Psychological and marital adjustment in couples following
a traumatic brain injury (TBI): A critical review
MARIE CLAUDE BLAIS1& JEAN-MARIE BOISVERT2
1Department of Psychology, Universite ´ du Que ´bec a ` Trois-Rivie `res, Que ´bec, Canada and2School of Psychology,
Laval University, Que ´bec, Canada
(Received 4 November 2004; accepted 20 June 2005)
The first part of this paper examines current data describing the psychological and marital adjustment of couples following a
traumatic brain injury (TBI). Although these findings reveal some discrepancies, they highlight that adjustment following
a TBI represents a genuine challenge for those involved in the process. The second part moves toward the examination
of factors associated with psychological and marital adjustment in both couple partners. Here again, there exists a large
diversity in empirical data and theoretical models informing this emerging area of interest. Nevertheless, cognitive variables
such as coping skills are commonly seen as critical variables to explain the adjustment level in people with TBI and their
spouse/caregivers. Concurrently with the discussion of the methodological issues and pitfalls encountered in this area of
research, the conclusion provides suggestions of further steps to undertake in this endeavour toward a better understanding
of the adjustment process following TBI.
Keywords: Adjustment, head-injured individuals, psychological, marital relationship, couples, care givers, adaptation process, coping
It is generally acknowledged that the consequences
of a TBI affect not only the injured individual, but
his or her relatives as well [1, 2]. In fact, the cognitive
[3–5], physical  and psychosocial changes [7–10]
following TBI are likely to have a significant and
often negative impact on family members .
Furthermore, maintaining a satisfying couple rela-
tionship, in spite of the significant role changes
that occur within the couple following the injury
may represent quite a challenge for both partners.
Accordingly, marital adjustment may be particularly
vulnerable to the effects of stress brought about by
these negative consequences .
The first part of this article reviews empirical data
describing the psychological symptoms experienced
by head-injured individuals and their partners, as
well as some methodological factors that may
account for discrepancies observed among these
data. It concludes with a brief review of current
knowledge on the marital relationship following
TBI. The aim of the second part of this article is to
explore theoretical models that enhance understand-
ing of the post-TBI adaptation process. The results
of studies identifying factors associated with adjust-
ment are also presented. Indeed, the role of the
coping process and specific coping skills for individ-
ual and marital adjustment is emphasized. Based on
the findings of the studies reviewed, the conclusion
of this paper provides suggestions of further steps
to undertake, as well as methodological issues to be
considered when conducting further works in this
promising area of research.
Part I: Psychological symptoms and marital
relationship in individuals with brain injury
and their spouse/caregivers following TBI
A growing body of literature examines the affective
symptoms experienced by the individual and his or
Correspondence: Marie Claude Blais, PhD, Professeur, De ´partement de Psychologie, Pavillon Michel-Sarrazin, local 3011, Universite ´ du Que ´bec a `
Trois-Rivie `res, QC, Canada G9A 5H7. E-mail: Marie-Claude.Blais1@uqtr.ca
ISSN 0269–9052 print/ISSN 1362–301X online # 2005 Taylor & Francis
Brain Injury, December 2005; 19(14): 1223–1235
her spouse/caregivers following TBI. Studies con-
ducted by Willer et al. [13–15] and studies from
Brooks’ [16–18], Kreutzer’s [19–21] and Oddy’s
[22–25] teams are some of the significant works in
Overall, research indicates that affective and
emotional symptoms, including anxiety and depres-
sion, are commonly observed sequelae among
head-injured individuals [16, 26–34]. However,
prevalence estimates of affective symptoms have
varied widely among studies. For instance, Linn
et al.  observed a great deal of depression
sub-scales of the Symptom Checklist 90-Revised
(SCL-90-R ) in their sample of 60 severely
brain-injured individuals, even after an average of 6
years post-injury. McKinlay et al.  observed
similar results, even when data were reported by
relatives. On the other hand, Van Zomeren and
Van Den Berg  reported increased anxiety and
depressed mood in a relatively low percentage of 57
people with severe TBI (18% and 19%, respectively).
Similarly, Marsh et al.  observed no consistent
elevated levels of affective, personality or psychiatric
disturbance, although their 18 subjects were found to
be more poorly socially adjusted in comparison to a
normal control group.
Spouses and caregivers may also experience a vari-
ety of difficulties secondary to caring for a person
who has experienced a head injury. Increased levels
of stress, depression and anxiety, together with
diminished social interaction and isolation, are some
of the problems commonly described [18, 19, 38,
39]. Research over the last few decades has resulted
commonly referred to as ‘caregiver burden’  and
several studies have attempted to predict caregiver
burden in TBI relatives [17, 31, 41, 42].
Most researchers agree that significant psychologi-
cal disturbance is commonly experienced by family-
caregivers during post-injury adjustment [27, 39].
