R34: Non-medical interventions are recommended for the first line treatment of behavioural disorders in traumatic brain injury patients as well as the distress experienced by families throughout the progression. This treatment must be conducted by therapists specialising in neuropsychological disorders of TBI, in consultation and in collaboration with the
professional teams and relatives (EC).
R35: The non-medical treatment of behavioural disorders involves various approaches:
holistic (programmed paths, social, professional, occupational activities...), cognitive-behavioural, family systemic, psychoanalytical, as well as adaptation of the behaviour of the patient's relatives, and healthcare and follow-up teams (EC).
R36: Different approaches can be combined according to the predominance of some symptoms or co-morbidities, and can be associated if necessary with specific treatments (post-traumatic syndrome, drug addiction...) (EC).
R37: Studies conducted using a scientifically validated methodology will be required to determine the most efficient non-medical approach for treating behavioural disorders in TBI patients: holistic, cognitive-behavioural, systemic, psychoanalytical (EC).
R38: Rehabilitation activities such as neuropsychology, speech therapy, physiotherapy, and ergotherapy help improve behavioural disorders. However, they must be personalised and specific, particularly with regard to neuropsychological rehabilitation (targeting dysfunctional processes), and are recommended within the framework of TBI patient care pathways (EC).
R39: A programme of occupational activities (sports, artistic, cultural...), or a
socio-professional project when possible, involving medico-social organisations such as SAMSAH, SAVS, GEM, UEROS in collaboration with the MDPH, are recommended due to their personal structuring, socialising and enhancing role. These programmes must an integral part of the patient’s overall treatment (EC).
R40: Additional studies are necessary to evaluate the adequacy and efficacy of the measures or the social or professional reinsertion programmes (EC).
3.2. Specific approaches and treatments 3.2.1. Holistic and institutional approaches
The holistic approach derived from holism in the 1920s considers that humans function as a complex whole within the framework of a model defined recently in the medical and biopsychosocial domain.
Contrary to the three previous approaches, holistic psychotherapy was not derived from an existing technique, but was specially designed for TBI patients. The principle is to address generally, progressively and in a coordinated manner the question of awareness of the handicap and its acceptance, through individual and group psychotherapy sessions, as well as cognitive rehabilitation in order to improve social and professional insertion. The patient progresses in successive stages according to the following conventional scheme: commitment, awareness, malleability, control of compensation processes, acceptance, identity, social reintegration.
In the United States, these programmes are extremely intensive, with up to 20 hours a week for 4 to
6 months. Goldstein on TBI patients from the First World War, then Ben Yshai and Prigatano in the 1980s, followed by Teasdale and Christensen in Europe, and North in France in the 90s promoted this treatment for traumatic brain injury patients. This concept is today an integral part of PMR practices and the work of aftercare and rehabilitation centres that specialise in the treatment of TBI patients, which in France include the Delta groups and in a way UEROS and some TBI SAMSAH.
Observation: The holistic approach improves emotional disorders, as well as social integration and interactions.
R41: Although access to the holistic approach is still limited due to the significant resources required for its implementation, it is particularly recommended for patients with problems of social integration (EC).
R42: Efforts must be made on a national scale to develop and evaluate the feasibility of holistic programmes at national level (EC).
3.2.2. Behavioural therapy (BT) and Cognitive behavioural therapy (CBT)
The cognitive-behavioural approach is a major branch of contemporary clinical psychology initially developed in Anglo-Saxon countries in the 1940s. The basic hypothesis is that the interpretation of the subjective experience is distorted by the influence of inappropriate cognitive schemas that can cause observable disorders and symptoms. Such schemas remain largely implicit, but their productions (mental images, "automatic" thoughts) are accessible to consciousness; they can therefore be identified, and if necessary, modified.
