Not uncommonly rehabilitation team members exhibit the typical human characteristic of protectiveness of their “territory,” i.e., their disciplinary knowledge and skills, and anxiety about working outside of their comfort zone. While these types of feelings are understandable and normative for human beings, a maximally effective transdisciplinary team is able to function beyond this level of self-interest and keep their eye on the mission. In this regard, the transdisciplinary team functions like other high performance teams, such as, elite surgical teams or military squads. Raemer [13] in Simulators in Critical Care and Beyond recommends four routines of military commando teams for emulation by high performance medical teams: (1) practice, (2) briefing, (3) debriefing, and (4) celebration.

Practice is essential for the efficient and effective operation of a high performance team. Nonetheless, busy schedules can restrict the amount of time that teams have to practice their roles as a team with a given participant. In order to develop the capacity for the members of transdisciplinary teams to assume each other’s roles, it is helpful for the team to discuss and role play the appropriate response to critical participant events. For instance, team members might review how to respond to expressions of anger from a participant, or how to respond to memory failures. In the former instance, the psychologist may be the primary team member to guide colleagues through the appropriate responses to the participant. In the latter, the occupational or speech therapist who is primarily responsible for organizing the cognitive rehabilitation program may be the primary guide. However, in the end, each team member should be able to, at least temporarily, respond as capably as a psychologist to expressions of anger and as ably as the memory expert on the team to memory failures.

Briefing refers to preparing for the mission, or in the case of rehabilitation teams, the coordinated treatment program with a given participant. In rehabilitation settings, this means designing and reviewing the integrated treatment plan. Documentation of a rehabilitation treatment plan is required in most rehabilitation settings. Regular review and appropriate updating of the treatment plan may be challenged by busy schedules of the treatment team members but is essential to assure high team performance.

Debriefing refers to regular examination of the functioning of the team in completing its mission with the participant. While most rehabilitation teams have team conferences on a regular basis, these conference are often focused on participant progress. The most informative debriefing sessions include not only participant status and performance (i.e., to what degree are the goals of the mission being accomplished) but also careful examination of the methods that are being used. What is working and what is not working? How can the team be more effective in working with this participant both as individual practitioners and as a team? A high performance CBIR team needs to have a formal debriefing conference three to five times a week. The objective of these debriefing conferences is to examine in what ways specific interventions as well as their overall plan with specific participants is effective as well as ineffective, and to revise their transdisciplinary rehabilitation plan to improve progress and outcome. Debriefing conferences typically occur without the participant present. The focus is primarily on team process and function and on participant status and progress only as these represent the functioning of the team.

Finally, effective, high performance teams regularly celebrate their successful missions. Central to the concept of celebration is tying the celebration to a specific accomplishment. Some CBIR teams formalize this celebration with a graduation party that includes the participant who has successfully completed the program, their close others, and the treatment team. However, to maintain esprit de corps and avoid burnout, even minor victories merit celebration.

Providing transdisciplinary CBIR can often be challenging and stressful. The participants selected for this type of intensive rehabilitation typically lack self-awareness, are disinhibited and intermittently aggressive, and can split the team through dramatic and frustrating behaviors. Briefing and debriefing sessions provide opportunities for team members to support each other, particularly team members who may be showing signs of stress and burnout. The team leader, who is often a neuropsychologist, has a primary role in supporting the healthy psychological functioning of the team.

Explicit ground rules for team interactions can also be helpful in avoiding inappropriate exchanges and harmful splitting among team members under stress. Disagreements and differences of opinion are healthy and constructive in brainstorming approaches to challenging participant behaviors. However, interactions with participants must be unified and consistent within the team. In the CBIR at Mayo Clinic, we developed a set of guidelines (Table 3) for team interactions. These were posted in the team conference area, and not infrequently referred to during heated team discussions.

