Cognitive Behavioral Therapy (CBT) can play an important role in brain injury rehabilitation. In this webinar, Dr. Snell provides an overview of CBT, details the process, and explains how CBT can help people with brain injuries identify and change disturbing thought patterns that have a negative influence on behavior and emotions.

Speakers: Tim Benak, Dr. Snell

Video Transcription


Dr. Snell – 00:53

Welcome everybody. Our topic today, the role of cognitive behavioral therapy and brain injury rehabilitation is really talking about what is CBT and what is the role within rehabilitation with individuals who have suffered neurological insults or injuries, and the what, why and who of cognitive behavioral therapy.

There’s going to be a little bit toward the end as well on kind of the how but I didn’t necessarily want to put that in. Since it doesn’t start with a W, it doesn’t fit that slide. So we had to go with that. So let’s start with “What”.

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy is a means of addressing distress within individuals looking at improving emotional functioning, behavioral functioning, and it really comes out of the middle of the 20th century where there were several psychologists, who really felt that the more traditional behavioral therapy didn’t fully address the nuances of thought and the involvement of our internal states when it came to how we react to situations how we perceive situations.

So our internal state plays a role when it comes to our choices, our actions and our behaviors, and really addresses the role of those automatic beliefs, what they called core beliefs, which are our subconscious internal automatic thought processes that are the result of our lifelong learning, our experiences. And as we have now seen, we have the capability throughout our life through something we call neuroplasticity to change how our brain functions. And that aspect of addressing those internal automatic beliefs is also something that we can change through conscious processes. And this is a therapy that’s really aimed at addressing that.

As a psychologist, again, the majority of time that somebody comes to you, you know, very rarely does somebody come to a psychologist and say, you know, hey, everything’s going great, my life things fantastic. The world’s a wonderful place. But you know, I think I could probably do better. You know, most of the time people are coming to us because they are in distress and the vast majority of diagnostic symptoms items that you see within the the DSM five.

One of the primary diagnostic criteria is that whatever the person is coming to you with, it is a disruption in their life it is causing them distress. If you have issues in your life, but they aren’t causing you distress, then it’s not something that you’re likely going to want to address.

But if you’re having, you know, problematic behaviors, maladaptive behaviors, emotions, thoughts that are limiting you in some way, this is a therapy that is looking at addressing that by looking at the underlying internal beliefs through which we all filter our perceptions through which our own internal biases are built upon.

And then altering those internal beliefs so that our behavior, our emotions, our thoughts better match what our goals and desires are and better match the reality in which we all exist.

Traditional Behavioral Therapy

So traditional behavioral therapy really looks stimulus and response. In other words, the classic Skinner box where when the light comes on, you press the bar and you get a reward that is a pure behavioral stimulus and response. It’s one that I kind of, well purposefully/inadvertently created at home.

Our dogs absolutely love defending their territory by barking at the front window anytime somebody walks past with another dog. Well, I noticed occasionally it’d be somebody walking by and our dogs didn’t notice it. So I would just kind of say Bark bark. And now the dogs would run to the front window and just furiously defend their territory. My wife, I must say, is not terribly amused by this little trick.

But what happened was, now when you just softly say “bark”, the dogs will jump up from whatever they’re doing and run to the front window. That is a stimulus and response.

Well, behavioral therapists, you know, felt that this accounted for the majority human learning and actions and interactions. But, cognitive behavioral therapy, these therapists that I mentioned earlier, they, they felt that this didn’t fully encapsulate the nuances of how human intellect is involved in how we choose to behave in any given situation.

So they said, you know, you have a stimulus, but you also have these internal core beliefs, you have these internal thought processes. And we filter that stimulus at any given time through those internal core beliefs, and then that results in a response. So it wasn’t just a knee jerk response.

So it’s not only the situation, it’s also other aspects of our internal core beliefs that result in our perceptions. And so to be given a gift, and then react to that as if you got something that, you know, that’s actually more punishment than it is reward. It depends on what’s called going on internally, what your own subconscious automatic processes are, that results in that.

Core Beliefs Influence Thoughts and Actions

Our core beliefs result in these automatic assumptions, basically what you would consider to be knee jerk responses. And these automatic thoughts result from that. These automatic thoughts are very much involved in shaping what we feel at any given moment, the conscious thoughts and behaviors that we have in response to a situation, a classic, you know, awareness, kind of internal response versus further information type of response.

An example that a psychologist that I worked with for many years, often gave when he said, You know, you’re sitting at a light red light and there’s a car in front of you and the light turns green, and the car in front of you doesn’t move. It just sits there and so you start to get irritated, you start to blow the horn. You get out eventually, because the car didn’t move through the entire cycle, and you’re not going to sit through another light, right? You get out and you walk up and there’s a woman who looks at you with a panic expression on her face and says, My baby’s not breathing.

Well, all of a sudden your world suddenly changes those perceptions of what’s going on. This person in front of you is not trying to intentionally irritate you, or get you goat. And I think oftentimes, you know, road rage incidents probably arise from the fact that we react on those internal thoughts. And as we will talk about we are really really bad at reading other people’s minds. But we often react as if we are absolutely understanding what people are thinking.

