Research investigating marital quality through the inclusion of relational assessments was initiated over 30 years ago in an exploration of the connection between spousal well-being and marital satisfaction following TBI.41 Although still embracing an individualistic perspective, Rosenbaum and Najenson41 integrated the evaluation of the marital relationship into research on the impact of TBI. In this foundational research, 10 wives of Israeli soldiers who had sustained a severe TBI were asked to assess the impact their husbands’ TBI had on their own functioning and were compared with SCI and healthy control groups. Study was conducted 1 year after injury. The components of the marital relationship that were assessed included the degree to which families participated in whole-family activities, the wives’ satisfaction with their husbands’ interpersonal relationship skills, and satisfaction in marital roles. The wives in the TBI group differed significantly from individuals in the control group on all 3 variables. Furthermore, a significant correlation between the spouse's mood and the amount of time spent by families on family activities was demonstrated. Although this seminal research introduced the infusion of relational assessment into TBI study, it was still anchored in an individual model; only spousal perceptions were examined, and the relationship was investigated as a variable contributing to individual functioning, rather than as a focal point of assessment.
Marital quality: Couples post-TBI compared with controls
Research making a direct comparison of TBI groups with controls on components of marital quality, without consideration of related or predictive variables, includes 2 studies. In 1992, Peters et al44 assessed 48 couples with 1 partner recovering from TBI and 24 couples following SCI. In addition, participants in the TBI group were subdivided by injury severity, with 31 couples in the moderate injury group a mean time of 43.10 months postinjury and 17 couples in the severe injury group a mean time of 52.71 months postinjury. Results were examined both across injury type and within the TBI group only. Patients in each group were asked to complete demographic questionnaires while spouses completed assessments of relational quality. Results demonstrated significantly higher levels of affectional expression, marital satisfaction, marital cohesion, and marital adjustment for partners of patients with SCI than for partners whose spouse had sustained a severe TBI. Furthermore, spouses in the SCI group expressed higher levels of marital satisfaction than partners of patients recovering from moderate TBI. Finally, the authors noted differences within the TBI group on the basis of injury severity for social role functioning but did not find significant differences related to marital assessments. Findings substantiated significant implications for spousal perception of relational functioning and quality following TBI but did not examine the relationship from the perspective of patients.
Bracy and Douglas47 reported findings from both partners and patients in an assessment of dyadic consensus related to interpersonal communication skills for 25 couples with mild, moderate, or severe brain injury as compared with 25 couples following an orthopedic injury. Researchers examined both the level of impact on communication skills across groups and the extent of consensus regarding perceptions of communicative abilities within groups. Although dyads in the TBI group reported significantly more communication challenges for patients than did dyads in the orthopedic group, TBI survivors and caregivers did not demonstrate a substantial lack of consensus within marriages, whereas partners in the orthopedic group revealed a significant lack of agreement with one another. Results revealed dyadic consensus to be a potential marital strength for couples in the TBI group. These findings underscore the value of assessing both the level of perceived challenges and the degree to which both individuals in a relationship share those perceptions.
Sexual satisfaction as a component of marital quality
Whereas researchers often investigate the quality of the marital dyad by assessing constructs, such as consensus, cohesion, adjustment, satisfaction, and affectional expression, a significant component of the coupled relationship is also marital sexual satisfaction. Although multiple studies49–52 investigate patients’ sexual functioning, interest, and ability after brain injury, the majority of them fail to include an assessment of satisfaction into the profile of postinjury patient sexuality. Since 1989, 5 studies have included either an assessment of marital satisfaction within the context of patient sexuality or an evaluation of marital sexual satisfaction as a contributing component of overall sexuality.40,42,43,45,46 In contrast with the tendency for studies assessing TBI and traditional measures of marital quality to assess only spousal perceptions, the majority of studies focusing on sexuality and marital satisfaction include only patient perception. None of the studies include both partners’ responses to marital sexual satisfaction inventories.
Kreutzer and Zasler42 were the first to include marital satisfaction as a variable when investigating sexual functioning across all levels of TBI injury severity. Although the study broadly investigated functioning through an assessment of 21 patients a mean of 16.2 months after injury, only the 16 patients in committed relationships answered survey questions regarding sexual satisfaction. More than half of patients believed their marital verbal communication to be at least “stable” (12% “improved communication”; 50% “stable communication”) and 40% rated overall marital satisfaction as “good or very good.” In 2003, Ponsford46 assessed marital satisfaction and communication, as it related to patient sexual functioning 1 to 5 years following moderate to severe injury. The author compared 250 postinjury survivors of TBI with a group of 150 healthy controls. Findings showed the TBI group to be significantly lower on measures of dyadic verbal communication and overall relationship quality. These studies present differential findings on the level of patients’ marital satisfaction within the context of marital sexual relationships.
