Cognitive Behavioural Therapy For Depression and Anxiety in Adults With Acquired Brain Injury. What Works For Whom?

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Cognitive behavioural therapy

for depression and anxiety
in adults with acquired brain
injury. What works for whom?
a a
Brian Waldron , Lisa Marie Casserly & Clodagh
a
O'Sullivan
a
ABI Ireland, Northumberland Avenue, Dun Laoghaire,
Co., Dublin, Ireland
Published online: 05 Nov 2012.
To cite this article: Brian Waldron , Lisa Marie Casserly & Clodagh O'Sullivan (2013)
Cognitive behavioural therapy for depression and anxiety in adults with acquired brain
injury. What works for whom?, Neuropsychological Rehabilitation: An International
Journal, 23:1, 64-101, DOI: 10.1080/09602011.2012.724196
To link to this article: http://dx.doi.org/10.1080/09602011.2012.724196
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NEUROPSYCHOLOGICAL REHABILITATION, 2013
Vol. 23, No. 1, 64–101, http://dx.doi.org/10.1080/09602011.2012.724196
Cognitive behavioural therapy for depression and

anxiety in adults with acquired brain injury. What
works for whom?
Brian Waldron, Lisa Marie Casserly, and

Clodagh O’Sullivan
ABI Ireland, Northumberland Avenue, Dun Laoghaire, Co. Dublin, Ireland
This paper reviews treatment outcome studies on cognitive behavioural therapy

(CBT) for depression and anxiety following acquired brain injury (ABI),
including traumatic brain injury (TBI), cerebral vascular accident (CVA),
anoxia and neurosurgery. Studies are included for review when the published
paper included an anxiety disorder or depression as the treatment focus, or
as part of outcome measurement. Relaxed criteria were used to select studies
including relevant single-cases, case series and single group studies along
with studies that employed control groups. Twenty-four studies were identified.
Twelve papers were of a single-case design (with or without replication). Two
papers used uncontrolled single groups and ten studies used a control group.
There were a total of 507 people in the various treatment and control groups,
which ranged in size from 6 to 67 persons. All participants in the study had
an ABI. Our review indicates CBT often shows a within-group pre- to post-
treatment statistical difference for depression and anxiety problems, or a stat-
istical difference between CBT-treated and non-treated groups. For studies
that targeted the treatment of depression with CBT, effect-sizes ranged from
0 to 2.39 with an average effect-size of 1.15 for depression (large effect).
For studies that targeted the treatment of anxiety with CBT, effect-sizes
ranged from 0 to 3.47 with an average effect-size of 1.04 for anxiety (large
effect). However, it was not possible to submit all twenty-four studies identified
to effect-size analysis. Additionally, it is clear that CBT is not a panacea, as
studies frequently indicate only partial reduction in anxiety and depression
Correspondence should be addressed to Dr Brian Waldron, Senior Clinical Psychologist,

ABI Ireland, Northumberland Avenue, Dun Laoghaire, Co. Dublin, Ireland. E-mail:
bwaldron@abiireland.ie
# 2013 Taylor & Francis

CBT IN ABI. WHAT WORKS FOR WHOM? 65
symptoms. This review suggests that if CBT is aimed at, for example, anger
management or coping, it can be effective for anger or coping, but will not gen-
eralise to have an effect on anxiety or depression. CBT interventions that target
anxiety and depression specifically appear to generate better therapeutic effects
on anxiety and depression. Gaps in the literature are highlighted with sugges-
tions for future research.
Keywords: Acquired brain injury; Traumatic brain injury; Cognitive behaviour-

al therapy; Depression; Anxiety.
INTRODUCTION
Anxiety and depression can follow acquired brain injury (ABI) as a result of bio-
logical, psychological and social factors that are altered by the ABI. Individuals
are not only faced with coming to terms with the traumatic event, but also the
biological and psychological changes and multiple losses associated with the
ABI. Anxiety and depression both have an effect on cognition, mood and motiv-
ation, which may hamper rehabilitation (Khan-Bourne & Brown, 2003).
Hibbard, Uysal, Kepler, Bogdany, and Silver (1998) found anxiety dis-
orders post traumatic brain injury (TBI) to be prevalent. They identified
post-traumatic stress disorder (PTSD; 19%), obsessive compulsive disorder
(OCD; 15%) and panic disorder (14%) as being the most frequent anxiety dis-
orders. They also reported that generalised anxiety disorder (GAD; 9%) and
phobias, including social phobia, specific phobia and agoraphobia (10%)
were present. Fleminger, Oliver, Williams, and Evans (2003) found that
20% to 40% of clients show signs of depression in the first year post-TBI.
Similarly, Koponen, Taiminen, Hiekkanen, and Tenovuo (2011) reported
that 12 months post-TBI, Axis I disorders were found in 47.4% of persons.
They report that 15.8% had depression, 5.3% had social phobia, and 2.6%
had PTSD. A study of depression two and a half years post-TBI revealed
that 42% met DSM-IV (American Psychiatric Association, 1994) criteria
for major depression (Kreutzer, Seel, & Gourley, 2001).
The incidence of post cerebral vascular accident (CVA) depression ranges
from 25% to 79%, depending on the screening measure and timing of the
assessment (Kneebone & Dunmore, 2000). In a review of several studies
totalling 2869 people, the rate of depression after CVA was 33% in the
acute and medium term, and 34% in the long term (Hackett, Yapa, Parag,
& Anderson, 2005).
Malec, Testa, Rush, Brown, and Moessner (2007) suggest our understand-
ing of depression post-TBI was historically oversimplified, with the focus on
pathophysiological changes, reactive depression, psychosocial factors or
coping skills in isolation. In recent years, the complex interrelationship
66 WALDRON, CASSERLY, AND O’SULLIVAN
between psychological and physiological factors has been acknowledged

(Malec et al., 2007). Factors include the nature of the neurological damage,
psychiatric history, premorbid adjustment, coping style, severity of emotional
trauma and poor psychosocial integration (Khan-Bourne & Brown, 2003;
Williams, Evans, & Fleminger, 2003a). Malec et al. (2007) found that percep-
tion of impairment was a strong indicator of depression, signifying that cog-
nitive factors, rather than neurological factors, may have a central role.
Hodgson, McDonald, Tate, and Gertler (2005) comment that cognitive behav-
ioural therapy (CBT) is suited to treating anxiety and depression post-ABI, as
it offers a structured approach focusing on concrete thoughts and behaviours.
Mateer, Sira, and O’Connell (2005) recommend that “cognitive rehabilitation

must integrate both cognitive and emotional interventions, and attend to
belief systems about, and affective responses to, cognitive challenges”
(p. 62). Khan-Bourne and Brown (2003) comment that CBT
(i) accommodates and seeks to tackle the many personal and social
sequelae that may contribute to psychological morbidity both acutely
and chronically; (ii) it provides the therapist with a wide range of
tools with which to work; and (iii) is inherently flexible (p. 98).
CBT’s foundations lie within the cognitive models of depression (Beck, 1967;
Beck, 1970). It is based on the principle that cognitions affect the development
and maintenance of emotions and behaviours (Heimberg, 2002). CBT focuses on
the “here and now”, teaches cognitive and behavioural skills for effective inter-
actions (Clark, Beck, & Alford, 1999), challenges pessimism, and promotes self-
efficacy. CBT also includes behavioural techniques such as graded exposure,
activity scheduling, relaxation training and social skills training.
Thorough reviews by Comper, Bisschop, Carnide, and Tricco (2005), and
Soo and Tate (2007) reveal few randomised control trials (RCTs) for psycho-
logical interventions for anxiety or depression following ABI. The lack of
RCTs is problematic for researchers and clinicians and results in the con-
clusions of previous reviews being limited to the few available well-designed
RCTs. The question of what works after ABI requires a comprehensive
review to include well-designed non-RCT studies of interventions for
anxiety and depression post-ABI.
METHOD
Procedure for inclusion of studies

This paper aims to identify effective CBT programmes for anxiety and
depression in adults with ABI. MEDLINE, PsycINFO and PubMed searches
of English language journals were conducted for the years 1990 to 2012. The
terms “acquired brain injury”, “traumatic brain injury”, “head injury”, “cer-
ebral vascular accident” and “stroke” were combined with such terms as
“CBT”, “cognitive behavioural therapy”, and “treatment outcome”. A
search of these databases revealed about 12 relevant articles. Those articles
were sourced and their references examined, which expanded the number
of papers to 24. Our meta-analysis relies on relaxed criteria to include non-
randomised group studies and studies that measured the outcomes of
anxiety or depression as part of a non-depression/non-anxiety related CBT
intervention. These criteria are more relaxed than those used in, for
example, a Cochrane review, and are aimed at including more studies, even
if less well designed, to allow for a more helpful scrutiny of the literature.
Studies where there was no measurement of anxiety or depression outcomes
are not included. Our meta-analysis aims to establish the extent to which CBT
is effective for anxiety and depression, and whether CBT needs to be aimed at
symptoms of anxiety and depression specifically. It also seeks to explore the
methodological features of published CBT studies.
Calculation and interpretation of effect-sizes

For studies with a control group, effect-sizes were calculated using the
formula d ¼ (M1 - M2) / SD, where M1 is the treatment group post-treatment
mean, M2 is the control group post-treatment mean and SD is the post-treat-
ment standard deviation of the control group. This formula is Glass’s D. For
single group studies, M1 is the pre-treatment mean, M2 is the post-treatment
mean and SD is the post-treatment standard deviation. According to Cohen
(1988), effect-size conventions are: small ¼ .30, medium ¼ .50, large ¼
.80. Effect-sizes reported pertain to anxiety and depression rather than
measures such as anger, social skills or coping. Follow-up effect-sizes are cal-
culated from post-treatment to follow-up rather than from pre-treatment to
follow-up (see Table 4).
RESULTS
Methodological characteristics of the studies

The characteristics of the 24 papers in our review are given in Tables 1 to 5.
All participants had an ABI in the form of a mild to severe TBI, CVA, anoxia
or neurosurgery for tumour removal or shunt insertion. Table 2 documents
whether the study was for TBI, CVA or a mixture of ABI types, along with
indicating whether anxiety and depression were assessed at one-, six- or
twelve-month follow-up. Table 2 also indicates whether the therapist was a
clinical psychologist/psychiatrist experienced with CBT and whether CBT
68
TABLE 1
Characteristics of studies of CBT in acquired brain injury
WALDRON, CASSERLY, AND O’SULLIVAN

