Traumatic brain injury (TBI) represents a significant public health concern in Australia and the United States. TBI can compromise cognitive, physical, and psychosocial function and limit the ability to live independently, maintain employment, and sustain relationships. (Degeneffe, 2019). As wealthy and industrialized countries, Australia (e.g., Parliament of Australia, 2020) and the United States (e.g., Friedman & VanPuymbrouck, 2018) provide a range of public funding and services to address these challenges.
In the civilian population, it is well documented in Australia and the United States that family members of persons with TBI provide an extensive array of caregiving supports. For example, Bursnall, Kendall, and Degeneffe (Reference Bursnall, Kendall and Degeneffe2018) reported analyses of interviews with 20 child and adolescent siblings of persons with acquired brain injury (ABI). In an attempt to regain a sense of equilibrium, participants sometimes played the role of a “surrogate parent” by protecting, monitoring, and including their brothers or sisters with ABI in their social networks. In the United States, Degeneffe and Burcham (Reference Degeneffe and Burcham2008) found in a sample of 233 adult siblings of persons with TBI, that participants provided both instrumental (e.g., handling finances) and affective (e.g., companionship) forms of care.
Historically, the literature suggests families provide care out of family obligation as well as a necessity in the face of insufficient public services (Degeneffe, Reference Degeneffe2001). Research over the past 40 years in Australia and the United States consistently shows that family caregivers endorse a variety of needs in response to the multifaceted challenges and burdens of providing care. For instance, Bellon et al. (Reference Bellon, Crocker, Farnden, Gardner, Sando and Peterson2015) reported counseling and emotional support were elevated areas of need of persons with TBI and their family caregivers in South Australia. In an American sample, Kolakowsky-Hayner, Miner, and Kreutzer (Reference Kolakowsky-Hayner, Miner and Kreutzer2001) noted family caregivers of persons with TBI wanted both instrumental and professional forms of social support.
While policymakers, clinicians, and researchers possess knowledge of family caregiver needs and outcomes in the civilian population, much less is known regarding family caregivers of veterans with TBI in Australia and the United States. This shortcoming in knowledge and awareness is unfortunate given how common (Lawrence-Wood et al., Reference Lawrence-Wood, McFarlane, Lawrence, Sadler, Hodson, Benassi, Bryant, Korgaonkar, Rosenfeld, Sim, Kelsall, Abraham, Baur, Howell, Hansen, Iannos, Searle and Van Hooff2019; Cummins et al., Reference Cummins, Elias, Lamb, Ponsford, Hopwood, Villemagne and Rowe2021) TBI is experienced among military personnel in both countries, in part resulting from extended engagement in joint military operations in Iraq and Afghanistan over the past 20 years (Sim, Wright, Kelsall, Magruder, & Karzic, Reference Sim, Wright, Kelsall, Magruder and Karzic2015).
In addition to the difficulties veterans face living with TBI, challenges are likewise experienced by the family caregiver populations among both countries. However, little research exists explaining the experience of family caregiving of persons with TBI from a veteran perspective. Clinicians and researchers might erroneously assume civilian research on family caregivers of persons with TBI equally apply to veteran families, without consideration of contextual factors specific to military and veteran families such as polytrauma, military culture, and access to social support.
Accordingly, this paper provides a primer on veteran families with TBI and recommendations for rehabilitation counselors in Australia and the United States. As both countries share a moral duty to address the support needs faced by families of veterans with TBI, rehabilitation counselors in both countries should collaborate on addressing these needs through research, teaching, and training.
Engagement to advance services and supports for families of veterans with TBI naturally builds on existing collaborations for common economic, political, and military interests. For example, the Free Trade Agreement (signed into law on January 1, 2005) between Australia and the United States dramatically increased trade between both countries (United States State Department, 2021). Politically and militarily, Australia and the United States have worked toward common objectives since World War I and have fought as allies since that time. In 1951, the military connection between both countries was legislatively established via the Australia, New Zealand, and United States Security Treaty (Office of the Historian, n.d.). Military engagement between Australia and United States will increase in future years from mutual concerns about China’s military expansion in the Pacific (Ignatius, Reference Ignatius2021).
