Reengagement in Meaningful Occupations During the Transition From Hospital to Home for People With Acquired Brain Injury and Their Family Caregivers

OBJECTIVE. To explore people's lived experiences of reengagement in meaningful occupations during the hospital-to-home transition phase after acquired brain injury (ABI).

METHOD. Participants included 20 people with ABI and 18 family caregivers. On the basis of a phenomenological approach, data collection entailed in-depth semistructured interviews at predischarge and 1 and 3 months postdischarge. Thematic analysis of interview transcripts involved open, axial, and selective coding techniques.

RESULTS. Two primary themes emerged from the analysis: desired versus actual participation and struggle for independence. Theme 1 depicts the key occupations of importance to people and their caregivers during transition and explores desired and actual participation in occupations. Theme 2 highlights the struggle to regain independence and the differing perspectives of the 2 participant groups concerning this process.

CONCLUSION. Clinical practice implications relate to client-centered goal setting, contexts and environments in which therapy occurs, and provision of information to patients and families.

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

PURPOSE

The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

METHOD

The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa=0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

RESULTS

The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

CONCLUSIONS

A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.

Relationship between executive functions and productivity outcomes following stroke

PURPOSE

Stroke occurs in many individuals of working age and can considerably disrupt their capacity for employment and other productive activities. Few studies have examined the relationship between loss of productivity and cognitive impairment, particularly deficits in executive function. The present study examined whether performance on tests of executive function is related to employment and productivity at 12-months follow-up.

METHOD

Twenty-seven individuals (mean age = 47.3 years, SD = 10.7) on average 2.1 years (SD = 1.6) post-stroke were recruited from hospital and community rehabilitation services and administered a theory-driven battery of executive function tests (i.e. Health and Safety sub-test, FAS Test, Five-Point test, Key Search Test and Tinkertoy Test). A 12-month follow-up assessment of employment outcome ('employed' or 'unemployed') and productivity (measured by the Sydney Psychosocial Reintegration Scale) was conducted.

RESULTS

A series of between-group comparisons identified that a measure of purposive behaviour and self-regulation (i.e. the Tinkertoy Test) best distinguished between the employed and unemployed groups (p < 0.01) irrespective of time since injury and neglect. Level of post-stroke productivity was significantly correlated with measures of planning (p < 0.05), self-monitoring (p < 0.01) and self-regulation (p < 0.05), as well as time since injury (p < 0.05) and functional status (p < 0.01).

CONCLUSIONS

These findings highlight the importance of routinely assessing executive functions to guide cognitive rehabilitation interventions following stroke.

A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model

It is now well established that pain is a multidimensional phenomenon, affected by a gamut of psychosocial and biological variables. According to diathesis-stress models of chronic pain, some individuals are more vulnerable to developing disability following acute pain because they possess particular psychosocial vulnerabilities which interact with physical pathology to impact negatively upon outcome. Attachment theory, a theory of social and personality development, has been proposed as a comprehensive developmental model of pain, implicating individual adult attachment pattern in the ontogenesis and maintenance of chronic pain. The present paper reviews and critically appraises studies which link adult attachment theory with chronic pain. Together, these papers offer support for the role of insecure attachment as a diathesis (or vulnerability) for problematic adjustment to pain. The Attachment-Diathesis Model of Chronic Pain developed from this body of literature, combines adult attachment theory with the diathesis-stress approach to chronic pain. The evidence presented in this review, and the associated model, advances our understanding of the developmental origins of chronic pain conditions, with potential application in guiding early pain intervention and prevention efforts, as well as tailoring interventions to suit specific patient needs.

Awareness typologies, long-term emotional adjustment and psychosocial outcomes following acquired brain injury

Previous research suggests considerable heterogeneity within groups of individuals identified as having low self-awareness or good self-awareness following acquired brain injury (ABI). The present study aimed to identify typologies of individuals according to neuropsychological and psychological factors related to awareness deficits and compare emotional adjustment and psychosocial outcomes at the initial assessment and 12-month follow-up. Eighty-four participants with ABI (mean time since injury = 3.9 years) were assessed on the Self-Awareness of Deficits Interview, Awareness Questionnaire, Symptom Expectancy Checklist, Marlowe-Crowne Social Desirability Scale, Hospital Anxiety Depression Scale, Sydney Psychosocial Reintegration Scale, and an error self-regulation index. A 12-month follow-up assessment of emotional adjustment and psychosocial outcomes was conducted. A hierarchical cluster analysis distinguished four awareness typologies, namely, "poor self-awareness" (n = 12), "high defensiveness" (n = 13), "high symptom reporting" (n = 15), and "good self-awareness" (n = 44). An overall comparison of outcomes indicated that the poor self-awareness and high symptom reporting typologies experienced poorer outcomes than the high defensiveness and good self-awareness typologies. The findings confirm that there are different awareness typologies and highlight the need to tailor interventions according to the nature of awareness deficits.

An integrated biopsychosocial approach to understanding awareness deficits in Alzheimer's disease and brain injury

Considerable emphasis has been placed upon cognitive neuropsychological explanations of awareness disorders in brain injury and Alzheimer's disease (AD), with relatively few models acknowledging the role of psychosocial factors. The present paper explores clinical presentations of unawareness in brain injury and AD, reviews the evidence for the influence of psychosocial factors alongside neuropsychological changes, and considers a number of key issues that theoretical models need to address, before going on to discuss some recently-developed models that offer the potential for developing a comprehensive biopsychosocial account. Building on these developments, we present a framework designed to assist clinicians to identify the specific factors contributing to an individual's presentation of unawareness, and illustrate its application with a case example.

