The Challenges and Rewards of Therapeutic Work with Brain-Injured Clients By Tom Medlar, LMHC on 10/12/23 - 8:19 AM

Over the course of my career, I have worked with many people who sustained brain injuries. In the 1980s, I worked in a brain injury rehab program set in a nursing home, then in private practice during the 1990s. For many years since, I have been an employed psychotherapist in nursing homes.

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In my experience, those who have acquired a head injury typically display irritability and quick flashes of verbal anger — aspects of “organic personality change.” The individual may be more impulsive, acting prior to thinking about likely consequences, might show less awareness of social boundaries, and have problems with short term memory. Sharing some of their stories will offer you a glimpse into some of the challenges and opportunities I’ve experienced in working with these clients.

Case Illustrations of Clinical Work with Brain-Injured Clients


One of the clients I met while working at an in-patient brain injury rehab program was Douglas, who was in his early twenties, and was injured riding his motorcycle while intoxicated. Anger management was a focus of therapy; he often expressed anger over being injured, and at his father for bringing him to the rehab program. One additional task of therapy was to assist him in formulating a new sense of personal identity — as he was not who he had been, and not yet who he was becoming, but was feeling lost and overwhelmed somewhere in the middle. Another goal was to strengthen his motivation to maintain sobriety in the future.

During a psychotherapy session one day he unexpectedly said, “Getting a brain injury was probably the best thing that could have happened to me.”

“Tell me why you say that, Douglas,” I asked.

“Because otherwise I don’t think there was any way I could have stopped drinking.” But that attitude and outcome are not achieved by all people.


During the time I was working in private practice, I also provided psychotherapy and consultation with a statewide head injury program in Massachusetts. That was where I met Brandt, who had an alcohol use disorder, and, over time, had acquired three different brain injuries because he was not able to stop drinking.

Brandt had his first head injury on a construction job site when he was under the influence of alcohol. To others in his life, Brandt appeared to have a friendly and outgoing personality. Yet the overly friendly, and often tactless and joking manner he displayed represented “changes of personality” associated with frontal lobe executive dyscontrol due to his first brain injury — when a piece of work equipment struck him in the forehead.

Because of his frontal lobe dysfunctions, Brandt found it difficult to anticipate or perceive likely consequences of his actions, and he might brush off or disregard cautions and advice offered to him by me or others in his life.

His second injury occurred when he had been drinking one night with friends. They ran out of beer, and Brandt jumped into his Volkswagen Beetle and sped off to buy more. He drove too fast around a curve in the road, the car rolled over and he was ejected from the car. He landed unconscious on the ground in the dark.

Brandt awakened and lifted his head, and immediately in front of his face was a gravestone. He had landed in a graveyard! How could there have been a more pointed and dramatic message about where his drinking would lead him? Nonetheless, he continued drinking until he had a third brain injury that resulted in significant disability, and he was moved into a group home for daily care.

Mrs. Kelly

During the period when I worked in private practice and was offering head-injury-related consultations, I went to Chicago for a co-presentation at a brain injury conference. I spoke about brain injury from a professional point of view, and the co-presenter, Mrs. Kelly, talked about the personal experience of living with a brain injury. Driving home one day, Mrs. Kelly had been struck and injured by a drunk driver.

During our presentation, Mrs. Kelly spoke of the life losses and challenges that had resulted from her injury including relearning to walk, talk, conduct daily tasks, the gains that resulted from her rehab, and from the continuing support of her husband, who had accompanied her to Chicago who was always in her company.

I spoke of the common goals and aims of brain injury rehab, and about the work of individual therapy, group therapy, and family or marital therapy following a brain injury. During our talk, we also shared a particularly poignant background to our shared experiences, because Mrs. Kelly had earlier been one of my teachers in high school. Using her characteristic humor, Mrs. Kelly once said to me, “I used to get mad that I keep forgetting things; but then I realized, why get mad, in a few minutes I’ll forget what I was mad about.”


My mother-in-law, Rose, became ill with dementia and spent the last months of her life in a nursing home close to where we live. She and I sat in a small dining room during a visit one day a few years ago. A nurse’s aide across the room spoke irritably to a female resident in a wheelchair.

Rose watched, and when the aide left the room, she shook her head and said, “I hate it when they talk that way. She spoke to her like she was a has-been. She’s not a has-been, she’s a have-been.”

“That’s such a wise and beautiful thing to say, Rose,” I remarked.


Around that time, I had long been working as an employed psychotherapist in nursing homes, and I was then seeing Ronald for psychotherapy in a different nursing home from where Rose resided. Ronald had been a scientist working at a prominent institute in California, and he drove a red convertible sports car — but sometimes too fast, and he sustained a brain injury in a collision.

What remaining family he had was in the Boston area, and so he found himself at a nursing home outside of Boston. Ronald was depressed and angry. He mostly stayed in his room, reading and listening to classical music. He would make derogatory comments about the other residents and the staff.

I told Ronald the story of the wise comment by my mother-in-law, and I challenged him to conduct a scientific experiment over the coming week: to go about the unit and research who the other residents have been in their lives.

The next week as I walked onto the unit, Ronald approached me holding a small notepad. Referring to notes he’d written, and pointing to different residents, he excitedly recounted things he had learned about them.   


Conducting psychotherapy with brain-injured clients has typically involved some modifications to my typical approach. It has been important for me to remain alert to the psychological consequences of organic brain dysfunction. My approach with these particular clients has been more educational and directive as opposed to my typical non-directive one; teaching about the effects of the injury and providing behavioral guidance and specific suggestions for social functioning. The information I provide in treatment is more concrete, and offered in smaller bits, with frequent repetitions to aid retention and recall.

I have found it to be enormously gratifying to work with these clients and encourage my colleagues to welcome rather than avoid these opportunities. It allowed me the chance to work with clinicians who taught me to appreciate the psychiatric effects of medical conditions. The work also allowed me opportunities to make a positive difference in the lives of persons who had been severely injured, and in the lives of some family members who had been devastated by the injury to their loved one. 

File under: The Art of Psychotherapy, A Day in the Life of a Therapist