By Paul Gertler MAPS
Approximately 150 per 100,000 Australians sustain a Traumatic Brain Injury (TBI) every year (Fortune & Wen, 1999). Of these, approximately 60 per cent are of working age and the most represented group is males aged between 15 and 19 years. The clinical experience of many health professionals is that people with TBI are frequently aggressive and often target family members and professional carers due to poor frustration tolerance and heavy reliance on others. A recent survey conducted in NSW found that three years after sustaining severe TBI, 74 per cent of people demonstrated irritability or aggression (Tate, Cameron, Winstanley, Miles & Harris, 2004). This behaviour can range from low level verbal aggression, such as swearing or mild threats, to violence causing physical injury.
Typically, the person with TBI is frustrated by cognitive problems affecting understanding or communication in social contexts. Frustration is cumulative but rarely expressed and so can sometimes seem to be unprovoked. When aggression does occur it is usually presents as a brief and explosive verbal or physical outburst, which quickly dissipates. This population is rarely vindictive, and outbursts are commonly directed towards family members and carers with whom the person is least inhibited, rather than members of the public.
Many people with TBI, particularly young men, are cared for by ageing parents or in families with small children. Aggressive behaviour can be a barrier to the integration of people with TBI into the broader community, leads to breakdowns in relationships, and makes the provision of ongoing care more difficult.
Interventions for people with TBI who are violent and aggressive
There are two basic modes for working with aggressive people with TBI - individual anger management training and behaviour support conducted with families or paid carers.
Individual anger management training has often been based on the stress inoculation training model pioneered by Novaco. This method was developed to be applied to general populations but is commonly adapted for people with TBI. Treatment is modified to take into account cognitive deficits common to TBI, such as problems with memory, attention and awareness. Anger management training aims to assist the individual by identifying trigger situations (e.g., misplacing something) and the early signs of anger (e.g., clenched fists, feeling hot). Once these are identified, the individual receives instruction on reducing the level of arousal and applying an alternative problem-solving approach. Often cognitive therapy techniques are used to identify and challenge maladaptive thoughts.
Behaviour support interventions look at the behaviour in relation to its contingencies - antecedents, consequences, and other associated factors such as cognitive deficits or emotional dysregulation. Key tenets of this approach include: methodical behavioural assessment; monitoring of observable behaviours; training all workers and family members to ensure a consistent approach; applying the techniques throughout the day in all situations; and focusing on building up pro-social behaviours.
The individual anger management and behavioural approaches often go hand-in-hand because the family or carers can help by prompting the individual to use arousal reduction and problem-solving techniques. The behaviour support approach can also be widened to include other people who are involved with the client, such as local shopkeepers, extended family members and even police officers.
There is much support in the literature for the effectiveness of behavioural approaches in reducing violent behaviour. Most of these articles take the form of case studies or small case series demonstrating the effectiveness of specific behavioural techniques. In addition, there is some support for individual anger management approaches, most particularly those using cognitive-therapy techniques (Demark and Gemeinhardt, 2002).
Finding support for people with TBI and their families
Access to psychological support for people with TBI depends on such factors as proximity to rehabilitation centres, the insurance arrangements in various States and the type of services funded. Generally a good point of contact if you need to refer a person with TBI is the Brain Injury Association of Australia http://www.bia.net.au/ and the State branches of the BIA.
Fortune, N. and Wen, X. (1999). The Definition, Incidence and Prevalence of Acquired Brain Injury in Australia. Australian Institute of Health and Welfare, Canberra.
Tate, R., Cameron, I., Winstanley, J., Miles, B. and Harris, R. (2004). Brain Injury Outcomes Study: Final Report. Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney.
Demark, J. and Gemeinhardt, M. (2002). Anger and its Management for Survivors of Acquired Brain Injury, Brain Injury, 16, 91-108.