NeuroRehabilitation 32 (2013) 771–779 771

DOI:10.3233/NRE-130901
IOS Press

Selecting the appropriate psychotherapies for

individuals with traumatic brain injury: What
works and what does not?
Ronald Ruff
San Francisco Clinical Neurosciences, University of California San Francisco, 909 Hyde Street, San Francisco,
CA 94109, USA
E-mail: ronruff@mindspring.com

Abstract.
BACKGROUND: When traditional psychotherapy is provided to patients with traumatic brain injuries (TBIs), the primary focus
is on treating mood changes such as depression, anxiety or anger. However, traditional psychotherapeutic methods developed
specifically for mood changes fall short when treating most TBI patients. In large part, this is because the psychological adjustment
difficulties that most TBI patients face are linked to life-altering changes that are interwoven with permanent physical, cognitive,
and social sequelae. In addition, mood changes in TBI patients are also caused by vocational and financial losses.
OBJECTIVE: The sudden onset of these unfamiliar and interdependent problems necessitates a psychotherapeutic approach that
acknowledges the inherent challenges of coping with multiple life-altering changes. For patients who experience a shattered sense
of self, interventions need to be explored to make life meaningful following a TBI.
METHODS: An existentially-oriented approach is introduced in the following steps: (1) identifying pre-injury future expectations,
(2) examining how the TBI has altered these expectations, (3) grieving the loss of the expected future, and (4) developing a realistic
future that is existentially meaningful.
RESULTS: Pivotal gains are achieved when patients rebuild their lives according to their own core values.
CONCLUSION: TBI patients can benefit from existential psychotherapy.

Keywords: Psychotherapy, emotional problems, traumatic brain injury, acquired brain damage, existential approach

1. Introduction for experienced dynamically oriented psychotherapists

Dynamically oriented psychotherapists focus their
treatment on the patient’s past (Gomez, 1997; Klein,
1984; Ogden, 1977). This approach has limited value
when treating individuals with traumatic brain injuries
(TBIs). Although the patient’s history prior to the brain
damage is diagnostically informative, focusing the
treatment on premorbid issues should be limited, if not
avoided altogether. Indeed, the well-accepted axiom of
“past behavior is the best predictor of future behavior”
simply does not apply to individuals who have sus-
tained a catastrophic injury. Thus, it can be challenging
who begin to treat patients with TBI to avoid relying on
this retrospective therapeutic approach. Even if the pre-
morbid coping mechanisms are uncovered, often these
coping mechanisms are not only blunted but also insuf-
ficient for dealing with the magnitude of the life-altering
changes that follow a TBI.
Psychotherapists trained in cognitive behavioral
interventions typically focus their treatment on mood
disorders such as the patient’s depression, anxiety or
anger (Beck, 1995; Doering & Exner, 2011; Dobson,
2001; Ponsford, 2012). This approach is beneficial
for TBI patients up to a point. Treating individuals

1053-8135/13/$27.50 © 2013 – IOS Press and the authors. All rights reserved
772 R. Ruff / Psychotherapy: What works and what does not?
with TBI is typically more challenging than treating
non-brain injured individuals, because their emotional
mood changes are not primarily psychogenic but rather
caused by an interaction of irreversible problems such
as seizure disorders, migraines, and lack of family sup-
port. Thus, both the magnitude and complexity of the
problems following a TBI are exponentially multiplied
due to the biopsychosocial nature of the deficits, while,
at the same time, the individual’s brain capacity for
cognitive processing of novel information is typically
reduced for multiple reasons (e.g., impulsivity, slower
processing of information, less patience, increased anx-
iety, distractibility and depression about one’s lack of
control).
It is beyond the scope of this article to review the
strengths and weaknesses of other potentially benefi-
cial psychotherapy modes for TBI patients. However,
in providing psychotherapy to TBI patients for over
30 years, the author has found that most patients are
encouraged by the recovery that typically takes place in
the early stages and hope for a full recovery. However,
when this does not occur, patients become scared and
avoid facing an uncertain and intensely difficult future.
