Intervention is defined as an act performed to prevent harm to a patient or to improve the mental, emotional, or physical function of a patient. Interventions referenced in this toolkit are aimed at treating symptoms associated with TBI and common co-occurring mental health conditions. There are currently no widely established evidence-based practices (EBPs) focused on TBI therefore many of these resources focus on symptom management and accommodations.
Adapting Interventions for Neurocognitive Deficits
Accommodations for neurocognitive deficits:
- Interventions should be introduced with a simple rationale
- Minimize environmental distractions
- Slow down the pace, provide frequent opportunities for patients to respond, generate feedback, and provide reinforcement to maintain patient engagement
- Provide written material/handouts where possible
- Repetition of key points
- Non-electronic devices might include checklists, pictures or icons, photograph cues, post-it notes, calendars, planners, and journals
Those with a history of mTBI may benefit from any number of EBPs and may or may not require modifications to treatment delivery. Those with a history of moderate to severe TBI are most likely to require modifications to treatment delivery.2
The Ohio Valley Center for Brain Injury Prevention and Rehabilitation has produced a training module titled: "Accommodating the Symptoms of TBI." Through this training you will learn to recognize the common symptoms of TBI and how to incorporate compensatory strategies into treatment practices to increase the odds of treatment success."Access the Training Here
Below are examples of several challenges professionals often face when implementing interventions with individuals with a history of TBI. Specific strategies are provided with each question. 1
Clinical Practice Guidelines
The following provides links to clinical practice guidelines offering information and direction to providers managing clients' recovery from the effects of TBI and co-occurring conditions.
Each guideline highlights critical decision points, and provides comprehensive, evidence-based recommendations for practitioners throughout the DoD and VA health care systems.
- Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury (mTBI) (2021)
- Military Health Systems TBI Center of Excellence (TBICoE)
- Guidelines for Concussion/Mild TBI and Persistent Symptoms (Ontario Neurotrauma Foundation)
- Assessment and Management of Patients at Risk for Suicide (2019)
- Management of Substance Use Disorder (SUD) (2021)
- Management of Major Depressive Disorder (MDD) (2022)
- Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017
- Management of Opioid Therapy (OT) for Chronic Pain (2017)
- The Primary Care Management of Headache
- 2021 Progressive Return to Activity (PRA) Following Acute Concussion/Mild Traumatic Brain Injury Clinical Recommendation
- Clinical Practice Guideline for the rehabilitation of Adults with Moderate to Severe TBI
Treatment of Co-Occurring Mental Health Issues
Treatment for TBI should address specific functional issues and not the injury per se. Interventions that treat co-occurring conditions, increase coping skills and executive functioning (cognitive flexibility, problem-solving, goal-directed behavior, emotional regulation) may provide great benefits for individuals across settings and populations.
- Areas of Focus
- Diagnostic Target
- Cognitive Behavioral Therapy
- CBT is a treatment proven to be effective for a range of clinical issues. (Depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness)
- CBT treatments allow for improvement in a variety of coping skills such as social skills, problem solving, critical reasoning, moral reasoning, cognitive style, self-control, impulse management, and self-efficacy.
- Dialectical Behavior Therapy
- DBT seeks to improve distress tolerance, emotional regulation, reduce aggressive and self-directed violent behavior.
- DBT utilizes a combination of skills training, problem solving, and validation to enable patients to reduce self-destructive, impulsive, and aggressive behaviors.
- Thinking for a Change
- Cognitive-behavioral curriculum developed by the National Institute of Corrections that concentrates on changing the criminogenic thinking of offenders.
- Focuses on cognitive restructuring theory, social skills development, and the learning and use of problem-solving skills.
Justice Involved Population
- Reasoning & Rehabilitation
- Intervention that teaches cognitive skills, social skills and values that are required for prosocial competence
- Focuses on critical reasoning, social perspective-taking, self-control, interpersonal cognitive problem-solving skills, and emotional management.
- Integrated Dual Diagnosis Treatment (IDDT)
- Intervention that targets mental illness, substance abuse and criminogenic risk factors have been effective at reducing recidivism and relapse rates and improving psychiatric symptoms.
- Focuses on combining specific treatment strategies for substance use disorders, into a comprehensive program that treats the entire person in a more holistic way.
Justice Involved Population
- Cognitive Processing Therapy
- CPT is a therapy shown to treat PTSD that teaches how to identify, evaluate, and ultimately modify the unpleasant thoughts following a traumatic experience.
- Focuses on developing healthier, balanced beliefs about trauma experiences, relieving feelings of distress related to memories of the trauma, facilitates return to enjoyable activities.
- Prolonged Exposure Therapy (PE)
- PE is a therapy for PTSD that helps patients gradually address their symptoms by addressing traumatic memories, feelings, and situations that people may be avoiding because of trauma.
- Focuses on helping people engage with and feel more comfortable in situations that have been avoided due to trauma, process through the traumatic event, change negative, unwanted beliefs by working through the memory and engaging in activities had previously been avoided.
- Social Skills Training (SST)
- SST is a group-based intervention that was developed to help individuals with Severe Mental Illness (SMI) develop ways to better express themselves and respond to others' thoughts, feelings, and needs.
