Living with acquired brain injury: Self-concept as mediating variable in the adjustment process

A single-case experimental evaluation of a new group-based intervention to enhance adjustment to life with acquired brain injury: VaLiANT (valued living after neurological trauma)

Adjustment to life with acquired brain injury (ABI) requires self-identity and behaviour to be updated, incorporating injury-related changes. Identifying and enabling new values-consistent behaviours could facilitate this process. We evaluated the feasibility, acceptability, and preliminary efficacy of VaLiANT, a new group intervention that aims to enhance "valued living" following ABI. We used a non-concurrent multiple baseline single-case experimental design (SCED) with an 8-week follow-up phase and randomization to multiple baseline lengths (5-7 weeks). Eight participants (50% women, aged 26-65; 4 Stroke, 3 Traumatic Brain Injury, 1 Epilepsy) attended eight group sessions with assessments before, during, and after the group. Target behaviour was valued living, assessed weekly by the Valued Living Questionnaire. Secondary outcomes included measures of wellbeing, mood, psychological acceptance, self-efficacy regarding ABI consequences, cognitive complaints, and intervention acceptability. Target behaviour was analysed through visual and statistical analysis while secondary outcome data were analysed via reliable change indices and descriptive statistics. Target behaviour data displayed no convincing patterns of improvement. Reliable improvements were found for most participants on secondary outcomes, particularly subjective wellbeing and anxiety. Intervention delivery was feasible with high acceptability ratings. Further investigation of VaLiANT is warranted, based on the feasibility and acceptability of intervention delivery and signals of efficacy identified across adjustment-related secondary outcomes.

The psychological adjustment needs of individuals following an acquired brain injury: A systematic review

This systematic review explored the psychological adjustment needs of individuals following an acquired brain injury (ABI). Whilst the landscape of rehabilitation in ABI has changed rapidly over the last decade, there is still a lack of emphasis on psychological processes in this area. An electronic search of PsycArticles, PsycINFO, PubMed, JSTOR, and Cochrane Library databases was conducted for records between January 2009 and December 2019 detailing the psychological adjustment needs of individuals in a general ABI population. A total of 17 studies with varying methodologies were initially extracted. Methodological quality was then independently assessed by the three authors, with 14 articles meeting the quality threshold. Across methodologies, key themes emerged in relation to: difficulties adjusting to a new sense of self, the critical nature of social support, and the multifaceted nature of the adjustment process which incorporates many internal and external factors. These results illustrate the importance of psychological factors in ABI rehabilitation and as such highlight that the emphasis on functional outcomes in ABI may be an obstacle to the facilitation of the process of psychological adjustment. This provides justification for a more psychologically informed, holistic approach and inspires further debate as to the fundamental importance of psychological adjustment for individual's post-ABI.

Engaging children and adolescents with acquired brain injury and their families in goal setting: The clinician perspective

This paper explored clinicians' experiences of the goal setting process with children and adolescents with acquired brain injuries (ABI) and their families in paediatric neurorehabilitation. Semi-structured interviews were conducted with 13 clinicians, all members of an interdisciplinary paediatric rehabilitation service, who work with children and adolescents with ABI and their families. Interview transcripts and additional data were analysed using constructivist grounded theory methods. Three main themes and sub-themes were developed: (1) Seeing the bigger picture: Goals change over time; Families set bigger picture goals; Need-to-dos: Goals that the child/adolescent needs to achieve; and Want-to-dos: Goals that the child/adolescent wants to achieve; (2) Collaborating as a team: Everyone needs to be on the same page; Hearing the child's/adolescent's voice; and Parents as advocates; and (3) Recognizing and navigating challenges: Child-/adolescent- and family-related challenges and Time as a service-related challenge. Participants perceived the clinician's role during goal setting as that of an active collaborator, enabling children and adolescents with ABI and their families to generate meaningful goals. These findings demonstrate insights into goal setting in paediatric ABI neurorehabilitation from clinicians' perspectives, and highlight the importance of collaboration, flexibility and anticipation of challenges in facilitating children's, adolescents' and families' involvement in this process.

Stuck in an Existential Quagmire: The Role of Perceived True Self-Knowledge in Client Stuckness

Introduction: Research suggests that perceived true self-knowledge is important for well-being. However, less discussion exists about how perceived true self-knowledge affects therapy outcomes. We suggest that perceived true self-knowledge may be important when attempting to address client stuckness (i.e., lack of progress in therapy; Beaudoin, 2008). We argue that when clients perceive a lack of true self-knowledge, they are unable to draw upon the true self-concept as a source of meaning. This may hinder therapeutic progress and contribute to client stuckness.

