Objective: This study aimed to evaluate the efficacy of Training to Reconnect with Emotional Awareness Therapy (TREAT) in enhancing emotional awareness and reducing alexithymia, emotion dysregulation, anxiety, depression, anger, and overall positive and negative affect in individuals with traumatic brain injury (TBI).

Setting: The research was conducted at an outpatient brain injury rehabilitation center.

Participants: A total of 44 adult participants with a history of complicated mild to severe TBI and elevated levels of alexithymia. Participants were on average 44 years old, 11.37 years post-TBI, mostly male (62%) and mostly White (79.4%).

Design: This was a randomized, wait-list controlled trial. Participants were either randomized into the immediate treatment (TREAT; n=20) arm or wait-list control (WLC; n=24) arm. Data was collected at the following timepoints: Time 1 (baseline); Time 2 (at 6 weeks); Time 3 (at 18 weeks); and Time 4 (WLC only). The TREAT arm received the intervention between Time 1 and Time 2; the WLC arm received treatment between Time 2 and 3. Therefore all participants had a post-treatment evaluation within a week of receiving the intervention and a 3 month follow-up.
Intervention: Participants underwent an eight-session structured program designed to enhance emotional awareness and the ability to label emotions accurately. Sessions were delivered in-person to participants individually by a trained clinical research assistant.

Outcome Measures: The Toronto Alexithymia Scale-20 (TAS-20; alexithymia), Levels of Emotional Awareness Scale (LEAS; emotional labeling), Difficulty with Emotion Regulation Scale (DERS; emotion dysregulation), General Anxiety Disorder-7 (GAD-7; anxiety), Patient Health Questionnaire-9 (PHQ-9; depression), State-Trait Anger Expression Inventory (STAXI; anger), Positive and Negative Affect Schedule (PANAS), and Patient Global Impression of Change (PGIC).

Results: Thirty-four participants completed the study according to protocol. Between group comparisons at Time 2 demonstrated that TREAT participants (n=18) had significant post-treatment reductions in alexithymia, emotion dysregulation, anxiety, and depression compared to WLC participants (n=16) who had not yet received the intervention (all p’s < .05). Analysis of the pooled sample (n=34) revealed significant improvements in all measured outcomes immediately after and three months post-intervention, except for the STAXI and the Positive Affect subscale of the PANAS. Notably, 80% of participants reported a meaningful change in global emotional functioning and quality of life on the PGIC. Intent-to-treat analyses (n=38) yielded similar results.

Conclusions: The findings indicate that TREAT is effective in reducing alexithymia and emotion dysregulation among individuals with chronic TBI. While there were positive trends for anxiety and depression, further research employing attention-control designs is needed to account for the attention aspect of the treatment.

Objectives: To examine early efficacy of the Building Emotional Self-awareness Teletherapy (BEST) intervention at reducing alexithymia and improving psychological functioning in service members (SM) and civilians with mild traumatic brain injury (mTBI).

Methods: Forty participants with mTBI (≥ 6 months post-injury) who had elevated alexithymia and emotion dysregulation were enrolled into a single-arm, double pre-test/ double post-test study (3-month follow-up). Assessments and treatment were administered remotely.

Intervention: BEST is eight 60-90 minute sessions delivered individually to participants by a clinical research assistant. It incorporates psycho-educational lessons and skill-building exercises teaching 1) the value of emotional self-awareness; 2) more specific and precise labeling of emotions; 3) how to recognize signs of emotional arousal and link sensations with emotions; and 4) how to identify and differentiate multiple co-existing emotions. Lessons revolve around an emotional compass as a guide to greater clarity into their feelings.

Preliminary Results: Participants were enrolled from 18 different states; had a mean age of 41 years old; were 55% male; and were predominantly White (77.5%) and non-Hispanic (90%). On average, participants were 13.22 years post-TBI. Retention is currently 97.5%. Preliminary analyses examined outcomes immediately post-intervention (n=27) and the 3-month follow-up (n=20). Results indicate significant improvements in alexithymia, emotion regulation, resilience, post-traumatic stress, anxiety, depression and anger, immediately and 3-months post-treatment (all p’s <.001 except anger and depression which were <.05. Respectively, 92.5% and 74% improved by ≥.5 standard deviation (SD) on our co-primary outcomes-alexithymia (Toronto Alexithymia Scale 20; TAS-20) and emotion dysregulation (Difficulty with Emotion Regulation; DERS), after receiving treatment, compared to 15% and 4% who had ≥.5 SD improvements between the double baseline (no treatment) period. On the Patient Global Impression of Change (PGIC), 85% of the sample (n=27) reported a noticeable change (≥5; moderately to a great deal better) in “emotional functioning” after treatment. Ninety-six percent agreed the training was relevant to their needs; 100% agreed they would use the lessons from the training in their daily life; 96% agreed they would refer a friend in similar need to the study; 88% agreed the program helped them deal more effectively with their emotions.

