Australian Clinical Practice Guideline for the non-pharmacological management of psychosocial difficulties in adults with moderate-to-severe traumatic brain injury

Quick reference guide

Psychosocial difficulties including mental health, behaviour, and social-cognitive difficulties, are common after moderate-to-severe TBI and can substantially affect relationships, employment, community participation, everyday activities and quality of life. The Guideline was developed de novo for the Australian context as comprehensive guidance focused specifically on psychosocial treatment was lacking. Its recommendations were informed by systematic reviews, lived experience and clinical expertise, and developed using the GRADE approach. The Guideline recommendations were approved by the National Health and Medical Research Council in September 2025.

Key recommendations

Recommendations are organised across the three psychosocial domains of mental health, behaviour and social cognition. The summary below reproduces all 16 recommendations from the main guideline. Recommendation type is shown in parentheses. The recommendations are to be interpreted in the context of good practice points. A summary of these good practice points is also provided below. Please refer to full guideline for detailed good practice points specific to each recommendation.

Mental health

Anxiety, depression, psychological distress, and suicidality

Recommendation 1. For adults with moderate-to-severe TBI, the GDG suggests Cognitive Behavioural Therapy may be offered to treat mental health difficulties (specifically, anxiety, depression, psychological distress, and/or suicidality). (Conditional evidence recommendation)

Recommendation 2. For adults with moderate-to-severe TBI, the GDG suggests that Acceptance and Commitment Therapy may be offered to treat mental health difficulties (specifically anxiety, depression, and/or psychological distress). (Conditional evidence recommendation)

Alcohol and substance misuse

Recommendation 3. For adults with moderate-to-severe TBI, the GDG suggests that psychological interventions, specifically health education about alcohol and substance misuse, motivational interviewing, and peer mentoring, may be offered to treat alcohol and substance misuse. (Conditional evidence recommendation)

Sexual dysfunction

Recommendation 4. For adults with moderate-to-severe TBI, the GDG suggests that Cognitive Behavioural Therapy, may be offered to treat sexual dysfunction. (Consensus recommendation)

Sleep difficulties/insomnia

Recommendation 5. For adults with moderate-to-severe TBI, the GDG suggests that Cognitive Behavioural Therapy may be offered to treat sleep difficulties/insomnia. (Conditional evidence recommendation)

Behaviour*

Physical and verbal aggression

Recommendation 6. For adults with moderate-to-severe TBI, contingency-based behavioural interventions# may be offered to manage verbal and/or physical aggression. (Consensus recommendation)

Recommendation 7. For adults with moderate-to-severe TBI, behaviour support interventions may be offered to manage verbal and/or physical aggression. (Consensus recommendation)

Recommendation 8. For adults with moderate-to-severe TBI, cognitive behaviour therapy may be offered to manage verbal and/or physical aggression. (Consensus recommendation)

Sexualised behaviour

Recommendation 9. For adults with moderate-to-severe TBI, behaviour support interventions may be offered to manage sexualised behaviours of concern. (Consensus recommendation)

Inappropriate social behaviours

Recommendation 10. For adults with moderate-to-severe TBI, behaviour support interventions may be offered to manage inappropriate social behaviours. (Consensus recommendation)

Apathy

Recommendation 11. For adults with moderate-to-severe TBI, behaviour support interventions may be offered to manage apathy. (Consensus recommendation)

Recommendation 12. For adults with moderate-to-severe TBI, psychological interventions (specifically, motivational interviewing, goal setting, values-based activity scheduling, and meta-cognitive techniques) may be offered to manage apathy. (Consensus recommendation)

Poor Treatment Adherence

Recommendation 13. For adults with moderate-to-severe TBI, behaviour support interventions may be offered to manage poor treatment adherence. (Consensus recommendation)

*Management of behaviours in this domain pertains to efforts to increase prosocial behaviours or reduce the occurrence of challenging behaviours through treatment and/or the adoption of management strategies.

# Contingency-based behavioural interventions include various differential reinforcement strategies, namely differential reinforcement of other behaviour, low rates of responding or an alternative behaviour; token economies; extinction procedures such as situational time-out (e.g., TOOTS, time-out on the spot) and response cost time out.

