Grief Counseling and Crisis Intervention in Hospital Trauma Units

Abstract

The demand for family counselors implementing crisis intervention and grief counseling in hospital trauma units continues to increase. Thus, this article provides a review of the nature of family counselors working with individuals and families affected by traumatic brain injury (TBI) and medical trauma in hospitals. Specifically, the article presents (a) unique aspects of crisis intervention and grief services provided in hospital trauma units, (b) effective rapport building strategies for family counselors working with families in crisis from TBI, (c) multidisciplinary collaboration in hospitals, (d) diagnostic approaches and common mental health disorders following TBI, (e) ethical issues working in hospitals, (f) family-focused grief therapy and stages of grief interventions, and (g) implications with a case example of a family counselor working with a family affected by TBI.

Keywords

family grief counseling traumatic brain injury grief and bereavement crisis intervention family-focused grief therapy

The Center for Head Injury Services (CHIS, 2012) documented that nearly 1 million children, adolescents, and young adults experience a medical trauma each year. Accordingly, the U.S. Department of Health and Human Services (HHS, 2012) reported that these medical traumas often result in traumatic brain injury (TBI), emerging as one of the most pervasive public health problems and the leading cause of death among children and adolescents. Furthermore, TBI (e.g., mild or severe) typically occurs after a sudden trauma to the brain, resulting from an accident or incidences of physical abuse (Gelber & Callahan, 2004). The various causes of TBI include (a) motor vehicle accidents (e.g., driving under the influence, texting while driving), (b) falls, (c) sharp object intrusion, (d) home accidents (e.g., fatal and nonfatal water-related accidents), and (e) gunshot wounds (DeRoon-Cassini, Mancini, Rusch, & Bonanno, 2010; McKinlay et al., 2008). The most prevalent causes of TBI stem from automobile accidents, slips and falls, or being struck by an object (McKinlay et al., 2008). Apart from the cause, most TBI cases generate impending disabilities and accumulated residual medical conditions (Tester, Kopplin, Creighton, Burke, & Ackerman, 2005). As an illustration, approximately 33% of TBI cases cause at least one evening of inpatient hospitalization, 70–90% of the injuries create mild TBI, and 10% of TBI cases develop into severe injury consequently prolonging a hospital stay (McKinlay et al., 2008). In more extreme situations, the TBI results in death (CHIS, 2012).

TBI and subsequent medical problems create residual psychological, cognitive, and emotional effects within the injured individual and their family members, indicating another public health concern (CHIS, 2012; HHS, 2012). The most common mental health issues include: (a) posttraumatic stress disorder (PTSD) and acute stress disorder (ASD), (b) anxiety, and (c) depression (DeRoon-Cassini et al., 2010; Holmes et al., 2007; Ruo et al., 2003). Thus, this article explores the mental and emotional issues surrounding TBI including prevalence rates, levels of severity, and the contributing factors related to the psychological effects following life-altering traumatic events. Due to the emotional reactions following TBI, family counselors often play an integral role in hospital trauma units as they address emotional issues (Livneh & Antonak, 2005). Moreover, family counselors offer a myriad of pertinent mental health services inclusive of coping skills training, crisis intervention, psychoeducation, and grief counseling (Corney, 1999; Edwards & Patterson, 2006). Crisis intervention and grief counseling for the individual and family system begins during hospitalization (Aitken & Curtis, 2004); especially when TBI leads to successive medical problems or in extreme circumstances, death. Therefore, the need exists for family counselors working in the hospital to assist families experiencing TBI.

For the purpose of family counselors working within counseling standards in hospitals, the International Association of Marriage and Family Counselors (IAMFC) Code of Ethics (Hendricks, Bradley, Southern, Oliver, & Birdsall, 2011) in C1 states, “couple and family counselors have the responsibility to develop and maintain basic skills in couple and family counseling through graduate training, supervision, and consultation … ” (p. 220). Further, IAMFC Code of Ethics (Hendricks et al., 2011) in C2 states, “couple and family counselors familiarize themselves with new developments in the field of couple and family counseling … ” (p. 220). Thus, the primary purpose of this article stands to delineate the family counselor’s role working in hospital trauma units while highlighting their unique responsibilities and new developments in crisis intervention and grief counseling. In addition, the authors focus on the prevalence rates and various types of mental health issues families experience in hospital trauma units following TBI. Next, a literature review exists on family-focused grief therapy (FFGT; Chan, O’Neill, McKenzie, Love, & Kissane, 2004; Kissane et al., 2003) and the stages of grief (Kübler-Ross, 1969; Schneider, 1984). Finally, the article includes implications for family counselors working with families in hospital trauma units including an in-depth case example.

