This paper surveys the issue of concrete thinking after brain injury—a phenomenon that is widely recognised clinically, but under-investigated in formal research settings. Through the lens of the classical work of Kurt Goldstein the paper outlines the diverse clinical manifestations of concreteness, and the barriers which this might present to the psychotherapeutic process. However, the paper also outlines the way in which preserved psychological functions in highly concrete patients, specially the capacity to focus on immediate reality, and experience emotions in present time, can be used as a lever for psychotherapeutic interventions. The paper concludes with a range of practical suggestions which may aid the psychotherapist in reaching out to this challenging patient group.