A fundamental concept underlying CBIR is development of a therapeutic milieu. In a nutshell, a therapeutic milieu is a treatment environment in which virtually every action and interaction has a therapeutic value, that is, assists participants in accomplishing the goals of treatment. In addition to formal treatments, the therapeutic value of all other activities in the treatment setting, such as, informal conversations among participants, with staff, with family/close others; going to lunch; and formal and informal outings, is recognized and reinforced. The rest of this section examines how the various elements of CBIR create a therapeutic milieu.

Most CBIR programs provide treatments in groups. Providing therapy to more than one participant simultaneously creates efficiency and lessens the personnel costs of providing treatment. However, this is not the primary rationale for group therapy. Group therapy also improves clinical care. Developing a positive dynamic for participants in a therapeutic group can be a powerful intervention to develop self-awareness, reinforce effort and progress, and create a therapeutic milieu.

Providing therapy in a group is not necessarily group therapy. In less effective groups, therapy is provided to one person in the group at a time. Others in the group may benefit from observation of the therapeutic process and serve to encourage and reinforce the intervention. However, what is missing in this scenario is the use of the powerful group dynamic. In a relatively short period of time, every group develops an identity that goes beyond the identity of the individual members. Each member finds a role in the group that is consistent with the identity of the group. Group identity and the roles can be positive or negative. A skilled group therapist will work with the group to create a positive and constructive milieu.

Examples of common roles in a group are: the rational one (who tries to be the voice of reason), the helper (who tries to be supportive), the challenger (who tends to question or challenge the “common wisdom” of the group or the leader), and the quiet one (who has difficulty speaking up in the group). This list is not exhaustive; roles in the group can be many, highly nuanced, and changing. These examples illustrate, however, how roles may be positive or negative. For instance, the rational one may in fact only think they are being rational, while they advance idiosyncratic ideas. The challenger can play an important function in making other group members think about recommendations and suggestions but, without a good group leader, can easily turn into a naysayer who enjoys the attention afforded to a “rebel.”

Typically, individuals find roles in the group that are consistent with their interpersonal style. In a psychotherapeutic group, getting members to reflect on the roles they play in the group, and how and when these roles are effective or ineffective, creates important learning experiences to improve the effectiveness of their interpersonal style. For instance, the quiet one may be a very good listener, but needs to learn to be more assertive to share the perceptions that they have for the benefit of the group and themselves. The helper offers valuable support to others, but may also feel, at times, that they are “always giving” (which they are). Like the quiet one, the helper may be able to learn through practice in the group to be more assertive in getting their own needs met as well as in helping others.

Most CBIR groups, however, are not fundamentally psychotherapeutic but are focused on other goals, such as, developing cognitive, social, or functional skills. In these other CBIR groups, understanding and developing the identity of the group and the roles of the members is critical to using the group process to accomplish the goals of the group. For example, in a cognitive group in which the primary goal is to help members develop and use memory notebooks, a positive group process can be a powerful tool. With skilled guidance and reinforcement from the therapist, the rational one will explain the sense of using a memory notebook; the challenger will question this and voice the objections that others have—so these can be addressed; the quiet one may need to be drawn out, but will often be the swing vote in the process to keep things moving in a positive direction; and the helper will reinforce everybody for using the memory notebook. This quick summary is of course an oversimplification but may give the basic idea of how group process can be used to accomplish the goals of any group, not just psychotherapeutic groups.

A basic premise underlying group process is that the members of the group will respond to their peers more readily than to therapists and that the guidance and reinforcement that they receive from each other is more powerful than that of a therapist. Like most people, people with TBI tend to listen most closely to their peers, to those people who they identify are most like themselves and who they feel share their life experience. The therapist’s skill is required to manage the group process and to keep its energy focused on moving its members positively toward accomplishing their goals.