However, here again, reported levels of depression
and anxiety have varied a great deal from one study
to another. Relevant data from two critical literature
reviews evaluating family psychosocial outcomes
following TBI [11, 18], as well as from further
studies [27, 30, 40, 43, 44], suggest that between
23–73% of carers show evidence of psychological
distress, including depression and anxiety.
on two self-rated
of these consequences
Factors that may explain discrepancies
in distress levels observed between studies
This brief review underscores the difficulty in
building a consistent body of knowledge concerning
psychological adjustment in persons with brain injury
and their spouse/caregivers. This difficulty may be
explained in part by methodological factors such as
the heterogeneity of samples across and within
studies. For instance, the studies reviewed involve
participants with TBI whose severity of injury varies
and who are at different stages post-injury. Moreover,
samples of caregivers often include relatives who
have different types of relationships to the person with
TBI. The following section describes the discrepan-
cies observed in the psychosocial outcomes among
persons with TBI and their spouse/caregivers,
according to these sampling factors.
Severity of injury
It is expected that samples including more severely
injured individuals and their caregivers will show
higher levels of affective symptoms. However, data in
the literature yield a more complex picture. There is
a notable lack of evidence to confirm the assertion
that TBI severity (often measured by indicators such
as length of coma (LOC) and duration of post-
traumatic amnesia (PTA)) is related to emotional
symptoms among individuals with brain injury .
In fact, results from several studies show no
significant relationship between patients’ TBI sever-
ity and level of emotional distress [17, 47–50]. In
other studies, however, severity of injury is positively
disturbances , as well as psychosocial disability
in persons with brain injury [51, 52].
Findings regarding the correlates between TBI
severity and distress experienced by relatives are
also equivocal. Douglas and Spellacy’s  results
indicate that severity of injury (as determined
by PTA) is one of the reliable and significant indi-
cators offamily functioning.
studies suggest that relatives’ self-ratings of depres-
sion and anxiety symptoms are not significantly
related to severity indicators such as PTA and
LOC [1, 30, 54]. Linn et al.’s  data indicate
that the presence of behavioural problems in
the partner with head injury, such as cognitive
dysfunction, aggressiveness or socially uninhibited
behaviour, is a more powerful predictor of psycholog-
ical distress among spouses. These findings are
consistent with the idea that relatives’ psychological
distress is related to the severity of longer term
neurobehavioural sequelae, such as level of disability
and behavioural and emotional changes, but not
to the severity of initial injury as measured by
LOC or PTA [18, 20]. However, experienced
clinicians may respond to this issue by asserting
that neurobehavioural sequelae themselves are often
associated with the nature and initial severity of
M. C. Blais & J.-M. Boisvert
Different stages post-injury
As affective changes may vary over time elapsed since
injury, it is expected that estimates of their pre-
valence vary according to time of sampling .
Most follow-up studies note significant residual
psychosocial problems (including depression and
anxiety) in persons with TBI over time (even 7 years
after trauma), with persistence of symptoms most
pronounced in those who are more severely injured
[17, 25, 55–57].
Among spouses and caregivers, research generally
indicates that stress and burden do not lessen with
time [19, 51, 53]. Indeed, follow-up studies per-
formed by the Glasgow group reveal that burden in
caring for the injured person tends to increase from
3 to 12 months after trauma and is sustained up to
7 years post-injury [16, 17, 31]. Oddy’s group also
observed increased stress in 5% of the relatives
(n¼54) they interviewed in the first 12 months
following injury . However, reported levels of
anxiety and depression 7 years after trauma were no
greater than those expected within the general popu-
lation . Finally, while some researchers found
no significant relationship between patients’ and
relatives’ self-ratings of affective symptoms and length
of time since injury (TSI [30, 58]), others suggest
that caregivers’ adjustment improves with TSI .
This brief literature review, although incomplete,
shows inconsistencies in regards to the link between
TBI severity and the time elapsed since the injury
and psychosocial adjustment in persons with TBI
and their spouses/caregivers. Not only are there dis-
crepancies between study findings, but the findings
seem to reveal no clear tendencies. This area of
research thus poses a considerable challenge.
The authors believe that a promising avenue
toward better understanding the link between TBI
severity at different stages following the injury and
psychosocial adjustment involves a multi-level asses-
sment approach. This approach could include global
indicators of severity (e.g. PTA or LOC), traditional
test-based measures (e.g. of executive function), in
addition to increasing the use of functional scales
(e.g. daily living activities, communication) and mea-
sures of community integration in order to obtain
a ‘real-world’ portrait of behavioural manifestations
of dysfunction. This approach would also greatly
benefit from the assessment of support needs .
Moreover, such a multi-faced approach induces the
creation and/or the consolidation of closer bridges
between rehabilitation clinicians and researchers.
Differential impact on spouses and parents
One factor of great importance in explaining dif-
ferences between studies of self-reported distress
levels in caregivers is the type of relationship to the
person with TBI (e.g. parent or spouse). Although a
few studies report that spouses and parents do not
in caring for a partner or a child with brain injury
[17, 23, 54, 61, 62], most researchers suggest
that TBI has a more negative impact on spouses
[1, 21, 63–66].
Brooks et al.  suggest that, even when parents
and spouses do not differ on measures of subjective
burden, the nature of the burden they experience is
different. Spouses and parents experience different
challenges and needs following TBI [41, 67].