So our core beliefs influence our thoughts and our actions. And you know, basically, if your core beliefs match well with what it is that you’re pursuing and the way the world really operates, then you’re probably a relatively psychologically well adjusted individual.

But oftentimes, those core beliefs get in the way of what we’re trying to accomplish, they limit us or they result in unhappiness and interference. And so you need to change those internal beliefs through which you filter the world and through which your perceptions are occurring, if they are causing you distress.

The Major “Triad” of Cognitive Distortions

So cognitive behavioral psychologists will tell you there’s a major triad here of distortions, and these are basically kind of broad categories that you can put the majority of these cognitive distortions into. Distortions of self, distortions of the world, and our distorted view of the future. And each of these play a role in how we view ourselves and how we emotionally experience the world.

Distorted View of Self

Distorted view of self often is one of negative thoughts about oneself, so I am unlovable or I am ineffective. We’ll talk a little bit about some of the things that that result from these types of thoughts. But the bottom line here is a negative expectation or view of one’s own self and effectiveness within interacting with others.

You know, a distorted view of self often results more in feelings of depression than anything else. So someone who is, if you’re looking at which of these major areas do you need to look at as far as changing those distortions, it’s kind of what are the major emotions that are present.

If you see depression is a primary symptom reflected, you see someone who’s down blue. Oftentimes it tends to be more associated with that distorted view itself.

Distorted View of the World

Now more anger and frustration tends to be associated with a distorted view of the world, seeing the world as just universally a hostile place or expectations that the world should be orderly and predictable. And we’ll talk about how those get in the way of our decision making.

Distorted View of the Future

And then lastly, that distorted view of the future general expectation and feeling that nothing is going to work out for me or in whatever situation you’re in. It’s always going to be like this.

It just has to do with our human nature of feeling like whatever experience we’re in right now. It’s always going to be like this, or whatever feelings, whatever things that we really love, whatever we really like. Those are always going to be our preferences and the interesting thing when it comes to that view of the future, as being relatively unchanged from the current status is that despite every bit of evidence that we have throughout our life that things are constantly changing, we sometimes seem to think that things are always going to be the same. And they they don’t stay the same even when we want them to. There’s always change within the world that we live in.

And so those are the major cognitive distortion categories. Let’s go into a little bit of detail on some of these. So a core belief example and result.

Distorted View of Self Example

So if you This is the distorted view of self, if you have the feeling, if you have this internal core belief that everybody has to love me, I need to be liked by everybody. You’re kind of setting yourself up for tremendous failure in that case, because no matter what you do, everybody is not going to like you.

We live in a very polarized society right now. So depending on what color shirt you have, or what sports team logo you have on your head, there will be people who simply will not like you. There are people who don’t like you, because of the country that you live in, your political views, your religion, all of these things, you know, depending on what group you fit into other groups are not necessarily going to like you.

And so if everybody doesn’t like me, then I’m no good. Well, if that is a core belief for you, you’re going to have a lot of folks that don’t like you, for one reason or another, you have no control over what other people like or don’t like. And so as a result, now, your self worth feelings are in the hands of everybody else. That I must do what others want. So they will like me.

Again, from a from a business standpoint, if you are in a leadership position, if you feel that everybody has to like every decision that you make, that decisional paralysis is going to mean that you’re not going to be able to make a lot more decisions, because I’ll guarantee you that any decision that you make somebody is going to be unhappy with, somebody can find a reason not to be happy with that particular decision.

So if your self worth is dependent upon everybody else approving of you and liking you, that is a difficult position to be in, because that is rarely ever going to be the case, if ever.

Distorted View of the World Example

Another core belief and result example would be that the world should be predictable and orderly. I think we would all love for that to be the case that all of our plans should work out, we should get what we want, when we want it, kind of a three year olds version of how the world should be. If I want it, it’s mine. The world should treat me the way that I want to be treated, and I should get what I want when I want it.

That really is not the way that the world works. And again, most of us have a fair amount of evidence that that’s not the way that the world works.

A more realistic way is to say, you know, I would like to be able to get most of the things that I want. But my view of self, my value as a person, my view of my success in life is not dependent upon me getting everything I want when I want it.

So really a more realistic way of looking at the world would be, it would be nice if I was able to get that. But if I don’t, it’s not the end of the world. It’s not a complete catastrophe. So not overreacting to those irrational thoughts.

Now irrational thoughts you can often pick up on from the statements that someone makes if you’re seeing these kind of exemplary statements, must, should, have to, never, always. We don’t live in a black and white world. And so if you see these types of statements that are on the extreme end of the spectrum, those tend to represent reactions to an irrational expectation.

So if something bad happens, I’ll never live this down. So in the middle of this presentation, I say something personally embarrassing and stupid. And then I’m going to say, I will never live this down. This is well, you know, I’m not that important. The rest of the world doesn’t revolve around me. And if I do something foolish, or embarrassing, yeah, I probably don’t want to repeat that the next time I do a presentation, but it’s not the end of the world. My life doesn’t stop simply because I’ve done something that I would have preferred not to have done publicly. I’m getting some laughter back out of the back of the room here. I can’t see how this will ever get any better.

