By Dr Dana Wong MAPS, School of Psychology and Psychiatry, Monash University, Dr Adam McKay MAPS, School of Psychology and Psychiatry, Monash University and Epworth Rehabilitation and Dr Ming-Yun Hsieh MAPS, Victorian Rehabilitation Centre and arbias

Psychiatric disorders such as anxiety and depression are experienced by more than 60 per cent of people with TBI and are often associated with reduced participation in work, leisure and social activities. The causes of psychological problems in TBI are multiple and diverse, and encompass neurological changes that result directly from the injury (e.g., to the limbic system and frontal lobes), as well as pre-injury factors (e.g., coping style) and post-injury circumstances such as capacity to adjust to functional limitations and the availability of social and health system supports.

There is a clear need for effective psychological interventions to address emotional distress and enhance psychosocial outcomes in people with TBI. However, TBI-related cognitive impairments in domains such as memory, verbal communication, attention, abstract thinking and self-awareness impose a significant potential barrier to the effective delivery of well established interventions such as cognitive behaviour therapy. Therapists may question whether people with moderate to severe TBI are able to comprehend the idea of an unhelpful thought, remember to do homework exercises, or show the capacity to change rigid behaviour patterns. Opportunities for intervention are also reduced by the limited availability of treatment services and psychologists with training and experience in both TBI and delivery of psychological therapies, each of which are necessary domains of expertise.

Adapting psychological interventions

Despite these barriers, there is a growing body of evidence indicating that people with TBI can benefit from cognitive behaviour therapy and other psychological interventions. A randomised controlled trial examining the effectiveness of motivational interviewing (MI) and CBT compared with ‘treatment as usual’ in treating anxiety and depression in people with moderate to severe TBI is currently being conducted by the Monash-Epworth Rehabilitation Research Centre. Participants’ cognitive difficulties are accommodated using a range of techniques (see Hsieh et al., 2012a). A three-session MI-based preparatory program was also developed to engage the clients and prepare them for the CBT program. Preliminary results from this ongoing study indicate that the CBT program was more successful in reducing anxiety symptoms at post-treatment than “treatment as usual” (Hsieh et al., in press). In addition, participants who received the MI pre-treatment showed greater reduction in anxiety, stress and non-productive coping, when compared to three sessions of non-directive counselling prior to CBT.

While these results are promising, numerous challenges were encountered when delivering the CBT program to participants, particularly in those with severe cognitive impairment. Perhaps unsurprisingly, participants with more severe brain injuries and poorer memory were less likely to respond positively to intervention (Hsieh, Ponsford, Wong, & McKay, 2012). It is therefore particularly important to consider how therapy can be effectively adapted for each client with TBI, based on a comprehensive case formulation. Drawing upon experiences from the trial, five strategies for using CBT with clients with TBI have been identified.

1. Facilitate treatment readiness from the beginning

  • TBI-related cognitive, psychosocial and physical changes may prevent the individual from fully engaging in therapy. Allow time to address such barriers (e.g., an overwhelming sense of grief and loss, acute crises, emotional lability or family distress) so the client feels more settled and ready for formal therapy. This pre-treatment phase can serve as an opportunity to collect evidence of the client’s resilience and strengths, which can then be used as ‘coping statements’ in later phases of treatment.
  • The ‘looking back on one’s own previous successes’ strategy in MI can facilitate clients' confidence about their capacity to succeed through treatment.
  • Elicit, amplify and summarise clients’ change talk and commitment language. Using clients’ own words, analogies and role models will increase the likelihood they will remember their own goals and action plan.
  • Emphasise personal choice and control. If the client has difficulty with idea generation, obtain permission to provide a menu of a small number of practical options to choose from. Highlight the client’s personal responsibility for the necessary behavioural changes.

2. Consider using behavioural techniques early in treatment to build confidence and engagement

  • Behavioural techniques (e.g., relaxation, behavioural activation, insomnia treatments, exposure therapies) are a good first-line treatment for anxiety and depression after TBI. They are usually easier for clients to understand and apply relative to cognitive-focussed techniques. Early treatment successes will help to increase the motivation of clients and confidence in their ability to change.
  • Relaxation strategies (e.g., abdominal breathing) are often mentioned by clients as being especially helpful, possibly because they are relatively straightforward and accessible. Providing recordings of relaxation techniques practised in sessions helps clients with memory problems.
  • A reduced ability to participate in meaningful activity is common after TBI and is a common basis for depression. Clients often need support in generating ideas for alternative activities if previous life activities are no longer possible due to cognitive, physical and emotional changes.
  • Clients often benefit from support in breaking down behavioural goals into achievable components and then developing a step-by-step plan to achieve their goals.

