Behavior Therapy and Cognitive Behavior Therapy are types of treatment that are based firmly on research findings. These approaches aid people in achieving specific changes or goals.
Changes or goals might involve:
A way of acting: like smoking less or being more outgoing;
A way of feeling: like helping a person to be less scared, less depressed, or less anxious;
A way of thinking: like learning to problem-solve or get rid of self-defeating thoughts;
A way of dealing with physical or medical problems: like lessening back pain or helping a person stick to a doctor’s suggestions.
Behavior Therapists and Cognitive Behavior Therapists usually focus more on the current situation and its solution, rather than the past.
They concentrate on a person’s views and beliefs about their life, not on personality traits.
Behavior Therapists and Cognitive Behavior Therapists treat individuals, parents, children, couples, and families.
Replacing ways of living that do not work well with ways of living that work, and giving people more control over their lives, are common goals of behavior and cognitive behavior therapy.
HOW TO GET HELP:
If you are looking for help, either for yourself or someone else, you may be tempted to call someone who advertises in a local publication or who comes up from a search of the Internet.
You may, or may not, find a competent therapist in this manner.
It is wise to check on the credentials of a psychotherapist.
It is expected that competent therapists hold advanced academic degrees.
They should be listed as members of professional organizations, such as the Association for Behavioral and Cognitive Therapies or the American Psychological Association.
Of course, they should be licensed to practice in your state.
You can find competent specialists who are affiliated with local universities or mental health facilities or who are listed on the websites of professional organizations.
You may, of course, visit our website (www.abct.org) and click on "Find a CBT Therapist"
The Association for Behavioral and Cognitive Therapies (ABCT) is an interdisciplinary organization committed to the advancement of a scientific approach to the understanding and amelioration of problems of the human condition.
These aims are achieved through the investigation and application of behavioral, cognitive, and other evidence-based principles to assessment, prevention, and treatment.
Brain Injury: One Name, Diverse Injuries
How Do I Identify How Severe a Brain Injury Is?
Traumatic brain injury (TBI) is an alteration in brain function or mental status
that results from external force. In TBI, changes such as ionic shifts, abnormal
metabolism of energy, and decreased cerebral blood flow temporarily (or permanently,
in the case of more severe TBI) disrupt brain functioning. It is important
to note that not all forces, blows, or jolts to the brain result in TBI.
Each TBI is identified as mild, moderate, or severe, based on injury characteristics
occurring at the time of the injury event. However, there are different classification
systems for brain injury and there is not always consensus among
experts in defining severity in a particular case. Diagnosis of TBI severity (especially
with respect to differentiation of mild TBI from moderate TBI) is still
under much discussion. Best practice reflects diagnosis by a provider with specialty
training in brain injury assessment since other conditions, such as sleep
disruption or psychological stress, can mimic putative effects of brain injury. A
diagnostic interview and physical exam are typically conducted when medical
care is sought. While the use of neuroimaging following mild TBI is debated, it is
used in suspected cases of moderate to severe TBI. Detection of evidence of
brain pathology using imaging as a means of TBI identification has been proposed.
While no standard definition or diagnostic criteria for mild TBI currently
exist, there are commonly used criteria for stratifying the severity of injury. The
VA and Department of Defense (DoD) have developed a widely used consensus
definition based on the American Congress of Rehabilitation Medicine criteria
(ACRM Mild TBI Committee, 1993). In these and other definitions, there is general
consensus that brain injury diagnosis does not require that the individual
experience loss of consciousness (LOC). Posttraumatic amnesia (PTA) is another
sign of brain injury, which manifests as a period where the individual is not able
to form new memories. PTA may look like loss of memory for events immediately
before, during, or after the injury, while the person is responsive or conscious.
PTA has subsided when there is return of continuous memory. PTA differs from
psychological dissociation. Alteration of consciousness (AOC) is another characteristic
of brain injury that reflects true disorientation and confusion. The above
should be differentiated from amnesia and reduction in awareness of one’s surroundings
seen in acute stress reactions. The VA/DoD system of classification
indicates that only one of the following need be present to diagnose TBI: LOC,
PTA, or AOC. Cognitive concerns, headache, loss of balance, and fatigue, among
other symptoms, can be present, but are nonspecific to TBI.
