)

Attachment Rupture

Protest, Pursuing

Distancing, Withdrawing

Abandonment: Anger/Anxiety

Criticised, Rejected, ConfusionAnger/Anxiety/ Hopelessness

Core EFT FormulationCore EFT Formulation

Stages in EFT Stages in EFT

The process of change in EFT has been delineated in nine The process of change in EFT has been delineated in nine treatment steps: -treatment steps: -

Cycle De-escalationCycle De-escalation Step 1. Assessment-creating an alliance and explicating the core Step 1. Assessment-creating an alliance and explicating the core

issues in the couple’s conflict using an attachment perspective.issues in the couple’s conflict using an attachment perspective. Step 2. Identifying the problem interactional cycle that maintains Step 2. Identifying the problem interactional cycle that maintains

attachment insecurity and relationship distress. attachment insecurity and relationship distress. Step 3. Accessing the unacknowledged emotions underlying Step 3. Accessing the unacknowledged emotions underlying

interactional positions. interactional positions. Step 4. Reframing the problem in terms of the cycle, the Step 4. Reframing the problem in terms of the cycle, the

underlying emotions, and attachment needs. underlying emotions, and attachment needs. Changing Interactional Positions.Changing Interactional Positions.

Step 5. Promoting identification with disowned needs and aspects Step 5. Promoting identification with disowned needs and aspects of self and integrating these into relationship interactions.of self and integrating these into relationship interactions.

Step 6. Promoting acceptance of the partner’s new construction of Step 6. Promoting acceptance of the partner’s new construction of experience in the relationship and new responses.experience in the relationship and new responses.

Step 7. Facilitating the expression of specific needs and wants and Step 7. Facilitating the expression of specific needs and wants and creating emotional engagement.creating emotional engagement.

Consolidation/ Integration.Consolidation/ Integration. Step 8. Facilitating the emergence of new solutions to old Step 8. Facilitating the emergence of new solutions to old

problematic relationship issues.problematic relationship issues. Step 9. Consolidating new positions and new cycles of attachment Step 9. Consolidating new positions and new cycles of attachment

behavior.behavior.

EFT following ABIEFT following ABI

Anecdotal case reports:Anecdotal case reports:

TBI: Chawla & Kafescioglu, 2012

Stroke - Stiell, Naaman & Lee, 2007; Stiell, Naaman & Lee, 2007; Stiell & Gailey, 2011Stiell & Gailey, 2011

Single case quantitative systematic Single case quantitative systematic evaluations (Yeates et al., 2013)evaluations (Yeates et al., 2013)

Couples Intervention: Couples Intervention: Reduce Partner Withdrawal, Amplification of Reduce Partner Withdrawal, Amplification of

Social Cues & Triggering Pro-Social Social Cues & Triggering Pro-Social Autonomic Response of SurvivorAutonomic Response of Survivor

EFT & Aphasia = first EFT EFT & Aphasia = first EFT paper in neuro literaturepaper in neuro literature

Stiell & Gailey (2011): More recent Stiell & Gailey (2011): More recent book chapter expanding practice book chapter expanding practice with aphasiawith aphasia

Kathy Stiell, Director of Family Support

Kathy is the co-founder of the Aphasia Centre of Ottawa and Director of Family Support. She has a Masters of Social Work from McGill University(1980) and is registered with the Ontario College of Certified Social Workers. Kathy is a clinical member of the Ontario Association of Marriage and Family Therapists and a certified therapist and supervisor in Emotionally Focused Therapy. She has provided leadership in making individual, couple and family counselling accessible to people living with aphasia

Attachment Rupture

Survivor: Imposed Withdrawal

Partner: Progressive Withdrawal

- Loss of confidence in abilities- Ignored by survivor-focused rehab- Unacknowledged experience-Abandonment: Anger/Anxiety

- Criticised, Rejected- Confusion- Anger/Frustration/

Anxiet/Hopelessness

Following Aphasia…Following Aphasia…

EFT & Aphasia (1): EFT & Aphasia (1): Creation of A Creation of A

Communication PlatformCommunication Platform Use facilitative communication strategies, Use facilitative communication strategies, technology and compensatory cognitive technology and compensatory cognitive strategies to enable functional strategies to enable functional communication of contentcommunication of content

But essential provide an emotionally-safe But essential provide an emotionally-safe attachment base in the therapy room to:attachment base in the therapy room to: allow survivor and partner to risk reaching allow survivor and partner to risk reaching

outout enable mutual understandingenable mutual understanding try again where previously failed and hurt try again where previously failed and hurt