Methods: We present theoretical evidence for the role of perceived true self-knowledge in experiences of stuckness. Then, we present case studies of two stuck clients and their therapeutic interventions as preliminary evidence for our model.

Results: Direct strategies geared at enhancing true self-knowledge by helping the client construct coherent self-concepts worked for one client, but not for the other. Indirect strategies, grounded in social psychological research, are outlined as a method of enhancing perceptions of true self-knowledge for clients who do not benefit from direct strategies.

Discussion: Potential moderators for the effectiveness of direct versus indirect strategies to enhance true self-knowledge are discussed. We then outline promising avenues for future research that include attempts to investigate the prevalence of self-alienation in clinical populations, and the effectiveness of strategies aimed at enhancing perceived true self-knowledge among clients experiencing stuckness.

A therapeutic songwriting intervention to promote reconstruction of self-concept and enhance well-being following brain or spinal cord injury: pilot randomized controlled trial

OBJECTIVE

To determine the size of the effects and feasibility (recruitment and retention rates) of a therapeutic songwriting protocol for in-patients and community-dwelling people with acquired brain injury or spinal cord injury.

DESIGN

Randomized controlled trial with songwriting intervention and care-as-usual control groups, in a mixed measures design assessed at three time points.

PARTICIPANTS

A total of 47 participants (3 in-patients with acquired brain injury, 20 community participants with acquired brain injury, 12 in-patients with spinal cord injury, and 12 community participants with spinal cord injury: 23 1208 days post injury).

INTERVENTIONS

The intervention group received a 12-session identity-targeted songwriting programme, where participants created three songs reflecting on perceptions of past, present, and future self. Control participants received care as usual.

MEASURES

Baseline, postintervention, and follow-up measures comprised the Head Injury Semantic Differential Scale (primary outcome measure), Patient Health Questionnaire-9, Emotion Regulation Questionnaire, and Satisfaction with Life Scale.

RESULTS

No significant between group pre-post intervention differences were found on the primary self-concept measure, the Head Injury Semantic Differential Scale ( p = 0.38, d = 0.44). Significant and large effect sizes from baseline to post between groups in favour of the songwriting group for Satisfaction with Life ( p = 0.04, n² _p = 0.14). There were no significant between group pre-post interaction effects for the Emotion Regulation Suppression subscale ( p = 0.12, n² _p = -0.08) although scores decreased in the songwriting group over time while increasing for the standard care group. There were no significant differences in baseline to follow-up between groups in any other outcome measures. Recruitment was challenging due to the small number of people eligible to participate combined with poor uptake by eligible participants, particularly the in-patient group. Retention rates were higher for the community-dwelling cohorts.

CONCLUSION

This study demonstrates the challenges in recruitment and retention of participants invited to participate in a music therapy study. Findings suggest this identity-focused therapeutic songwriting protocols may be more beneficial for people who have transitioned from in-patient to community-contexts given the greater proportion of participants who consent and complete the intervention. Preliminary effects in favour of the intervention group were detected in a range of well-being measures suggesting that a larger study is warranted.

The role of centrality to self-concept in moderating the associations between injury perceptions and outcomes

OBJECTIVES

To test the centrality of injury to self-concept as a moderator of the associations between injury perceptions and outcomes.

METHODS

Two concurrent studies on samples of injured individuals.

MEASURES

The centrality of injury to one's self concept was measured by the degree of self-injury separation (PRISM); injury perceptions were measured by the injury perception questionnaire; and outcomes by standard scales of self-assessed health, physical, emotional and social functioning, vitality, depression, anxiety and somatisation. Regression analyses examined the significance of adding the interactions between injury centrality and injury perceptions to explained outcome variance, beyond their separate contributions.

RESULTS

Both injury centrality and injury perceptions significantly explained variance in patients' functioning and well-being. Injury centrality moderated the associations between various injury perceptions and outcomes, especially pronounced for emotional representations of the injury. As hypothesised, the effects of injury perceptions on outcomes were stronger among patients for whom the injury was central to their self-concept compared to patients who perceived the injury as peripheral to their self-concept.

CONCLUSIONS

'Centrality to the self' is a moderator of the impact of perceptions on outcomes of injuries. The findings suggest ways to tailor interventions to sub-groups of injured patients based on injury centrality to their self-concept.

Meaning Making Process and Recovery Journeys Explored Through Songwriting in Early Neurorehabilitation: Exploring the Perspectives of Participants of Their Self-Composed Songs Through the Interpretative Phenomenological Analysis

Objectives: This pilot study examined how 15 participants in early rehabilitation described their self-composed Songs 6- to 12-months following participation in a 6-week identity-focused songwriting program. Specific focus was given to the process of meaning making and identity reconstruction in the participants’ self-composed songs.