Unique Aspects of Family Counseling Services in Hospital Trauma Units

Counseling services in a hospital trauma unit include (a) individual, group, and family counseling; (b) educational and support services; and (c) case management to provide counseling referrals and resources (Aitken & Curtis, 2004; Chan et al., 2004; Corney, 1999). Most counseling services employ crisis intervention for the individual suffering TBI and for their family affected by the medical trauma. In doing so, family counselors administer short-term, brief therapy approaches due to the fact that individuals and their families often experience a limited hospital stay (Holmes et al., 2007). The short-term, abbreviated services typically include a focus on preventing mental health issues within the family system following the traumatic experience of TBI. Thus, family counselors need to proactively seek out training materials and prepare for the unique work circumstances in hospitals. For example, the family counselor’s individual client often needs airway support and medical sedation following TBI. Therefore, the focus of counseling treatment shifts from the individual to the entire family system (Gearing, Saini, & McNeill, 2007). After accounting for the medical condition, the family counselor conducts an initial assessment and evaluates the mental health status of family members, which provides the family counselor an opportunity to identify problematic psychological distress (Aitken & Curtis, 2004). To illustrate the point, when an individual client arrives to the hospital after a serious TBI accident, the family counselor immediately seeks out the family and begins processing the traumatic experience of their injured loved one (e.g., child, sibling, and family member). Additional examples of unique counseling aspects in the hospital environment include (a) building rapport during grief counseling and crisis intervention, (b) assessing for mental health issues following TBI, (c) multidisciplinary collaboration, (d) decision-making processes, and (e) discharge planning.

Building Rapport With Families During Grief Counseling and Crisis Intervention

Upon initial evaluation, family counselors may need to garnish appropriate protective gear (e.g., gown, face mask, goggles) when the hospital requires specific safety precautions. Consequently, the need exists that family counselors become aware that the gear creates verbal and nonverbal communication barriers and stifles the assessment process (Gearing et al., 2007). In other words, the communication barriers present a challenge in obtaining pertinent information. Once accounted for, the family counselor collects past biological, social, and psychological histories of the individual and family to better understand the purpose for hospitalization and to learn of preexisting mental health concerns (Burns, 2010). The biopsychosocial information provides an understanding into the family’s dynamics and helps to properly address mental and emotional concerns that may arise or become exacerbated due to the TBI diagnosis.

Family counselors encourage an exchange of information with the family system by describing the logistical procedures (e.g., intake, information gathering, paperwork) and explaining the purpose for counseling support services in the hospital following TBI. The reason for a family counselor explaining the aspects of counseling stems from the resistance in speaking about mental health concerns that many families display. Simultaneously, the family counselor needs to gather personal information and complete paperwork while empathizing and validating the individual and family’s need to emotionally process the traumatic event (Nakash, Dargouth, Oddo, Gao, & Alegría, 2009). The initial stages of the counseling process vary in the hospital from alternative settings (Aitken & Curtis, 2004), but the family counselor’s ability to instantly build rapport remains consistent within all types of counseling environments. For example, Rogers (1957) suggested fundamental qualities that a family counselor needs to display including warmth and genuine concern. Within all counseling settings, he stated that appropriate nonverbal and verbal cues such as silence, empathy, reflection, and eye contact strengthen the initial therapeutic bond and promote trust in the counseling relationship. More specific to hospital environments, Sharpley, Jeffrey, and McMah (2006) recommended that the family counselor expresses empathy and portrays a nonjudgmental presence in order to instantaneously generate therapeutic rapport following TBI. Similarly, Sharpley, Munron, and Elly (2005) suggested that the same qualities (e.g., empathy, silence, warmth) used effectively in other counseling environments proved valuable in the development of rapport between family counselors and families in hospital settings. The family counselor must implement these specific rapport-building techniques in order to create a safe, comfortable counseling environment within the hospital setting. Sharpley et al. (2005) found that family counselors (N = 59) who utilize greater amounts of silence and appropriate nonverbal behavior increase their chances of producing a strong counselor–client connection. Empirical support found that silence integrated into the intake and information gathering process provides an opportunity for individuals and families to reflect on their thoughts and emotions about the TBI (Livneh & Antonak, 2005). Next, the family counselor transitions into assessing mental health issues in the family following the rapport building stage of grief counseling in hospitals.

Assessing Mental Health Issues Following TBI

Physicians often lack the training to identify mental health and emotional disorders, indicating the importance of enlisting a family counselor’s expertise to assist in assessment (Aitken & Curtis, 2004). Compared to the medical staff (e.g., physicians, nurses, technicians), family counselors receive advanced training in assessing and working with mental health issues. Thus, family counselors tend to provide competent services in addressing mental health concerns in comparison to medical staff. Consequently, the family counselor focuses on determining any mental health issues and the family counselor substantiates any psychological concerns that surface to best serve individuals and families in the hospital. Schulte, Isley, Link, Shealy, and Winfrey (2004) recommended that collecting biopsychosocial information focuses counseling and treatment based on preexisting mental health issues and the severity of trauma. In order to create a course of treatment for emotional issues, the family counselor must first understand some of the most pervasive mental health issues that families experience following TBI.