Again, that would be a distorted view of the future. because things change, things change over time. So yeah, I think it might be realistic to say at this moment, I can’t see how this is going to change. I think we all kind of feel like this with With COVID-19, right, all the changes that they have caused to our lives, to our routines, to our relationships. I can’t see how this is ever going to change, it will, it will change.

And so I think it’s, you know, having that more realistic view of the world that things do change over time. It is not irrational to say that I don’t like the way things are going right now. But it is irrational to say they are never going to get better. Because things do change.

Irrational thoughts. Let’s go into a few kind of specifics here.

What would be the selective attention aspects. So in other words, a person who is depressed tends to filter all of their perceptions through that general negative mood and so you pick up more easily on negative aspects of any given situation than you do the positive aspects.

So you have you know the classic Debbie Downer of you know, I won the lottery, Oh, great, now I’m gonna have to pay all these taxes. It is finding the negative in any given situation. So, you know, the filtering through our internal thought processes can result in that.

I mentioned this one a little bit earlier magical thinking or mind reading. One is that magical thinking everything would be better if…If I just had if I was two inches taller, if I had a full head of hair, if I had a better car, if I had a bigger house, you know, my life would be better.

There is the classic statement that goes along with that which is, remember, no matter where you go, there you are, it’s you. That’s your internal perception that is you that determines your your mood and your emotions. The world simply exists around you and you kind of choose how to react to it.

And mind reading, assuming you know what other people are thinking and then basing your behavior reactions, emotions, thoughts on the basis of your expectation.

So when somebody cuts you off in traffic when the woman was stopped at the light in front of you, you are reacting in the moment if you’re getting angry and irritated on your belief that the person is just doing that to piss you off. And in fact, you don’t know what the other person is thinking you don’t know why those actions occur.

So it is that attribution theory that other people do things because they’re jerks, and I do things because it’s beyond my control. Other people do things because they feel like it’s beyond their control as well. We all kind of have the same processes going on. So there is a whole host of irrational thoughts that all of us at one time or another utilize in making our decisions and deciding how to act and react.

And all of these, you can kind of see the whole list here all of these can result in basically irrational reactions. So in other words, we’re reacting to those internal thought processes, rather than to the world as it is.

Cognitive Behavioral Therapy is Focused on Challenging Our Irrational Thoughts

So cognitive behavioral therapy is really focused on challenging those irrational thoughts and learning a different way of responding. But first you have to realize that they are irrational, simply being told that you’re reacting to irrational thoughts is not adequate for someone to change those experiences.

It’s kind of like telling somebody you know, you should probably improve your diet, get a little bit of exercise and and you know, use moderation with most things in your life. Oh, okay. Well, great, thanks. I’m going to go change everything about my life now. It’s not enough simply to have the information you have to practice it.

So it’s like anything else when it comes to learning. When it comes to learning a physical, emotional or cognitive process, we have to practice it to the point that it becomes automatic. We have to practice it and engage in that neuroplasticity of changing how our brain operates.

The first and foremost thing here again, I think oftentimes when we talk about the fact that people are reacting to their internal thought processes, and they’re basing their emotions, behaviors and actions on those, is you’re saying this is all in my head. Well, yes, it is. It is our brains that determined all of this. It is the programming that we put into our brain that determines how we are able to do things, and from a cognitive standpoint, the way in which we think.

So we have to learn for ourselves to some degree. Again, if my son, kind of like me and my father, if I had listened to all the advice that I got early on, I probably would not have had near as much distress in my late adolescence and early adulthood as I did.

But all of us seem to have to learn the hard lessons, the hard way. We have to experience things in order to truly internalize them. And that’s why practice is important. Simply being told this is a different way to think does not make you think differently. You actually have to practice that.

It is practicing those more rational, aligned thoughts that are important in this process, rather than simply just kind of flow and going with the flow of the automaticity that you’ve established throughout your life.

The Process of Cognitive Behavioral Therapy

First off, just the assessment process of sitting down talking to somebody figuring out what are the irrational thoughts that are driving the distress they’re experiencing providing that education and reconceptualization. And then acquisition of skills predominantly through and we’re going to talk about this homework through actually experiencing things. That’s the training and consolidation. The ongoing process would be again, making sure that we don’t backslide into our old routines that generalization and maintenance of skills and follow up that’s involved.

An important aspect of cognitive behavioral therapy is that it is a very specific goal oriented process. And it is time limited. It is not a forever therapy process.

You want to teach the patient, the client, this process and you want to guide their understanding of it so that as they understand this global process of refuting those irrational beliefs. They’re able to do that moving forward and generalize it over to other things. So you want to teach that patient or client to dispute and change those thoughts and beliefs and replace them with a more rational alternative.

And again, learning through assignments through practice and the neuroplasticity piece, through repetition, what we know about human learning, and how we change our brain.

