rec 5338 value added project
TRANSCRIPT
SarahWalters
REC5338
27July2016
ValueAddedProjectReport
Initially,theextentofmyValueAddedProjectwastobethedevelopmentofanew
“StressManagement”group.Iwoulddevelopanoutlineforthegroup,curatesupport
materialsfortheoutlineddiscussions,andleadthefirstroundofthegroupwithminimum
supportfrommysupervisor,whowouldinturnbeabletousethedevelopedoutlineand
materialstoleadasecond(third,fourth,etc.)roundofthegroupwithminimum
preparation.Idid,infact,developsaiddiscussionoutlineandsupportmaterialsandlead
theinitial8-weekgroupfor12participants.However,uponbeingtaskedwithhostingthe
summer’sResearchReviewsessions–monthlymeetingsofthemanagementstaffand
therapiststoreviewevidencebasedpracticeresearchanddiscussimplicationsforResCare
programming–Isawanopportunityforexpandingthescopeoftheprojecttoincreaseits
value.
IneachofthetwoResearchReviewsessionsthatIhosted,Ipresentedanarticle
addressinggroupinterventionssimilartotheonethatIhaddeveloped;thefirstarticle’s
studiedinterventionwasamindfulness-basedstressreductionprogram,andthesecond
article’saprogramcombiningsocialskillstrainingandanxietymanagement.My
presentationsofthesearticleswere,inpart,focusedonconsideringhowwecouldadapt
thedesignofthestudiedinterventionstoimproveourownStressManagementgroup.A
secondaryfocuswasontheencouraginglypositiveresultsidentifiedbytheresearchers,as
IsoughttoengagetheteaminadiscussionofhowtobringthoseresultstoResCare
PremierTexas.Wekeyedinontheideathatthesuccessofthestudiedinterventions
seemedtobelinkedtothethoroughintegrationofgroupconceptsthroughoutdaily
programming,astheneedtoexpandourparticipants’learningandpracticeofgroup
conceptsbeyond1-hourweeklysessionshadbecomeobvious.Theteamagreedthata
prudentstrategyforexpandingthatlearningwouldbetoincreaseitspermeationintodaily
programmingthroughafocusonsupportingdirectcarestaffinsupportingparticipants.
Thissupportwouldincludeeducatingprogramstaffongroupconcepts,supportingtheir
implementationofhomepracticesforparticipants,andcontinuingtodeveloptheStress
Managementgrouptointegratebasicsocialskillstrainingandcopingtechniques.While
thatprocesswillcontinuebeyondmytenureastheRecreationTherapyInternatResCare
Premier,IhavesetitinmotionasIhavesharedthegroupoutlineandsupportmaterials
withourProgramDirectorsanddirectsupportstaff,identifiedresourcesforparticipants’
homepractice,andbeguntolocatethematerialsnecessarytoimprovetheStress
ManagementgrouplessonplanbasedontheinterventionsconsideredinmyResearch
Reviewpresentations.
IthoroughlyenjoyeddevelopingandleadingtheStressManagementgroupandfeel
Igainedagreatdealofconfidenceinmyabilitytofacilitateadiscussion-basedgroup,
somethingIfeltwouldbeasignificantchallengeformeasaRecreationTherapistbeforeI
beganmyinternship.Thelessonplanoutlineandcuratedsupportmaterialswouldlikely
havebeenasufficientlyvaluablecontribution.However,IamthrilledthatIwaspushedto
leadResearchReviewsessionsthatledtotheimprovementoftheStressManagement
groupandofferedmeanopportunitytoengageinevidencebasedpractice.Iamalsovery
happythatthediscussionsheldinthoseResearchReviewsessionsledtotheinitiationofa
processthatwillincreasetheimpactofthegrouponparticipantsandleadtolastingchange
inthephilosophyofgrouplearningprovisionandthepermeationofthatlearningintodaily
programmingatResCarePremierTexas.
TheStressManagementGroupOutlinewithsupportmaterials,ResearchReview
presentations,andreviewedarticlesarepresentedalongsidethisreport.
Stress Management Group Outline
Weekly Lesson Plans
Week 1: What is Stress? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Week 2: Relaxation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Week 3: Cognitive Restructuring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Week 4: Active Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Week 5: Stress Management in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Week 6: Assertiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Week 7: Receiving Criticism & Dealing with Aggression . . . . . . . . . . . . . . . . . . . . . 8
Week 8: Putting it All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Handouts
Symptoms of Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Relaxation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Progressive Muscle Relaxation Script . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
The Cognitive Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
The Cognitive Model Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cognitive Distortions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Active Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Reflections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Passive, Aggressive, and Assertive Communication . . . . . . . . . . . . . . . . . . . . . . . . 25
“I” Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Responding Assertively to Criticism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Dealing with Aggressive People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Fair Fighting Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Stress Management Group Wrap-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Week 1: What is Stress?
Handouts: “Symptoms of Stress”
Defining Stress
o Ask participants, “What does ‘stress’ mean to you?”, “What is ‘stress?’”, etc.
o Offer dictionary definition of stress, “a state of mental tension and worry
caused by problems in your life, work, etc.” (Merriam-Webster.com, 2016).
Causes of Stress
o Introduce the term “stressor” and offer the dictionary definition, “something
that makes you worried or anxious; a source of stress” (Merriam-
Webster.com, 2016).
o Ask participants, “What causes you stress?”, “What are your stressors?”, etc.
Positive vs. Negative Stress
o Ask participants, “So, is stress always a bad thing?”, “Do you think stress can
ever be a good thing?”, etc.
o Introduce the concept of positive stress and differentiate it from negative
stress; explain that the difference is in the positivity or negativity of the
stressor.
o Ask participants for examples of times they’ve experienced positive stress
and point out that, while positive stress may be motivating or compelling, it
still “adds to your cup” and has the same effects/symptoms as negative stress
when “your cup gets too full.”
Effects of Stress
o Ask participants, “So, what are the effects or symptoms of being under too
much stress?”, “What happens when your cup gets too full?”, etc.
o To facilitate discussion, pass out “Symptoms of Stress” handout
(Therapistaid.com, 2012).
The Stress Cycle(s)
o Introduce the concepts of the negative and positive stress cycles and draw a
simplified version (Stressor Thought Feeling Behavior Stressor) of
each cycle on the board based on the following diagrams:
(UT Counseling & Mental Health Center, 2016)
o Ask participants, “Which cycle do you think is better?”, “Would you rather be
caught in the positive or negative cycle?”, etc.
o Wrap-up day’s discussion by explaining that the goal of this group is to move
ourselves from the negative to the positive stress cycle so that we can keep
our cups from getting too full!
Week 2: Relaxation Techniques
Handouts: “Relaxation Techniques,” “Progressive Muscle Relaxation Script”
Week 1 Review
o Have participants remind you of definition of stress and stressor, differences
between positive and negative stress, and effects of stress.
o Re-draw the positive stress cycle on the board.
What is relaxation?
o Explain that the first step we’ll take towards getting into the positive stress
cycle is to practice some ways we can cope with stress – or “empty our cups”
– when it does happen. Identify relaxation as the method we’ll discuss.
o Ask participants, “What is relaxation?”, “What does it mean to relax?”, etc.
o Offer the dictionary definition of “relax,” “to become less tense, tight, or stiff;
to stop feeling nervous or worried; to spend time resting or doing something
enjoyable” (Merriam-Webster.com, 2016).
How to Relax
o Ask participants, “How do you relax?”, “What do you do to relax?”, etc.
o Emphasize the value of recreation/leisure for relaxation! Try to draw out
examples of relaxation that involve recreation/leisure.
o Explain that, while it’s great to use recreation to relax and empty our cups,
there are some other strategies for relaxation that we might want to add to
our list of coping techniques.
o Pass out the “Relaxation Techniques” handout (Therapistaid.com, 2013) and
discuss each of the techniques outlined.
Practicing Relaxation
o Pass out the “Progressive Muscle Relaxation Script” handout
(Therapistaid.com, 2014) and explain that there are many printed resources
like this one that can help us practice different relaxation techniques on our
own. Express that anyone who needs assistance locating those resources is
welcome to ask CTRS!
o Explain that many people enjoy using things like videos, audio recordings,
phone apps, etc. for guided relaxation. Offer appropriate examples of apps
using phone and, as you prepare to show videos for practice, guide
participants through that process of accessing videos on YouTube.
o Play a 10-minute guided meditation video for the class and suggest that all
participate so that we may practice relaxation together. Next, play a 10-
minute guided progressive muscle relaxation video.
o Wrap-up the day’s class by debriefing the experiences of practicing these two
relaxation techniques and, again, emphasizing that CTRS is more than willing
to share resources with anyone who is interested. Explain that direct care
staff are familiar with what we’re doing and will be able to offer support, too.
Week 3: Cognitive Restructuring
Handouts: “The Cognitive Model,” “The Cognitive Model Practice Exercises,” “Cognitive
Distortions”
Weeks 1-2 Review
o Have participants review terms from Weeks 1-2 and briefly review the
concepts of relaxation learned in Week 2.
o Re-draw the positive stress cycle on the board.
The Cognitive Cycle
o Introduce the concept of the cognitive model and draw the diagram on the
board (Situation Thoughts Emotions Behaviors). Point out that this
model is pretty similar to the stress cycle and emphasize that it seems to be
the order that really matters. Explain that the ideas we’re discussing are
based on this concept illustrated in the model that “how you think determines
how you feel which determines how you behave” (Therapistaid.com, 2016).
o Discuss this concept of the order of the model and consider how a clinically
identified deficit related to impulsivity could complicate it. Emphasize that
everyone has impulsive and irrational thoughts and that the key here is to
practice taking responsibility for those thoughts so that we can control them.
What is cognitive restructuring?
o Pass out packet including “The Cognitive Model,” “The Cognitive Model
Practice Exercises,” and “Cognitive Distortions” handouts (Therapistaid.com,
2016; Therapistaid.com, 2015; Therapistaid.com, 2012).
o Explain that this idea of practicing taking control over our thoughts is called
“Cognitive Restructuring.” Emphasize that the first step is to become aware
of our thoughts in stressful situations and take responsibility for them, rather
than making the excuse that a situation caused our negative behavior or that
a person made us feel (and then act) in a negative way. Acknowledge that it
might feel like these things are happening but that we are going to practice
taking control to change that!
o Work through the example of switching an irrational, negative thought with a
rational, neutral one given on “The Cognitive Model” worksheet
(Therapistaid.com, 2016). Next, work through the scenarios given on “The
Cognitive Model Practice Exercises” worksheet (Therapistaid.com, 2015).
Continue to emphasize the importance of being aware of and taking
responsibility for our initial thoughts in stressful situations and that, with
practice, we can be in control of how we think, feel, and act!
Cognitive Distortions
o Review the “Cognitive Distortions” handout and discuss how these types of
irrational thoughts make us feel badly and result in negative behaviors
(Therapistaid.com, 2012). Emphasize that they put us back into the negative
stress cycle and add to the stress of an already stressful situation.
o Wrap-up the day’s conversation by discussing how changing our thoughts to
make them neutral or positive does the opposite – it puts us into the positive
stress cycle by limiting or eliminating the stress of a stressful situation.
Week 4: Active Listening
Handouts: “Active Listening,” “Reflections”
Weeks 1-3 Review
o Have participants review the terms discussed in Weeks 1-3. Re-draw the
positive stress cycle on the board. Briefly review the two methods of
managing stress that we’ve discussed so far.
o Remind participants that we’re working on making sure our cup doesn’t get
too full. Point out that relaxation helps us empty our cup when it’s getting full
and cognitive restructuring helps us keep stress from filling up our cup in the
first place. Transition to today’s topic by explaining that it’s another method
of keeping stress from filling up our cup in the first place.
What is listening?
o Ask participants, “What does ‘listening’ mean to you?”, “Is there a difference
between hearing and listening?”, etc.
o Discuss difference between hearing and listening. Offer dictionary definitions
– listening is “to pay attention to someone or something in order to hear
what is being said, sung, played, etc.” while hearing is simply “to be aware of
sound through the ear” (Merriam-Webster.com, 2016).
Active Listening
o Ask participants, “What do you think it means to listen actively?”, “What is
active listening?”, etc.
o Pass out the “Active Listening” handout (Mindtools.com, 2016). Work through
the steps of active listening and discuss each.
Reflections
o Explain that we won’t move on to responding today but that a big part of
active listening is giving feedback that helps us listen better by clarifying
what has been said.
o Pass out the “Reflections” handout (Therapistaid.com, 2015). Introduce
reflections as a great way to understand what is being said, discuss the
technique, and work through the practice scenarios.
o Wrap-up the day’s conversation by discussing the importance of
understanding what someone really means before you react/respond.
Emphasize how misunderstanding someone and reacting negatively can
make an already stressful situation that much more stressful, while clarifying
and defusing the situation instead removes or eliminates the stress.
Week 5: Stress Management in Practice
Stressful Games
o Select several board games that are particularly stressful, such as Operation
or Jenga. As you play each game, continue to subtly and appropriately
increase the stress level by introducing or shortening a time limit, adding
distractions, etc.
o Wrap-up the day by debriefing the experience with playing the games.
Connect the experience to “real-world” experiences with stress (While
acknowledging that board games happen in the real world and cause real
stress!) as well as conversations and concepts from Weeks 1-4. Encourage
participants to reflect on what was stressful about playing the games, what
increased the stress level, and how they coped (or didn’t cope) with the
stress.
Week 6: Assertiveness
Handouts: “Passive, Aggressive, and Assertive Communication” and “”I’ Statements”
Weeks 1-5 Review
o Have participants review the terms discussed in Weeks 1-4 and reflect on
their experience in Week 5. Re-draw the positive stress cycle on the board.
Briefly review the two methods of managing stress through communication
that we’ve discussed so far as well as the coping technique, relaxation, and
the concept of cognitive restructuring.
o Remind participants that we’re working on making sure our cup doesn’t get
too full. Point out that relaxation helps us empty our cup when it’s getting full
while cognitive restructuring and active listening help us keep stress from
filling up our cup in the first place. Transition to today’s topic by explaining
that it’s another method of making positive changes to our communication
strategies that keep stress from filling up our cup in the first place. Explain
that what we’ll discuss today is one step past the last concept we talked
about – how to respond after we’ve actively listened.
Passive vs. Aggressive vs. Assertive Communication
o Pass out the packet including the handouts “Passive, Aggressive, and
Assertive Communication” and “”I’ Statements” (Therapistaid.com, 2012;
Therapistaid.com, 2014).
o Ask participants, “What does passive mean to you?”, “What does passive
communication look like?”, “How does a passive person communicate?”, etc.
Do the same for aggressive and assertive communication, working through
the “Passive, Aggressive, and Assertive Communication” handout
(Therapistaid.com, 2012).
o Ask participants to choose which kind of communication they think would be
the least stressful/the most positive. Encourage them to land on assertive!
More on Assertive Communication
o Discuss assertive communication in more depth. Emphasize that assertive
communication is respectful and allows both parties to have their needs and
wants acknowledged.
o Point out that, just as in the cognitive model, it’s key that we take
responsibility for what we’re saying so that we can take control.
“I” Statements
o Introduce the “I” Statements technique as one way to take responsibility for
our side of the conversation while respecting the other person and treating
them kindly. Work through the “’I’ Statements” handout to practice the
technique.
o Wrap-up the day’s conversation with a discussion about how being assertive
and using a technique like “I” Statements helps to decrease or eliminate
stress from stressful conversations. Encourage participants to reflect on how
remaining calm, respectful, and kind will help us keep from feeling stressed
and will also make the conversation easier by not riling the other person.
