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

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.