The most prevalent psychopathological symptoms and diagnoses following medical trauma and TBI include PTSD, ASD, and depression (DeRoon-Cassini et al., 2010; Medley & Powell, 2010). Pervasive in nature, particular attention focuses on underdiagnosed symptoms of anxiety, denial, shock, anger, and adjustment (Livneh & Antonak, 2005). It becomes critical for the family counselor to be familiar with the frequency and severity of emotional symptoms following TBI and how the chronic nature affects a family’s functioning after TBI (Jotzo & Poets, 2005). Subsequent mental health concerns produced by TBI require that family counselors gain experience in diagnosis and assessment affording them the opportunity to identify problematic behaviors and emotional distress. Appropriate and thorough assessment may lead to a reduction of symptoms during treatment (Frazier et al., 2009). Conclusively, family counselors must be able to effectively build rapport in order to employ grief counseling and to address these prevalent mental health issues with families and to implement counseling services in hospital trauma units.

Multidisciplinary Collaboration and Decision-Making Processes

Another unique aspect to counseling in hospital trauma units includes the myriad of essential hospital staff members (e.g., family counselors, physicians, and nurses) collaborating to improve an individual’s medical condition during their hospital stay. Hospital staff members typically consult with one another in a multidisciplinary fashion while working together during crisis intervention. Schulte et al. (2004) explained the collaborative approach endorses the well-being of family members as it builds a collegial alliance between hospital staff, the family, and the family counselor to maximize continuity of care (Schulte, Isley, Link, Shealy, & Winfrey, 2004). Furthermore, a collaborative approach may increase treatment compliance and amplify the family’s quality of life. For example, staff collaboration while working with families may decrease mental health issues because the teamwork increases the chance of recognizing emotional distress (Aitken & Curtis, 2004).

Moreover, the family counselor offers support during meetings with the family, physicians, head nurses, and other administrators when discussing medical treatment progress and alternative medicinal routes. During this time, Gearing, Saini, and McNeill (2007) recommended that family counselors work as mediators to process information given to the family about an individual’s medical condition. For example, families usually need support during decision-making processes, especially when they learn of declining health conditions or when they need to make difficult decisions concerning continued care. During a decision-making time, the family counselor uses basic counseling skills (e.g., open questions, reflections) to mediate between the family and medical staff and the family counselor expresses any concerns about the mental health issues for family members. For the most part, family counselors do not hold an extensive amount of power in the hospital setting, but their knowledge of family dynamics, decision making, and mental health issues directly affect key decision-making processes for families. Subsequently, the imperative need exists that family counselors remain open and willing to participate in interdisciplinary collaboration and to clearly communicate vital information about the family using their clinical judgment and perception (Aitken & Curtis, 2004; Chan et al., 2004).

Another responsibility in the hospital includes assisting in discharge procedures and reintegrating families back into their current living situations (Aitken & Curtis, 2004; Soskolne, Kaplan, Ben-Shahar, Stranger, & Auslander, 2010). The family counselor first evaluates the family’s needs in order to coordinate a continuum of multidisciplinary care and to ensure a safe discharge of the individual. The family counselor connects families to community resources assisting with the transition from the hospital to the next place of care. Such tasks include referral services to various agencies, day cares, government aid agencies, financial programs, housing, and long-term mental health counseling. Due to the lack of knowledge most families contain about these programs, a higher chance exists that families will seek out these services when the family counselor facilitates the process (Aitken & Curtis, 2004). To illustrate, Soskolne, Kaplan, Ben-Shahar, Stranger, and Auslander (2010) examined families (N = 1,066) participating in referral procedures and found that (a) families discharged with referrals actually received services in the community, (b) participants felt their specific needs were met in the hospital, and (c) families believed that the discharge planning process was sufficient. Therefore, family counselors include the family during the hospital discharge process in hopes to increase an effective transition and continuity of care from hospital to home.