Therapeutic alliance is the bond of trust and collaborative working relationship that develops between therapist and participant in effective therapy. The concept of therapeutic alliance originally developed through studies of psychotherapy where it was identified as a “necessary but not sufficient (NBNS)” condition for therapeutic change [14, 15]. That is, a therapeutic alliance does not in and of itself produce positive behavioral change; however, change will not occur or will occur only minimally if a bond between therapist and participant is not present. In recent years, therapeutic alliance has been increasingly studied in brain injury rehabilitation and has been found to have a similar positive effect on outcome [16–18]. Although therapeutic alliance often involves feelings of liking and affection between participant and therapist, it is more than this. Therapeutic alliance is “mission-oriented” in that both therapist and participant see themselves as a team that is working collaboratively to accomplish the participant’s goals. The participant develops trust in the therapist’s treatment recommendations and feedback; the therapist also develops trust that the participant is dedicated and committed to the therapy despite the inevitable ups-and-downs of therapeutic progress.

Self-awareness of disability is present in a significant minority of cases of moderate to severe brain injury. Most likely because of cognitive impairments affecting both their ability to conceptualize as well as to remember changes in themselves due to their injuries, participants with impaired self-awareness (ISA) act as if they are the same people they were before their injury. Sherer and Fleming present a thorough discussion of ISA in this volume. The focus here will be on addressing ISA through CBIR and the therapeutic milieu.

Most participants selected for CBIR have some degree of ISA, and ISA is often the overarching disability that will most dramatically interfere with community reintegration for them. ISA can be effectively addressed through CBIR and typically cannot be addressed through more specific individual therapies, for instance, cognitive rehabilitation alone. Participants with no self-awareness of disability cannot be engaged in rehabilitation. In their minds, they are unimpaired; so rehabilitation is of no value. However, most participants are able to identify a specific problem for which they will acquiesce that they may need a little help, often with the encouragement of family or close others. Addressing the identified disability for participants with ISA is the hook to engage the participant; the CBIR treatment plan, however, can be more comprehensive and include addressing ISA as part of the rehabilitation program. Working to develop self-awareness is a delicate operation of balancing feedback with support. The trusting, collaborative working relationship that characterizes therapeutic alliance is essential to this work. The therapeutic milieu is also particularly important to the development of accurate self-awareness after TBI because the development of more accurate self-appraisal is most effectively accomplished if appropriate and consistent feedback and support are provided throughout the day rather than only in a few therapy sessions dedicated to this process.

ISA is challenging to address and may be complicated by pre-injury personality tendencies to respond to stress with denial or support from close others who are also coping by a degree of denial. In almost all cases, it is unreasonable to expect that self-awareness that is impaired due to brain injury will ever completely return to normal after a brain injury. Goals for CBIR should be to improve self-awareness to the degree that the participant can (1) participate effectively in rehabilitation, (2) set realistic goals for rehabilitation and community reintegration, and (3) not engage in behaviors in which they are at risk for harm because of their disabilities. Nonetheless, CBIR provides an effective means to achieve these goals through interventions described below.

Education about brain injury generally and specific to the individual. Explaining the nature of brain injury in general and how it has affected the individual with TBI specifically typically will not in and of itself greatly improve ISA. However, this knowledge is a NBNS condition for improving ISA. A participant cannot be expected to understand how their brain injury has affected them—particularly the more subtle effects—if no one has taken the time to thoroughly explain this to them. General education about brain injury is provided in CBIR groups with easily readable and understandable written material provided as a reference. Education specific to the individual participant can also be provided in a group context, including review of neuropsychological test results, neuroimaging, and how the two connect. It may be psychologically less stressful to learn about the effects of brain injury from review of a peer’s case. Group members also provide mutual support to confronting the stressful realities of brain injury and the sense that none of the members “are alone” in struggling with the effects of brain injury. Educational information will likely need to be repeated several times over the course of a CBIR program—as the participant’s self-awareness improves, they will become more able to assimilate this information.

