Hugh and Rosemary Rawlins stayed together since his brain injury in 2002, but she suffered post-traumatic stress. Casey Templeton for The New York Times

Contrary to conventional wisdom, marriages can survive after a spouse suffers a brain injury and the personality changes that often go with it. But that is not to say these marriages will be happy.

Some studies find divorce rates well below the United States average among these couples. A 2007 investigation found that the rate was around 17 percent in couples followed for as long as 90 months.

But "while people may technically be married, the quality of their relationship has been seriously diminished," said an author of the 2007 study, Jeffrey S. Kreutzer, a psychologist at Virginia Commonwealth University in Richmond.

Dr. Kreutzer and other psychologists at V.C.U. are among a few therapists in the United States trying to develop marriage counseling techniques tailored to couples dealing with brain injuries. For them, recovery often means teaching uninjured spouses to forge a relationship with a profoundly changed person.

"You're asking people to just look forward, to not look back at all," said Emilie Godwin, another V.C.U. psychologist. "To try to recreate a relationship."

One marriage that survived was that of Terry and Vicky Curtis of Coralville, Iowa, even though about a month after surgery to remove a brain tumor in 2006, he told her she was free to leave. "I'm not the person you married," he said.

Mr. Curtis knew he had become cold, impulsive and incapable of focus. But it would be 18 months before doctors explained that complications from surgery had caused a brain injury.

Once a software programming analyst, Mr. Curtis, 57, has "a lot fewer interests" than he did before the injury, and he estimates he has lost 90 percent of his friends.

"It's a new you," he said, "and they just can't cope with that."

Even relatives well versed in the changes wrought by brain injury constantly struggle not to take outbursts or remarks personally, therapists said.

"The word that describes it is just 'lonely,'" said Mrs. Curtis of her role as caregiver. Counseling has helped Mrs. Curtis to manage her expectations, both for Mr. Curtis's recovery and her own responses.

"We'll have a whole day where he's just fine, and it's just like the old Terry," she said. "And then he'll say something out of whack, and I'll say, 'Oh, yeah, it's 2011.'"

Psychologists say this type of halting progress adds to "ambiguous loss." Reminders of the damage appear and disappear, and often couples struggle with grief that is never fully resolved.

Said Dr. Godwin: "People hold on to hope that just as when they survived the crash and they had this miraculous recovery, that they will overcome these challenges that other people may not in this miraculous way. That's not going to happen."

Some couples manage to put their lives back together. In 2002, while Hugh Rawlins was in an induced coma, half his skull removed to allow his brain to swell, doctors told his wife, Rosemary, that he might be angry, even abusive when and if he learned to talk again.

Mr. Rawlins had been struck by a car while riding his bike near his home in Glen Allen, Virginia. After years of halting rehabilitation and a devastating, failed attempt to return to his old job, Mr. Rawlins is a financial executive at a midsize engineering company. An avid surfer before the accident, he rides the waves off North Carolina's Outer Banks, where the couple spends almost every weekend.

He never became the aggressive misanthrope doctors warned about. And he's back on the bike.

But each positive step in Mr. Rawlins's recovery has posed difficulties for his wife. His determination to ride his bike sent her into therapy.

"All of a sudden I was in this position of always telling what you can do, what you can't do - it's horrible," said Mrs. Rawlins, who documented her family's ordeal in "Learning by Accident," a self-published memoir. Mrs. Rawlins, like many other caregivers, ultimately received a diagnosis of post-traumatic stress disorder.

Despite progress toward stable relationships, many couples stay trapped in a pattern in which the uninjured spouse does everything for the survivor, even when it's no longer necessary, researchers have found.

Dr. Kreutzer tells his patients some post-injury changes can be positive. Indeed, Mrs. Rawlins was thrilled to find that her once wry and stoic husband is much less emotionally inhibited.

"The touchy-feely stuff, that shows more in me now," he acknowledged.

More and more, Mrs. Rawlins believes that her husband is back to his "old self." She's just no longer sure she remembers who that was.

The New York Times

(China Daily 01/29/2012 page10)