This led me to focus more and more on exploring ways
to guide patients toward developing a meaningful life
following a TBI.
The approach that follows does not replace treat-
ments for symptom reduction, but is based on the
fact that not all symptoms can be eliminated or even
reduced. Thus, living with permanent symptoms is a
reality that most patients with significant TBI face.
Therefore, an intervention is needed that neither claims
nor presumes to fix all legacies of injury but instead
provides tools for coping with the deficits by creating
a meaningful life. Many years of treating TBI patients
in psychotherapy led me to develop a five-step inter-
vention that offers patients an opportunity to create a
meaningful future.
2. Step 1. Identifying future expectations that
existed prior to the TBI
Most individuals live not only within the context
of their past memories, but also maintain their emo-
tional equilibrium by constructing plans and hopes
for their future. The emphasis on future plans is par-
ticularly pronounced in younger individuals, who are
often preoccupied with future dreams and aspirations.
Middle-aged individuals also look forward to a future,
which includes, for example, achieving career goals
and/or successfully raising their children. As individ-
uals near their retirement age they frequently focus
on planning a secure and stable future. These exam-
ples highlight that future expectations exist throughout
our lives. Indeed, most individuals are attached to their
future expectations.
In most traditional modes of psychotherapy future
expectations receive only cursory attention (Wein-
berger & Eig, 1999). Instead the diagnostic workup
focuses primarily on the exploration of developmental
issues that trigger both adaptive and maladaptive ways
of coping (Feiring, 1984; Svanberg, 1998). Negative
emotional experiences during childhood with parents,
siblings, and friends are explored. This can unravel
the patient’s overarching beliefs, habits, or interpreta-
tions that likely led to his or her ongoing psychological
problems. However, when the post-traumatic emotional
impairments overshadow or substantially exacerbate
any emotional maladies that existed prior to the brain
damage, then this retrospective approach is no longer
an appropriate focus in psychotherapy.
Following a moderate or severe TBI an individual is
confronted with the fact that, short of a miracle, a return
to their former life is not possible. It is this feeling of
being stuck with impairments indefinitely that fuels the
most intense and often most insurmountable emotional
pain. To escape this painful reality, denial often replaces
realistic expectations with false hopes, such as believing
that if they keep trying, they will achieve a full recov-
ery. Because these individuals are fixated on returning
to their former lives, adhering to psychotherapy that
emphasizes a retrospective approach is not only inef-
fective, but can also be counterproductive, since it can
imply that a return to their former self is feasible.
While providing psychotherapy to TBI patients, I
noticed that instead of focusing on the patients’ past,
I started to spend more and more time focusing on the
future expectations that patients held prior to their TBI.
Eliciting these expectations provided an understanding
of the magnitude of the patients’ shattered hopes and
dreams. I vividly recall treating a 19-year-old handsome
and athletic looking man, who after his TBI was also
unable to walk. After making progress in coping with
his anxiety and depression I asked how he was doing
overall. He stated that he appreciated my efforts and the
tools he had learned, but the gains were inconsequential.
He then explained that being brain-injured and confined
to a wheelchair would prevent anyone from marrying
him. Moreover, his long-held dream of playing base-
ball with a son of his own, as his father had played with
him, was permanently shattered. I realized that without
 R. Ruff / Psychotherapy: What works and what does not?
knowing what his vision for his future was, my psy-
chotherapeutic intervention was not only incomplete
but also doomed to fail.
In sum, psychotherapy with TBI patients should
explore to what degree the patient’s self worth was
linked to achieving his or her future plans and dreams.
The degree to which a TBI has derailed an individ-
ual from his or her expected trajectory represents most
likely the primary source of emotional pain. If the future
expectations prior to the TBI are not explored in psy-
chotherapy, the treatments will remain incomplete if not
inconsequential.