Conclusions: The high satisfaction and retention rates are very encouraging, especially for individuals with alexithymia who frequently struggle with traditional psychotherapy. Further, preliminary findings suggest that BEST may be effective at improving psychological health in individuals with mTBI who are many years post-injury, with sustainable results. However, randomized controlled trials in larger, more racially and ethnically diverse samples are necessary to better understand the benefits of BEST in the TBI population.


Disclaimer for Dr. Pickett: The views expressed in this abstract are those of the authors and do not necessarily reflect the official policy of the Department of Defense or the US Government.

Psychological distress is often elevated after an individual experiences a moderate to severe traumatic brain injury (TBI) and they undertake a long process of adjusting to their new reality. Acceptance and commitment therapy (ACT) has demonstrated initial promise to alleviate this distress but processes of therapy, such as development of psychological flexibility, are less clearly established.
Individuals (n=46) with a TBI (PTA=> 7 days) were recruited from community brain injury services across NSW, Australia. They were randomized on a 2:2:3 ratio, to either ACT (delivered by video consulting [VC]: Face to face [F2F]) or a constrained treatment as usual (cTAU) control, with those in the ACT group receiving 9 sessions of ACT. Primary outcome measures were measured at pre, post and three-month follow-up, and included psychological distress (Depression Anxiety Stress Scale-21: DASS-21), process measures of experiential avoidance (Acceptance and Action Questionnaire: AAQ-ABI) and engaged living (Engaged Living Scale: ELS) with secondary outcome measures assessing quality of and satisfaction with life (Quality of life after Brain Injury and Satisfaction with Live Scale). Statistical methods implemented intention to treat analysis using piece wise multilevel modelling. Non inferiority analyses were non-significant at all three time points indicating delivery of treatment by VC was as good as delivery by F2F on all primary and secondary outcome variables. The ACT groups were combined and compared to the cTAU control group at pre and post intervention with those in the ACT group reporting significant reductions in psychological distress (t(40.9) = -2.78 p= 0.008) and experiential avoidance (t(68.8) = -3.32 p= 0.001) and significant improvements in their engaged living (t(76.6) = 3.61 p= 0.001) and quality of and satisfaction with life (t(58.6) = 3.64 p= 0.001) when compared to the cTAU. Treatment gains were maintained at three months post treatment.
This research provides further support for ACT being an effective treatment for psychological distress after a moderate to severe TBI with significant reductions in distress and improvements in quality of life. In addition, the results indicate that remote delivery via VC is a good as when the intervention is delivered F2F. This has positive implications for more versatile psychology service delivery models for rural and remote communities and for those in urban areas who may experience access difficulties in physically attending treatment clinics.

Objective: This randomized controlled trial (RCT) investigates the effectiveness of hypnosis in improving working memory (WM) among patients with acquired brain injury (ABI), through comparing it´s effect to an active and a passive control group. The establishment of cost-effective, evidence-based interventions for WM deficits following ABI is essential. Although clinical hypnosis has shown remarkable efficacy across various medical conditions, its potential in cognitive rehabilitation is still underexplored. Drawing inspiration from the groundbreaking work of Lindeløv et al. (2017), which highlighted significant improvements in WM through hypnosis, this study seeks to replicate those findings within a Norwegian context. Additionally, it aims to broaden the scope of analysis by incorporating every day life outcomes and examining self-efficacy as a potential mechanism in the effect of hypnosis. Ultimately, this study aims to contribute to effective, low-cost rehabilitation strategies that empower ABI patients to maximize their cognitive outcomes and improve their quality of life.

Methods: Eighty patients with non-progressive acquired brain injury (ABI), at least 12 months’ post-injury, have been recruited at Sunnaas Rehabilitation Hospital. The median time since injury was 42 months (Q1 = 31, Q3 = 60). The mean age of participants was 49 years (SD = 12.2), with a median education level of 14 years (Q1 = 12, Q3 = 16). Fifty-six percent of the participants were men. Eighteen participants had traumatic brain injury (TBI), 43 had experienced a stroke, and 19 were diagnosed with other conditions such as encephalitis.
Of the 80 participants, 75 had no prior experience with hypnosis, while 5 reported previous exposure. Regarding pre-treatment expectations for hypnosis as an effective therapeutic intervention, none of the participants reported having no expectations, 42 expressed medium expectations, 20 indicated high expectations and had 18 no opinion.
Participants were randomized into one of three groups: hypnotic intervention with four weekly 60-minute sessions, an active control group receiving same volume of mindfulness sessions, and a passive control group. The hypnotic intervention targets enhancing working memory (WM) by invoking pre-injury abilities and visualizing brain plasticity. Outcome measures include the WM Index from WAIS-IV and self-reported WM from the BRIEF-A, along with secondary measures of memory self-efficacy, emotional distress, quality of life, and community integration. Assessments occur at baseline, post-intervention, and six months after baseline. Most patients have received interventions and second testing (T2), with 55 participants having completed the study (T3).