Ethical Issues Working in Hospital Trauma Units

According to the IAMFC Code of Ethics (Hendricks et al., 2011), specific ethical standards address confidentiality and privileged information when offering family counseling. For example, IAMFC Code of Ethics (Hendricks et al., 2011) in B1 states, “couple and family counselors may disclose private information to others under specific circumstances known to the individual client or client family members … ” (p. 219). Further, the IAMFC Code of Ethics (Hendricks et al., 2011) in B3 states, “ … disclose of private information may be mandated by law. For example, states require reporting of suspected abuse of children or other vulnerable populations … ” (p. 219). Family counselors need to inform clients and their families of situations when their confidential information must be released due to the family counselor’s legal obligation of reporting abuse, suicidal thoughts, and homicidal thoughts. Consequently, informing families about a release of information decreases the chance of harming the therapeutic relationship (Brown & Strozier, 2004). In hospital trauma units, the ethical codes ensure quality training and standards of counseling that best serve the interest of clients in regard to confidentiality, privileged information, and prevention of harm (Ponton & Duba, 2009).

The IAMFC Code of Ethics (Hendricks et al., 2011) provides ethical guidelines on respecting privileged information of the client and family. Upholding confidentiality can be difficult though in the hospital when many cases become broadcasted on the local news. For instance, local news stations announce information about a major accident occurring in a local town or city and the family counselor works with the client and family of that breaking news story. Family counselors remain encouraged to seek supervision in the hospital trauma unit when a need exists to report felonious abuse and injury to authorities and supervisors or when a family counselor struggles with issues of confidentiality due to their client becoming a part of a major news story.

Incorporating FFGT and the Stages of Grief

Grief refers to the reaction and distress associated with a major loss and bereavement concerns the state of losing a person to death (Schneider, 1984; Zhang, El-Jawahri, & Prigerson, 2006). Approximately half of family counselors work with individuals and families experiencing death and loss. Therefore, bereavement and grief issues account for at least half of the problems most commonly addressed in counseling (Corney, 1999; Frazier et al., 2009). In hospitals, family counselors work with injured individuals and family members to concentrate on issues of crisis, loss, grief and bereavement, and quality of life (Livneh & Antonak, 2005). Mourning death differs fundamentally from grieving an ambiguous loss, which occurs when the person remains alive but physically and psychologically impaired (Boss, 2010). For families to begin the healing process in the hospital, a family counselor uses appropriate treatment modalities, including psychoeducation on the stages of grief, whether the family grieves an ambiguous loss of their child’s health or if the family mourns the actual death of a child.

FFGT

Family counselors using a systems approach known as FFGT (Kissane & Bloch, 2002) focus on utilizing coping skills, communication, endorsing family strengths, sharing feelings about grief, and maximizing individual and family functioning (Chan et al., 2004; Kissane, Bloch, McKenzie, McDowall, & Nitzan, 1998). Originally, FFGT was created in the early 1990s from the results of several studies on family functioning (e.g., Kissane & Bloch, 2002; Kissane et al., 1996, 1998). A review of these studies provides evidence that the FFGT model remains appropriate for families dealing with grief and bereavement from the death of a loved one.

Initially, Kissane et al. (1996) evaluated adaptive outcomes for 169 families (N = 670) utilizing the FFGT model, measuring variables a total of 3 times within 13 months. Kissane and colleagues found important factors such as cohesiveness, conflict, and expressiveness contribute to adaptability and maladaptive functioning. For example, families exhibiting cohesiveness tended to contain more resiliency in response to the trauma and grief. On the other hand, family conflict often indicated low cohesiveness and expression and high amounts of dysfunction. The results from the study highlight the importance of family counselors recognizing and identifying dysfunctional family patterns versus adaptive behaviors when working with grief and trauma in the hospital.

Almost a decade later, Kissane et al. (2003) evaluated the effectiveness of FFGT as a therapeutic modality used with families and individuals (N = 257) dealing with illness, injury, and bereavement. In the results, Kissane and colleagues found that families receiving FFGT experienced a decrease in their psychosocial concerns; subsequently, an increase in adaptability and coping skills occurred over time. In addition, Chan, O’Neill, McKenzie, Love, and Kissane (2004) evaluated the effectiveness of FFGT with high-risk families (N = 81) coping with medical grief. Chan and colleagues described the FFGT process includes three phases: assessment, intervention, and termination. The concept of building rapport remained consistent across all three phases of counseling (Chan et al., 2004), while the stages varied on other aspects of the counseling process. During assessment, the family counselor determined the family’s major concerns and collected information about the family’s history and family functioning dynamics (Chan et al., 2004; Kissane et al., 1996, 1998). For example, the family counselor promotes self-disclosure through the use of door opening questions (e.g., Tell me more about that. Please, go on.) During the intervention stage, the family counselor reassured the family about their resiliency and addressed key concerns (Chan et al., 2004; Kissane et al., 1998). For instance, the family counselor focuses on adaptive solutions while highlighting the pain of experiencing grief. During the termination stage, the family counselor focused on reassurance and terminating therapy.