3. Step 2. Facilitate an understanding of how
the TBI has altered patients’ lives
Because an accurate understanding of the self is
funneled through the brain, this understanding often
becomes flawed when the brain is damaged (Carroll
& Coetzer, 2011; Heller, Levin, Mukherjee, Reis, &
Panko, 2006; Weinryb & Mathiesen, 2004). Moreover,
psychotherapists should accept their limitations in fully
understanding what it is truly like to live inside an
injured brain. Thus, a therapist should raise the follow-
ing two pivotal questions throughout the treatment:
1. How can my patient’s damaged brain achieve
an accurate understanding of who she or he has
become?
2. How well does my own healthy brain allow me
to grasp fully what it is like to function inside the
damaged brain of my patient?
The likelihood of a patient achieving acceptance
is dependent on her or his ability to comprehend
and remember. Thus, especially during the early
phases of recovery, the psychotherapist needs to deter-
mine intermittently to what degree these abilities are
impacted. This monitoring should include a differen-
tiation between neurogenic denial (i.e., anosognosia)
versus denial that is psychologically motivated (Pri-
gatano, 2010).
The desire to search jointly for the best possible
answers should instill the psychotherapist not only with
a sincere humility but also with openness to understand
each patient in unique and unexpected ways. Using
phrases with patients such as: “I understand” or “I
know what you are going through” risks invalidating
the patient’s experience. Instead, replacing these with:
“I have never had brain damage, so I do not know what
you are going through” or “My patients have taught me
773
what it is like and I want to learn from you as well” are
not only respectful statements but also encourage the
patient to continue to refine their self-understanding as
to how the TBI has fundamentally altered their life.
Therapists often develop an ambitious and efficient
treatment plan. However, well-intended plans of march-
ing clients through psychotherapy organized according
to a sequence of multiple phases, each with defined
treatment durations, often do not work. Instead, patients
change when they are emotionally ready and willing.
This can cause havoc with well-intended “treatment
plans” or “managed care directives”, which insist on
having the psychotherapist commit in advance to a num-
ber of sessions. Progress often plateaus, especially if the
patient’s improvements lead to newly gained insights
that the problems are greater than they expected when
they entered psychotherapy.
Not all patients are suitable for psychotherapy.
Patients with severe memory deficits who are, for exam-
ple, unable to remember having been in therapy a week
ago should not participate in ongoing talk therapy.
These patients may, however, make gains in behavioral
therapy, physical therapy, and other modalities where
gains are not dependent on declarative memory but
rather on working or procedural memory (Manchester
& Wood, 2001; Wood, 1990; Wood & McMillan, 2001).
Furthermore, family therapy and aggressive environ-
mental engineering techniques can be very useful in
bolstering patient functioning in the context of a severe
amnestic disturbance.
Psychotherapy with a person with TBI should assist
in a gradual understanding of what functions are pre-
served, what functions are deficient, and finally, what
disabilities are permanent.
3.1. Preserved functions
After years of diagnostically examining thousands
of individuals with acquired brain damage, I was
struck by the fact that I had focused almost exclu-
sively on the patients’ problems without exploring their
strengths. After an intake session with a gentleman who
became particularly distraught, I asked him to report his
strengths with the hope of providing some relief. The
result was not only positive, but provided unexpected
benefits. I found that this information was useful at vari-
ous junctures throughout the treatment. This gentleman
was no longer able to work as an accountant after sus-
taining a significant TBI. To occupy his time, he decided
to volunteer in two small nonprofit organizations. How-
ever, this work was mostly administrative and did not
774 R. Ruff / Psychotherapy: What works and what does not?
provide him with much satisfaction. Moreover, he was
confronted with the same flaws in his short-term mem-
ory that prevented him from returning to his former
occupation. When describing his strengths, he men-
tioned that his children just recently thanked him for
choosing to read to them different bedtime stories
according to each of their interests. As they grew older
they also appreciated his effort for selecting just the
right books tailored to each of their particular interests.
Eliciting this particular strength allowed us to discuss
and then implement a plan for him to tutor kids from a
local school with reading difficulties. This experience
was most positive. In fact, he stated that tutoring kids
made him feel even happier than when he was work-
ing as an accountant. Without asking this gentleman to
list his strengths, this suggestion would have not been
possible.
