What About Cognitive Rehabilitation Therapy?

What About Cognitive Rehabilitation Therapy?

For people with brain injury and their families, cognitive problems may be the greatest barrier to returning to “normal” life. These difficulties involve memory, attention, social behavior, safety judgment, and planning and carrying out future actions. They affect a person’s ability to care for himself, keep appointments, complete tasks, or interact with people appropriately. At stake is the person’s ability to succeed at work, school, or home. Without treatment for cognitive problems, the long-term effects can be devastating.

What is CRT?

Cognitive Rehabilitation Therapy (CRT) is a broad term used to describe treatments that address the cognitive problems that can arise after a brain injury. Given the wide range of symptoms and severity of cognitive problems in individuals with brain injury, CRT does not refer to a specific approach to treatment. Although physical injuries, or speech or swallowing problems are typically covered by insurance, some health insurers deny coverage for CRT. Struggles with reimbursement may be due in part to the “invisible” nature of cognitive problems, but also to a lack of understanding about what CRT is.

The Institute of Medicine (IOM)’s 2011 report1 provides the following broad definition: “Cognitive rehabilitation attempts to enhance functioning and independence in patients with cognitive impairments as a result of brain damage or disease, most commonly following TBI or stroke.” (IOM, 2011, p. 76). It clarifies that CRT is different from cognitive behavioral therapy, a treatment approach for emotional and psychiatric problems. The IOM describes two broad approaches to CRT:

  • Restorative treatment, whose goal is to improve the cognitive system to function in a wide range of activities;
  • Compensatory treatment, which trains solutions to specific problem areas such as using memory notebooks or learning self-cuing strategies.

CRT has many variables: providers, settings, focus, and treatment formats. Many different types of professionals deliver services described as CRT. These providers are typically credentialed and licensed by their professions and state boards. They include, but may not be limited to:

  • speech-language pathologists
  • occupational therapists
  • physical therapists
  • neuropsychologists
  • vocational rehabilitation counselors
  • nurses
  • physiatrists

CRT services are provided in different settings, such as

  • Hospitals
  • Inpatient rehabilitation units
  • Outpatient departments
  • Community brain injury rehabilitation centers

Treatment may also be delivered in a variety of formats (individual, group therapy, day treatment program), and intensities (intensive inpatient rehabilitation, daily outpatient, or weekly).

Accessing CRT

Ideally, cognitive assessment to evaluate level of alertness, orientation to surroundings, and memory of recent events begins from the moment someone with a brain injury is admitted to the hospital. With moderate or severe cognitive impairments, individuals may receive CRT during an inpatient rehabilitation program and then be discharged to an outpatient setting for further treatment. The treatment team and discharge coordinator typically make recommendations about the treatment setting and type of provider that will be most effective in working with the kinds of cognitive problems that the individual displays.

For example, someone with a moderate degree of cognitive impairment may benefit from a comprehensive outpatient CRT program that includes individual treatment as well as group therapy for social/behavioral goals. The program may include functional activities such as planning outings into the community, or work or school re-entry. Comprehensive programs like this may be staffed by providers from multiple disciplines.

More targeted therapy may be delivered by a single provider. For example, a person with cognitive issues related to language processing (following directions, using written strategies for memory and organization) may focus on speech-language pathology services. Someone working on the cognitive skills for driving or home management may receive occupational therapy. The professional who delivers the service may describe the treatment as CRT or in terms unique to that profession.

People who sustain a concussion or mild TBI without being hospitalized may have a more difficult time being referred for CRT and having treatment covered by insurance. Often the Emergency Room report doesn’t describe cognitive problems, or the person doesn’t notice difficulty concentrating or remembering until she returns to work or school. Without medical documentation of the problem, insurers may decline to make referrals or pay for CRT.

Challenging Insurance Denials for CRT

Because of the variability in patients and the CRT they may receive, research studies, to date, have not identified a single most effective treatment. In some cases, reports of limited research about CRT has led private health plans to deny CRT. The IOM report calls for more research on CRT, but recognizes the difficulty in obtaining conclusive results. The report states in italics “In fact, the committee supports the ongoing clinical application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI.” (IOM, 2011, p. 257).

