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Traumatic brain injuries are complex in the sense that unlike physical medical conditions, they cannot be easily seen with the naked eye. Traumatic brain injuries, let’s call them ‘TBI’ for short are, common yet not often talked about in society. The problem with brain injuries is that sometimes the person who survived the trauma may look normal on the outside, but inside, their head tells a different story. The topic of TBI, and the effects it has on intimacy, was chosen due to my mother being a survivor. She had a serious accident around 2008 and her trauma is still present today. Looking normal on the outside is what prevented her from getting any therapy so it has been about 11 years and she is not the person she used to be. Earlier this summer when my dad stated that he wanted to divorce my mom, I took a long hard look at the whole situation and questioned the extent to which TBI affected their relationship.
This paper’s goal is to look at the past literature to see how head trauma can affect intimate relationships between a TBI survivor and their partner or significant other. First, we will look at what intimacy is and what contributes to a healthy relationship. Following this we will look at an example of trauma, such as PTSD and how it can impact physical, emotional, and sexual intimacy of the survivor and their partner. An interesting study composed of in-depth interviews by survivors of TBI and their partners will be explored and then lastly, suggested therapy options from the ‘Treatment Model for Sexuality Disturbance Following Brain Injury’ will be discussed.
Intimacy is an important fundamental need for humans since we are social beings and when negative life situations occur, it can have an impact on relationships. Maslow’s hierarchy is a pyramid that includes categories of needs an individual requires in order to achieve self-actualization. The third category following physiological and safety needs is belonging needs. Humans need belonging in order to develop a positive self-esteem. The experiences of giving and receiving love can lead an individual to internalize positive self-esteem that contributes to an assurance of self-confidence and self-actualization (Abnormal Psychology Perspectives, 2016). Intimacy and relationships are therefore a very important need that we constantly seek out.
Now, what exactly defines ‘intimacy?’ According to Gill et al. (2011), intimacy is an interpersonal or sexual relationship with another person and this relationship must have elements of positive emotional connections and commitment between the pair. Healthy relationships are built on foundations such as trust, communication, and most importantly, friendship. Bo and Mills (2004) mention some criteria for healthy relationships such as open communication between partners, negotiating conflicts by accommodation and compromising between partners, providing support during a crisis, playing together openly and spontaneously, and lastly, they remain monogamous and faithful to each other. When life throws a negative curveball to couples, they must try and deal with it in a certain way and this can be tough if couples don’t know how.
Trauma can range from things like being caught in natural disaster to finding out that you have cancer. According to Mills and Turnbull (2004), traumatic events lay on a continuum of severity from acute situations to stressful long-term events. Acute situations can be getting into a car accident whereas being a victim of sexual assault or domestic violence would be a long-term stressful event. Depending on the situation and the severity of the trauma, feelings such as distress and helplessness could lead the survivor to develop post-traumatic stress disorder (PSTD). This can have a significant impact on the victim as well as the people they interact with daily. When traumatic situations occur, it could effect on the different types of intimacy such as psychological and emotional, sexual intimacy, and operational intimacy. A research article called ‘Broken Hearts and Mending Bodies: The Impact of Trauma on Intimacy’ was written by Mills and Turnbull in 2004. We’ll be looking specifically at their intimacy categories and how they are affected by trauma.
Psychological & emotional intimacy can be categorized together since they are very much related. When an individual experiences trauma, their self-esteem could become damaged and this could have an impact on their self-actualization. As was mentioned before about Maslow’s triangle, not reaching one’s self-actualization creates dissatisfaction. An increase of hostile emotions such as anger and irritability will lead to wanted verbal and physical hostility. Mills and Turnbull (2004) state how this can lead both partners to feel a sense of confusion, doubt, guilt and feelings of sadness or depression. These types of conflicts can have an impact on the quality of their relationship.
Sexual intimacy has to do with the interest of sex. Following trauma, sexual libido may increase or decrease, but it’s more common to see a decline (Mills & Turnbull, 2004). In cases of trauma, it is possible that sexual arousal could become impaired significantly. Mills & Turnbull (2004) mention how men may not be able to experience an erection whereas women may not be able to achieve proper lubrication which leads to painful intercourse. Anorgasmia, or a delayed orgasm, is present for both men and women with trauma. Anti-depressant medication may also contribute to these sexual problems. Supporting these claims, a study by Hibbard et. al (2000), found that men with TBI have problems with erectile dysfunction and sexual desire while women with TBI have problems with arousal, inability to achieve orgasm, and difficulty with vaginal lubrication.
Operational intimacy has to do with role expectations. After the trauma one partner may take on the role as the ‘carer’ and this may become permanent (Mills & Turnbull, 2004?). The ability to have independence for both partners can create tension and resentment since most commonly, majority of decision-making potentially falls onto one partner – more likely the one without injury (Gills et al, 2001). This again may create a decrease in the quality of relationship satisfaction. These three categories can be affected by the aftermath consequences of the trauma as well as the post-injury behaviour by the survivor of TBI.