Beyond economic, political, and military relationships, Australia and the United States follow similar approaches to addressing the needs of persons with disabilities and often face similar challenges in their rehabilitation systems. McLennan and associates (Reference McLennan, Buys, Matthews, Randall, Millington and Crocker2021) observed that the rehabilitation counseling systems in Australia and the United States struggle with fragmentation and lack of public recognition. Also, Matthews, Buys, Crocker, and Degeneffe (Reference Matthews, Buys, Crocker and Degeneffe2007) noted persons with disabilities in both countries face high unemployment and a chronic undersupply of qualified rehabilitation counselors. Both McLennan et al. and Matthews et al. stressed the importance of rehabilitation counselors in Australia and the United States working together and learning from each other to develop best-practice approaches in their respective countries given their common challenges and areas of professional expertise.
Following this theme, this paper stresses the necessity of rehabilitation counselor engagement to increase awareness and best-practice approaches to address the needs of family caregivers of veterans with TBI in Australia and the United States. Accordingly, this paper addresses the following: a) an overview of military-related TBI, b) families of veterans with TBI, and c) concluding observations.
An Overview of Military-Related TBI
Military engagement and collaborations between the United States and Australia over the past 20 years have resulted in TBI for many military service members. In 2015, Lawrence-Wood et al. (Reference Lawrence-Wood, McFarlane, Lawrence, Sadler, Hodson, Benassi, Bryant, Korgaonkar, Rosenfeld, Sim, Kelsall, Abraham, Baur, Howell, Hansen, Iannos, Searle and Van Hooff2019) surveyed 486 former and 864 current Australian Defence Force (ADF) members deployed to the Middle East sometime between June 2010 and June 2012. A total of 49.1% of current ADF members and 47.4% of former ADF members reported incurring a TBI (mild, moderate, or severe) at some point in their lives. The Defense Medical Surveillance System (2021) reported there was 439,609 U.S. military personnel with a diagnosed (worldwide) TBI from 2000 through the first quarter of 2021. A formal diagnosis of service-connected TBI as a function of military service by active duty and veteran systems in Australia and the United States make veterans with TBI eligible for a broad range of income support, healthcare, and rehabilitation services. The magnitude of TBI in both countries illustrates the enormous challenge of adequately meeting the needs of injured veterans and their families now and in future years.
While TBI is always a possible consequence of combat (Cifu, Cohen, Lew, Jaffee, & Sigford, Reference Cifu, Cohen, Lew, Jaffee and Sigford2010), military engagements in Afghanistan (since 2001) and Iraq (since 2003) present elevated TBI risk due to improvised explosive devices (IEDs) and other blast forms of injury. Because of this association, TBI is often referred to as “the signature injury” of these wars (Lindquist, Love, & Elbogen, Reference Lindquist, Love and Elbogen2017). Indictive of this risk, it is estimated as many as 15% to 20% of U.S. military personnel deployed to Iraq and Afghanistan incurred mild TBI injuries during their service (Baldassarre et al., Reference Baldassarre, Smith, Harp, Herrold, High, Babcock-Parziale and Pape2015). Similarly, it is estimated (Brain Injury Australia, 2016) one in 10 ADF service members deployed to the Middle East incurred mild TBI. The high prevalence of TBI is particularly concerning given the numbers of military personnel that served in Iraq and Afghanistan. From 2001 to 2014, more than 26,000 Australian Army (n.d.) soldiers served in Afghanistan. Approximately 2450 ADF personnel were deployed to military operations in Iraq in 2003 and 2005. Comparatively, approximately 2.5 million U.S. military personnel served in both conflicts from 2001 to 2015 (Sim et al., Reference Sim, Wright, Kelsall, Magruder and Karzic2015).