Caregiving spouses lose their major source of emo-
tional support and companionship [1, 14]. At the
same time, they are likely to experience more signifi-
cant role changes, a decrease in parenting support, as
well as a loss of sexual intimacy and empathic com-
munication with their partner with head injury
[1, 11, 21, 68]. Additionally, financial strain and
a decrease in social opportunities are commonly
observed [1, 14]. Caregiver parents return, instead,
to a role that in many respects is familiar. They
may be better prepared than partners to accept the
burden of care [1, 69] and are likely to have more
support available to them .
Regardless of qualitative differences in caregivers’
relationships to the injured person, the samples of
most studies conducted in this area thus far combine
both spouses and parents. They thus fail to distin-
guish between strains on the marital, as opposed to
the parental relationship . As a result, literature
that specifically examines spouses’ psychological
adjustment following TBI is scant . Of exception
are the works by Linn et al. , Livingston et al.
[54, 62] and Rosenbaum and Najenson .
Overall, their results indicate that spouses of individ-
uals with TBI demonstrate significantly higher scores
on affective symptoms scales. More specifically, the
results from Rosenbaum and Najenson  show
that the wives of husbands with brain injury reported
drastic life changes associated with depressed mood,
social isolation and role reversal. However, after revi-
siting family outcome literature, Perlesz et al. 
draw attention to the fact that many studies fail to
highlight the high proportions of spouses who do
not acknowledge elevated levels of psychosocial
distress following injury. Given this tendency, it is
all the more relevant to compare their psychological
outcomes to those of normal control spouses.
Contrary to what is observed for severity and time
elapsed since injury, there seems to be a clearer
tendency with regard to the differential impact and
specific challenges of the type of relationship the
caregiver has to the person with brain injury. This
empirical data, combined with clinical observations
suggesting that spouses and parents experience
different distress levels
Psychological and marital adjustment
awareness of the importance of creating homogenous
samples for further works in this area.
realities following the TBI,increases
Marital relationship following TBI
Over the last decades, several researchers have
explored marital stability following acquired brain
injury [25, 52, 72–74]. Many brought to attention
the increased risks of relationship breakdown follow-
ing TBI. For instance, Tate et al.  report a
divorce rate of 55% 6 years following TBI, while
only 42% of couples from Wood and Yurkadul’s 
study maintained their relationship over 5 years.
Nevertheless, there are very few studies exploring the
actual experience of couples who remain together
throughout the chronic stage of TBI .
Moore and his colleagues are among the few
researchers who have conducted works in the area
of post-TBI marital relationships [12, 70, 75, 76].
In an often-cited study, his team  observed that
wives of severely brain-injured men report lower
marital adjustment than moderately brain-injured
and spinal cord injured groups, as indicated by
their lower results on standardized scales of dyadic
satisfaction, cohesion, adjustment and affection
expression. These authors explain their findings
mainly by the fact that wives of the severely brain-
injured groupmust deal withgreaterneuropsycholog-
ical changes and physical fall-out from the injury, as
compared to those from moderately brain-injured
and spinal cord injured groups. In a previous study,
Peters et al.  observed that the wives of 55 men
with brain injury report greater dyadic adjustment
when the initial injury was relatively mild and
when they perceive their husband to be better
psychosocially adjusted and when they experience
low levels of financial strain. These studies point
out important findings regarding marital adjustment
among the wives of individuals with a TBI, particu-
larly in relation to injury severity. However, they do
not provide any information about the marital
satisfaction of the husbands with brain injury. Most
studies conducted thus far have only sampled either
people who experienced a TBI or their spouses.
A study by Willer et al.  presents the advantage
of evaluating both TBI couple partners. Using
small-group discussions, the investigators listed
problems identified by each group of partners. Loss
of autonomy and independence were identified as
the most significant problems for both men and
women with TBI. Conversely, able-bodied spouses
were notably more concerned about their partners’
changes in personality and cognitive abilities, lack
of insight, loss of autonomy and mood swings. This
important research conducted by Willer et al. 
is one of the few studies, along with those of Elsass
and Kinsella  and McKinlay and Brooks 
that include the self-perceptions of individuals with
TBI in addition to those of their partners or relatives.
Therefore, these studies provide a major impetus
for further research attention to be paid to the per-
spectives of participants with brain injury. One can
point out that the qualitative aspect of Willer’s
study and the non-standardized group discussion
method used could limit the validity, reliability and
generalizability of the data gathered in this research.
Nevertheless, this study highlights the major con-
cerns of both partners of TBI couples, hence yielding
important and interesting directions for this relatively
new area of research.
In a more recent study, Gosling and Oddy 
examined the quality of marital and sexual relation-
ships in 18 couples 1–7 years after the male partner
had sustained a TBI. Overall, female partners rated
both their marital and sexual satisfaction as signifi-
cantly lower after the TBI and significantly lower
than that reported by their partners with brain
injury. These authors also employed a qualitative
method with a focus on the able-bodied female
partner’s perspective. In a semi-structured interview,
all women reported major role changes, mostly
experienced as an increase in their responsibilities.
These new roles, referred to by many as a parental
role with total decision-making responsibilities, are
relatively incompatible with a role of sexual partner.
Consistent with the results of other studies [1, 14],
several women reported the loss of an equal or
sharing relationship and the loss of companionship.