- Focuses on improving social skills that help make progress towards goals, learn to maintain better conversations, develop help seeking behaviors, and independence. Additionally, it facilitates effectively expressing emotions, resolving conflicts, improving/maintaining relationships, and building assertive skills.
- Problem-Solving Therapy (PST)
- PST is a therapy those experiencing depression or suicidal thoughts. PST develops coping skills to help address challenging life circumstances and chronic daily stressors.
- PST is a goal-oriented treatment that teaches how to identify, understand, and evaluate problems to help individuals move towards action. Focuses on strengthening the ability to address negative feelings associated with suicide and depression. Increase confidence in confronting situations in a deliberate way, enhance motivation, and increase the ability to think through problems.
- Motivational Interviewing (MI)
- MI is a therapy that can help develop healthier habits related to substance use, smoking, nutrition, exercise, chronic health problems, and risky behaviors.
- Focuses on exploring values and goals for treatment and reasons for change while emphasizing collaboration, compassion, respect and a patient's capacity for self-determination.
- Motivational Enhancement Therapy (MET)
- MET is a therapy for those thinking about changing their use of alcohol or drugs. This brief intervention focuses on exploring your reasons and motivations for changing substance use behavior.
- IPT focuses on developing an increased awareness of reasons for and commitment to changing substance use. Encourages the development of healthier substance use habits and health-related behaviors.
- Interpersonal Therapy (IPT)
- IPT is a therapy that focuses on healing relationship problems that may be the cause or result of depression.
- IPT focuses on understanding the connection between interpersonal issues and depression, while helping develop social skills to deal with these problems.
- Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD)
- CBT-SUD teaches Veterans how to make and maintain changes in substance use and improve their quality of life.
- CBT-SUD encourages Veterans to adopt an active, problem-solving approach to cope with the many challenges associated with substance use conditions.
- Substance Use Disorder
- Cognitive Behavioral Therapy for Depression (CBT-D)
- CBT-D treatments often focus on identifying and altering unhelpful thought patterns and behaviors that contribute to or worsen symptoms of depression.
- Focuses on developing more balanced and helpful thoughts while enhancing one's ability to engage in self-management and lead to increased engagement in pleasurable or productive activities.
- Behavioral Activation (BA)
- BA seeks to improve mood by teaching ways to build personally rewarding daily activities, become action-oriented, and focus on problem-solving.
- Focuses on increasing participating in hobbies and social events to enhance healthy behaviors, positive experiences, thoughts, and mood. Teaches one the ability to turn overwhelming tasks into attainable achievements.
- Acceptance and Commitment Therapy for Depression (ACT-D)
- ACT-D helps people accept thoughts and emotions in ways that leads to committed action towards their values.
- A decrease in negative thoughts and feelings. Increased awareness and focus to become fully connect. The ability to clarify values and take action to achieve what means the most to people.
Considerations for Special Populations
Military & Veteran Populations
Visit the Department of Veterans Affairs Community Provider Toolkit: Working Together to Serve Veterans to participate in online "mini-clinics" for civilian clinicians. These educational, assessment, and treatment tools are geared to help support the rehabilitation and recovery of Veterans living with mental illness.
Mini-clinics for providers include the following topics:
- Suicide Prevention
- Serious Mental Illness
- Women Veterans
- Smoking & Tobacco Use
- Substance Use
Justice Involved Populations
Correctional programs that focus on the transition to the community (such as prerelease, work release, halfway houses, or other programs specifically aiming at reentry) and programs that have initiated some form of treatment (such as substance abuse, life skills, education, or mental health) in prison that is linked to community programs that will continue the treatment once the prisoner has been released. Community re-entry staff should be trained to identify a history of TBI and have access to appropriate consultation with other professionals with expertise in TBI. Some main considerations are: 1) transition services to accommodate problems resulting from a TBI, 2) case management and assistance with placements into community mental health and/or substance abuse treatment programs as indicated.
Areas Targeted During Re-Entry
- Substance Abuse Treatment
- Mental Health
There are several useful resources that may assist professionals and supports of children and adolescents with brain injury (particularly, moderate/severe injuries) who are transitioning back into school and home settings. Consult with schools regarding identification, school re-entry planning, IEP/504 Plan development, intervention selection and implementation, long-term monitoring of students and other issues professionals face in supporting students with brain injury.
- Provide consultation to parents of any student with brain injury referred to the team and ongoing communication regarding services the team is providing for student.
- Monitor students annually until graduation for manifestation of new cognitive/
behavioral/ social issues.
- Disseminate brain injury resource information (e.g., written information, links to websites, referrals to community resources, etc.) to educators, families, and community providers working with students with BI.
- Provide training on the educational implications of brain injury to educators as well as groups in their local community (e.g., parent, medical, rehabilitation).
School professionals can assess academic impact, determine appropriate academic adjustments and adjust supports as symptoms subside (See: Brain Injury Alliance Colorado's Concussion Tool)
- Have student removed from physical play at recess, physical education, and athletics
- School should be informed of injury and presenting symptoms
- Schools should be informed of what to watch for and symptoms that may develop later in recovery
- Provide information on academic adjustments and sample symptom checklist
- Severity of symptoms and symptom threshold will impact level of participation in academics
- School professionals can provide valuable feedback regarding the student's symptoms, their recovery process, and academic supports provided for symptoms