Kissane, Bloch, McKenzie, McDowall, and Nitzan (1998) suggested FFGT lasts approximately 6–8 sessions. However, the duration and frequency of counseling depends on the specific needs of the family and the counseling environment (Chan et al., 2004). Ultimately, family counselors using FFGT provide a way to address and normalize the emotional process of losing a healthy child or grieving the death of a loved one while addressing poor coping skills, irrational beliefs, and barriers to psychosocial adaptation. Among the irrational beliefs that families hold following TBI, specific challenges and psychological responses occur after trauma. For example, Haverkamp (1994) suggested that when families face negative circumstances, individual family members appeared to naturally search for an explanation or a reason. Ross (1977) indicated that the search for reasoning influences a phenomenon known as fundamental attribution error (i.e., falsely blaming oneself for the cause of a negative experience). Fundamental attribution error usually transpires in order to justify the reasoning for an unfortunate circumstance and often leaves family counselors with the responsibility to help individuals and families understand the reality of the situation (Haverkamp, 1994; Ross, 1977). For example, a family may fault their parenting skills and discipline style for a car accident rather than attributing the environmental factors (e.g., slippery roads) that played a major role in the acquisition of a TBI. Adversely, the family minimizes external and situational factors that contribute to the cause of events and attribute internal characteristics (e.g., parenting style, lack of focus on children) to the causality of TBI or death. Thus, family counselors learn to assist families in exploring their engrained core values, views of personal responsibility, and worldviews that contribute to their possible faulty beliefs surrounding the TBI. Family counselors also need to discuss the concept of grief, bereavement, and loss to family members to prepare them for the mental health issues that comorbidly exist with the stages of grief.

Stages of Grief and Bereavement

As mentioned previously, family counselors incorporate psychoeducation with families when experiencing grief, whether they lose a child or the health of a child. Kübler-Ross (1969) created one of the first grief models in a five-stage series. Additionally, Schneider (1984) described a seven-stage model of grief and bereavement. The following integrated, five-stage grief model (Kübler-Ross, 1969; Schneider, 1984) describes the major concerns a family often experiences when dealing with ambiguous loss or death. The first phase includes an initial awareness and denial. The initial awareness occurs when reality sets in and the person experiences a definable, concrete loss accompanied by psychological characteristics such as “shock, alarm, and disbelief reactions to the initial awareness of loss” (Schneider, 1984, p. 83). The disbelief, shock, and numbness stem from the fact that their loved one will not be able to do certain activities (Kübler-Ross, 1969). For example, the family member disbelieves that the deceased person will not be present at school, at home, or at work.

The second phase includes strategies to overcome loss inclusive of anger, bargaining, and resentment. The strategies phase includes the development of defense mechanisms as the person battles between holding on and letting go. The defense mechanisms may become more prevalent in the presence of anticipating grief and ambiguous loss (Schneider, 1984). Anger, emotional rage, blame, and resentment become defense mechanisms as well a form of negotiation, known as bargaining (Kübler-Ross, 1969). For example, a person believes they played some part in their loved one’s injury or death. The individual falsely assumes that they had power to prevent the event from occurring. The bargaining typically resembles an overburden of responsibility or blame related to the situation (Kübler-Ross, 1969).

The third phase, awareness of loss, “is the extensive and intensive exploration of the extent of the loss and its immediate present implications (e.g., loneliness, helplessness, exhaustion)” (Frears & Schneider, 1981, p. 342). Emotional symptoms similar to sadness and emptiness accrue and deepen in response to the event (Kübler-Ross, 1969). Family counselors normalize and validate these feelings as a part of the grief process that leads to healing. The fourth phase, gaining perspective on loss, occurs when a family member’s energy spent toward the grief and bereavement becomes free. The three functions of this stage include healing, acceptance, and resolution. During the fourth phase, a family member begins to recognize their capabilities to pull through this difficult experience (Kübler-Ross, 1969). Family members recognize their capability to face and accept the reality of losing their loved one.

The final phase, resolving and reformulating the loss, includes “the individuals opportunity to detach themselves from those aspects of their lives that are now over” (Schneider, 1984, p. 72). During the phase, a sense of personal empowerment arises in areas where balance and energy disappeared due to focusing on the bereaved loved one. For example, a person may participate in new activities of personal enjoyment because time and energy are no longer directed toward grieving the bereavement (Schneider, 1984).

Case Example

Tommy, an 8-year-old male, enters the emergency room at a local children’s Level-1 trauma hospital with major injuries, including severe TBI, following a major motor vehicle accident. Tommy and his family were riding in the car down a major interstate when a driver, under the influence of substances, slammed into the car on the passenger side where Tommy was sitting. Despite Tommy wearing his seatbelt, he sustained massive head injuries and trauma to the spinal cord. More specifically, the severe spinal cord injury resulted in complete severance of the spinal cord and he needs ventilator breathing support due to the TBI he sustained.

