Couples Therapy Following Aphasia & Acquired Brain Injury
Dr Giles Yeates
Community Head Injury Service, Aylesbury
Giles.Yeates@buckspct.nhs.uk
Reflecting on Our Own Aphasia within Our
Relationships
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In Our Intimate Relationships:
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In Our Therapeutic Relationships:
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When it no longer feels worthwhile to say more, to try to reach out and
reconnect, hopelessness
When it doesn’t feel safe to try and risk reconnecting, for fear of getting it
wrong again
When communication with clients with aphasia feels so effortful, against
the odds, that meaningful conversations are not attempted
In Our Professional Team Communications:
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When therapeutic opportunities are not explored in team thinking-throughconversation, due to assumptions of clients’ ability
The Elephant in the Room in NeuroRehab sessions….
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Loss of empathic connection between survivors of brain injury and
those around them
Withdrawal, disconnection, and/or intrusion, insensitivity
A distressing priority for relatives, mostly likely resulting in resigned,
impotent responses by clinicians
Juxtapose the need for an ‘interdependence’ rehab goal in contrast to
typical goals for independence
Aphasia as Identity &
Relationship Theft
Aphasia & Couples
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Aphasia as Identity Theft (Shadden, 2005 )
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Robbing cherished selves from partners
This loss disturbing sense of self in non-injured
partner (Yeates, 2013)
Sabat & Harré (1992) Discourse analysis of
interactional loss of social self following dementia
language difficulties
Aphasia & Couples Outcomes:
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Association between post-stroke aphasia and marital
satisfaction of partner, the latter lower than wives of
non-aphasic stroke survivors (Łapkiewicz et al.,
2008; Williams, 1993; Williams & Freer, 1986)
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But mixed evidence on association between aphasia
severity and marital satisfaction
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Wives’ perception of aphasia severity a key
moderator, related to level of nurturance provided &
independent of survivor communication
performance (Buxbaum, 1967)
Difficulties in Social Cognition/Pragmatic
Communication & Couples Relationships
(Yeates, 2013)
Perspectival Intersubjective
Space: Predicting/Decoding the
mental states of others & appreciating
different perspectives….
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Works in tandem with attunement
process
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Depends on network of medial frontal
cortex, posterior superior temporal
sulcus and temporal pole/?amygdala
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Theory of Mind/Mentalising &
Perspective-Taking Deficits post
injury (e.g., Frith, 2006 ; Rowe et al., 2001; Samson et
al., 2007)
“We-centric Intersubjective Space”:
Aligning/attuning to others’ affective states
•
• Emotion Recognition & Affective Communication:
• Simulation, Resonance or Contagion?
• Involvement of anterior cingulate, amygdala, insula &
somatosensory cortex
• Emotion recognition & experiential deficits post injury:
Fear, Anger & Disgust (see review by Goldman & Sripada, 2005)
Closing the social loop through
appropriate responding….
- Mainly involves orbito- and medial frontal cortex, also insula,
amygdala & temporal poles, damage to which results in:
- Accessing social knowledge (Channon & Crawford, 2000)
- Making social judgements & using social norms (Milders et al., 2003)
- Social Proxemics (Morris et al., 2007)
- Social Reasoning (Stone et al., 2002)
- Social problem solving (Grafman et al., 1996)
- Affect
regulation (Burgess & Wood, 1990)
- Interoceptive-based decision making (Bechara et al., 1994; Damasio, 1994)
Social Cognition Predictors of Couple Relationship Functioning
(preliminary findings, n= 55)
Survivor Neuropsychology
Partner Psychosocial
Variables
Happiness Recognition
TASIT EET Happy
Mentalising
Mind in Eyes
Identification of Social
Rule Violations
Partner -Rated Relationship Variables
.334
+
-
.272
Carer Strain
DAS Total
-
.342
Physical Intimacy
CSI
-
Dyadic Adjustment
DAS AE
+ .219
Soc Sit Violations
Demand-Withdraw
Interactional Pattern
Comm Q D-W
Emotion Recognition
TASIT EET
+
.152
Cohesion of Relationship
DAS COH
How to Help? A Case for A Relational
Approach to Aphasia Rehabilitation
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‘Skull Seduction’ after ABI (Yeates, 2007; 2011):
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Clinicians can perpetuate partition of clients & relatives in the
literature by seeing couple separately, focusing mostly on
survivor
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Acting exclusively as brain injury experts can perpetuate the
focus on the damaged brain as a repository of all problems
and only where the recovery takes place, limits the family’s
options for change together
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Skye McDonald (2000): call of “let’s get social” in
aphasiology, situated within relationships and social context
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….& fetishising independence & autonomy
Feeling versus thinking in Romantic Love: An
opportunity in the heat of emotion?
(Bartels &
Zeki, 2004)
Emotionally-Focused Couples
Therapy (EFT)
Core EFT Formulation
Attachment Rupture
Protest, Pursuing
Abandonment:
Anger/Anxiety
Distancing, Withdrawing
Criticised, Rejected,
Confusion
Anger/Anxiety/
Hopelessness
Stages in EFT
The process of change in EFT has been delineated in nine treatment steps:  Cycle De-escalation
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Changing Interactional Positions.
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Step 1. Assessment-creating an alliance and explicating the core issues in the
couple’s conflict using an attachment perspective.
Step 2. Identifying the problem interactional cycle that maintains attachment
insecurity and relationship distress.