Results: Comprehensive baseline data will be presented at the conference, highlighting key findings relevant to the study.

Conclusion: Traditional rehabilitation approaches for working memory (WM) deficits in patients with acquired brain injury (ABI) have yielded modest results, highlighting the need for novel interventions. Hypnosis, a proven therapeutic tool in various medical fields, holds untapped potential for cognitive rehabilitation, as suggested by preliminary research. If the results of this trial replicate earlier findings, hypnosis could offer an effective, low-cost, and accessible method to boost WM, improve daily functioning, enhance self-efficacy, and elevate the quality of life for ABI patients. Moreover, success in this study could pave the way for broader applications, extending to other neurological conditions such as mild traumatic brain injury, where WM deficits are a critical concern.

Introduction: Implementation strategies are necessary for improving the adoption, implementation, and sustainment of clinical interventions in real-world treatment settings. However, implementation strategy descriptions often lack sufficient detail necessary for replication and understanding whether the strategies could be feasible for scaling-out interventions equitably in other settings. Brain injury (BI) rehabilitation has been slow to use implementation science to facilitate the adoption and implementation of interventions across care settings, thus hindering potential health benefits and quality of care for individuals with BI.

Objective: We describe the processes for implementing Neurologic Informed Care (NIC) – a novel approach to addressing BI through clinical staff trained to screen for BI and accommodate cognitive impairments – in substance use treatment clinics.

Methods: We utilized the Strategies, Timeline, Activities, and Resources log to detail implementation strategies used for increasing NIC adoption (defined as the number of providers who agree to use NIC) and implementation (evidence of the use of NIC). We report strategies using recommendations for implementation strategy reporting (i.e., actor, action, targets, temporality, dose, and justification).

Results: Two PhD-level investigators (actors) completed 30 activities (actions) representing 18 unique implementation strategies. During the 12-month Pre-Implementation Phase (temporality), 14 strategies were delivered across four domains: 1) Relationship development through site meetings (dose: 12 hours of preparation/delivery) with state and county mental health/addiction board leaders, clinic leaders, and staff (targets) to build buy-in and support for NIC implementation (justification); 2) Training and education (35 hours of preparation/delivery) with clinic staff to increase knowledge and skills to deliver NIC; 3) Changing infrastructure (4 hours) in collaboration with staff to document implementation of NIC components through electronic health record or self-report survey; and 4) Clinician support through preparing site-level champions (4 hours) to support local implementation efforts and ensure readiness for implementation. During the first 3-months of Implementation (currently ongoing), four strategies were delivered across three domains: 1) Providing interactive assistance to site champions through planned meetings (7 hours) to problem-solve barriers to implementation; 2) Data audits on NIC implementation (4 hours) and feedback (7 hours) to champions to improve implementation; and 3) Booster training (1 hour) with champions and staff to enhance skills and self-efficacy to deliver accommodations. Seven staff adopted NIC across three residential treatment programs from the two clinics (100% adoption goal). Forty-seven BI screens were conducted (16 at Site 1; 31 at Site 2), and 83% were positive for BI. Although clients most commonly reported problems with emotional dysregulation, mental inflexibility, and attention, staff reported using accommodations for memory, impulse control, and comprehension most often.

Conclusions: Strategies to improve staff-level fidelity to accommodation use are necessary for improving alignment with client needs. Additional research should examine implementation costs and impacts on treatment outcomes to understand return-on-investment.

Traumatic brain injury (TBI) and mental health and substance use (MHSU) are global public health concerns. Many individuals with TBI also experience a MHSU and many individuals with MHSU have also sustained a TBI. However, there is currently limited information on integrated care for TBI and MHSU. This systematic review summarized existing integrated care for individuals with TBI and MHSU and identified barriers and facilitators to integrated care. Electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global) were systematically searched and a narrative synthesis was conducted. Fifty-nine peer-reviewed articles were identified, of which 49 described treatments, 4 described programs, and 7 described screening activities. Clinical integration at the micro- (N=38) and meso-levels (N=10), service integration at the micro- (n=6) and meso-levels (n=5), and functional integration at the meso-level (N=1) were identified. Few articles reported on facilitators and/or barriers related to integrated care. This review provided evidence that integrated care for TBI and MHSU already exists. The following opportunities to facilitate the integration of TBI and MHSU care were identified: (a) integrating accommodations to address cognitive challenges experienced by individuals with TBI, (b) multidisciplinary teams to improve patient outcomes by addressing other sequelae of TBI and MHSU, (c) supporting caregivers by addressing transportation barriers, and (d) promoting education among health professionals so they can be familiar with TBI and MHSU.