Upon arrival to the hospital, the family counselor intercepted the family (e.g., two parents and one sibling) and brought them into a small office to discuss the accident and to assess the family for any mental health concerns. The family counselor considers Tommy as the identified client even though he remains physically unable to receive counseling services due to airway support and medicine sedation restricting his functioning. Thus, the family counselor assigned to this case will work directly with his family throughout hospitalization since Tommy remains incapacitated.

The family counselor completes a family intake using the FFGT model (Kissane et al., 2003), which included assessing information about Tommy (e.g., Did Tommy reach developmental milestones within normal range? Does Tommy have any siblings?), mental health issues about the client (e.g., Does Tommy have any preexisting mental health issues such as depression, anxiety, attention deficit disorder/attention deficit hyperactivity disorder, oppositional defiance disorder?), and mental health issues about the family (e.g., Has anyone on either side of the family received diagnosed of any mental health issues? If so, what are the diagnoses and is the family member currently taking medication? What coping skills does each family member have in place? How well would you rate his or her coping skills?). The family counselor collected information pertinent to assessing for the mental health effects from TBI since mental health symptoms often exacerbate in the face of trauma and grief.

Through the assessment, the family counselor learned that Tommy’s mother has a preexisting bipolar disorder diagnosis, most recent episode including depression, and that Tommy’s father struggles with anxiety symptoms (e.g., racing thoughts). The family counselor used empathy and reflection skills to build rapport during this time of crises. Additionally, the family counselor ensured that they understand the importance of self-care during this traumatic event, especially with preexisting mental health concerns present. Finally, the family counselor began using psychoeducation to describe the process of grief since the doctors determined that Tommy would sustain moderate TBI, if he were able to live through the current TBI altogether. The family counselor explained the five stages of grief (Kübler-Ross, 1969; Schneider, 1984) that they may transition through over time. The family counselor worked within the FFGT model for a week beginning with the initial assessment phase, through the treatment stage, and into termination.

Throughout this time, the family counselor focused on normalizing the grief and highlighted positive coping strategies. One of the greatest challenges was the attribution error when Tommy’s mother consistently blamed herself for the accident since she was driving and arguing with Tommy at the same time. She tended to blame her parenting skills, or lack thereof, rather than focusing on the drunk driver who created the accident. Working within the FFGT model, the family counselor addressed the irrational beliefs and taught Tommy’s mother how to challenge these negative, faulty beliefs when she feels sad. The family counselor continued to normalize her grief as well.

After a week passed, the family appeared distraught and devastated by Tommy’s lack of physical progress. The doctors suggested that all medical staff meet with the family to make a decision about discontinuing life support. In collaboration with the family’s counselor, the team of doctors began discussing the sensitive nature of Tommy’s declining health. The team of doctors working with Tommy and his family disclose that he will not be able to breathe on his own and the doctors report that the spinal cord injury is too severe for repair. The doctors have also proceeded to pronounce him brain dead. Throughout the meeting, the family counselor intervened when the family members became emotional from hearing the doctors discuss Tommy’s physical state. The family counselor used empathy (i.e., warmth and eye contact) and reflection skills (e.g., I can see that you feel devastated by hearing this news) in an effort to create an emotionally safe space for the family to grieve. As the meetings ends, the family counselor continued to meet with the family to specifically address the mother and the father’s predispositions to mental health issues. The family counselor continued working within the FFGT model and reminded the parents of specific coping skills (e.g., deep breathing, challenging irrational beliefs) to use as they process and work through their grief. The family counselor and the family processed the family strengths such as support and love between each other to further promote positive coping.

While working on the case, the family counselor did not need to report the accident and the family counselor did not have to break confidentiality. However, they experienced the unique ethical dilemma that many family counselors working in hospitals encounter. She received phone calls from friends and engaged in conversations with her own family members about the major accident that severely injured a child. The friends attempted to discuss the case with the family counselor, but the family counselor remained bound by the IAMFC Code of Ethics (Hendricks et al., 2011) to avoid disclosing any information about the case. The family counselor responded with various statements that did not confirm or deny working with Tommy (e.g., You know, I am unable to discuss whether this child is my client or not.) and mentioned confidentiality in general (e.g., Either way, I would not be able to discuss any details about any client that I meet with in the hospital due to confidentiality.).