According to the VA/DoD TBI classification system, mild TBI has occurred
when loss of consciousness is 30 minutes or less, and/or PTA is up to 24 hours,
and/or AOC is up to 24 hours. Moderate TBI has occurred when LOC is between
30 minutes and 24 hours, and/or PTA is greater than 24 hours up to 7 days,
and/or AOC is 24 hours up to 7 days.
Severe TBI is rated when LOC is greater
than 24 hours, and/or PTA is greater than 7 days, and/or AOC is greater than 7
days. Other common systems of classification include the Glasgow Coma
Scale as well as the American Academy of Neurology, Colorado, and Cantu
The term "concussion" is used by some to describe a mild injury and often
suggests a condition from which the individual will recover, although views
differ concerning whether the term "mild brain injury" and "concussion"
should be used interchangeably. The term "severe concussion" is generally
avoided as it leads to definitional confusion.
What Are Some Common Types and Causes of Brain Injury?
Brain injuries can be classified as closed or open. A closed brain injury
means that external force did not break the skull. An open, or penetrating,
brain injury means the person was hit with an object that broke the skull and
entered the brain (i.e., the dura mater, or, the outer layer of the meninges, is
penetrated). Either type of injury may cause bleeding in the brain or the layers
that surround the brain. Anoxic brain injuries result from lack of oxygen
to the brain and can be due to unexpected surgical events, near drowning,
drug abuse, or strangulation. Blast injuries (otherwise known as blastinduced
neurotrauma or BINT) result from the pressure wave occurring in
an explosion, and are typically closed head injuries. Blast injuries are characterized
as primary (injury from overpressurization force of the blast wave),
secondary (injury from projectiles such as bomb fragments or flying debris),
tertiary (injuries from displacement of person by the blast wind), or quaternary
(all other injuries from the blast). The brain is more clearly vulnerable
to both secondary and tertiary blast injury. There is discussion around
whether primary blast forces directly injure the brain, with support from animal
models suggesting that the primary blast could potentially cause TBI
directly. The primary blast can also cause formation of gas emboli, leading to
stroke. Common causes of TBI include motor vehicle accidents, assault, falls,
parachute jumps, sports injuries, and military-related blast or blunt force
What Types of Cognitive Changes Can Be Seen After Brain Injury?
Problems with memory (especially trouble forming new, short-term memories
and trouble remembering to-do's), attention, speed of thinking, and
executive functioning (planning, organizing, switching between tasks, problem
solving, mental flexibility, inhibition of irrelevant responses, initiation,
monitoring, and persistence with goal-directed thought and activity) can be
seen across the severity spectrum of brain injury. Other changes that can be
seen, especially in some cases of severe brain injury, include aphasia (partial
or total loss of the ability to communicate in words), difficulty speaking
clearly, visual spatial problems, problems in judgment or difficulty anticipating
unsafe situations, or changes in reading or writing. There can be inattention
to the left or right, which can have safety consequences. Restricted
awareness of changes is also more common in individuals with severe brain
injury. People who do not fully realize their limitations may be accustomed
to hearing others tell them they are not safe to be alone. It has been helpful
for people with brain injuries to understand this problem as though the
brain itself wants to ignore others' feedback.
What Social, Emotional, and Behavioral Changes Can Be Seen as a Result of Brain Injury, and for Whom?
Social, emotional, and behavioral changes arising directly from brain injury
are most evident in cases of more severe brain injuries, and result from
injury to brain tissue. Changes can include trouble "filtering" or restraining
emotions or thoughts one would normally avoid saying, feeling less patient,
crying more, wanting to isolate, having trouble with healthy decision-making,
feeling as if people are getting on one's nerves more easily, and unusual
social skills (sometimes called "orbitofrontal" syndrome). Mood swings
("emotional lability") can occur in these cases. Brain injuries can also result
in lethargy, "flat" mood, and difficulty getting started on or completing tasks
(this can look like lack of motivation or decreased goal-directed activity).
Depressed mood is a common outcome across severity levels of TBI. It can be
very helpful for survivors to understand these as brain-based changes when
this is the case, and to note when changes are evident.
Emotional and behavioral problems can also result from psychological
denial of changes and/or stress associated with life changes following the
injury. Some individuals regain awareness of their situation before they have
developed the emotional coping skills to cope with loss of function, potentially
exacerbating emotional and behavioral problems.