Post-
N per group Type of Treatment Treatment
Authors, country, type of study CBT aims Mean age Gender ABI Tests used duration difference Key findings
Ko (1997) A: CBT ¼ 01 A: 54 A: M Mild TBI CCL A: 90 mpw A: T2 , T1 † Case A: CBT, mainly behaviour
Singapore OCD for 4 therapy using exposure and response
1 × single-case Individual weeks prevention was successful in this
CBT case study.
† There was a reduction in CCL scores
following a short treatment and
scores were further improved at six-
month and two-year follow-up.
Williams et al. (2003a) A: CBT ¼ 01 A: N/R A: M Severe TBI HADS A: N/R over A: T2 , T1 † Case A: CBT was partially effective.
United Kingdom OCD MOCI 8 months HADS scores dropped from the mild
1 × single-case Individual and moderate ranges for anxiety and
CBT depression to the normal range after
CBT and cognitive rehabilitation.
† Scores on the MOCI were also
reduced.
Arco (2008) A: CBT ¼ 01 A: 24 A: M Severe TBI Check list A1: 5 sessions A: T2 , T1 † Case A: CBT, mainly self-regulatory
Australia OCD over 5 behaviour therapy, was effective.
1 x single-case Individual weeks Following treatment, scores on a
CBT A2: 8 sessions check list system for frequency of
over 11 counting behaviour were reduced
weeks from 80% of hourly intervals to 0%
with maintenance of 0% on follow-
up.
† At six-month follow-up, counting
was absent, and voiding had
decreased further.
McMillan (1991) A: CBT ¼ 01 A: 19 A: F Severe TBI BDI A: N/R mpw A: T2 , T1 † Case A: CBT was reported to have
United Kingdom PTSD for 16 been successful in this case study.
1 x single-case Individual weeks There was a reduction in BDI scores
CBT from the moderate range to the
normal range with maintenance at
four-month follow-up.
† There were also improvements in
appetite, sleep and mood.
McNeil & Greenwood (1996) A: CBT ¼ 01 A: 28 A: M Severe TBI IES A: N/R mpw A: T2 , T1 † Case A: CBT was reported to have
United Kingdom PTSD for 7 been partially successful in this case
1 x single-case Individual CBT weeks study.
† There was a reduction in IES scores

from the severe range to the
moderate range.
† The IES scores remained above the
cut-off after the intervention.
† Improvements in day-to-day
functioning were reported by the
client.
McGrath (1997) A: CBT ¼ 01 A: 33 A: M Mild TBI HADS A: N/R A: T2 , T1 † Case A: CBT was reported to have
United Kingdom PTSD been partially successful in this case
1 x single-case Individual CBT study. There was a reduction in
HADS depression scores from the
mild range to the minimal range.
† The HADS anxiety scale remained in
the mild range.
CBT IN ABI. WHAT WORKS FOR WHOM?

† Improvements in occupational and
social functioning were reported by
the client.
King (2002) A: CBT ¼ 01 A: 47 A: M Severe TBI BAI IES A: 18 sessions A: T2 . T1 † Case A: This single-case CBT study
United Kingdom PTSD over 28 describes a severe PTSD treatment
1 x single-case Individual CBT months abreaction.
† CBT was reported by the author to
have been relatively successful,
however the paper acknowledges
that only a minimal reduction in IES
scores occurred, with an increase in
the BAI from the moderate range to
the severe range following a difficult
treatment.
Bryant et al. (2003) 1: CBT ¼ 12 1: 29.42 1: M ¼ 33% Mild TBI BDI-II BAI IES 1: 90 mpw for CBT , SC † CBT participants had fewer PTSD
Australia 2: SC ¼ 12 2: 33.00 2: M ¼ 33% CAPS 5 weeks criteria than those receiving SC at
Randomised control PTSD 2: 90 mpw for post-treatment (8% versus 58%) and
Individual CBT 5 weeks at six-month follow-up (17% versus
58%).
69
(Continued)
Table 1. Continued.
70
Post-

† Participants’ CAPS scores, IES

scores and BAI scores dropped from
pre-treatment to post-treatment.
There was no statistical change in
BDI-II scores.
† At six-month follow-up there were
no additional effects for either the
BDI-II or BAI, however the CAPS
scores and IES scores remained
reduced for the CBT group.
Williams et al. (2003b) A: CBT ¼ 01 A: N/R A: M Severe TBI HADS IES A: N/R A: T2 , T1 † Case A: CBT was partially effective.
United Kingdom B: CBT ¼ 01 B: N/R B: F CAPS B: 120 mpw B: T2 , T1 HADS depression scores dropped to
2 x single-cases Individual CBT PTSD for N/R the non-clinical range. HADS
weeks anxiety and IES PTSD scores
remained moderate.
† Case B: CBT was partially effective.
CAPS PTSD symptoms were
reduced at discharge, with a
reduction from the severe range to
the moderate range.
Batten & Pollack (2008) A: CPT ¼ 01 A: 24 A: M Mild TBI CAPS A: 19 sessions A: T2 , T1 † Case A: CPT was partially effective
United States PTSD over 36 (no longer meeting full criteria on the
1 x single-case Individual CPT weeks CAPS).
† The client continued to experience
PTSD symptoms at a sub-threshold
level.
† Improvement on self-reported
depression was indicated, although
the paper does not report scores or
the depression measure used.
Kneebone & Hull (2009) A: TFCBT ¼ A: 23 A: M SHYMA + HADS IES A: 45–75 A: T2 , T1 † Case A: TFCBT was effective, with
United Kingdom 01 PTSD surgery mpw for decreases in HADS scores from the
1 x single-case Individual CBT 20 weeks severe range to the mild range and
decreases on the IES from the
moderate range to the mild range.
† At six-month follow-up both the
HADS and IES scores were in the
subclinical range.
† The benefits of the intervention were

maintained at one-, three-, and six-
month follow-up.
Chard et al. (2011) 1: CPT-C ¼ 42 1: 36.00 1: M ¼ 100% Mild to severe CAPS BDI-II A: 120 mpw A: T2 , T1 † CPT-C was partially effective. The
United States PTSD TBI for 7 residential programme resulted in
Single group design Group + weeks + significant decreases in scores on the
individual CPT group BDI-II and on the CAPS.
† The BDI-II scores remained in the
mild range for the moderate to severe
TBI group and in the moderate range
for the mild TBI subgroup post
intervention.
† Both groups had been in the severe
depression range at pre-treatment.
Hodgson et al. (2005) 1: CBT ¼ 06 1: 44.20 1: M ¼ 66% TBI + CVA + SPAI HADS 1: 60 mpw for CBT , WL † The CBT group showed

Australia 2: WL ¼ 06 2: 33.80 2: M ¼ 50% anoxia SEI 9 to 14 improvements in HADS scores with
Randomised control Soc. anxiety weeks a drop from the mild range to the
Individual CBT 2: Waiting list normal range for both anxiety and
depression, as compared to the WL
group whose scores remained
moderate. Improvements were
maintained at one-month follow-up.
† The CBT group’s social anxiety
scores on the SPAI and self-esteem
scores on the SEI were not
significantly different in comparison
to the WL group.
McDonald et al. (2008) 1: SST + CBT 1: 35.50 1: M ¼ 77% Severe TBI + DASS-21 1: 60 mpw for CBT ¼ SA † Social activity did not lead to
Australia ¼ 13 2: 34.30 2: M ¼ 62% anoxia TASIT 12 weeks SA ¼ WL increased performance relative to the
Randomised control Group + 2: SA ¼ 13 3: 35.30 3: M ¼ 77% BRISS-R + group waiting list.
individual CBT 3: WL ¼ 13 2: Soc. † The CBT + SST group improved on
Soc. skills activities subscales of the BRISS-R. No effects
alone were found for the TASIT, or for
3: Waiting list depression and anxiety as measured
by the DASS-21.
71
(Continued)
Table 1. Continued.
72
Post-

† Treatment effects after CBT + SST

were limited to measures of social
behaviour.
Anson & Ponsford (2006a/b) 1: CBT ¼ 31 1: 38.30 1: M ¼ 84% Mild to mod. CSA HADS 1: 180 mpw T2 ¼ T1 † Group CBT to promote adaptive
Australia Coping TBI RSES for 5 coping strategy use and adjustment
Waiting list control Group weeks resulted in increased adaptive coping
based CBT following intervention, as measured
by the CSA.
† No significant changes in HADS
anxiety or depression scores or self-
esteem as measured by the RSES was
observed following CBT.
Medd & Tate (2000) 1: CBT ¼ 08 1: 35.88 1: M ¼ 87% Mild to severe STAXI SEI 1: 60 mpw for CBT ¼ WL † The CBT group showed a significant
Australia 2: WL ¼ 08 2: 34.00 2: M ¼ 87% TBI + HADS 5 to 8 decrease in anger on the STAXI
Randomised control Anger mgt CVA weeks between pre-treatment and post-
Individual CBT 2: Waiting list treatment, and this was maintained at
two-month follow-up.
† No generalisation of treatment effects
to self-esteem on the SEI, the HADS
anxiety scale or the HADS
depression scale were found.
Salazar et al. (2000) 1: MDT ¼ 67 1: 25.00 1: M ¼ 93% Mod. to severe DSM-IV 1: 60 mpd for MDT , HT † Depression remained stable at 18%
United States 2: HT ¼ 53 2: 26.00 2: M ¼ 96% TBI 8 weeks and 16% over one year for the MDT
Randomised control Group + MDT rehab + group residential group and worsened from
individual CBT 2: 30 mpw for 19% to 27% for the HT group.
8 weeks † Anxiety remained stable at 9% and
9% over one year for the MDT
residential group but worsened from
10% to 20% for the HT group.
Tiersky et al. (2005) 1: CBT ¼ 11 1: 47.55 1: M ¼ 54% Mild to mod. SCL-90-R 1: 150 mpw CBT , WL † Compared with the waiting-list
United States 2: WL ¼ 09 2: 46.00 2: M ¼ 33% TBI for 11 control group, the CBT group
Randomised control Individual Mood & weeks showed partially improved
CBT anxiety 2: Waiting list emotional functioning for anxiety
and depression on the SCL-90-R
† On average, the CBT group remained
clinically at risk post CBT on the
basis of the average SCL-90-R cut-
off score for the group.