Over the years, I have learned that knowing the full
extent of a patient’s strengths is invaluable. Just as
a therapist needs to be diligent in obtaining a thor-
ough history of the deficits, I recommend obtaining
an equally thorough history of the “good stuff”. This
includes physical, emotional and cognitive strengths, as
well as social and spiritual support, positive recreation
and financial opportunities. Looking back on the many
years when I did not sufficiently tap into my patients’
“good stuff”, I not only missed developing a more
balanced perspective but I also overlooked beneficial
opportunities. Thus, I recommend that psychotherapists
ask their patients to routinely report their strengths.
3.2. Deficits
The diagnostic workup benefits from interviewing
and consulting multiple sources. The intake interview
should be supplemented by a review of the medical
records. Some patients offer and consent to the therapist
interviewing collateral sources (e.g., typically referral
sources or family members). Obviously it is essen-
tial to compare the psychotherapist’s understanding of
the deficits with the patient’s understanding of what
he or she perceives as deficits. Frequently a discrep-
ancy emerges. This should be expected, especially with
individuals with severe TBI (Klonoff, 2010; Prigatano,
2010).
Not only do the symptoms change over time, there
are multiple interactions among deficits. When a
patient is referred for a neuropsychological work-up,
I list and describe the pertinent physical, emotional,
cognitive, social, vocational, and financial problems.
However, as a psychotherapist, I make a concerted
effort to examine the interaction among symptoms. This
allowed me, for example, to understand that while my
patient’s headache diminished her cognitive efficiency
and affected her mood, the headaches also severely
impacted her social and recreational activities. If asked
out on a date, she had to make a contingency plan in
case of a migraine attack. She stopped playing tennis
because she became embarrassed and too upset when
she played poorly. Over time, her reduced socializa-
tion lead to isolation, which lead to increased overall
anxiety and sadness. These interactions among symp-
toms, or dysfunctional loops, need to be understood to
address not only isolated symptom but also – and more
importantly - the symptom interactions.
Understanding deficits and subsequent dysfunctional
loops also allows one to prioritize difficulties, treat mal-
leable symptoms and manage stress. Discussing deficit
management is an opportune time to delineate factors
that are within a patient’s control and those that are not
modifiable, no matter how hard the patient works. For
the latter, ways to either cope with or circumvent these
deficits in their daily lives should become the focus.
3.3. Permanent disabilities
Deficits affect individuals differently due to the envi-
ronment in which they need to function. For example, if
an English teacher’s visuospatial processing is impaired
she can still function as a teacher. Similarly, if a car-
penter’s word finding is impaired he can still work.
However, both an English teacher with word finding
difficulties and a carpenter with visuospatial impair-
ments are no longer able to function successfully in
their professions. Therefore, it is important to iden-
tify for each individual the extent to which permanent
deficits cause detrimental limitations in their return to
their former daily life. This distinction is consistent with
the definition for disability or disablement established
by the International Classification of Functioning and
Disability (ICF, 1999).
In our context, permanent disabilities thwart the
individual in their educational, vocational, and/or psy-
chosocial functioning. In contrast, “deficits” allow an
individual to continue to function, albeit with a reduced
efficiency or a reliance on accommodations.
Past a certain point of recovery, these “permanent dis-
abilities” will likely never be resolved, in spite of the
distress they create. Patients often continue to search
for solutions to resolve their permanent and unchange-
able disabilities, causing the patient to focus evermore
in an inflexible way and thus getting stuck. If the loss of
 R. Ruff / Psychotherapy: What works and what does not?
these functional abilities is not accepted, then the pre-
occupation with finding new ways to fix the disabilities
stands in the way of rebuilding a realistic life. Mind-
fulness and other exercises that bring the patient into
the present moment to fully experience his or her diffi-
culties without judgment have shown to be particularly
helpful for coping with both permanent psychological
and chronic medical problems (Bohlmeijer, Prenger,
Taal & Cuijpers, 2010; Kabat-Zinn, 1984). These inter-
ventions help the individual to identify with sensations,
memories, feelings and urges that remind them of their
identity in context and not solely as a patient with a
TBI. This can also be helpful in facilitating acceptance
of permanent and devastating disabilities.