Indeed, many women deplored a lack of expression
of physical or emotional affection from their injured
partner, although these women felt their husbands
have positive feelings toward them. This study 
provides useful qualitative data. However, as pointed
out by the authors themselves, the sample was rela-
tively small and was almost exclusively comprised
of spouses of individuals with severe TBI. Hence,
data may be unrepresentative of the experience of
people with milder head injury and their partners.
Summary and comments
Findings from the studies reviewed suggest that
psychological and marital adjustment following TBI
represent a genuine challenge for both individuals
with brain injury and their spouses. However, it is
still unclear whether persons with TBI and their
partners experience significant levels of psychological
distress. First, reported levels have varied widely
across studies. As discussed, taking into account
variables such as the severity of the injury and the
stage post-injury may even complicate endeavours
to establish a global portrait of this population.
Secondly, the majority of works conducted among
M. C. Blais & J.-M. Boisvert
parents without taking into account particularities
of spouses’ adjustment within a marital context.
Furthermore, there is a lack of consistency in the
definition of adjustment variables (e.g. stress, burden,
distress, psychological symptoms) and the instru-
ments used to measure them. Such differences in
measures and concept definitions limit the compar-
ability of findings that may even appear contradictory
[11, 18, 30, 79]. Moreover, research conducted
thus far depicts a general profile of couples’ marital
adjustment following TBI, focusing mostly on the
uninjured spouse’s perspective. However, little is yet
known about the factors associated with post-injury
marital satisfaction. Indeed, several of the studies
reviewed used a qualitative approach with a relatively
small sample and very few included a control group.
The development of a specific and consistent
body of knowledge regarding the psychological and
marital adjustment of both couple’s partners follow-
ing TBI calls for the design of quantitative studies
conducted with large and homogeneous samples
including control groups. There is also a need
for enhancing consistency in the definition of
adjustment variables, which are lacking clear and
unequivocal definitions at this time. While the first
part of this paper aimed to describe the psychological
symptoms and marital difficulties experienced by
individuals with brain injury and their spouses,
the following part is rather oriented toward an
understanding of the post-TBI adaptation process
through the exploration of relevant theoretical
models and factors that have been empirically
associated with adjustment.
Part II: Factors involved in the adjustment
process following TBI: Conceptual models
and empirical data among injured
individuals and their spouse/caregivers
Current research efforts are moving toward a better
understanding of the adjustment process following
TBI . Accordingly, the emergence of studies
aimed at identifying the factors involved in the
adjustment process is observed. However, these
studies are still limited by their quantity and a certain
lack of consistency among their findings. Among the
reasons for the fact that results point to different
directions is a lack of a clear and unequivocal defini-
tion of the adjustment construct at this time. This is
understandable given the complexity of the adjust-
ment issue, which stands at the converging point of
several research areas in psychology and rehabili-
tation. As a consequence, there is currently little
specific data providing only a limited understanding
of the adjustment process among persons with
brain injury and their partners. However, it appears
important at this point to bring together the current
existing knowledge in order to foster the integration
of this promising field in TBI research.
Adjustment in individuals with TBI
The process of adjustment to TBI fallout is dynamic,
complex and often specific to the individual’s
circumstances like, for instance, life cycle influences,
TBI sequelae, resources and barriers, financial and
vocational factors, as well as the individual’s social
network [45, 81]. As described in the first part of this
article, several studies attempted to identify how
some trauma/accident and demographic variables
(e.g. severity of the injury, time since injury, age of
the patient, extent of social support) influence the
adjustment level of individuals after TBI . First,
given their large diversity and their often contra-
dictory nature, the results of these studies tend to
provide a split understanding of the adjustment
issue, with each factor being considered in isolation
. Secondly, these moderator and predictor
variables do not lend themselves to direct interven-
tions . In light of these facts, researchers have
become aware that a global understanding of
emotional adjustment following TBI also necessi-
tates examination of psychologically mediated variables
and more specifically the way the individual per-
ceives and reacts to the consequences of TBI. There
is, thus, a growing interest in knowing how two
individuals differently experience similar circum-
stances. In this context, current conceptual models
pay major attention to the cognitive moderators
involved in the adjustment process.
Godfrey et al.  and the theoretical framework
of Moore and Stambrook  emphasize the role
of cognitive appraisal and the coping process of the
individual involved in a rehabilitation process.
Although Godfrey et al.’s SAC model is appealing
for its theoretical aspects and its informative descrip-
tion of the awareness concept, it is described in gen-
eral terms, while there still is little specific empirical
evidence for its components and links between them.
Moore and Stambrook’s model describes, to a
larger extent, the cognitive moderators—and, more
precisely, the cognitive beliefs involved in their theo-
retical framework, as well as the negative cycle they
may be involved in. Stated briefly, these authors
suggest that ‘generalized expectancies of external
locus of control, combined with a stable and global
attributional style for negative outcomes arising from
non-contingent and sub-optimal outcomes in many
aspects of the TBI patient’s life, lead to feelings
of low personal control over the environment’
(p. 118). These beliefs contribute to the TBI
individual’s experience of a negative emotional
Psychological and marital adjustment
state, which feed back to the cognitive beliefs and a
negative emotional state. This process may lead to
poor coping strategy selection which, in turn, is likely
to lead to increased non-contingent and sub-optimal
outcomes and, thus, strengthen the negative cycle.