Family/close other education and participation. Brain injury education should also include the participant’s close others. Close others also often have very limited knowledge about how the brain works and how it recovers from injury. Misconceptions about brain function and recovery may lead to unrealistic expectations. As mentioned previously, close others can also have biased and inaccurate assessments of the participant’s status. In order for any ISA intervention to be successful, it is very important that the rehabilitation team and the participant’s close others are “on the same page” regarding the participant’s abilities, goals, and expectations for recovery. This is important so that the participant’s close others can become allies of the CBIR team in reinforcing more accurate self-assessments and realistic expectations by the participant as well as appropriate progress toward realistic goals. The most common situation is one in which the rehabilitation team and the participant’s close others generally agree on the participant’s status and the participant tends to minimize their disabilities and their impact on their activities. However, the author has observed every possible variation of discrepancy in the appraisal of the participant’s current abilities by the participant, close others, and the rehabilitation team. The MPAI-4 (to be discussed in more detail later) is designed primarily as an evaluation and outcome measure to be completed by consensus of a rehabilitation team. Nonetheless, during the initial interdisciplinary evaluation, we have routinely asked participants and a close other to complete the MPAI-4 independently of each other. Comparing these self- and close other assessments with the assessment of the CBIR team on the same measure gives a clear idea of where areas of agreement and disagreement are present regarding the participants’ abilities, adjustment and community reintegration. We have found it more productive to know from the beginning where we agree and where we disagree, rather than to be surprised by these discrepancies in perception or expectation once a rehabilitation treatment plan has been set in motion. Sometimes disagreements are not easily or quickly resolved. Our approach has been to begin focusing on areas in which there is relatively good agreement about the need for rehabilitation and gradually work on coming together in areas where expectation of needs are more discrepant.

Structured repeated learning experiences with feedback. While education may be NBNS for improving self-awareness, repeated exposure to situations in which the participant’s disabilities and their consequences are made apparent to the participant is very likely the active ingredient in treatment to improve self-awareness. CBIR offers numerous opportunities each day for this type of learning to occur. These types of experiences are potentially very stressful to participants—no one likes to be confronted with their failures or mistakes. Consequently, very direct or harsh feedback to participants about their disabilities, failures, and mistakes is usually not constructive. To the contrary, confronting participants about, for example, their memory problems, is most likely only going to reinforce denial and resistance. A more productive approach is to structure these experiences as supportive learning opportunities. It is not uncommon, however, for CBIR team members to disagree about how direct and confrontational feedback to a given participant should be and can lead to heated debate that threatens to split the team. Agreeing on the most constructive approach with a given participant will appropriately occupy many briefing/debriefing sessions and require skill and sensitivity from the team leader to help team members deal with their frustrations in working with participants with severe ISA.

Peer feedback. Feedback may take many forms: feedback from therapists, results of objective tests or measures, recorded video. However, the most effective feedback is from peers. Like most of us, people with TBI tend to listen most closely to people who they feel are much like themselves. Direct confrontation is also better tolerated when delivered by peers than when delivered by authority figures like therapists. Shrewd and skillful management of group process and dynamics and the therapeutic milieu by the CBIR team will result in many constructive opportunities for this type of feedback.

Individual and group psychotherapy. The development of more accurate self-appraisals is a double-edged sword. More accurate self-appraisal will lead to more appropriate goal setting and avoidance of activities in which current disabilities will frustrate success or put the participant at risk. However, more accurate self-appraisal can also lead to feelings of discouragement, depression, anger, and other emotional reactions as the participant begins to recognize that life has changed because of brain injury and that some activities and goals that they had prior to the injury may be forever out of reach. For this reason, psychotherapeutic interventions to address feelings of loss and to develop coping skills are another essential component of any intervention to address self-awareness. As self-awareness increases, sometimes depression can become marked, and intensive treatment, including medication should be considered.

In this author’s experience, the transition between increased self-awareness and reactive emotional distress is not clearly staged. That is, the participant does not suddenly develop self-awareness and then become depressed or angry. Rather the process is one in which self-awareness improves a little; negative emotional reactions occur; and the participant defends against these unpleasant feelings with a degree of minimization and denial. With psychotherapeutic intervention, these defensive reactions diminish and self-awareness improves a little more—only to begin the cycle again. Support and feedback of peers in psychotherapy and other CBIR groups can be very effective in helping participants to work through these cycles of psychological growth.