† More significant improvements were
seen for anxiety than for depression.
Bradbury et al. (2008) 1: CBT ¼ 10 1: 39.80 1: M ¼ 50% Mod. to severe SCL-90-R 1: 45–75 CBT , INF † CBT evidenced significant
Canada 2: INF ¼ 10 2: 42.50 2: M ¼ 50% TBI + DASS-21 mpw for improvements on both the SCL-90-R
Matched control Group + Mood & CVA + CIQ 11 weeks and the DASS-21.
individual CBT anxiety anoxia + WOCS-R 2: 45–75 † No significant effects were observed
surgery mpw for in the information-only control
11 weeks group.
† On average the CBT group did not
remain clinically at risk post CBT on
the basis of the average SCL-90-R
cut-off score for the group.
† Some CBT group participants
continued to have elevated scores

post CBT.
Arundine et al. (2012) 1: CBT ¼ 17 1: 42.94 1: M ¼ 53% Mod. to severe SCL-90-R 1: 45–90 1: T2 , T1 † CBT evidenced significant
Canada Mood & TBI + DASS-21 mpw for improvements on both the SCL-90-R
Single group design Group + anxiety CVA + CIQ 11 weeks and the DASS-21.
individual CBT anoxia + WOCS-R † On average the CBT group did not
surgery remain clinically at risk at post-
treatment or at follow-up on the basis
of the average SCL-90-R cut-off
score for the group.
† While DASS-21 depression scores
remained stable from post-treatment
to six-month follow-up, the DASS-
21 anxiety scores deteriorated
significantly over the six months.
Lincoln et al. (1997) 1: CBT ¼ 19 1: 67.10 1: M ¼ 42% CVA BDI 1: N/R mpw 1: T2 , T1 † For the group as a whole there was a
United Kingdom Mood HADS for 3 to 15 significant decrease during the
19 x single-cases Individual CBT weeks treatment period on the BDI and on
the HADS depression scale from the
moderate range to the mild range.
73
(Continued)
Table 1. Continued.
74
Post-

† Five patients showed significant

improvement, one patient showed
significant deterioration, and the
scores of fourteen patients did not
differ significantly between baseline
and treatment phases. CBT was
effective for a subset of participants.
Lincoln & Flannaghan (2003) 1: CBT ¼ 39 1: 67.10 1: M ¼ 51% CVA BDI WDI 1: 60 mpw for CBT ¼ AP † There were no significant differences
United Kingdom 2: AP ¼ 43 2: 66.10 2: M ¼ 51% 10 weeks AP ¼ WL between the groups in mood,
Randomised control 3: WL ¼ 41 3: 65.00 3: M ¼ 51% 2: 60 mpw for independence in activities of daily
Individual CBT Mood 10 weeks living, handicap, or satisfaction with
3. Waiting list care after treatment.
† All three groups’ mean BDI scores
were in the mild range at pre-
treatment, post-treatment and follow-
up. CBT was found to be ineffective
in this study.
Rasquin et al. (2009) A: CBT ¼ 01 A: 44 A: F CVA BDI-II SCL- A: 60 mpw A: T2 ¼ T1 † Case B: The BDI-II score dropped
The Netherlands B: CBT ¼ 01 B: 48 B: F 90-R for 8 B: T2 , T1 from the severe range to the minimal
5 x single-cases C: CBT ¼ 01 C: 46 C: F weeks C: T2 ¼ T1 range post treatment (with relapse to
Individual CBT D: CBT ¼ 01 D: 39 D: F B: 60 mpw D: T2 , T1 the moderate range at three-month
E: CBT ¼ 01 E: 54 E: M for 8 E: T2 , T1 follow-up).
Mood weeks † Case D: The BDI-II score dropped
C: 60 mpw from the moderate range to the mild
for 8 range post treatment (with
weeks maintenance of improvements at
D: 60 mpw three-month follow-up).
for 8 † Case E: The BDI-II score dropped
weeks from the moderate range to the mild
E: 60 mpw for range post treatment (with relapse to
8 weeks the moderate range at three-month
follow-up).
Topolovec-Vranic et al. (2010) 1: CBT ¼ 09 1: 42.50 1: M ¼ 62% Mild to mod. CES-D PHQ-9 1: 60–120 T2 , T1 † Participants identified reading,
Canada Mood TBI mpw for 6 memory and comprehension
Single group design Online CBT weeks requirements as limitations to
benefiting from an online CBT
programme.
† CES-D scores at twelve-month
follow-up were decreased from
100% of persons above the cut-off
prior to treatment to 56% below the
cut-off after treatment.
† PHQ-9 scores at twelve-month
follow-up were decreased from

100% of persons above the cut-off
prior to treatment to 44% below the
cut-off after treatment.
ABI ¼ acquired brain injury; AP ¼ attention placebo group; BAI ¼ Beck Anxiety Inventory; BDI ¼ Beck Depression Inventory; BDI-II ¼ Beck Depression Inventory-II; BRISS-R ¼ Behav-
iourally Referenced Rating System of Intermediary Social Skills-Revised; CAPS ¼ Clinician Administered Post Traumatic Distress Scale; CBT ¼ cognitive behavioural therapy; CCL ¼ Compul-
sion Check-List; CES-D ¼ Centre for Epidemiological Studies-Depression Scale; CIQ ¼ Community Integration Questionnaire; CPT ¼ cognitive processing therapy; CPT-C ¼ CPT-cognitive
only; CSA ¼ Coping Scale for Adults; CVA ¼ cerebral vascular accident; DASS-21 ¼ Depression Anxiety Stress Scale-21; DSM-IV ¼ Diagnostic and statistical manual of mental disorders, fourth
edition; HADS ¼ Hospital Anxiety and Depression Scale; HT ¼ home treatment; IES ¼ Impact of Events Scale; INF ¼ provision of information treatment; MDT ¼ multidisciplinary team treat-
ment; MOCI ¼ Maudsley Obsessive Compulsive Inventory; mpw ¼ minutes per week; mpd ¼ minutes per day; N/R ¼ not reported in original paper; OCD ¼ obsessive compulsive disorder;
PHQ-9 ¼ Patient Health Questionnaire-9; PTSD ¼ post-traumatic stress disorder; RSES ¼ Rosenberg Self-Esteem Scale; SA ¼ social activity; SC ¼ supportive counselling; SCL-90-R ¼ Symp-
tom Checklist-90-Revised; SEI ¼ Self-Esteem Inventory (Coopersmith, 1975); SHYMA ¼ syndrome of hydrocephalus in young and middle-aged adults; SPAI ¼ Social Phobia Anxiety Inventory;
SST ¼ social skills training; STAXI ¼ State-Trait Anger Expression Inventory; T1 ¼ Time 1; T2 ¼ Time 2; TASIT ¼ The Awareness of Social Inference Test; TBI ¼ traumatic brain injury;
TFCBT ¼ trauma-focused cognitive behavioural therapy; WDI ¼ Wakefield Self-Assessment of Depression Inventory; WL ¼ waiting list; WOCS-R ¼ Ways of Coping Scale-Revised.
75
76

TABLE 2
Methodological features of studies of CBT in acquired brain injury?
Williams McNeil & Batten & Kneebone &

Ko et al. Arco McMillan Greenwood McGrath King Bryant et al. Williams et al. Pollack Hull Chard et al.
Feature (1997) (2003a) (2008) (1991) (1996) (1997) (2002) (2003) (2003b) (2008) (2009) (2011)
Therapeutic focus OCD OCD OCD PTSD PTSD PTSD PTSD PTSD PTSD PTSD PTSD PTSD
TBI 1 1 1 1 1 1 1 1 1 1 0 1
CVA 0 0 0 0 0 0 0 0 0 0 0 0
Anoxia/surgery 0 0 0 0 0 0 0 0 0 0 1 0
Self-rated 0 1 1 1 0 1 0 1 1 0 1 1
depression
Self-rated anxiety 1 1 1 0 1 1 1 1 1 1 1 1
Control group 0 0 0 0 0 0 0 1 0 0 0 0
Random 0 0 0 0 0 0 0 1 0 0 0 0
assignment
Post-treatment 1 1 1 1 1 1 1 1 1 1 1 1
assessment
1- to 6-month 1 0 1 1 0 0 0 1 0 0 1 0
follow-up
7- to 12-month 0 0 0 0 0 0 0 0 0 0 0 0
follow-up
13- to 24-month 1 0 0 0 0 0 0 0 0 0 0 0
follow-up
Experienced 1 1 1 1 0 1 0 1 1 1 1 1
therapists
Group CBT 0 0 0 0 0 0 0 0 0 0 0 1
Individual CBT 1 1 1 1 1 1 1 1 1 1 1 1
Therapeutic focus Social Social Coping Anger mgt MDT rehab Mood & Mood & Mood & Mood Mood Mood Mood
anxiety skills skills anxiety anxiety anxiety
TBI 1 1 1 1 1 1 1 1 0 0 0 1
CVA 1 0 0 1 0 0 1 1 1 1 1 0
Anoxia/surgery 1 1 0 0 0 0 1 1 0 0 0 0
Self-rated 1 1 1 1 1 1 1 1 1 1 1 1
depression
Self-rated anxiety 1 1 1 1 1 1 1 1 0 0 0 0
Control group 1 1 1 1 1 1 1 0 0 1 0 0
Random 1 1 1 1 1 1 0 0 0 1 0 0
assignment

Post-treatment 1 1 1 1 0 1 1 1 1 1 1 0
assessment
1- to 6-month 1 0 0 1 0 0 1 1 0 1 1 0
follow-up
7- to 12-month 0 0 0 0 1 0 0 0 0 0 0 1
follow-up
13- to 24-month 0 0 0 0 0 0 0 0 0 0 0 0
follow-up
Experienced 0 1 1 0 1 1 1 0 0 0 1 0
therapists
Group CBT 0 1 1 0 1 0 1 1 0 0 0 0
Individual CBT 1 1 0 1 1 1 1 1 1 1 1 1
1 ¼ design feature was reported in original paper as present; 0 ¼ design feature was not reported in original paper/was absent.
77
78
TABLE 3
PEDro ratings of methodological quality of group studies of CBT in acquired brain injury

Topolovec-
Bryant Chard Hodgson McDonald Anson & Medd Salazar Tiersky Bradbury Arundine Lincoln Lincoln & Vranic
et al. et al. et al. et al. Ponsford & Tate et al. et al. et al. et al. et al. Flannaghan et al.
(2003) (2011) (2005) (2008) (2006a) (2000) (2000) (2005) (2008) (2012) (1997) (2003) (2010)
Therapeutic focus PTSD PTSD Social Social skills Coping Anger MDT Mood & Mood & Mood & Mood Mood Mood
anxiety skills mgt rehab anxiety anxiety anxiety
1. Eligibility 1 1 1 1 1 1 1 1 1 1 1 1 1
specified
2. Randomly 1 0 1 1 1 1 1 1 0 0 0 1 0
allocated
3. Allocation 0 0 1 1 0 1 1 1 0 0 0 1 0
hidden
4. Groups similar 1 0 1 0 0 1 1 1 1 1 0 1 0
at baseline
5. Blinding of 0 0 0 0 0 0 0 0 0 0 0 0 0
subjects
6. Blinding of 0 0 0 0 0 0 0 0 0 0 0 0 0
therapist
7. Blinding of 1 1 0 1 0 0 0 1 0 0 1 1 0
assessors
8. Adequate 1 0 1 0 1 1 1 0 1 1 0 1 1
follow-up
9. All subjects 0 0 0 1 0 0 1 0 0 0 1 0 0
analysed by
“intention to
treat”
10. Between- 1 0 1 1 1 1 1 1 1 1 0 1 0
group
comparisons
reported
11. Point 1 1 1 1 0 1 1 1 1 1 1 1 1

measures and
measures of
variability
Total for items 2 6† 2 6 6† 3† 6† 7† 6† 4† 4† 3 7† 2
to 11
PEDro ratings calculated by Waldron, Casserly & O’Sullivan unless sourced from http://www.psycbite.com, as indicated by †.
79
80