The Importance of Homework

Now, it’s not enough just to be aware of your irrational thoughts. It’s being aware of the fact that we all feel like things are always going to be like they are now that’s not enough to actually change our emotions. We have to experience it and then reflect back on those experiences. That’s the repetition that helps solidify that.

The vast majority of change that a patient experiences is within those experiences they have in the assignments. It is within their own experiences. So as we see that things don’t necessarily follow that irrational expectation, we alter our expectation, we alter that internal code.

I’ve given the example before that Jon and I did a video one time and as a part of it, and don’t ask me why, we went to the mall in February wearing, basically, you know, Hawaiian shirts, Bermuda shorts, zinc oxide on the nose, and flip flops. And now we expected you know, everybody you know, this is February in Omaha, it is freezing cold outside sub zero temperatures, and we’re going to be walking around them all in our Hawaiian shirts.

We fully expected that mall security is going to be on us just the second we walked through the door, you know? Everybody’s going to be looking at us. I think you know, most of the time that’s the way we feel. We often feel socially subconscious because we always feel like everybody else is judging and looking at us.

What we found in walking through the mall is, we might have gotten a glance, but people went on about their lives. You know, nobody thinks about us as much as we think that they think about us. That’s the mind reader piece.

The example I always like to say is your own mother doesn’t think about you as much as you think she does. You know, in the middle of this presentation, I’m worried that people are hanging on every word and critiquing all of the mistakes and pauses. And, in fact, you’re probably thinking about what you can have for lunch or what you’ve got going on later today.

People simply don’t put as much importance on ourselves as we feel like they do. And so you have to experience that and pay attention to that repeatedly to change that irrational thought, that irrational expectation.

Now, these are some different ways that you can have people do this as well. And part of it is really to just review and repeat those experiences. So when you’re having people read and reflect on other people’s stories, you want to relate that to their own experiences. If they are doing some logging or journaling themselves, you also want to have them go back and review that because again, you are having them specifically repeat those experiences. They’re getting practice.

Cognitive exercises or real world situations that challenge those irrational beliefs and sometimes they can be bizarre. Albert Ellis, as matter of fact, one that he wrote about in one of his books, had to do with a woman who had a tremendous amount of social anxiety so that, you know, just walking across this college campus, I feel like everybody is looking at me and judging me.

And he, as an assignment, had her walk across campus with a banana tied to a string dragging behind her. And the purpose of that knot was was not to embarrass but to show her that even if you do something that normally you would consider to be relatively bizarre, everybody else is not simply going to stop, point, laugh and make fun of you.

People might wonder, why is that girl dragging a banana. But that’s not the focus of their life, they they go on, and to do that does not crush your soul or in your day. And so you can do something that would otherwise be considered odd or embarrassing, and it’s not the end of the world. And as a matter of fact, some people actually kind of enjoy doing things that are odd, or would otherwise be embarrassing.

Gilbert Gottfried has made a career out of that and a very successful one. He is one of the most amazing comics that we have. And it’s because he steps outside the bounds of normal societal social expectations. And in doing so, is able to point out to us interesting things that it’s just a an entity mechanism of delivering information.

I mentioned journaling, graded exposure working toward a goal, as well. So how can we get someone to change their internal automatic thought processes through these experiences and assignments. And, the experiments themselves, walking across campus dragging a banana behind you, was testing a hypothesis.

So if I do this, I’m going to be so completely embarrassed. I’m going to be just in a laying on the side of the sidewalk crying because everybody is just gathered around me in a circle pointing and laughing at me. That’s just not the way the world works. You know, everybody else has their own stuff going on, and you’re not that important. And learning that you are not that important, is somewhat liberating, because it allows you to not end your world because something embarrassing has happened. You move on.

You have to experience that. Again, like any kind of learning, the most important aspect of learning is first and foremost repetition. So doing things over and over, you get more comfortable with it. Most people are extremely scared of any kind of public speaking. And it is only through the experience of repeatedly engaging in public speaking, that you get more comfortable with it over time.

I don’t remember which comedian it was several years ago, but there was a national survey looking at what are what are the greatest fears that people have. And public speaking was number one, and death was number two. And so he said, what this means is, at a funeral, the vast majority of people would rather be in the casket than performing the eulogy.

Tim Benak – 29:19

Yeah, I remember in my role traveling around and giving presentations and offices and the first time I traveled with you, and you did a presentation, I asked you, Like, how do you prepare and you’re like, I just remember that no one in here is actually paying attention to what I’m saying. If you mess up or if you skip something, you say something. So that was a little nugget that I took four years ago. Now I remember every time I’m in front of people, I’m like, I don’t think anyone’s actually listening to me. So it’s okay if I mess up.

Dr. Snell – 29:50

Well, you hope that they listen. And you hope that you can make an impact with the information. But at the same time,  it’s simply a presentation, right? Kind of like a meal. You ever had a bad meal? Yeah. Did you have a better one later? Yeah, things change. Right? So not the end of the world.

Emotional Disruption Following Brain Injury

So let’s talk about CBT and brain injury rehab and why is an important consideration. First and foremost would be that depression is much more common following any type of injury, not just brain injury, any type of trauma that a person experiences.