Step 3. Accessing the unacknowledged emotions underlying interactional
positions.
Step 4. Reframing the problem in terms of the cycle, the underlying emotions,
and attachment needs.
Step 5. Promoting identification with disowned needs and aspects of self and
integrating these into relationship interactions.
Step 6. Promoting acceptance of the partner’s new construction of experience in
the relationship and new responses.
Step 7. Facilitating the expression of specific needs and wants and creating
emotional engagement.
Consolidation/ Integration.
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Step 8. Facilitating the emergence of new solutions to old problematic
relationship issues.
Step 9. Consolidating new positions and new cycles of attachment behavior.
EFT following ABI
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Anecdotal case reports:
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TBI: Chawla & Kafescioglu, 2012
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Stroke - Stiell, Naaman & Lee, 2007; Stiell & Gailey,
2011
Single case quantitative systematic evaluations
(Yeates et al., 2013)
Couples Intervention:
Reduce Partner Withdrawal, Amplification of Social Cues &
Triggering Pro-Social Autonomic Response of Survivor
EFT & Aphasia = first EFT paper in
neuro literature
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Stiell & Gailey (2011): More recent book chapter
expanding practice with aphasia
Kathy Stiell, Director of Family Support
Kathy is the co-founder of the Aphasia Centre of
Ottawa and Director of Family Support. She has a
Masters of Social Work from McGill
University(1980) and is registered with the Ontario
College of Certified Social Workers. Kathy is a
clinical member of the Ontario Association of
Marriage and Family Therapists and a certified
therapist and supervisor in Emotionally Focused
Therapy. She has provided leadership in making
individual, couple and family counselling
accessible to people living with aphasia
Following Aphasia…
Attachment Rupture
Survivor: Imposed Withdrawal
- Criticised, Rejected
- Confusion
- Anger/Frustration/Anxiet/
Hopelessness
Partner: Progressive Withdrawal
- Loss of confidence in abilities
- Ignored by survivor-focused rehab
- Unacknowledged experience
-Abandonment: Anger/Anxiety
EFT & Aphasia (1): Creation of A
Communication Platform
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Use facilitative communication strategies,
technology and compensatory cognitive
strategies to enable functional communication of
content
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But essential provide an emotionally-safe
attachment base in the therapy room to:
allow survivor and partner to risk reaching out
 enable mutual understanding
 try again where previously failed and hurt
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Example from Stiell & Gailey (2011)
Jane
Roger
Laura
EFT & Aphasia (2): Supporting Pro-Nurturing
Couples Interactions
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Externalising aphasia as a thief and intruder into
the relationship, a common adversary of the
couple (Shadden, 2005; White & Epston, 1990)
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RISSSC (Johnson, 2004): Repeat, Imagery, Soft, Slow,
Simple, Client’s Words
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In-Session Enactments: reaching from
vulnerability
Deconstructing survivor’s anger and partner’s feeling of rejection
Roger
Jane
Levels
of Joy
“This dialogue was a turning point for Jane and helped her moved out of a withdrawn
position in the cycle. She was able to share her underlying fear of being a failure as a
caregiver. This fear became acute when she could not make Roger happy and she
wondered if they would ever be happy again as a couple.
Recognising Roger’s inability to initiate conversations both therapists actively led him
in giving feedback that direct addressed her attachment needs. Skillfully the two
therapists worked together to facilitate a new conversation for the couple by
tentatively suggesting that Roger could actively talked to Jane about sadness. The
therapists encouraged Roger that it may not be so scary to reach for Jane and that he
might not need to get so angry especially when he realised it pushed her away….
Jane’s ability to be in touch with Roger’s sadness restored her felt connection.”
Conclusions:
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Interdependence is a legitimate rehab goal, desired by many
survivors and partners
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Aphasia is not only a change in the communication potential for
survivors, but potentially also a change to the very fabric of
intimate interactions and selves of both survivors and partners
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This change is characterised by a loss of emotional safety,
closeness and increased mutual withdrawal
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As clinicians we can support couples through opportunities to
re-connect with support, using communication platforms to
foster exchange of communication content and emotional
security to reach out to one another
Further Reading:
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Bowen, C., Yeates, G. N., & Palmer,S. (2010) A Relational Approach to
Rehabilitation: Thinking about Relationships after Brain Injury. London: Karnac.
Johnson, S. (2004). The Practice of Emotionally-Focused Couples Therapy. London:
Routledge
Shadden, B. (2005). Aphasia as identity theft: Theory and practice. Aphasiology,
19: 211-223.
Stiell, K. & Gailey, G. (2011). Emotionally focused therapy for couples living
with aphasia. In J.L., Furrow, S.M. Johnson & B.A. Bradley (Eds.), The
Emotionally Focused Casebook (pp.113-140). New York, NY: Routledge.
Yeates, G.N. (2013). Towards the neuropsychological foundations for couples
therapy following acquired brain injury (ABI): A review of empirical evidence
and relevant concepts. Neuro-Disability & Psychotherapy, 1(1), 117- 150.
Yeates, G.N., Edwards, A., Murray, C. & Creamer, N. (2013). Couples
therapy as social cognition intervention following acquired brain injury: Single
case evaluations of emotionally-focused couples therapy (EFT). NeuroDisability & Psychotherapy 1(2), 151-194.
www.iceeft.com (for Italian & international training)