When the Brain Changes: Understanding the Role of Psychotherapy After Brain Injury

When the Brain Changes: Understanding the Role of Psychotherapy after Brain Injury

Brain injury can change far more than memory, concentration or physical functioning. For the person experiencing it, a brain injury can affect their relationships, emotional regulation, behaviour, confidence, identity, independence and sense of who they are.
And sometimes the psychological impact is the part that is least visible to other people.

I have worked with people affected by acquired brain injury (ABI), including traumatic brain injury (TBI), for many years — as a therapist, clinical lead and supervisor. One of the things that has stayed with me throughout that work is how important it is to understand the whole person, rather than seeing the brain injury as a collection of cognitive or physical symptoms.

A person may look physically well while experiencing profound changes internally. They may be struggling to manage emotions, process information, control impulses, understand changes in their behaviour, maintain relationships or come to terms with a life that feels very different from the one they had before.

This is where psychotherapy can have an important role.

Brain injury is not simply a physical injury

Brain injury can result from many different causes, including traumatic brain injury, stroke, infection and other neurological conditions. The effects can be physical, cognitive, emotional and behavioural — and these areas often interact with one another.
Someone may experience difficulties with:

• memory and concentration
• processing information
• fatigue
• emotional regulation
• impulsivity
• anger or frustration
• anxiety or depression
• changes in relationships
• confidence and self-esteem
• independence
• behaviour and social functioning
• identity and sense of self.

The difficulty is that some of these changes are much easier to see than others. A physical disability may be immediately apparent. Cognitive and emotional changes can be much less visible.

As academic papers I have been reflecting on describe, emotional difficulties and personality changes can sometimes receive considerably less attention during rehabilitation than physical or cognitive difficulties, despite their potentially profound effect on long-term adjustment.
Because invisible does not mean insignificant.

Who am I now?

One of the most important psychological questions following brain injury can be: “Who am I now?” A brain injury can represent a sudden disruption to the person’s previous sense of self.

Perhaps they were working, parenting, studying, socialising, exercising or living independently.
Perhaps they had a particular role within their family or community.
Then something happens — and suddenly some of those things may no longer be possible in the same way.

There can be grief for the person they were, alongside the challenge of discovering who they are becoming.
This isn’t necessarily a straightforward process of “getting back to normal”.

Sometimes rehabilitation involves helping someone develop a new understanding of themselves, their abilities and their future.

The literature around psychotherapy after brain injury has highlighted identity reconstruction as an important part of longer-term rehabilitation and adjustment. That is an area where psychotherapy can offer something different from purely cognitive or physical rehabilitation.

Sometimes less really is more

One of the ideas I particularly appreciated in Coetzer, R. (2014) is the question: Does therapy always have to mean doing more?

In mainstream psychotherapy, we can sometimes become very focused on techniques, models, homework, formulations and increasingly complex interventions.
But what happens when the person sitting in front of us has difficulties with memory, processing speed, attention or cognitive flexibility?
What happens when they become overwhelmed by too much information?
What happens when remembering what was discussed last week is itself difficult?
In these circumstances, simplicity can be enormously valuable.

Coetzer, R. (2014) argues for identifying the core elements of psychological therapy and doing those things well, repeatedly and compassionately, rather than assuming that a more intensive or complicated intervention will automatically produce better outcomes. That doesn’t mean lowering expectations of therapy. It means adapting therapy to the person.

The therapeutic relationship matters

One of the most important interventions may sometimes be something that sounds deceptively simple:

Listening. Really listening.

Brain injury can make communication more complicated. A person may need longer to process what has been said. They may struggle to find words, organise their thoughts or communicate their experience in the way they previously could. They may also become frustrated because other people continually misunderstand them.

A therapist therefore needs to be prepared to slow down. To notice, to listen differently, to resist the temptation to fill every silence or immediately “fix” something. The therapeutic relationship can provide a space where the person doesn’t have to constantly explain or defend their experience.

Coetzer, R. (2014) describes listening not simply as a communication skill, but as an important therapeutic intervention in itself — particularly when cognitive, emotional and behavioural changes make traditional communication more difficult.

Sometimes the most therapeutic thing we can offer is our willingness to stay alongside someone while they make sense of what has happened to them.

Therapy may need to be adapted

This is an important point for therapists. Working therapeutically with someone who has experienced an acquired brain injury isn’t necessarily about abandoning psychological models such as CBT, ACT, behavioural or narrative approaches.

It may instead be about asking: How do I make this approach accessible to this particular person?
For example, a complex CBT intervention may need to become much more concrete. A person may benefit from one simple idea that they can remember and use, rather than being given several different concepts to take away.
Similarly, ACT’s emphasis on values and meaningful action can sometimes provide an alternative to endlessly trying to challenge or change thoughts — particularly when some of the person’s thoughts reflect very real losses and changes in their life.

The question becomes less: “How do I help them think differently?” and more “How can I help them live as meaningful a life as possible within the reality of what has happened?”
That can be a very different therapeutic conversation.

Repetition isn’t failure

Another important consideration is time. Psychological adjustment following brain injury can be a long process.

A person may move through awareness, frustration, grief, acceptance and adaptation — and they may move backwards and forwards between these experiences. What seems to have been understood in one session may need revisiting. What was achievable one week may be difficult the next.

That doesn’t necessarily mean therapy isn’t working. It may simply reflect the nature of brain injury and the person’s ongoing process of adjustment. The paper makes the interesting observation that, for some people, time and repetition may be more valuable than intensity. For therapists, that can require patience. We may need to resist the pressure to constantly introduce something new. Sometimes progress comes from returning to the same important ideas again and again — until they become familiar, meaningful and usable outside the therapy room.

Beyond the injury: the person remains

Perhaps the most important principle for me is this: The person is not their brain injury. They have experienced a brain injury. That distinction matters.

There is a danger that someone can gradually become defined by their diagnosis, their impairments, their rehabilitation goals or the things they can no longer do. Psychotherapy can create space for something else.
For memories of who they were.
For exploration of who they are now.
For grief about what has changed.
For recognition of what remains.
And, importantly, for consideration of what might still be possible.

That doesn’t mean offering unrealistic optimism or pretending that the injury hasn’t changed things. It means creating space for realistic hope.

A different kind of therapeutic work

My experience of working with brain injury has reinforced for me that good psychological therapy isn’t necessarily about having the most sophisticated technique.

Sometimes it is about understanding the person in front of you well enough to know what they need.
Sometimes it is slowing things down.
Sometimes it is saying less.
Sometimes it is repeating something that matters.
Sometimes it is listening.
Sometimes it is helping someone recognise a strength or behaviour that they hadn’t noticed themselves.

And sometimes it is simply being prepared to stay with someone through a very long process of adjustment.

Brain injury rehabilitation is often talked about in terms of recovery. But perhaps we should also talk about adaptation, identity, meaning and living well after what has happened.

Psychotherapy has a valuable role to play in that process. And perhaps, sometimes, less really is more.

Further reading:
Coetzer, R. (2014) ‘Psychotherapy after acquired brain injury: Is less more?’, Revista Chilena de Neuropsicología, 9(1E), pp. 8–13. doi:10.5839/rcnp.2014.0901E.03.