TABLE 4
Effect-sizes for symptom improvement following CBT in acquired brain injury
Williams McNeil & Bryant Williams Batten & Chard

Ko et al. Arco McMillan Greenwood McGrath King et al. et al. Pollack Kneebone & et al.
(1997) (2003a) (2008) (1991) (1996) (1997) (2002) (2003) (2003b) (2008) Hull (2009) (2011)
Measure used % change HADS BDI-II BDI IES HADS BAI BDI-II HADS CAPS HADS BDI-II
BAI CAPS
Post-treatment
Depression - - - - - - - 0.40 - - - 1.07
Anxiety - - - - - - - 0.48 - - - 1.74
6-month follow-
up
Depression - - - - - - - 0.35 - - - -
Anxiety - - - - - - - 0.42 - - - -
12-month follow-
up
Depression - - - - - - - - - - - -
Anxiety - - - - - - - - - - - -
Therapeutic focus Social Social skills Coping Anger mgt MDT rehab Mood & Mood & Mood & Mood Mood Mood Mood
anxiety skills anxiety anxiety anxiety
Measure used HADS DASS-21 HADS HADS % change SCL90-Anx DASS- DASS-21 BDI BDI BDI-II CES-D
SCL90-Dep 21
Post-treatment
Depression 2.39 0.12 0.00 0.46 - 0.87 1.24 1.60 0.77 0.00 - -
Anxiety 3.47 0.18 0.00 0.42 - 0.79 1.24 - - - - -

6-month follow-
up
Depression 1.35 - 0.00 0.22 - - 1.66 -0.48 - 0.00 - -
Anxiety 1.11 - 0.00 0.26 - - 1.66 - - - - -
12-month follow-
up
Depression - - - - 0.00 - - - - - - 2.15
Anxiety - - - - 0.00 - - - - - - -
Effect-sizes calculated by Waldron, Casserly & O’Sullivan on basis of Glass’s D. SCL90-Dep ¼ SCL-90-R depression scale; SCL90-Anx ¼ SCL-90-R anxiety scale.
81
82

TABLE 5
Qualitative description for symptom improvement following CBT in acquired brain injury
Kneebone &
Williams et al. Arco McMillan McNeil & McGrath King Williams et al. Batten & Hull Chard et al.
Ko (1997) (2003a) (2008) (1991) Greenwood (1996) (1997) (2002) Bryant et al. (2003) (2003b) Pollack (2008) (2009) (2011)
Measure used % change HADS BDI-II BDI IES HADS BAI BDI-II BAI HADS CAPS HADS BDI-II CAPS
Pre-treatment
Depression - Moderate Severe Moderate - Mild - Moderate Moderate - Mild Severe
Anxiety - Mild - - Severe Mild Moderate Severe Severe - Severe -
Post-treatment
Depression - Normal Minimal Normal - Minimal - Mild Normal - Normal Moderate
Anxiety - Normal - - Moderate Mild Severe Mild Moderate - Mild -
6-month follow-up
Depression - - Minimal Normal - - - Mild - - Normal -
Anxiety - - - - - - - Mild - - Normal -
12-month follow-up
Depression - - - - - - - - - - - -
Anxiety - - - - - - - - - - - -
Therapeutic focus Social Social skills Coping Anger mgt MDT rehab Mood & Mood & Mood & anxiety Mood Mood Mood Mood
anxiety skills anxiety anxiety
Measure used HADS DASS-21 HADS HADS % change SCL90-Anx DASS-21 DASS-21 SCL90- BDI BDI BDI-II CES-D
SCL90-Dep SCL90-GSI GSI
Pre-treatment
Depression Mild Mild - Normal - . Cut-off Moderate Moderate Moderate Mild - . Cut-off
Anxiety Mild Normal - Moderate - . Cut-off Moderate Moderate - - - -

Post-treatment
Depression Normal Mild - Normal - . Cut-off Normal Normal Mild Mild -
Anxiety Normal Normal - Mild - , Cut-off Normal Normal - - -
6-month follow-up
Depression Normal - - Normal - - Normal Normal - Mild - -
Anxiety Normal - - Mild - - Normal Normal - - - -
12-month follow-up
Depression - - - - - - - - - - - , Cut-off
Anxiety - - - - - - - - - - - -
Qualitative descriptions are based on the case study’s reported score or the reported mean score for the CBT group(s) on the manual for the test in question at pre-test, post-test and follow-up. SCL90-GSI ¼
SCL-90-R Global Severity Index.
83
was carried out on an individual or group basis. Table 4 presents the effect-
sizes for group studies where it was possible to calculate them. Effect-sizes
cannot be calculated for single-cases. Table 5 documents qualitative descrip-
tions of clinical change on measures of depression and anxiety.
One study evaluated group CBT and eighteen studies evaluated individual
CBT, one of which was internet-based without a therapist (Topolovec-Vranic
et al., 2010). Two papers used a treatment group where some persons received
group CBT and some received CBT individually over the phone (Arundine
et al., 2012; Bradbury et al., 2008) and three studies involved each participant
receiving a combination of group and individual CBT (Chard, Schumm,
McIlvain, Bailey, & Parkinson, 2011; McDonald et al., 2008; Salazar et al.,
2000).
Eleven papers used a single-case design (with or without replication). The
methodological design of these studies was classified with the taxonomy used
by Perdices and Tate (2009), which distinguishes between four types of
single-case designs in terms of degree of experimental control. Firstly, clini-
cal case descriptions represent the lowest level of sophistication where treat-
ment efficacy is not quantified. The Batten and Pollack (2008) paper was the
only study of this type. Secondly, pre/post designs measure dependent vari-
ables in a single patient on only one or two occasions before and after treat-
ment. Most of the non-group studies fell into this category (King, 2002;
Kneebone & Hull, 2009; Ko, 1997; McGrath, 1997; McMillan, 1991;
McNeil & Greenwood, 1996; Williams et al., 2003a; Williams, Evans, &
Wilson, 2003b). Thirdly, biphasic A–B designs involve multiple obser-
vations of the dependent variable in the baseline and treatment phases.
There were no studies of this type. Fourthly, multi-phase (.2 phases) and
multiple baseline designs involve observations across several treatment and
baseline phases. Replication across patients, therapists or settings, increases
generalisability and evidence for external validity. The Arco (2008) study
represents an example of this methodology, as Arco provides data points
across eleven weeks for voiding and counting, and provides anxiety and
depression scores at pre-treatment, post-treatment and follow-up. Similarly,
Rasquin, van de Sande, Praamstra, and van Heugten (2009) report depression
scores over several baseline weeks, several treatment weeks and at follow-up.
It is clear that a large number of the single-case reports included, while
valuable in providing descriptions of interventions, do not in fact provide
experimental control and therefore their contribution to the evidence base
is limited.
Four papers used uncontrolled single groups and nine studies used a
control group. To assess the methodological quality of group studies, each
study was rated using the PEDro Scale (Maher, Sherrington, Herbert,
Moseley, & Elkins, 2003). The PEDro scores (see Table 3) used the
PsycBITE database (http://www.psycbite.com) as a benchmark of concurrent
validity. There was broad variability in methodological quality, with scores

ranging from 2/10 to 7/10 on the scale. It should be acknowledged that it
is very difficult to have blind subjects and therapists (two of the PEDro
items). Generally, participants know if they are getting CBT or not, and thera-
pists know if they are providing CBT or not. Lower PEDro scores tended to be
caused by not having a control group (Arundine et al., 2012; Chard et al.,
2011; Lincoln, Flannaghan, Sutcliffe, & Rother, 1997; Topolovec-Vranic
et al., 2010), which precluded a score for random allocation, allocation
being hidden, or groups being similar at baseline. However, adequate
follow-up and analysis of data on an intention-to-treat basis could have
been features of single group studies but were sometimes absent, lowering
the PEDro score further with increased potential for bias.
Substantive findings for obsessive compulsive disorder

Ko (1997) showed in a single-case study that CBT was effective for OCD that
resulted from a mild TBI following a road traffic accident (RTA). The client
had developed a fear of contamination with hand-washing and avoidance of
potentially contaminated objects. CBT, mainly behaviour therapy using
exposure and response prevention, was successful. There was a reduction
in Compulsion Check-List (Marks, 1986) scores following four 90 minute
sessions (from a score of 72 to 60). Additional improvements were seen at
two-year follow-up with a further reduction in scores (to a score of 26).
In a single-case study by Williams et al. (2003a), CBT with cognitive reha-
bilitation (CR) was shown to be effective for OCD following severe TBI after
an RTA. The intervention over eight months included relaxation, manage-
ment of negative thoughts and graded exposure. The Hospital Anxiety and
Depression Scale (HADS; Zigmond & Snaith, 1983) anxiety and depression
scores dropped from the mild and moderate ranges respectively to normal at
post-treatment. Scores on the Maudsley Obsessive Compulsive Inventory
(MOCI; Hodgson & Rachman, 1977) were also reduced (but not to below
cut-off). While there was no follow-up data, the client reported improvements
in social and community integration.
Arco (2008) used a single participant changing criterion experimental
design to evaluate an intervention for OCD following a severe TBI due to
an RTA. This study shows the importance of the therapeutic relationship
over long periods of time between therapists and clients. The client had pre-
sented with a Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown,
1996) score in the minimal range at the start of the OCD treatment. Interest-
ingly the client had previously received CBT treatment for depression. The
first set of sessions (see Table 1) consisted of five hours over five weeks,
and included cognitive restructuring, challenging negative thoughts and be-
havioural activation, and resulted in a drop from the severe range to the
minimal range on the BDI-II. The minimal range score was maintained during
the no-therapy gap to the time of starting OCD treatment (three to four
months). The OCD intervention was mainly behaviour therapy and “consisted
of regular in-home consultations, self-regulation procedures including self-
recording of compulsive behaviour, stress-coping strategies, errorless reme-
diation, social reinforcement, and gradual fading of intervention” (Arco,
2008, p. 109). During the baseline, counting occurred during 80% of hourly
intervals, with twelve bladder voids per day. CBT (eight sessions over
eleven weeks) produced elimination of compulsive counting (to 0%) and
voiding was reduced to eight times per day. At six-month follow-up
(during which there were fortnightly booster sessions), counting remained

at 0%, and voiding had decreased to seven times per day.
Substantive findings for post-traumatic stress disorder