Week 7: Receiving Criticism & Dealing with Aggression
Handouts: “Responding Assertively to Criticism,” “Dealing with Aggressive People,” “Fair
Fighting Rules”
Weeks 1-5 Review
o Have participants review the terms discussed in Weeks 1-6. Re-draw the
positive stress cycle on the board. Briefly review the two methods of
managing stress through communication that we’ve discussed so far as well
as the coping technique, relaxation, and the concept of cognitive
restructuring.
o Remind participants that we’re working on making sure our cup doesn’t get
too full. Point out that relaxation helps us empty our cup when it’s getting full
while cognitive restructuring, active listening, and assertiveness help us keep
stress from filling up our cup in the first place. Transition to today’s topic by
explaining that it’s another method of making positive changes to our
communication strategies that keep stress from filling up our cup. Explain
that what we’ll discuss today is an expansion of the last topic we covered –
we’ll go from discussing assertiveness generally to focusing on how to be
assertive when faced with criticism and/or aggression.
Responding to Criticism Assertively
o Pass out the packet that includes the handouts “Responding Assertively to
Criticism,” “Dealing with Aggressive People,” and “Fair Fighting Rules”
(Michel & Fursland, 2008; Brightside.me, 2016; Therapistaid.com, 2012).
o Discuss the differences between constructive and destructive criticism.
Emphasize that constructive criticism is valid and helps us to improve while
destructive criticism tends to be invalid and simply mean.
o Work through “Responding Assertively to Criticism” handout (Michel &
Fursland, 2008). Discuss each strategy for responding to both constructive
and destructive criticism. Consider each example offered and prompt
participants to offer alternative responses. Emphasize the importance of
being calm and assertive, and of acknowledging any valid piece of feedback
while respectfully rejecting or ignoring any exaggerations or untruths.
Turning Destructive Criticism into Constructive Criticism
o Discuss how combining some of the skills we’ve learned – specifically active
listening and assertiveness – can help us turn destructive criticism into
constructive criticism. Emphasize that remaining calm and respectful (and
demanding that same respect in concern) while asking clarifying questions
allows us to get at the true message and benefit from it.
Dealing with Aggressive People
o Work through the “Dealing with Aggressive People” handout (Brightside.me,
2016). Emphasize the idea that it’s much more effective to fight fire with
water than with more fire. Discuss each of the five “steps” and what effect
using this strategy might have on the person you’re communicating with.
Briefly work through the “Fair Fighting Rules” handout to reinforce the
strategies (Therapistaid.com, 2012).
o Wrap-up the day’s session by discussing how using these strategies in a
stressful conversation will not only help us avoid escalating the situation but
will help us defuse it. If appropriate, discuss the concept of mirror neurons to
illustrate that, while assertiveness is difficult and feels a little unnatural, it
can really do the trick in managing a conversation partner’s aggression.
Week 8: Putting it All Together
Handouts: “Stress Management Group Wrap-Up”
Putting it All Together
o Pass out the “Stress Management Group Wrap-Up Handout.” Work through
the handout, discussing each week’s topics in brief detail and allowing
participant’s to take notes. Encourage participants to do most of the talking
and offer reminders as necessary.
o Debrief the group by focusing on processing questions about what we
learned, why we discussed the topics we discussed, how we plan to use the
strategies and techniques we learned, etc.
Symptoms of Stress
Provided by TherapistAid.com © 2012
Stress is one way that our bodies respond to the demands of our lives. A little bit of stress can
be healthy—it keeps us alert and productive. However, all too often, we experience too much
stress. Too much stress can result in serious physical, emotional, and behavioral symptoms.
Physical Emotional Behavioral
Fatigue
Sleep difficulties
Stomachache
Chest pain
Muscle pain and
tension
Headaches and migraines
Indigestion
Nausea
Increased sweating
Weakened immune system
Neck and back pain
Loss of motivation
Increased irritability
and anger
Anxiety
Depression or sadness
Restlessness
Inability to focus
Mood instability
Decreased sex drive
Unhealthy eating
(over or under eating)
Drug or alcohol use
Social Withdrawal
Nail biting
Constant thoughts about stressors
Relaxation Techniques
TherapistAid.com © 2013 | Page 1
When a person is confronted with anxiety, their body undergoes several changes and
enters a special state called the fight-or-flight response. The body prepares to either
fight or flee the perceived danger.
During the fight-or-flight response it’s common to experience a “blank” mind, increased
heart rate, sweating, tense muscles, and more. Unfortunately, these bodily responses do
little good when it comes to protecting us from modern sources of anxiety.
Using a variety of skills, you can end the fight-or-flight response before the symptoms
become too extreme. These skills will require practice to work effectively, so don’t wait
until the last minute to try them out!
Deep Breathing
It’s natural to take long, deep breaths, when relaxed. However, during the fight-or-flight
response, breathing becomes rapid and shallow. Deep breathing reverses that, and sends
messages to the brain to begin calming the body. Practice will make your body respond
more efficiently to deep breathing in the future.
Breathe in slowly. Count in your head and make sure the inward breath lasts at least 5 seconds. Pay attention to the feeling of the air filling your lungs.
Hold your breath for 5 to 10 seconds (again, keep count). You don’t want to feel uncomfortable, but it should last quite a bit longer than an ordinary breath.
Breathe out very slowly for 5 to 10 seconds (count!). Pretend like you’re breathing through a straw to slow yourself down. Try using a real straw to practice.
Repeat the breathing process until you feel calm.
Imagery
Think about some of your favorite and least favorite places. If you think about the place
hard enough—if you really try to think about what it’s like—you may begin to have feelings
you associate with that location. Our brain has the ability to create emotional reactions
based entirely off of our thoughts. The imagery technique uses this to its advantage.
Make sure you’re somewhere quiet without too much noise or distraction. You’ll need a few minutes to just spend quietly, in your mind.
Think of a place that’s calming for you. Some examples are the beach, hiking on a mountain, relaxing at home with a friend, or playing with a pet.
Relaxation Techniques
TherapistAid.com © 2013 | Page 2
Paint a picture of the calming place in your mind. Don’t just think of the place briefly—imagine every little detail. Go through each of your senses and imagine what you would experience in your relaxing place. Here’s an example using a beach:
a. Sight: The sun is high in the sky and you’re surrounded by white sand. There’s no one else around. The water is a greenish-blue and waves are calmly rolling in from the ocean.
b. Sound: You can hear the deep pounding and splashing of the waves. There are seagulls somewhere in the background.
c. Touch: The sun is warm on your back, but a breeze cools you down just enough. You can feel sand moving between my toes.
d. Taste: You have a glass of lemonade that’s sweet, tart, and refreshing.
e. Smell: You can smell the fresh ocean air, full of salt and calming aromas.
Progressive Muscle Relaxation
During the fight-or-flight response, the tension in our muscles increases. This can lead to a
feeling of stiffness, or even back and neck pain. Progressive muscle relaxation teaches us
to become more aware of this tension so we can better identify and address stress.
Find a private and quiet location. You should sit or lie down somewhere comfortable.
The idea of this technique is to intentionally tense each muscle, and then to release the tension. Let’s practice with your feet.
a. Tense the muscles in your toes by curling them into your foot. Notice how it feels when your foot is tense. Hold the tension for 5 seconds.
b. Release the tension from your toes. Let them relax. Notice how your fingers feel differently after you release the tension.
c. Tense the muscles all throughout your calf. Hold it for 5 seconds. Notice how the feeling of tension in your leg feels.
d. Release the tension from your calf, and notice how the feeling of relaxation differs.
Follow this pattern of tensing and releasing tension all throughout your body. After you finish with your feet and legs, move up through your torso, arms, hands, neck, and head.
Progressive Muscle Relaxation Script
TherapistAid.com © 2014 | Page 1
Progressive muscle relaxation is an exercise that reduces stress and anxiety in your body by having you
slowly tense and then relax each muscle. This exercise can provide an immediate feeling of relaxation,
but it’s best to practice frequently. With experience, you will become more aware of when you are
experiencing tension and you will have the skills to help you relax. During this exercise each muscle
should be tensed, but not to the point of strain. If you have any injuries or pain, you can skip the affected
areas. Pay special attention to the feeling of releasing tension in each muscle and the resulting feeling of
relaxation. Let’s begin.
Sit back or lie down in a comfortable position. Shut your eyes if you’re comfortable doing so.
Begin by taking a deep breath and noticing the feeling of air filling your lungs. Hold your breath for a few
seconds.
(brief pause)
Release the breath slowly and let the tension leave your body.
Take in another deep breath and hold it.
(brief pause)
Again, slowly release the air.
Even slower now, take another breath. Fill your lungs and hold the air.
(brief pause)
Slowly release the breath and imagine the feeling of tension leaving your body.
Now, move your attention to your feet. Begin to tense your feet by curling your toes and the arch of your
foot. Hold onto the tension and notice what it feels like.
(5 second pause)
Release the tension in your foot. Notice the new feeling of relaxation.
Next, begin to focus on your lower leg. Tense the muscles in your calves. Hold them tightly and pay
attention to the feeling of tension
(5 second pause)
Release the tension from your lower legs. Again, notice the feeling of relaxation. Remember to continue
taking deep breaths.
Next, tense the muscles of your upper leg and pelvis. You can do this by tightly squeezing your thighs
together. Make sure you feel tenseness without going to the point of strain.
(5 second pause)
Progressive Muscle Relaxation Script
TherapistAid.com © 2014 | Page 2
And release. Feel the tension leave your muscles.
Begin to tense your stomach and chest. You can do this by sucking your stomach in. Squeeze harder and
hold the tension. A little bit longer.
(5 second pause)
Release the tension. Allow your body to go limp. Let yourself notice the feeling of relaxation.
Continue taking deep breaths. Breathe in slowly, noticing the air fill your lungs, and hold it.
(brief pause)
Release the air slowly. Feel it leaving your lungs.
Next, tense the muscles in your back by bringing your shoulders together behind you. Hold them tightly.
Tense them as hard as you can without straining and keep holding
(5 second pause)
Release the tension from your back. Feel the tension slowly leaving your body, and the new feeling of
relaxation. Notice how different your body feels when you allow it to relax.
Tense your arms all the way from your hands to your shoulders. Make a fist and squeeze all the way up
your arm. Hold it.
(5 second pause)
Release the tension from your arms and shoulders. Notice the feeling of relaxation in your fingers, hands,
arms, and shoulders. Notice how your arms feel limp and at ease.
Move up to your neck and your head. Tense your face and your neck by distorting the muscles around
your eyes and mouth.
(5 second pause)
Release the tension. Again, notice the new feeling of relaxation.
Finally, tense your entire body. Tense your feet, legs, stomach, chest, arms, head, and neck. Tense harder,
without straining. Hold the tension.
(5 second pause)
Now release. Allow your whole body to go limp. Pay attention to the feeling of relaxation, and how
different it is from the feeling of tension.
Begin to wake your body up by slowly moving your muscles. Adjust your arms and legs.
Stretch your muscles and open your eyes when you’re ready.
The Cognitive Model Thoughts Emotions Behaviors
© 2016 Therapist Aid LLC Provided by TherapistAid.com
Cognitive behavioral therapy (usually referred to as “CBT”) is based upon the idea that
how you think determines how you feel and how you behave. The diagram and example
below show us this process:
Something happens. It could be anything.
You have thoughts about what has just
occurred.
You experience emotions based upon
your thoughts.
You respond to your thoughts and feelings
with behaviors.
Example: Pharrell
Situation: A stranger scowls at Pharrell while passing him on the street.
Pharrell’s Thoughts: “I must’ve done something wrong… I’m so awkward.”
Pharrell’s Emotions: Embarrassed and upset with himself.
Pharrell’s Behaviors: Pharrell apologizes to the stranger and replays the situation over and over
in his head, trying to understand what he did wrong.
In this example, you might’ve noticed that Pharrell’s thought wasn’t very rational. The
stranger could’ve been scowling for any number of reasons. Maybe the stranger just got
dumped, or maybe he scowls at everyone. Who knows?
As humans, we all have irrational thoughts like these. Unfortunately, irrational or not,
these thoughts still affect how we feel, and how we behave. Consider how Pharrell
might’ve responded to the same situation if he had a different thought:
Thought Emotion Behavior
“What a jerk!” Angry Pharrell shouts: “What’s your problem?!”
“He must be having a bad day…” Neutral Pharrell walks away and forgets the incident.
Using the cognitive model, you will learn to identify your own patterns of thoughts,
emotions, and behaviors. You’ll come to understand how your thoughts shape how you
feel, and how they impact your life in significant ways.
Once you become aware of your own irrational thoughts, you will learn to change them.
The thoughts that once led to depression, anxiety, and anger will be replaced with new,
healthy alternatives. Finally, you will be in control of how you feel.
The Cognitive Model Practice Exercises
TherapistAid.com © 2015 | Page 1
Examples
See how two people can experience the same situation in different ways based upon
their thoughts. Each example depicts a negative and rational thought, and a typical
outcome of each thinking style.
Situation: Jason and Kurt both receive a negative evaluation at work.
Jason
Kurt
Negative Thought: “I can’t do anything right. I bet I get fired because of this!”
Rational Thought: “I guess I didn’t work hard enough—I’ll have to come up with a better plan for next time.”
Emotion: Depressed and nervous. Emotion: Disappointed but motivated.
Behavior: Jason avoids his boss because he believes he’s in trouble. He feels nervous the next time he’s confronted with challenging work, and performs poorly.
Behavior: Kurt seeks out his boss to talk about how he can improve. He approaches his next task as a challenge and gradually improves.
Situation: Gwen and Shirley both have an argument with a close friend.
Gwen
Shirley
Negative Thought: “We always argue! Why can’t she ever see my side? This is so unfair.”
Rational Thought: “That was rough—I should apologize. We can both be stubborn sometimes.”
Emotion: Angry and blaming. Emotion: Forgiving and regretful.
Behavior: Gwen stays angry at her friend and does not reach out to repair the relationship. Over time, Gwen’s friendship becomes more and more toxic.
Behavior: Shirley accepts a portion of the responsibility and apologizes to her friend. They communicate and continue to strengthen their relationship.
The Cognitive Model Practice Exercises
TherapistAid.com © 2015 | Page 2
Practice
Write down an alternative rational thought for each situation. What do you think the
resulting emotion and behavior might be?
Situation: Emily is cut off by another driver and has to quickly hit her brakes.
Negative Thought: “What a jerk! They don’t care about anyone but themselves. I could’ve crashed!”
Emotion: Angry
Behavior: Emily drives aggressively to provoke the driver who cut her off. Emily is still angry when she gets home, and yells at her family.
Rational Thought:
New Emotion and Behavior:
Situation: Travis notices his wife hasn’t helped around the house for a week.
Negative Thought: “Does she even care? She knows I’ll clean up, so she abuses my kindness!”
Emotion: Angry and sad.
Behavior: Travis lets the dishes pile up and doesn’t say anything to his wife. He doesn’t ask why she hasn’t helped, and becomes angrier when he assumes she’s just selfish.
Rational Thought:
New Emotion and Behavior:
The Cognitive Model Practice Exercises
TherapistAid.com © 2015 | Page 3
Situation: Regina is invited to a birthday party by an acquaintance.