Understanding the family caregiving experience for Australian and American veterans with TBI requires consideration of how this group of veterans is unique from other care recipient populations. For example, veterans with and without TBI present a different array of post-combat behaviors and functional impairments. Baldassarre and associates (Reference Baldassarre, Smith, Harp, Herrold, High, Babcock-Parziale and Pape2015) examined neurobehavioral symptoms among U.S. military veterans that served in the Middle East. A total of 210 veterans with TBI were compared to 188 veterans without TBI. The TBI sample endorsed statistically greater levels of post-traumatic stress disorder (PTSD), anxiety, depression, pain, insomnia, alcohol use, unemployment, and disability. Also, the TBI sample reported statistically higher levels of somatic, cognitive, affective, and vestibular neurobehavioral symptoms of dysfunction along with a higher total number of overall symptoms. Before deployment, the two groups were not statistically different concerning the presence of a behavioral health condition.
Another consideration is that TBI experienced by military service members might be qualitatively different than TBI in the civilian population. For example, in their review, Burke, Degeneffe, and Olney (Reference Burke, Degeneffe and Olney2009) described why PTSD and TBI were often jointly experienced following IED attacks in military operations in Iraq. TBI and PTSD could occur independently as the incidence of both conditions (Hoge et al., Reference Hoge, McGurk, Thomas, Cox, Engel and Castro2008; Summerall, Reference Summerall2008) was elevated following IED attacks. Also, the etiologies of TBI and PTSD were at times interrelated (Burke et al., Reference Burke, Degeneffe and Olney2009). In the chronic uncertainty of combat operations in Iraq, military personnel sometimes lacked sufficient ability to effectively cope due to prolonged stress and anxiety. TBI possibly reduced the ability to employ cognitive strategies to productively respond to stress and anxiety. PTSD can develop when the person with TBI becomes aware of the etiology of their injury. Also, PTSD was conceivably more likely when TBI compromised structural, endocrine, genetic, and neurochemical function in the brain. Post-deployment, Burke et al. (Reference Burke, Degeneffe and Olney2009) noted the population of veterans with TBI and PTSD faced unique challenges with stigma, reintegration, and stress on the family unit.
In addition to co-existing TBI and PTSD, blast injuries can also result in a more expansive array of polytrauma injuries. Beyond the complexities of living with TBI, IED and other blast injuries can create additional areas of impairment. Polytrauma injury refers to impairments in two or more cognitive, psychological, physical, or psychosocial systems (Degeneffe, Tucker, & Griffin, Reference Degeneffe, Tucker, Griffin, Millington and Marini2015). Specific to blast caused mild TBIs, Cifu et al.’s review (Reference Cifu, Cohen, Lew, Jaffee and Sigford2010) found common areas of additional dysfunction occur in vestibular, auditory, visual, and communicative function.
The importance of understanding TBI specific to the veteran experience is vital in helping Australian and American families meet the demands of a caregiver role many did not anticipate nor were sufficiently prepared to assume. Families of veterans returning home without TBI or other service-connected disabilities already face significant difficulty with reintegration expressed by such outcomes as spousal mental health distress and child behavioral challenges (Degeneffe et al., Reference Degeneffe, Tucker, Griffin, Millington and Marini2015). Rehabilitation counselors and other professionals in Australia and the United States need to be aware of the general challenges veterans face in reintegrating back to family life. However, rehabilitation counselors require specialized training and knowledge to understand how to support family caregivers of veterans with TBI that is substantially different from other veterans as well as civilians with TBI.
Families of Veterans with TBI
As military operations drawdown in Afghanistan and Iraq, policymakers and disability professionals increasingly recognize the consequences of extended and dangerous military deployments on veterans and their family caregivers. Specific to TBI, Australia and the United States approach the needs of caregivers at different levels of intensity and awareness. While Australians are beginning to recognize the unique needs of family caregivers of veterans with TBI, this area of focus has received far more service and research attention in the United States.