And there are many different factors that go along with that, first and foremost, the situational issues. After brain injury, an individual, you know, oftentimes has significant, particularly that the nature and severity of injuries that we often see here at QLI, these are life changing injury.

And at least for the time period, when the person is here with us, there’s a huge interruption to their normal routines. So there are situational factors that you know, if I can’t go to work, that’s going to affect my sense of self. If I can’t be at home with my family, that’s going to affect my sense of self.

Neurologically, there are aspects of injury that affect our neurotransmitters. So biochemical is certainly an aspect, our cognition, our ability to understand our self awareness, and our role in our social network. All of these things are changed as a result.

An important aspect to keep in mind as well is that variability of presentation secondary to brain injury, this is a very important thing that I want you to pay attention to. There is a huge amount of variability. Depression does not always present in a classic DSM diagnosis fashion after brain injury.

So in other words, the neurological sequelae of their injury may change how depression is manifested in a patient who has had a brain injury. So you need to look at other aspects of indicators. So difficulties with self monitoring and self awareness can certainly be an interference deficits in memory can make it difficult for an individual to be able to even to report how have they been feeling over the last couple of weeks and ongoing sense of continuity of self.

You have to look at other indicators of depression like changes in sleep. You have to use caution with that though, because again, a disruption of sleep is also a hallmark of a neurological insult. Changes in appetite, again, you have to look at the neurological sequelae that might be affecting those as well.

Most helpful, likely, in my opinion, would be descriptions from people who know this individual very well. So family members, caregivers, so they are much more attuned to that individual’s baseline emotional functioning, and, you know, what are the things that brought this individual pleasure in the past? And are they receiving the same amount of pleasure from those types of activities and engagements now?

So, behavioral descriptors and emotional descriptors from family members and caregivers is probably one of the main things that you would want to evaluate when you’re looking at the possibility of depression following brain injury.

From a behavioral standpoint, there’s also a very complex link between depression, particularly after brain injury and aggression. So if you have an impulse control disorder, if you have frontal executive dysfunction as a result of your neurological insult, you are much more likely to demonstrate irritability, anger, maybe even assaultive behavior in the short term after brain injury and so these can also be reflective more of an emotional reaction to the awareness of what is different.

Increased Rate of Depression

Depression is not always the same after a brain injury and you have to be aware of that when you’re looking at the diagnostic aspects.

There is an increased rate of depression following brain injury. Studies have shown predominant increase that is, as you see on the slide there, up to 61%. There are studies that have shown even higher levels and it has to do with the combination of factors. It’s situational factors, social factors, biochemical factors, all of these can contribute to the increase of depression. And a big one certainly being the interruption in one’s life routines.

I think all of us have experienced likely some mild degree of increased depression and anxiety. Again, back to COVID-19. It has interrupted our general routines and lifestyles and as human beings, we don’t like change, we like things to stay the same. Interestingly enough, in a world where things constantly change, we want things to stay the same. And so we react to that emotionally as well.

Now, these rates of diagnosis of depression after TBI don’t take into account the number of individuals who have a sub-clinical level of diagnostic criteria. So in other words the diagnostic criteria demand certain symptoms be present. And oftentimes, that increase in just kind of general depressive mood might not rise to a level that would be diagnosed as a clinical depression but certainly may represent a substantial change in mood.

And it’s important to treat this because we know that depression following brain injury is associated with poor outcomes, poor cognitive outcomes, poor social outcomes, poor functional outcomes and a self reporting of a poor quality of life. And other neuro behavioral challenges can also be more of an issue when it’s accompanied by untreated depression.

So given that we know a great deal about treating depression, identifying it and treating it is important for individuals who’ve had a neurological insult because of the additional issues that can be brought about as a result that depression.

Anxiety Disorders Following Brain Injury

From the standpoint of anxiety as well. Studies that have looked at this with around a 2.3 fold increase, a diagnoseable level of anxiety disorder at around 24% of the population in a particular study I was looking at, and there’s a lot of overlap as well with the physiological symptoms that might be associated with TBI.

One of the core symptoms of the DSM five diagnosis for generalized anxiety disorder includes feeling restless, on edge, easily fatigued, difficulty concentrating, irritability, sleep disturbance.

Well, these are all things that are a neurological sequelae of a brain injury. And so there is certainly going to be an increased risk for diagnosis of this because those symptoms are present and they are not necessarily just an exacerbation of a pre existent issue.

If an individual didn’t have symptoms of a generalized anxiety disorder or these restlessness, fatigue, concentrating difficulties, irritability. If those symptoms weren’t present prior to a brain injury, then you would just naturally assume that they are a direct sequelae to the injury, they are secondary to that injury.

Now, if those symptoms did exist previously, oftentimes they are exacerbated, they are worsened by the fact that the person now has this this brain injury which is also causing a worsening of those symptoms. So there is a huge overlap between those symptoms and the increased diagnostic probabilities in that group.

Post Traumatic Stress Disorder

Other aspects of obsessive compulsive disorder are the relationship between the severity of injury and post traumatic stress disorder. Interestingly enough, people with milder brain injuries are more likely to demonstrate Post Traumatic Stress Disorder.