Two studies have included marital sexual satisfaction as a component of patients’ sexual profiles. In 1990, Garden et alR41 assessed 15 couples following TBI through measures of sexual interest, frequency, attractiveness, and functioningand spouse-only measures of marital sexual adjustment. Study findings indicated that a majority (8 of 15) of spouses reported overallmarital sexual satisfaction since injury, whereas a minority (6 of 15) believed that their partners were satisfied. Kreuter et alR38 assessed marital sexual satisfaction from the perspective of 92 patients post-TBI. All levels of injury severitywere included and postinjury time frames ranged from 1 to 20 years. Results demonstrated that 89% reported marital sexualsatisfaction and 61% believed their partner to be sexually satisfied. Although the patient group investigated by Kreuter et alR38 demonstrated higher levels of marital sexual satisfaction than the spousal group in the study of Garden et alR41, both groups were more confident in their own levels of satisfaction than that of their partners. From a comparisonof these 2 studies, one might surmise that both partners in a couple may be relatively satisfied with their sexual relationship but maybe uncertain of their partner's level of satisfaction.
In 1999, Gosling and Oddy45 examined spouses’ marital and sexual satisfaction pre- and postinjury for 18 couples a mean of 4.1 years postinjury. All patients in the study were recovering from a severe TBI and a control group was not utilized. Results from spousal completion of the Golombok and Rust Inventory of Sexual Satisfaction and Golombok and Rust Inventory of Marital State indicated that both marital and sexual satisfaction were significantly higher preinjury. Whereas patients did complete a portion of the Golombok and Rust Inventory of Marital State and findings demonstrated that spouses were significantly less satisfied with their marriage than patients, all other assessments of marital and sexual quality were drawn from spousal completion of measures. The inclusion of a comparison between spouse and patient reports on 1 component of satisfaction distinguishes this research from other studies investigating sexual satisfaction solely from 1 partner's perspective but still fails to assess sexuality systemically.
Patient and family functioning: Variables correlating with marital quality
Marital quality post-TBI has also been assessed through the evaluation of the relationship between patient and family functioning and marital satisfaction. Twenty years ago, Peters et al21 examined 110 couples up to 8 years following TBI. The authors investigated the relationship between patient injury severity and spousal marital satisfaction. Findings indicated that wives of patients who had sustained a severe TBI experienced significantly less marital cohesion than wives of patients in moderate or mild groups, and there was no comparison with a control group. Furthermore, injury severity, physical limitations, time postinjury, neuroticism, number of negative life events, financial strain, and psychosocial adjustment were all correlated with marital consensus, affectional expression, and marital adjustment. Although these findings established a connection between spousal perception of overall marital quality and degree of injury impact, patient perceptions of relational quality were not assessed.
The same researchers19,20 published 2 additional reports again spanning all injury severity levels and using slightly varied sample sizes and a similar profile of measurement instruments to examine the relationship between patients’ psychosocial and mood profiles and family-coping skills to spousal reports of marital satisfaction. Study findings revealed marital adjustment to have a positive relationship with effective family-coping strategies19 and couple age and/or the age of children in the home19,20 and an inverse relationship with financial stability.19 Whereas these findings combine to construct a template for identifying at-risk couples post-TBI, descriptions of study methodology are insufficient to rule out the possibility that all 3 studies are drawing from the same sample of participants.
Recently researchers have again begun to focus on the relationship between criterion variables and marital satisfaction or adjustment.16,17,48 Wood et al17 included only spouses of patients recovering from a severe TBI at mean of 5 years postinjury to assess the perceived relationship between survivor characteristics and marital satisfaction. Researchers reviewed responses on an author-constructed measure to compare 23 spouses separated from their partner with 25 spouses still in a committed relationship with no comparison with controls. Although the groups differed significantly in the level to which spouses believed patient mood swings were related to marital satisfaction, both married and separated spouses listed patient mood swings, quick temper, and fatigue as the 3 variables most related to dissatisfaction within their marriage.