In sum, when patients are able to realistically accept
the persistent sequelae alongside their strengths, the
patients are often more able to grieve the losses and
avoid flawed and unrealistic expectations.
4. Step 3. Grieving the loss of the expected
future
Acceptance requires that patients also come to terms
with the fact that their current limitations will affect
their future plans. Elisabeth Kübler-Ross’ well-known
model for five stages of grief (Kübler-Ross, 1969)
describes a theory that she developed subsequent to
interviewing hundreds of patients. In addition to her
pioneering work with individuals facing death, she
expanded her work to include the treatment of indi-
viduals dealing with serious illnesses. Thus, her model
is most helpful when applied to patients with moderate
to severe acquired brain damage.
Coping with a TBI requires a prolonged adjustment
process, which varies between individuals, but typi-
cally includes at least some of the five stages. Table 1
describes the five reactions to TBI. As Kübler-Ross’
theory posits, not everyone experiences the stages in a
particular order. Although each person reacts to a TBI
in a unique manner, a serious TBI does include some
of the elements identified in the five steps.
Empirical research across various catastrophic per-
sonal losses (e.g., divorce, incarceration, job loss,
disease, chronic illness, drug addiction, disasters) has
found that the order of the five stages varies, but most
individuals experienced at least two stages. However,
women were more likely than men to experience all
five stages (Maciejewski et al., 2007). As with all mod-
els, exceptions do occur also in grief reactions; if a TBI
patient suffers from a dense lack of awareness (anoso-
775
gosia), then the loss is not understood, either from a lack
of recognizing the deficits or a severe memory problem,
and consequently no grief reactions ensue (Prigatano,
2010).
4.1. Facing a recovery
TBI patients benefit from the knowledge that there
are two ways in which the brain recovers. The first is
referred to as “spontaneous recovery” or healing, which
does not require effort on the patient’s part. However,
healing is time limited with the greatest gradient taking
place during the first six to 12 months, tapering off grad-
ually over the next six months (see Fig. 1). Following
severe TBI, healing continues at modest to mild levels
during the second year as well. Thereafter, gains due to
the healing of the brain are not likely.
The second mechanism for improvements is based
on re-learning. These gains are not automatic, but are
directly related to the effort and energy that is expended
by the patient. In various treatment modalities a patient
can relearn how to walk, speak, dress independently or
write with the non-dominant hand.
While patients are making gains, especially dur-
ing the early stages when both healing and relearning
are combined, there exists a sizeable risk that patients
expect continued improvement until full recovery is
reached. When, after the end of the first or second
year the expected recovery falls short, patients typi-
cally become frustrated, angry, sad or even depressed.
If patients are in psychotherapy during this time, then
patients’ expectations can be processed with the aim of
avoiding unrealistic expectations. Thus, psychotherapy
can be helpful in providing the necessary coping mech-
anisms to contend with their losses and thus reduce or
even prevent chronic anger and depression.
4.2. Treating denial
Treating psychological denial and unrealistic expec-
tations during a patient’s recovery can be conceptual-
ized in the following stepwise approach:
(1) Assess the patient’s willingness to consider new
information; if there is a willingness, then pro-
ceed, otherwise wait until the patient is ready to
receive guidance.
(2) The psychotherapist needs to encourage the
patient to distinguish between his or her wishes
for the future versus facing the present reality; if
the patient understands but nonetheless muddles
776 R. Ruff / Psychotherapy: What works and what does not?

Table 1
Kübler-Ross’ Five Stage Model modified to Individuals TBI
Stages Typical Reactions following TBI Treatment Considerations
Denial “I will make a full recovery!” In the early days of being confronted with the TB damage,
“The doctor’s prognosis does not apply to me.” minimal or no intervention is indicated. Over time, most
patients accept the physical residuals first, and thereafter the
cognitive limitations. Often patients need to be informed as to
their emotional residuals.