Negative Thought: “I won’t know anyone at this party and I’ll just seem out of place. She probably invited me because she felt obligated.”
Emotion: Sad and anxious.
Behavior: Regina lies and tells her friend she already has plans for the night of her party. Regina and her friend fail to develop their friendship.
Rational Thought:
New Emotion and Behavior:
Situation: Thom notices a girl on the bus who keeps looking his direction.
Negative Thought: “Do I have something on my face? Is my fly down? Maybe I smell bad or something. I need to get home and take a shower.”
Emotion: Self-conscious and anxious.
Behavior: Thom avoids the girl and rushes off the bus without looking up from his shoes.
Rational Thought:
New Emotion and Behavior:
Cognitive Distortions
Provided by TherapistAid.com © 2012
Cognitive distortions are irrational thoughts that can influence your emotions. Everyone
experiences cognitive distortions to some degree, but in their more extreme forms they
can be harmful.
Magnification and Minimization: Exaggerating or minimizing the importance of
events. One might believe their own achievements are unimportant, or that their
mistakes are excessively important.
Catastrophizing: Seeing only the worst possible outcomes of a situation.
Overgeneralization: Making broad interpretations from a single or few events. “I felt
awkward during my job interview. I am always so awkward.”
Magical Thinking: The belief that acts will influence unrelated situations. “I am a good
person—bad things shouldn’t happen to me.”
Personalization: The belief that one is responsible for events outside of their own
control. “My mom is always upset. She would be fine if I did more to help her.”
Jumping to Conclusions: Interpreting the meaning of a situation with little or no
evidence.
Mind Reading: Interpreting the thought sand beliefs of others without adequate
evidence. “She would not go on a date with me. She probably thinks I’m ugly.”
Fortune Telling: The expectation that a situation will turn out badly without
adequate evidence.
Emotional Reasoning: The assumption that emotions reflect the way things really are.
“I feel like a bad friend, therefor I must be a bad friend.”
Disqualifying the Positive: Recognizing only the negative aspects of a situation while
ignoring the positive. One might receive many compliments on an evaluation, but focus
on the single piece of negative feedback.
“Should” Statements: The belief that things should be a certain way. “I should always
be friendly.”
All-or-Nothing Thinking: Thinking in absolutes such as “always”, “never”, or “every”. “I
never do a good enough job on anything.”
Active Listening
1. Pay Attention
Give the speaker your undivided attention, and acknowledge the message. Recognize that non-
verbal communication also "speaks" loudly.
Look at the speaker directly.
Put aside distracting thoughts.
Don't mentally prepare a rebuttal!
Avoid being distracted by environmental factors. For example, side conversations.
"Listen" to the speaker's body language.
2. Show That You're Listening
Use your own body language and gestures to convey your attention.
Nod occasionally.
Smile and use other facial expressions.
Note your posture and make sure it is open and inviting.
Encourage the speaker to continue with small verbal comments like yes and uh huh.
3. Provide Feedback
Our personal filters, assumptions, judgments, and beliefs can distort what we hear. As a listener,
your role is to understand what is being said. This may require you to reflect what is being said
and ask questions.
Reflect what has been said by paraphrasing. "What I'm hearing is," and "Sounds like you are
saying," are great ways to reflect back.
Ask questions to clarify certain points. "What do you mean when you say…", "Is this what
you mean?"
Summarize the speaker's comments periodically.
4. Defer Judgment
Interrupting is a waste of time. It frustrates the speaker and limits full understanding of the
message.
Allow the speaker to finish each point before asking questions.
Don't interrupt with counter arguments.
5. Respond Appropriately
Active listening is a model for respect and understanding. You are gaining information and
perspective. You add nothing by attacking the speaker or otherwise putting him or her down.
Be candid, open, and honest in your response.
Assert your opinions respectfully.
Treat the other person in a way that you think he or she would want to be treated.
Mind Tools Editorial Team (2016). Active listening: Hear what people are really saying. Retrieved from
https://www.mindtools.com/CommSkll/ActiveListening.htm
Reflections Communication Skill
TherapistAid.com © 2015 | Page 1
Using a technique called reflection can quickly help you become a better listener. When
reflecting, you will repeat back what someone has just said to you, but in your own words. This
shows that you didn’t just hear the other person, but you are trying to understand them.
Reflecting what another person says can feel funny at first. You might think the other person will
be annoyed at you for repeating them. However, when used correctly, reflections receive a
positive reaction and drive a conversation forward. Here’s an example:
Speaker: “I get so angry when you spend so much money without telling me.
We’re trying to save for a house!
Listener: “We’re working hard to save for a house, so it’s really frustrating when it
seems like I don’t care.”
Quick Tips
The tone of voice you use for reflections is important. Use a tone that comes across as a
statement, with a bit of uncertainty. Your goal is to express: “I think this is what you’re telling
me, but correct me if I’m wrong.” Your reflections don’t have to be perfect. If the other person
corrects you, that’s good! Now you have a better understanding of what they’re trying to say.
Try to reflect emotions, even if the person you’re listening to didn’t clearly describe them. You
may be able to pick up on how they feel by their tone of voice or body language.
Switch up your phrasing, or your reflections will start to sound forced. Try some of these:
“I hear you saying that…”
“It sounds like you feel…”
“You’re telling me that…”
Focus on reflecting the main point. Don’t worry too much about all the little details, especially
if the speaker had a lot to say!
Reflections Communication Skill
TherapistAid.com © 2015 | Page 2
Practice
“I was in a bad mood yesterday because work has been so stressful. I just can’t
keep up with everything I have to do.”
Reflection:
“I feel like I’m doing all of the work around the house. I need you to help me clean
and do the dishes more often.”
Reflection:
“I’ve been worried when you don’t answer your phone. I always think something
might’ve happened to you.”
Reflection:
“I don’t understand what she wants from me. First she says she wants one thing,
then another.”
Reflection:
Passive, Aggressive, and Assertive Communication
Provided by TherapistAid.com © 2012
Passive Communication
When using passive communication, an individual does not express their needs or
feelings. Passive individuals often do not respond to hurtful situations, and instead
allow themselves to be taken advantage of or to be treated unfairly.
Traits of passive communication: · Poor eye contact
· Allows others to infringe upon their rights
· Softly spoken
· Allows others to take advantage
Aggressive Communication
Aggressive communicators violate the rights of others when expressing their own
feelings and needs. They may be verbally abusive to further their own interests.
Traits of aggressive communication: · Use of criticism, humiliation, and domination
· Frequent interruptions and failure to listen to others
· Easily frustrated
· Speaking in a loud or overbearing manner
Assertive Communication
With assertive communication, an individual expresses their feelings and needs in a way
that also respects the rights of others. This mode of communication displays respect
for each individual who is engaged in the exchange.
Traits of assertive communication: · Listens without interrupting
· Clearly states needs and wants
· Stands up for personal rights
· Good eye contact
“I” Statements
Provided by TherapistAid.com © 2014
Taking responsibility for your feelings will help you improve your communication when you feel upset or angry. One way to achieve this is by using “I” statements. This technique will allow you to communicate what is upsetting while minimizing blaming. If our statements feel too blaming, the person we are trying to speak to will often become defensive.
“I” Statement format: “I feel ______ when you ______ because ______.”
Examples
Regular “You make me angry because you are always late”
“I” Statement “I feel frustrated when you come home late because I stay awake worrying.”
Regular “You never call. You don’t even care.”
“I” Statement “I feel hurt when you forget to call because it seems like you don’t care.”
Practice
Scenario Your friend keeps cancelling plans at the last minute. Last weekend you were waiting for them at a restaurant when they called to tell you they would not be able to make it. You left feeling hurt.
“I” Statement
Scenario You are working on a project with a group and one member is not completing their tasks on time. You have repeatedly had to finish their work which has been very frustrating.
“I” Statement
Scenario A friend who borrows movies from you usually brings them back damaged. They want to borrow one again but you’re feeling worried.
“I” Statement
Responding Assertively to Criticism
Dealing with Constructive Criticism
We all need to be able to accept constructive criticism. Depending on the way the criticism
is presented to you, you can respond in a number of different ways.
1. Accept the criticism
If the criticism is valid then just accept it without expressing guilt or other negative
emotions. Accept that you are not perfect and that the only way we can learn is to
make mistakes, see what we need to change and move on. Thank the person for the
feedback if appropriate. See the criticism as a gift.
2. Negative assertion
This technique involves not only accepting the criticism but openly agreeing with the
criticism. This is used when a true criticism is made to you. The skill involves calmly
agreeing with the criticism of your negative qualities, and not apologizing or letting
yourself feel demolished. For example, someone may say:
Criticism: “Your desk is very messy. You are very disorganized”.
Response: “Yes, it’s true, I’m not very tidy”.
The key to using negative assertion is self-confidence and a belief that you have the
ability to change yourself if you wish. By agreeing with and accepting criticism, if it is
appropriate, you need not feel totally demolished. This type of response can also
diffuse situations. If someone aggressive is making the criticism they may expect you
to become defensive or aggressive back. By agreeing with them the tension in the
situation is diffused.
3. Negative inquiry
Negative inquiry consists of requesting further, more specific criticism. If someone
criticizes you but you are not sure if the criticism is valid or constructive you ask for
more details. For example:
Criticism: “You’ll find that difficult won’t you, because you are shy?”
Response: “In what ways do you think I’m shy?”
If the criticism is constructive, that information can be used constructively and the
general channel of communication will be improved. If the criticism is manipulative or
destructive then the critic will be put on the spot.
Dealing with Destructive Criticism
Unfortunately we are all going to encounter destructive criticism at some point in our lives.
This can be more difficult to deal with than constructive criticism. If we practice the
techniques below, we can become skilled at dealing with these difficult situations. As with
all skills remember it will take practice and some time to feel confident using these skills.
You will notice that some of the skills are the same as for dealing with constructive
criticism.
1. Disagree with criticism
The first technique for dealing with destructive criticism is simply to disagree with it. It
is important that you remain calm and watch your non-verbal behaviors including tone
of voice as you do this as it is easy to become aggressive or passive when disagreeing.
Keep your voice calm, your eye contact good. For example:
Criticism: “You’re always late”.
Response: “No, I’m not always late. I may be late occasionally, but I’m certainly not
always late”.
2. Negative Enquiry
As described above, if someone makes a comment you may not be sure if it is
constructive or destructive criticism. We need to check what is meant. If the criticism is
destructive then we can either disagree with it as above, or we can use one of the
diffusion techniques described below.
3. Fogging aka Clouding aka Diffusion
The three names above all refer to the same techniques. The idea behind the
techniques is to defuse a potentially aggressive or difficult situation. You can use this
style when a criticism is neither constructive nor accurate. The tendency for most
people when presented with destructive criticism is either to be passive and crumble
or be aggressive and fight back. Neither of these are good solutions. Essentially what
the techniques do is find some way of agreeing with a small part of what an antagonist
is saying. By staying calm and refusing to be provoked or upset by the criticism you
remove its destructive power.
Example 1:
Criticism: “You’re not reliable. You forgot to pick up the kids, you let the bills pile up
until we could lose the roof over our head, and I can’t ever count on you to be there
when I need you.”
Response: “You’re certainly right that I did forget to pick up the kids last week after
their swimming lesson.”
Example 2:
Criticism: “If you don’t floss your teeth, you’ll get gum disease and be sorry for the
rest of your life.”
Response: “You’re right I may get gum disease.”
Additional tips to remember when being criticized:
1. Respond to the words not the tone of the criticism.
It is important when you are being criticized to separate the suggestions in the
criticism from the way that they are being spoken to you. Often when people are giving
criticism they can come across as confrontational, even aggressive. This may mean that
we dismiss what they are saying despite the fact that the criticism may be a useful one.
We need to practice separating the criticism from the style of criticism. Even if people
speak in an angry manner, we should try to detach their emotion from the useful
suggestions which lie underneath.
2. Don’t Respond Immediately.
It is best to wait a little before responding. If we respond with feelings of anger or
injured pride we will soon regret it. If we wait patiently it can enable us to reflect in a
calmer way.
3. When Feeling Criticized:
1. Stop - Don’t react until you are sure what is going on.
2. Question – have you really been criticized? Are you mind-reading?
3. Check if you need to by asking the other person. For example, you can say: “What did
you mean by that?”
4. Once you have worked out if it is really a criticism, decide if it is valid or not and
respond using one of the techniques above.
Michel, F. & Fursland, A. (2008). Assert yourself: How to deal assertively with criticism.
Retrieved from http://www.cci.health.wa.gov.au/docs/Assertmodule%207.pdf
Dealing with Aggressive People
It is almost certain that we will have to deal with aggressive people in our lives. Aggression
arises during a conflict when one person feels the need to protect their interests or fight
to gain something, often at the expense of others. So let’s be clear that aggression
is something at our expense.
First of all, you can recognize an aggressive person if:
They interrupt you or talk loudly to keep you from speaking.
They do not allow your point of view and input.
You often have the sense that your boundaries are being crossed.
Interaction with the person usually leads to tension.
You feel energetically and emotionally exhausted after interacting with them.
Unfortunately, we can’t avoid these people. So we need to find a solid balance between
assertiveness and empathy to deal with them. Follow these 5 steps to master the art
of dealing with aggressiveness.
Keep Your Cool
Fighting fire with fire will only make things worse and spur the other person’s aggression.
A few tips for staying calm, even when you feel like you’re bursting with anger:
Take a deep breath.
Get up to get a glass of water or your phone. Doing something else diffuses the
tension that is building up in the moment.
Think of how much you will regret the things you might say out of anger.
Point Them Out
Call it as you see it. Don’t go along with the conversation as if nothing is bothering you.
However, you need to point out that the other person is being aggressive with
an empathetic statement rather than agitating them even more. Avoid using the words
’you’ or ’your,’ and try something along the lines of:
’There is no need to stress, we will resolve it/find a way/work it out.’
’Could you please lower your voice.’
If you do this early on, it will help knock them out of the place of being unaware
of themselves and be more conscious of what they are doing. As a result, it can help the
person be more open to hearing whatever you say.
Empathize
Put yourself in the other person’s shoes, and try to understand the reasons why he/she
is being aggressive. As we mentioned above, aggression is a natural reaction in order
to protect or claim something. Try to consider:
How would you feel if you were in that situation?
Is there something else going on in the person’s life that makes him/her generally
very easily agitated and quick-tempered?
Be Assertive
It might sound contradictory that you can be empathetic and assertive, but one doesn’t
exclude the other. Understanding the other person’s position does not mean you will allow
them to be aggressive.
Keep your voice low and steady. This will show confidence and will not spur the
other person into trying to talk more loudly than you.
Stand your ground, and don’t allow the person to monopolize the discussion. Speak
out on your opinion.
Remain respectful, and ask for the same respect in return.
If the level of aggression begins to increase, respond with more force and
assertiveness to show that your tolerance is decreasing.
Focus
If someone is overtaken by their emotions, they lose sight of the matter at hand and how
the whole argument even started! By focusing the conversation on the important things
and facts, you are helping the other person revert to thinking and reasoning. For example:
’All that matters is that...’
Try to make the other person laugh as it will completely disarm them.