Some of this has to do with the aspects associated with recall, reexperiencing flashbacks, memory associated with a trauma. For an individual who has had a very severe traumatic brain injury, there is typically an interruption to the process, the neurological structures and networks that’s involved in recording that information. In other words in putting into long term memory storage, that experience.

I think there’s something of a protective factor involved there in very severe brain injuries that actually probably works better in the patient’s favor that they don’t remember every aspect of what happened in their accident and their post accident treatment.

That is probably somewhat helpful from the standpoint of PTSD that might otherwise be present. With the severity of injury that we tend to see with individuals who come to QLI, who need long term or longer term, more than just acute rehabilitation treatment in a hospital to need residential post hospital treatment, that represents a level of severity of injury that means that the vast majority of individuals that we see don’t have any direct memory or recall of their injury itself. And so there’s a little bit of a protective factor there because if you do not have that memory, you do not have a memory to flashback to. You don’t have a memory to intrude.

PTSD is relatively rare with severe to profound injuries. It’s much more common with mild injuries where those neurological structures are capable of recording and remembering that trauma at that time.

The other piece is there’s a huge overlap between PTSD symptoms and mild traumatic brain injury symptoms. Some of the things like light sensitivity, irritability, changes in mood, changes in sleep. These are common to PTSD from individuals who have had trauma that are unrelated to neurological insult. They’re also common with mild traumatic brain injury, and so you tend to see overlap with those as well.

Those are all symptoms that are amenable to the treatment with and utilizing cognitive behavioral therapy. And so that’s why it is important to do that.

For individuals who have had any type of a pre injury history of depression, they are certainly going to be at much greater risk for developing depression after TBI. Again, individuals without a pre injury history of depression we know that symptoms of depression worsen the neurological aspects, the social aspects, the return to work aspects after a brain injury. It’s important that these things be treated.

We know that CBT is one of the most empirically well supported interventions, or treatments for depression in the general population, and it applies equally to individuals who have had a brain injury. We have studies that demonstrate that it is empirically well supported for treatment of depression of anxiety disorder of PTSD of chronic pain.

So with a classic diagnosis symptoms consistent with depression, are with those subclinical aspects for an individual who is demonstrating adjustment issues after depression. Studies have demonstrated the utility of this with this population and it is important that those aspects be treated because of the potential interfering factors that can exist.

CBT treated cases demonstrate significant improvement compared to no treatment. It is effective for the specific problem that you’re focusing on. Again, CBT is typically goal oriented, so in other words, there is a specific aspect of an individual’s functioning that you are targeting, and it doesn’t necessarily generalize and it doesn’t fix everything.

Now, ideally, if you understand the global concepts involved, you can generalize this, that requires a level of cognition, as well, a level of self awareness. The goal of the therapist is really to teach the process to the patient. Again, it starts probably as a more directive process, but through this learning process you want the individual to be able to apply this themselves, you want to replace your voice as a therapist with their own voice in their head moving forward so that they can direct their own challenging of their irrational thought processes.

Now, awareness is an important aspect that can be a barrier to interventions that are dependent upon self assessment, and a common acceptance of reality or even in the moment, self reflection. With a greater severity of injury, there’s a greater likelihood of compromised awareness.

Now fortunately, from the standpoint of traumatic brain injury, the vast majority of cases fall outside of those more severe injuries. The vast majority of brain injuries that occur are mild or moderate in nature, meaning that the interfering effective awareness impacts a relatively small percentage of individuals who have sustained injuries.

Even for injured individual who have very severe traumatic brain injuries, in the process of recovery, that awareness tends to be something that is an evolution. A person tends to become more aware as their cognitive recovery progresses.

You also have to look at the role of frontal executive functioning from the standpoint of impulse control. And, again, that contributes to self awareness.

Another is the right hemisphere neural substrates that are associated with issues of awareness. Right hemisphere insults are more focal, right hemisphere damage tends to have a greater impact on one’s emotional functioning and processing, and to some degree issues of awareness as well, not that awareness is fully located in any one place in the brain. Right hemisphere, damage does tend to disproportionately affect that aspect of functioning.


For a population of individuals who have sustained a brain injury, oftentimes it is necessary to adapt some of the practices and processes of cognitive behavioral therapy so that you get the degree of repetition that you need or that you can provide the supports that are necessary.

Now, as we’re talking about these subconscious processes and irrational beliefs, we’re talking about some relatively abstract concepts. So an individual need not necessarily fully grasp and understand all the nuances of that to actually be able to benefit from the behavioral aspects of experiencing differences and having those pointed out.

It might be necessary to be a little bit more directive if you have an individual with significant cognitive limitations. If you have a patient that you’re working with who has shorter attention or memory deficit, you might need to increase the adjunctive use of directing specific attention to aspects or even using written notes reminders, in order to have the degree of external assistance that a person needs in order to be successful.

You also might break things down like we do with any type of learning for an individual after a significant brain injury where you present information in smaller chunks and with more repetition and with more direct, pointing out the concrete aspects of that situation. Those adaptations might be necessary for somebody after brain injury depending on the degree of cognitive recovery that they have demonstrated.