Thus, the causes of emotional and behavioral changes in TBI are multiple
and diverse, and encompass neurological changes that result directly from
the injury (e.g., to some of the brain areas where emotion and behavior regulation
is mediated, such as the limbic system and frontal lobes), as well as
pre-injury factors (e.g., coping style) and post-injury factors such as difficulty
adjusting to functional limitations and limited availability of social and
health system supports. All or any combination can be present.
Recovery and Treatment Considerations After Brain Injury: A Guide for Clinical Decision-Making
What Can We Expect Recovery to Look Like After Brain Injury?
Recovery depends strongly on whether professionals classify the injury as
mild, moderate, or severe. This classification is based on duration of acute
injury characteristics, such as loss of consciousness, posttraumatic amnesia,
and alteration of consciousness.
It is important to remember that there are many people who have experienced
a brain injury who have gone on to success related to their job, school,
and personal lives.
In the case of mild brain injury (concussion), a complete recovery is often
expected. Mild TBI is different from moderate or severe TBI in terms of
expectation for recovery. Recovery following experiencing of a single mild
TBI is rapid and full in most cases (1 to 2 weeks until full recovery is the
Concussions such as those occurring in a military setting tend to occur
within the context of other factors that predict persistence in behavioral and
cognitive problems, such as sleep deprivation, emotional stress, and/or physical
injuries and pain. These latter factors may instead be explanatory in cognitive
difficulties. Patient education in these cases has been shown to be one
of the most effective ways to decrease symptoms.
While almost everyone recovers from a single concussion within days, the
time it takes to heal also depends on the number of brain injuries in one's
lifetime and other variables (e.g., age). In a small minority of cases (>10% to
20%) and namely in cases of repetitive mild injury or re-injury prior to full
recovery, there can be a more prolonged recovery or increased likelihood of
long-term residual from brain injury. Second impact syndrome is less common,
where an individual is re-injured before the brain has had an opportunity
to heal, which may result in death. Older people also may be less likely to
recover fully. To date, the literature suggests that recovery from blast (e.g., in
the combat setting) does not differ from TBI recovery related to nonblast
causes, although this area is actively under investigation. In the case of moderate
to severe brain injury, learning to compensate for difficulties can take
time and often requires a team treatment approach with significant involvement
of family members or other supporters.
What Are Other Factors That Can Make Recovery Easier or More Difficult After TBI?
Cognitive and physical rest for the week following a concussion will maximize
recovery. While the questions of how much and what kind of rest are under
investigation, it is customary for athletes to refrain from play or military personnel
to refrain from duties such as report writing, going on convoys, or
performing guard duty within the week following TBI. Individuals should
receive plenty of sleep during this time. Rest will also protect the individual
from subsequent concussion during healing. Temporary symptoms also
resolve faster when a person rests.
Brain injury survivors can feel overwhelmed by their memory problems,
but one useful coping strategy has been to isolate each memory problem,
make a list, and attack one problem at a time. Following mild TBI, negative
global, stable attributions about memory problems (e.g., "they will never go
away") tend to predict symptom persistence.
Abstinence from alcohol and drug use is also likely to improve cognitive
efficiency over time. Alcohol has been shown to differentially and negatively
affect individuals with TBI.
What Assessment and Treatment Steps Can Be Considered After Brain Injury?
In general, immediate medical attention is recommended where brain injury
is suspected. Recovery from most mild brain injuries generally takes a benign
course, although close monitoring for potential complications such as
intracranial bleeding, seizures, or worsening of symptoms is recommended in
some cases. If the brain has been severely injured, neurosurgical evaluation
or efforts to control elevated intracranial pressure may be useful.
Physical and cognitive rest is essential for the week after brain injury.
Individuals with milder injuries should be able to return to duty, work, or
normally performed activities when they are symptom free with exertion and
have had an appropriate amount of time to recover. Recovery is different for
every person and depends on the nature and severity of injury.
To develop recommendations to promote recovery, assessment as close to the
time of injury as possible is critical for maximizing accuracy of diagnosis, for
maximizing long-term functioning, and for evaluating potential for return to
work, school, or safety needs around completion of activities of daily living.
During the acute phase after injury, education about prognosis with positive
expectancy in most cases of mild TBI is helpful. The first-line treatment
for individuals who have experienced mild TBI or concussion is education
about benign expected outcome and the importance of avoiding re-injury or
other factors that can impede recovery such as alcohol use. The Heads Up
campaign on the Centers for Disease Control website
(http://www.cdc.gov/concussion/headsup) provides some useful handouts
regarding TBI prevention. If an individual's symptoms do not resolve within 1
to 2 weeks following concussion, they will benefit from a more comprehensive
evaluation. Consideration of the contribution of psychological factors to
persisting symptoms is warranted.