A qualitative interview study done by Gill et al. (2011) explored the experience of intimacy from the viewpoint of both the persons with TBI and their intimate partners. A great deal of past literature has only focused on the person with TBI and not so much their uninjured partner. This study is very insightful because it gives specific examples of each partner’s viewpoints. The goal of this study was to gain insight on the participants experience of intimacy, the factors affecting their intimacy, and need for rehabilitation services (Gill et al., 2001).
Announcements of their study were presented in support groups, TBI programs, and rehabilitation centers which then allowed researchers to recruit 12 couples from Chicago and 6 from Houston. Participants had to be 21 years or older, had to have adequate comprehension and communication skills, and TBI had to be diagnosed in 1 member of the couple occurring 6 months or more months prior to the study. Each individual was interviewed for approximately 60 to 90 minutes and were separate from their partner for this time. Audio-recording was done for each interview and was later transcribed by the researchers.
Data analysis of the interviews determined intimate themes and subthemes that could be defined. Researchers focused on two major themes: barriers to intimate relationships and factors related to relationship strength. These were consistent across interviews and developed an assortment of detailed subthemes. Barriers to intimate relationship subthemes include: emotional reaction to changes, negative feelings, sexual strains & incompatibilities, role changes or conflicts, communication difficulties & uncertainties, and balance/role strain. Some subtypes for factors related to relationship strength included: unconditional, unselfish love; commitment to staying & working on the relationship, communication, and spending time together/friendship.
The results that the researchers gained are important because it helps us see from both sides how the intimacies are affected by trauma. With regards to the subtheme emotional reaction to changes, they found that TBI survivors felt a sense of guilt and that they were letting their partners down. They felt like they could not live up to the role of being a good intimate partner. Guilt was experienced more by men as one participant stated, “as a man, some of those difficulties make you feel, you know, like less than a man, like not a complete person, and, as if you’re letting that other person down all the time…” (Gill et al., 2001). For women it was common to feel unattractive due to their disabilities. Hibbard et al. (2000) also found that for women, attractiveness and having one’s body viewed by their partner during intercourse created difficulties in sexual functioning since they were overcome with negative emotions.
In Gill’s 2001 interview study, the subtheme negative feelings indicate that most partners felt like their partner was a different person. Embarrassment was a feeling some partners felt toward their significant other’s behaviour after experiencing TBI. Resentment was another common emotion due to some of the partners feeling like they were taking on additional roles. Both of these subthemes show how it can impact psychological and emotional intimacy. Self-esteem can be affected for both partners in the sense that the survivor with TBI may not feel adequate anymore which possibly can lead to frustration by their partner. When negative feelings arise it can create a tension that can impact the couple because it can lead to hostile behaviour.
Sexual strains & incompatibilities was another common subtheme that relates back to our sexual intimacy category. These concerns mainly came from the uninjured partners in the interview study. This study supports what we talked about in the sexual intimacy category because many of the uninjured partners discussed how the behaviour of their partner with TBI was vastly changed post-injury. Some problems included erection difficulties, decreased stamina, and lack of interest or desire. The unattractiveness feeling that comes with TBI causes difficulties in sexuality – as was mentioned previously, and this can contribute to the lack of interest or desire by the survivor. Reduced sexual activity was another main concern because this caused the uninjured partner to feel sad and frustrated since their sexual needs were not being met. Some partners tried to encourage their injured partner to explore sexuality which heightened positivity but for others there was a sense of loss and rejection (Gill et al., 2001).
We’ll talk next about role changes/conflicts and balance/role strain since they are tied in with one another. There were different perspectives of the survivors and their uninjured partners. Many survivors with TBI reported feeling a decrease in independence due to the inability to manage tasks and they felt like they were treated like children since their partners had to take care of them (Gill et al., 2001). Partners without TBI admitted to feeling like a parent at times which caused them to have emotional conflicts since they needed to find the balance between intimate partner and ‘carer.’ When we talked about operational intimacy before, it was mentioned that often after trauma, one partner takes on the guardian role. This role change can upset the dynamic of an intimate relationship and these interviews support the claim of how this category of operational intimacy is affected.
Looking at the factors that relate to relationship strength, there are some subthemes that relate back to psychological & emotional, sexual, and operational intimacy. These factors in Gill’s 2001 study tended to emerge consistently for both partners. First, there was unconditional, unselfish love; commitment to staying and working on the relationship. Most survivors in the study showed an appreciation for their partner staying with them through recovery and appreciated their commitment. The uninjured partners in return mentioned how it bolstered them to know that their partner with TBI still appreciated and loved them (Gill et al., 2001). Through this deep appreciation it can have an impact on psychological intimacy. If the uninjured partner supports and loves the person with TBI, this can result in a greater self-esteem. This is beneficial since TBI participants did mention feeling a sense of guilt – as was seen previously. In return, if the injured partner feels grateful for the support and shows a sense of appreciation, this can also lead to a greater self-esteem of the uninjured partner. All in all, the sense of reciprocation yields a greater result for relationship strength following TBI.