Aim: Present results and clinical implications of a goal-oriented and individualized rehabilitation intervention for children with acquired brain injury (ABI), their families and their schools: the Child-In-Context-Intervention Study (CICI).

Methods: The CICI is a randomized controlled trial (RCT) investigating the effect of a goal-oriented individualized intervention containing seven telehealth family sessions, four school-meetings and a parent seminar. The aim was to enhance everyday functioning at home and in school. This presentation will combine study data regarding goal attainment, efficacy analysis of the RCT, and qualitative and quantitative process evaluation (e.g., acceptability, usefulness, experienced impact, and fidelity data).

Results: Fifty-eight children, their families and their schools were included. Children were aged 6-16 years (48% girls), median of 6 years post injury. Most parents lived together, and all children attended school. Causes of ABI were TBI (16), tumors (15), stroke (10), infection (8), anoxia (6) and other (3). Goal Attainment Scaling (GAS) was established for all 90 SMART-goals set in the intervention group. Results showed high goal attainment, with positive progress (mean 2.1 steps on GAS) on 94 % of the goals. The CICI group reported significantly greater improvements in unmet health care needs, family function, and parental anxiety and depression. No differences were observed on the primary outcomes of parenting self-efficacy and brain injury symptoms nor on child-reported measures. The intervention group was highly satisfied with the intervention. On a custom-made acceptability scale with score range from 1-5, median ratings ranged from 4 (children) to 4.6 (parents). Qualitative interviews were conducted with 12 persons from six families, revealing that the families highly appreciated the school-home collaboration, the increased understanding of the children’s and families’ challenges, as well as the positive progress on their challenges. Attendance and adherence to protocol was high, and a process evaluation revealed a high degree of adaptability of the intervention to the individual needs and resources of each family.

Discussion: The CICI resulted in positive treatment effects at the individual family level. At a group level, the intervention improved contextual factors that are known to influence a child’s long-term rehabilitation outcome, such as family functioning and parent mental health. The intervention was appreciated for its holistic approach in including both family and school, for the knowledge conveyed and for the flexible approaches it offered. The presentation will discuss challenges regarding the measurement of individualized rehabilitation at a group level and questions regarding the validity of child report, as well as clinical implementation implications of the study.

Background : Returning to work (RTW) is an important goal for individuals sustaining traumatic injury [Multi-Trauma Orthopaedic (MTO), traumatic brain injury (TBI), spinal cord injury (SCI)]. Vocational rehabilitation is often unavailable or delayed, and controlled evaluation limited.

Objectives: This study evaluated the impact of providing an Early Intervention Vocational Rehabilitation Service (EIVRS) following traumatic injury on employment outcomes, mental health and quality of life one and two years post-injury.

Methods: A randomized parallel two-group design was used to compare the EIVRS group with a control group receiving usual rehabilitation. Outcomes included hours worked and time to return to first job (primary outcomes), anxiety, depression and quality of life one and two years post-injury. Participants were adults aged 16-70, employed pre-injury. Eighty-eight EIVRS treatment and 82 controls were recruited; mean 47 days post-injury, 75% male, mean age 38 years. Dedicated EIVRS therapists provided activities associated with fostering hope for RTW, thinking about, preparing for, returning to work, building RTW goals into rehabilitation, employer liaison and peer support.

Results: There were no significant group differences in employment outcomes at one year, but EIVRS participants reported lower anxiety. Quantile regressions revealed that at two year follow-up, the EIVRS group worked more hours (Median=38; IQR: p25=24, p75=40) and took significantly less time from injury to RTW (Median=166 days; IQR: p25=87, p75=279.5) than controls (Median=28.5; IQR: p25=23, p75=35.5; p=.018; and Median=238 days; IQR: p25=143.5, p75=325; p=.04, respectively). Quantile regressions by diagnosis showed a significant main effect of group (p=.02) but no interaction between group and diagnosis (p=.60). Trends for shorter time to RTW were strongest in the MTO and TBI groups at two years. At two years there were no group differences in anxiety, depression or quality of life.

Conclusions: Offering EIVRS may reduce time to RTW and increase hours worked two years after traumatic injury.