In 2007, two sets of researchers published findings on the relationship between variables related to patient functioning and overall marital satisfaction. Both Burridge et al16 and Blais and Boisvert48 included patients and spouses in their assessment of patient variables and marital constructs. Furthermore, both studies included a roughly equivalent number of survivors in mild, moderate, and severe injury categories and compared couples post-TBI with control groups. Burridge et al16 found the 40 couples a mean time of 3.3 years postinjury in the TBI group to be less satisfied with their marriages and to have a more substantial pre–post change in marital satisfaction than the 40 couples in a healthy control group. A profile analysis of spouses revealed that those with lower marital satisfaction reported lower levels of survivor functioning and less survivor insight into socioemotional skill levels. Blais and Boisvert48 linked problem solving, perception of spouse communication skills, and fewer avoidance-coping strategies to marital satisfaction for 140 couples a mean of 3.1 years post-TBI as well as for the 140 in the healthy control group. However, whereas couples in the control group demonstrated a relationship between both their perception of their spouse's communication skills and their perception of their own communication skills to marital satisfaction, couples in the TBI group only related their perception of their spouse's communication skills to marital satisfaction. These findings were true for survivors as well as for caregiving spouses.
Marital quality: Discussion
Literature examining various components of marital quality within populations recovering from brain injury has evolved within 3 frameworks: comparison of couples after TBI with control groups on components of marital quality without investigation of related variables; exploration of either marital or sexual satisfaction within the context of patients’ sexual profiles; and identification of predictive or correlated personal and familial variables, as they relate to overall components of marital quality. Findings primarily reveal negative outcomes related to marital quality but stand in contrast with studies demonstrating positive outcomes. Reports of positive outcomes include spousal43 and patient40,42 satisfaction within the context of the marital sexual relationship and indication that couples after TBI may have increased levels of consensus regarding communication challenges.47 Although the reviewed studies aimed to identify aspects of change in marital quality after brain injury, the reliance upon data derived from only 1 partner in all but 3 studies16,47,48 suggests that findings may actually highlight either spousal-only or patient-only perceptions regarding the marital relationship, rather than revealing the impact on the whole relationship. Furthermore, variability in study methodology such as inconsistent assessment with regard to injury severity, variations in the use of designs including control groups, and wide ranges in time postinjury results in an incomplete understanding of the relationship between marital quality and sample characteristics.
Although marital quality was introduced within the brain injury literature more than 30 years ago, a cohesive framework for understanding the quality of marital relationships post-TBI has not yet evolved. Blais and Boisvert22 concluded that the lack of agreement between researchers on which constructs most illuminate marital quality, divergent assessment of criterion variables, and exclusion of the patient perception in most studies have led to an incomplete understanding of marriages within the field of brain injury. Whereas these limitations all contribute to an unclear picture of marriages, the failure of most studies to take a systemic perspective when assessing relational constructs by including both partners may be the primary reason for the lack of clarity in this area.
This literature review aims to identify studies that investigate the relational construct of marital quality from a systemic perspective. While other critical reviews22,23 have included studies investigating individual constructs (eg, depression, aggression, caregiver stress) that are thought to influence marital quality, this review is limited to research investigating at least 1 relational construct (eg, marital satisfaction, dyadic consensus). Whereas the use of a systemic framework would also suggest excluding studies where only 1 partner is chosen to report on the married relationship, only 3 studies16,47,48 would meet this criteria. New research investigating dyadic perceptions is needed to understand the influence that relational changes following TBI have on the quality of the marriage.
EMBRACING A SYSTEMIC PERSPECTIVE: A MARRIAGE AND FAMILY THERAPY FRAMEWORK
Systemic family processes have been investigated in the field of MFT since the mid-twentieth century.53 However, despite established theoretical models explaining systemic interactions and validated assessment instruments to gauge marital quality, the field of brain injury rehabilitation has borrowed very little from this complementary discipline. Clinical experience and existing research16,46,48 both indicate that marriages following brain injury exhibit contextual differences from marriages within the general population. Therefore, by using accepted systemic models as a springboard, researchers have the ability to construct a cohesive picture of the impact of TBI on marital satisfaction and stability.
The postmodern era54 within the field of MFT, has embraced a constructionist paradigm. Social constructionism, a category within the overarching perspective of constructivism,29 specifically explains relationships as the development of reality within the social interchanges between people.55 The language and interpersonal communications between individuals define how each person perceives his/her own reality and further shapes how every experience and thought are interpreted.56 Within the marital dyad, social constructionism asserts that both partners create and define one another's experience through a continuous, interactive, and interpersonal interplay. On the basis of systemic principles, the evaluation of any relational construct requires input from all individuals involved in the relationship. Furthermore, marital quality is assessed, as it relates to the relationship itself rather than through distinct individual perspectives and is grounded in the notion that the whole is greater than the sum of its parts.57 Individual perspectives on any social relationship would be more than just incomplete assessments but instead would be isolated ingredients giving the illusion of representing a completed whole.