Brightside.me (2016). 5 Tips for Dealing with Aggressive People. Retrieved from
http://brightside.me/inspiration-psychology/5-steps-for-dealing-with-aggressive-people-
175755/
Fair Fighting Rules
Provided by TherapistAid.com © 2014
Before you begin, ask yourself why you feel upset. Are you truly angry because your partner left the mustard on the counter? Or are you upset because you feel like you’re doing an uneven share of the housework, and this is just one more piece of evidence? Take time to think about your own feelings before starting an argument.
Discuss one issue at a time. “You shouldn’t be spending so much money without talking to me” can quickly turn into “You don’t care about our family”. Now you need to resolve two problems instead of one. Plus, when an argument starts to get off topic, it can easily become about everything a person has ever done wrong. We’ve all done a lot wrong, so this can be especially cumbersome.
No degrading language. Discuss the issue, not the person. No put-downs, swearing, or name-calling. Degrading language is an attempt to express negative feelings while making sure your partner feels just as bad. This will just lead to more character attacks while the original issue is forgotten.
Express your feelings with words and take responsibility for them. “I feel angry.” “I feel hurt when you ignore my phone calls.” “I feel scared when you yell.” These are good ways to express how you feel. Starting with “I” is a good technique to help you take responsibility for your feelings (no, you can’t say whatever you want as long as it starts with “I”).
Take turns talking. This can be tough, but be careful not to interrupt. If this rule is difficult to follow, try setting a timer allowing 1 minute for each person to speak without interruption. Don’t spend your partner’s minute thinking about what you want to say. Listen!
No stonewalling. Sometimes, the easiest way to respond to an argument is to retreat into your shell and refuse to speak. This refusal to communicate is called stonewalling. You might feel better temporarily, but the original issue will remain unresolved and your partner will feel more upset. If you absolutely cannot go on, tell your partner you need to take a time-out. Agree to resume the discussion later.
No yelling. Sometimes arguments are “won” by being the loudest, but the problem only gets worse.
Take a time-out if things get too heated. In a perfect world we would all follow these rules 100% of the time, but it just doesn’t work like that. If an argument starts to become personal or heated, take a time-out. Agree on a time to come back and discuss the problem after everyone has cooled down.
Attempt to come to a compromise or an understanding. There isn’t always a perfect answer to an argument. Life is just too messy for that. Do your best to
come to a compromise (this will mean some give and take from both sides). If you can’t come to a
compromise, merely understanding can help soothe negative feelings.
Stress Management Group Wrap-Up
Putting it All Together
Week 1 What is Stress?
Defining Stress
Causes of Stress
Positive vs. Negative Stress
Effects of Stress
The Stress Cycle(s)
Week 2 Relaxation Techniques
What is relaxation?
How to Relax
Practicing Relaxation
Week 3 Cognitive Restructuring
The Cognitive Model
What is cognitive restructuring?
Cognitive Distortions
Week 4 Active Listening
What is listening?
Active Listening
Reflections
Week 5 Practicing Stress Management
What does a playing stressful game teach us about managing our stress?
Week 6 Assertiveness
Passive vs. Aggressive vs. Assertive Communication
More on Assertive Communication
“I” Statements
Week 7 Receiving Criticism & Dealing with Aggression
Responding to Criticism Assertively
Turning Destructive Criticism into Constructive Criticism
Dealing with Aggression
Week 8 Putting it All Together
What did we learn about stress and how to manage it?
What techniques did you gain for emptying your cup?
What strategies did you gain for keeping your cup from filling up?
Why did we spend so much time talking about talking?
MINDFULNESS-BASED STRESS REDUCTION IMPROVES LONG-TERM MENTAL FATIGUE AFTER STROKE OR TBIJOHANSSON, B., BJUHR, H., & RONNBACK, L. | DECEMBER 2012 | BRAIN INJURY
PARTICIPANTS
¡ Inclusion criteria included:¡ Diagnosis of Acquired Brain Injury (Stroke or TBI)
¡ Aged 30-65
¡ 12 months or more post-injury
¡ Glasgow Outcome Scale (GOS) score of moderate disability or higher
¡ Mental Fatigue Self-Assessment (MFS) score of 10/25 or higher
¡ 29 participants included in study
¡ 15 participants included in MBSR Group 1, 14 participants included in Control Group/MBSR Group 2
¡ 22 participants completed MBSR program, 12 in Group 1 and 10 in Group 2
¡ 12 females and 11 males completed MBSR program
INTERVENTION
¡ Mindfulness-Based Stress Reduction
¡ “a structured public health intervention to cultivate mindfulness in medicine, healthcare and society” (p. 1623)
¡ Includes gentle mindfulness yoga, progressive relaxation/body scanning, sitting guided meditation, and active meditations
¡ Studied MBSR Program
¡ 8-week program
¡ One 2.5-hour long group session per week
¡ 45-minute home practice 6 days per week with guided instructions and CDs
ASSESSMENT MEASURES
¡ Assessment measures included:
¡ Mental Fatigue Self-Assessment (MFS)
¡ Comprehensive Psychopathological Rating Scale (CPRS) for depression and anxiety
¡ Neuropsychological tests such as the Trail Making Test and tests for digit coding/span and verbal fluency
¡ Participants assessed at baseline and post-intervention
¡ MBSR Group 1 participants assessed at baseline and upon completion of MBSR program
¡ Control Group/MBSR Group 2 participants assessed at baseline, upon Group 1’s completion of MBSR program, and upon completion MBSR program
¡ Primary end-point measure MFS score
¡ Secondary end-point measures neuropsychological test results, specifically information processing speed and attention
RESULTS
(p.1623)
RESULTS
¡ MFS score improvements of about 5 points for both groups post-intervention
¡ No change in MFS score for Control Group
¡ Significant decreases in general and mental fatigue, sensitivity to stress, depressed feelings, anxiety, pessimistic thoughts, irritability, concentration difficulty, and slowness of thinking post-intervention
¡ Significant increases in sleep quality and processing speed post-intervention
¡ Results independent of time since injury, gender, other demographic factors
¡ Researchers acknowledge deficits related to ABI a barrier for participation in MBSR programs, but emphasize that the intervention’s adaptability and repetitive, guided nature make it successful in increasing attention and decreasing mental fatigue
APPLICATION
¡ MBSR “offers strategies to better handle stressful situations appropriately and economize with mental energy” (p. 1627)
¡ How can we bring these benefits to ResCare Premier Texas?
¡ Extending group learning by integrating topics throughout groups and ensuring that they permeate daily programming
¡ Supporting home practice by supporting direct care staff
REFERENCE
Johansson, B., Bjuhr, H., & Ronnback, L. (2012). Mindfulness-based stress seduction improves long-term mental fatigue after stroke or TBI. Brain Injury, 26, 1621-1628.
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Mindfulness-basedstressreduction(MBSR)improveslong-termmentalfatigueafterstrokeortraumaticbraininjury
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Brain Injury, December 2012; 26(13–14): 1621–1628
ORIGINAL ARTICLE
Mindfulness-based stress reduction (MBSR) improves long-termmental fatigue after stroke or traumatic brain injury
B. JOHANSSON, H. BJUHR, & L. RONNBACK
Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska
Academy, University of Gothenburg, Gothenburg, Sweden
(Received 31 August 2011; revised 28 May 2012; accepted 30 May 2012)
AbstractObjective: Patients who suffer from mental fatigue after a stroke or traumatic brain injury (TBI) have a drastically reducedcapacity for work and for participating in social activities. Since no effective therapy exists, the aim was to implementa novel, non-pharmacological strategy aimed at improving the condition of these patients.Methods: This study tested a treatment with mindfulness-based stress reduction (MBSR). The results of the programmewere evaluated using a self-assessment scale for mental fatigue and neuropsychological tests. Eighteen participants withstroke and 11 with TBI were included. All the subjects were well rehabilitated physically with no gross impairmentto cognitive functions other than the symptom mental fatigue. Fifteen participants were randomized for inclusion in theMBSR programme for 8 weeks, while the other 14 served as controls and received no active treatment. Those who receivedno active treatment were offered MBSR during the next 8 weeks.Results: Statistically significant improvements were achieved in the primary end-point—the self-assessment for mentalfatigue—and in the secondary end-point—neuropsychological tests; Digit Symbol-Coding and Trail Making Test.Conclusion: The results from the present study show that MBSR may be a promising non-pharmacological treatmentfor mental fatigue after a stroke or TBI.
Keywords: Mental fatigue, TBI, stroke, MBSR, mindfulness, information processing speed, attention
Introduction
Mental fatigue is common and disabling aftera stroke or traumatic brain injury (TBI) [1–3]. Thesymptom is included in (and defined within) thediagnoses Mild cognitive impairment, Neurastheniaand Post-traumatic brain syndrome. Persistentmental fatigue is also commonly reported after TBIand stroke, irrespective of severity [4–8]. The personwho suffers from this mental fatigue is able toperform activities involving mental effort for shortperiods only and, notably, it will take longer thannormal to restore energy levels after beingexhausted. This mental fatigue will make it moredifficult for the person to return to work and
participate in social activities. Accompanying symp-toms, such as irritability, sensitivity to stress, con-centration difficulties, emotional instability andheadache may further impair social interactions [2,9–11]. Many suffer for years in the absence of anadequate treatment.
It was estimated that 30% of TBI victims sufferfrom severe fatigue 6 months after the injury [12].Improvement was reported during the first year,after which it was limited [13]. Thus, up to 70%reported fatigue 5 years after TBI [6] and O’Connoret al. [14] reported that the fatigue may be presenteven 10 years after the trauma. The degree of mentalfatigue after TBI is not related to the severity of the
Correspondence: Birgitta Johansson, Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The SahlgrenskaAcademy, University of Gothenburg, Per Dubbsgatan 14, 1tr, SE 413 45 Gothenburg, Sweden. Tel: þ46-31-3421000. Fax: þ46-31-3422467.E-mail: [email protected]
ISSN 0269–9052 print/ISSN 1362–301X online � 2012 Informa UK Ltd.DOI: 10.3109/02699052.2012.700082
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brain injury, age or time since injury [8]. Factorswhich could be significant in determining whetherthe mental fatigue will be referred to as persistentinclude genetic variations [15] as well as previouspsychiatric disease [16]. Furthermore, fatigue afterbrain injury was suggested not to be explained as aneffect of depression, pain or sleep disturbance [17].Persistent mental fatigue is also commonly reportedafter stroke, irrespective of severity [4, 5, 7, 18–21].
Mental fatigue is suggested to be a diffuse ormulti-focal brain disorder [22] related to decreasedneuronal efficiency [3], with extreme sensitivity tomental and concentration activities [23]. The con-nection to concentration activities is clearly noticedin the fluctuation in the fatigue over daytime, withmorning most often reported as the best time of theday and afternoon and evening being the worst [9].Azouvi et al. [24] proposed that mentally tiringactivities after brain injury are related to reducedresources and that patients with brain injury alsodescribe mental activity as more energy-demandingthan healthy persons. After a severe TBI, subjectsshowed an increase in reaction time during a dual-task condition and reported a higher subjectivemental effort. TBI subjects also performed sloweron a complex attention test, made more errorsand reported a higher level of subjective fatigue [25].These results reflect the recent results from thisgroup [9].
For some individuals affected by long lastingmental fatigue, it can take several years to find theright balance between rest and activity in daily life,find strategies and to accept the new situation.Since no effective therapy exists today, the authorshave endeavoured, in this study, to find a suitablemethod with the intention of relieving the long-termburdens of mental fatigue including concentrationproblems and helping patients to find a balancein the performance of ordinary activities and accep-tance in their daily lives. Therefore, a treatmentwith mindfulness-based stress reduction (MBSR)was tested. MBSR is designed for an heterogeneouspopulation. It is an educational programme, notabout training to remove something unwanted,but rather to learn to live life to the fullest. MBSRis a clinically effective method for a wide rangeof conditions as stress, depression, pain and fatigueand cancer, with the potential of helping individualsto cope better with their difficulties [26–29].Mindfulness meditation is also suggested to belinked to improvement in attention and cognitiveflexibility [30] and changes in brain neuronal con-nectivity, with indicated improved attention [31].
The effect with MBSR on mental fatigue afterTBI and stroke has not previously been studied.It is hypothesized that, compared to the waitlistregime, patients randomly assigned to the MBSR
programme will experience improvement at 8 weeksin their assessment of mental fatigue (MFS).This study used the following as end-points: a self-evaluation questionnaire for mental fatigue (MFS,mental fatigue scale) [10] and neuropsychologicaltests to determine processing speed, attention andworking memory, all cognitive functions connectedto mental fatigue after TBI and stroke [9].
Materials and methods
Subjects
Twenty-nine stroke or TBI victims were included.They were all healthy and held positions of employ-ment before falling ill or becoming injured. Allparticipants had recovered from neurological symp-toms but had been suffering from pathologicalmental fatigue for at least 1 year before inclusion.In comparison with healthy subjects, the cognitivelevel was very similar to the anticipated level indi-cated in the standardized norms relating to neuro-psychological tests and also in comparison with thefindings of previous studies of participants withmild TBI, also suffering from mental fatigue [9].At the start of the study, each person had attaineda steady-state level concerning social and occupa-tional performance. The persons included in thestudy were recruited from an advertisement in a localdaily newspaper. Both men and women wereincluded. All participants provided an informedconsent. The study was approved by the EthicalReview Board, Gothenburg, Sweden, dno. 408-10.
Inclusion criteria
(1) Subjects who, >12 months earlier, suffered astroke or TBI.
(2) Aged 30–65.(3) Glasgow Outcome Scale (extended), moderate
disability (�5) or a score indicating a higherlevel of recovery.
(4) Self-assessment questionnaire for mental fati-gue, with a score of 10 or higher.
Exclusion criteria
(1) Significant co-morbidity including psychiatricor neurological disorder. No history of alcoholor drug abuse.
(2) Significant cognitive impairment.
Medication permitted
Stable therapies were allowed. This was defined astherapies which had started at least 6 months before
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inclusion and had continued unchanged duringthe study period.
Description of study
The participants were randomized, either to theMBSR group 1 or to the control group who wereplaced on a waitlist for the MBSR programme ata later stage (MBSR group 2, Figure 1). All wereassessed before the start and after 8 weeks. Fifteenindividuals were included in the MBSR group 1programme. One of the participants decided not tostart. Furthermore, extensive cognitive difficultiesbecame apparent during the pre-assessment for oneparticipant and that person would not have beenable to start on the basis of the inclusion criteria.However, the person wanted to try the MBSRprogramme, but stopped after the first session, as itwas not possible to follow the instructions forthe programme. During the MBSR programme,one dropout was reported after 3 weeks. A total of12 persons completed the MBSR programme(group 1). The control group on waitlist for MBSRconsisted of 14 persons. One of the controls declinedthe MBSR programme offered at a later stage, dueto a shortage of time. The travel to the sessions wastoo taxing for one person who was extremely tired.Two persons dropped out after one and threesessions, respectively. Ten persons subsequentlycompleted the second MBSR group programme(group 2).
MBSR method
MBSR is a structured public health interventionto cultivate mindfulness in medicine, healthcareand society. It includes a range of both formaland informal practices. The intervention is based onKabat Zinn’s [32] MBSR programme. The formalpractices in MBSR are described by Cullen [33] andinclude gentle Hatha yoga (with an emphasison mindful awareness of the body), the body scan(designed to systematically, region-by-region, culti-vate awareness of the body without tensing andrelaxing of muscle groups associated with progres-sive relaxation) and sitting meditation (awarenessof the breath and systematic widening the fieldof awareness to include all four foundations ofmindfulness: awareness of the body, feeling tone,mental states and mental contents). As such, the
intention of MBSR is much greater than simplestress reduction. The programme consists of eightweekly �2.5-hour long group sessions, one day-longsilent led retreat between session six and sevenand home practice of �45 minutes, 6 days a week.They received guided instructions and CDs forhome practice.
