Implications

The study’s findings have some important implications for clinical practice as well as for the agencies involved in providing support for families affected by TBI. According to the stress, appraisal, and coping theory, coping strategies can interact with emotions and as seen in this study have a potential influence on psychological distress and QoL of the caregiver. This in turn can possibly affect the well-being of the TBI individual and the entire family. Professionals need to assess the coping skills used by the caregivers as the findings showed that some were associated with higher levels of depression and anxiety. As emotion-focused coping, especially escape-avoidance coping was related to higher levels of psychological distress, the use of alternative coping skills and a more problem-focused approach needs to be encouraged. It is also important to identify the coping strategies that are unrelated to adverse outcomes in individual caregivers, in order to educate them about alternative ways of coping. Using the stress, appraisal, and coping model interventions could be designed to teach TBI caregivers appropriate coping skills aimed specifically at dealing with stressful situation related to TBI caregiving, resulting in caregivers being able to appraise those situations as more controllable and increasing the chances of more beneficial outcomes. One example would be educating caregivers about the use of escape-avoidance coping. They would learn that this coping option can assist them in getting a short-term reprieve from stress in order to have some “time out”, but also alerts them of the potential negative effects of using this strategy for an extended period of time. Interventions need to consider the long-term effects of caregiving and that coping strategies may change over time, depending on situations and the appraisal of those. However, as the correlations between coping, psychological distress, and QoL were mostly weak, there is a possibility that the use of specific coping strategies does not have a strong impact on the outcome.

Clinicians and service providers need to be aware of the difficulties caregivers experience and that the main focus needs to be on the prevention or treatment of psychological distress. Considering that one third of the caregivers experienced significant symptoms of psychological distress, their emotional well-being needs to be assessed as this can have an impact not only on the individual but also on the person

120 they are caring for as the well-being of both can influence each other (Chronister & Chan, 2006). In addition, the finding that depression and anxiety were related to lower physical, psychological, social, and environmental QoL adds to the urgency to address psychological distress. Caregivers need to be targeted early in the caregiving process in order to identify distress and prevent it from becoming a serious mental health issue.

The finding that seeking social support was related to higher anxiety and that social QoL was the domain with the lowest score, suggests that caregivers did not receive either the amount or quality of support they were looking for. They should therefore be encouraged to not only ask for support when needed, but to also give feedback if the amount and quality of support meets their requirements. It is important to provide them with the necessary information in order to care for their loved one, support them emotionally, and facilitate accessibility to services. It would also be of benefit to encourage caregivers to maintain a large social network. This would be useful to not only provide support but also to decrease the necessity of relying on few people for this. In addition, adult day care if appropriate for the TBI individual and respite for caregivers to reduce strain and enable leisure activities and social contact, need to be made available.

As physical health was a concern for many participants and physical QoL was lower than in the general public, information about the importance of self-care needs to be given. Health professionals involved in caring for TBI families need to be aware of a possible reluctance by caregivers to ask for help and would be advised to inquire not only about mental but also physical health.

Finally, cognitive therapy, which aims to address a person’s appraisal of events or beliefs about events, could be beneficial in targeting a caregiver’s appraisal of a stressful situation as threatening or uncontrollable (Matthews & Wells, 1996). Cognitive reframing and cognitive restructuring have been found to be beneficial in reducing caregiver stress (Minnes et al., 2000).

Overall, it is important to provide information early on and to support families in dealing not only with the emotions related to traumatic injury, but also give them practical advice and information in addressing TBI related problems that occur. This should start ideally in the hospital and continue during the rehabilitation phase, therefore assisting caregivers in adjusting to the changes. The content of any interventions should integrate all factors in order to be effective. However, they should

121 not only increase caregivers’ knowledge but also focus on improving outcomes such as psychological distress and QoL.