Holistic marital quality assessment
To assess the marital relationship, MFT researchers have identified a set of constructs that compose the quality of the relationship. Holistic assessment of the relationship is achieved by evaluating the summed total of complementary and interrelated relational constructs. Models frequently used to define the components contributing to overall quality include dyadic adjustment24,26,58 and the circumplex model.25 Each of these models relies upon dyadic assessment to create an understanding of the socially constructed relationship within marriages.
Initial investigation of the marital relationship will benefit from utilizing self-assessment measures that most effectively illustrate the socially created constructions within a relationship that contribute to marital quality. Dyadic adjustment is evaluated by identifying both partners’ perspectives on measures of dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression and is often assessed through use of the Dyadic Adjustment Scale (DAS)26,58 (see Table 1 for construct definitions). The circumplex model views the marital relationship as being comprised of dualistic perspectives on relational cohesion, relational flexibility, and interpartner communication.25 Researchers investigating relationships from within this model often rely on the Family Adaptability and Cohesion Evaluation Scales IV (FACES IV).59–61 Whereas other models of marital assessment exist (eg, Lock-Wallace Revised Marital Adjustment Test, Couples Satisfaction Index),62,63 research on marriage quality has drawn heavily from the DAS and multiple editions of the FACES.25,26 The constructs within these dyadic adjustment and the circumplex model are compatible with one another, with comparisons easily drawn between dyadic and relational cohesion and dyadic consensus and interpartner communication.
Marital quality: Relationship to stability and health
Research on marriages within the general population has demonstrated a strong relationship between marital quality and marital stability.5–7 Through assessment of relational constructs within a systemic frame incorporating the perspective of both partners, studies have demonstrated that components of the relationship have a much more significant correlation to marital outcome than do individual characteristics such as personality traits or psychosocial profiles.64 In a meta-analysis of studies investigating the relationship of marital breakdown to relational versus individual constructs, authors reported a significantly stronger effect size for the relationship between stability and positive relational components (r = 0.33 for women; r = 0.46 for men) than stability and individual traits (r = −0.22 for women; r = −0.20 for men).65
Marriage and family study has also established a substantial relationship between marital quality and overall individual health. Poor marital quality has been associated with indicators of declining health, including increasing physical symptomology, disability, and negative perceptions of health.1,3 Furthermore, chronic illness or injury has been related to declining levels of marital satisfaction and adjustment.2,4 Thus, the interrelationship between health and marital quality implies a need to assess either index when the other has been impacted.
A systems perspective: Discussion
The study of marriage and the family is rooted in the idea that a system is more than the summed total of individuals. Researchers in this discipline have called for a paradigmatic shift when studying relationships. When viewed through a socially constructed lens, marriages are made up of the interactions between individuals, rather than independent spousal reflections on the relationship. To evaluate the unit of marriage specifically, marriage and family researchers have developed models that identify the relational constructs essential to understanding the whole marriage. Although it is possible for instruments designed to assess marriages, such as the DAS and the FACES IV, to be utilized with only 1 spouse, doing so results in a markedly different evaluation than when both spouses are included in assessment. To achieve a true understanding of the relationship of marriage, it is essential that researchers operate within a theoretically consistent structure, which includes assessing both partners on all domains identified as relevant by the guiding model.
Optimal brain injury rehabilitation is linked to positive overall health indices and is in large part connected to the willing presence of familial caregivers. Given the predominance of spouses in the caretaking role,8 the established correlations between both marital quality and stability and marital quality and health suggest that a comprehensive understanding of dimensions of marital quality following brain injury is crucial to building effective rehabilitation models. The accepted theoretical frameworks, validated models, and corresponding assessment tools for investigating the marital relationship provide a template for comprehensive evaluation of post-TBI relationships.
IMPLICATIONS: INVESTIGATING MARRIAGE AFTER TBI USING A SYSTEMIC PERSPECTIVE
The field of brain injury rehabilitation has long recognized the need to assess the impact of injury on marriages. In 1976, Rosenbaum and Najenson41 introduced the idea of evaluating spousal emotional and psychosocial responses to TBI. However, evaluating the impact of injury on each individual in a marriage and evaluating the relationship itself are different endeavors. To date, studies in the rehabilitation field that have looked at the married relationship explicitly have been focused on either marital stability or marital quality.14–17 A critical review of these studies demonstrates that significant gaps in knowledge still exist when attempting to understand how marriage is impacted after brain injury.