Measures
The assessments included self-assessment of men-tal fatigue (MFS), the level of depression andanxiety and neuropsychological tests. The MFSis a multidimensional questionnaire containing15 questions [9, 10]. It incorporates affective,cognitive and sensory symptoms, duration of sleepand day-time variation, all common symptoms afterbrain injury and stroke [11]. The ComprehensivePsychopathological Rating Scale (CPRS) was usedfor depression and anxiety [34]. The neuropsycho-logical tests measured information processing speed,attention and working memory. The tests includedwere Digit Symbol-Coding and Digit Span from theWAIS-III scale [35], the FAS verbal fluency test [36]and the Trail Making Test (TMT) A and B [37].A series of new Trail Making Tests (C, D) wereconstructed to evaluate higher demands such as dualtasks. The tests were constructed with three and fourfactors, respectively [9]. Reading speed was mea-sured with a test used for dyslexia screening [38].
End-points
The primary end-point was to investigate the ther-apeutic effects of MBSR as measured by the MFS.Secondary end-points were the results from neuro-psychological tests, with specific focus on informa-tion processing speed and attention.
Statistical analysis
A comparison between the groups was made andthe ANCOVA analysis of covariance was conductedfor this purpose. The paired t-test was usedfor repeated measurements within groups. TheMann-Whitney U-test was used when analysingseparate items included in the self-assessmentscales. The Bonferroni adjustment was used aftermultiple comparisons. Pearson’s correlation wasused to find the correlation between mental fatigueand processing speed. SPSS 16.0 for Windows wasused for data analysis.
Results
Demographic data
No significant differences in age and education werefound between the MBSR group 1 and the control
Figure 1. Schematic presentation of study design.
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group on waitlist, but the control group reporteda longer time since brain injury or stroke (Table I).However, there were no variables which correlatedsignificantly to time since injury or stroke. As agehas an effect on cognitive function and the timesince injury differed, ANCOVA analysis of covari-ance was conducted to adjust for differences invariables relating to age and time since injury/stroke.Furthermore, no differences were found betweengender and type of disorder in any of the variablesincluded in the self-assessment and the measure-ments of cognitive functions.
Self-assessment scales
The MBSR group 1 and the control groupon waitlist did not differ significantly in their
self-assessment of MFS at the start of the pro-gramme (ANCOVA, F¼ 1.16, p¼ 0.29), but therewas a significant difference between the two groupsafter 8 weeks (F¼8.47, p¼ 0.008, Figure 2). Theparticipants who completed the MBSR programme(group 1) showed a decline in their self-assessmentof MFS (paired T-test, p¼ 0.004), while the controlgroup was unchanged during the 8 weeks (pairedT-test, p¼ 0.89, Figure 2). The control groupcompleted the MBSR programme (MBSR group2) at a later stage and they also showed a similar andsignificant decline in the MFS after 8 weeks ofMBSR (p¼ 0.002, Figure 2). Depression and anx-iety were not changed when comparing the MBSRand control group on pre- and post-test. However,a repeated measure (paired t-test) detected signifi-cantly decreased scores over time for both MBSR
Figure 2. Mean (� SEM) score for reported mental fatigue (MFS). Test 1 (pre-test) before MBSR or controls on waitlist and test2 (post-test) after 8 weeks with MBSR or controls on waitlist. MBSR group 2 (the former controls on waitlist) before and after MBSR(tests 2 and 3).
Table I. The distribution of individuals according to the following groups: age, education, sick leave, time sinceinjury or stroke and also the distribution and numbers of males and females.
MBSRgroup 1
Control groupon waitlist
MBSRgroup 2
Number of persons who completed the programme 12 14 10Age (M�SD) 53.7� 6.11 57.1� 7.26 59.1� 6.3Years since TBI/stroke (M�SD) 3.3� 3.84 9.8� 7.54 10.5� 8.42Education (years, M�SD) 15.9� 2.2 15.5� 3.2 15.5� 3.3Females/males 5/7 10/4 7/3TBI/stroke 5/7 5/9 5/5Numbers on sick leave (0, 25, 50 or 100%) 3–0% 2–0% 2–0%
1–25% 2–25% 1–25%2–50% 0–50% 0–50%1–75% 1–75% 1–75%5–100% 9–100% 6–100%
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groups for depression (MBRS group 1, p¼ 0.006;MBSR group 2, p¼0.002) and anxiety (MBRSgroup 1, p¼ 0.004; MBSR group 2, p¼ 0.02).No such changes were found for the control groupon waitlist (depression, p¼0.84; anxiety, p¼ 0.79).The anxiety and depression scores were low(Figure 3).
Separate questions included in the
self-assessment scales
As both groups who received MBSR changed in avery similar pattern for MFS and CPRS, the twogroups were grouped together for the statisticalanalysis of separate items (24-hour variation notincluded here, Figure 3). The items from the MFS,tiredness, mental fatigue, mental recovery, slownessof thinking and sensitivity to stress were significantlydecreased after MBSR. The over-lapping items wereon an intermediate level and the items which weresignificantly decreased were irritability and lackof initiative, while none of the specific items fordepression and anxiety from CPRS were signifi-cantly decreased (Mann-Whitney, corrected formultiple comparison using the Bonferroni-Holmapproach). In total, there were higher scores forthe items included in the mental fatigue scalecompared with the items depression and anxiety inthe present study.
The report showing a distinct difference in24-hour variation was not included in the aboveanalysis as it only measures yes or no. Eight of theparticipants in the MBSR group 1 were reported ashaving a clear 24-hour variation during the day and,of these, seven participants reported morning to bethe best time of day, both at pre- and post-test.From the waitlist group, 13 participants reporteda distinct 24-hour variation and, for 10 of these,morning was the best time of day and, at the post-test, 11 reported a 24-hour variation.
Cognitive tests
Between-group analysis. The MBSR group 1 andthe control group on waitlist did not differ signifi-cantly on the cognitive tests at the pre-test, exceptthat MBSR group 1 was faster than controls onTMT A (p¼ 0.049). This effect was similar atthe post-test (p¼ 0.032). This may reflect a slightdifference between the groups from the outset.However, the between-group analysis detected asignificant effect after 8 weeks. The MBSR group 1performed TMT B and TMT C faster than controlson waitlist (ANCOVA, TMT B; F¼7.39, p¼ 0.013,TMT C; F¼ 4.84, p¼ 0.039, Figure 4). TMT Bis considered as a divided attention test. However,after adjustment for processing speed in this study(TMT A was used as a covariate; TMT A is mainlyfocused on visual scanning and motor speed), the
Figure 3. The figure shows the median values for each self-assessed item for the mental fatigue (MFS) and depression and anxiety (CPRS)scales before and after the MBSR programme. Items occurring in both scales are encircled. Both groups who received MBSR are groupedtogether in the figure, since there was a very similar pattern in the changes in these groups for mental fatigue and depression and anxiety.In the figure, higher scores reflect a more severe symptom. A rating of 0 corresponds to normal function, 1 indicates a problem, 2 indicatesa pronounced symptom and 3 indicates a maximal symptom.
Mindfulness (MBSR) and mental fatigue 1625
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effect disappeared, for TMT B and TMT C, indi-cating a limitation in processing speed. The sameeffect for TMT B was reported by Felminghamet al. [39].
Within-group analysis. Repeated measures (pairedt-test) within the separate groups revealed a signif-icant improvement on TMT C as well as DigitSymbol-Coding for both groups after MBSR(TMT C; group 1: p¼ 0.001, group 2: p¼ 0.007,digit coding; group 1: p¼ 0.026, group 2: p¼ 0.028,Figure 4). A significantly improved result wasalso found for the MBSR group 1 on TMT B(p¼0.017). No significant changes over time weredetected for the control group on waitlist. A signif-icant increase in word fluency over time was alsoreported for the MBSR group 1 (p¼ 0.050) andgroup 2 (p¼ 0.044), but not for the control group(p¼0.081). No significant changes were found forworking memory, TMT A, D and reading speed.
Correlation between changes in mental fatigue and
information processing speed
The participants from the two MBSR groupsimproved in a similar way, both in MFS (less totalscore) and increased processing speed (more cods/2 minutes, Digit Symbol-Coding). The difference inimprovement between pre- and post-test were usedin a correlation analysis and a significant correlationfor improvement in mental fatigue and informationprocessing speed was detected (r¼�0.48, p¼ 0.023,Figure 5).
Discussion
According to this study, MBSR appears promisingfor the treatment of persons suffering from mentalfatigue after stroke or TBI, as statistically significant
results were obtained from both primary andsecondary end-points (MFS and tests quantifyinginformation processing speed, respectively).Improvement was independent of gender, typeof injury, as well as time since injury or strokeand age.
No other studies have been performed to deter-mine the effect of MBSR on mental fatigue.However, a small study of 10 subjects who wereincluded in the MBSR programme for 12 weeks aftermild TBI showed significantly improved quality-of-life and decreased depression [40]. However,a randomized study with a short MBSR programme,over a 4-week period, did not detect any subjectiveor cognitive changes [41].
Mental fatigue theories suggest that cognitiveactivities require more resources than normal [24]and result in a greater neural activity compared
Figure 4. Cognitive tests (mean�SEM). Trail Making Test B and C and Digit Symbol-Coding shown for MBSR group 1 before and afterMBSR, controls on waitlist before and after the 8 weeks and also the effect of MBSR for group 2.
Figure 5. There was a significant correlation (r¼�0.48,p¼ 0.023, post- minus pre- test value was used) betweendecreased mental fatigue (MFS) and improved processing speed(Digit Symbol-Coding) after MBSR for both groups.
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to controls during a given mental activity [42]. Thisindicates an increased cerebral effort after braininjury. One reason why MBSR was effective maybe that this treatment offers strategies to betterhandle stressful situations appropriately and econo-mize with mental energy.
Mindfulness intervention is fundamentally basedon a disciplined practice which involves cultivatingawareness for the present moment in order tobecome wise and compassionate, awake and aware.For people suffering from mental fatigue this causesa dilemma, since tiredness, which is named as one ofthe classical hindrances to cultivating mindfulnessin the Buddhist scriptures, is more or less constantlypresent. Interestingly, after three or four MBSRsessions together with the teacher, the participantsattended the sessions more awake and the introduc-tion of new techniques with more physical involve-ment as yoga and walking meditation facilitatedfocused attention. Through the programme newtechniques for everyday use were practiced inthe struggle to find a good balance between activityand rest.
Difficulties remembering newly-introduced prac-tices were common among the participants, as wellas difficulties remembering themes from group dis-cussions and learning dialogues with the teacher.Considerations were taken to this and also to theparticipants needs for more time to pause and reflect.The main themes and content of the programme wassecurely kept and repeated. Overall, adaptationof the programme were required to find a tempo ofteaching and enable learning and insights withoutleaving the participants more tired by the full agendaand rich content of the programme.
Meditation techniques in healthy subjects weresuggested to improve attention performances,processing speed and cognitive flexibility [30].Mindfulness meditation (MBSR) is also associatedwith changes in brain activity involved in attention[31, 43]. Subjects with mental fatigue have difficul-ties within these domains and will easily becomeeven more fatigued if the activity is not adapted totheir capabilities. It is, therefore, interesting to seethat MBSR seems to increase attention and alsoprocessing speed. Mental fatigue may be caused by adysfunction or imbalance in the signalling system(s)in the brain and that the brain works with lessprecision [42]. Improvements in the neural networkmay have been achieved during the course of thisstudy.
Limitations
A limitation of this study is that the numbers ofparticipants were relatively small. More participantsare warranted to be included in future studies and it
is anticipated that the study effects over time of suchstudies will be extremely valuable.
Conclusion
Patients suffering from mental fatigue after a strokeor TBI are an extremely important group to identifyand treat, from healthcare and socio-economicpoints of view, due to their impaired capacity towork. There is currently no therapy available to treatthis symptom. Therefore, novel therapies, bothpharmacological and non-pharmacological, wouldbe of the utmost importance. The results from thisstudy are extremely promising.
Acknowledgement
The authors express their gratitude to IngridGrunden for bringing up the idea of mindfulnessand taking part in the early planning of the study.
Declaration of Interest: The authors reportno conflicts of interest. This work was supportedby grants from AFA Insurance and The Health &Medical Care Committee of the Region VastraGotaland.
References
1. DeLuca J. Fatigue as a window to the brain. A Bradfordbook. Cambridge, MA; London, UK: The MIT Press; 2005.
2. Rodholm M, Starmark J-E, Svensson E, von Essen C.Asteno-emotional disorder after aneurysmal sah: Reliability,symptomatology and relation to outcome. Acta NeurologicaScandinavica 2001;103:379–385.
3. Ronnback L, Hansson E. On the potential role of glutamatetransport in mental fatigue. Journal of Neuroinflammation2004;1:22.
4. Winward C, Sackley C, Metha Z, Rothwell PM. A popula-tion-based study of the prevalence of fatigue after transientischemic attack and minor stroke. Stroke 2009;40:757–761.
5. Staub F, Bogousslavsky J. Fatigue after stroke: A major butneglected issue. Cerebrovascular Disease 2001;12:75–81.
6. Olver JH. Outcome following traumatic brain injury:A comparison between 2 and 5 years after injury. BrainInjury 1996;10:841–848.
7. Neass H, Nyland HI, Thomassen L, Aarseth J, Myhr K-M.Fatigue at long-term follow-up in young adults with cerebralinfarction. Cerebrovascular Disease 2005;20:245–250.
8. Belmont A, Agara N, Hugeron C, Gallais B, Azouvi P.Fatigue and traumatic brain injury. Annales de Readaptationet de Medecine Physique 2006;49:283–288.
9. Johansson B, Berglund P, Ronnback L. Mental fatigue andimpaired information processing after mild and moderatetraumatic brain injury. Brain Injury 2009;23:1027–1040.
10. Johansson B, Starmark A, Berglund P, Rodholm M,Ronnback L. A self-assessment questionnaire for mentalfatigue and related symptoms after neurological disordersand injuries. Brain Injury 2010;24:2–12.
Mindfulness (MBSR) and mental fatigue 1627
Bra
in I
nj D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y G
oteb
orgs
Uni
vers
ity o
n 12
/05/
12Fo
r pe
rson
al u
se o
nly.
11. Lindqvist G, Malmgren H. Organic mental disorders ashypothetical pathogenetic processes. Acta PsychiatricaScandinavica 1993;88:5–17.
12. Stulemeijer M, van der Werf S, Bleijenberg G, Biert J,Brauer J, Vos PE. Recovery from mild traumatic brain injury:A focus on fatigue. Journal Neurology, Neurosurery andPsychology 2006;253:1041–1047.
13. Bushnik T, Englander J, Wright J. Patterns of fatigue and itscorrelates over the first 2 years after traumatic brain injury.Journal of Head Trauma Rehabilitation 2008;23:25–32.
14. O’Connor C, Colantonio A, Polatajko H. Long termsymptoms and limitations of activity of people with traumaticbrain injury: A ten-year follow-up. Psychol Rep 2005;97:169–179.