Anger “This is not fair!” Because of the pronounced anger, many of these individuals
“Why did this have to happen to me?” tend not to respond favorably to psychotherapy. It is difficult
“Who is to blame?” to treat individuals who blame others or God for their
hardship. While feelings of rage and envy are fully
externalized, psychotherapy that aims to reframe these
feelings is often rejected.
Bargaining “I understand that I have brain damage, but I will work Bargaining involves the hope and desire to overcome the TBI
very hard to obtain a full recovery.” sequelae. Often bargaining includes negotiations with a
“I will see the best doctors and do whatever it takes, in higher power; in exchange for a reformed lifestyle the bargain
order to make a full recovery or at least get is to achieve a full recovery. If entering psychotherapy is part
substantially better.” of the bargain to achieve a full recovery, psychotherapists
must explain that they are poor bargaining partners, due to
their limited power to affect a complete recovery.
Depression “I’m so sad, why bother with anything?” During the fourth stage, persons with TBI begin to accept the
“I’m not going to return to the person I was before the permanency of the residuals. Most individuals during this
TBI, so what’s the point of living this way?” state withdraw from others, converse sparingly, and avoid
“I miss my old life, and I hate my new life.” recreational activities. Crying, grieving, and processing this
pain can be guided in psychotherapy. The focus of therapy
should not be aimed at cheering up the patient, but rather on
grieving the loss and processing the emotional pain. This is a
time to cry.
Acceptance “It’s going to be okay.” When acceptance emerges on the horizon, psychotherapy can
“I can’t fight it, I might as well learn to live my new life assist the patient to face the outcome. Especially in this
in the best way I can.” phase, the psychotherapeutic approach differs between those
acquired brain damage patients with progressive versus
none-progressive brain damage.

Perceived
d Hope
For Complete
Recovery

Fig. 1. Emotional Gap Following Brain Injury. Based on the significant recoveries experienced in the early phases, most TBI patients expect that
this trend will return them to baseline. However, if the recovery falls short of this expectation, then patients are acutely faced with a crisis, which
often leads to depression or even an existential crisis.

this separation, then the psychotherapist should
facilitate a deeper appreciation for the benefits of
honestly examining reality in order to establish
realistic goals, re-gain control, and learn to cope
with the acquired brain damage.
Patients should be encouraged to separate between
their wishes for the future versus the present reality.
Most patients hold on to the following two beliefs. First,
most patients assume that if they do not adhere to the
belief that they will make a full recovery, their improve-
 R. Ruff / Psychotherapy: What works and what does not?
ments will be less favorable. The second commonly
expressed belief is as follows, “I know I can do anything
as long as I try my very best!” These two beliefs can
serve as the basis for denial. Both of these viewpoints
are flawed and therefore need to be confronted in psy-
chotherapy. As to the first belief, flawed expectations
do not enhance a person’s recovery. Contrary to what
most of us have heard repeatedly throughout our child-
hood, it simply not true that, “You can do anything you
want to do as long as you try your best”. This is a phrase
that parents and teachers tell their children to encourage
them to try hard. As to the recovery of brain functions,
we simply have no control – despite trying hard – to
return our brain to the way it was prior to the TBI.
In sum, acceptance requires time for the patient to
grieve the sequelae caused by the TBI, but in addition,
time is needed to grieve the loss of his or her expected
future. This differentiation needs to be clearly under-
stood by the patient. Both grieving processes take time
for reflection and acceptance. The primary benefit of
grieving one’s expected future is to develop realistic
future expectations. Conversely, unrealistic goal set-
ting based on flawed future expectations sabotages the
psychotherapeutic outcome.
5. Step Five. Developing a realistic future that
is existentially meaningful
Let us return to the earlier mentioned 19-year old
handsome and athletic looking man, who sustained a
severe TBI and was also unable to walk. After receiving
cognitive behavior therapy combined with supportive
psychotherapy, he stated that he appreciated my effort
and the tools he learned during psychotherapy, but
added that these gains were basically inconsequential.