A review of awareness interventions in brain injury rehabilitation

Unawareness related to brain injury has implications for participation in rehabilitation, functional outcomes, and the emotional well-being of clients. Addressing disorders of awareness is an integral component of many rehabilitation programmes, and a review of the literature identified a range of awareness interventions that include holistic milieu-oriented neuropsychological programmes, psychotherapy, compensatory and facilitatory approaches, structured experiences, direct feedback, videotaped feedback, confrontational techniques, cognitive therapy, group therapy, game formats and behavioural intervention. These approaches are examined in terms of their theoretical bases and research evidence. A distinction is made between intervention approaches for unawareness due to neurocognitive factors and approaches for unawareness due to psychological factors. The socio-cultural context of unawareness is a third factor presented in a biopsychosocial framework to guide clinical decisions about awareness interventions. The ethical and methodological concerns associated with research on awareness interventions are discussed. The main considerations relate to the embedded nature of awareness interventions within rehabilitation programmes, the need for individually tailored interventions, differing responses according to the nature of unawareness, and the risk of eliciting emotional distress in some clients.

The association between awareness deficits and rehabilitation outcome following acquired brain injury

The relationship between awareness of deficits and rehabilitation outcome following acquired brain injury (ABI) has yet to be established. The aim of the present review was to examine empirical evidence concerning the issue of whether awareness of deficits is necessary for rehabilitation gains and provide guidelines to assist clinical decision-making. The search strategy entailed identification of longitudinal group outcome studies with individuals who had experienced ABI of varying aetiology published between 1980 and 2006 in which awareness of deficits was systematically measured from the outset of rehabilitation and examined in relation to post-intervention functional outcomes. Eligible studies were evaluated against indicators of methodological quality. The review yielded 12 empirical studies, of which four indicated that individuals with greater awareness of deficits achieve more favorable rehabilitation outcomes and six provided partial support for this association. Two studies failed to support this view. Overall, the key issues requiring consideration when forming opinions and developing interventions for individuals with awareness deficits include the following: (a) how awareness is conceptualized and determined; (b) the perceived impact of poor self-awareness and possible adverse effects of targeting awareness; (c) biopsychosocial factors underlying awareness deficits; (d) the clients' goals and expectations in the intervention; and (e) the scope, intensity and resources of the rehabilitation context. Clinical recommendations are made regarding the circumstances in which it might be optimal to target the development of awareness in the context of rehabilitation.

A metacognitive contextual intervention to enhance error awareness and functional outcome following traumatic brain injury: a single-case experimental design

Very few empirically validated interventions for improving metacognitive skills (i.e., self-awareness and self-regulation) and functional outcomes have been reported. This single-case experimental study presents JM, a 36-year-old man with a very severe traumatic brain injury (TBI) who demonstrated long-term awareness deficits. Treatment at four years post-injury involved a metacognitive contextual intervention based on a conceptualization of neuro-cognitive, psychological, and socio-environmental factors contributing to his awareness deficits. The 16-week intervention targeted error awareness and self-correction in two real life settings: (a) cooking at home; and (b) volunteer work. Outcome measures included behavioral observation of error behavior and standardized awareness measures. Relative to baseline performance in the cooking setting, JM demonstrated a 44% reduction in error frequency and increased self-correction. Although no spontaneous generalization was evident in the volunteer work setting, specific training in this environment led to a 39% decrease in errors. JM later gained paid employment and received brief metacognitive training in his work environment. JM's global self-knowledge of deficits assessed by self-report was unchanged after the program. Overall, the study provides preliminary support for a metacognitive contextual approach to improve error awareness and functional outcome in real life settings.

Convergent validity of self-awareness measures and their association with employment outcome in adults following acquired brain injury

PRIMARY OBJECTIVE

To examine the convergent validity of three measures of self-awareness and their correlation with employment status in 38 adults with acquired brain injury.

RESEARCH DESIGN

A cross-sectional study examining correlations between standardized measures of self-awareness and employment outcome.

METHODS AND PROCEDURES

Self-awareness was assessed using the Self-Awareness of Deficits Interview (SADI), the Self-Regulation Skills Interview (SRSI) and the Awareness Questionnaire (AQ). Employment outcome was classified using a five-point work status rating scale and work items from the Sydney Psychosocial Reintegration Scale (SPRS).

MAIN OUTCOMES AND RESULTS

Significant correlations were found between the SADI total score and the AQ discrepancy score and between the total SADI score and the SRSI indices. The work status rating scale was significantly correlated with the SADI and SRSI scores but not the AQ.

CONCLUSIONS

The findings support the convergent validity of the three measures of self-awareness and highlight the need to address self-awareness deficits in vocational rehabilitation.

The relative importance of metacognitive skills, emotional status, and executive function in psychosocial adjustment following acquired brain injury

OBJECTIVES

To examine the interrelationships between metacognitive skills and measures of emotional status and executive function following acquired brain injury (ABI), and examine their relative importance to psychosocial outcomes.

DESIGN

A cross-sectional multicentre study employing correlational and multiple regression analyses.

PARTICIPANTS

Sixty-seven adults with ABI living in the community, on average 4.4 years (SD = 4.7) postinjury.

MEASURES

Sydney Psychosocial Reintegration Scale, Self-Awareness of Deficits Interview, Self-Regulation Skills Interview, Hospital Anxiety Depression Scale, Beck Hopelessness Scale, and standardized measures of executive function.

RESULTS

Metacognitive skills correlated with level of hopelessness and executive measures of idea generation and error self-regulation. The best predictor of psychosocial outcome was depressive symptoms, with specific outcomes additionally related to error self-regulation and intellectual awareness.

CONCLUSIONS

The findings highlight the need to evaluate interventions targeting depression and metacognitive skills to improve psychosocial outcomes.