How can Acceptance and Commitment Therapy help people with brain injury and their families?

Acceptance Commitment Therapy (ACT) is an action focused approach to psychotherapy. It aims to help people to accept that emotions are normal reactions to circumstances that should not impede living a fulfilling life [1]. Combining behaviour change techniques, mindfulness strategies and metaphors, ACT helps people develop psychological flexibility allowing them to stop avoiding, denying, and struggling with emotions and distress. ACT is based upon six main processes:  

1. Cognitive diffusion – learning to detach from unhelpful thoughts instead of getting caught up in them. 
2. Acceptance – allowing thoughts and feelings to exist without trying to control them. 
3. Present-moment awareness – being engaged in the present instead of focusing on the past. 
4. Self-as-context – recognising that our own thoughts and emotions do not define us. 
5. Value clarification – finding what is most important to us in life. 
6. Committed action – taking meaningful steps towards our values despite fears.  

How do the core processes of ACT apply to people with a brain injury?

People with a brain injury may experience behavioural, emotional, and cognitive difficulties which can have a significant impact on quality of life, functioning, independence, and participation (return to activities in daily life) [2].

Studies show that five years after brain injury, a large percentage of people are diagnosed with psychiatric conditions, with anxiety, mood and substance misuse disorders being the most common [3]. Studies have also found that the psychological effects of a brain injury are closely related to disability and quality of life [4, 5].

Despite this, rehabilitation programmes have traditionally prioritised behavioural issues and cognitive impairments and have focused less on the emotional and psychological impact of brain injury. While psychotherapy techniques, such as cognitive behavioural therapy (CBT), have been used to effectively manage symptoms of anxiety and depression in people with brain injuries, many such techniques come with barriers. For example, CBT can be abstract and involves a process called ‘cognitive restructuring’ which can be difficult for people with cognitive impairments to understand and implement.

Furthermore, there may be situations where a person’s negative thoughts reflect an accurate cognitive assessment of the impact their brain injury has had on them. When treating people with brain injuries, it is important that psychotherapies are adapted accordingly.

Whilst the research investigating the effectiveness of ACT for managing anxiety and depression in people with brain injury is limited, it is interesting to consider how the principles of ACT may be applied to improving outcomes and reducing distress after a brain injury.  

1. Cognitive diffusion

Following a brain injury, some people develop negative thoughts patterns. For example, thinking ‘I will never be the same.’ ACT may be utilised to help people view these thoughts as separate from themselves, which may reduce their negative impact on mental health. 

2. Acceptance of limitations and challenges 

Brain injury survivors often struggle with frustration, grief, poor awareness, or denial of cognitive and physical impairments. ACT may be useful for helping people to acknowledge and process these challenges, so that people do not feel like they’re being controlled by, or struggling against, them thereby reducing emotional distress. 

3. Mindfulness and present-moment awareness

Anxieties about the future and sadness may be experienced following a brain injury [3]. ACT utilises the practise of mindfulness to bring focus to the present, improving emotional regulation and reducing distress.  

4. ‘Self’ as context 

Research indicates that people who have experienced a brain injury report alterations in their sense of self, whereby people rate their ‘current self’ more negatively than their ‘past self’. This has been related to poorer outcomes [6]. ACT may be useful for helping people understand their thoughts and feelings as experiences that occur within their ‘self’, rather than defining who they are. 

5. Clarifying values and goal setting 

A brain injury can cause changes to a person’s sense of purpose or identity [7]. ACT may help people identify their values (e.g. relationships, independence, creativity) and set realistic goals. 

6. Committed action and behaviour change 

ACT may be used to support people with a brain injury to focus on rebuilding a fulfilling life. This therapy approach promotes making small and manageable steps towards meaningful activities personalised to that individual. For example, if a person values social connection but has difficulty remembering names, committed action might include finding ways of participating in social events which might include using visual cues or taking breaks.  

Focusing on meaningful activities, helps people rebuild a fulfilling life despite limitations. An important central tenet of ACT therefore is to improve functionality as opposed to focus on reducing symptoms per se, which is the focus of other traditional therapies including cognitive behavioural therapy. 

