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Adapting behavioural activation for brain injury rehabilitation

By Georgia Stevenson, Assistant Psychologist at Kerwin Court

Learn how behavioural activation techniques are adapted for brain injury rehabilitation to enhance engagement and promote recovery.

Behavioural activation (BA) is a therapeutic approach originally developed within the framework of cognitive behavioural therapy (CBT) to treat depression by helping people engage in activities that promote positive reinforcement [1].

Positive reinforcement refers to the process of encouraging or establishing a pattern of behaviour by offering reward when that behaviour occurs.  

Behavioural activation can be particularly effective for individuals recovering from brain injuries. However, the traditional BA model needs to be adapted to address the unique needs of people with brain injury, whose cognitive impairments and emotional struggles may present a barrier to engagement in meaningful activities. 

The role of behavioural activation in recovery 

Behavioural activation operates on the premise that increasing engagement in valued activities can counteract the negative cycles of avoidance, inactivity, and low mood that often follow a brain injury [1].

After a brain injury, people may withdraw from previously enjoyed activities due to physical limitations, cognitive impairments, or emotional distress. This withdrawal can lead to a decrease in positive reinforcement, exacerbating feelings of depression and further reducing motivation. 

In the context of brain injury rehabilitation, BA helps people with brain injury to reconnect with activities that provide them with a sense of purpose and joy. This engagement is crucial for improving mood, enhancing cognitive function, and supporting the overall recovery process. 

Often, a BA session involves sitting down with the person and explaining how behaviours can influence emotions. The person is then asked to identify three activities that bring them pleasure and three that give them a sense of achievement.

This can often be difficult if mood is low, so prompts and suggestions are given when needed. Together, these activities are then scheduled for the week ahead. In the following session, the goals are reviewed, and the person reflects on how they felt before and after engaging in the activities.  

Adapting behavioural activation for brain injury rehabilitation 

Given the cognitive and emotional challenges faced by people with brain injury, behavioural activation needs to be adapted to ensure it is accessible and effective. Here are some adaptations to consider: 

  1. Simplify tasks and goals: People with brain injury often experience difficulties with executive function, making it hard to plan, start, or complete complex tasks such as preparing food or managing one’s own medication. To address this, activities involved in behavioural activation interventions should be broken down into smaller, manageable steps. As for rehabilitation in general, the BA intervention goals should be achievable, and tailored to the person’s current cognitive and physical abilities. For example, a broad goal, like “engage in social activities,” can be formulated more specifically as “go on a group walk every week.” 
  1. Incorporating visual aids and reminders: Memory and attention deficits are common after a brain injury, making it difficult to remember scheduled activities or follow through on plans. Visual aids, such as calendars, checklists, and smartphone reminders, can help people keep track of their daily activities and stay engaged in their behavioural activation plans. 
  1. Increasing positive reinforcement: Reinforcing small successes is vital for maintaining a person’s motivation after a brain injury. It is helpful for staff and family to provide frequent, positive feedback for any level of participation in behavioural activation activities. This reinforcement helps build confidence and encourages continued engagement. 
  1. Collaborative goal setting: Involving the person with brain injury in setting their rehabilitation goals is essential for ensuring that the activities selected are meaningful and aligned with their values. This general rehabilitation principle is especially important when using behavioural activation interventions. Collaboration can increase the person’s intrinsic motivation, making engagement in activities more likely. For example, if the person with brain injury values creativity but struggles to engage with traditional art forms due to motor impairments, adapted creative activities like digital art or photography can be considered. 
  1. Addressing emotional barriers: Depression, anxiety, and frustration can create significant barriers to participation in behavioural activation. Incorporating techniques designed to address these emotional challenges can help. For example, mindfulness exercises or relaxation techniques can be integrated into the behavioural activation plan to help the person with brain injury manage negative emotions and stay engaged. Implementing a rating scale before and after each session, asking how the person felt in terms of mood, pleasure and achievement, can also help people to reflect on their improvements when engaging in the behavioural activation activities. This can, in turn, encourage future participation. 

Evidence of effectiveness 

Research has shown that behavioural activation can be effectively adapted for people with cognitive impairments, including those recovering from brain injuries [2-4]. For instance, a study involving people with stroke found that those who participated in behavioural activation showed greater improvements in mood compared to those who did not receive BA-based interventions [5].

These findings provide promising initial evidence of the benefits of behavioural activation in mood management following a brain injury. 

Additionally, there are case studies from clinical practice highlighting the success of behavioural activation in helping people with brain injury rebuild their lives [6].

Those who initially struggled with depression and social withdrawal were able to gradually reintegrate into their communities, engage in fulfilling activities, and experience a marked improvement in their overall quality of life through adapted behavioural activation interventions. 

Conclusion 

Behavioural activation is a valuable therapeutic approach in brain injury rehabilitation, offering a structured way to help people reengage in meaningful activities that promote recovery.

By adapting behavioural activation techniques to address the specific cognitive and emotional needs of people with brain injury, therapists can enhance the effectiveness of rehabilitation programs, leading to better outcomes and improved quality of life.

As research on behavioural activation continues to evolve, this intervention is likely to remain an important part of brain injury care, supporting people to regain a sense of purpose and joy in their lives. 

References

[1] Veale, D. (2008). Behavioural activation for depression. Advances in Psychiatric Treatment, 14(1), 29-36. 

[2] Thomas, S.A., Drummond, A.E, Lincoln, N.B., Palmer, R.L., das Nair, R., Latimer, N.R., Hackney, G.L., Mandefield, L., Walters, S.J., Hatton, R.D., Cooper, C.L. (2019) Behavioural activation therapy for post-stroke depression: the BEADS feasibility RCT. Health Technology Assessment, 23(47). 

[3] Yisma, E., Walsh, S., Hillier, S., Gillam, M., Gray, R., & Jones, M. (2024). Effect of behavioural activation for individuals with post-stroke depression: systematic review and meta-analysis. BJPsych Open, 10(5), e134. 

[4] Kusec, A., Murphy, F.C., Peers, P.V., Bennett, R., Carmona, E., Korbacz, A., Lawrence, C., Cameron, E., Bateman, A., Watson, P., Allanson, J., duToit, P. & Manly, T. (2023). Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): results from a randomised controlled pilot feasibility trial for low mood in acquired brain injury. BMC Med, 21, 445. 

[5] Thomas SA, Walker MF, Macniven JA, Haworth H, Lincoln NB. (2013). Communication and Low Mood (CALM): a randomized controlled trial of behavioural therapy for stroke patients with aphasia. Clinical Rehabilitation, 27(5), 398–408.   

[6] Kusec, A., Methley, A., Murphy, F.C.  Peers, P. V., Carmona, E. & Manly, T. (2023) Developing behavioural activation for people with acquired brain injury: a qualitative interpretive description study of barriers and facilitators to activity engagement. BMC Psychol,11, 207. 

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