McMillan (1991) showed in a single-case study that CBT and behaviour
therapy was effective with PTSD following severe TBI after an RTA. The
client had frequent thoughts about her friend who died in the accident and dis-
played avoidance of reminders of the accident. There were weekly CBT ses-
sions with behavioural exposure over 16 weeks. The client’s intrusive
thoughts and feelings were discussed and she was encouraged to confide in
her family and with a friend. She was assisted to visit previously avoided situ-
ations using graded in vivo exposure, initially with support and then alone.
CBT was reported to have been successful with a reduction in the original
Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961) score from the moderate range to the normal range. The
author reports maintenance at four-month follow-up but does not give the
follow-up score (see Table 5). While it appeared the therapy was a success,
the study lacked measures of PTSD or Anxiety (see Table 2).
McNeil and Greenwood (1996) demonstrated in a single-case study that
CBT and behaviour therapy was partially effective with PTSD following a
severe TBI from an RTA. The client had significant retrograde amnesia,
but also had intrusive thoughts and nightmares about the accident.
First, traditional anxiety management techniques and graded exposure to

the avoided stimuli were used. Second the client was assisted to devise an
accurate account of what had actually happened from friends, relatives,
and the police; and finally they received psycho-education on TBI and,
in particular, retrograde amnesia and post-traumatic amnesia to reduce
the guilt he felt about his inability to remember information (p. 243).
There were seven sessions over a seven-week period. CBT was partially
successful with reduction in Impact of Events Scale (IES; Horowitz,
Wilner, & Alvarez, 1979) scores. The Corneil, Beaton, Murphy, Johnson, and
Pike (1999) method of IES score interpretation indicated that the change in
the McNeil and Greenwood (1996) paper was a drop from the severe range
to the moderate range. The IES score remained above cut-off post interven-
tion and there was no follow-up (see Table 5).
McGrath (1997) reported on a single-case study involving PTSD following
mild TBI from an RTA. The client had nightmares and intrusive thoughts
about the accident, along with avoidance of driving and situations he per-
ceived as dangerous. Additionally, he developed OCD-like checking beha-
viours. The single-case study suffers as neither the length of sessions nor
the number of sessions was reported. CBT included relaxation, challenging

of thoughts, graded exposure to driving, response prevention for checking,
stress management and supportive counselling. Therapy was reported to
have been partially successful, with a reduction in HADS depression scores
from the mild range to the minimal range and improvements in occupational
and social functioning. However, the HADS anxiety scale remained in the
mild range following treatment and no follow-up was reported (see Table 5).
In a bravely reported single-case study by King (2002), PTSD treatment
was complicated by a serious abreaction in a client with severe TBI. He
had fallen from a boat, suffered a penetrating TBI from the propeller and
nearly drowned. There were 18 CBT and behaviour therapy sessions over a
28-month period. King (2002) reports “the treatment model was a standard
one for PTSD, adapted from previous exposure-based protocols” (p. 69).
Psycho-education, anxiety management, systematic desensitisation to
avoided situations, and exposure to memories were implemented. Initially
the client made progress and was able to talk through memories with
reduced distress. After Session 7 he developed protracted re-experiencing
of feelings of suffocation, blackness, coldness and salt water over a two-
day period. Therapy was partially successful on the basis of return to employ-
ment and less social anxiety. However, only a minimal reduction in IES
scores occurred (remaining in the severe range) with an increase in Beck
Anxiety Inventory (BAI; Beck & Steer, 1993) scores from the moderate
range to the severe range (see Table 5). Follow-up scores were not reported.
In an RCT on acute stress disorder (a precursor to PTSD) after mild TBI
with 12 persons who received CBT (five 90-minute individual sessions)
and 12 persons who received supportive counselling (SC), Bryant, Moulds,
Guthrie, and Nixon (2003) found CBT to be superior to SC. The cohort
had experienced an RTA or a non-sexual assault. CBT comprised education,
relaxation, exposure to traumatic memories and avoided situations, and cog-
nitive restructuring. Exposure to memories was also performed as homework.
The SC comprised of trauma education and problem solving. Those receiving
CBT had fewer PTSD criteria on the IES and the Clinician Administered
PTSD Scale (CAPS; Blake et al., 1995) than those receiving SC at post-
treatment (8% versus 58%) and at six-month follow-up (17% versus 58%).
While participants’ mean BAI scores dropped from pre-treatment (severe
range) to post-treatment (mild range), there was no statistically significant
change in scores on the BDI-II. However, their article table shows the
BDI-II group mean dropped from the moderate range to the mild range
(see Table 5). Bryant et al. (2003) state that at six-month follow-up there
were no effects for either the BDI-II or BAI (although their table shows main-
tenance of mild range scores for anxiety and depression at follow-up). The
CAPS scores and IES scores also remained reduced for the CBT group at
follow-up. Effect-sizes are listed in Table 4.
Williams et al. (2003b) showed CBT with CR to be partially effective for

an adult male who sustained a severe TBI in an RTA in which his girlfriend
died. He experienced nightmares and flashbacks, and avoided driving and
crowds. The HADS depression scale dropped from the moderate range to
the normal range. However, the HADS anxiety scale only dropped from the
severe range to the moderate range and the IES scores only dropped from
the severe range to the moderate range (see Table 5). The second case
involved a female with PTSD as measured by the CAPS following a penetrat-
ing ABI (stabbed in the head). CBT included relaxation, management of
negative thinking and graded exposure. CAPS scores at discharge dropped
from the severe range to the moderate range yet follow-up scores were not
presented for either case.
Batten and Pollack (2008) provide a single-case report of a soldier
deployed to Iraq and Afghanistan who had a mild TBI, PTSD and depression.
He had experienced a very traumatic event that involved his shooting dead of
an unarmed teenager in ambiguous circumstances. The main treatment was
cognitive processing therapy (CPT; Resick & Schnicke, 1993). There were
12 sessions of CPT (a variant of exposure-based CBT) with booster sessions.
After 19 sessions over six months he no longer met full criteria for PTSD on
the CAPS but continued to experience symptoms at a sub-threshold level. He
also reportedly made progress with depression, although neither post-treat-
ment CAPS nor depression scores were reported (see Tables 2 and 5). No
follow-up was reported.
Kneebone and Hull (2009) report on a single-case of CBT for PTSD in a
man with the syndrome of hydrocephalus in young and middle aged adults
(SHYMA). The hydrocephalus necessitated neurosurgery for shunt place-
ment. On post-surgical assessment there were problems with executive func-
tions and dysarthria. He developed PTSD symptoms including intrusive
memories of hospitalisation, and avoidance of activities. Trauma-focused
cognitive behavioural therapy (TFCBT) refers to the spectrum of CBT treat-
ments that predominantly use trauma-focused cognitive, behavioural or cog-
nitive-behavioural techniques, including exposure (Bisson & Andrew, 2007).
The 20-session intervention resulted in decreases in HADS anxiety scores
from the severe range to the mild range. IES scores dropped from the moder-
ate range to the mild range. At six-month follow-up both HADS anxiety and
IES total scores were reduced further to the normal and subclinical ranges
respectively. The graph in the original paper appears to show HADS
depression scores being reduced from the mild range to the normal range
with maintenance at follow-up (see Table 5).
Chard et al. (2011) present findings from a US Veterans Administration
programme for co-morbid PTSD and TBI in 42 soldiers returning from Iraq
and Afghanistan who met CAPS criteria for PTSD. They evaluated a CPT
version that omits the writing/reading of trauma accounts in favour of the
cognitive challenging and rehearsal aspects termed CPT-cognitive only

(CPT-C). Participants completed seven weeks of residential therapy in a com-
bined group and individual format. The CPT-C group was held twice per
week and individual CPT-C sessions were conducted at least twice per
week. The treatment was augmented with speech therapy, psycho-education
groups and a cognitive enhancement group. The programme resulted in sig-
nificant decreases in BDI-II and CAPS scores. The BDI-II scores dropped
from the severe range to the moderate range. No follow-up was reported.
Substantive findings for social anxiety and social skills

Hodgson et al. (2005) conducted an RCT for social anxiety post TBI, CVA
and anoxic ABI. Twelve participants were allocated to either CBT or a
waiting list. The six-person CBT group received between nine and fourteen
sessions of 60-minute individual CBT which included relaxation, cognitive
strategies, graded exposure and assertiveness skills. The CBT group’s
HADS anxiety and depression scores dropped from the mild range to the
normal range at post-treatment. The waiting list group remained in the mod-
erate range. Improvements for the CBT group were maintained at one-month
follow-up (see Table 5). However, changes in social anxiety and self-esteem
for the CBT group as measured by the Social Phobia Anxiety Inventory
(SPAI; Turner, Beidel, Dancu, & Stanley, 1989) and the Self-Esteem Inven-
tory (SEI; Coopersmith, 1975) were not significant. Interestingly, this study
did not use a group social skills training (SST) format, which is considered
to be an important treatment component in some CBT models of social
phobia (Clark & Wells, 1995) and in non-ABI studies of group CBT versus
group SST for social phobia (van Dam-Baggen & Kraaimaat, 2000). The
study used individual CBT, which appears to have worked for general
anxiety and depression but perhaps failed to address the social phobia as it
lacked a group component through which fear of negative evaluation can
be challenged by the group.
There is a study of group-based SST for ABI, however it was geared at
social awareness and social skills rather than social anxiety. McDonald
et al. (2008) conducted an RCT comparing an SST group intervention (com-

bined with individual CBT) against social activities (SA) alone and a waiting-
list control for severe ABI. Thirty-nine participants (thirteen in SST and CBT,
thirteen in SA, and thirteen on the waiting list) completed the study. The SST
involved 12 weekly group sessions of three hours. Participants also had
weekly one-hour individual CBT for self-esteem, anxiety, and depression.
The SA involved 12 weekly sessions of four hours that did not focus on
SST, nor was there CBT. The SA group did not differ from those on the
waiting list. By contrast, the SST and CBT group improved on subscales of
the Behaviourally Referenced Rating System of Intermediary Social Skills-
Revised (BRISS-R; Wallander, Conger, & Conger, 1985). No effects were

found for the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond &
Lovibond, 1996), despite individual CBT for the SST group. The authors indi-
cate that “the groups were, on average, in the mild-to-moderate range for
anxiety, depression, and stress on DASS scales at pre-test. This changed
little at post-test and there was no overall treatment effect” (p. 1655). No
follow-up was reported.
Substantive findings for coping skills

Anson and Ponsford (2006a) evaluated CBT for coping skills in 31 individ-
uals with TBI. This study represents the only entirely group-based interven-
tion in this meta-analysis. Groups ran for 90 minutes twice a week, for five
weeks (ten sessions). Individual therapy was suspended for the duration.
Groups addressed anxiety, depression and self-esteem through problem
solving, relaxation training, activity scheduling and challenging maladaptive
thinking. Coping increased significantly, as measured by the Coping Scale for
Adults (CSA; Frydenberg & Lewis, 1996) and gains were maintained at six-
to twenty-four-month follow-ups. No changes in HADS scores or self-esteem
as measured by the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965)
were observed. HADS means and standard deviations were not reported.
Effect-sizes are therefore listed as zero, as the results are described as non-sig-
nificant. In an additional paper on the same study, Anson and Ponsford
(2006b) reported that better outcomes were associated with greater self-
awareness of deficits, less severe injury, higher pre-morbid intellectual func-
tioning and greater anxiety prior to intervention.
Substantive findings for anger management

