Four levels of psychotherapy after brain injury

Psychotherapy treats both the mind and the brain—which makes it a suitable treatment even in cases where the brain has been damaged by a stroke or injury. However, there are dozens of different psychotherapeutic approaches and hundreds of specific therapies. Which ones are suitable for brain damage?

Every DIY enthusiast knows that sometimes a hammer helps, while other times a screwdriver is more appropriate. The same applies when planning therapy: the key question is what we actually want to achieve. Ideally, of course, we would make all the consequences of brain injury disappear with a wave of a magic wand, but medicine lacks such a wand. In addition to reducing the direct, biological consequences of the injury, one of the fundamental goals is to compensate for lost functions. And above all, the best possible quality of life, because a recovered patient is not only one who has regained as many functions as possible—but, above all, one who is living well.

A study on current psychotherapy for patients with brain injury From Meaning to Symptom Reduction begins by distinguishing four levels of recovery:

1. Symptom reduction. These may include motor or cognitive limitations; however, the direct biological consequences of brain injury often also include emotional problems, ranging from depression to irritability and anger.
2. Reduction of inappropriate behavior. Biological consequences and the difficulty of coping with the situation often trigger or exacerbate bad habits—therapy can thus also prevent, for example, the development of alcohol or drug addiction.
3. Improvement in emotional coping. In response to occupational, social, and personal changes, patients naturally experience secondary emotional problems as well. Uncertainty regarding both the recovery of one’s own abilities and future employment prospects and one’s standing in the family and society is often just as challenging as acute problems—and, unlike the direct biological effects of brain damage, it is not, in principle, untreatable.
4. Rediscovering a purpose in life. Therapies focusing on the fourth dimension help patients “find a new meaning in life in the face of (rather than in spite of) the effects of brain damage,” the study’s authors emphasize the importance of finding one’s own role in the new world into which neurological damage has thrust the patient.

In the Beginning Was Freud

How do various psychotherapies relate to the four levels of healing? They began with the discovery of unconscious processes that influence a person’s mental life. Sigmund Freud’s work gave rise to psychotherapies known as depth and psychodynamic psychotherapies, which view human problems in the context of the unconscious—shaped by innate temperament, childhood upbringing, and past traumas. These connections elude the individual—and the therapist is the expert who can uncover them. The therapist thus helps the patient understand the hidden processes that govern their behavior, enabling them to become their own master.

In the twenty-first century, psychodynamic roots have given rise, for example, to relational psychoanalysis, which focuses on interpersonal relationships. This is because people do not merely adapt their behavior to their surroundings; they also adjust their thinking and emotional experiences based on cues from those close to them. Examples include the quite ordinary, reassuring words of friends or family —but also less obvious cues in their behavior, based on which we can, for example, determine whether it is appropriate in a given situation to let others take care of us or to overcome difficulties and take care of ourselves. The consequences of an injury will naturally disrupt the previous balance in relationships—and psychotherapy can help restore that balance, thereby giving a person back the opportunity to benefit from fulfilling relationships with others.

Cognitive-behavioral therapy targets problematic symptoms

Postwar America, however, sought more scientific theories than Freudian notions of hard-to-measure unconscious processes. Moreover, Nazi eugenics had discredited the idea that human traits are innate. Behavioral therapy offered an alternative: the belief that the human psyche is governed by principles similar to those governing the behavior of laboratory mice or Pavlov’s dogs. The therapist thus attempts to gradually change habitual responses to stimuli and life situations.

Behavioral methods were gradually joined by cognitive methods, which address the complexities of human thought, but the basic idea remains: mental health issues stem from inappropriate reactions to the environment in which a person lives—and the therapist therefore retrains them. Cognitive-behavioral therapy (CBT) is thus based on a rational understanding of one’s own capabilities and errors in judgment. It educates patients and teaches them to think and act in ways that will ultimately improve their quality of life. Because it deals primarily with specific, clearly defined problems, it is effective mainly at the first and second levels.

Postmodern approaches in psychotherapy offer new solutions

However, a mechanistic understanding of the human psyche was incompatible with the hippie atmosphere of the 1960s—and, moreover, it could not explain the cruelty of which quite ordinary people were capable, as demonstrated by the Vietnam War or the famous prison experiments. This gave rise to other approaches that sought the essence of the human psyche in a sense of life’s meaning and contribution to society—and viewed mental illness as a lack thereof. Humanistic and existential therapy, therefore, does not explain anything to the client or try to re-educate them, but rather supports them in finding their own place in the world—for example, in the face of changes forced upon them by a brain injury.

The complexities of the world in which we live eventually gave rise to other, “postmodern” therapies that emphasize the uniqueness of each of us, including narrative therapy. This therapy focuses on the meaning we attach to various people, values, relationships, and experiences, and shows that this meaning is not fixed and that we can change it. Such therapy supports coping with changes following brain injury by finding new starting points and perspectives on the world and oneself, thus focusing primarily on the third level.

Current trends in psychotherapy mainly include mutual enrichment and the blending of different approaches. The broad group of “third-wave therapies third-wave” therapies adds spiritual or existential elements to cognitive-behavioral methods. The result is, for example, a fusion of CBT and mindfulness meditation, which, by calming the individual on both biological and psychological levels, targets the first and third levels of healing.

The individual levels of coping with brain injury naturally overlap, and it makes no sense to separate them. A model that distinguishes between them, however, highlights the importance of psychotherapy in the care of individuals who have suffered brain injury—and also reveals how different approaches can each contribute in their own way to restoring quality of life.

Further reading: A study describes in detail the different psychotherapy approaches following a brain injury FROM MEANING TO SYMPTOM REDUCTION: Contemporary approaches to psychotherapy after traumatic brain injury.