Table 36–1. Suggested tactics for the psychotherapeutic
Gain a historical perspective
Obtain information from family, friends, employers,
and teachers concerning preinjury growth and development, health,
education, occupation, personality, interests, values, goals, and
impediments. Specifically, include a discussion
of the patient's favorite fairy tales, stories, music,
and topics that help mold the patient's personal life. Understand
key and early memories that seem to influence how the patient approaches
key relationships in life. Clearly understand the patient from a
cultural and psychodynamic perspective.
Find areas of shared meaning
Determine what having a brain injury means to the patient
and how he or she perceives its effects. At first, the psychiatrist (or
psychotherapist) may have to take the initiative,
explaining the mechanism of traumatic brain injury in simple terms,
relating the patient's difficulties to the injury, and
describing the problems, events, and so on that can be expected
in the future.
Encourage the patient to take the lead
Concentrate on the concrete real-life difficulties
that the injury has caused the patient. Early in treatment, focus
on the here and now, avoid discussing the past (it requires good
memory, and it is over), avoid discussing the future (it requires
the ability to abstract, and at this point it is beyond comprehension). However,
be prepared to discuss topics that you suspect are relevant to the
patient's neuropsychological and psychosocial difficulties,
even if the patient cannot articulate them on certain days.
Help the patient develop simple coping strategies
For example, suggest that the patient keep a notebook,
follow a sequence of predetermined steps, rest before becoming too
fatigued, request that a confusing message be repeated slowly and
in simpler terms, set up priorities for a series of necessary tasks. Through
cognitive rehabilitation exercises, demonstrate how compensations
are helpful, but be mindful as to their cost in terms of time and
Manipulate aspects of the environment to enable the
patient to function more effectively
For example, suggest organizing household equipment,
utensils, dishes, and so on in a systematic fashion; labeling drawers
and closets; using an alarm or calendar watch. Teach
the patient to use a memory compensation notebook during the process
Mobilize the assistance of family members, employers,
teachers, and friends to help keep the social and work demands as
noncomplex and as manageable as possible. Work at
developing a strong working alliance with key family members.
Build on the patient's assets
Build on the patient's remaining assets and
avoid focusing on the residual deficits. Do not make every task
seem like a test. But "keep in front of
the patient" in a therapeutic way what, in fact, are the
patient's neuropsychological deficits that he or she must
deal with on a daily basis. This touches on the important issue
of separating denial from unawareness after traumatic brain injury.
Focusing on issues that the patient denies may only cause more irritation.
Reducing unawareness, however, will greatly assist the patient.
Engage the patient in meaningful goal-directed activities
Use members of professional groups that are action
oriented, such as actors, dancers, and artists, in addition to the more
traditional rehabilitation staff. Include voluntary
work trials if possible. Therapists working with the patient in
various therapies should go to the work trial to determine how the
patient actually performs, and to use this as important information
in individual and group psychotherapy.
The patient's world may differ from that of
Interpret the meaning of behavior with caution. Provide
guidance to improve inappropriate behavior with authority. Again,
the problem of impaired awareness vs. denial of disability must
be kept in mind when working with these patients and their family
Many patients are adolescents or young adults in various
stages of development; for most of these patients, some improvement
in physical condition and cognitive function can be expected over
time. Remember that a patient's abilities and emotional
state can vary from moment to moment depending on preceding events,
the character of the task, the degree of alertness and motivation,
and the environmental conditions. To help maintain
flexibility, periodically obtain consultation from other psychotherapists
to get their view on how to manage difficult problems with the patient.
Recognize that the approach to therapy should change
as the patient changes
This should happen both within and across treatment
sessions. Ideally, the treatment approach should move gradually
from one that is concerned primarily with the management of concrete,
here-and-now, practical problems to one that places greater demands
on the patient to consider psychodynamic issues. This
insightful point needs to be revisited repeatedly.
Instill hope in the patient and family without expressing
unwarranted optimism. The hope must always be realistic in
nature in order for it to be helpful to the patient and the family.
Measure the outcome of your clinical
Measure outcome in both objective and
subjective terms to determine the value of this service for patients.
This becomes crucially important for future funding (see Prigatano
and Pliskin 2003).