Cognitive Behavioral
Therapy

William H. Frey, PhD, Professor, Department of Neurology at the University of Minnesota, has reviewed this article for content accuracy.

What is Cognitive Behavioral Therapy?

Cognitive Behavioral Therapy (CBT) is a type of psychological therapy that works to change harmful thought patterns. In the context of persistent post-concussive symptoms, these thought patterns often manifest as a fear that one will not recover from their injury, which can trigger the cycle shown in the diagram below:

CBT can interrupt this cycle by working to reframe harmful thoughts. Through reframing, CBT helps ensure that recovery is not impacted by any negative emotional or behavioral processes.

For a more detailed explanation of CBT, click here.

What is it like to go to a Cognitive Behavioral Therapist?

Below, we’ve outlined what it might be like to see a Cognitive Behavioral Therapist, based on the information provided by Dr. William Frey, Ph.D., a leading psychologist in the field of concussion treatment.

Your therapist will most likely explain CBT simply starting with the concussion reminder: “Because you have had a concussion and your thoughts and concentration may be disrupted, have a significant other or friend read and go over this with you.” In session, your therapist may ask you to do the following as part of an initial assessment:

Make a list of all the emotional and physical feelings you’ve been having since sustaining a concussion. Don’t leave anything out, even if it is not listed as a concussion symptom.
Which of these symptoms seem to be getting better and which ones seem the same or worse? The persistent physical symptoms you are dealing with are the core concussion consequences and are disruptive, so don’t ignore them.
Would you tell your significant other or friend your secret fears and concerns about your situation. They can include nightmares, lawsuits, and all intrusive thoughts. Write them down—as scary or silly as they may seem—because they are important to understanding how to feel better.
Your personality may hinder or help your recovery, but everyone experiences some psychological distress following a concussion. You may feel depressed, uninterested in doing activities you would typically enjoy, as well as tired, annoyed, and angry a lot. You may worry about what is going on in your body and mind and even have trouble being positive. Your symptoms may make you feel inadequate or helpless, or you may get hyper-active trying to recover fast.
Because your mind and body work together, your finely tuned system is now out of adjustment and you may not be aware of this overtime work to restore equilibrium and control. Understanding this process is crucial.

After this assessment, your therapist will help you focus on how to deal with each of these areas with unique and mindful strategies. With thoughtful practice and behavioral repetition, you can enhance your approach to your rehabilitation and recovery.

Why should you seek out CBT?

The 5th International consensus statement on concussion in sport lists CBT as one of the primary treatments for persistent post-concussive symptoms*.

*Persistent post-concussive symptoms (PPCS) are defined as symptoms that last beyond what is considered to be a normal recovery time frame. The normal time frame for recovery is 10-14 days for adults, and four weeks for children. Symptoms that last beyond these time frames are considered "persistent symptoms." There is not yet a consensus on the expected time frame for recovery for adolescents.

The consensus statement was produced in 2016 by a panel of leaders and experts in concussion management and provides the most up-to-date, research-backed guidelines for the treatment of concussion patients by medical professionals.

It is important to note that the consensus statement recommends CBT as part of “a collaborative approach” to treating concussion patients. In other words, leading doctors recommend that CBT should not be provided in isolation, but as part of a comprehensive rehabilitation regimen that may also include physical therapy or an aerobic exercise program.

How CBT helps in the concussion recovery process

CBT has been shown to be effective for treating many PPCS, including depression, anxiety, insomnia, headaches, and PTSD. Not only does CBT shorten the recovery time for PPCS, but it also reduces the percentage of concussion patients that develop PPCS in the first place. See the sections below for more details on how CBT treats specific PPCS.

Depression

Depression is a mental disorder that is often characterized by persistent feelings of sadness and a loss of interest in activities that were previously enjoyed, among other symptoms. CBT has been shown to reduce depression in both youth and adults. In a meta-analysis that examined the overall effectiveness of CBT for treating depression, the researchers found that CBT was effective at alleviating people’s symptoms. Furthermore, the review indicated that these improvements were maintained over time.

Dr. Joel Becker describes CBT for depression.

Anxiety

Anxiety disorders are often characterized by frequent episodes of intense and persistent worry and fear about everyday situations.

CBT has been shown to reduce anxiety in both youth and adults. A meta-analysis that examined the efficacy of CBT for treating various anxiety disorders found that CBT was effective at alleviating people’s symptoms.

Insomnia

Insomnia is a sleep disorder in which you have trouble falling or staying asleep. Given that some level of insomnia is present in ⅔ of adolescents with PPCS, much research has examined how to treat the disorder. Research has shown that CBT can effectively treat insomnia. For instance, a study that examined the effectiveness of Cognitive Behavioral Therapy for insomnia (CBT-I)—a version of CBT that is tailored to treat insomnia—found that CBT-I provided remission of insomnia in 80 to 90% of adolescents with PPCS.