As he started to roll his wheelchair toward the door, I
heard myself spontaneously asking, “Do you have any
heroes?” He turned his wheelchair slightly towards me,
paused, and after about 15 seconds responded: “My
Grandmother”. I followed up by asking why. He sim-
ply said, “My Grandmother is loving but tough yet she
has always has been there for me.” I responded, “Is there
any reason why you can’t be like your Grandmother?”
He paused for quite some time while turning his chair
back in my direction and with a gentle smile answered,
“No, not really.” Then before exiting, he glanced back
at me with big smile and said, “Thanks doc!”
This patient was the impetus for me to expand my
psychotherapy from symptom reductions to actively
engage my TBI patients in creating new and meaning-
ful futures. This process included the following three
777
steps: (1) have the patient identify his or her basic core
values that make life meaningful, (2) assist the patient
in grieving the old (pre-TBI) expected future, and (3)
have the patient start to explore ways in which he or she
can rebuild a meaningful future based on self-selected
core values.
5.1. Identifying core values
When introducing this task, I typically note that in
Western society, the “core values” we are repeatedly
exposed to in movies, TV and magazines include a
desire for wealth, power, prestige, fame, youth, and
sex. However, when most of my patients identify their
heroes, they select individuals such as a grandmother,
father, teacher, coach or a historical role model like
Abraham Lincoln, Mahatma Gandhi, Martin Luther
King, Jr., Nelson Mandela, Mother Theresa, or Albert
Einstein. While there is nothing wrong with youth, pres-
tige, fame, wealth or sex, for my patients, the core values
they most often identify are honesty, fairness, justice,
and contribution to others. Thus, when asked to reflect
and write down their core values, patients typically
return to the next session with attributes that include
virtues that they can achieve with or without having a
TBI.
5.2. Grieving the loss of the expected future
After the patient selects her or his core values,
the next step in this psychotherapeutic approach is to
facilitate the patient’s understanding that many of the
premorbid plans for the future are no longer achievable
due permanent disabilities. As noted above, the patient
is actively encouraged to grieve not only future losses
caused by permanent disabilities, but also the loss of the
expected future. The therapist needs to guide and sup-
port this process, since the patient’s loss and detachment
from long held future expectations is both painful and
requires courage. Particularly for young individuals, it
is a shattering task to lose one’s future goal of getting
married, completing their education, having children,
and having a job. Instead, they are often struggling with
finding new friends, living in their own home, or even
needing help with transportation, food preparation and
grooming.
While grieving the loss of the expected future, many
patients either over- or underestimate the extent of their
losses. At times, these misconceptions can be readily
corrected. However, for some domains it may be sim-
ply too premature to determine if an expectation has a
778 R. Ruff / Psychotherapy: What works and what does not?
reasonable chance to being achieved. In rare instances,
a level of denial or unrealistic expectation can be toler-
ated, if without this expectation the patient feels utterly
hopeless or even suicidal. Despite these exceptions, the
benefits of accepting a realistic future usually outweigh
the benefits of adhering to unrealistic expectations. The
latter demotivates and leads a patient to wait for gains
instead of engaging realistically in facing their life. It
is often helpful to examine their role models, since for
most role models, (e.g. Martin Luther King, Jr., Nel-
son Mandela, Mahatma Gandhi) their character strength
was shaped by how they faced and dealt with their
own adversities. Thus, having patients in step 1 identify
their core values can substantially facilitate and reorient
the patient in creating new future expectations that are
positive.
5.3. Living according to core values
Psychotherapy that focuses on a “meaning” was
developed by Victor Frankl (1968), which he called
Logotherapy. Trained as a psychiatrist, Frankl was
imprisoned for three years in Nazi concentration camps
during World War II. After he regained his freedom he
learned that his entire family had been killed. Based
on this traumatic experience, he authored a semi-
nal book entitled Man’s Search for Meaning (Frankl,
1968), which captures his astute insights for coping
with these life-altering tragedies. The insights and tools
he described can be adopted for patients that suffer
from TBI or other serious illnesses. Frankl observed
that tragedy typically leads to a self-centered focus.