Families and providers can work together to challenge insurance denials if they occur. Families can appeal denials, and ask the professional to provide detailed reports of functional progress made by the patient or articles demonstrating the effectiveness of the technique being used. Professional associations such as the American Speech-Language-Hearing Association provide assistance to speech-language pathologists and their patients by writing letters supporting CRT. Finally, appeals can be made to the state’s Insurance Commission, where a review will take place at a level beyond the health plan.

Cognitive rehabilitation therapy may be like the proverbial elephant — it feels different to different people depending on their circumstances and perspective. But, as patients and families will attest, CRT is as fundamental a need in TBI recovery as physical rehabilitation — and for some, even more essential to their quality of life.  


Institute of Medicine. 2011. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. The National Academies Press.

Posted on BrainLine June 5, 2012. Reviewed July 26, 2018.

Written exclusively for BrainLine by Janet Brown, MA CCC-SLP, director, Health Care Services in Speech-Language Pathology, American Speech-Language-Hearing Association. www.asha.org.

Comments (17)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

Hi I am 57 female married with 2 grown sons and grandchildren.
I have a non traumatic cognitive brain injury-mild/moderate in some areas. I knew something was wrong with me. But never gots you rehab because thought I knew how to deal with it.well i18 yrs have gone by and i did my best except now i have had changes. My husband is fed up with me and refuses to participate in any rehab with me so he doesn’t know how to talk to me or how to help. Do u have literature and i.need a counselor because we are heading for divorce . We are in a very bad way. Do u havE ANY COUNSELOR BECAUSE WE ARE BARELY MARRIED NOW.

i had a ruptured brain annuryzm almost 4 years ago,i was 57 years old,i am now 62,i did go to rehab afterwards,i drew clocks,they took me for walks,i seemed to pass with flying colors,i was there for 1 week,the next day I had a small stroke,went back to mass general for another week,then had in home physical therapy,i have played memory games ,scrabble and ev erything i could think of for my memory,I am now almost 62,and im losing things all the time,i forget things constantly,and im overdrawing on my bank acct,I was always very good with that stuff,I was the person that people came too,because I remembered everything,I was diagnosed with anxiety,yes of course anyone would if they constantly lost things,I get very angry sometimes at the fact,that Im different now,Who can I see to help me cognitivly

I'm sorry to hear of your health declines. That's never easy and so hard to adapt to and accept. I would recommend seeing a counselor (to discuss your anxiety). There is always a huge stigma associated with going to a counselor, but I am a huge advocate for seeking this type of help. I see a counselor twice a week; it's nice to talk to someone that is unbiased and trained to help.
I would also recommend seeing an occupational therapist- they can help you live your life to the fullest with the brain and abilities that you have now. Yes, your body and brain has changed, but you are still you. Occupational therapists are trained to help you with your cognitive deficits and your "new" and different brain.

Start by talking to your doctor and asking for help- you don't have to feel bad about anything.

Hope this helps a little bit...


Doctors will keep suggesting you go to therapy to rehabilitate the parts of your brain that you are struggling with however the best method to improve brain function is to practice repetitive actions such as those brain games or memorization skills. Another method to use is association techniques such as visual cues, notes, reminders on your phone, imploring the help of friends and family to remind you of certain things until you automatically strengthen those parts of your brain again. Also, try alternative methods of therapy, yoga, music therapy, art, and meditation can help as well. If you can stay away from medications that are unnecessary try to improve brain function before turning to them as the medication is usually a coverup relief for the real underlying issue and does nothing to actually resolve or strengthen your cellular communication in the brain.

I am not a professional, however, these methods will not harm you and something out of the blue might catch you by surprise by working.

I'm trying to apply a cognitive therapy for musicians to in prove dystopian and reduce muscle cramp.. I am going to apply a therapy..
(to conduct an open eye action and the to do the same action with eyes closed)
Can I get any help regarding the name of these kind of therapy

I was referred by my neurologist after a fall for cognative memory to a speech therapist. I had been tested by both. The therapist told me to do Saduku games and keep a daily calendar (which I already had been doing) I am having lots of trouble remembering even to look at the daily calendar, pay my bills, remember words, events, etc. The therapist says I don't really need any more since she gave me the two things to do. Is that what Cognative therapists do? Or is she just unqualified??

