Goal- and Client-Directed Interventions for Adults With Traumatic Brain Injury (2013–2020)

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for effectiveness of interventions that address psychosocial, behavioral, and/or emotional skills to improve social participation and other everyday activities and occupations for persons with TBI?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is goal- and client-directed interventions to improve psychosocial outcomes for adults with traumatic brain injury.

Clinical Scenario

Traumatic brain injury (TBI) is a leading cause of death and disability that affects about 2.5 million Americans each year. Although the symptoms and severity of TBI vary among people, psychosocial, behavioral, and emotional changes are common and significantly impact successful and satisfying community participation. The increased prevalence of psychological problems in people with TBI, including depression, anxiety, suicidal ideation, substance abuse, sleep disorders, and posttraumatic stress disorder, highlights the need for appropriate and empirically based interventions. Psychological issues are commonly cited among those unmet rehabilitation needs (Mahoney et al., 2021), and these directly fall within occupational therapy’s scope of practice.

Fundamental to occupational therapy practice is the engagement of clients and families in goal setting to develop goals that are personally meaningful and relevant (Prescott et al., 2019). Collaborative goal setting is consistent with the client-centered philosophy of occupational therapy and has been found effective in improving occupational performance and psychosocial functioning in people with TBI (Doig et al., 2011). Occupational therapy practitioners have knowledge, skills, and training in assessing and treating psychological impairments to improve occupational performance following TBI, making their role in the rehabilitation process vital across the continuum of recovery.

Summary of Key Findings

Three articles were included in the review related to interventions focusing on client-selected interventions or activities. These three articles were further divided into two categories, depending on whether goal setting or goal management was central to the intervention (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).

Bottom Line for Occupational Therapy Practice

Occupational therapy practitioners engage clients in goal-directed and personally meaningful occupations to facilitate successful and satisfying community participation. There is growing recognition both within and outside occupational therapy for the importance of collaborative goal setting in TBI rehabilitation (Bogner et al., 2019; Grant & Ponsford, 2014). Involving clients and families in the goal-setting process has been associated with increased motivation to participate in rehabilitation along with improved understanding of client and caregiver roles relative to the rehabilitation process. Collaborative goal setting facilitates interventions that support engagement in meaningful occupations, which is also fundamental to occupational therapy practice. Moderate strength of evidence supports interventions involving collaborative goal setting, whereas low strength of evidence exists for client-driven community engagement using volunteer experiences. Evidence from this review suggests that one-to-one goal-directed sessions may be conducive to increased community participation and social relations. Group interventions provided opportunities for additional feedback and support, contributing to improvements in executive functioning that can be difficult to address in individual sessions. The use of cuing and/or homework between treatment sessions can remind participants of established goals and the agreed upon criteria for goal attainment. Community-based activities, such as volunteering, whereby participants actively select personally meaningful volunteer settings, may increase socialization and perceived self-efficacy.