The adversarial alliance: Developing therapeutic relationships between families and the team in brain injury rehabilitation

Abstract

Families of individuals who have survived brain injuries experience significant distress, and may resist accepting their relative's neurobehavioural deficits. Staff who work with brain-injured patients and their relatives are charged with the seemingly paradoxical task of helping families support rehabilitative efforts and be goal-oriented, while simultaneously communicating often negative realities about prognosis. In the midst of what may be an intermittently conflict-laden relationship, families and staff must become synergistically involved in a therapeutic partnership. This paper defines aspects of this 'adversarial alliance' which is often established between families and staff. The relationship between patient discharge outcome and perceived family stress and satisfaction with the rehabilitation programme was reviewed. Data analyses yielded the following conclusions: families evaluated retrospectively to have been 'highly stressed' were also perceived to experience more conflict with the rehabilitation team; family stress was related to poorer adjustment to the patient's disability (at admission); greater family/team conflict correlated with lower cognitive and physical functioning at admission, longer length of stay, younger patient age, and lower programme satisfaction. Implications for programme development and treatment guidelines are discussed.

“I’m Trying To Be the Safety Net”: Family Protection of Patients With Moderate-To-Severe TBI During the Hospital Stay

“…Healthcare providers must be able to distinguish which family caregiving strategies are being used to prevent family caregivers from being labeled as uncooperative, controlling, or disruptive. Careful assessment from healthcare providers on the occurrence of these protective caregiving strategies will allow healthcare providers to enact adversarial alliance strategies (Family Caregiver Alliance, 2009; McLaughlin & Carey, 1993)The findings that family caregivers work to protect the patient’s safety during the hospital stay emphasize the need for person- and family-centered care (Lor, Crooks, & Tluczek, 2016), which directly relates to guidelines for development of an adversarial alliance, or a therapeutic relationship, between family caregivers and staff (McLaughlin & Carey, 1993; Norcross, 2010). An adversarial alliance is defined as an attempt to develop a collaborative partnership out of an intermittently conflict-laden relationship between family caregivers and healthcare providers (McLaughlin & Carey, 1993).…”

“…Careful assessment from healthcare providers on the occurrence of these protective caregiving strategies will allow healthcare providers to enact adversarial alliance strategies (Family Caregiver Alliance, 2009; McLaughlin & Carey, 1993)The findings that family caregivers work to protect the patient’s safety during the hospital stay emphasize the need for person- and family-centered care (Lor, Crooks, & Tluczek, 2016), which directly relates to guidelines for development of an adversarial alliance, or a therapeutic relationship, between family caregivers and staff (McLaughlin & Carey, 1993; Norcross, 2010). An adversarial alliance is defined as an attempt to develop a collaborative partnership out of an intermittently conflict-laden relationship between family caregivers and healthcare providers (McLaughlin & Carey, 1993). Some attributes of both person- and family- centered care and development of an adversarial alliance relevant to these findings include: 1) inclusion of the person’s and family’s interests and needs in the plan of care; 2) effective communication between person/family and staff; 3) staff having appropriate responses to families who are highly stressed, such as using special outreach efforts; 4) self-awareness; 5) empowerment of the person and family; and 6) viewing the family as a unit of care (Family Caregiver Alliance, 2009; Lor et al, 2016; McLaughlin & Carey, 1993).…”

Health-Related Quality of Life in Caregivers of Individuals With Traumatic Brain Injury: Development of a Conceptual Model

“…14,21,27-32 Furthermore, caregiver burden and stress is also associated with negative outcomes in individuals with TBI including poorer functional ability, poorer cognition, decreased psychosocial well-being, less social integration, poorer work productivity, and poorer adjustment. 24,33-39 …”

A therapist experiential model of treatment for brain injury

“…Other catalysts of the Warning and Danger Zones include tricky or "adversarial" working alliances (McLaughlin & Carey, 1993), often intensified by a myriad of patient factors, including unremitting organic unawareness, poor coping techniques (often pre-and post-injury), entrenched denial and/or resistance, and pervasive unrealism . Patients' premorbid and deep-seated characterological problems (e.g., Axis II Borderline, Narcissistic, and Antisocial Personality Disorders) characterized by poor motivation and integrity; emotional instability; irresponsible and impulsive actions; argumentative or aggressive behavior; grandiosity; and disregard of the rights, feelings, or wishes of others (Hibbard et al, 2000;Judd & Wilson, 2005; are cumbersome challenges and worrisome for the therapist, as these behaviors inevitably interfere with goal setting and achievement.…”