Conclusion

As a result of TBI, the counseling process begins in the hospital trauma unit, and treatment focuses on the injured individual as well as the family system. Therefore, family counselors must be trained to provide counseling services for families in order to decrease the possibility of psychological impairment and residual mental health problems because of TBI. TBI may create emotional, social, and psychological distress because of the disabilities and traumatic experiences sustained (DeRoon-Cassini et al., 2010; Holmes et al., 2007; Medley & Powell, 2010; Ruo et al., 2003). The family counselor’s role immediately focuses on offering grief counseling and crisis intervention as a preventative method of treatment. A focus on the delineation of the counseling process in hospital trauma units serves as an informational guide for family counselors; illuminating the implications of counseling families affected by TBI and the specific challenges that may arise. This snapshot of how family counselors may negotiate the counseling process within hospitals provides critical information for family counselors working with TBI individuals and their families.

Due to increasing numbers of TBI (HHS, 2012), a crucial need exists that family counselors understand the physical and psychological effects of TBI on individuals and family systems (McKinlay et al., 2008). Family counselors must recognize the practical counseling implications (i.e., effective techniques and interventions) that will serve an individual and their family’s best interests. Training must focus on specific challenges that family counselors may encounter while providing family counselor services in hospital trauma units. Future research must continue to evaluate early counseling intervention in trauma units and at the beginning of hospitalization in order to validate the effectiveness of specific interventions. Further research exploring the role of family counselors in hospitals is needed and will help enhance specific supervision techniques as well as endorse the use of ethical practices when working with TBI individuals and their families.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Aitken

J. B.

Curtis

(2004). Integrated health care: Improving individual care while providing opportunities for mental health counselors. Journal of Mental Health Counseling, 26, 321–331.

Boss

(2010). The trauma and complicated grief of ambiguous loss. Pastoral Psychology, 59, 137–145. doi:10.1007/s11089-009-0264-0

Brown

Strozier

(2004). Resisting abuse at what cost? The impact of mandated reporting laws on the process and content of therapy. Contemporary Family Therapy: An International Journal, 26, 45–60. doi:10.1023/B: COFT.0000016911.48414.7d

Burns

(2010). Counseling adult individuals experiencing chronic pain. Journal of Counseling & Development, 88, 483–490.

Chan

E. K. H.

O’Neill

McKenzie

Love

Kissane

D. W.

(2004). What works for therapists conducting family meetings: Treatment integrity in family-focused grief therapy during palliative care and bereavement. Journal of Pain & Symptom Management, 27, 502–512. doi:10.1016/j.jpainsymman.2003.10.008

Corney

(1999). Mental health services in primary care: The overlap in professional roles. Journal of Mental Health, 8, 187–194.

DeRoon-Cassini

Mancini

A. D.

Rusch

M. D.

Bonanno

G. A.

(2010). Psychopathology and resilience following traumatic injury: A latent growth mixture model analysis. Rehabilitation Psychology, 55, 1–11. doi:10.1037/a0018601

Edwards

Patterson

(2006). Supervising family therapy trainees in primary care medical settings: Context matters. Journal of Marital and Family Therapy, 32, 33–43.

Frazier

Tennen

Gavian

Park

Tomich

Tashiro

(2009). Does self-reported growth posttraumatic growth reflect genuine positive change? Psychological Science: Research, Theory, & Application in Psychology Related Sciences, 20, 912–919.

10.

Frears

L. H.

Schneider

J. M.

(1981). Exploring loss and grief within a holistic framework. The Personnel and Guidance Journal, 59, 341–345.

11.

Gearing

R. E.

Saini

McNeill

(2007). Experiences and implications of social workers practicing in a pediatric hospital environment affected by SARS. Health & Social Work, 32, 17–27.

12.

Gelber

D. A.

Callahan

C. D.

(2004). The neurologic examination of the patient with traumatic brain injury. In Ashley

M. J.

(Ed.), Traumatic brain injury: Rehabilitative treatment and case management (2nd ed., pp. 3–26). Boca Raton, FL: CRC Press.

13.

Haverkamp

B. E.

(1994). Cognitive bias in the assessment phase of the counseling process. Journal of Employment Counseling, 31, 155–167.

14.

Hendricks

B. E.

Bradley

L. J.

Southern

Oliver

Birdsall

(2011). Ethical code for the International Association of Marriage and Family Counselors. The Family Journal, 19, 217–224. doi:10.1177/1066480711400814

15.

Holmes

Hodgins

Adey

Menzel

Danne

Kossmann

Judd

(2007). Trial of interpersonal counseling after major physical trauma. Australian & New Zealand Journal of Psychiatry, 41, 926–933. doi:10.1080/00048670701634945

16.

Jotzo

Poets

C. F.

(2005). Helping parents cope with the trauma of premature birth: An evaluation of a trauma-preventive psychological intervention. Pediatrics, 115, 915–919. doi:10.1542/peds.2004-0370

17.

Kissane

D. W.

Bloch

(2002). Family focused grief therapy: A model of family-centered palliative care and bereavement (facing death). Philadelphia, PA: Open University Press.

18.