15. Sundstrom A, Nilsson L-G, Cruts M, Adolfsson R, VanBroeckhoven C, Nyberg L. Fatigue before and after mildtraumatic brain injury: Pre-post-injury comparisons in rela-tion to apolipoprotein E. Brain Injury 2007;21:1049–1054.
16. Lundin A. Mild traumatic brain injury: Clinical course andprognostic factors for postconcussional disorder [disserta-tion]: Karolinska Institutet, Department of Clinical Sciences,psychiatry section. Stockholm: Stockholm University; 2007.
17. Cantor JB, Ashman T, Gordon W, Ginsberg A, Engmann C,Egan M, Spielman L, Dijkers M, Flanagan S. Fatigue aftertraumatic brain injury and its impact on participation andquality of life. Journal of Head Trauma Rehabilitation2008;23:41–51.
18. Ingles JL, Eskes GA, Phillips SJ. Fatigue after stroke. Arcivesof Physical Medicine and Rehabilitation 1999;80:173–178.
19. Schepers VP, Visser-Meily AM, Ketelaar M, Lindeman E.Poststroke fatigue: Course and its relation to personal andstroke related factors. Archives of Physical Medicine andRehabilitation 2006;87:184–188.
20. Groot de MH, Phillips SJ, Eskes GA. Fatigue associatedwith stroke and other neurologic conditions: Implications forstroke rehabilitation. Archives of Physical Medicine andRehabilitation 2003;84:1714–1720.
21. Colle F, Bonan I, Gellez Leman MC, Bradai N, Yelnik A.Fatigue after stroke. Annales de Readaptation et de MedecinePhysice 2006;49:361–364.
22. Chaudhuri A, Behan PO. Fatigue in neurological disorders.Lancet 2004;363:978–988.
23. Ronnback L, Johansson B. Long-lasting mental fatigue aftertraumatic brain injury or stroke – a new perspective.Saarbrucken: LAP Lambert Academic Publishing; 2012.
24. Azouvi P, Couillet J, Leclercq M, Martin Y, Asloun S,Rousseaux M. Divided attention and mental effort aftersevere traumatic brain injury. Neuropsychologia 2004;42:1260–1268.
25. Ziino C, Ponsford J. Selective attention deficits andsubjective fatigue following traumatic brain injury.Neuropsychology 2006;20:383–390.
26. Smith BW, Shelley BM, Dalen J, Wiggins K, Tooley E,Bernard JS. A pilot study comparing the effects of mind-fulness-based and cognitive-behavioral stress reduction.Journal of Alternative and Complementary Medicine2008;14:251–258.
27. Grossmana P, Niemannb L, Schmidtc S, Walachc H.Mindfulness-based stress reduction and health benefits:A meta-analysis. Journal of Psychosomatic Research2004;57:35–43.
28. Kabat-Zinn J, Lipworth L, Burney R. The clinical use ofmindfulness meditation for the self-regulation of chronicpain. Journal of Behavioral Medicine 1985;8:163–190.
29. Carlson LE, Garland SN. Impact of mindfulness-based stressreduction (MBSR) on sleep, mood, stress and fatiguesymptoms in cancer outpatients. International Journal ofBehavioral Medicine 2005;12:278–285.
30. Moore A, Malinowski P. Meditation, mindfulness andcognitive flexibility. Consciousness and Cognition 2009;18:176–186.
31. Kilpatrick LA, Suyenobu BY, Smith SR, Bueller JA,Goodman T, Creswell JD, Tillisch K, Mayer EA,Naliboff BD. Impact of mindfulness-based stress reductiontraining on intrinsic brain connectivity. Neuroimage 2011;1:290–298.
32. Kabat Zinn J. Full full catastrophe living: How to cope withstress, pain and illness using mindfulness meditation.15th ed. London: Piatkus Books; 2001.
33. Cullen M. Mindfulness-based interventions: An emergingphenomenon. Mindfulness 2011;2:186–193.
34. Svanborg P, Asberg M. A new self-rating scale for depressionand anxiety states based on the comprehensive psychopatho-logical scale. Acta Psychiatrica Scandinavica 1994;89:21–28.
35. Wechsler D. Wechsler adult intelligence scale – third edition,WAIS-III, Swedish version. Pearson Assessment; 2003.
36. Ellis DC, Kaplan E, Kramer JH. Delis-Kaplan executivefunction system – d-kefs. San Antonio, TX: ThePsychological Corporation; 2001.
37. Reitan RM, Wolfson D. The Halstead-Reitan neuropsycho-logical test battery. Theory and clinical interpretation.Tucson, AZ: Neuropsychology Press; 1985.
38. Madison S. Lasdiagnos. Lund: Las och Skrivcentrum; 2003.39. Felmingham KL, Baguley IJ, Green AM. Effects of diffuse
axonal injury on speed of information processing followingsevere traumatic brain injury. Neuropsychology 2004;18:564–571.
40. Bedard M, Felteau M, Mazmanian D, Fedyk K, Klein R,Richardson J, Parkinson W, Minthorn-Biggs MB. Pilotevaluation of a mindfulness-based intervention to improvequality of life among individuals who sustained traumaticbrain injuries. Disability and Rehabilitation 2003;25:722–731.
41. McMillan T, Robertson I, Brock D, Chorlton L. Briefmindfulness training for attentional problems after traumaticbrain injury: A randomised control treatment trial.Neuropsychological Rehabilitation 2002;12:117–125.
42. Kohl AD, Wylie GR, Genova HM, Hillary F, Deluca J.The neural correlates of cognitive fatigue in traumatic braininjury using functional MRI. Brain Injury 2009;23:420–432.
43. Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attentionregulation and monitoring in meditation. Trends in CognitiveScience 2008;12:163–169.
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A MULTI-DISCIPLINARY SOCIAL COMMUNICATION AND COPING SKILLS GROUP INTERVENTION FOR ADULTS WITH ACQUIRED BRAIN INJURY: A PILOT FEASIBILITY STUDY IN AN INPATIENT SETTINGAPPLETON, S., BROWNE, A., CICCONE, N., FONG, K., HANKEY, G., LUND, M., . . . YEE, Y. | JANUARY 2011 | BRAIN IMPAIRMENT
SETTING & PARTICIPANTS
¡ Study conducted in partnership with Australian state-supported Acquired Brain Injury (ABI) rehabilitation and neurorehabilitation services
¡ ABI rehabilitation service a 29 bed unit with 48.6 day average LOS
¡ Neurorehabilitation service a 27 bed unit with similar LOS
¡ Inclusion criteria included:
¡ ABI rehabilitation and neurorehabilitation inpatients
¡ English-speaking
¡ Aged 18 to 59
¡ Mid-to-moderate high level language difficulties
¡ Severe-chronic ABI diagnosis
¡ No minimum or maximum time post-injury but most within 1 year
¡ 15 participants completed baseline assessment, 9 completed a majority of the intervention, and 7 completed the 3-months post-intervention assessment
INTERVENTION
¡ Social Skills program
¡ Based on Improving First Impressions program developed by McDonald, Bornhofen, and colleagues
¡ “aims to maximise learning using repetition and structure with less reliance on complex cognitive skills” ((McDonald, Bornhofen, et al., 2008)
¡ Focuses on a variety of basic social skills topics using handout-supported lecture as well as modelled and participant role plays
¡ Anxiety Management program
¡ Based on a Cognitive Behavioral Therapy program developed by Hodgson, McDonald, Tate, and Gertler
¡ Includes handout-supported lecture and practice of relaxation techniques, coping strategies, and assertiveness strategies
¡ Studied Social Skills and Anxiety Management program
¡ 4 weeks – 3 1.5-hour group sessions per week for a total of 12 sessions
¡ 3 to 5 participants per group
INTERVENTION
(p. 213)
ASSESSMENT MEASURES
¡ Assessment measures included:¡ Speech Pathology measures including the Bedside Evaluation Screen Test (BEST), La Trobe
Communication Questionnaire (LCQ), and Correct Information Unit (CIU) analysis
¡ Psychological measures including the Hospital Anxiety and Depression Scale (HADS), Mini International Neuropsychiatric Interview (MINI), Coping Self-Efficacy Scale (CSE), and WHO Quality of Life Assessment (WHOQOL BREF)
¡ Participants assessed at baseline, post-intervention, and 3-months post-intervention
RESULTS
(p. 217)
RESULTS
(p. 218)
RESULTS
¡ Significant improvements on speech pathology and psychological measures post-intervention
¡ Greater perceived communicative ability, informativeness, and efficiency of corrected speech
¡ Increased coping self-efficacy and quality of life, decreased depression and anxiety
¡ Participant feedback indicated an enjoyment of the group context and the content covered, but an issue with the timing of group as it interfered with scheduled tea time
APPLICATION
¡ Researchers suggest the program was successful as it paired exposure to social anxiety with strategies for reducing that anxiety.
¡ How can we bring these benefits to ResCare Premier Texas?¡ Extending group learning by integrating topics throughout groups and
ensuring that they permeate daily programming¡ Supporting home practice by supporting direct care staff¡ Introducing an expanded Stress Management group that also covers the basic
social skills that cause our participants such stress!¡ Exploring the resources identified by this study – information on Improving First
Impressions workbook and CBT program incoming
REFERENCES
Appleton, S., Browne, A., Ciccone, N., Fong, K., Hankey, G., Lund, M., . . . Yee, Y. (2011). A Multidisciplinary social communication and coping skills group intervention for adults with acquired brain injury (ABI): A Pilot feasibility study in an inpatient setting. Brain Impairment, 12(3), 210-222.
Hodgson, J., McDonald, S., Tate, R., & Gertler, P. (2005). A randomised controlled trial of a cognitive–behavioural therapy program for managing social anxiety after acquired brain injury. Brain Impairment, 6(3), 169–180.
McDonald, S., Bornhofen, C., Togher, L., Flanagan, S. Gertler, P., & Bowen, R. (2008). Improving first impressions: a step-by-step social skills program. Sydney, Australia: School of Psychology, University of New South Wales.
210 BRAIN IMPAIRMENT VOLUME 12 NUMBER 3 DECEMBER pp. 210–222
Address for correspondence: Dr Sally Appleton, Clinical Psychologist, State Head Injury Unit, Ground FloorE Block, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia. E-mail:[email protected]
A Multidisciplinary Social Communicationand Coping Skills Group Intervention forAdults with Acquired Brain Injury (ABI): A Pilot Feasibility Study in anInpatient Setting
Sally Appleton,1, 2, 7 Allyson Browne,1, 3, 4, 5 Natalie Ciccone,6 Kim Fong,7 Graeme Hankey,8Michelle Lund,7 Adrienne Miles,9 Candice Wainstein,7 Jan Zach,9 and Yvette Yee9
1 Statewide Trauma Service of Western Australia, Royal Perth Hospital, Australia2 State Head Injury Unit, Sir Charles Gairdner Hospital, Perth, Australia3 Anaesthesiology and Pharmacology Unit, School of Medicine and Pharmacology, University of Western Australia, Australia4 Burns Injury Research Unit, School of Surgery, University of Western Australia, Australia5 National Drug Research Institute, Curtin University of Technology, Perth, Australia6 Speech Pathology, School of Psychology and Social Science, Edith Cowan University, Perth, Australia7 Rehabilitation Medicine, Royal Perth Hospital, Australia8 Neurology, Royal Perth Hospital, Australia9 Speech Pathology, Royal Perth Hospital, Australia
There is evidence that individuals with an acquired brain injury (ABI) are atincreased risk of developing psychological problems and that they commonly
experience difficulties in social communication, associated with poorer long-termoutcomes. Although several relevant group interventions have been evaluated,there has been limited exploration of the feasibility of an ABI inpatient intervention.This nonrandomised pilot study tested the feasibility of an inpatient multidisciplinarysocial communication and coping skills group intervention within 1-year post trau-matic/nontraumatic ABI. Seven participants completed a 4-week group program (3× 1 hour sessions per week) facilitated by a speech pathologist and clinical psy-chologist and were assessed pre/post intervention and at 3 months with theLa Trobe Communication Questionnaire, Correct Information Unit analysis, HospitalAnxiety and Depression Scale, Mini International Neuropsychiatric Interview,Coping Self-Efficacy scale and World Health Organization Quality of Life assess-ment. Most participants improved between baseline and 3 months post interventionin terms of greater informativeness and efficiency of connected speech andreduced anxiety and they provided positive feedback about the group program.Despite the challenges and limitations of this pilot study, the findings are encour-aging and support both the value and feasibility of developing such a program intoroutine inpatient rehabilitation services.
Keywords: acquired brain injury, social communication skills
It has been estimated that 18% (4 million people)of the population of Australia in 2009(21,783,183) had a disability, of whom 43,566people (1%) had a head injury or acquired brain
damage, which represents twice as many peoplesince 2003 (Australian Bureau of Statistics[ABS], 2011). Communication, cognitive (atten-tion/concentration, learning/memory, executive
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function), motor-sensory, psychosocial andbehavioural impairments are all common follow-ing acquired brain injury (ABI), which includesboth traumatic (e.g., due to a motor vehicle acci-dent) and nontraumatic injuries (e.g., due to astroke or brain tumour).
Evidence suggests that individuals with anABI commonly experience difficulties in socialcommunication, incorporating pragmatic lan-guage skills (e.g., Channon & Crawford, 2010),which is associated with reduced social integra-tion and satisfaction with life (Dahlberg et al.,2006). Furthermore, individuals with an ABI havean increased risk of developing psychologicalproblems, particularly depression and anxiety(e.g., Williams & Evans, 2003). In individualswith traumatic brain injuries (n = 100), 45% havebeen found to meet the diagnostic criteria for clin-ical depression and 38% a diagnosis of anxiety(Whelan-Goodinson, Ponsford, Johnston, &Grant, 2009). The presence of social communica-tion and psychological difficulties is likely tointerfere with rehabilitation and hence, importantlonger term outcomes such as return to work (e.g.,Hofgren, Esbjornsson, & Sunnerhagen, 2010).
Given that the effects of an ABI can have con-sequences for all aspects of an individual’s life,comprehensive rehabilitation of all impairments iscrucial to achieve optimal outcomes. A recent sys-tematic review of rehabilitation programs for1,094 ABI individuals with psychosocial andbehavioural difficulties concluded that compre-hensive and holistic approaches demonstrated themost significant benefits in psychosocial function-ing (Cattelani, Zettin, & Zoccolotti, 2010).However, despite the prevalence of psychosocialand behavioural problems, ‘the rehabilitation ofinappropriate social behaviour still seems to beconsidered supplementary to other neuro-psycho-logical interventions rather than a core part of thetreatment program’ (Cattelani et al., 2010, p. 53).