Social Cognition

Emotion perception and theory of mind

Recommendation 14. For adults with moderate-to-severe TBI, the GDG suggests that social-cognitive interventions may be offered to treat difficulties with emotion perception and/or theory of mind. (Conditional evidence recommendation)

Empathy

Recommendation 15. For adults with moderate-to-severe TBI, the GDG suggests that evidence-based interventions that target other social-cognitive difficulties (specifically, emotion perception and theory of mind) may be offered to treat difficulties with empathy as they address some phenomena that are overlapping with empathy. (Consensus recommendation) 

Alexithymia

Recommendation 16. For adults with moderate-to-severe TBI, the GDG suggests that specific social-cognitive interventions that employ emotional self-awareness methods may be offered to treat difficulties with alexithymia. (Consensus recommendation) 

Summary of good practice points

• Interventions should be tailored in view of any cognitive, communication and emotion-regulation difficulties. Adaptations may include simplified material, written or visual aids, additional support, increased treatment dose, booster sessions, environmental supports and integration with cognitive or multidisciplinary rehabilitation.
  
  
• Ensure clinicians have appropriate training, competence and understanding of both the intervention and its adaptation for people with moderate-to-severe TBI.
  
  
• Use valid and reliable assessment methods to inform formulation, treatment planning and outcome monitoring, with measures that are accessible and appropriate to the person’s cognitive, communication, cultural and linguistic needs. Behavioural interventions should use clear operational definitions and observational recording where relevant.
  
  
• Consider the person’s cultural, religious and demographic background, life circumstances and context when assessing difficulties, judging outcomes and selecting or delivering interventions. The supplementary chapters that accompany this Guideline provide further guidance for First Peoples, people from culturally and linguistically diverse backgrounds, and rural and remote communities.
  
  
• Use person-centred formulation and goal setting. For behavioural difficulties, functional analysis/case formulation should generally guide intervention planning; relevant differential diagnoses, barriers and enablers, insight/awareness, medical factors and co-occurring difficulties should also be considered as applicable.
  
  
• Involve close others where appropriate and with the person’s permission, particularly when cognitive impairment affects treatment engagement or generalisation. Close others may benefit from psychoeducation, training and support; their capacity, safety, confidence, stress and mood should be considered and monitored.
  
  
• The use of restrictive practices in behaviour support interventions such as physical, mechanical, environmental or chemical restraint to reduce/manage behaviours of concern, should be used only if necessary to prevent harm to self or others. Movement toward a zero-use policy is advised and compliance with relevant laws is essential. If used, restrictive practices should be time-limited, move swiftly toward a pathway of elimination, and be used only when other options (e.g., de-escalation procedures) to manage behaviours of concern have been exhausted.
  
  
• Use multidisciplinary collaboration and referral where appropriate and select treatment modalities (including telehealth where useful) according to the individual’s needs, preferences, goals and circumstances.

Target audience

The Guideline is intended for healthcare professionals across the care continuum, including psychiatrists, rehabilitation physicians, psychologists, occupational therapists, speech pathologists, social workers, general practitioners and lifestyle support workers. It is also relevant to multidisciplinary teams, policy and funding bodies, advocacy organisations, and other stakeholders involved in TBI care.

Implementation considerations

Recommendations should be interpreted together with their accompanying Good Practice Points and applied within the clinician’s scope of practice. Treatment decisions should prioritise the autonomy, goals and preferences of the person with TBI, and multidisciplinary collaboration or referral should be used where required. Clinicians should also consider relevant legislation, organisational policies, health service standards and National Disability Insurance Scheme (NDIS) requirements where applicable.

Additional related documents

Specific group supplementary chapters

First Peoples and the TBI clinical practice guideline: a commentary on its application. In Australian Clinical Practice Guideline for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Evans, J., Cullen, J., Smith, P., Armstrong, E., Emery, H., and Honan, C.A., on behalf of the TBI Psychosocial Guideline Development Group (2026). University of Tasmania. View chapter.

