1.1

Introduction

The psychological or neuropsychiatric disorders, both emotional and behavioral, of traumatic brain injury patients represent one of the major problems in the repercussions phase, effecting 50% to 70% of these patients with serious consequences for their personal, family and the socioprofessional lives . One year after the accident, 40% present more than two psychiatric symptoms . Most of the authors recommend psychotherapy — whether it be individual psychodynamic therapy , individual or group cognitive behavioral therapy (CBT) , or holistic therapy — with the caveat of adapting the technique to the specific disorders of traumatic brain injury patients .

Recently, the authors were also interested in caring for the families and caregivers, who are now included in the information and support programs . These programs can sometimes underestimate the complexity of the individual and family situations. The family neuro-systemic approach, developed by Destaillats et al. and used by other authors , proposes a complex approach to these difficulties, according to three points of view: individual, institutional and family. It calls on semi-direct interviews based on systemic hypotheses, which seems to us particularly appropriate to the situation of these patients and their circles of friends and family.

After several years of training and working in the Handicap and Family service of the Physical Medicine and Rehabilitation (MPR) department of the University Hospital Center of Bordeaux, we tried to widen this approach to include the individual support of ambulatory traumatic brain injury patients. We present, here, the results of a preliminary evaluation for the first 5 years.

1.2

Patients and methods

1.3

Results

1.3.4

Qualitative results

As shown in Fig. 1 , the qualitative analysis highlights a high frequency of psychological disorders before the beginning of the therapy: 46 patients (98%) had at least one psychological disorder and 37 patients (79%) had a behavioral disorder; both types of disorders were associated in 38 cases (81%). Depression (29 cases; 61%) and anxiety (24 cases; 51%) were the most frequent, while bipolarity (9 cases; 19%) and psychosis (3 cases; 6%) were less frequent. The behavioral disorders were distributed in fairly homogeneously: apathy (20 cases; 42%), aggressivity (15 cases; 32%), disinhibition (13 cases; 27%), and addiction (12 cases; 25%).

Qualitative results.

After the therapy, a significant improvement was noted in the psycho-emotional disorders, which disappeared completely for 10 patients ( P < 0.01), while the behavioral disorders disappeared completely only in one case. Among the psycho-emotional disorders, especially depression and anxiety were improved significantly ( P < 0.001), respectively disappearing in 14 patients (48%) and eight patients (33%). Bipolarity and psychosis were not improved significantly. Among the behavioral disorders, only the aggressivity was significantly improved ( P < 0.01) in six patients (40%); apathy, disinhibition and addiction remained unchanged.

1.4

Discussion

For a long time, the psychotherapy for traumatic brain injuries has been dominated by the psychoanalytical approach in France and the cognitive behavioral approach in the Anglo-Saxon countries for cultural reasons. Both approaches are efficient and have demonstrated advantages in clinical studies or case analyses for the institutional sector. Recently, family therapy , especially systemic family psychotherapy , has been recommended in addition to individual psychotherapy. Although implemented for more than 15 years by the Bordeaux team , the family neuro-systemic approach has not been the subject of a published clinical study until now. In addition, while a majority of patients are monitored after they released from the institutions by psychiatrists or psychologists, we found no data in the literature on their results. To the best of our knowledge, this first published study on the psychological follow-up using the neuro-systemic approach with a cohort of ambulatory traumatic brain injury patients.

This study is an exploratory study in which the results must be considered with prudence. First of all, it is a retrospective open study without control group. Even though we tried hard to standardize the semiology with reference to DSM IV, the evolution under treatment remains difficult to evaluate exactly, especially as the psychotherapy context does not permit separating the evaluator from the therapist. There was also probably an interaction between medicine and systemic psychotherapy. There is probably a synergic effect of these parallel therapies, as Soo et al. found in his review of the literature about CBT. Finally, we systematically classified the patients who dropped out of sight and stopping the therapy sessions with the poor results, when the other factors could have intervened with some of the patients. By keeping these limits in mind, the study nevertheless highlights interesting data.

