Restoring Emotional Self-Awareness After Brain Injury: Research Explores Novel Approach

Many patients with traumatic brain injury (TBI) experience persistent anxiety, depression, anger, and difficulty managing stress—symptoms that can linger long after the initial injury. A systematic review found that 54% of individuals with chronic TBI were diagnosed with Axis I disorders, with 36% and 43% having clinical levels of anxiety and depression, respectively.¹ Studies in samples who were at least 1 year post-TBI also show that about one-third experience problematic anger and 18% have posttraumatic stress.² While these challenges are common following TBI, they often are difficult to treat, particularly when individuals struggle to recognize and describe their own emotional states.

Central to the difficulties faced by many with TBI is alexithymia, a condition characterized by difficulty recognizing, labeling, describing, and differentiating emotions. Studies suggest the prevalence of alexithymia in individuals with TBI is approximately 15%.³ While this number may seem low, based on annual global incidences of TBI, it translates to 10,350,000 new cases per year of individuals who will endure a TBI and may experience elevated levels of alexithymia. Research shows that alexithymia 1 year after TBI predicts lower resilience, worse emotional functioning, and suicidal ideation the following year.⁴

Individuals with alexithymia may feel overwhelmed, stressed, or angry, but lack the clarity needed to understand what they are actually feeling or why. Without that clarity, engaging effectively in psychotherapy can be challenging, and emotional distress may manifest instead as anxiety, depression, posttraumatic stress symptoms, or problematic anger.

Building Emotional Self-Awareness Teletherapy

A new intervention, Building Emotional Self-awareness Teletherapy (BEST), aims to address this foundational problem of alexithymia by helping individuals with TBI—both civilians and military service members—bolster their emotional self-awareness, an essential step toward psychological health and resilience. The premise is straightforward. When people can correctly identify what they are feeling, they are better equipped to regulate emotions, cope with stress, and engage meaningfully in treatment. In this way, BEST is designed as a psychotherapy primer—particularly for individuals with alexithymia who may not benefit fully from traditional therapy.

BEST is an 8-session, 1-on-1 emotional self-awareness training program, delivered by a trained instructor over 60- to 90-minute sessions. Despite the term teletherapy sometimes being used to describe its format, BEST should not be considered psychotherapy. It does not seek to change emotions, challenge thoughts, or treat psychiatric diagnoses. Instead, BEST focuses on teaching participants to accurately recognize and label emotions.

BEST targets several fundamental capacities that support emotional health and resilience:

• Working through unpleasant feelings and emotional distress
• Regulating emotions
• Coping and resilience
• Interpersonal functioning, including emotional intelligence and social closeness

To achieve these outcomes, the program directly addresses 4 core components of emotional awareness:

• Attention and detection: noticing the presence of emotions and becoming more sensitive to emotional signals
• Clarity: knowing exactly what one is feeling, using specific emotional labels, and distinguishing among emotions
• Breadth: expanding the range of emotions a person can recognize and experience
• Emotional perspective-taking: understanding life events through an emotional lens

The first 4 sessions focus on psychoeducation and skill-building:

• Session 1 introduces the value of emotional awareness, contrasts vague vs specific emotional labels, and begins building emotional vocabulary.
• Session 2 expands emotional vocabulary and teaches participants to differentiate emotions from thoughts, behaviors, and physical sensations.
• Session 3 focuses on recognizing bodily cues as signals of emotions and linking those cues to emotional labels.
• Session 4 helps participants identify multiple co-occurring emotions, reducing confusion often described as feeling “overwhelmed” or “stressed,” and recognizing emotions that may underlie anger.
• Sessions 5 through 8 shift to implementation exercises, using emotionally evocative video scenarios that allow participants to practice identifying, labeling, and differentiating emotions in real-world contexts.

BEST is designed for adults with a history of TBI, ranging from mild to severe, who demonstrate elevated alexithymia (ie, score at least half of standard deviation above the norm on a standardized measure of alexithymia, such as the Toronto Alexithymia Scale-20⁵ or the Perth Alexithymia Questionnaire.⁶

While many individuals with alexithymia also experience clinically significant anxiety, depression, or PTSD, BEST is not an assessment tool and does not diagnose or treat these conditions. Instead, it addresses emotional processing deficits that may contribute to or exacerbate such disorders.

Research

To date, BEST has been evaluated in 3 studies. The first study was a single arm pilot trial in 17 participants who had a moderate to severe TBI and comorbid alexithymia (as measured by the the Toronto Alexithymia Scale 20; TAS-20).⁷ Findings were promising, supporting acceptability and feasibility. This led to the next study, which was a randomized waitlist-controlled trial involving 44 civilians with moderate to severe TBI.⁸ In this study, to be eligible participants had to be at least 1 year post-injury; have scored at least a half standard deviation above cited norms on the TAS-20; be free of major psychiatric diagnoses (eg, schizophrenia), or any other neurological disorder or injury that could impact emotional functioning (eg, autism, dementia, stroke). For practicality purposes, participants were allowed to be on medications and/ or participating in psychotherapy at the time of the study. Participants were randomly assigned to the intervention (n=20) or waitlist control (n=24) arm. Those receiving the intervention (then called TREAT and delivered in person, but otherwise the same as BEST) demonstrated significantly lower levels of alexithymia (TAS-20), emotion dysregulation (Difficulty with Emotion Regulation Scale), anxiety (Generalized Anxiety Disorder-7), and depression (Patient Health Questionnaire-9) and greater levels of emotional awareness (Levels of Emotional Awareness Scale) compared with those in the waitlist control group, after controlling for baseline performance.