In addition to in-person CBT-I, CBT apps have been shown to be effective at combating insomnia.

Headaches

Post-traumatic headaches (PTH) are one of the most prevalent symptoms in children with persistent post-concussive symptoms. PTH last more than three months following a concussion. According to a review of pediatric post-concussion syndrome (PCS), CBT is effective for treating PTH in children. Due to the predominance of headaches in children with PCS, CBT could improve the beneficial effects of medications. CBT might even be advantageous compared to psychopharmacology, due to its lower costs and lack of side effects.

Cognitive Impairment

CBT can be adapted for persistent cognitive challenges following a concussion. A study conducted by Ponsford et al. investigated CBT-ABI, a form of CBT designed for acquired brain injury patients.

According to the researchers, adaptations included “incorporating simplified concepts, concrete behavioral examples, pictorial handouts and cues, and considerable repetition, as well as booster sessions.”

The study found that CBT-ABI was able to reduce anxiety and depression in patients that suffered a moderate to severe traumatic brain injury (TBI).

PTSD

CBT can be beneficial for patients with a history of TBI that are struggling with post-traumatic stress disorder (PTSD). A review of PTSD studies found that CBT had positive effects, often in combination with other treatments.

Dr. Michael Roy describes CBT for PTSD.

How to find a therapist

Below, you can explore numerous resources that will help you access CBT. You can receive CBT through licensed providers that offer their services in-person or online, as well as through apps that allow you to engage in CBT with a chatbot.

In-Person Therapy

1: Start with Psychology Today.

Psychology Today is where you will find most therapists’ information about their provided services.

Step 1: Type in your zipcode into the search box. Once you do, you will be taken to a screen of therapists available in your area.

Step 2: Narrow your search using the left-hand sidebar. In order to find a therapist that offers CBT, select “CBT” under “Types of Therapy.” Under “Issues,” press “+” to expand the list and select “traumatic brain injury.” You can implement as many filters at once as you want. Once you click on a filter, your selection will be shown as a green tag at the top of the screen. Click the “x” on the tag if you wish to remove the filter.

Step 3: Click on a therapist’s name in order to access their profile.

2: If you are having trouble with Psychology Today, feel free to check out these alternative resources.

The Association for Behavioral and Cognitive Therapies has a CBT therapist search tool (Note: sleep disorders are listed on the website, but not insomnia, concussions, post-concussion syndrome, or brain injury).
You can search for a behavioral sleep specialist on the homepage of the Society of Behavioral Sleep Medicine. Click on “Provider Search” in the navigation bar.
The Sleep Foundation has an article on how to choose and find different treatments for insomnia, including CBT.
You can also research rehabilitation clinics in your area. These clinics routinely work with patients suffering from persistent concussion symptoms and other forms of TBI.

Online Therapy and Apps

If you are unable to see a CBT-practicing therapist in-person or would simply prefer to seek out CBT through an online provider, there are currently many options available. While some of these resources require a fee, others are free of charge. Explore the list below for more detail on specific resources.

Fee-based

Talkspace allows you to communicate with a therapist via text messages, audio messages, as well as picture and video messages in a private chat room. Talkspace markets itself as a more affordable and convenient option for therapy.
BetterHelp is the largest online counseling platform worldwide. They provide convenient and affordable access to licensed therapists via text messaging as well as audio and video conferencing.
Sleepio is a CBT-based sleep improvement program intended to help overcome insomnia. The program has proven effective and is recommended by Dr. Charles Czeisler, Professor of Sleep Medicine at Harvard Medical School.
Somryst is a CBT-I app intended to treat patients ages 22 and older with chronic insomnia. Like Sleepio, Somryst has proven effective and is recommended by Dr. Charles Czeisler, Professor of Sleep Medicine at Harvard Medical School.

Free of charge

CBT-i Coach is a CBT-I app developed by the U.S. Department of veterans affairs. The app is intended to augment, rather than replace, therapy from a healthcare professional. However, the app can still be used on its own. You can download the app for free on iTunes or Google Play.
Woebot is an app that provides CBT through artificial intelligence (AI) chatbot. A study of Woebot published in JMIR Publications found that the chatbots “appear to be a feasible, engaging, and effective way to deliver CBT.”
Wysa is an app that provides CBT through an AI chatbot. The app was rated by ORCHA as the best app for health and care in 2020.
The Path to Better Sleep course is an online CBT-I course designed to help veterans with sleep problems.

Choosing the therapist who is right for you

When attempting to find a therapist who practices CBT, you may feel inclined to choose the therapist with the best credentials or reputation. However, research has shown that it is more important to seek out a therapist with whom you can build a good working relationship. In other words, the key component of successful therapy is the connection between you and your therapist; if you feel understood by your therapist, there is a greater chance that the therapy will remedy your symptoms.