This promising conceptual model shares similarities
with that of Godfrey et al.’s, as both are interested
in the coping process. Hereafter, some empirical
evidence is reviewed concerning the use of coping
strategies by individuals with TBI throughout their
Using qualitative methods, Willer et al.  listed
the most frequently used coping strategies among
male and female spouses with TBI, as well as
young men with brain injury . These studies
were among the very first efforts examining this
specific topic and were informative in that they
identified several strategies used by these popula-
tions. These strategies mostly related to increased
involvement in family decisions and activities outside
the home, as well as to developing greater awareness
of limitations. These studies also showed that males
and females with brain injury are likely to favour
different coping strategies. Nonetheless, the findings
of this observational study do not inform on the
relevance of the strategies used for emotional
Other authors examined the relationships between
the use of specific coping strategies and outcome
variablesof the adjustment
TBI [45, 84–89].Among
Stambrook’s team conducted several studies using
a cluster analytical approach with the revised Ways
of Coping Questionnaire (WOC-R ). Overall,
they found that individuals with TBI who made a
relatively indiscriminant use of a large number of
coping strategies had high self-ratings of depression,
as well as more psychosocial, cognitive and physical
difficulties as compared to the two following clusters.
Subjects who relied more upon self-control and
positive reappraisal coping strategies, combined
with lower external locus of control, showed higher
adjustment scores on these outcome measures.
Positive reappraisal and self-control are respectively
useful in the search for meaning in an experience
and for attempts to gain mastery over an event; two
critical issues for cognitive adaptation [88, 91].
Finally, a cluster characterized by a low use of any
of the coping strategies measured by the WOC-R
was associated with low levels of mood and psycho-
social difficulties. An interesting possibility that
may account for the latter results is that subjects
from this cluster are actively denying their disabilities
and are, therefore, not actively ‘coping’ as they
perceive no ill effects of their TBI . These results
suggest that there may be an optimal range of
‘self-deception’ or denial strategies that may serve
to decrease anxiety associated with overwhelming
circumstances at a sooner stage in the recovery
process . However, for these authors, it appears
that repression, escape and denial coping strategies
among TBI survivors are linked with poorer life
outcomes in later stages of recovery.
therefore, supposed that individuals with TBI use
specific coping strategies, other authors rather
observed coping strategy patterns in the TBI popula-
tion similar to those of non-neurologically impaired
control subjects [84, 87]. More specifically, results
from Curran et al.  indicate that coping strategies
characterized by worry, wishful thinking and self-
blame are significantly associated with higher levels
of depression and anxiety in both TBI and control
group participants who had previously experienced
serious orthopaedic injuries. Similarly, Malia et al.
 observed that less use of avoidance coping,
wishful thinking and emotion-focused coping strate-
gies are related to better self-reported psychosocial
functioning in both the short- and long-term follow-
ing the injury (between 6 months to 2.5 years
post-brain injury). This study suggests the advantage
for patients in dealing with problems (using problem-
focused strategies), rather than running away from
them, in order to attain good psychosocial adjust-
ment. Using a factor analysis approach with the
COPE questionnaire , other authors  arrived
at similar conclusions. They observed two dimen-
sions of coping, namely approach-oriented (active)
and avoidance-oriented (passive). While avoidance-
oriented coping was associated with depression, lack
of active coping was related to apathy. Interestingly,
their results indicate that coping style is not related
to lesion location.
Karlovits and McColl  used a qualitative
approach to describe the coping strategies used
by 11 adults with severe brain injury for coping
with the critical period of community reintegration.
They observed several coping strategies that are simi-
lar, in some respects, to those found in the literature.
These may be grouped into three categories:
problem-focused, perception-focused and emotion-
focused. The use of a ‘perception-focused’ category
is consistent with the ‘reappraisal’ cluster observed
in Moore and Stambrook’s studies [45, 88, 89].
For Karlovits and McColl, creating this category
allows researchers to be more specific and emphasize
that individuals with head injury can successfully
change the meaning of potentially stressful circum-
stances. The most striking result of this study
concerns the avoidance strategy. This strategy was
observed in this sample, as in former studies,
although it was manifested differently. Avoidance
is traditionally defined in the coping literature as
M. C. Blais & J.-M. Boisvert
running away from a problem and, thus, considered
as an emotion-focused strategy. However, results from
Karlovits and McColl demonstrate that avoidance
can also involve preventing problems from arising.
In fact, participants from this study used avoidance
‘to prevent problems or to avoid fanning the flames’
(p. 858). This strategy, thus, involves recognizing
the problem and trying to deal with it. As such,
avoidance can be viewed as an active positive and
problem-focused strategy. Although this observation
was made from a small sample of severely injured
individuals and, therefore, may be not generalizable
to other samples, it provides a new and helpful
insight into the complex process of coping.
