Managing Anxiety and Emotional Regulation in Adults With ABI
Anxiety is a prevalent and often underestimated feature of life after acquired brain injury. For many adults with ABI, anxiety is not simply an emotional state but a driver of behaviour, risk and disengagement from support. When combined with impaired cognition, reduced insight and difficulty processing change, anxiety can escalate quickly into crisis. This article builds on learning from mental health and dual diagnosis in ABI and should be understood within established ABI service models and care pathways.
Services that fail to recognise anxiety early often misinterpret behaviour as resistance, aggression or non-compliance. This leads to reactive practice, unnecessary restriction and poor outcomes. Effective ABI services treat anxiety as a core support need, not an add-on.
How anxiety presents in ABI services
Anxiety following ABI rarely looks like verbalised worry alone. It often presents through avoidance, rigidity, reassurance-seeking, heightened sensitivity to noise or change, and sudden escalation when routines are disrupted. Memory impairment and executive dysfunction can intensify anxiety, as individuals struggle to predict or understand what will happen next.
Staff responses are critical. Inconsistent approaches, rushed communication or unclear expectations can unintentionally amplify anxiety and increase risk.
Operational example 1: Anxiety-driven refusal of support
A man with ABI repeatedly refused personal care and appointments, leading to safeguarding concerns. Initial records described him as “non-engaging”.
A review identified anxiety linked to fear of losing control and previous negative care experiences. The service adapted practice by introducing clear visual schedules, advance explanations and consistent staffing. Day-to-day delivery focused on offering choices rather than demands. Effectiveness was evidenced through reduced refusals, improved engagement logs and fewer safeguarding alerts.
Operational example 2: Anxiety, change and behavioural escalation
A woman living in supported living experienced frequent behavioural incidents following rota changes. Each incident required escalation to senior staff.
The service identified anxiety triggered by unpredictability. A structured transition plan was introduced for staffing changes, including pre-visits and written profiles. Incident data showed a sustained reduction in escalations, supporting internal quality assurance and commissioner confidence.
Operational example 3: Community anxiety and risk-taking
A provider supporting a man with ABI noted repeated community incidents linked to anxiety in unfamiliar environments. Risk assessments focused on restriction rather than understanding triggers.
A revised approach prioritised graded exposure, staff coaching and reflective supervision. Risk-taking reduced over time, evidenced through incident trends and improved outcome reviews.
Embedding anxiety-aware governance
Governance systems must explicitly recognise anxiety as a driver of risk and behaviour. Providers should ensure care planning, incident review and supervision processes explore emotional triggers, not just surface behaviour.
Audit tools should test whether anxiety-related adjustments are implemented consistently across shifts and teams.
Commissioner expectation
Commissioners expect ABI providers to demonstrate proactive management of anxiety, particularly where it affects placement stability or crisis use. Evidence of reduced escalation, improved engagement and personalised risk management is central to placement assurance.
Regulator expectation (CQC)
CQC expects providers to understand and respond to emotional needs under the Safe and Caring domains. Inspectors look for evidence that anxiety is anticipated, that staff adapt their approach, and that restrictive practices are avoided wherever possible.
Outcomes and long-term impact
When anxiety is recognised and managed effectively, individuals experience greater emotional stability and independence. For services, this results in safer care, improved regulatory outcomes and stronger commissioning relationships.