You may need to change these adaptations as a person progresses through their recovery. So as the person is more able to grasp and benefit from those understanding aspects and self awareness aspects of more abstract concepts, then you would alter them.

It’s a moving target attack or brain injury and you want to make sure that your treatment is following with that moving target as well.

Another adaptation that has been occurring over the past several years and has really kicked into high gear with COVID-19 is non face-to-face therapies. There are several studies pre-COVID-19 that have found that the effectiveness of cognitive behavioral therapy is not platform or format dependent.

Similar results have been observed for internet assisted or telephonic delivery of services as compared with face to face services. So post COVID-19 changes have all but required the use of remote contact methods but there is also with this been a substantial opening up of telehealth services, and telerehab services.

Many of the clients that have received such services actually appreciate the convenience of not having to travel to a therapist’s office, you know, the decrease time that’s involved in having to travel, you take that out of the equation. Plus you’re in your own home, comfortable, familiar environment. So for many aspects of health, including those of rehabilitation, there are some tremendous benefits to being able to utilize a telehealth service, so receiving those services at home. There are lots of reasons that patients appreciate that and one in which now, this has become much more common, as a result simply of the pandemic issues that we’re having to grapple with.

Tim Benak – 50:53

Jeff is, is that a stock photo up there?

Dr. Snell – 50:57

No, that’s Brad. That’s one of our physical therapists actually involved in telerehab.

Tim Benak – 51:03

Just a good looking photo, wanted to point that out.

Dr. Snell – 51:06

I’m sure Brad will appreciate that as well. QLI does have a telerehab program, and we have seen a great deal of increase in referrals simply because of the fact that individuals with COVID-19 have not been able to get out to offices that were no longer seeing outpatients.

Those changes have, fortunately already had some degree of empirical support, that it is an effective treatment even with that adaptation.

There have been some questions that I had seen recently just about COVID-19. For example, specifically, is this therapy effective using internet assisted techniques rather than face to face. And like I said, fortunately, these studies go back four, five, six years, because telerehab is something that has been evolving over time. It is something that fortunately is already in place. And it’s good that we already have that.

Open Questions about CBT

Now there are some questions, every question hasn’t been answered about CBT. We’re still learning some things and some of the studies that are still looking at what is effective.

One of them is looking at what is the dose that is effective, how many minutes over how many sessions, and that not something that has been completely nailed down at this point.

Generally speaking, about eight to ten weeks is what most CBT therapeutic processes run. That would be the number of sessions typically eight to twelve sessions is what you would look for from a funding approval standpoint if you’re going to begin a CBT process with a patient and generally that is the amount of time that a therapist would consider to be ideal from the standpoint of most cognitive behavioral interventions.

Again, it is a time limited and focused process. It’s not signing up for a never ending series of therapy sessions.

In rehabilitation, we’re also dealing with the issues of variance within recovery, variance from funding sources on what they consider to be necessary from the standpoint of treatment. Sometimes those therapy processes are interrupted particularly in the acute rehabilitation setting.

But ideally, in an outpatient setting, you would get approval for that and be able to move forward throughout that entire string of therapy sessions following pretty much a manualized approach, adapting as necessary for your patients’ unique variances.

We also know that relationship, that therapeutic alliance is one of the most salient factors in any type of therapy. It almost seems like with most therapeutic approaches, it doesn’t matter which approach you take, if you have a good relationship with your patient.

Being able to include measures of that therapeutic alliance is something that a few studies have looked at, but the vast majority of studies are more looking at a manualized approach and comparing it to a different type of manualized approach for which is the superior.

Most studies really haven’t advanced to the point of comparing individual face to face therapy with group based therapy for specific aspects. Again, right now, we’re not doing a lot of group based therapy face to face but certainly there’s the opportunity for more of a group setting. If you’re talking about something like what we’re doing right now, which would be talking with a larger group of individuals over the internet.

Here is a list of resources. There are some updated resources within here as well, with some more recent studies looking at some of the CBT with internet assisted processes. I would encourage you if you have any questions about CBT and TBI to please type those in or when you put in your feedback forms, if you would also include any questions that you have there as well. If you can get those to Tim, he will forward those on to me and we will be glad to address any specific questions that you might have. I’ll turn it over to you.

Tim Benak – 55:36

Absolutely. So, as Jeff mentioned, do ask those questions now and I’ll get those over to Jeff while I pull up the poll question on the screen right now. So you should see that right now.

Some folks do have issues of this, sometimes it could be a pop up blocker that’s blocking this from coming up because it is a separate screen that pops up over the slideshow that we have. So if you do run into those issues, just reach out to us directly. We can make sure that we record your your answer and get that the appropriate follow up email sent out to you.

Jeff, we did have a few questions come through. Let’s see here.

Questions for the Speaker

Someone asked, do you think smartphones and social media has made it harder for people not to feel like they’re being judged? If they are different or do something, you know, make a mistake. Do you think that kind of those social aspects have added to some of those issues?