After a brain injury, individuals who experience moderate to severe
injuries (and potentially a minority of individuals with mild injuries who do
not experience symptom resolution) may be considered for rehabilitation.
The purpose of rehabilitation is to facilitate functioning and productivity in
performing activities of daily living, and to teach people how to compensate
for problems. Rehabilitation also enables professionals to give a multi- or
interdisciplinary assessment after brain injury, with appropriate safety recommendations
and treatment plans.
Each person responds differently to rehabilitation. Some people after moderate
to severe brain injury receive rehabilitation treatments in an acute,
inpatient program, while other people with milder injuries receive rehabilitation
through outpatient services.
In the case of more severe injuries, rehabilitation, unlike other types of
health care, rarely provides a "cure," because professionals are unable to "fix"
or cure severe brain injury completely. The discussion around problem
reduction and compensation rather than cure can be difficult. A stay in the
rehabilitation center, however, can help individuals adjust well.
Rehabilitation is most commonly offered on an inpatient basis for weeks to
months, because it requires the input of multiple specialists, including physicians,
neuropsychologists, physical therapists, speech pathologists, occupational
and recreational therapists, and social workers, among others, working
together. Some of these professionals focus on teaching strategies for managing
attention, memory, problem solving, behavior, and communication.
Driving safety evaluations and vocational rehabilitation may be appropriate.
Other types of rehabilitation that are psychologically oriented focus on
increasing the individual's self-esteem by facilitating tasks or pleasant activities
that he or she can learn to successfully complete. This process helps
decrease adjustment reactions such as feelings of worthlessness, depression,
It is common for the individual with brain injury to wonder why the rehabilitation
team wants him/her to see a psychologist. A psychologist will frequently
help the person with a brain injury and his/her support system to
understand and adjust to his/her medical situation and changes in abilities.
This can include problem-solving activities to help the individual learn to
adapt to changes in daily functioning, and/or cognitive behavioral therapy to
address depressive symptoms or anger. It is also important for the psychologist
and other professionals to assess risk for suicide, capacity for intentional
and unintentional self-harm, and potential safety issues following TBI.
Neuropsychological assessment conducted by a neuropsychologist frequently
helps individuals with brain injury, their support system, and other healthcare
providers to understand the severity of the injury, strengths and weaknesses,
prognosis (that is, whether one's functioning is expected to return to
pre-injury levels or not), implications for daily functioning, and treatment
planning for medical care. The assessment provides direction for vocational
and educational choices or accommodations, as well as safety guidance for
Should Treatment for Posttraumatic Stress Disorder (PTSD) Be Deferred Until After Assessment and Treatment for TBI?
How Can PTSD Treatment Be Adapted to Maximize Therapy Outcome After TBI?
Empirically supported treatment for PTSD has typically been implemented
for individuals who have experienced mild to moderate TBI. For these cases,
it is generally accepted that following the first weeks post-injury, treatment
for acute stress (or later, PTSD) does NOT need to be deferred. While cognitive
rest is generally recommended for the first several days post-TBI, a growing
body of literature suggests that TBI may increase risk for the development
of PTSD and depression, and likewise may interfere from recovery of PTSD
and depression. There is no evidence to date to suggest that psychotherapy
for mental health symptoms interferes with recovery from TBI. While the
research in this area is evolving, initial evidence suggests that individuals
with TBI benefit from psychotherapy for PTSD symptoms as well as for
adjustment concerns related to TBI. Modification of treatments for PTSD to
accommodate cognitive difficulties may help to facilitate recovery (e.g., writing
down key points from the session; speaking slowly in short sentences).
Thus, effective treatments for PTSD (such as prolonged exposure and cognitive
processing therapy [CPT]) are felt to work well for those who have experienced
mild to moderate TBI. Additional suggestions for modifying CBT-oriented
treatments for individuals with TBI are detailed below.
What Treatments Help With Emotional and Behavioral Changes After Brain Injury?
Neuropsychological assessment can help guide choice of treatment modality.
Cognitive behavioral therapy (CBT), social skills training, and more recently,
mindfulness-based stress reduction approaches are used to treat emotional
and behavioral changes related to TBI. In general, therapy that targets the
way survivors talk and think about recovery can positively affect the way the
survivor feels and behaves.