This brief review demonstrates that the coping
process following TBI represents a relevant area of
research and also underscores some complexities of
this endeavour. The studies presented support the
hypothesized relationship between coping strategies
individuals. Therefore, these data support the inclu-
sion of cognitive and behavioural moderators such as
coping strategies in a model of post-TBI psychologi-
cal adjustment. However, the studies examined are
limited by their cross-sectional approach, which
does not allow for prediction of causal relationships
between the use of specific coping strategies and
psychosocial outcomes. Therefore, there is a critical
needfor prospective and
‘providing information about the direction of causal-
ity, e.g. do persons with brain injury use emotion-
focused coping less because they feel better adjusted,
or does the use of emotion-focussed coping make
people feel worse?’ (, p. 615). Such data would
provide clearer intervention hints for this population.
Adjustment in caregivers
A glance at the literature regarding TBI reveals the
flourishing of work on caregiver’s burden and the
caregiving process. This growing interest is not
surprising knowing that, in the current North
American health care system, relatives are increas-
ingly involved in caring for people living with
impairments . Within this context, caregiver
tasks and responsibilities are likely to represent
significant stress because of the emotional and
physical demands that these responsibilities involve
One can find in the literature several useful theore-
tical models for describing caregiver and/or family
adaptation following TBI. These include the Double
ABCX model of Family Adjustment and Adaptation
, which inspired the more recent framework of
McCubbin and colleagues, the Resiliency Model of
Family Stress, Adjustment, and Adaptation [95–97].
These models are based on a family systems
approach and include the family’s schema; family
themes, identity and relationships with the outside
world following head injury . Other models
include the Perceived Stress Model of Caregiver Burden
[42, 98], the Stress Process described by Pearlin et al.
, as well as the Resources Model of coping [99, 100].
These last three frameworks focus on the caregiver’s
experience rather than on the family adaptation
Given the number of different theoretical models,
it is noticeable that research in this area has been
driven by several disciplinary perspectives and
theoretical orientations . Indeed, one can argue
that ideas derived from these frameworks take on
seemingly divergent stands. One problem in this area
of research is the use of different terms by several
authors that describe supposedly similar concepts.
This leads to confusion and a lack of a comprehen-
sive view of caregiver adaptation following TBI.
For example, some researchers employ unchangingly
the terms ‘resources’, ‘buffers’ and ‘protective
factors’, as well as ‘perceived stress’ and ‘appraisal’.
Nevertheless, the frameworks previously listed
have given rise to an important advancement in this
field. Whereas the majority of studies to date have
tried to predict caregiver’s adjustment from charac-
teristics of the individual with brain injury (such as
injury severity, time since injury, cognitive and per-
sonality changes) and characteristics of the caregiv-
ing situation (e.g. availability of financial resources
or social support), these models are rather interested
in mediators between the caregiving situation and the
stress experienced by the caregiver and/or his or her
adjustment level. In other words, each of these
conceptual frameworks are based on the idea that
‘it is not the objective characteristics of the caregiving
situation that determine adjustment, but the care-
givers’ appraisal of their situation’ (, p. 179).
These frameworks thus focus on caregivers’ appraisal
of the situation, as well as the coping strategies these
individuals are using in order to manage the stress
they experience. The next section presents empirical
findings regarding these critical mediators for under-
standing caregivers’ adjustment following TBI.
In a study cited before, Willer et al.  used a
qualitative approach to highlight the coping strategies
used by husbands and wives of 31 individuals
who sustained a head injury. Results showed how
husbands and wives differed in their use of coping
strategies. Stated briefly, women described organized
support groups as very helpful, whereas men pre-
ferred highly individualistic coping strategies (e.g.
suppressing feelings). Selecting some of the coping
strategies described by Willer, Kosciulek 
designed a rating form to assess coping behaviours
in families (the
Psychological and marital adjustment
observed that positive reappraisal and family tension
management are two coping strategies predictive of
family adaptation. Kosciulek  defines positive
reappraisal as a redefinition of stressful events to
make them more manageable. Hence, the same
stressful event—such as a head injury—may either
lead to family dysfunction or successful adaptation,
depending upon the family’s interpretation of the
event; that is, a manageable family challenge or a
catastrophic event. These results provide empirical
support to the Resiliency Model of Family Stress,
Adjustment and Adaptation.
Pursuing his work, Kosciulek  developed the
concept of family schema in accordance with the
family systems approach and cognitive theories.
Family schema are described by McCubbin and
McCubbin  as a set of beliefs, values, goals, prio-
rities and expectations held by families about them-
selves in relationship to each other and about their
relationship to the community and the social
system. Family schemas shape the family’s appraisal
of stressful situations. Kosciulek’s study among 87
primary caregivers (predominantly mothers and
wives) suggest family schema variables such as man-
ageability (i.e. belief that the demands posed by
family problems are manageable which, in turn
leads a family to search for resources) and meaning-
fulness (i.e. tendency to see life as meaningful,
which provides motivational drive to solve problems)
are predictive of family adaptation.
The schema concept was recently furthered by
Stebbins and Pakenham . These authors investi-
gated five key irrational schematic beliefs (IB) in
116 parents and spouses of persons with a brain
Worrying, Demand for Approval and Emotional
Irresponsibility. Their results indicate that greater
adherence to these IB is related to higher levels of
global psychological distress in caregivers; revealing
that cognitive interpretation of events play an impor-
tant role in adjustment to TBI caregiving. More
specifically, the IB Worrying sub-scale explains the
largest amount of variance in global psychological
distress. Although one agrees with the idea that
worrying has been linked to maladjustment in
general and specific populations, it is not clear
whether the Worrying sub-scale used in this study
intended to measure worry itself rather that ‘exces-
sive worry’. That is, one considers that, within
people with a TBI and their relatives, worrying
thoughts are likely to have a ‘reality basis’ like, for
example, cognitive, motor and language difficulties.