I am a licensed speech-language pathologist in the state of Texas I and would recommend you look for a more specialized speech-language pathologist. A well qualified therapist should be able to offer compensatory strategies for immediate assistance, such as a calendar, but also activities to target neuroplasticity . (the ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury.

Hi Jacqueline, sorry to hear you are struggling with your memory. I have a pretty awful memory myself, so I know how frustrating that can be! It sounds like the speech therapist you saw may not have very much experience in cognitive rehabilitation. You are clearly having difficulty with these daily tasks, and a good speech therapist should be able to help you get a little closer to your prior level of function. I encourage you to find another speech-language pathologist if you're not happy with her.

Good luck!

Does insurance pay for Cognitive Therapy for PPA diagnosis?

Anthem has denied this therapy for my husband. He had a ruptured aneurysm in 2013. He has had surgery and then ciuls. He suffers from severe short term memory loss. The insurance stated that "cognitive therapy is not beneficial for this type of injury."

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After 14 years post injury for my son I am still of the opinion that the jury may still be out re possible/probable/increased improvements in cognitive issues - some improvement sure but not in leaps and bounds. Is this because this area of rehab is poorly addressed as opposed to the physical and insurance companies don't want toknow about it or is this simply the reality?
Hey Denise! I def know what you mean! I had a tbi in 1982 just 2 weeks before graduation from college. I worked exactly the number of quarters needed to received SS-disability. Contact SS online and see if you can qualify. I had to end up going before a judge, but I was accepted!Hang in there and never give up! look me up on FB-Donna Burge in Louisiana!

I have also been referred to cognitive rehabilitation since my TBI symptoms improved and I do want to go back to work after 8 years of being out of work. So, I was referred to vocational rehabilitation. I have a PhD in science and worked for 30+ years either in hospitals labs or scientific industry. I have attended 5 sessions of VOC and all I do is office management type tests: creating a billing sheet for an office, scheduling of tasks including time to take child to school, go to bakery, go to work, go to cleaners, etc. Some of these places are not close to home, etc. These tests are tricky, but nothing is scientific or clinical. Another test was data entry. This is not helping me with improving my self confidence to do my previous job. I wonder where we can find these types of tests online... this is all I am doing in vocational rehab. The VOC rehab counselor gives me verbal instructions, I have to listen and respond as if I were in the army... yes sargent!!!! type behavior... I feel put down, demeaned, criticized, yet I do most of the tests correctly. The instructions to do the tests are very poor and the counselor has to verbalize instructions, and then she is right there breathing over your shoulders while you do what you do. This is totally crazy- I never experienced any manager treat me like this. Yes, my anxiety is very high, and I don't want to complete these assessments anymore. Has anyone had a similar experience?

Wow! Thank-you for this article. I have experienced a \"Closed-Head Injury\" in 1986 relative to a car accident. It has taken me almost 26 years to get properly diagnosed and I have yet to receive the appropriate treatment. I had received a Bachelor degree in Nursing before the accident, had troubles at work for years not knowing the reason, went back to school received a Masters degree in Rehabilitation Counseling-2002 from a brick & mortar building=Bowling Green State Univ., BG,Ohio.Took me 3 years to complete the 2 year program~I had about a 3.5 grade point average, still cannot find work. Still have migraine headaches.Been married/divorced/separated.Receive no income whatsoever. Live with separated husband, otherwise I\'d be homeless @ 49 years of age. I can drive but my car was repossessed after I lost my last job in 2009 due to \"budget cuts\" job elimination at the hospital where I graduated from Nursing school in 1986. Any advice, prayers, comments, suggestions would be appreciated. Thanks, Denise

I have had a similar path. Two serious concussions, at age 13, and 25. Received BS in engineering at the age of 38, after years of school part time while working as a technician in manufacturing. Now retired after over twenty jobs, most highly skilled. Two weeks ago suffered another serious concussion at the age of sixty five from a bicycle crash. I was wearing a helmet. Had I not, it would have been a more severe TBI. The mental and emotional problems I have experienced lifelong are noticeably worse. I have Kaiser insurance. While it is good in many areas, mental health is their one weakness. I am "self medicating" with a legacy copy of some computer engineering software I have. I have been using the program AutoCAD in my hobby of designing and building model planes. After the accident it has become noticeably more difficult. I keep at it, but tire of it easily.