Example from Stiell & Example from Stiell & Gailey (2011)Gailey (2011)

Jane

Laura

Roger

EFT & Aphasia (2): Supporting EFT & Aphasia (2): Supporting Pro-Nurturing Couples Pro-Nurturing Couples

InteractionsInteractions Externalising aphasia as a thief and Externalising aphasia as a thief and

intruder into the relationship, a intruder into the relationship, a common adversary of the couple common adversary of the couple (Shadden, 2005; White & Epston, 1990)(Shadden, 2005; White & Epston, 1990)

RISSSC RISSSC (Johnson, 2004): (Johnson, 2004): Repeat, Imagery, Repeat, Imagery, Soft, Slow, Simple, Client’s WordsSoft, Slow, Simple, Client’s Words

In-Session Enactments: reaching In-Session Enactments: reaching from vulnerabilityfrom vulnerability

Deconstructing survivor’s anger and partner’s feeling of Deconstructing survivor’s anger and partner’s feeling of rejectionrejection

““This dialogue was a turning point for Jane and helped her moved out of a This dialogue was a turning point for Jane and helped her moved out of a withdrawn position in the cycle. She was able to share her underlying fear of withdrawn position in the cycle. She was able to share her underlying fear of being a failure as a caregiver. This fear became acute when she could not being a failure as a caregiver. This fear became acute when she could not make Roger happy and she wondered if they would ever be happy again as a make Roger happy and she wondered if they would ever be happy again as a couple. couple.

Recognising Roger’s inability to initiate conversations both therapists actively Recognising Roger’s inability to initiate conversations both therapists actively led him in giving feedback that direct addressed her attachment needs. led him in giving feedback that direct addressed her attachment needs. Skillfully the two therapists worked together to facilitate a new conversation Skillfully the two therapists worked together to facilitate a new conversation for the couple by tentatively suggesting that Roger could actively talked to for the couple by tentatively suggesting that Roger could actively talked to Jane about sadness. The therapists encouraged Roger that it may not be so Jane about sadness. The therapists encouraged Roger that it may not be so scary to reach for Jane and that he might not need to get so angry especially scary to reach for Jane and that he might not need to get so angry especially when he realised it pushed her away…. when he realised it pushed her away….

Jane’s ability to be in touch with Roger’s sadness restored her felt Jane’s ability to be in touch with Roger’s sadness restored her felt connection.”connection.”

Jane Roger

Levels of Joy

Conclusions:Conclusions: Interdependence is a legitimate rehab goal, desired by Interdependence is a legitimate rehab goal, desired by

many survivors and partnersmany survivors and partners

Aphasia is not only a change in the communication Aphasia is not only a change in the communication potential for survivors, but potentially also a change to the potential for survivors, but potentially also a change to the very fabric of intimate interactions and selves of both very fabric of intimate interactions and selves of both survivors and partnerssurvivors and partners

This change is characterised by a loss of emotional safety, This change is characterised by a loss of emotional safety, closeness and increased mutual withdrawalcloseness and increased mutual withdrawal

As clinicians we can support couples through opportunities As clinicians we can support couples through opportunities to re-connect with support, using communication platforms to re-connect with support, using communication platforms to foster exchange of communication content and to foster exchange of communication content and emotional security to reach out to one anotheremotional security to reach out to one another

Further Reading: Bowen, C., Yeates, G. N., & Palmer,S. (2010) A Relational Approach to

Rehabilitation: Thinking about Relationships after Brain Injury. London: Karnac.

Johnson, S. (2004). The Practice of Emotionally-Focused Couples Therapy. London: Routledge

Shadden, B. (2005). Aphasia as identity theft: Theory and practice. Aphasiology, 19: 211-223.

Stiell, K. & Gailey, G. (2011). Emotionally focused therapy for couples living with aphasia. In J.L., Furrow, S.M. Johnson & B.A. Bradley (Eds.), The Emotionally Focused Casebook (pp.113-140). New York, NY: Routledge.

Yeates, G.N. (2013). Towards the neuropsychological foundations for couples therapy following acquired brain injury (ABI): A review of empirical evidence and relevant concepts. Neuro-Disability & Psychotherapy, 1(1), 117- 150.

Yeates, G.N., Edwards, A., Murray, C. & Creamer, N. (2013). Couples therapy as social cognition intervention following acquired brain injury: Single case evaluations of emotionally-focused couples therapy (EFT). Neuro-Disability & Psychotherapy 1(2), 151-194.

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