In the acute phase of recovery, brief psychoeducational and cognitivebehavioral
interventions have consistently been shown to result in improvement
in managing cognitive and psychological symptoms for brain injury survivors.
CBT has been helpful in the acute phase post-TBI and beyond in
helping survivors to manage the anxiety, depressive symptoms, and insomnia
that can be present following TBI. CBT is used to help individuals regulate
negative affect, consider alternative goals, and modify self-concept following
brain injury. Initial clinical trials show that CBT delivered soon after mild TBI
is well tolerated and may facilitate recovery in individuals at risk for chronic
postconcussive symptoms. In these cases, CBT can address recovery expectations
and perceived consequences of TBI. Behavioral techniques such as
relaxation, behavioral activation, and treatment of insomnia are frequently
first-line approaches for anxiety and depression after TBI because they are
relatively straightforward and accessible. Behavioral pain management
approaches are often integrated as well, given the high co-occurrence of polytrauma
injuries (i.e., injury to more than one organ system, one of which
includes the brain). When substance use problems are present, concurrent
treatment for substance use is typically the treatment of choice.
The emotional context in which the TBI occurred can be essential in
understanding the clinical presentation of brain injury survivors and in determining
when CBT is used and how it is integrated into other treatments. CBT
is frequently used to target TBI-specific cognitions and psychiatric symptoms.
Initial evidence suggests that therapies which were designed to target posttraumatic
stress symptoms, which can be frequently present, can also be of
benefit. Whether treatments should first address acute stress, if present, or
other psychiatric symptoms (including substance use), if present, in samples
of brain injury survivors is under discussion.
Efficacy of CBT after TBI can very much depend on both the person's level
of cognitive functioning and the ways in which the CBT is adapted to increase
its accessibility for individuals with cognitive limitations. TBI-related cognitive
impairments in domains such as memory, verbal communication, attention,
abstract thinking, and self-awareness can impose a significant potential
barrier to the effective delivery of CBT, although this tends to be more the
case following severe TBI. Therapists may need to assess the extent to which
people with moderate to severe TBI are able to comprehend the idea of an
unhelpful thought or remember to do homework exercises, and it is therefore
important to consider how therapy can be effectively adapted for each person
with TBI, particularly in light of the pattern and severity of cognitive difficulties.
Speech and language inefficiencies should be understood prior to
embarking upon a course of CBT.
Despite potential barriers, there is a growing body of evidence indicating
that people with TBI can benefit from CBT. There are several ways in which
CBT can be adapted for individuals with TBI. Procedural learning, role-playing,
repetition, and structure can increase the likelihood that CBT will be
effective. Use of prerecorded relaxation sessions may be helpful for those with
memory problems. Brain injury survivors may need support in generating
ideas for pleasant activities if previous life activities are no longer possible
due to cognitive and other changes; expect to devote more time to this and to
counter negative thoughts, as a reduced ability to participate in previously
defined meaningful activities is common. The use of a "therapy partner," such
as a family member, to help with homework or to challenge negative thoughts
has been incorporated. In vivo work (in the case of prolonged exposure therapy
for PTSD) has been used in individuals with significant cognitive deficits,
and individuals with difficulty verbalizing what they are seeing can be encouraged
to bring in tangible reminders of their traumas such as photos or
mementos to stimulate discussion.
Exploration of beliefs about the TBI itself (i.e., the cause and prognosis of
TBI, symptoms, and functional difficulties) can be very helpful in the later
phase of therapy, as these can often be sources of distress. A book entitled
Psychotherapy After Brain Injury, by Pamela Klonoff (Guilford, 2010), provides
therapists with guidance for helping patients with beliefs about self,
identity, capabilities, and acceptance after brain injury.
Behavior therapy is also an effective intervention in cases where there is
greater functional impairment or severity of injury. Behavior therapy has
been effective in helping individuals to relearn skills such as self-care and
completion of chores following TBI. Behavioral approaches taught to the family
(e.g., use of cues with fading over time; behavioral reinforcement system)
may be the preferred approach in working with individuals with severe TBI.
For individuals with moderate to severe TBI, CBT or behavioral management
approaches are frequently delivered within the context of an overarching
multidisciplinary rehabilitation treatment program, simultaneously with
other treatments. The emphasis on education and skill-building is broadly
consistent with the goal-oriented approach of rehabilitation.