Australian approach
Likely due to having substantially fewer military personnel affected by TBI in recent military operations in Iraq and Afghanistan compared to U.S. military forces, the Australian military and veteran government organizations have not paid specific attention to the needs of family caregivers of persons with TBI. A review of websites for Australia’s three military forces, the Air Force, Army, and Navy, make no mention of support for families impacted by TBI. However, Australian military dependents are eligible to receive general practice, specialist care, and allied service healthcare (Department of Defence, n.d.). In addition to family services provided by the military services, families can also utilize services from the non-governmental organization, Defence Families of Australia (DFA). DFA (2020) indicates it “…is the official body appointed by the Government to represent the views of Defence Families. It aims to inform the Government and Defence of the needs of ADF families” (p. 2). DFA staff members are partners of current ADF military personnel. DFA works to understand and advocate for military families through annual surveys and reporting on family needs in such areas as employment, education, and on-base services. Of note, TBI was not mentioned on the DFA website nor its 2020 annual review report (DFA, 2020).
The Australian Government Department of Veterans’ Affairs (DVA) (n.d.-b) offers a range of pension benefits to eligible veterans and partners, former partners, or widows. Eligibility is based on such criteria as age, service-connected disability, and/or income. DVA (n.d.-a) also provides families with a range of additional financial benefits in such areas as education, funeral expenses, childcare, and disability trusts. Also, DVA offers financial compensation for family members of injured ADF veterans under the Military Rehabilitation and Compensation Act 2004 (Department of Veterans’ Affairs 2020).
Like ADF, DVA does not promote specialized services or information for family caregivers of veterans with TBI. However, there does appear to be emerging awareness of the unique needs among family caregivers of Australian veterans with TBI through the presentation of the DVA website “rehabilitation success stories.” Each story includes a picture of the veteran and a narrative description of their military service and the role of family and other sources of support in helping veterans reach adjustment in their post-military service lives.
Consistent with DVA’s rehabilitation success stories, the non-profit agency, Brain Injury Australia (BIA) (2016), places specific attention on veterans with TBI and their family caregivers. Like DVA, BIA presents stories of veterans and their families impacted by TBI and made a request on its website for veterans with TBI and/or their families to share their stories. Compared to these initial steps in advancing public consciousness of the combat-related TBI, the public and veteran systems in the United States possess greater awareness due to the magnitude of military participation in Iraq and Afghanistan.
American approach
The U.S. Department of Defense (DOD) (which oversees active duty, reserve, and National Guard forces) and the U.S. Department of Veterans Affairs (VA) offer specific research, clinical support, and caregiver support to address the needs of active duty and veteran personnel with TBI and their family members. This infrastructure to respond to TBI has been continually built over the past 20 years since military operations were initiated in Afghanistan. The government’s dedication to creating specific support systems reflects an understanding of the needs of veterans with TBI and their caregivers in comparison to other veteran families and different from TBI family caregiving in the civilian population.
Research efforts
The extant research on family caregivers of military service/veterans with TBI in the United States is primarily conducted by the VA or by VA personnel in partnership with civilian researchers. This area of research focuses on family caregiving among those injured during the past 20 years of combat operations in Iraq and Afghanistan, in part due to a 2006 U.S. Congressional mandate that the DOD/VA research family caregivers of service members/veterans that served in this era (Carlozzi et al., Reference Carlozzi, Brickell, Psych, French, Sander, Kratz and Lange2016).
The available research indicates that care involvement among families of service members and veterans with TBI can be extensive. Griffin et al. (Reference Griffin, Friedemann-Sánchez, Jensen, Taylor, Gravely, Clothier and Van Ryn2012) evaluated family caregiving participation among 564 self-identified primary family caregivers of U.S. veterans with TBI. Many of these caregivers face high care demands. For example, a total of 49% of family caregivers of persons with high-intensity support needs provided more than 80 h of weekly care.