Interventions to improve cognitive function are an integral part of CBIR programs. The most common targets for cognitive rehabilitation are attention, memory, problem-solving, and goal-setting. Because cognitive abilities interact, a thorough neuropsychological evaluation is essential to planning a targeted cognitive rehabilitation program. For example, almost all individuals presenting for CBIR (or their close others) will report that they have “memory problems.” However, for many, the problem is not so much with storing and retrieving new information but with attending to the information when it is presented so that it can be stored in memory. Participants whose primary cognitive disability is attention will benefit from different cognitive rehabilitation methods than those whose primary problem is long-term storage and retrieval. For others, difficulty in organizing new information for memory storage may be the primary problem. These individuals typically also have great difficulty organizing other aspects of their lives and consequently, organization may be the primary target for intervention and memory only a secondary target.

The functional impact of cognitive impairments is also important to evaluate. While cognitive impairments may be a very significant frustration and impediment to community reintegration for many people with TBI, this is not true for all. Some individuals have learned to compensate for low average or mildly below average cognitive abilities throughout their lives, and have found work and other activities where strong cognitive abilities are not required. Such individuals often do not require intensive cognitive rehabilitation in order to re-engage with their communities—regardless of the results of their neuropsychological testing.

A number of evidence-based methods for rehabilitation of various cognitive functions have been identified through a series of reviews [19–21]. Haskins and colleagues [22] have recently published a manual that clearly describes in practical terms how to apply these techniques in practice. The Haskins book also provides a number of exercise guides and materials for use by therapists. A recent volume by Sohlberg and Turkstra details the most effective processes for organizing cognitive rehabilitation interventions. Cognitive rehabilitation techniques are reviewed in this volume as well (see Chaps. 9–11). The interested reader is directed to these other sources for a more in-depth treatment of this topic. The focus here is on integrating cognitive rehabilitation into the therapeutic milieu.

Attention Process Training (APT). Originally developed by Sohlberg and Mateer [23], APT involves practice in which the complexity in auditory and visual modalities of the foci of attention is gradually increased. In their volume on cognitive rehabilitation, Sohlberg and Mateer [24] also describe a number of exercises in which attentional focusing and shifting, dividing attention, and shifting attention can be practiced in everyday life. Similar exercises can be practiced in a group setting and throughout the day in the CBIR therapeutic milieu.

Group therapy and the milieu also provide opportunities to address emotional reactions that may interfere with attention. Depression, anxiety, anger, and worry all interfere markedly with the range of attentional functions. This is true for the normal population and doubly so for individuals with TBI. In some cases, the frustration of loss of attention may set off strong negative emotions and create a downward spiral for the participant in which the negative emotions lead to further difficulty regulating attention—leading in turn to increased frustration, anxiety, dysphoria or anger—creating further loss of attentional control. Through cognitive-behavioral therapy, individuals who experience such disruptive emotional reactions learn to identify the thought processes that lead to these negative emotions and interrupt them with more constructive self-talk. In a group milieu, other participants and therapists can assist by prompting this kind of self-talk when they observe a loss of attention accompanied by emotional upset.

The Memory Notebook. Development of a “memory notebook” for each participant is a standard component of CBIR. These notebooks should be individualized to the needs of each participant with sections designed to help organize their schedule and make frequently used information readily accessible (see Chap. 9 for further detail). Although the “memory notebook” appears to be almost universally used as a name for this tool, one of the participants with whom we worked challenged this. He made the point that the use of daily planners, smart phones, and other memory assists has become ubiquitous in the normal population, and asked why these aids should be called something different when used by people with TBI. In fact, his point is well taken. Simply referring to the “memory notebook” as what it is, i.e., a calendar, planner, or smart phone, may normalize the experience of its use for the person with TBI and help increase its acceptance.