The aim of the therapy is therefore to help the subject modify beliefs, thoughts and behaviour in two ways:
(1) Cognitive: "cognitive restructuring" process. Through a therapeutic alliance, this process involves recognising dysfunctional thoughts, identifying and testing the validity of cognitive distortions, and developing more rational alternatives. The methodology is rigorous, with systematic evaluations, and the introduction of realistic progressive contractual targets that are self and hetero-assessed
(feedback).
(2) Behavioural: for example, gradual exposure to situational problems; implementing behavioural experiences; developing an "internal dialogue"; keeping therapeutic and daily logs; using role-play;
teaching problem-solving strategies; or even using relaxation techniques.
Spurred by Wood and Ponsford in particular, CBT was first developed for TBI patients in the 1980s. It is currently recommended and used as a first line treatment in Anglo-Saxon countries. CBT seems appropriate with regard to the convergence of behavioural, emotional and cognitive disorders through its highly structured nature (attitude of the practitioner is admittedly empathic, but remains very active), the designation of specific, concrete objectives, and the focus on the "here and now". This cognitive-behavioural approach is commonly described for the non-pharmacological treatment of behavioural disorders in TBI patients, but ironically, it is not yet widely diffused or practiced in France.
R43: Despite limitations linked to the intensity of cognitive deficiencies and the capacity of self-analysis required, CBT is recommended particularly in patients with symptoms such as anxio-depression, irritability or anger (EC).
R44: When cognitive disorders (in particular mnestic and executive) are too pronounced, more behaviour-specific interventions are recommended (EC).
R45: Efforts must be made on a national scale to develop and evaluate the use of CBT in France irrespective of the fact that there are numerous international scientific studies suggesting the benefits for some behavioural disorders in TBI patients (EC).
3.2.3. Systemic family approaches
Family therapy was developed in the United States in the early 1950s under the influence of Gregory
Bateson and the Palo Alto school. The combination of communication theory (cybernetics) and ethnology resulted in the creation of a new discipline: systems theory (study of relationships between systems), and when applied to the family (considering the family as a system) became Systemic Family Therapy (SFT). This approach, influenced by diverse successive movements, became very popular in the 1960s with the opening of Family Therapy centres in the United States. It consists in analysing the family over several generations, during interviews, detecting verbal and non-verbal communication disorders (secrets, ignorance of distress, jealousy, alliances, conflicts), and attempting to improve dialogue between family members and the therapist.
Family therapy was introduced in Europe and France in the 70s. Spearheaded by P.Caillé,
Neuburger, M El Kaim, and JP Mugnier, amongst others, it has been taught since the 1980s and is used more particularly in situations of domestic violence and sexual abuse, behavioural disorders of children or adolescents, or marital problems (couple therapy).
The first articles addressing the treatment of families of TBI sufferers were published in the 1980s.
Initially leaning towards support and information, the treatment has progressively developed to include various psychotherapeutic branches and in particular, the systemic approach. In France, in the 1990s, JM Destaillats, C Belio and JM Mazaux developed the neuro-systemic approach, which takes into account family problems whilst integrating neurological disorders and the social
environment of the TBI (institutional, occupational, professional...). Confronted with the accident, in particular the neurological sequelae and the psychological and environmental consequences, the objective of the therapy is to enable co-(re)construction with the patient, family and healthcare team, as proposed by Dumond et al. (2012).
Observation: The literature review confirms the hypothesis regarding the efficacy of systemic family therapy for families of TBI patients.
R46: Providing attention, information, support and treatment for families using a systemic family approach if necessary, is recommended in any institutional or extra-institutional organisation receiving or assisting TBI patients and their families (cf. memorandum DHOS 2004) (EC).
3.2.4. Psychoanalytic and psychodynamic psychotherapy
Psychoanalytic psychotherapy is an adaptation of Freud's psychoanalysis defined in the 1920s, which was too restrictive in numerous situations. Ferenczi in the 30s, then Winnicot and Balint in the 60s and 70s proposed changes to make the therapy more accessible: one-to-one interviews; semi-structured interviews; possibility of adapting the payment, frequency and duration; possibility of institutional practice... They retained the basic Freudian theories regarding the presence of an unconscious mind where unresolved childhood conflicts are concealed and which are expressed by symptoms. Psychotherapy consists in creating a therapeutic or intersubjective relationship with the patient driven by transference and countertransference between the patient and the therapist to reach, through words, the subconscious and solve intra-psychic conflicts.