Communication is the next one we’ll talk about because when we talked about what contributes to a healthy relationship, open communication was a big factor. This study’s results shows that good communication was a critical factor to maintaining strength of the intimate relationship between partners. Better communication also helped the couples deal with the several changes experienced after TBI (Gill et al., 2001). Providing support to a partner requires good communication because it allows both partners to understand the feelings and needs of each other. A quote from one participant illustrates conflict resolution through good communication: “sometimes we don’t agree on the same idea…we always just keep talking about it, talking about it, talking about it until we get the final solution” (Gill et al., 2001).
Spending time together/friendship is the last subtheme we will discuss in regards to factors relating to relationship strength. Emphasis on spending time together from several couples was made in regards to this subtheme because it reinforced the bond between them. A participant mentioned how she tries to do little surprises for her partner which makes her happy because that’s what she used to do for him pre-injury. This act of friendship can make the couple feel good and further strengthens the relationship. By the couples finding the time to still care and support each other is what allowed for greater relationship strength.
A treatment model for sexuality disturbance following brain injury, was proposed by neurologist, W.F Blackerby in 1990. He mentions many treatments that relates to these subthemes that we’ve been discussing so far. Counseling and training is a rehabilitation topic that was discussed in this model. Sexuality is sometimes a sensitive and private topic so he mentions how therapists need to be properly trained so they can guide couples in the right direction and without judgement. Sometimes partners need to communicate more intimately and effectively than they did before the injury (Blackerby, 1990). When trauma happens communication about intimacy may be tough but it’s also what contributed to greater relationship satisfaction.
Concrete foundations of intimate skills can be a part of counselling and these include both verbal and non-verbal aspects. Some examples of verbal skills include: the use of “I,” “you,” and “we” while partners share their feelings which contributes to positive feedback rather than complaints and criticism (Blackerby, 1990). Non-verbal aspects include: tone of voice, eye contact, gestures, and touching – if any one of these were perceived in a negative fashion it could create tension and hostility between partners. Again, this all relates back to the intimacy categories that are affected by trauma. If couples work to become better at these skills, it will create better understanding between them and lead to a higher quality relationship.
Another factor that relates to greater relationship strength had to do with spending time together and friendship. The treatment model for sexuality disturbance mentions special activities which are designed into rehabilitation programs to provide opportunities that allow the practice and reinforce of various aspects of sexuality and intimate relationships (Blackerby, 1990). An example he gave was massage classes because it allows partners to give and receive pleasure – a non-sexual physical behaviour that produces closeness and sensitivity to responses between the partners. This can be beneficial because it’s typically slow and encourages intimate but not sexual touching between partners. TBI survivors that struggle with sex may work their way up to being more intimate and overtime they could regain that ability to wanting to engage in sexual acts. When partners include each other in activities it can strengthen the relationship and that was seen in the interview study.
The last treatment category we’ll discuss is the behavioural sexuality intervention. This approach can help with the sexual intimacy category that was discussed previously. This therapy focuses on prescribed activities to be done in private by both partners and it starts off through simple shaping of sexual behaviours (Blackerby, 1990). This lets sexual intimacy to be more gradual and allows the partners to identify the difficulties that arise. The therapist is then able to work with the couple and provide advice to help those individual barriers. Couples would initially start off with slow steps and this could be something as simple as holding hands and maintaining eye contact while each partner says 3 compliments to the other person. Eventually as the couple work through therapy they would start to engage in more intimate acts through each assignment – an example of this would be touching each other in bed before sleeping. Each of these activities is meant to address the specific situation and difficulties that the partners have in the relationship (Blackerby, 1990). The problems regarding sexual intimacy can be worked on through this therapy and allow couples to gain that aspect of closeness and desire.
Overall, this paper was to demonstrate how trauma can affect the aspects of intimacy. A lack of communication, negative feelings, and a change in roles following TBI can be detrimental to relationship satisfaction. It can be very challenging for both partners in the sense that the uninjured partner may not know how to help or may take on a parent role and the survivor may struggle with independence while feeling guilt and shame. Unconditional love and support seemed to be the greatest factors in relationship strength. TBI survivors and their partners need to find ways to address the issues they have which may include inefficient communication skills and sexual barriers. The treatment model of sexuality following disturbance of brain injury suggests a good start to helping couples regain intimacy. Further research into relationship and sex therapies for these types of partners is something that should be explored in more depth because the treatment model that was discussed date back to 1990. It will be interesting to see what kinds of studies will be produced about TBI survivors and their partners in years to come.
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