Methods: Data were collected through individual semi-structured interviews (n = 15) and analyzed using interpretative phenomenological analysis. Findings were developed idiographically as super-ordinate themes unique to each participant, then analyzed across cases to identify recurrent themes and subthemes.

Results: Participants described the songwriting process as taking them through one of four distinct recovery journeys described by individuals following acquired neurodisability who underwent a focused therapeutic songwriting program. These included (1) re-conceptualizing values and shifting perspectives about self (my body is broken but my mind has been set free); (2) recognizing acquired inner resources to negotiate discrepancies in self (hope is there); (3) confirming existing values and identifying resources and coping strategies (I have what I need to move forward); (4) confirming previously held values and ongoing process of negotiating discrepancies in self (I don’t yet have the answers).

Conclusion: The current study provides insight into the nature and process of meaning making and recovery journeys perceived by individuals with neurodisability. Our findings suggest that songwriting could be a therapeutic tool to facilitate identity reconstruction in neurorehabilitation.

A common-sense model of injury perceptions

The aim of this study was to clarify the difference between perceptions of injury and illness. A qualitative study using semi-structured interviews was conducted with 38 individuals who had been injured in the past, 8 medical psychologists, 62 graduate psychology students, and 19 health professionals treating injured patients. Data were analyzed by modified analytic induction and constant comparison methods. Common-sense perceptions of injury overlapped with some perceptions of illness, and 4 new themes were elicited. It was concluded that there are themes unique to injury perceptions that should be recognized in research as well as in clinical interventions.

Life goal attainment in the adaptation process after acquired brain injury: the influence of self-efficacy and of flexibility and tenacity in goal pursuit

Objective:

To investigate attainment of important life goals and to examine whether self-efficacy, tenacity in goal pursuit and flexibility in goal adjustment contribute to adaptation by affecting levels of emotional distress and quality of life in patients with newly acquired brain injury.

Methods:

Data were collected from a prospective clinical cohort study of 148 patients assessed after discharge home (mean time since injury = 15 weeks) and one year later. At follow-up, attainment of life goals (set at baseline) and satisfaction with attainment was scored (10-point scale) and patients were asked how they adjusted unattained goals. Emotional distress was measured with the Hospital Anxiety and Depression Scale (HADS), quality of life with the Life Satisfaction Questionnaire (LiSat-9), self-efficacy with the TBI Self-efficacy Questionnaire (SEsx) and tenacity and flexibility with the Assimilative/Accommodative Coping Questionnaire (AACQ). Random effects regression analyses and structural equation modelling were used.

Results:

In total, only 13 % of initial life goals were achieved in one year. Patients who maintained efforts to reach their original goals had higher average levels of tenacity, but did not differ in level of self-efficacy compared with patients that disengaged. Patients with higher self-efficacy were more successful in attaining important life goals, which correlated with higher quality of life. Patients with higher self-efficacy, higher tenacity in goal pursuit, and higher flexibility in goal adjustment were less emotionally distressed, again correlating with higher quality of life.

Conclusions:

To optimise adaptation it seems appropriate to promote self-efficacy and both tenacity and flexibility during rehabilitation treatment.

Establishing a person-centred framework of self-identity after traumatic brain injury: a grounded theory study to inform measure development

OBJECTIVE

To develop a theoretically sound, client-derived framework to underpin development of a measure reflecting the impact of traumatic brain injury (TBI) on a person's self-identity.

DESIGN

Grounded theory, based on transcription of audio recordings from focus group meetings with people who have experienced TBI, analysed with constant comparative methods.

SETTING

8 different urban and rural communities in New Zealand.

PARTICIPANTS

49 people (34 men, 15 women), 6 months to 36 years after mild-to-severe TBI.

RESULTS

The central concept emerging from the data was that of desiring to be or having lost a sense of being an integrated and valued person. The three main subthemes were: (1) having a coherent, satisfying and complete sense of oneself, (2) respect, validation and acceptance by others and (3) having a valued place in the world.

CONCLUSIONS

This study reinforces the notion that change in self-identity is an important aspect of life after TBI, and provides information on what this concept means to people with TBI. In order to scientifically evaluate relationships between self-identity and other aspects of health (eg, depression, quality of life), and to test the effect of interventions to address problems with self-identity after TBI, a quantitative tool for evaluation of this construct is required. Themes from this research provide a foundation for the development of a measure of self-identity grounded in the language and experience of people with TBI.