Medd and Tate (2000) evaluated an RCT of individual CBT anger manage-
ment for people with TBI or CVA. There was a CBT group of eight
persons and a waiting list of eight persons. The CBT group received
between five and eight individual one-hour sessions, while those on the
waiting list monitored their anger. The CBT was based on Novaco’s (1975)
self-instructional training. A model demonstrating how trigger events lead to

anger depending on the thoughts that occur was taught. The programme
aimed to increase
participants’ awareness of their anger by probing for cognitive, phys-

ical, and emotional changes that occur when and if they first start to
become angry. The final sessions involved imparting and practising
various strategies to deal with an angry response, namely relaxation,
self-talk, cognitive challenging, assertiveness training, distraction, and
timeout (p. 192).
Improvements at post-treatment on the State-Trait Anger Expression

Inventory (STAXI; Spielberger, 1988) were found for the CBT group.
There was no generalisation to the SEI or HADS. HADS depression scores
remained normal at all timescales. HADS anxiety scores dropped from the
moderate range to the mild range at post-treatment and remained mild at
follow-up (see Table 5).
Substantive findings for multidisciplinary rehabilitation

Salazar et al. (2000) published an RCT of 67 military personnel with moder-
ate to severe TBI who received an eight-week inpatient multi-disciplinary
team (MDT) rehabilitation programme and 53 persons with TBI who com-
pleted a home treatment (HT) programme. MDT patients conformed to mili-
tary standards and participated in a structured daily routine. Group therapies
included planning and organisation, cognitive skills, pragmatic speech, milieu
psychotherapy (modelled after Prigatano 1989), and community re-entry. The
HT group received TBI education and were given materials and strategies for
cognitive and organisational skills. They were trained in home exercises, and
encouraged to watch news programmes and read. While the MDT group
received 60 minutes of group and individual psychotherapy per day, the
HT patients received weekly 30-minute telephone calls from the psychiatric
nurse. While the MDT group did not show benefits over HT in terms of return
to employment or return to duties, the study tables suggest benefits to the
MDT group not specifically commented on by the authors. While DSM-IV
major depression remained stable at 18% and 16% over the 12 months
post-treatment for MDT, it worsened from 19% to 27% for HT. Similarly,
DSM-IV generalised anxiety remained stable at 9% and 9% over 12
months for MDT but worsened from 10% to 20% for HT. This study did
not show that the group members who received residential MDT benefited
in terms of mood or anxiety, although the MDT may have prevented the
deterioration that was observed in the HT group. Effect-sizes are listed as
zero in Table 4 on the basis of a formula for percentage change.
Substantive findings for depression and anxiety

Tiersky et al. (2005) used an RCT to examine the effectiveness of CBT and
CR in treating anxiety and depression following mild TBI. There were eleven
CBT participants and nine waiting-list participants. The CBT group received
50 minutes of individual CBT three times per week and 50 minutes of indi-
vidual CR three times per week, for 11 weeks. CBT goals included increasing
coping, stress reduction and relapse prevention. CBT included the use of
thought records, behavioural experiments, and cognitive rehearsal. The
CBT group began with severe emotional distress, as measured by the
Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1994), and while at

post-treatment they had improved significantly, improvement was not to
within normative limits. “At baseline, the mean SCL-90-R Global Severity
Index (GSI) T-score for the treatment group was 67.5. After the intervention,
the mean T score was 63.0, which is still a cut-off for psychiatric caseness”
(p. 1571). Similar findings were observed for the SCL-90-R depression
scale. However, the CBT group showed levels of anxiety on the SCL-90-R
that returned to normal at post-treatment (see Table 5). Effect-sizes could
not be calculated for the follow-up as means and standard deviations were
not reported.
Bradbury et al. (2008) evaluated CBT for anxiety and depression, using
both face-to-face group and individual telephone delivery in a matched-con-
trolled trial. Ten outpatients were assigned to CBT (five in a group and five
telephone delivered) and ten to an information-only control. There were
eleven CBT sessions, including one introductory individual session plus ten
further sessions, administered in either group or telephone format. Partici-
pants in the education group were provided information on ABI, and seque-
lae. In contrast to the Tiersky et al. (2005) study, table data show the CBT
group’s mean SCL-90-R GSI T-score dropped below 63 (the cut-off) at
post-treatment with maintenance at one-month follow-up (see Table 5).
The control group’s mean GSI T-score remained above cut-off. Similarly,
changes were observed on the DASS-21 for the CBT group but not for the
control group. The DASS-21 depression and anxiety scores both dropped
from the moderate range to the normal range at post-treatment with mainten-
ance at follow-up (see Table 5).
Arundine et al. (2012) reported on seventeen participants with ABI who
received CBT. These were the ten treated participants from the Bradbury
et al. (2008) study and seven of the information-only control participants
who were subsequently offered CBT. The SCL-90-R and DASS-21 were
again used. Eleven CBT sessions were provided either in a group format,
or individually by telephone. In a similar finding to Bradbury et al. (2008),
the CBT group’s mean SCL-90-R GSI T-score dropped below 63 (the cut-
off) at post-treatment and this was maintained at six-month follow-up (see
Table 5). DASS-21 depression and anxiety scores also fell at post-treatment to
normal. However, while the depression subscale did not change from post-
treatment to follow-up, scores on the anxiety subscale worsened from post-
treatment to follow-up. Despite statistical change, the scores as rated by
this meta-analysis’s authors remained in the normal range for anxiety and
depression over the six-month follow-up (see Table 5). Effect-sizes are
listed in Table 4.
Substantive findings for depression

Lincoln et al. (1997) used 19 A–B single-cases to evaluate CBT for post-
CVA depression. Participants completed the BDI weekly during a four-
week baseline. They then completed between three and fifteen sessions of
manualised CBT (on average eight sessions) and filled out the BDI weekly.
“There were 5 patients who showed significant improvement, 1 patient
showed significant deterioration and the scores of 14 patients did not differ
significantly between baseline and treatment phases” (p. 117). For the
group as a whole there was a decrease on the BDI and HADS depression sub-
scales from the moderate range to the mild range for both tests (see Table 5).
The authors do not report HADS anxiety scores and no follow-up was
reported (see Table 2). Effect-sizes are listed in Table 4. The authors con-
cluded that CBT is effective for some CVA patients. They state that it
appeared subjectively that ongoing illnesses and more cognitive impairment
was associated with poorer outcomes. Anson and Ponsford (2006b) made a
similar comment around insight and cognitive ability in relation to their study.
Subsequently, Lincoln and Flannaghan (2003) reported on an RCT for
depression after CVA. Thirty-nine participants were randomly allocated
to CBT, forty-three persons received an attention placebo (AP), and forty-
one persons were placed on a waiting list. The AP group had 10 visits of
60 minutes over three months, during which no therapy occurred. The
CBT group had 10 manualised sessions of 60 minutes over three months.
CBT included education, graded task assignment, activity scheduling, and
challenging cognitions. Outcomes at three and six months, on the BDI
and Wakefield Depression Inventory (WDI; Snaith, Ahmed, Mehta, &
Hamilton, 1971) revealed no significant differences between groups. All
three groups’ mean BDI scores were in the mild range at pre-treatment,
post-treatment and follow-up (see Table 5). Of the 123 persons in the
study, only 62 had an International Classification of Diseases-10 (ICD-10;
World Health Organization, 2008) diagnosis of depression. Analysis for
that group also showed no significant differences. However, there is an
issue around the authors’ comment that the number of CBT sessions
ranged “from 0 to 15” (Lincoln & Flannaghan, 2003, p. 112), suggesting
that at least some CBT group members in fact had no CBT. As the study
does not report BDI or WDI standard deviations, effect-sizes are listed as
zero, as the results are described as non-significant.
Rasquin et al. (2009) evaluated CBT for depression following CVA. Five
outpatients received individual manualised CBT for 60 minutes per week
over eight weeks. CBT included mood recording and evaluation, relaxation,
visualisation, cognitive restructuring and activity scheduling. Assessment was
by weekly BDI-II during the four-week baseline, twice during the eight-week
treatment phase, and again at three-month follow-up. At post-treatment,
improvements were observed for three participants. Scores were not reported
consistently for all participants and an average score across the five partici-
pants was not reported (see Table 5). It appears that one person dropped
from the severe range to the minimal range. Two persons dropped from the
moderate range to the mild range. The remaining two scores were unchanged.
The authors do not comment in detail on the three-month follow-up; however,
it appears on the basis of a graph in the original article that two of the three
who showed improvement relapsed to the moderate range at follow-up. In
addition, this study employed the SCL-90-R, which did not show changes
for four of the five participants.
Topolovec-Vranic et al. (2010) examined a six-week internet-delivered CBT
intervention MoodGYM (http://www.moodgym.anu.edu.au) for depression
following mild and moderate TBI using a single group design. MoodGYM con-
sists of “five CBT modules, a personal workbook (containing 29 exercises and
assessments), an interactive game and a feedback evaluation form” (p. 763).
Assessment at twelve-month follow-up used the Centre for Epidemiological
Studies Depression Scale (CES-D; Radloff, 1977) and the Patient Health Ques-
tionnaire 9 (PHQ-9; Spitzer, Kroenke, & Williams, 1999). Of the twenty-one
people recruited, thirteen completed the six-week intervention and nine com-
pleted the twelve-month follow-up. This is a significant drop out rate and the
study was not conducted on an intention-to-treat basis. While participants ident-
ified reading, memory and comprehension as limitations, there was a thera-
peutic effect. The group’s mean CES-D score at pre-treatment was above the
cut-off for probable depression. At twelve-month follow-up the group’s mean
CES-D score was below the cut-off of 23 for probable depression, but above
the cut-off of 16 for possible depression (see Table 5). There was no post-treat-
ment measurement in this study, just a twelve-month follow-up.
DISCUSSION
Clinical implications of outcome studies