What Treatment Approaches and Strategies Help With Memory and Attention (Cognitive) Changes After Brain Injury?
For individuals with milder brain injuries and where indicated, positive
expectancy about the natural course of recovery can reduce worry about
memory and attention, thereby preventing exacerbation of the cognitive
problems caused by stress. In addition, in individuals with milder injuries,
reductions in cognitive symptoms can often be most effectively achieved with
reductions in psychological distress; thus, psychotherapy is an appropriate
recommendation. Further, because it is observed that stress can make it difficult
for people to take advantage of brain injury assessment and treatments,
psychotherapy can be an important part of a broader treatment plan, in turn
improving memory and concentration through stress reduction.
In 2011 the Institute of Medicine (IOM) issued a report that evaluated the
evidence and developed treatment guidelines for cognitive rehabilitation, an
emerging set of therapies that help individuals increase their ability to
process information and to move through daily life by recovering or compensating
for impaired cognitive functions. The benefits of using cognitive rehabilitation
with individuals with moderate to severe cognitive impairments are
more well-documented than for those with mild cognitive difficulties. While
support for efficacy of cognitive rehabilitation interventions is limited to date,
the ongoing use of cognitive rehabilitation for survivors of TBI while
improvements are made in the standardization, design, and conduct of studies
is recommended. The IOM report calls for more research on cognitive
rehabilitation. The report is available at: http://www.iom.edu/Reports/2011/Cognitive-Rehabilitation-Therapy-for-Traumatic-Brain-Injury-Evaluatingthe-Evidence/Report-Brief.aspx?page=1.
Approaches used in cognitive rehabilitation training include compensatory
strategies (i.e., use of strategies that “work around” the impaired cognitive
abilities) and restorative strategies (i.e., drills and practice in cognitive tasks
that directly target impaired cognitive functions). A restorative approach
helps the patient reestablish a cognitive function, while compensatory
approaches help the individual to adapt to an ongoing impairment. In cognitive
rehabilitation that focuses on teaching of external compensatory strategies,
consistent use of an external calendar system with integration of to-do
lists is taught. Family members are frequently incorporated and can provide
prompts which are faded over time. For brain injury survivors, it can be frustrating
to have to relearn skills mastered before injury, and skill-building that
emphasizes distress tolerance and readiness to learn (e.g., relaxation training)
can augment treatment.
Helping the Survivor of Brain Injury and His/Her Supporters Cope With Changes
What Thoughts, Beliefs, Fears, and Emotional Responses Can People Have After Brain Injury in Coping With Changes?
Individuals who have experienced mild TBI can be fearful that perceived consequences
of mild TBI will remain with them for life. It is important for
affected individuals to evaluate the evidence for and against this with a
trained professional. It is far more common for individuals with one or few
concussions to experience complete recovery within several days to 1 year. It
is also very common for individuals to attribute emotional changes to brain
injury when these may represent exacerbation of preexisting symptoms
and/or stressors. This is known as the "good old days" bias. On the other
hand, service members and athletes may not note new changes, expecting to
return to their roles.
People with moderate to severe brain injury and for whom long-term
residual effects are expected may be grieving perceived lost dreams. There
can be a fear of loss of control or loss of independence, which may lead survivors
to decline help of others who are trying to put supports in place.
Hopelessness can occur. If individuals realize that these themes are common
following brain injury, they may be less likely to have catastrophic reactions
in response to changes in independence and skills.
It also may be overwhelming to cope with the responses of others and the
shift in identity that may occur. Loss of intimacy can occur with partners.
People can feel as though they have let their family or partner down, and use
negative thinking traps such as "labeling" (i.e., the person contradicts reality
by telling him or herself that s/he is now "lazy" or "unintelligent" after the
injury) or "all-or-nothing thinking" (i.e., the person believes that if s/he can't
do everything as was done before the injury then the outcome will be terrible,
or believes that s/he won't return to work or school unless s/he can do as well
as before the injury). Unfair comparisons to other individuals with brain
injuries may be made. It is helpful for people with brain injuries to remember
that brain injuries are like fingerprints and no two are the same; the only fair
comparison is between "you" and "you."
What Are Some Helpful Thoughts and Coping Strategies That Can Keep the Individual With Brain Injury Moving Forward in His or Her Recovery?