Evaluation of literature in the areas of marital stability and marital quality after brain injury reveals significant methodological flaws and inconsistent reports of outcomes. Studies suggests that divorce or separation rates after brain injury may fall anywhere from 15% to 78%.31,33 This significant variation is likely due to a large number of studies relying on small samples, significantly dated research that may not reflect medical advances in brain injury outcome and the implications for spousal relationships, investigations that are primarily single-center, and variability in study populations with regard to injury severity. In addition, studies that have looked for variables predicting or related to marital breakdown have reported a wide range of findings. Despite existing literature in MFT that demonstrates a predictive relationship between marital quality and marital stability, no studies have investigated this within marriages after brain injury.
Studies that have examined the relationship between TBI and marital quality have also failed to present a consistent picture of outcomes. A primary reason for this inconsistency in findings may be the failure of researchers to borrow a systemic frame when using assessment instruments from the field of MFT. Most researchers have attempted to explain marital quality after TBI by including only spousal responses on marital assessment instruments. However, without assessment of the whole married system, these findings reveal spousal perception of marital changes after brain injury rather than changes to the actual marriage.
To effectively evaluate marriages after brain injury, researchers need to wholly embrace the approach to marital assessment established by the field of MFT. (1) The first step requires understanding relationships from a systemic, constructed perspective, rather than approaching the marriage from the more traditional individual models guiding psychology. Constructionist theory suggests that this is done by understanding relationships as the interactions between individuals. (2) The next step is using established concepts and models for understanding the marital relationship, including dyadic adjustment and the circumplex model. (3) Finally, relationships should be measured with a corresponding assessment instrument, including the DAS and the FACES IV. Effective application of these instruments requires that researchers include both spouse and patient responses to assess marriage and evaluate the relationship as a whole.
Existing MFT studies suggest that within the general population, marital quality is related to marital stability. In addition, research has demonstrated a strong relationship between marital quality and individual health. If findings in the general population are also true for couples after brain injury, marital quality becomes an important component of effective rehabilitation. By borrowing the suggested MFT theory, models for assessment, and instruments to evaluate marriages and by undertaking representative multicenter studies, researchers can begin to investigate (1) accurate divorce rates, (2) whether breakdown is related to marital quality following injury, (3) whether TBI impacts the quality of the married relationship, and (4) whether marital quality is related to individual health outcomes after brain injury. Findings from these suggested studies would have the potential to highlight the importance of marital intervention after TBI. In addition, clinical interventions built out of marriage research could ultimately lead to an improvement in rehabilitation outcomes following brain injury.
The current gaps in understanding of the dyadic impact of TBI on marital subsystems call for a targeted and grounded assessment of relationships. The use of social constructionism as a guiding theory suggests that initial investigation should rely on self-assessment models such as dyadic adjustment or the circumplex model to understand the shared constructions of married couples from a subjective perspective. However, once an initial understanding of the impact of brain injury on marital quality is established, suggested directions for future researchers include incorporating assessment models from MFT that use observations of process dynamics between couples to evaluate couple quality and stability. While self-assessment instruments are beneficial in illuminating the primary guiding themes within a relationship related to relational quality, research on process dynamics indicates that objective observations of couple interactions can enhance researcher understanding of marital dynamics and better inform correlations with marital stability. Future researchers should consider that through integration of subjective assessment methods and objective process assessment models, development of a newly constructed model specific to the impact of brain injury on marital systems will be possible.
In summary, current research evaluating marriage after brain injury is insufficient because of methodology and study design limitations. An established connection in MFT literature between the quality of marriage and overall health as well as marriage stability suggests that marital quality may be an important component of optimal brain injury rehabilitation. Accurate assessment of marriages can be achieved by applying systemic theories, assessment models, and measures from the field of MFT and conducting research with theoretical consistency. Future researchers are encouraged to build upon research approaches presented here with the incorporation of process analysis and an objective perspective to ultimately develop a model of the relationship between marriage and TBI. Findings from this suggested line of research would enable clinicians to validate the usefulness of attending to the marriage and would provide direction for effective construction of marital intervention after TBI.
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Keywords:© 2011 Lippincott Williams & Wilkins, Inc.
brain injuries; craniocerebral trauma; family therapy; literature review; marital relationship; traumatic brain injury