Exploring variables associated with change in cognitive behaviour therapy (CBT) for anxiety following traumatic brain injury

Abstract

Purpose: In a pilot randomized controlled trial, we investigated the effectiveness of a 12-weekly anxiety treatment programme adapted for individuals with moderate-severe TBI, based on cognitive behaviour therapy (CBT) and Motivational Interviewing (MI). The current study explored the variables associated with treatment response and group differences in change expectancy and working alliance. Methods: Twenty-seven participants recruited from a brain injury rehabilitation hospital were randomly assigned to MI + CBT, non-directive counselling (NDC) + CBT and treatment-as-usual and assessors were blinded to treatment conditions. Correlation and multiple regression were used to examine the association between reduction in anxiety ratings and a number of clinical, injury and cognitive variables. Random effects regression was used to examine group difference in changes in working alliance and expectancy. Results: There was a trend suggesting that greater injury severity may be predictive of poorer response to CBT and injury severity was significantly related to memory functioning. Participants receiving MI pre-treatment showed a greater increase in change expectancy at the end of CBT and at follow-up, but not at the end of MI. Conclusions: There is a need to further investigate the effectiveness of treatment for individuals with different injury severity and to explore the relationship between change expectancy and treatment outcome.

Implications for Rehabilitation

• Whilst cognitive behaviour therapy (CBT) has demonstrated effectiveness in treating anxiety, individuals with traumatic brain injury (TBI) may have difficulty benefiting from such therapy due to injury-related cognitive limitations.

• Individuals with greater injury severity and/or poor memory functioning are likely to have greatest difficulty in benefiting from CBT.

• For these individuals it is important to monitor their use of CBT skills, adapt therapy to meet their limitations (e.g. increased repetition, intensity or treatment dosage), provide follow-up booster sessions, and assist clients to develop realistic therapy goals.

Keywords::

• Anxiety
• cognitive behaviour therapy
• traumatic brain injury

Acknowledgements

The authors would like to thank all participants and staff members at the Monash-Epworth Rehabilitation Research Unit and Epworth Rehabilitation Centre, especially Dr Kerrie Haines, Dr Kate Gould, Dr Lisa Johnston, Natalie Gracia and Dr Kylie Altson. Special thanks to Dr John Taffe for his advice on statistical analysis. We gratefully acknowledge Dr Henny Westra and Dr David Dozois, who generously provided us with their Motivational Interviewing treatment manual for adaptation.

Declaration of interest: This study was supported in part by grants from the National Health and Medical Research Council and Monash University, and a scholarship from the Victorian Brain Injury Recovery Association (Australia). The funding sources had no role in study design and analysis of data. The authors alone were responsible for the content and writing of the paper.

Notes

¹This participant was included in the treatment trial due to treating teams’ observations of significant anxiety in daily life.