It is important for survivors to focus on what has been accomplished since the
injury ("look forward, not backward"). Coping can also focus on improved
sleep hygiene, self-care, and identification of pleasant activities. It can be
helpful for the individual to work with a therapist to challenge "should" statements
such as "I am supposed to be employed right now" or "I ought to
remember everything." Addressing the relationship between self-worth and
one's ability to work, as well as challenging unhelpful thoughts such as "I
should not need help" or "I am a failure if I can't be self-sufficient," can be
helpful. Alternative balanced statements include, "I would prefer to work, but
I can have other sources of meaning or be productive in other ways" or
"People with medical conditions sometimes need assistance." Reevaluating
one's value based on the type of person one is and other types of participation
in life can be helpful. "Big-picture thinking" can be helpful (e.g., "I am not
good at keeping track of details now because of the brain injury. Instead, I
will help people focus on the big picture/what’s really important in life and on
Psychotherapy after brain injury generally focuses on realistically achievable
acceptance. A goal to work toward includes being able to hold two ideas
in mind at the same time, such as "I don't like the impact of this brain injury"
and "It isn't going to stop me and I can find a way of living in peace."
Individuals are encouraged to avoid contrasting current problems with imagined
successes should alternative choices have been made pre-injury; frequent
pre-injury comparisons promote depression. People can burden themselves
with unrealistic comparisons of what their potential would have been,
or make overly optimistic pre-injury comparisons (known as the "good old
days" bias), leading to depression. It is impossible to know what could have
been had life played out differently. Similarly, fortune-telling (anticipating
that one’s recovery will decline or that quality of life will always be poor) is
common; however, it is impossible to know the future that awaits us. Helping
individuals to set realistic goals in their recovery and to engage in perspective-
taking regarding short-term versus long-term consequences of decisions
can be helpful. Learning to tackle all-or-nothing thinking traps, such as "I am
only interested in attaining what I did before the brain injury, and I won't settle
for less" or "I am going immediately back to work," can be of benefit. Goalattainment
scheduling has been used to help individuals get out of the thinking
trap of accepting only the best or the worst outcome for their lives.
Instead, individuals learn to identify sub-goals that help them advance
toward the top goal that is most realistic.
What Are Some of the Challenges That Family or Other Support System Members Face After Brain Injury?
Members of the survivor's support system (termed "supporters") play a critical
and often underappreciated role in recovery after brain injury. Brain
injury involves not only the injured individual but also those close to that person
who may also be going through a grief and acceptance or acknowledgment
process. Coping with brain injury has been posited to be especially difficult
because for many it is an "ambiguous" loss; that is, the survivor remains
physically present and may even look unchanged, but is cognitively and/or
Supporters sometimes cope with loss and financial challenges by falling
into a "parental" or nurturer role (sometimes reluctantly) and/or withdrawing
into work. Supporters try to balance the need to provide financially with
overwork. Supporters can feel guilty for taking care of their own needs rather
than those of the injured person. Supporters face changing roles and the need
to work toward adjusting expectations and learning new skills while maintaining
balance. Learning new ways of distributing responsibilities and pacing
oneself are beneficial. Asking oneself what one wants to do, what one is or
feels obligated to do, and what one can handle doing safely are important
questions. Supporters frequently need to take more time for themselves to
avoid compassion fatigue. Supporters can benefit from attendance at a caregiver
support group, keeping a regular schedule, being assertive about getting
the support needed, and educating themselves about available resources.
Supporters may also have irrational beliefs about not having protected the
person with TBI from the injury. Supporters sometimes begin to engage in
anticipatory grief for losses that may not occur, assuming that goals are now
out of reach. Supporters can become the unwitting target of frustration in the
recovery process, because they are sometimes tasked with setting unwanted
safety limits or enforcing treatment compliance. Individuals who do not
appear to have a legal or traditional/permanent relationship to the individual
with TBI might feel that their grief is invalidated by others, and will need to
weigh whether direct communication of needs would be of benefit.
What Communication Skills Can Friends, Family, and Providers Use With Individuals After Brain Injury?
The following strategies are especially helpful in cases where the TBI has had
a significant impact on the individual’s daily functioning. For others in the
survivor's life, there can be a natural inclination to assume a parental role,
but people with brain injury may instead expect to be treated in the same
manner as they were before the injury. Supporters can rely on professionals
to explain their rationale to the survivor so that everyone knows where any
restrictions in activities came from. This conversation can be recorded or
written with the therapist's and survivor's permission. Written guidelines can
also provide cueing in the case of memory problems.