From the authors’ point of view, it is not irrational
for the TBI individual and his or her relatives
to worry about facts which bring about a lot of uncer-
tainty. Denying such problems would rather be
irrational. This is not to say that one should
not develop interventions to decrease worrying in
this population. However, this might be better
achieved by encouraging people to take action. Yet,
behavioural activation is seen as one of the active
mechanisms of change in cognitive-behavioural
interventions, which in turn may have a positive
impact on worrying [102, 103].
Results from a well-designed study conducted
by Sander et al.  using the WOC questionnaire
suggest that greater use of emotion-focused coping
strategies (e.g. pretending that the stressful event
did not occur) is significantly related to lower
psychological health, as demonstrated by caregivers’
lower scores on the General Health Questionnaire
(GHQ ). Surprisingly,
problem-focused coping (e.g. seeking information,
planning the next step) was not significantly asso-
ciated with their psychological health. One reason
stated by the authors for explaining their data,
which contradicted their hypothesis, is that some
the stressful situation may consist of ‘confrontive’
behaviours that may be inappropriate or ineffective
for coping with the effects of TBI experienced by
a loved one. This contrast with the results of
Blankfeld and Holahan , who observed that
positive reappraisal) are significantly related to better
psychological adjustment in their sample of 45
caregivers of head-injured individuals. Nonetheless,
results from the latter two studies [59, 105] consis-
tently support the hypothesis that social support
(or satisfaction with support received) is associated
with lower emotional distress in caregivers. Further-
more, Sander et al.  showed that time since
injury has no effect on caregivers’ coping style,
which suggest that caregivers’ overall approach to
coping with TBI fall-out remains relatively stable
over time. Finally, after conducting a path analysis,
Chwalisz [42, 98] also found that caregivers’ charac-
teristics (e.g. stress appraisal, coping strategies)
predict their adjustment level in a fashion delineated
in her theoretical model of caregiver burden follow-
ing brain injury (the Perceived Stress Model of
The studies presented above support, to a large
extent, the relevance of conducting research on the
relationship between caregivers’ resources and their
adjustment level post-TBI. However, coping dimen-
sions are still differently classified and named by
some authors. Moreover, different instruments for
measuring these dimensions are used, unfortunately
making this area of research even more complex
and sometimes generating seemingly contradictory
results. However, problem-oriented coping strategies,
along with positive reappraisal of stressful situations,
as well as seeking social support, appear to be
M. C. Blais & J.-M. Boisvert
critical variables for caregivers’ adjustment, which is
consistent with findings among other populations
[106, 107]. Therefore, counselling approaches,
including the development of problem-solving strate-
gies and behavioural activation, concurrently with
cognitive restructuring, may be helpful for stress
reduction in caregivers of people with TBI.
Coping and marital adjustment
Coping skills have also been investigated in a marital
context, although very few studies have evaluated this
variable in couples following a TBI. Willer et al. 
identified the coping strategies used by both partners
to adjust themselves to the consequences of TBI.
However, one is aware of only one study that actually
evaluated the relationship between the utilization of
coping strategies and marital adjustment in TBI
couples. Using cluster analysis, Moore et al. 
found that couples who use high amounts of
F-COPES  measured coping strategies show
the highest dyadic adjustment, as measured by the
Dyadic Adjustment Scale , in their sample of
57 couples of severely to mildly head-injured male
individuals. Although limited, these promising results
should encourage researchers to pursue investiga-
tion of coping skills as critical moderators of dyadic
adjustment following a critical stressor for a couple,
such as a head injury. It is even more important to do
so since it is known that coping skills have been
linked to marital adjustment in both non-distressed
and distressed couples [110–112], as well as in
couples facing specific stressors [113, 114]. Indeed,
Bodenmann et al.  included the enhancement
of coping abilities (at individual and dyadic levels) as
a specific target in their preventive training pro-
gramme for couples (Couples Coping Enhancement
Training (CCET)), itself inspired by the work of
Markman’s team . Examining the efficacy of
this programme over a period of 1 year among 143
couples from the general population, these authors
demonstrated that couples participating in the
programme significantly improved in their marital
quality following the training and that this effect
remained stable for 1 year. Therefore, it would be
relevant to evaluate whether such a programme,
adapted to the specific needs of TBI couples, could
be of help to enhance their individual and dyadic
coping skills, as well as their marital satisfaction.
In response to the numerous demands and stressors
following a TBI, both couple partners are likely
to experience psychological difficulties, such as
anxiety and depression symptoms. Many of the
results of studies observing these symptoms are
Nevertheless, researchers agree on the fact that
post-TBI adjustment represents a genuine challenge
for those involved in the process. The literature
also emphasizes the difficulties that couples may
encounter, such as significant role changes and loss
of sexual intimacy and empathic communication,
which are likely to strain their dyadic adjustment.