3. Simplify cognitive therapy techniques

  • Ensure clients understand the differences between thoughts, feelings and behaviours before talking about their inter-relationship. Help clients to label their emotions.
    Teaching clients the link between their thoughts, feelings and behaviours will be aided by using a simple model, concrete examples, and exercises that require them to guess what someone might be thinking given certain emotions and behaviours.
  • Explore beliefs about the TBI itself, for example, the cause and prognosis, as these can often be sources of distress.
  • Cognitive restructuring and challenging may be too difficult for some TBI clients to undertake without considerable support. For clients with difficulties generating ideas, therapists can suggest possible alternative thoughts that can be turned into coping statements to be written down and rehearsed. Behavioural experiments may also help to make testing of alternative beliefs more concrete. For more severely impaired TBI clients, a ‘therapy partner’ such as a family member can helpful to support the use of coping statements and alternative thoughts.

4. Provide support for cognitive impairments that targets individual strengths and weaknesses

  • Clients would ideally undergo a neuropsychological assessment prior to commencement of therapy to identify cognitive strengths and weaknesses. It is helpful to capitalise on strengths, for example, by using diagrams to describe concepts to clients with good visual memory.
  • Provide written handouts and notes for psychoeducational material and homework exercises, which the client can compile in a folder to be brought to each session. Help clients organise the treatment materials, such as by placing current homework exercises at the front of the file, and labelling sections.
  • Make use of modern technology such as smartphones. For example, goals and homework exercises can be texted to the client, and reminders with an audible alarm can be entered into the client’s calendar.
  • Thought records could include a list of possible emotions or thoughts that the client can tick off, rather than having to generate and remember them. Helpful thoughts and coping statements can be written on small cue cards to be kept in the client’s wallet or pocket.
  • Slow down treatment delivery by focussing on only one or two concepts each session, and repeating and revising important concepts every session. Regularly summarise and check the understanding of concepts.
  • Collaborate with other allied health workers and family members so they become co-therapists and reinforce positive behavioural change.

5. Encourage generalisation and maintenance of skills

  • Emphasise from the beginning of treatment that every minute can be opportunity to practise CBT skills.
  • Do regular reviews of the client's progress and revise goals frequently. A checklist with a rough timeframe can serve as a useful visual prompt. Educate clients from the beginning of therapy that treatment goals may change over time depending on their circumstances and rehabilitation progress, so the focus of therapy will be on helping them to develop skills in coping with changes.
  • Help clients to practise coping strategies in more naturalistic settings in the community (e.g., at home, at school, on the street). In an inpatient setting, it may be necessary to engineer opportunities for the client to practise skills (e.g., inviting the family to the ward to share a meal with the client and the treating team).
  • When developing a relapse prevention plan, take into account that TBI often results in difficulty identifying emotional states and understanding non-verbal cues. This may require an emphasis on social skills training to help clients rebuild or strengthen their social support networks, so that others can help identify signs of relapse.

Conclusion

To make psychological therapies accessible to people with TBI it is important they are adapted to compensate for cognitive problems. Psychologists who deliver therapies to clients with TBI should have both knowledge of TBI and skills in delivering interventions such as CBT. Treatment is most likely to be effective when conducted based on a comprehensive case formulation that takes into account cognitive strengths and weaknesses and the nature and severity of the brain injury, as well as psychosocial and physical factors. Close interdisciplinary collaboration is essential, and psychological input usually needs to be long term, with regular review and booster sessions. Careful consideration of these issues increases the likelihood of a productive and effective therapeutic relationship with these complex and often fascinating clients.

Acknowledgements
The randomised controlled trial of MI and CBT described in this article is an NHMRC funded study. For more information about the study, please contact Christina Furtado on Christina.Furtado@epworth.org.au. Special thanks to the study participants and staff at the Monash-Epworth Rehabilitation Research Centre, Epworth Hospital and the Victorian Rehabilitation Centre.

The principal author can be contacted at dana.wong@monash.edu

References

Hsieh, M.-Y., Ponsford , J., Wong, D., & McKay, A. (2012). Exploring variables associated with change in cognitive behaviour therapy (CBT) for anxiety following traumatic brain injury. Disability & Rehabilitation, 34(5), 408-415.

Hsieh, M.-Y., Ponsford , J., Wong, D., Schönberger, M., McKay, A., & Haines, K. (2012a).A cognitive behaviour therapy (CBT) programme for anxiety following moderate-severe traumatic brain injury (TBI): Two case studies. Brain Injury, 26(2), 126-138.

Hsieh, M.-Y., Ponsford , J., Wong, D., Schönberger, M., Taffe, J., & McKay, A. (in press).Motivational interviewing and cognitive behaviour therapy for anxiety following traumatic brain injury: A pilot randomised controlled trial. Neuropsychological Rehabilitation.

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InPsych April 2012