For all involved, consider talking in a distraction-free and non-brightly-lit
place. A one-on-one format may work better than "family meeting" format for
communication. Speak slowly, as though you are throwing a bunch of commas
(like bullet points) into your sentences, since speed of thinking may have
been affected by the brain injury. Avoid multi-part questions. Pause to check
for understanding (survivor can summarize in his/her own key words). Use
"key words" that summarize the message. Remind the person that he or she
can write down information you are providing in their calendar/notebook
during the conversation. The survivor can learn that they will attend where
their eyes are orienting and can use this as a cue to stay "on track" and maintain
eye contact as time post-injury progresses. Remember that the person
has brain-based difficulties with memory and attention and it is most likely
that they are not intentionally tuning you out. In terms of helping the survivor
to compensate for memory and attention problems, it may be prearranged
that the support person will cue the survivor to apply specific skills
in specific situations. It is often the case that the survivor simply requires the
cue rather than needing the skill to be retaught, and that knowing when to
apply the skill (skill generalization) is the challenge.
For survivors who are forgetful, cues can be introduced over time so that
the individual with brain injury performs successively more challenging tasks
with supervision ("cue, don't do"). Assist the person with breaking complex
tasks into a series of simpler tasks. While walking with the person, point out
landmarks: these may later serve as reminders of paths to places.
If you were/are significantly involved with the person with brain injury,
rehabilitation providers want to gather information from you and to involve
you in care. Communicate with providers to the extent possible. Family members
are sometimes cautioned to avoid making any major decisions until they
have sufficient information from specialists to be able to understand the survivor’s
long-term prognosis. Consider the impact of communications on the
recovery and coping of the person with brain injury. Some families have
found it helpful to discuss concerns individually with providers both separately
and together from the person with TBI. Consider whether all who want
to be involved in the life of the person with brain injury but who disagree can
come together for a common goal.
What Communication Skills Can the Individual With Brain Injury Use to Improve Relationships With Others?
The brain injury survivor often needs to slow down speech to get words out,
to take a step back before discussing personal things, and to manage discussion
of one's injury while looking for cues to continue or limit (eye contact).
Active listening skills can be learned or relearned, with a focus on nonverbal
cues (e.g., maintaining a friendly expression, remaining at an arm's length
How Can I Find Someone to Help Assess and Treat Brain Injury?
How Can I Locate More Support for an Individual After Brain Injury?
In some cultures there is a belief that family members and the affected individual
ought to be able to handle brain injury on their own. However, this
belief can lead to not receiving available support or treatment to achieve maximal
outcomes. It is important for those who require help to recognize that
this is a time to pursue support without feeling guilty or inadequate.
Survivors and families can be reminded that everyone has something they can
work on, and very few people have innate specialized knowledge on how to
cope with brain injury.
The Brain Injury Association of America (http://www.biausa.org) has state
chapters that can provide local referral resources for treatment facilities,
respite care, transportation, care coordination, support groups, educational
materials, and providers who can help. Also, frequently the regional neuropsychological
society has an online roster of neuropsychologists who specialize
in assessment and treatment.
For military personnel and veterans, the Defense and Veterans Brain
Injury Center (DVBIC; see http://www.dvbic.org) and the Veterans Affairs
(VA) Polytrauma System of Care (http://www.polytrauma.va.gov) can connect
people with appropriate assessment and treatment. Nowadays the VA is
making it easier to access treatment. Both the Department of Defense and
Department of Veterans Affairs use DVBIC as their clearinghouse for patient
and family educational materials about TBI. DVBIC can help people connect
with case management, which can help individuals get resources they need
for day to day living. Caregivers play a critical role in the recovery of individuals
with moderate to severe TBI, and the VA supports a family caregiver program
that applies to caregivers of individuals with TBI (http://www.caregiver.va.gov). This program can provide a stipend, training for caregivers,
support via telephone or in-person meetings, in-home skilled nursing, respite
care, and a variety of other services for those determined eligible. A fact sheet
is available with tips on caring for a Veteran with TBI (http://www.caregiver.va.gov/pdfs/FamilyCaregiversGuideToTBI.pdf).
For those who are affected by brain injury, please remember that you are
not alone and that there are so many resources and strategies to understand
and compensate for brain injury.
For more information or to find a therapist:
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