A number of group interventions targetingsocial communication and coping skills have beenevaluated in individuals with an ABI (e.g., Anson& Ponsford, 2006; Bedard et al., 2003; Braden etal., 2010; McDonald, Tate, et al., 2008).McDonald, Tate, et al. (2008) conducted a wait-list controlled trial of a 12-week ‘Improving FirstImpressions’ social skills program (McDonald,Bornhofen, et al., 2008). The program consistedof a 3-hour weekly group session focusing onsocial perception and social behaviour, and a 1-hour weekly individual psychological sessionfocusing on emotional adjustment. A total of 39traumatic brain injury (TBI) outpatients, whowere at least one-year post injury, participated and
showed modest improvements in social behaviour.Braden et al. (2010) evaluated the effectiveness ofa 13-week group interactive structured treatment(GIST) for social competence in 30 military per-sonnel at least one-year post-TBI. This cognitive–behavioural therapy (CBT) approach integratedwith group therapy and comprehensive neuro-rehabilitation (Hawley & Newman, 2010),demonstrated significant improvements in socialcompetence, which were maintained at 6 months(Braden et al., 2010). A CBT-based 5-weekcoping skills group intervention was found toincrease adaptive coping strategies among 31 indi-viduals, 46 days to 7 years post-TBI (Anson &Ponsford, 2006). Bedard et al. (2003) also demon-strated improvements in quality of life in 10 indi-viduals, at least one-year post-TBI following a12-week mindfulness-based group intervention.
The vast majority of these group interventionshave included participants at least one-year postinjury who have been discharged from hospitaland have returned to the community. However,there may be benefits to both patients and healthservice delivery in providing earlier multidisci-plinary intervention for ABI-related social com-munication and adjustment difficulties. Providinggroup treatment at an inpatient stage for thosepatients identified earlier as experiencing socialcommunication difficulties, may help to minimisethe development of related issues once dis-charged. An inpatient multidisciplinary groupintervention may provide an opportunity for peer-learning and support between participants andcould help raise awareness of these issues amongpatients and their families. In addition, the inpa-tient setting may provide a safe context forpatients to experiment with learned communica-tion or mood management strategies and to obtainhelpful feedback. Within this setting, skill supportand reinforcement may be offered to shape bothinterpersonal and emotional functioning prior todischarge, a time in the rehabilitation processwhich provokes a significant degree of anxiety forboth patients and families.
Comprehensive inpatient and outpatient reha-bilitation from an interdisciplinary team, includ-ing speech pathologists and psychologists isrecommended as part of evidence-based clinicalguidelines for stroke rehabilitation and recovery(National Stroke Foundation, 2010). Employing amultidisciplinary collaboration may improve theeffectiveness of intervention as the roles of speechpathologists and psychologists can be complimen-tary, particularly in ABI rehabilitation settings(e.g., Draper et al., 2007; Wertheimer et al., 2008).In addition, it may improve the efficiency of ser-
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vice delivery associated with group multidisci-plinary intervention as opposed to individual dis-cipline specific treatment.
This pilot study aimed to test the feasibility ofa multidisciplinary social communication andcoping skills group intervention for patientswithin one-year post-ABI, including traumaticand nontraumatic injuries in a resource-limitedinpatient setting.
Materials and MethodsSettingThis study was conducted at The State AcquiredBrain Injury Rehabilitation Service (SABIRS) andState Neurological Rehabilitation Unit (SNRU) atRoyal Perth Hospital, Shenton Park Campus,Perth, Western Australia. In the year 2007–2008,179 patients were admitted to the 29-bed SABIRSward for an average length of stay of 48.6 days.The SNRU is a 27-bed unit treating approximately200 patients per year.
DesignA pilot nonrandomised feasibility study of a socialcommunication and coping skills group.Participants were assessed at baseline, post inter-vention and at 3 months post intervention by face-to-face interview. Ethical approval for the studywas obtained from the Royal Perth HospitalHuman Research Ethics Committee.
ParticipantsAt the point of recruitment, participants wereEnglish speaking hospital inpatients, aged 18 to75 years with diagnosed mild to moderate high-level language difficulties due to an ABI (as indi-cated by a score of at least 85 on the BEST-2)including traumatic (e.g., due to a motor vehicleaccident) and nontraumatic injuries (e.g., due to astroke or brain tumour). Patients were onlyapproached once the appropriate treating consul-tant had given their permission.
Patients were excluded if they (a) had severereceptive or expressive dysphasia (as indicated bya score of 84 or less on the BEST-2); (b) moder-ate/severe dysarthria or dyspraxia as assessed bytheir speech pathologist; (c) had a history of neu-rological damage or disease prior to their ABI; (d)were unfit to participate as assessed by their treat-ing team; (e) were aggressive, suicidal or psy-chotic at the time of screening; (f) were alreadyreceiving routine individualised speech pathologyor clinical psychology input, which their treatingteam considered more appropriate for their reha-
bilitation. All patients meeting the entry criteriawere invited to participate.
Group InterventionThe ‘social club’ intervention, as it was termed,consisted of 12 group sessions (duration of 1.5hours each) over 4 weeks (i.e., 3 sessions perweek). The group sessions were co-facilitated bya speech pathologist and clinical psychologist andbetween 3 to 5 participants were invited to attendeach group program.
The content of the intervention was basedupon the Improving First Impressions social skillsprogram (McDonald, Bornhofen, et al., 2008).This program was specifically developed for indi-viduals with severe–chronic TBI by psychologistsand speech pathologists. It aims to maximiselearning using repetition and structure with lessreliance on complex cognitive skills (McDonald,Bornhofen, et al., 2008), and has demonstratedfavourable outcomes in terms of social behaviour(McDonald, Tate, et al., 2008).
The Improving First Impressions social skillsprogram (McDonald, Bornhofen, et al., 2008) wasadapted for the purposes of this pilot project to beappropriate to an inpatient population, who maybe medically unstable, at a more acute stage ofrehabilitation and in a more limited timeframe.The warm-up activities were altered, the mod-elling of role plays provided in video format andparticipant role plays removed.
Additional psychosocial content was modifiedfrom an individual CBT program for managingsocial anxiety following ABI, which includedrelaxation techniques, cognitive strategies, gradedexposure and assertiveness skills (Hodgson,McDonald, Tate, & Gertler, 2005). This outpatient9- to 14-week program has been evaluated in 12individuals at least one-year post traumatic ornontraumatic ABI and has demonstrated effectiveoutcomes (Hodgson et al., 2005). For the purposesof this pilot study, due to the recency of ABI andconsequent inpatient status, the psychosocial con-tent focused on the introductory (i.e., model ofsocial anxiety) and affective components (i.e.,behavioural anxiety management strategies) of theprogram. It was designed to both complement andfacilitate engagement with the social skills com-ponents as it was anticipated that participation inthe program may increase individual’s social anx-iety. Table 1 shows the content of the 12 sessionsof the social club program.
The group sessions included video role playsand live relaxation exercises (using scripts writtenspecifically for this study) and were supportedwith participant handouts both from the
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Improving First Impressions social skills program(McDonald, Bornhofen, et al., 2008), and thosedeveloped specifically for this study titled‘Managing anxiety in social situations’ and‘Relaxation exercises’, and audio relaxation trackson Mp3 players (recorded for the purposes of thisstudy). The structure of each session consisted ofrecall of previous session, review of homework,warm-up activity, main topic, tea break, maintopic, review session, set homework. On comple-tion of the program, participants were awarded acertificate of attendance.
Sociodemographic and Health MeasuresSeveral sociodemographic and health characteris-tics of participants were assessed at baselineincluding age, gender, education, pre-ABI occu-pation, marital status, substance misuse history,mental health history, current psychotropic medi-cation, nature of event, type of injury, GlasgowComa Scale (GCS) at scene, time since injury, andlength of admission.
Speech Pathology MeasuresThe communicative abilities of the participantswere assessed through the following measures.
Bedside Evaluation Screening Test (BEST-2;West, Sands, & Ross-Swain, 1998). This is astandardised tool to assess and quantify languagedisorders in aphasic adults. It assesses language
competencies in three modalities: (a) AuditoryComprehension, (b) Verbal Expression, and (c)Reading. The 7 subtests focus on conversationalexpression, naming objects, describing objects,repeating sentences, pointing to objects, pointingto parts of a picture, and reading. Total scoresindicate severity of aphasia in which lower scoresindicate greater severity (0–84 Severe impairment;85–105 Moderate impairment; 106+ Mild/Noimpairment). Test–retest reliability was high (alphacoefficients ≥ 0.93; West at al., 1998). The BEST-2was used to assess eligibility for the study and wasnot used as an outcome measure.
La Trobe Communication Questionnaire (LCQ;Douglas, O’Flaherty, & Snow, 2000). This 30-item measure of perceived communicative abilitycan be completed by both individuals with ABIand their carers. Responses are on a 4-point Likertscale in which a greater overall score representsmore severe perceived impairment (scores range30–120). The measure has high internal consis-tency (alpha coefficients ≥ 0.90) and test–retestreliability (alpha coefficients ≥ 0.80), and hasbeen successfully used in TBI individuals, demon-strating sensitivity to the effect of injury severity(Douglas, Bracy, & Snow, 2007).
Correct Information Unit (CIU) analysis(Nicholas & Brookshire, 1993). Developed withindividuals with aphasia, this is a standardisedrule-based method of scoring the informativeness
TABLE 1Structure and Content of the ‘Social Club’ Intervention
Session Content
Adapted from the Improving First Impressions Adapted from a social anxiety social skills program (McDonald, Bornhofen, management program (Hodgson et al., 2005)et al., 2008)
1 Greeting Adjustment to ABI and introduction to social anxiety2 Making introductions *3 Listening and watching Controlled breathing4 Starting a conversation Controlled breathing5 Developing, maintaining and ending *
a conversation6 Topic selection Controlled breathing7 Giving and accepting compliments Progressive muscle relaxation8 Being assertive — saying no *9 Being assertive — joining in Progressive muscle relaxation10 Asking for and offering to help Progressive muscle relaxation11 Coping with disagreements *12 Wrapping up — what have we achieved? Review of behavioural anxiety management strategies
Note: * Due to the limited availability of the clinical psychologist, some group sessions were facilitated by the speechpathologist only and did not contain any anxiety-management content.
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and efficiency of connected speech elicited by var-ious common stimuli. For the purposes of this pro-ject, four stimuli were used to assess PictureDescription, Picture Narrative, ProceduralNarrative, Personal Narrative. For each sample,the number of words per minute (WPM), % CIUs,and CIUs per minute were calculated (only thelatter measurement is reported here). Bothintrarater and interrater reliability have beenshown to be high and scores on the measure arerelatively stable over time (Nicholas &Brookshire, 1993).
Psychological MeasuresThe psychological characteristics of the partici-pants were assessed through the following mea-sures.
Hospital Anxiety and Depression Scale (HADS;Zigmond & Snaith, 1983). This self-reportscreening test was designed to measure depressionand anxiety in hospitalised patients with physicalhealth problems as it does not sample somaticsymptoms. There are 7 items assessing depressionand 7 assessing anxiety, which are scored on a 4-point Likert scale with higher scores representinghigher distress. Total scores for anxiety or depres-sion are normal (0–7), borderline caseness (8–10), and probable caseness (11–21). The HADShas high internal consistency of both subscales(anxiety: alpha coefficients = -0.68–0.93, depres-sion: alpha coefficients = -0.67–0.90) (Bjelland,Dahl, Haug, & Neckelmann, 2002). It has beenused previously in ABI populations (e.g.,Eriksson, Kottorp, Borg, & Tham, 2009; Fleming,Kuipers, Foster, Smith, & Doig, 2009; Hodgson etal., 2005) and has been shown to be an effectivemeasure of emotional distress in the TBI popula-tion in terms of its factor structure (Schonberger &Ponsford, 2010).
Mini International Neuropsychiatric Interview6.0 (MINI; Sheehan et al., 1998). This standard-ised structured diagnostic psychiatric interviewidentifies DSM-IV and ICD-10 psychiatric disor-ders. For the purposes of this study, only the majordepressive episode and posttraumatic stress disor-der (PTSD) modules were used to indicate a cur-rent, recurrent or past episode. These moduleshave high interrater reliability (alpha coefficients= 1.00; 0.95) and test–retest reliability (alphacoefficients = 0.87; 0.73; Sheehan et al., 1998).
Coping Self-Efficacy scale (CSE; Chesney,Neilands, Chambers, Taylor, & Folkman, 2006).This 26-item self-report measure assesses per-ceived efficacy for coping with changes and
threats. Responses are rated on a scale of 0(cannot do at all) to 10 (certain can do). An over-all score (0–260) was calculated by summing theratings where greater scores represent greatercoping self-efficacy. Internal consistency and test–retest reliability were high for the 3 factors ofproblem-focused coping, stopping unpleasantemotions and thoughts, and social support(Chesney et al., 2006).
World Health Organization Quality of Lifeassessment (WHOQOL BREF; The WorldHealth Organization Quality of Life Group[WHOQOL Group], 1998). This 26-item abbrevi-ated self-report version of WHOQOL-100assesses 4 domains of quality of life: (1) Physicalhealth, (2) Psychological, (3) Social relationships,and (4) Environment. Responses are on a 5-pointLikert scale. Each domain score is calculated bythe mean score within that domain in whichhigher scores indicate greater quality of life. Meanscores are multiplied by 4 to be comparable to theWHOQOL-100 scores. This measure has beenfound to have high internal consistency (alphacoefficients = 0.75–0.89) and test–retest reliability(alpha coefficients = 0.74–0.95) in individualswith a TBI (Chiu et al., 2006).
Participant FeedbackFeedback was sought from participants at the endof the final group session using a brief self-reportquestionnaire (see Appendix) prior to a group dis-cussion.
ProcedureParticipants were recruited during a 9-monthperiod. Potential participants, who met the eligi-bility criteria as determined by their medicalrecords and liaison with their treating team, wereapproached in person by a member of the researchteam to determine their willingness and availabil-ity to participate. Interested patients were pro-vided with an information sheet. Those patientswho consented were then screened through a face-to-face interview to ensure that they met thespeech pathology and psychological study crite-ria. All individuals who did not meet these criteriawere excluded from the study and the treatingteam was notified of any clinically significantissues identified (e.g., suicidality). Liaison andconsent from a participant’s next of kin wasobtained whenever possible, although this was nota condition of ethical approval for the study.Consenting participants who were screened andmet all the study criteria were invited to partici-pate in a face-to-face baseline assessment prior to
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starting the 4-week group intervention. If individ-uals were discharged from hospital in the mean-time, they were still invited to participate in thegroup intervention post discharge. Face-to-facepostintervention assessments were conductedwithin two weeks of finishing the group interven-tion. Participants were invited to attend a finalfollow-up assessment at 3 months (post baseline).
Statistical MethodsDescriptive statistics were used to describe partic-ipants’ sociodemographic characteristics commu-nication and psychological impairments, andfeedback on the group program. The data wereanalysed using PASW Statistics 18 (2010).
ResultsParticipantsDuring the 9-month recruitment period, 108patients were admitted to the SABIRS (for a totalof 120 admissions as some patients had multipleadmissions). Other potential participants werealready inpatients at the start of the recruitmentperiod. A total of 99 patients were not approachedto participate in this study from SABIRS for thefollowing reasons: (a) not diagnosed with mild–moderate high-level language difficulties (n = 34);(b) non-ABI (n = 13); (c) severe dysphasia (n=10); (d) moderate/severe dysarthria/dyspraxia (n= 9); (e) non-English speaking (n = 5); (f) previ-ous ABI (n = 4); (g) already receiving routineindividualised speech pathology/clinical psychol-ogy input (n = 3); (h) too brief length of admission(n = 3); (i) not aged 18 to 75 years (n = 1); (j) unfitto participate as assessed by their treating team (n= 1); (k) other (n = 16). During this same period,67 patients were admitted to the SNRU (for a totalof 85 admissions as the some patients had multi-ple admissions). Recruitment from the SNRU wasinitiated approximately four months into therecruitment period due to recruitment difficultiesfrom the SABIRS. (Data are unavailable regardingthe number of patients not approached from theSNRU and the reasons for exclusion.)