The care families provide comes at a cost to their well-being across multiple dimensions. With burden, for example, Brickell et al. (Reference Brickell, French, Gartner, Driscoll, Wright, Lippa and Lange2019a) found in a sample of 214 family caregivers of service members/veterans with TBI higher perceptions of burden was related to meeting the care recipients daily living support needs, encountering additional parenting responsibilities, incurring financial challenges tied to caregiving, and experiencing less time to devote to personal needs. With psychological well-being, Moriarty et al. (Reference Moriarty, Winter, Short and True2018) reported depressive symptomology among 83 family members of veterans with TBI was higher when participants experienced greater caregiving burden, when care recipients experienced TBI and PTSD, and when greater family financial difficulties were incurred. In a study of 45 family caregivers of military service members or veterans with TBI, Carlozzi et al. (Reference Carlozzi, Brickell, Psych, French, Sander, Kratz and Lange2016) reported quality of life was sometimes compromised with their social, emotional, physical/medical, and cognitive health.
Several researchers have evaluated what family caregivers need to be better able to manage the demands of caregiving for a veteran with TBI. This research indicates most family members face similar needs to civilian populations (e.g., Kolakowsky-Hayner et al., Reference Kolakowsky-Hayner, Miner and Kreutzer2001) in addition to needs specific to military and veteran communities. For example, Brickell et al. (Reference Brickell, Lippa, French, Gartner, Driscoll, Wright and Lange2019b) determined areas of unmet need among 264 family caregivers of service members and veterans that incurred TBI after October 2001. Brickell et al. evaluated need in the following categories: (1) caregiving help, (2) caregiving instruction, (3) guidance providing emotional support, (4) finding services, (5) navigating DOD/VA, (6) interaction with other caregivers, (7) caregiver medical health, and (8) caregiver emotional health. For all eight domains, it was more likely needs were not met than met.
Specialized services
Like the ADF and DVA, the U.S. military services and VA provide (e.g., VA, 2020) a range of financial, health, and educational benefits to military/veteran dependents. However, as professionals, policymakers, and the American public continually recognize the magnitude of need presented by TBI, the country further offers a range of specialized services to address the multifaceted needs of family caregivers.
In 2005, the United States established the Polytrauma System of Care (PSC). The system features an integrated system of care from inpatient to community-based care. Inpatient care is provided by five large Polytrauma Rehabilitation Center (PRC) facilities, geographically dispersed throughout the continental United States. PRCs utilize professional disciplines with various areas of polytrauma-related expertise and follow a family-centered service philosophy (Degeneffe et al., Reference Degeneffe, Tucker, Griffin, Millington and Marini2015). Following PRC discharge, the PSC includes a network of outpatient clinics and points of contact at each PSC/VA facility. PSC services and professionals are dispersed throughout the country to provide locally-based support (VA, 2015). PSC services are designed to prepare family caregivers for each phase of the rehabilitation process (Degeneffe et al., Reference Degeneffe, Tucker, Griffin, Millington and Marini2015).
In recognition of the unique challenges of providing care to a veteran with TBI, the U.S. government provides support to family caregivers of veterans with TBI not available to the civilian population with the Caregivers and Veterans Omnibus Health Services Act of 2010 (Griffin et al., Reference Griffin, Friedemann-Sánchez, Jensen, Taylor, Gravely, Clothier and Van Ryn2012). The act supports caregivers of veterans injured in military operations (after September 11, 2001) with stipends, training, and various support services. Included in these services is the VA (2021) Caregiver Support Program, which offers online courses, in-person classes, telephone support, peer assistance, and website information directed to family caregivers of veterans with TBI and other disabling conditions. For example, caregiver self-care courses address stress management emotion management, and effective communication strategies. VA caregiver services are available in English and Spanish.
Concluding Observations
All wars result in lifelong disability and chronic illness. For the recent conflicts in the Middle East, TBI presents particular risk due to the onset of IEDs and other blast forms of weaponry. As the previous review highlights, TBI incurred during military service is complicated by the overlay of PTSD and other polytrauma injuries. TBI in the military does not occur in a vacuum. Rather, family caregivers in Australia and the United States are likewise impacted and in need of professional support.
As the United States and Australia continue as allies in unstable and dangerous military engagements, likely, both countries will indefinitely face TBI among their troops. Additionally, TBI experienced by thousands of veterans over the past 20 years will continue to challenge families in responding to this life-long disability. Australia and the United States possess resources and services to meet the needs of the caregivers for this unique population. Now is the time for rehabilitation counselors in both countries to partner to address the needs of family caregivers of veterans with TBI.