Kissane

D. W.

Bloch

Dowe

D. L.

Snyder

R. D.

Onghena

McKenzie

D. P.

Wallace

C. S.

(1996). The Melbourne Family Grief Study, I: Perceptions of family functioning in bereavement. The American Journal of Psychiatry, 153, 650–658.

19.

Kissane

D. W.

Bloch

McKenzie

McDowall

A. C.

Nitzan

(1998). Family grief therapy: A preliminary account of a new model to promote healthy family functioning during palliative care and bereavement. Psycho-Oncology, 7, 14–25. doi:10.1002/(SICI)1099-1611(199801/02)7:1<14:: AID-PON313>3.0.CO;2-D

20.

Kissane

D. W.

McKenzie

D. P.

Forbes

O’Neill

Bloch

(2003). Psychosocial morbidity associated with patterns of family functioning in palliative care: Baseline data from the family focused grief therapy controlled trial. Palliative Medicine, 17, 527. doi:10.1191/0269216303pm808oa

21.

Kübler-Ross

(1969). On death and dying. New York, NY: Touchstone.

22.

Livneh

Antonak

R. F.

(2005). Psychosocial adaptation to chronic illness and disability: A primer for counselors. Journal of Counseling & Development, 83, 12–20.

23.

McKinlay

Grace

R. C.

Horwood

L. J.

Fergusson

D. M.

Ridder

E. M.

MacFarlane

M. R.

(2008). Prevalence of traumatic brain injury among children, adolescents and young adults: Prospective evidence from a birth cohort. Brain Injury, 22, 175–181. doi:10.1080/02699050801888824

24.

Medley

A. R.

Powell

(2010). Motivational interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review. Neuropsychological Rehabilitation, 20, 481–508. doi:10.1080/09602010903529610

25.

Nakash

Dargouth

Oddo

Gao

Alegría

(2009). Patient initiation of information: Exploring its role during the mental health intake visit. Patient Education and Counseling, 75, 220–226. doi:10.1016/j.pec.2008.10.010

26.

Ponton

R. F.

Duba

J. D.

(2009). The “ACA code of ethics:” Articulating counseling’s professional covenant. Journal of Counseling & Development, 87, 117–121.

27.

Rogers

C. R.

(1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. doi:10.1037/h0045357.

28.

Ross

(1977). The intuitive psychologist and his shortcomings: Distortions in the attribution process. In Berkowitz

(Ed.), Advances in experimental social psychology (vol. 10). New York, NY: Academic Press.

29.

Ruo

Rumsfeld

J. S.

Hlatky

M. K.

Liu

Browner

W. S.

Whooley

M. A.

(2003). Depressive symptoms and health-related quality of life: The heart and soul study. JAMA: Journal of the American Medical Association, 290, 215–221. doi:10.1001/jama.290.2.215

30.

Schneider

(1984). Stress, loss, and grief. Rockville, MD: Aspen Systems Corporation.

31.

Schulte

T. J.

Isley

Link

Shealy

C. N.

Winfrey

L. L.

(2004). General practice, primary care, and health service psychology: Concepts, competencies, and the combined-integrated model. Journal of Clinical Psychology, 60, 1011–1025.

32.

Sharpley

C. F.

Jeffrey

A. M.

Mcmah

(2006). Counsellor facial expression and individual-perceived rapport. Counseling Psychology Quarterly, 19, 343–356. doi:10.1080/09515070601058706

33.

Sharpley

C. F.

Munro

D. M.

Elly

M. J.

(2005). Silence and rapport during initial interviews. Counseling Psychology Quarterly, 18, 149–159. doi:10.1080/09515070500142189

34.

Soskolne

Kaplan

Ben-Shahar

Stanger

Auslander

G. K.

(2010). Social work discharge planning in acute care hospitals in Israel: Individuals’ evaluation of the discharge planning process and adequacy. Research on Social Work Practice, 20, 368–379.

35.

Tester

D. J.

Kopplin

L. J.

Creighton

Burke

A. P.

Ackerman

M. J.

(2005). Pathogenesis of unexplained drowning: New insights from a molecular autopsy. Mayo Clinic Proceedings, 80, 596–600.

36.

The Center for Head Injury Services. (2012). Brain injury statistics [data file]. Retrieved from http://www.headinjuryctr-stl.org/

37.

U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Neurological Disorders and Stroke. (2012). NINDS traumatic brain injury information page [data file]. Retrieved from http://www.ninds.nih.gov/disorders/tbi/tbi.htm

38.

Zhang

El-Jawahri

Prigerson

H. G.

(2006) Update on bereavement research: Evidence-based guidelines for the diagnosis and treatment of complicated bereavement. Journal of Palliative Medicine, 9, 1188–1203. doi:10.1089/jpm.2006.9.1188