Mental Health and Concussion

February 2023 will mark 15 years since my introduction to concussions. After deciding that sacrificing my brain health was not worth finishing my last season as a Division I soccer player, it was time to figure out life after sport. Based on what we know now, my recovery trajectory could have been a lot shorter, but there was no one to fault for us not understanding that my prolonged healing was partially due to my history of chronic headaches, anxiety, and depression. Fortunately, I underwent therapy with a psychologist (actually, she was an intern at the time) who was researching biofeedback and neurofeedback as concussion treatment. Within a few months of daily practice of these techniques, I was more stable and started the journey to figuring out my new normal.

Since then, I stumbled through grieving what could have been, re-organizing my identity, and discovering new things about myself. In 2012, I started working towards my doctorate in clinical psychology. One month before my graduate program started, I was rear-ended by a double-trailer semi-truck and sustained another concussion. My first experience had vestibular ramifications and this one was no different. After completing occupational therapy, physical therapy, and vision therapy, I knew it was time to re-engage in psychotherapy, something I had done throughout my life. As I attempted to find a therapist, I quickly realized it was going to be difficult to find a provider who was familiar with concussions. It seemed they were either freaked out that I had ever had a brain injury or avoided talking about it altogether.

As a result of my experiences and what I read in research, I worked to gain years of experience in neuropsychology, rehabilitation psychology, and sports psychology. I capped off my training in the Department of Rehabilitation Medicine at Mount Sinai Hospital in New York City where I worked alongside physicians, nurses, physical therapists, occupational therapists, and speech therapists. Together, we supported people in recovery after moderate to severe TBI, stroke, other acquired Brian injuries, and spinal cord injuries. As you can imagine, this experience was invaluable and was vital to understanding the complex nature of injuries to the central nervous system (i.e., brain and spinal cord).

While I was in the midst of learning and growing as a clinician, I continued to follow media coverage about concussion. Their twisted portrayal of the research seemed to fall into two camps: concussion was not something to get worked up about or concussion meant life-altering and irreparable brain damage (i.e., CTE). Regardless of the angle, the articles I was reading in the most influential media outlets all lacked the very things that are crucial to recovery: hope and support.

As I began working as a clinician outside the hospital setting, I realized there was a lack of awareness in the mental health profession about up-to-date information regarding concussion. This is not to take a jab at my colleagues, the reality is that clinicians are pulled in many different directions and have a lot of information to consider when developing a treatment plan. So, unless it is an area of specialty or passion, most generally trained clinicians are not going to be knowledgable about concussions. My sense is that they believe that this is not something they will see unless they work with athletes or in hospitals. They may also think concussions do not require psychological treatment, which is inherently untrue. Anything health-related should include some emotional component to healing because the mind and body are the same thing, despite how much we try and pretend otherwise.

As I work toward educating other clinicians on psychological factors related to concussion, it is also important for consumers to understand how their symptoms are intertwined with emotions.   When it comes to concussion, there are several things to consider. First, mood problems often result from disturbance to the body’s homeostasis (i.e., illness and injury). Then there is the disruption to your daily routine and not meeting expectations about being “productive.” An incredibly important consideration is that depression, anxiety, ADHD, headaches, and many more conditions share symptoms with concussions. On the very surface depression can cause fatigue and difficulties sleeping. Anxiety often shows up with irritability and insomnia. ADHD by definition means one is inattentive and may also be forgetful, disorganized, and impulsive. Headaches are associated with cognitive and emotional challenges, especially if they are chronic. Just from these few sentences it is easy to see how quickly these symptoms could be attributed to concussion if there was a hit to the head. To complicate matters further, we can’t identify whether symptoms are from these pre-existing diagnoses, from a concussion, or are a combination of both (unless you are the rare person who doesn’t have any medical or emotional challenges before hitting your head, and in your case, kudos!).

There are also other considerations like whiplash, cervical spine injuries, vestibular injuries, and autonomic nervous system dysregulation that have to be considered and ruled out as these are conditions that present with similar symptoms to concussions, but require different treatments. This is not to say that long-term effects can’t happen, but it is far less likely unless you happen to be an NFL player from the 80s as the tremendous number of hits they took without proper equipment has been linked to long-term problems. In fact, long-term symptoms are actually often the result of emotional consequences (e.g., anxiety, depression) of concussion rather than un-healed brain damage. That said, I am wary of giving absolutes as this information is based on what research is showing us right now. It has changed a lot in the last 5 years, and I anticipate this trend to continue because that’s how science works 😊

As you can imagine, if mental health professionals are not educated on concussions they are just as susceptible to continuing to follow old information, taking in misinformation as truth, and believing sensationalized headlines as the rest of the population. The reality is, psychotherapy can be incredibly helpful for concussion recovery. While there are many benefits, I’ll highlight a few here. First, coping skills reduce anxiety which reduces blood pressure that can lessen headaches. Then, re-organizing how you think about and understand your symptoms can help you figure out how to make them work for you instead of feeling at their mercy. Perhaps most importantly, building acceptance of your current situation while maintaining optimism strengthens autonomy and feelings of hope for the future while reducing helplessness, worthlessness, and worry that can linger after prolonged recovery.

 Many of you have probably tried therapy and found it unhelpful. Perhaps you had an obviously unpleasant experience because your clinician unintentionally invalidated your experience and the impact of your symptoms. Perhaps you felt validated, but your therapist failed to hold a space for hope. Support and hope are keys to recovery! Finding a therapist who is knowledgeable about concussion  and is not afraid for your future can be challenging, but it IS possible!

Understanding the complexity of concussion recovery from a personal and professional perspective allows me to offer comprehensive care to my clients, educate other clinicians, and offer guidance to those who are in recovery.  Tune in to the Concussion Resource Center Education Series on January 26, 2023, at 5:30pm MST to learn more about the emotional impact of concussions. I’ll offer tips for how to find a knowledgeable mental health care provider to help you during your recovery, identify pink flags that suggest changing therapists might be a good idea, and recognize red flags for when it’s without question time to switch things up. I look forward to meeting you then!

Samantha Sanderson Brown, PsyD, HSP

Licensed Clinical Psychologist