In understanding the clinical implications of the studies, consideration should
be given to the issue of the treatment focus versus therapeutic effect. The
group-based studies show that if CBT is aimed at a particular problem, for

example coping skills, social skills or anger management, it can be effective
for coping skills, social skills or anger management, but will not necessarily
generalise to have a significant therapeutic effect on anxiety or depression
(Anson & Ponsford, 2006a; McDonald et al., 2008; Medd & Tate, 2000).
However, CBT that targets anxiety disorders and depression specifically
appears to generate better therapeutic effects on anxiety and depression
(Arundine et al., 2012; Bradbury et al., 2008; Bryant et al., 2003; Chard
et al., 2011; Hodgson et al., 2005; Lincoln et al., 1997; Rasquin et al.,
2009; Tiersky et al., 2005; Topolovec-Vranic et al., 2010).
For studies that targeted depression, effect-sizes ranged from 0 to 2.39 with
an average effect-size of 1.15 for depression (large effect), indicating that the
average CBT-treated case fared better than 87% of untreated cases. For
studies that targeted anxiety, effect-sizes ranged from 0 to 3.47 with an
average effect-size of 1.04 for anxiety (large effect), indicating that the
average CBT-treated case fared better than 85% of untreated cases. These
effect-sizes can be contrasted with outcomes for depression and anxiety
where the CBT was not aimed at depression or anxiety specifically. In
those studies where the CBT focused on social skills, coping skills or anger
management, effect-sizes ranged from 0 to 0.46 for depression and 0 to
0.42 for anxiety. The average effect-size was 0.16 for depression (small
effect) and 0.17 for anxiety (small effect), indicating that the average case
fared better than only 58% of untreated cases. Care should be taken in inter-
preting individual effect-sizes in this meta-analysis, as many factors in an
individual study can give rise to a large effect-size. For example, it would
seem that the Topolovec-Vranic et al. (2010) study demonstrates that
online CBT has excellent outcomes. That is not entirely true; the study
shows that for the less than 50% of participants who did not drop out, CBT
was somewhat effective.
Additionally, for anxiety disorders, Williams et al. (2003a), Bryant et al.
(2003), and Hodgson et al. (2005) show that when the treatment focus is on
a specific anxiety disorder (PTSD, PTSD and social anxiety respectively)
there appears to be improvement in a spectrum of anxiety symptoms. The
implication for mood disorders is less clear. Hodgson et al. (2005) showed
generalisation to depression on the basis of intervention for social anxiety.
However, Bryant et al. (2003) did not interpret their results as showing gen-
eralisation to depression on the basis of intervention for PTSD (although their
group means suggest depression may have been clinically lower even if not
statistically lower). In the Williams et al. (2003a) paper depression was
within the normal range prior to and after intervention.
There is also the question of the statistical significance versus the clinical
significance of change. Our review reveals that CBT regularly shows either a
within-group pre- to post-treatment statistical difference for depression and
anxiety problems, or a statistical significance between those treated with CBT

and the various control groups after therapy. However, in terms of clinical
significance, it is clear that CBT is not a panacea as, firstly, studies frequently
indicate only partial reduction in symptoms and, secondly, there are fre-
quently treated cases that do not improve. Table 5 documents qualitative
descriptions of clinical change. According to the manual for the test in ques-
tion, the labels such as normal, minimal, mild, moderate and severe corre-
spond to the score obtained by the individual in a single-case study, or the
CBT groups’ mean scores at the various time points. The table is designed
to complement the effect-size table and give a more readily understandable
description of the degree of clinical change. Studies rarely show complete

remission of depression or anxiety symptoms. These issues are the case for
studies even where the CBT has been targeted on anxiety and depression
(King, 2002; Lincoln & Flannaghan, 2003; Lincoln et al., 1997; McGrath,
1997; McNeil & Greenwood, 1996; Rasquin et al., 2009; Tiersky et al.,
2005; Topolovec-Vranic et al., 2010; Williams et al., 2003b).
So, the question remains, what works? There is not a totally clear answer,
as there is yet to be a study on the dose-response relationship for CBT.
Despite this gap, some initial tentative observations could be made (see
Table 1 for CBT “dosage” in each study). The following assumes 60
minute sessions where the study does not report how many minutes were in
a session but does report how many weeks of therapy there were (see Table
1). Our review shows that for OCD, published studies indicate improvements
for total CBT input of 360 minutes (Ko, 1997) and for 480 minutes (Arco,
2008). For PTSD, studies show some improvements for a total CBT input
(spread between five and twenty weeks) of 420 minutes (McNeil & Green-
wood, 1996); 450 minutes (Bryant et al., 2003); 840 minutes (Chard et al.,
2011); 960 minutes (McMillan, 1991); 1140 minutes (Batten & Pollack,
2008); and 1200 minutes (Kneebone & Hull, 2009); but one single-case
study demonstrated treatment abreaction and no change despite 1080
minutes over 28 weeks (King, 2002). In terms of depression and anxiety in
general, post-TBI specifically, for CBT delivered over a period of six to
eleven weeks, studies show maintenance rather than benefit for 480
minutes (Salazar et al., 2000) but improvement for 660 minutes (Arundine
et al., 2012; Bradbury et al., 2008) and 720 minutes (Topolovec-Vranic
et al., 2010), although one study shows only marginal benefits despite 1650
minutes of CBT over eleven weeks (Tiersky et al., 2005). For depression
and anxiety in general, post-CVA specifically, studies report that 53% of
people showed some improvement with 504 minutes of CBT (average of
8.4 sessions of 60 minutes) over about ten weeks (Lincoln et al., 1997) and
60% of people showed some improvement with 480 minutes over
eight weeks (Rasquin et al., 2009), yet there was a lack of overall
improvement in one study of 600 minutes over ten weeks (Lincoln & Flanna-
ghan, 2003).
In conclusion, firstly there is little evidence for generalisation or “knock on
effect” of general CBT treatments. It appears that clinicians need to target
specifically those outcomes that they wish to change with a specifically
honed CBT programme for exactly that outcome. Secondly, it is clear that
while CBT can be effective for anxiety and depression in studies where
CBT is targeted at anxiety and depression, CBT will not result in a positive
outcome for every person with an ABI. It is worth noting that CBT is not a
“magic bullet” or panacea in non-ABI populations either.
RECOMMENDATIONS
Considerations in planning future outcome studies

On the basis of this review it became apparent that a number of questions that
the authors had in mind could not be answered in any way due to gaps in the
literature.
There is a question around whether a small number of CBT sessions or a
large number of CBT sessions is appropriate for treating an anxiety disorder
or depression post-ABI. This would answer the question of the dose-response
relationship. Some of the authors of the papers included here expressed con-
cerns about poor outcomes being potentially associated with delivering too
few sessions. This question is associated with the issue of the therapeutic
relationship between the client and the therapist, something that is not expli-
citly addressed by any of the studies. Future research should incorporate a
measure of therapeutic alliance along with exploring whether a longer set
of sessions results in a better outcome.
There is yet to be a study to ascertain whether group-based CBT or
individual face-to-face CBT is best for treating any anxiety disorder or
depression. There was not a single study that addressed this.
Similarly, there is yet to be a study on group-based SST versus individual
face-to-face CBT for social anxiety post-ABI.
These gaps are significant for practising clinicians and the current state of
the literature leaves the question of what works for whom post-ABI open for
future research.
REFERENCES
American Psychiatric Association (1994). Diagnostic and statistical manual of mental dis-
orders. DSM-IV (4th ed.). Washington, DC: Author.
Anson, K., & Ponsford, J. (2006a). Evaluation of a coping skills group following traumatic brain
injury. Brain Injury, 20, 167–178.
Anson, K., & Ponsford, J. (2006b). Who benefits? Outcome following a coping skills group
intervention for traumatically brain injured individuals. Brain Injury, 20, 1–13.
Arco, L. (2008). Neurobehavioural treatment for obsessive-compulsive disorder in an adult with
traumatic brain injury. Neuropsychological Rehabilitation, 18, 109–124.
Arundine, A. M., Bradbury, C. L. P., Dupuis, K. M. A., Dawson, D. R. P., Ruttan, L. A. P., &
Green, R. E. A. P. (2012). Cognitive behavior therapy after acquired brain injury: Mainten-
ance of therapeutic benefits at 6 months post treatment. Journal of Head Trauma Rehabilita-
tion, 27, 104–112.
Batten, S. V., & Pollack, S. J. (2008). Integrative outpatient treatment for returning service
members. Journal of Clinical Psychology: In Session, 64, 928–939.

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York,
NY: Harper & Row.
Beck, A. T. (1970). Depression: Causes and treatment. Philadelphia, PA: University of Penn-
sylvania Press.
Beck, A. T., & Steer, R. A. (1993). Manual for the Beck Anxiety Inventory (BAI). San Antonio,
TX: The Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory II
(BDI-II). San Antonio, TX: The Psychological Corporation.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for
measuring depression. Archives of General Psychiatry, 4, 561–571.
Bisson, J., & Andrew, M. (2007). Psychological treatment of post traumatic stress disorder
(PTSD). Cochrane Database of Systematic Reviews Online, (3), doi:10.1002/
14651858.CD003388.pub3
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., &
Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of
Traumatic Stress, 8, 75–90.
Bradbury, C. L., Christensen, B. K., Lau, M. A., Ruttan, L. A., Arundine, A. L., & Green, R. E.
(2008). The efficacy of cognitive behavior therapy in the treatment of emotional distress
after acquired brain injury. Archives of Physical Medicine and Rehabilitation, 89(12
Suppl.), S61–S68.
Bryant, R. A., Moulds, M., Guthrie, R., & Nixon, R. D. V. (2003). Treating acute stress dis-
order following mild traumatic brain injury. American Journal of Psychiatry, 160,
585–587.
Chard, K. M., Schumm, J. A., McIlvain, S. M., Bailey, G. W., & Parkinson, R. B. (2011).
Exploring the efficacy of a residential treatment program incorporating cognitive processing
therapy-cognitive for veterans with PTSD and traumatic brain injury. Journal of Traumatic
Stress, 24, 347–351.
Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientific foundations of cognitive theory and
therapy of depression. New York, NY: John Wiley & Sons.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R.
Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and
treatment (pp. 69–93). New York, NY: Guilford Press.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ:
Lawrence Erlbaum Associates.
Comper, P., Bisschop, S. M., Carnide, N., & Tricco, A. (2005). A systematic review of treat-
ments for mild traumatic brain injury. Brain Injury, 19, 863–880.
Coopersmith, S. (1975). Self-esteem inventories. Palo Alto, CA: Consulting Psychologists
Press.
Corneil, W., Beaton, R., Murphy, S., Johnson, C., & Pike, K. (1999). Exposure to traumatic inci-
dents and prevalence of posttraumatic stress symptomatology in urban fire fighters in two
countries. Journal of Occupational Health Psychology, 4, 131–141.
Derogatis, L. R. (1994). Symptom Checklist 90 Revised: Administration, scoring and pro-
cedures manual (3rd ed.). Minneapolis, MN: National Computer Systems.
Fleminger, S., Oliver, D. L., Williams, W. H., & Evans, J. (2003). The neuropsychiatry of
depression after brain injury. Neuropsychological Rehabilitation, 13, 65–87.
Frydenberg, E., & Lewis, R. (1996). Coping Scale for Adults. Hawthorn, Victoria: The Austra-
lian Council for Educational Research.
Hackett, M. L., Yapa, C., Parag, V., & Anderson, C. S. (2005). Frequency of depression after
stroke: A systematic review of observational studies. Stroke, 36, 1330–1340.
Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety disorder: Current