Previous engagement
While Australia and the United States hold a long history of partnership in military engagements, the same cannot be said for engagement in addressing the needs of veterans with TBI and their family caregivers. However, some preliminary steps are in place due to the efforts of the Monash Centre for Occupational and Environmental Health, Monash University (Melbourne, Australia), and the Medical University of South Carolina (Charleston, United States) (Sim et al., Reference Sim, Wright, Kelsall, Magruder and Karzic2015). The project proposed a set of joint research activities between the DVA and the VA with three projects (p. 1) including “1. Comparative literature review of selected health and social outcomes and review of health services; 2. Comparative study on treatment pathways and access to healthcare; and 3. Parallel post-deployment health studies.” Overall, the project recognized the value of better understanding the similarities and differences in how both countries address the needs presented by military deployments. This focus provides a starting point for a shared response to the needs of veterans with TBI and their family caregivers.
What we do not know
While rehabilitation counselors, other professionals, and policymakers possess a limited understanding of family involvement and outcome from providing care to veterans with TBI much remains to be known. First, the extant research only relies on American samples with no specific focus on the influence of culture, race, and ethnicity. The shortcoming of this approach is not accounting for the unique economic, cultural, and historical influences on family outcomes specific to Australian society. For example, Aboriginals and Torres Strait Islanders have been combatants in military operations since Australia’s inception (Australian War Memorial, 2021). Australia’s historical relationship to its indigenous Aboriginal and Torres Strait Islander populations is marked by colonization, segregation, and assimilation. The Aboriginal and Torres Strait Islander populations face higher levels of poverty, incarceration, and other outcomes from a history of systematic discrimination and structural disadvantages (Australians Together, 2021). Australia’s indigenous populations face higher levels of TBI compared to the general civilian population (e.g., Pozzato, Tate, Rosenkoetter, & Cameron, Reference Pozzato, Tate, Rosenkoetter and Cameron2019). It is problematic to assume that what applies to American samples would equally be relevant to understanding the experiences of indigenous families impacted by military TBI. Likewise, the United States shares a painful history with its indigenous American Indian population (Lhamon et al., Reference Lhamon, Adegbile, Heriot, Kirsanow, Kladney, Narasaki and Yaki2018), calling into question the relevance of the extant research. Future research should develop needs assessments and intervention strategies specific to the historical context and cultural preferences of indigenous families.
A second area not sufficiently addressed in the research is the development of interventions specific to the needs of families of veterans with TBI in Australia and the United States. Shepherd-Banigan et al. (Reference Shepherd-Banigan, Shapiro, McDuffie, Brancu, Sperber, Van Houtven and Williams2018) prepared a systematic review for the VA examining intervention studies for family caregivers of persons with TBI, PTDS, or polytrauma. Regarding research on caregivers and care recipients with TBI, Shepherd-Banigan et al. identified a total of nine studies conducted from 1995 to 2016. Of the nine, only one intervention, the Veterans’ In-home Program (VIP), (Moriarty et al, Reference Moriarty, Winter, Robinson, Piersol, Vause-Earland, Iacovone and Gitlin2016; Winter et al., Reference Winter, Moriarty, Robinson, Piersol, Vause-Earland, Newhart and Gitlin2016) specifically focused on family caregivers of U.S. veterans with TBI. VIP interventions supported 37 veterans with TBI and their family caregivers by implementing interventions to improve veterans’ capacities through cognitive function compensatory strategies, emotion-regulation approaches, and home environment modifications. Compared to a control group via a randomized controlled trial, family caregivers demonstrated lower ratings of depression and burden.