First of all, the good feasibility of this therapy must be underlined, as demonstrated by the relative low rate of patients who dropped out of sight. Considering the cognitive disorders of the patients and the non-institutional character of the psychotherapy, we would have expected a higher rate of abandonment or memory lapses. Another element of satisfaction is the large number of interviews performed per patient: an average of 11 (among which at least one family interview) over a period of 13.5 months. We were afraid a mediocre compliance with this population, considering the cognitive and behavioral disorders.

These results can be explained by a good collaboration with the team of Medical-Social Support Service for Handicapped Adults ( Service d’accompagnement médico-social pour adultes handicapés : SAMSAH), which performs a stellar job for support and assistance, and a good adaptation of the neuro-systemic interview technique for this type of patients. In fact, the semi-direct interviews and their length (45–60 mn), the issues tackled (e.g., disability, emotions, traumatic history, family, sexuality), and the therapist taking cognitive disorders into account were very appreciated, according to numerous spontaneous statements. The cognitive disorders were not a major obstacle to therapy, with the caveat of having identified them correctly and taking them into account in the interviews.

The study’s good global results must be noted, with an improvement of the disorders in 73% of the cases, correlated to number of interviews. This pleads in favor of the therapy’s efficiency, even though it must be taken into account the beneficial effect of the patient’s social focus and the medicine taken during the follow-up period. The best results are obtained for the most handicapped patients. GOS 3 patients (severe handicap) vs. GOS 2 patients (moderate handicap), the most handicapped patients often had a lower level of awareness of the disability and thus lower expectations.

On the qualitative plan, the improvement concerns especially the patients with depression, anxiety and aggressivity. These observations have been already reported by the other authors in a CBT context or, more recently, following music therapy sessions . This sensory approach seems to be interesting and evokes the other techniques with physical mediation, such as the hypnosis or Eye Movement Desensitization and Reprocessing (EMDR). We use regularly EMDR but have not explored this subject with specific studies for the traumatic brain injury patients yet. It is certainly a vast field for exploration in the future.

Despite the lack of statistically significant differences, the role of medicinal treatment has to be taken into account. At the beginning of the therapy, two thirds of the patients had begun, or modified, a treatment of antidepressants or thymo-regulators. Most of the studies summarized in Richard and Ferrapie’s literature review found efficient the medicinal treatment offered for depression, anxiety and aggressivity. However, certain authors found a minimal benefit of medicinal treatments with respect to non-medicinal approaches. Certain behavioral disorders, such as apathy and disinhibition, are not improved by the therapy, probably due to their organic etiology. Similarly, addiction is not very sensitive to the individual therapy, requiring recourse to specialized structures.

The case-by-case analysis of the failures and the patients who dropped out of sight allowed us to identify several causes. The first cause is unmistakably anosognosia, which entails incomprehension of the interest of the psychotherapy, and sometimes blocking the therapist in a context of rationalizing the disorders. In three cases, the patients completely refused to think about their cognitive disorders, generally projecting their difficulties on their family/friends or on the nursing staff. The second cause is the lack of patient motivation; in these cases, the psychotherapy responded to more the demands of the support team, the family circle, or the spouses, than a real demand of the patient. These patients were not anosognosic, but they did not want a psychotherapist to solve their problems. In two cases, the refusal to stop drinking alcohol encountered the same process.

1.5

Conclusion

The results of our study, to be interpreted with the customary methodological precautions, are unmistakably positive, finding a good patient participation and an improvement of the psychological state in two thirds of the cases, correlated to the follow-up time and the number of therapy sessions. Anxiety, depression and aggressivity were improved; apathy, disinhibition and addiction were not improved. Even though there are still points to be improved, such as the failure rates and the patients who dropped out of sight, in our opinion, the individual neuro-systemic approach seems to be appropriate for the psychological support of ambulatory traumatic brain injury patients. Additional research with a control group and a subjective analysis of the quality of life will be studied to better validate this hypothesis.

This study was the subject of a paper in 24th SOFMER Congress in Lyon on 23 October 2009 and obtained the Allergan Sofmer Cofemer prize for “improvement of the quality of life 2009”.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgements

The authors would like thank Jean-Paul Mugnier, Director of the Institute of Systematic Studies, for the quality of his classes and his supervision, and Professor Michel Barat who gave me the taste of the scientific rigor and the meaning of being human.