Considerations for people from culturally and linguistically diverse backgrounds. In Australian Clinical Practice Guidelines for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Ponsford, J., Workneh Wolde, K., and Shah, M. F., on behalf of the TBI Psychosocial Guideline Development Group. (2026). University of Tasmania.

Considerations for rural and remote Australians. In Australian Clinical Practice Guideline for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Adams, B., Honan, C.A., Emery, H., Simpson, G., on behalf of the TBI Psychosocial Guideline Development Group. (2026). University of Tasmania.

Supporting guideline documents

Administrative Report. In Australian Clinical Practice Guideline for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Honan, C.A., Emery, H., Simpson, G., Carrier, S., Gertler, P., McDonald., S., Ownsworth, T., Douglas, J., Wearne, T., Morgan, A., Ponsford, J., Evans, J., Adams, B., Wong, D., on behalf of the TBI Psychosocial Guideline Development Group. (2026). University of Tasmania.

Technical Report. In Australian Clinical Practice Guideline for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Honan, C.A., Emery, H., Simpson, G., Carrier, S., Gertler, P., McDonald., S., Ownsworth, T., Douglas, J., Wearne, T., Morgan, A., Ponsford, J., Evans, J., Adams, B., Wong, D., on behalf of the TBI Psychosocial Guideline Development Group. (2026). University of Tasmania.

Dissemination Plan. In Australian Clinical Practice Guideline for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Honan, C.A., Emery, H., Simpson, G., Carrier, S., Gertler, P., McDonald., S., Ownsworth, T., Douglas, J., Wearne, T., Morgan, A., Ponsford, J., Evans, J., Adams, B., Wong, D., on behalf of the TBI Psychosocial Guideline Development Group. (2026). University of Tasmania.

Public Consultation and Expert Review Summary. In Australian Clinical Practice Guideline for the Non-Pharmacological Management of Psychosocial Difficulties in Adults with Moderate-to-severe Traumatic Brain Injury. Honan, C.A., Emery, H., Simpson, G., Carrier, S., Gertler, P., McDonald., S., Ownsworth, T., Douglas, J., Wearne, T., Morgan, A., Ponsford, J., Evans, J., Adams, B., Wong, D., on behalf of the TBI Psychosocial Guideline Development Group. (2026). University of Tasmania.

Systematic reviews

Psychosocial interventions for mental health difficulties following moderate-to-severe traumatic brain injury: A systematic review and meta-analysis. Carrier, S., Wong, D., Emery, H., Gertler, P., Simpson, G. K., Zuber, O., Ownsworth, T., McDonald, S., Douglas, J., Wearne, T., Honan, C.A. & Guideline Development Group. (2026). Neuropsychological Rehabilitation, 1-50. 

Psychological interventions for challenging behaviours following moderate-to-severe traumatic brain injury: A systematic review, meta-analysis and GRADE evaluation. Gertler, P., Emery, H., Doubleday, J., Tate, R. L., Filipčíková, M., Honan, C. A., Wong, D., Carrier, S., Ownsworth, T., Douglas, J., McDonald, S., Wearne, T., Simpson, G.K. & Guideline Development Group. (2026). Neuropsychological Rehabilitation, 1-44. 

Treatments for social cognitive difficulties following moderate-to-severe traumatic brain injury: A systematic review and meta-analysis. Emery, H., McDonald, S., Wong, D., Carrier, S., Gertler, P., Simpson, G., Ownsworth, T., Douglas, J., Wearne, T., Skromanis, S., Honan, C.A. & Guideline Development Group. (2026). Neuropsychological Rehabilitation, 36(5), 1030-1072. 

Other Papers

Defining the scope of clinical practice guidelines for managing psychosocial difficulties following moderate-to-severe traumatic brain injury. Emery, H., Wong, D., Simpson, G., Gertler, P., Carrier, S., McDonald, S., Ownsworth, T., Douglas, J., Wearne, T., Morgan, A.T,, Tate, R., Zuber, O., Skromanis, S., Doubleday, J., Honan, C.A. on behalf of the TBI Psychosocial Guideline Development Group (2026). Brain Impairment.