A third area that needs attention concerns veteran TBI diagnoses. Many veterans that live with TBI have never been formally diagnosed by a physician, either during or after the time they were injured (Waszak & Holmes, Reference Waszak and Holmes2017). Therefore, it is difficult to know how many veterans (and their families) that could be eligible for services are ultimately served by veteran benefit, healthcare, and rehabilitation systems. Diagnosing a service-connected TBI allows utilization of available veteran system services. In the United States, of the 77,665 veterans who applied for services under the VA Veterans Benefits Administration (Whiteneck, Cuthbert, & Mellick, Reference Whiteneck, Cuthbert and Mellick2015) from January 2007 to September 2013, 34,320 (44.2%) were determined as having a TBI-related service-connected disability. Also, veterans with TBI receive services within and outside of VA health and rehabilitation systems. In 2012, a total of 64% of veterans with TBI-related service-connected disabilities received support from a PSC setting, while 54% were served by a community-based outpatient clinic. Given the relative lack of focus on TBI in the DVA, specific screening rate data for veteran TBI in Australia is not available (Sim et al., Reference Sim, Wright, Kelsall, Magruder and Karzic2015). Further information on access to veteran programs among persons with TBI and their family caregivers in Australia and the United States is needed to provide a more current and comprehensive understanding.
A fourth area that remains unknown is the impact of civilian programs, healthcare policies, and advocacy organizations on supporting veterans with TBI and their family caregivers. Not all veterans with TBI will seek or qualify for DVA or VA benefits. Also, Australia and the United States differ in healthcare provision. Australian veterans are more likely to be served by its public healthcare Medicare program, whereas American veterans are more likely to receive healthcare through the VA (Sim et al., Reference Sim, Wright, Kelsall, Magruder and Karzic2015). Further, civilian TBI advocacy organizations such as the BIA (2016) and the Brain Injury Association of America (2021) seek a voice in raising awareness about the needs of veterans and their family caregivers. Currently, it is not known how effective civilian organizations are in engaging with or speaking for veterans with TBI and their families.
Training and research collaborations
Australia and the United States are two countries with specific academic degrees, graduate training, and research tailored to the rehabilitation counseling profession. Both countries advance a common purpose and focus in preparing rehabilitation counselors to work with persons with disabilities to maximize independence, facilitate employment, and contribute to the quality of life (Matthews et al., Reference Matthews, Buys, Crocker and Degeneffe2007). This common professional identity presents opportunities for shared research and training efforts to address the support needs of family caregivers of veterans with TBI in Australia and the United States.
The present review highlights the lack of scholarly focus on family caregivers of veterans with TBI. In this absence, rehabilitation counselors are left with anecdotal knowledge or guesswork when providing supportive services to veterans with TBI and their family caregivers. Further, there can also be complete neglect of addressing the challenges presented by family caregiving for a veteran with TBI. Because of the profession’s understanding of medical aspects of disabilities, family systems, disability policy, and counseling skills, rehabilitation counselors working for ADF, DVA, DOD, VA, and civilian agencies are potentially well suited to provide evidence-based approaches, which should be developed by shared research efforts among colleagues in Australia and the United States.
Shared research efforts need to occur concurrently with an increased focus on military and veteran needs in pre-service education. The training of Australian rehabilitation counselors is undergirded by curricula standards set by the Rehabilitation Counselling Association of Australasia (RCAA) (n.d.) and the Australian Society of Rehabilitation Counsellors (ASORC) (2020). Training requirements for rehabilitation counselors in the United States are set by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) (2015). Across these three organizations, the word “military” is not cited and the word “veteran” only appears once in the CACREP accreditation manual (as a type of benefit system). Graduates of rehabilitation counseling education programs in Australia and the United States are not sufficiently prepared to work with veterans and their family caregivers. Practitioners and faculty members in their respective countries need to advocate for required specialized instruction on the military and veteran populations.
As both countries are challenged in addressing the needs of family caregivers of veterans with TBI, this paper stresses the need for shared purpose and collaboration in research and training in the rehabilitation counseling profession. It is hoped this paper will provide awareness and serve to motivate those in our profession to explore opportunities for engagement to address the needs of this neglected population.
Acknowledgements
The author would like to acknowledge San Diego State University for granting the sabbatical leave time to write this paper.
Financial support
This paper received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflict of interest
The author has no known conflict of interest to disclose.