What does the evidence say?

Research has shown that ACT can be adapted for people who have experienced a brain injury and consequent cognitive impairments.

A study of people six months after a mild, moderate, or severe brain injury, found that an eight-week course of ACT was beneficial for reducing distress as well as increasing psychological flexibility and commitment to act towards value-based goals [8].

The beneficial effects were maintained at a follow-up three months later. These findings provide promising initial evidence of the benefits of ACT for mood management as well as psychological adjustment following a brain injury.  

A pilot study in which 19 people with a severe brain injury participated in a seven-week group ACT  programme, also  found a significant decrease in stress and anxiety [9]. This adds to the evidence suggesting the potential of ACT for reducing psychological distress after a brain injury.

It is believed that these benefits can better enhanced by making small alterations to the delivery of the therapy, for example, utilising visual materials, summaries, and repetition [10].  

Conclusion 

ACT is a valuable therapeutic approach for managing mood and helping some individuals with brain injuries move towards valued goals instead of focusing on the reduction of symptoms.

The integration of ACT components into rehabilitation programmes may support engagement with those programmes, thereby supporting a person’s wellbeing and quality of life. 

On the other hand, more longitudinal and large-scale studies are needed to identify which individual components of ACT contribute most to changes in mood and psychological adjustment.

Additionally, we need better understanding of the factors that determine what the best time for intervention might be, given that adaptations in thinking patterns and processing experiences can take time.

Finally, even though ACT can be adapted to accommodate cognitive impairments, some people, such as those who have aphasia, may still find the intervention too demanding [10]. 

References  

1. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. Guilford Press 
2. Hart, T., Fann, J. R., Chervoneva, I., Juengst, S. B., Rosenthal, J. A., Krellman, J. W., Dreer, L. E., & Kroenke, K. (2016). Prevalence, risk factors, and correlates of anxiety at 1 year after moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 97(5), 701– 707.  
3. Alway, Y., Gould, K. R., Johnston, L., McKenzie, D., & Ponsford, J. (2016). A prospective examination of Axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury. Psychological Medicine, 46(6), 1331-1341. 
4. Zahniser, E., Nelson, L. D., Dikmen, S. S., Machamer, J. E., Stein, M. B., Yuh, E., et al. (2019). The temporal relationship of mental health problems and functional limitations following mTBI: A TRACK-TBI and TED study. Journal of Neurotrauma, 36,1786- 1793. 
5. Albrecht, J. S., Barbour, L., Abariga, S. A., Rao, V., & Perfetto, E. M. (2019). Risk of depression after traumatic brain injury in a large national sample. Journal of Neurotrauma, 36(2), 300-307. 
6. Beadle, E. J., Ownsworth, T., Fleming, J., & Shum, D. (2016). The impact of traumatic brain injury on self-identity: A systematic review of the evidence for self-concept changes. The Journal of Head Trauma Rehabilitation, 31(2), E12-E25. 
7. Villa, D., Causer, H., & Riley, G. A. (2021). Experiences that challenge self-identity following traumatic brain injury: a meta-synthesis of qualitative research. Disability and Rehabilitation, 43(23), 3298-3314. 
8. Sander, A. M., Clark, A. N., Arciniegas, D. B., Tran, K., Leon-Novelo, L., Ngan, E., … & Walser, R. (2021). A randomized controlled trial of acceptance and commitment therapy for psychological distress among persons with traumatic brain injury. Neuropsychological Rehabilitation, 31(7), 1105-1129. 
9. Whiting, D., Deane, F., McLeod, H., Ciarrochi, J., & Simpson, G. (2020). Can acceptance and commitment therapy facilitate psychological adjustment after a severe traumatic brain injury? A pilot randomized controlled trial. Neuropsychological Rehabilitation, 30 (7), 1348-1371.  
10. Rauwenhoff, J. C., Bol, Y., van Heugten, C. M., Batink, T., Geusgens, C. A., van den Hout, A. J., … & Peeters, F. (2023). Acceptance and commitment therapy for people with acquired brain injury: Rationale and description of the BrainACT treatment. Clinical Rehabilitation, 37(8), 1011-1025.