status and future directions. Biological Psychiatry, 51, 101–108.
Hibbard, M. R., Uysal, S., Kepler, K., Bogdany, J., & Silver, J. (1998). Axis I psychopathology in
individuals with traumatic brain injury. Journal of Head Trauma Rehabilitation, 13, 24–39.
Hodgson, J., McDonald, S., Tate, R., & Gertler, P. (2005). A randomised controlled trial of a
cognitive-behavioural therapy program for managing social anxiety after acquired brain
injury. Brain Impairment, 6, 169–180.
Hodgson, R. J., & Rachman, S. (1977). Obsessional-compulsive complaints. Behaviour
Research and Therapy, 15, 389–395.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). The Impact of Events Scale: A measure of
subjective stress. Psychosomatic Medicine, 41, 209–218.
Khan-Bourne, N., & Brown, R. G. (2003). Cognitive behaviour therapy for the treatment of
depression in individuals with brain injury. Neuropsychological Rehabilitation, 13, 89–107.
King, N. S. (2002). Perseveration of traumatic re-experiencing in PTSD; a cautionary note
regarding exposure-based psychological treatments for PTSD when head injury and dysex-
ecutive impairment are also present. Brain Injury, 16, 65–74.
Kneebone, I. I., & Dunmore, E. (2000). Psychological management of post-stroke depression.
British Journal of Clinical Psychology, 39, 53–65.
Kneebone, I. I., & Hull, S. L. (2009). Cognitive behaviour therapy for post-traumatic stress
symptoms in the context of hydrocephalus: A single case. Neuropsychological Rehabilita-
tion, 19, 86–97.
Ko, S. M. (1997). Obsessive compulsive disorder following head injury. International Journal
of Clinical Practice, 51, 336–338.
Koponen, S., Taiminen, T., Hiekkanen, H., & Tenovuo, O. (2011). Axis I and II psychiatric dis-
orders in patients with traumatic brain injury: A 12-month follow-up study. Brain Injury, 25,
1029–1034.
Kreutzer, J. S., Seel, R. T., & Gourley, E. (2001). The prevalence and symptom rates of
depression after traumatic brain injury: A comprehensive examination. Brain Injury, 15,
563–576.
Lincoln, N. B., & Flannaghan, T. (2003). Cognitive behavioral psychotherapy for depression
following stroke: A randomized controlled trial. Stroke, 34, 111–115.
Lincoln, N. B., Flannaghan, T., Sutcliffe, L., & Rother, L. (1997). Evaluation of cognitive be-
havioural treatment for depression after stroke: A pilot study. Clinical Rehabilitation, 11,
114–122.
Lovibond, S. H., & Lovibond, P. F. (1996). Manual for the Depression Anxiety Stress Scales.
Sydney: Psychological Foundation.
Maher, C. G., Sherrington, C., Herbert, R. D., Moseley, A. M., & Elkins, M. (2003). Reliability
of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy, 83,
713–721.
Malec, J. F., Testa, J. A., Rush, B. K., Brown, A. W., & Moessner, A. M. (2007). Self-assess-
ment of impairment, impaired self-awareness, and depression after traumatic brain injury.
Journal of Head Trauma Rehabilitation, 22, 156–166.
Marks, I. M. (1986). Behavioural psychotherapy: Maudsley pocket book of clinical manage-
ment. Bristol: IOP Publishing.
Mateer, C. A., Sira, C. S., & O’Connell, M. E. (2005). Putting Humpty Dumpty together again:
The importance of integrating cognitive and emotional interventions. Journal of Head
Trauma Rehabilitation, 20, 62–75.
McDonald, S., Tate, R., Togher, L., Bornhofen, C., Long, E., Gertler, P., & Bowen, R. (2008).
Social skills treatment for people with severe, chronic acquired brain injuries: A multicenter
trial. Archives of Physical Medicine and Rehabilitation, 89, 1648–1659.
McGrath, J. (1997). Cognitive impairment associated with post-traumatic stress disorder and
minor head injury: A case report. Neuropsychological Rehabilitation, 7, 231–239.
McMillan, T. M. (1991). Post-traumatic stress disorder and severe head injury. British Journal
of Psychiatry, 159, 431–433.
McNeil, J. E., & Greenwood, R. (1996). Can PTSD occur with amnesia for the precipitating
event? Cognitive Neuropsychiatry, 1, 239–246.
Medd, J., & Tate, R. L. (2000). Evaluation of an anger management therapy programme follow-
ing acquired brain injury: A preliminary study. Neuropsychological Rehabilitation, 10,
185–201.
Novaco, R. W. (1975). Anger control: The development and evaluation of an experimental
treatment. Lexington, MA: Lexington Books.
Perdices, M., & Tate, R. L. (2009). Single-subject designs as a tool for evidence-based clinical
practice: Are they unrecognised and undervalued? Neuropsychological Rehabilitation, 19,
904–927.
Prigatano, G. (1989). Rehabilitation interventions after traumatic brain injury. In P. Bach-Y-
Rita (Ed.), Traumatic Brain Injury (pp. 175–190). New York, NY: Demos.
Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the
general population. Applied Psychological Measurement, 1, 385–401.
Rasquin, S. M. C., van de Sande, P., Praamstra, A. J., & van Heugten, C. M. (2009). Cognitive-
behavioural intervention for depression after stroke: Five single case studies on effects and
feasibility. Neuropsychological Rehabilitation, 19, 208–222.
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treat-
ment manual. Newbury Park, CA: Sage.
Rosenberg, M. (1965). Society and the adolescent self image. Princeton, NJ: Princeton Univer-
sity Press.
Salazar, A. M., Warden, D. L., Schwab, K., Spector, J., Braverman, S., Walter, J., . . . Ellenbo-
gen, R. G. (2000). Cognitive rehabilitation for traumatic brain injury: A randomized trial.
Journal of the American Medical Association, 283, 3075–3081.
Snaith, R. P., Ahmed, S. N., Mehta, S., & Hamilton, M. (1971). Assessment of the severity of
primary depressive illness: The Wakefield Self-Assessment Depression Inventory. Psycho-
logical Medicine, 1, 143–149.
Soo, C., & Tate, R. L. (2007). Psychological treatment for anxiety in people with traumatic
brain injury. Cochrane Database of Systematic Reviews Online, (3). doi:10.1002/
14651858.CD005239.pub2
Spielberger, C. D. (1988). State-Trait Anger Expression Inventory. Orlando, FL: Psychological
Assessment Resources.
Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999). Validation and utility of a self-report
version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental dis-
orders. Patient Health Questionnaire. Journal of the American Medical Association, 282,
1737–1744.
Tiersky, L. A., Anselmi, V., Johnston, M. V., Kurtyka, J., Roosen, E., Schwartz, T., & DeLuca,
J. (2005). A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury.
Archives of Physical Medicine and Rehabilitation, 86, 1565–1574.
Topolovec-Vranic, J., Cullen, N., Michalak, A., Ouchterlony, D., Bhalerao, S., Masanic, C., &
Cusimano, M. D. (2010). Evaluation of an online cognitive behavioural therapy program by
patients with traumatic brain injury and depression. Brain Injury, 24, 762–772.
Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley, M. A. (1989). An empirically derived
inventory to measure social fears and anxiety: The Social Phobia and Anxiety Inventory.
Psychological Assessment, 1, 35–40.
van Dam-Baggen, R., & Kraaimaat, F. (2000). Group social skills training or cognitive group
therapy as the clinical treatment of choice for generalized social phobia? Journal of
Anxiety Disorders, 14, 437–451.

Wallander, J. L., Conger, A. J., & Conger, J. C. (1985). Development and evaluation of a be-
haviorally referenced rating system for heterosocial skills. Behavioral Assessment, 7,
137–153.
Williams, W. H., Evans, J. J., & Fleminger, S. (2003a). Neurorehabilitation and cognitive-be-
haviour therapy of anxiety disorders after brain injury: An overview and a case illustration of
obsessive-compulsive disorder. Neuropsychological Rehabilitation, 13, 133–148.
Williams, W. H., Evans, J. J., & Wilson, B. A. (2003b). Neurorehabilitation for two cases of
post-traumatic stress disorder following traumatic brain injury. Cognitive Neuropsychiatry,
8, 1–18.
World Health Organization (2008). ICD-10: International statistical classification of diseases
and related health problems (10th ed.). New York, NY: Author.
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psy-
chiatrica Scandinavica, 67, 361–370.
Manuscript received November 2010

Manuscript accepted July 2012
First published online November 2012

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This article was downloaded by: [University of Stellenbosch]

On: 29 September 2013, At: 07:46

Cognitive behavioural therapy

To link to this article: http://dx.doi.org/10.1080/09602011.2012.724196

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Cognitive behavioural therapy for depression and

Brian Waldron, Lisa Marie Casserly, and

This paper reviews treatment outcome studies on cognitive behavioural therapy

Correspondence should be addressed to Dr Brian Waldron, Senior Clinical Psychologist,

# 2013 Taylor & Francis

Keywords: Acquired brain injury; Traumatic brain injury; Cognitive behaviour-

between psychological and physiological factors has been acknowledged

Mateer, Sira, and O’Connell (2005) recommend that “cognitive rehabilitation

Procedure for inclusion of studies

Calculation and interpretation of effect-sizes

Methodological characteristics of the studies

WALDRON, CASSERLY, AND O’SULLIVAN

† There was a reduction in IES scores

CBT IN ABI. WHAT WORKS FOR WHOM?

N per group Type of Treatment Treatment

WALDRON, CASSERLY, AND O’SULLIVAN

† Participants’ CAPS scores, IES

† The benefits of the intervention were

CBT IN ABI. WHAT WORKS FOR WHOM?

N per group Type of Treatment Treatment

WALDRON, CASSERLY, AND O’SULLIVAN

† Treatment effects after CBT + SST

off score for the group.

CBT IN ABI. WHAT WORKS FOR WHOM?

N per group Type of Treatment Treatment

WALDRON, CASSERLY, AND O’SULLIVAN

† Five patients showed significant

CBT IN ABI. WHAT WORKS FOR WHOM?

WALDRON, CASSERLY, AND O’SULLIVAN

Williams McNeil & Batten & Kneebone &

CBT IN ABI. WHAT WORKS FOR WHOM?

WALDRON, CASSERLY, AND O’SULLIVAN

CBT IN ABI. WHAT WORKS FOR WHOM?

WALDRON, CASSERLY, AND O’SULLIVAN

Williams McNeil & Bryant Williams Batten & Chard

CBT IN ABI. WHAT WORKS FOR WHOM?

WALDRON, CASSERLY, AND O’SULLIVAN

CBT IN ABI. WHAT WORKS FOR WHOM?

validity. There was broad variability in methodological quality, with scores

Substantive findings for obsessive compulsive disorder

(during which there were fortnightly booster sessions), counting remained

Substantive findings for post-traumatic stress disorder

First, traditional anxiety management techniques and graded exposure to

the number of sessions was reported. CBT included relaxation, challenging

Williams et al. (2003b) showed CBT with CR to be partially effective for

cognitive challenging and rehearsal aspects termed CPT-cognitive only

Substantive findings for social anxiety and social skills

et al. (2008) conducted an RCT comparing an SST group intervention (com-

Revised (BRISS-R; Wallander, Conger, & Conger, 1985). No effects were

Substantive findings for coping skills

Substantive findings for anger management

self-instructional training. A model demonstrating how trigger events lead to

participants’ awareness of their anger by probing for cognitive, phys-