Consequently, the risk of marital breakdown follow-
ing a TBI is increased. Furthermore, some studies
have documented the links between demographic/
trauma variables and the adjustment level in people
who have sustained a TBI and their spouses.
Unfortunately, the results of these studies are some-
times inconsistent. Moreover, they provide a frag-
mented picture of the factors that are associated with
adjustment following a TBI and do not allow for the
development of direct strategies to intervene among
Recent studies in this research area put an empha-
sis on the adaptation perspective. There is a growing
interest in knowing how people with a TBI and their
relatives adapt to the consequences of trauma.
Concurrently, theoretical models aimed at depicting
the adjustment process in people with TBI and their
caregivers have been either adapted from general
stress and coping literature or newly developed.
The large diversity observed in the models that
have been presented in this article reveals inconsis-
tencies in this recent area of research. The lack of a
clear definition of the adaptation construct and its
outcome indicators are among the reasons that
might account for this problem. Nevertheless, cogni-
tive mediators are commonly seen, across several
models, as critical variables to explain the adjustment
level in people with TBI and their relatives.
Cognitive variables that are significantly associated
with adjustment levels have been empirically identi-
fied, with an emphasis on coping skills. Briefly,
frequent use of problem-solving skills and positive
reinterpretation of problems encountered, combined
with low use of avoidant coping skills and magical
thinking have been associated with higher adjustment
levels both in individuals with a TBI and their
caregivers. These results suggest that this variable is
worthy of further exploration, especially considering
that such knowledge could lead to direct intervention
strategies for individuals with TBI and their partners.
To help couples in which one partner has sustained a
TBI, further works should put an emphasis on
the adjustment perspective, directing efforts at
identifying the personal characteristics and the
mechanisms by which people adapt to significant
stressors following the trauma. Researchers should,
Psychological and marital adjustment
thus, conduct systematic studies exploring the link
between specific variables and adjustment in persons
with brain injury and their spouses. Following the
pattern developed for coping skills, other relevant
variables could be investigated such as social
problem-solving skills and, for the individual with a
TBI, specific social skills that may be particularly
relevant for people with a physical disability .
Furthermore, given that spouses and parents do not
experience the same stress following TBI , future
studies should be conducted among specific samples
(either spouses or parent caregivers) in order to
evaluate whether specific strategies are helpful for the
adaptation of each of these groups.
As of yet, the investigation of critical mediators of
adjustment following TBI has mostly focused on
cognitive variables. There is still a lot to accomplish
within this promising avenue of research, especially
in regards to dyadic adjustment after TBI, since no
cognitive factors associated with marital satisfaction
have yet been identified.
Besides cognitive variables, authors should investi-
gate other factors associated with marital satisfaction
that are known to be active ingredients of behavioural
marital therapy. For instance, communication skills
have been found to be relatively helpful for individual
and marital adjustment in general and specific popu-
lation samples [118–123]. Although communication
has been explored within the context of family func-
tioning following TBI [21, 53], the authors are not
aware of any study investigating communication
skills within the context of marital relationships
following TBI. Secondly, it is known that people
with a TBI may have to revise their personal, profes-
sional and recreational aims. Therefore, it would be
relevant to verify how these changes influence
both spouses’ common goals, as well as determine
whether this constitute a critical factor for marital
adjustment. Moreover, Jacobson et al.  include
mutual acceptation as a critical component of their
integrative behavioural couple therapy. Acceptance
interventions are aimed at helping couples use their
unsolvable problems as a vehicle to establish greater
closeness and intimacy. Could such interventions be
relevant within TBI couple populations? Results
of these further studies aiming to identify critical
variables associated with the adjustment process of
individuals with TBI and their spouses could then
programmes destined to TBI couples. A training
programme, like that of Bodenmann et al. ,
could represent a promising starting point to tackle
Finally, to be consistent with current health
policies in western countries, further studies should
not limit their investigation to either the individual
with TBI or his/her partner, but rather work toward
of sound intervention
the development of integrated models that take into
account the interactions between these two actors
within the marital relationship. Apart from the
study by Moore and Stambrook , one is not
aware of any research that has evaluated the link
between one’s spouse’s behaviours (e.g. mutual
reinforcement, coping strategies) and the level of
individual and marital adjustment observed in the
other partner. Yet, certain findings from studies
conducted among people with physical disability
have shown that some behaviours of the able-bodied
spouse influence the treatment progress of the
injured individual .
As recommended by Antonak et al. , future
research in this area should include well-designed
prospective, longitudinal investigations among large
representative samples and use validated and similar
instruments across studies. Longitudinal studies are
critical to determining the specific strategies and
resources needed by persons with brain injury and
their spouses to adapt throughout the rehabilitation
stages following the injury. The inclusion of compar-
ison groups would also enable verification of the
extent to which the results obtained are specific to
the TBI population. While doing so, researchers
and clinicians must develop practical mechanisms
for the efficient transfer of this valuable scientific
knowledge to clinical practices in health care systems
and especially rehabilitation centres.
This study was funded by the Social Sciences and
wish to thank every person that have contributed
to this study, especially Sandra Hopps, PhD, for
her English revision, as well as Robert Ladouceur,
PhD, Michel Loranger,
Truchon, PhD, for their helpful comments on the
prior versions of this paper.
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