A 39-year-old woman who experienced a moderate TBI at the age of 22 presented for neuropsychological evaluation with complaints of attention problems and anxiety. There was no other significant medical history. The patient graduated from high school and was employed full-time in a call center. She was the single mother of an 11-year-old boy. During the clinical interview, the patient described feeling overwhelmed at work following a recent promotion and uncertain of her ability to handle new job responsibilities. Her son is enrolled in gifted classes at his middle school, and she stated she was “not smart enough since my injury” to help her son with his increasingly difficult homework or to communicate with his teachers. She reported feeling “sick to my stomach” at a recent back-to-school night as the teachers reviewed upcoming student projects. Neuropsychological evaluation revealed mild impairments in information processing speed and variable performance on measures of attention, verbal learning, and memory. Performance on other cognitive measures was within normal limits. Responses to self-report measures of emotional functioning revealed moderate to severe anxiety and mild depressive symptoms. The patient was referred for psychological treatment for anxiety and depression.

The results of the neuropsychological evaluation suggested that this patient would be a good candidate for a psychological intervention that included components of CBT, and her treatment plan was developed in accordance with this model. The patient expressed good understanding of this therapeutic approach and was able to identify thoughts with minimal prompting. She was an active and engaged participant during treatment sessions; however, she demonstrated very poor completion of assigned homework. Discussion of this homework issue revealed that the patient misplaced her homework on some occasions and, at other times, did not remember it until she was on the way to her appointment. Thus, this failure to complete the homework reflected a memory problem rather than noncompliance with the treatment plan. The therapist applied a structured problem-solving approach to the discussion of potential compensatory strategies she could use to help remember her homework, including the use of a memory station, memory notebook, smartphone, and checklists. The patient expressed a strong preference for use of her smartphone applications to help remember homework, and to have electronic versions of the homework that she could access easily. The patient, in collaboration with the therapist, developed a compensatory strategy centered around her smartphone to help her remember her homework. This strategy became quite successful following some initial refinement of the components. The patient’s role in developing this strategy and successfully managing this memory problem was also used as evidence to counter her belief that she was “not smart enough” since her injury.

A 19-year-old male who experienced a severe TBI at the age of 7 was referred to a post-acute brain injury rehabilitation program for vocational services. Neuropsychological evaluation showed impairments in multiple domains including attention, learning, memory, executive functions, and processing speed, as well as clinically significant depressive symptoms. Clinical interview revealed that the patient had some acquaintances, but no close friends; he socialized exclusively with family. Notable social communication deficits were observed including poor eye contact, the telling of moderately offensive jokes, frequent interruptions characterized by off-topic comments. The examiner noted that the client frequently acted younger than his age. His stated goals were to get a job, to obtain his driver’s license, and to have a girlfriend.

In contrast to Case 1, the results of the neuropsychological evaluation described in Case 2 documented several cognitive impairments that would likely impact his ability to benefit from a CBT-based approach, especially impairments in executive functions. Thus, a more behavioral approach to the treatment of his depressive symptoms appeared warranted. The client expressed understanding of, and agreement with, his treatment plan. Further assessment revealed that the client enjoyed outdoor activities such as playing sports and walking with his dog. The client and therapist developed a schedule of regular meaningful activities and investigated community-based recreational sports programs which led to his registration in a local judo class. Initially, he had some difficulty following his activity schedule. He reported that he could not remember what he was supposed to do first. Family also reported that he would confuse the order of the steps or get distracted by another activity and fail to return to the task. The therapist helped the client to develop checklists that contributed to improved completion of the tasks. Also, family decided to start paying client for completing household chores, including simple yard work and laundry, to reward successful task completion. Participation in meaningful activities and task completion improved. This was associated with improvements in depressive symptoms. The patient also participated in a social skills intervention group to address his social communication problems. Strengthening social skills can contribute to improved relationships with others, and thus increase perceived social support, which also plays an important role in the experience of emotional distress.