Dr. Snell – 56:40

Does social media have the potential of making you feel worse about yourself or better? Is that is that kind of the root of the question?

Putting anything out there on social media, there are going to be folks that will disagree with any position you take with any thing you say. And if you take that feedback personally, yes, it has the potential to grossly impact your sense of self and your mood.

If someone criticizes you online and that causes you to feel bad, then you probably shouldn’t post anything online because somebody is not going to like it. You can post the most innocent thing, the thing that you would think everybody would agree with, and somebody will shoot holes in it. So I see on our Next Door app, as a matter of fact, somebody posts something occasionally and it’s like, okay, let’s bring out the trolls and start a flame war.

Some people just like to watch the world burn too. And so if you say something, some people will say something back just to get a reaction, just to be funny and snarky sometimes. But funny and snarky, can also be very personally hurtful and damaging if you take it personally.

Tim Benak – 58:01

We call those keyboard warriors, they can hide behind their keyboard. Right?

Dr. Snell – 58:04

Well, and again, I would say you should give emotional weight equivalent to the relationship that you have with that person. If you have no relationship with that person, you should put no emotional angst into anything they have to say or any opinion they have. If it’s your own mother and you have a close relationship with your mother and your mother criticizes you about something, you should probably listen.

Tim Benak – 58:33

Okay, so someone asked, what sort of constraints do you think are important in designing tele psychology or CBT intervention? Not being face to face, do you think that there are any constraints or what things maybe you have to do differently? You know, I think you touched on that a little bit with just the the studies that are out there, but is there anything that you’ve had to change or that you foresee having to be different through a tele.

Dr. Snell – 58:59

That’s a question that I would probably refer to Dr. Durbin, who is our psychologist here who is involved in our tele rehab program. Kathy is doing a lot of psychological therapy through the media of telerehab, and I would ask her for her experiences as well.

There are certainly numerous articles that have been published out there that talk about some issues that you do have to take into consideration in providing any psychological service remotely. One of which would be contingencies in place for things that normally you would do more face to face.

If you have a client, for example, who is in an acute crisis, how do you respond to that remotely as opposed to being in a situation where you were face to face with that person? If you are providing face to face therapy, you also typically know kind of what are the emergency services that might be necessary to put in place if you have a patient who, for example, is expressing concerns of self injury or self harm. If you’re doing that remotely, you also have to have contingencies in place for how to address that, which becomes a little bit more difficult if you’re talking about performing therapy with someone who is, you know, six states away.

Tim Benak – 1:00:23

Absolutely. Dr. Snell’s information is up on the screen. Do I still have a couple minutes here? He did mention, if you do have any questions do reach out to him directly, but also send them to myself. When you do the evaluation, we’ll get those sent over. Somebody asked about, let’s see here. How different is this approach when providing CBT for something like let’s say chronic pain?

Dr. Snell – 1:00:46

There are similarities actually the cognitive behavioral therapy that demonstrates the most scientific evidence-based effectiveness for chronic pain is something called acceptance and commitment therapy or ACT.

ACT is an offshoot, a further extension, a third wave, for example of cognitive behavioral therapy because again, it’s utilizing the same process. It’s addressing those underlying thought processes and how they influence our actions and behaviors.

But it is more specifically tailored to the issues that you’re dealing with with chronic pain. For example, making room for and allowing for those negative aspects in our life that exist. You can’t simply make them go away by wishing them away, but acknowledging that they are there but not letting them drive your decisions, not letting them drive your choices. So I would encourage you from a chronic pain standpoint, to look at the cognitive behavioral therapy, the third wave CBT therapy, called acceptance and commitment therapy.

Tim Benak – 1:02:07

And then we had a few people actually ask about this, pop up to this question here. 87% of the cases that did better with CBT for depression, were there are medications involved as well, or just the therapy?

Dr. Snell – 1:02:20

There is a wide variety with those studies that have looked at each. Neither are the most effective when done in the absence of the other. So in other words, when you’re talking about mood and depression, you’re talking about neuro chemicals, you’re talking about neurotransmitters, and you’re talking about neural networks. And so if you treat those both with medication, as well as with cognitive behavioral therapy, that shows the greatest efficacy than either of them in isolation.

Tim Benak – 1:02:53

Okay, I think we’ll wrap up there. So, in August, we’re going to actually just do a podcast, Dr. Snow it will be on again.

Dr. Snell – 1:03:00

What am I going to be talking about?

Tim Benak – 1:03:02

I don’t know, I actually haven’t told them yet. But there won’t be a webinar in August. But we will be doing a podcast. We did one back in, I believe it was June, it may have been May, the months are just flying by here. So it’ll be the similar style. Join us for that discussion. You’ll be receiving information on that in the coming weeks. We will also get you all the follow up emails for this webinar today, here in the next, you know, four to six hours. So be on the lookout for those. As always send us questions. If you have them. We’ll get them over to Jeff, and we appreciate you joining us.

Dr. Snell – 1:03:34

Thanks for joining us. Nice to talk to you again and we’ll see you next month.

Categories: Brain Injury, Cognitive Behavioral Therapy