Since the 1980s, psychoanalytic psychotherapy has been used for traumatic brain injury patients, but major changes have been made to take into account short-term specificities and neurological
sequelae. This approach was developed in France in the second half of the 80s, spearheaded by H.Oppenheim and P. Fayol. Relatively complex problems regarding identity and psychological reconstruction disorders after the trauma can thus be addressed in depth.
R47: Despite certain limitations linked to the lack of scientific evaluation, therapists acquainted with TBI sequelae, and in particular cognitive disorders, can propose
psychoanalytic psychotherapy to patients in conjunction with and in addition to the overall treatment (EC).
3.2.5. Physical activity treatment techniques
This is a very general and disparate section for a certain number of approaches using the body to mentalize and treat psychological and behavioural disorders in traumatic brain injury patients. These techniques are used alongside traditional approaches and could be interesting for some mood disorders such as anxiety and post-traumatic syndromes. Breathing is used in relaxation, body movements in Tai Chi, listening in music therapy, body sensations in hypnosis, and eye movement in EMDR (Eye Movement Desensitisation Reprocessing).
Observation: Tai Chi improves anxiety, mood and self-esteem in TBI patients.
Observation: A music therapy programme can improve mood and anxiety in TBI patients.
Observation: EMDR is sometimes used to treat post-traumatic stress in TBI patients with sufficient concentration and eye movement. Additional studies are required before any recommendations can be established.
Observation: Ericksonian hypnosis is sometimes proposed to treat anxiety and
post-traumatic stress in TBI patients with an adequate ability to mentalize. Additional studies are required before any recommendations can be established.
3.3. Relational treatment techniques and approaches
When no structured programmes or validated studies are available, some treatment principles and relational approaches can be used on a daily basis by the patient’s carers and relatives, as described by Croisiaux and his team from the Braise centre in Anderlecht, Belgium. These guidelines or recommendations systematically take the invisible handicap of traumatic brain injury patients (cognitive and psycho-behavioural disorder) into consideration in the relationship with the patient.
R48: Avoid stressful and interference situations; take cognitive problems into consideration (do one thing at a time, avoid distractions, tasks too long...); take fatigue and the person's psychological condition into account; avoid major changes and surprises: the person needs maximum stability; be aware that what is learnt is not acquired definitively; a change or disruption can call all the work into question and necessitate adjustments (EC).
R49: Be structured, clear and precise; speak slowly, adapting the language to comprehension issues (short sentences, simple words) but without treating them like a child so as not to make them feel denigrated. Assist the person step by step, even if the tasks seem simple (EC).
R50: Respect the person and their need for independence: do not act or think for them too fast, give them every opportunity to take control of their life (EC).
R51: Note down important information using media adapted to the patient's cognitive or sensory disorders: paper or electronic diary, computer interface, board, post-it... (EC).
R52: Respect the tools implemented and encourage their use every day. Pass on information to all those concerned (brain-damaged patient, confidante, family, professionals, helpers...) in compliance with rules regarding confidentiality (EC).
R53: Do not take any irritation, aggressiveness personally. Step back and draw on the professionals or support services. Do not respond to aggressiveness with aggressiveness (EC).
R54: The aim of aggression management training is to help the patient identify the growing feeling of tension and learn how to isolate themselves in such situations. For the family, the aim of this training is to identify any history of aggressive outbursts, analyse and prevent triggering and aggravating factors, adapt behaviour and style of communication, use verbal signals to show the patient they are aggressive; presence of a calming member of the care team during episodes, recall happy events (EC).
R55: Encourage encounters with families of other TBI patients (AFTC) or associations (GEM...) to share experiences (EC).