Most recently, the developers of the interventions explored BEST in military service members and civilians who had endured a mild TBI at least 6 months prior to the trial. This study was designed as a single arm feasibility trial, as it was uncertain how military service members would respond to training that focused on emotional awareness and labeling; additionally, it was the first time the intervention was being delivered remotely.⁹ Once again, results were promising, showing high satisfaction, including military service members. Furthermore, not only did the results show an improvement in alexithymia, emotion regulation, anxiety and depression, positive changes were also observed in posttraumatic stress (PCL-5) and resilience (Brief Resilience Scale) Beyond these average improvements, results also indicated that 75% and 70% of participants improved by ≥0.5 SD on the TAS-20 and Levels of Emotional Awareness Scale (co-primary outcomes) and 60% on the Difficulty with Emotion Regulation Scale (secondary outcome). On the Patient Global Impression of Change, 83% of participants reported noticeable positive changes in their emotional functioning.

One combat veteran who experienced multiple TBI from combat deployments, training exercises, and exposure to blasts found value in BEST. His first TBI occurred in 2009 and the most recent was in 2020, about 3 years prior to him joining the study. Before enrolling in the study, he received treatments focusing on cognition, healthy living (eg, better sleep and eating habits), as well as mental health treatment. However, at the time, he did know what he was feeling or how to communicate what he was experiencing.

The service member reported joining the study because, “My wife began noticing I was developing a ‘quick fuse’ with external influences and reacting in a different fashion, such as clenched jaws and grinding of teeth. She equated it to me turning into the ‘Hulk’ when I would get emotionally overstimulated,” the service member said. “For happy or joyous events, I would have very muted emotional reactions—limited smiling or lack of excitement or joy. In her eyes, it seemed like I was always mad or on the brink of an emotional outburst.” The service member called the BEST intervention valuable.

“The biggest help the BEST program provided me was tapping into emotional intelligence and understanding the impact emotions had on external responses. Too often my instinctive response was anger. I didn’t realize the buildup of compounding emotions,” he said. “After completing the program, I can now quantify and apply a name to the emotion I’m feeling and triage my response. It also allows me to communicate to others where I am emotionally.”

Recently, the BEST investigators were awarded a $4.3 million dollar grant from the Department of Defense to conduct a larger, more rigorous trial to determine the efficacy of BEST. This multi-site trial is being led by Neumann at Hackensack Meridian JFK Johnson Rehabilitation Institute. Other sites include Indiana University; National Intrepid Center of Excellence (NICoE); Navy Medical Center Camp Lejeune; Minneapolis Veterans Affairs Hospital; and University of South Florida.

This newly funded, multi-center trial led by JFK Johnson Rehabilitation Institute will further evaluate BEST in a randomized controlled trial (RCT) for military service members (n=76) and civilians (n=76) with mild TBI. This RCT will compare BEST with another program called Brain Health Guidance (BHG), which teaches a holistic approach, focusing on building healthy habits to improve brain functioning and well-being (eg, healthy eating, exercising, sleeping). Half of the participants will be randomized to BEST and the other to BHG. The study will explore whether the outcomes from the previous study will hold up against another intervention, and whether gains will be maintained up to 6 months post-training. Results of this 4-year study are expected to be available at the end of 2029.

Concluding Thoughts

It is important to note that while many individuals who participated in BEST training improved their emotional functioning with this treatment on its own, investigators do not believe it is a “magic bullet” and nor should it be a standalone solution. Rather, the expectation is that BEST builds a foundation upon which other treatments can leverage to be more effective when treating individuals with alexithymia. For instance, it is the hope that patients with emotional distress and elevated levels of alexithymia can get BEST training before starting traditional psychotherapeutic approaches, such as acceptance and commitment therapy, cognitive behavioral therapy, cognitive processing therapy, or dialectal behavioral therapy. While these other treatments touch upon emotional awareness and naming of emotions, it is not the central focus. This means that some patients without these fundamental skills may not continue or fully benefit from a course of counseling or psychotherapy.

Dr Neumann is the manager of brain injury research at Hackensack Meridian JFK Johnson Rehabilitation Institute.

This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs, the Defense Health Agency J9, Research and Development Directorate, and the U.S. Army Medical Research Acquisition Activity at the U.S. Army Medical Research and Development Command, through the Traumatic Brain Injury and Psychological Health Research Program under Award No. W81XWH-22-2-0064 and HT9425-25-1-0889. Opinions, interpretations, conclusions, and recommendations are those of the author and are not endorsed by the Department of Defense.

References

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