As recovery from a TBI progresses, more specific, non-psychopharmacologic measures to deal with the confusion and agitation are appropriate. These measures are best applied in a formal rehabilitation setting where the environment can be structured to minimize likelihood of injury. This typically begins within an acute rehabilitation hospital but then, with prolonged delirium, may extend to post-acute rehabilitation residential settings. Occasionally, the agitation dimension has a degree of aggressiveness (e.g. biting, hitting) that requires a specific setting commonly referred to as a “neurobehavioral” program. These are highly specialized, locked environments where the staff is trained in behavioral contingent management techniques and in appropriate physical control methods. Such programs are essential in safely dealing with the assaultive patient until this period resolves with progressive recovery. In a very few cases, however, this aggressiveness never resolves and a permanent placement in a locked facility is indicated.
Cognitive Disturbance and Cognitive Therapy
Cognitive disturbance is the most common significant deficit following TBI. This encompasses many dimensions, including impairment of attention and concentration, increased distractibility, reduced speed of information processing, memory issues, difficulty with logical thinking or problem solving, and so on.
Usually, a variety of these aspects is affected in a unique profile and a comprehensive neuropsychological test battery is needed to measure the extent of each. Most can be expected to significantly improve with time following injury. It is believed that this process of recovery continues for 18 to 24 months. Though it is likely that improvement progresses beyond this period, it becomes progressively so minor as to be ultimately clinically trivial.
The most common approach to these deficits is “cognitive therapy,” which is a collection of rehabilitation techniques intended to guide a recovering TBI survivor through graded cognitive “exercises.” It is believed that these will guide the recovering brain to better function. This basic theory is one which has numerous supporters and detractors. The evidence for its efficacy is not overwhelmingly convincing. Nevertheless, cognitive therapy is generally accepted as, at worst, it teaches compensatory methods to the patient, and at best, it potentially actually advances recovery.
Current clinical standards dictate these treatments be provided for up to the period of “active” recovery, which is the 18 to 24 month period mentioned above. The utility of these approaches should be periodically reevaluated throughout this process. A lack of progress in cognitive ability generally indicates a lack of efficacy for that patient. In such cases, the effort should be discontinued.
However, it is important to recognize that the lack of effect may be because the intervention was attempted too soon after injury (during the period of delirium), or that some co-morbidity (e.g. depression or pain) has interfered with the process. Under these circumstances, a later re-engagement in the effort may be appropriate.
The issue of psychotherapeutic counseling (as distinct from cognitive remediation) arises often in TBI. For minor injuries, this is undoubtedly useful in many cases. For the cases of moderate and severe TBI, there is a question of the efficacy of these psychodynamic approaches when the basic underlying functions of attention, judgment, memory and insight may be significantly impaired. There is clearly some level of severity above which such efforts are futile, yet there are some patients who appear to clearly benefit.
Unfortunately, it is difficult to be prescriptive about when or when not to attempt psychodynamic treatments. The judgment of experienced clinicians should be relied upon in each case.
A more open-minded approach should be kept regarding other aspects of counseling that address more compensatory techniques. Examples include the use of memory notebooks, “time out” responses to emotionally difficult situations, and specific community survival procedures such as public transportation use or emergency responses like dialing 911. Interventions that involve couple or family counseling are also quite beneficial in helping the patient’s social support system adapt to the changes following TBI.
Job coaching and vocational counseling, when appropriate, are also effective ways to aid a survivor to regain some meaningful work opportunity which additionally can do a great deal to help with the emotional distress following TBI. Group therapy with peer survivors has often been reported useful for all types of counseling following TBI.
Wrapping it all up
It is perhaps most important to realize that the neuropsychiatric deficits following TBI are both the most “hidden” to casual observation, but are at the same time the most universally present, and that the neuropsychiatric deficits overall become the most disabling. While there are limitations to the degree to which these can be reduced by current techniques, there are many approaches which have been shown generally effective to some degree and which, for some patients, can have dramatic and “life-saving” impact. In planning for management of the TBI survivor and his or her family, this aspect of care should never be overlooked.