His psychotherapeutic approach encouraged patients
to minimize their emphasis on being a victim while
actively striving to find meaning for their future life.
success, but rather try to become a person of value.” Albert Einstein
The responsibility of finding meaning subsequent to
a TBI can be a daunting challenge. Breaking this task
down into the following concrete steps can facilitate
this process. However, the order should be adjusted
according to the patient’s preferences.
(1) Based on the premise that each of us is respon-
sible for making our own life meaningful, the
patient should be encouraged to “search” and not
borrow shelf-ready answers.
(2) The search for meaning should not be oriented
on the past. Instead, the patient should be encour-
aged to prospectively assign the meaning for his
or her future life with a TBI.
(3) Given the abstract nature of assigning future
meaning to one’s life, this task can be facilitated
by focusing on core values. Core values focus on
determining what specific values are truly mean-
ingful for living a meaningful life. Thus, the link
between core values and the person’s meaning
should be clearly established.
(4) Many individuals with TBI benefit from specific
prompting to uncover their core values. Thus ask-
ing them to identify a person they highly respect
can facilitate a discussion that identifies why this
person is their role model. This in turn can yield
core values that the patient holds. If no hero is
identified, examples of generally admired indi-
viduals (e.g., Abraham Lincoln, Mother Theresa,
Albert Einstein) can facilitate the exploration.
Psychotherapists should prepare themselves for
patients asking them to identify their own core
values. I have no issue with sharing my core val-
ues with my patients after they identify their own.
This can lead to positive discussions where I can
learn from my patients and they may add to or
expand their own list of core values. See Table 2
for a list of commonly identified core values.
(5) The benefits of selecting their own core val-
ues and meaningful future should be discussed
and processed. This discussion should allow the
patient to recognize that developing a meaningful
life after sustaining a TBI can reduce the frustra-
tion of not being able to return to one’s life before
the TBI. Moreover, self-respect can be enhanced
when the patient realizes that they are able to live
their lives according to these core values. Thus,
their life is inherently meaningful.
Table 2
Commonly identified core values. “Try not to become a person of
Wisdom provided by Role Model Core value
“God is truth and truth is God” Truth
Mahatma Gandhi
“The injustice anywhere is a threat to justice Justice
everywhere”
Martin Luther King Jr.
“Love your neighbor as you love yourself” Love
Jesus Christ
“The only life worth living is a life lived in Contribution
service to others”
Albert Einstein
“No future without forgiveness” Peace
Desmond Tutu
“Success consists of going from failure to failure Humility
without loss of enthusiasm”
Winston Churchill
 R. Ruff / Psychotherapy: What works and what does not?
(6) This process should not be rushed. Taking time
to explore and modify one’s core values is ther-
apeutic in itself. Living each day with a greater
awareness of what is most important can facili-
tate a more balanced perspective as opposed to
living with a focus on all the deficits and hard-
ships. When patients select and determine their
own core values, they empower themselves to
foster a meaningful life.
(7) Finally, a commitment to accept responsibility
for determining the meaning of one’s life can
focus the patient on positive and reachable goals.
Many TBI patients are angry, embarrassed, and
depressed with the person they have become.
However, if they admire the values they chose,
and they live and incorporate these values into
their daily lives, then they grow to like the per-
son they have become. They have achieved what
is most relevant for us all, living a meaning-
ful live even while enduring tragic and difficult
hardships.
The above mentioned patient was convinced that his
future was meaningless because of his TBI sequelae
and being confined to a wheelchair. The question that
allowed him to identify his Grandmother as his hero
also allowed him to identify his core values, which
were accessible to him despite having suffered a TBI.
Once he identified his core values, his level of activ-
ity expanded. He chose not only to regularly visit his
Grandmother, but also to participate in a community
program for the disabled, where he was hoping to join
the rugby wheelchair team. Despite daily challenges, he
knew that he respected his core values, and the knowl-
edge that he lived by these values provided him an
assurance and at times even a comfort that he was living
a life that was meaningful.
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