Figure 1 outlines the progress of participantsthrough the study.
Of the 31 SABIRS and SNRU patientsapproached to participate, 20 consented and werescreened and of these, 15 completed the baselineassessment. A total of 12 participants started thegroup intervention and 9 completed at least 50%of the group program. Differences between partic-ipants and nonparticipants or completers and non-completers could not be tested statistically due to
small sample sizes. Results are presented for the 7participants who completed the group interven-tion, postintervention assessment and 3-monthfollow up.
Baseline, Post Intervention and 3 Months
Sociodemographic and health characteristics:Table 2 shows the sociodemographic characteris-tics of the 7 group participants. Participants rangedin age from 18 to 59 years (median = 24) and 71%(n = 5) were female. Four participants (57%) had aTBI as a result of a motor vehicle accident and 3(43%) had suffered an ABI as a result of a stroke,12 to 73 weeks previously (median = 28). This hadresulted in an admission of 15 to 55 weeks (median= 37) to either the State Acquired Brain InjuryRehabilitation Service or Neurology Rehabilitation
FIGURE 1Progress of participants through the study
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Unit at Royal Perth Hospital. At baseline, 71% (n =5) had a mental health history, 4 (57%) of whichwere taking psychotropic medication. Participantsattended 55% to 100% (median = 91) of the 11-ses-sion group programs (one session per program wason a public holiday). For the duration of the groupprogram, the majority of participants (n = 6; 86%)remained inpatients. Of the total 11 group sessionsthat were missed, 5 (45%) were due to the partici-pant being unwell, 3 (27%) were due to otherappointments and on 3 (27%) occasions, nil reasonwas given.
Speech outcomes: At baseline, 5 participants(71%) scored within the ‘mild’ range on the BEST-2 (see Table 3).
Scores on the LCQ (self-rated) reduced for43% (n = 3) of participants between baseline and 3months by 1 to 11 scores indicating greater per-ceived communicative ability. For 86% of partici-pants (n = 6), there was an increase in average CIUsper minute between baseline and 3 months by 1 to23 scores representing greater informativeness andefficiency of connected speech (see Table 3).
Psychological outcomes: Table 4 shows the psy-chological characteristics of participants through-out the study.
At baseline, 2 participants scored above clinicalthreshold on the HADS anxiety subscale and 1 onthe depression subscale. Post intervention and at 3months, two participants scored above the clinicalthreshold on the anxiety subscale and 2 on the
TABLE 2Sociodemographic Characteristics of the Group Participants (n = 7)
Participants1 2 3 4 5 6 7
Age 59 18 24 21 23 54 54Gender Female Female Male Female Female Female MaleEvent CVA MVA MVA MVA MVA 2o seizure CVA CVANature of brain injury SAH SDH Contusions IPH Oligodendro- *Ischemic MCA terri
(Grade 3) (Left frontal) (Left frontal) (Left frontal) (Grade 2) and H glioma tory infarct(Left frontal)* (right) (right)
GCS at scene 15 5 4 6 — 15 — Number of weeks 22 42 73† 39 28 26 12since brain injury**
Length of admission 44 39 43 15 55 37 23(weeks)††
Marital status Married Single De facto Single Single Married DivorcedEducation TAFE Year 10 Year 11 Year 11 — Year 10 TAFEOccupation Manager Parks worker Tradesman Care worker Care worker Self-employed TradesmanMental health history Y Y N Y Y Y NSubstance abuse history N Y Y N N N YPsychotropic medication Y Y Y N Y N Nat baseline
Status for duration Inpatient Inpatient Inpatient Outpatient§ Inpatient Inpatient Inpatientof group attendanceN (%) of group 11 (100%) 10 (91%) 6 (55%) 9 (82%) 10 (91%) 9 (82%) 11 (100%)sessions attended§§
Note: CVA = cerebrovascular accident (stroke); MVA = motor vehicle accident; SAH = subarachnoid haemorrhage; SDH =subdural haematoma; IPH = intraparenchymal haematoma; H = Haemorrhage; MCA = middle cerebral artery; GCS =Glasgow Coma Scale; TAFE = Technical and Further Education.* Participant 5 was found to have a brain tumour on investigation of the TBI post-MVA due to a seizure. ** At baseline. † The treating team requested that this patient was included in the study despite being more than one-year post injury
as behavioural difficulties had contributed to a lack of engagement in routine therapies to date.†† In the State Acquired Brain Injury Rehabilitation Service or State Neurological Rehabilitation Unit.§ Was screened while an inpatient. §§ The group program was designed to include 12 sessions over four weeks. However, due to public holidays, all
group programs included 11 sessions over four weeks.
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depression subscale (these were not the same indi-viduals at the different time points). Scores on theHADS anxiety subscale decreased overall for 57%(n = 4) of participants from baseline to 3 months by1 to 4 scores. Three participants’ scores changedbetween clinical categories, one from probablecase to normal and one from borderline case tonormal, and one from normal to probable case.Scores on the HADS depression subscaledecreased overall for three participants from base-line to 3 months by 1 to 2 scores. One participant’sscores changed between clinical categories, fromnormal to probable case. Only one participant(Participant 2) met the diagnostic criteria for PTSDat baseline, post intervention or 3 months. Withregard to major depression, the same two partici-pants recorded a diagnosis at baseline, post inter-vention and 3 months. However, an additionalparticipant met the criteria for a past diagnosis ofmajor depression at 3 months. Scores on the CSEscale increased for two participants (29%) overallbetween baseline and 3 months by 7 to 15 scoresindicating greater coping self-efficacy. Eight of the28 scores (29%) on the four domains of theWHOQOL-BREF increased by 1 to 8 scoresbetween baseline and 3 months indicating greaterself-perceived quality of life.
Subjective FeedbackAll seven participants provided some feedbackon the social club group program. Participantsliked: ‘a chance to meet and hear people with thesame problems and discuss them in a friendlymanner’, ‘being with other patients informallyand talking positively about other things’, ‘talk-ing about my moods’, ‘learning about ways todeal with anxiety’, ‘a chance to help others’.They most liked that the program had ‘broughtup lots of things I had not thought of’.Participants did not like the timing of the pro-gram as it interfered with other therapies orteatime and they generally did not enjoy thehomework tasks. Nil topics were considered tobe missing from the program (although one par-ticipant suggested: ‘maybe have a session whereyou can ask anything?’) and most topics wereconsidered to be relevant. With regard to improv-ing the program, a change of location and dura-tion/frequency of sessions (both increasing anddecreasing) was suggested. A total of four of theseven participants (57%) preferred the groupprogram to usual individual therapy sessions. Allparticipants reported that the group had beenhelpful, with 57% (n = 4) finding the group pro-gram ‘very’ or ‘quite a bit’ helpful.
TABLE 3Communication Characteristics of the Group Participants at Baseline, Post Intervention and 3-month Follow-Up (n = 7)
Participants1 2 3 4 5 6 7
Baseline:BEST-2 total score* 102(Mod.) 110(Mild) 105(Mod.) 119(Mild) 115(Mild) 113(Mild) 119(Mild)La Trobe Self total score 37 67 46 44 41 39 57La Trobe Other total score** — 70 — — — — —CIUs/Minut 74 58 25 115 42 142 92
Post intervention:La Trobe Self total score 34 65 43 49 36 44 56La Trobe Other total score — 51 — 40 — — —CIUs/Minute 97 75 54 106 56 120 91
3 months:La Trobe Self total score 38 66 40 36 30 42 64La Trobe Other total score — — — 27 — 65 —CIUs/Minute 97 74 42 116 56 150 71
Change from baseline to 3 monthsLa Trobe Self total score† +1 -1 +6 -8 -11 +3 +7CIUs/Minute†† +23 +16 +17 +1 +14 +8 -21
Note: * BEST-2 total scores: 0–84 Severe impairment; 85–105 Moderate impairment; 106+ Mild/No impairment. ** There is a large amount of missing data for the La Trobe questionnaire (other self-report) due to nonreturn of mea-sures.† A negative change score represents an improvement. †† A positive change score represents an improvement.
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TABLE 4Psychological Characteristics of the Group Participants at Baseline, Post Intervention and 3-Month Follow-Up (n = 7)
Participants1 2 3 4 5 6 7
Baseline:HADS anxiety total score* 11 (PC) 14 (PC) 0 (N) 4 (N) 9 (BC) 5 (N) 6 (N)HADS depression total score 7 (N) 11 (PC) 0 (N) 2 (N) 3 (N) 1 (N) 2 (N)MINI Major depression** Y (Rec.) Y (Past) N N N N NMINI PTSD N Y N N N N N
Coping Self-Efficacy Scale total score 202 220 216 72 251 197 188WHOQOL-BREF: Physical health† 9 12 15 13 20 14 14WHOQOL-BREF: Psychological 10 13 17 15 17 16 17WHOQOL-BREF: Social relationships 20 13 16 15 20 16 9WHOQOL-BREF: Environment 10 12 14 16 19 17 15
Post intervention:HADS anxiety total score 11 (PC) 11 (PC) 0 (N) 10 (BC) 10 (BC) 5 (N) 2 (N)HADS depression total score 4 (N) 11 (PC) 0 (N) 4 (N) 11 (PC) 5 (N) 1 (N)MINI major depression Y (Rec) Y (Rec) N N N N NMINI PTSD N Y N N N N N
Coping Self-Efficacy Scale total score 120 215 184 108 240 206 239WHOQOL-BREF: Physical health 14 12 16 15 16 15 10WHOQOL-BREF: Psychological 14 12 15 16 17 16 15WHOQOL-BREF: Social relationships 20 12 17 15 16 15 13WHOQOL-BREF: Environment 13 14 17 18 20 17 15
3 months:HADS anxiety total score 7 (N) 13 (PC) 2 (N) 5 (N) 7 (N) 13 (PC) 3(N)HADS depression total score 5 (N) 12 (PC) 6 (N) 1 (N) 3 (N) 11 (PC) 2(N)MINI major depression Y (Rec.) Y (Rec.) N Y (Past) N N NMINI PTSD N Y N N N N N
Coping Self-Efficacy Scale total score 143 169 231 79 241 160 178WHOQOL-BREF: Physical health 9 11 11 14 20 13 14WHOQOL-BREF: Psychological 17 11 15 17 17 13 15WHOQOL-BREF: Social relationships 19 13 16 15 20 13 9WHOQOL-BREF: Environment 18 15 17 19 20 15 15
Change from baseline to 3 months:HADS anxiety total score†† -4 -1 +2 +1 -2 +8 -3
(PC N) (PC = PC) (N = N) (N = N) (BC N) (N PC) (N = N)HADS depression total score†† -2 -1 +6 -1 0 +10 0
(N = N) (PC = PC) (N = N) (N = N) (N = N) (N PC) (N = N)MINI major depression Y (Rec.) = Y (Past) N = N N Y N = N N = N N = N
Y (Rec.) Y (Rec.) (Past)MINI PTSD N = N Y = Y N = N N = N N = N N = N N = N
Coping Self-Efficacy Scale total score§ -59 -51 +15 +7 -10 -37 -10WHOQOL-BREF: Physical health§ 0 -1 -4 +1 0 -1 0WHOQOL-BREF: Psychological§ +7 -2 -2 +2 0 -3 -2WHOQOL-BREF: Social relationships§ -1 0 0 0 0 -3 0WHOQOL-BREF: Environment§ +8 +3 +3 +3 +1 -2 0
Note: * Domain scores were transformed to be within the range 4-20 in order to be directly comparable to WHOQOL-100. ** MINI major depression: Y (Cur.) = current episode; Y (Rec.) = recurrent episode; Y (Past) = past episode.† HADS anxiety/depression total scores: 0–7 = normal (N); 8–10 = borderline caseness (BC); 11–21 = probable caseness(PC).†† A negative change score represents an improvement.§ A positive change score represents an improvement.
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DiscussionThis was a pilot study to investigate the feasibilityof a multidisciplinary social communication andcoping skills group intervention for adult inpa-tients within one-year post-ABI.
Although attendance at the group programwas variable, the majority of participantsimproved between baseline and 3 months in termsof greater informativeness and efficiency of con-nected speech and reduced anxiety. Of the twoparticipants scoring above clinical threshold onthe HADS anxiety subscale at baseline, one con-tinued to indicate probable caseness and onescored within the normal range at 3 months. Theparticipant who scored above the clinical thresh-old on the HADS depression subscale at baseline,remained a probable case at 3 months and oneparticipant moved from scoring within the normalrange at baseline to over the clinical threshold at 3months. Therefore, the results are reflective of thecontent of the group program, which targetedsocial anxiety rather than depression. In addition,the group program may have functioned as anexposure exercise to social anxiety and allowedparticipants to habituate over time. Although par-ticipants reported greater quality of life at 3months, there was a lack of improvement oncoping self-efficacy. This may be due to a lack of‘real-life’ practice to build examples of successesin such a supportive setting of inpatient rehabilita-tion in which staff are aware of ABI-relateddeficits and are positive and receptive to all socialcommunication attempts. For some individuals,the intervention may have improved their insightregarding their ABI-related deficits, which in turncould have resulted in greater anxiety and lowmood. Demakis, Hammond, and Knotts (2010)found that the individuals with better psychologi-cal functioning one-year post-TBI were those withmore severe disability, which the authors suggestmay be due to the individuals enduring cognitivedeficits such as poor insight.
Participants provided positive feedback aboutthe group program, particularly regarding meetingothers with an ABI and having an opportunity totalk about their emotions, although they wouldprefer different timing so as not to interfere withother rehabilitation activities. More than half ofparticipants preferred the group program to usualindividual therapy and all participants found thegroup helpful to some degree, with most reportinga high level of helpfulness. This may be due to thegroup program providing an opportunity for bothnormalisation of post-ABI difficulties and sociali-sation with other patients that may not routinelyoccur.
Previous outpatient social communication andcoping skills interventions in individuals with anABI have failed to demonstrate changes in partic-ular psychosocial outcomes. Although McDonald,Tate, et al. (2008) showed significant improve-ments in social behaviour in 39 TBI outpatientsfollowing a 12-week Improving First Impressionssocial skills program, there was nil significantchange in their communicative ability or emo-tional adjustment. Similarly, an individual cogni-tive–behavioural program for managing socialanxiety in 12 ABI outpatients has shown signifi-cant improvements in anxiety and depression butonly trends in reducing social anxiety (Hodgson etal., 2005).
The findings of this study may reflect thenumerous challenges of translating best practiceresearch design into complex clinical settingssuch as ABI inpatient wards. The main challengein this study related to participant recruitment,which was limited by ongoing inpatient dis-charges (often to rural locations), the demands ofroutine rehabilitation therapies, patients oftenhaving poor insight and motivation and theinvolvement of the treating team. The treatingteam’s decision that some patients were psycho-logically unfit to participate in the study wassometimes based on unhelpful beliefs that thescreening and assessment process would heightenemotional distress including suicidality screeningtriggering suicidal ideation. Despite local ethicscommittee approval, authorisation from the treat-ing team was also required before patients couldbe approached. This suggests that translatingresearch into long-established clinical systems canbe challenging, not only regarding patient compli-ance, but also concerning the education of relevantstaff and fostering of strong trust relationships. Inaddition, the development of clearly defined pro-tocols around risk management that are accessibleto both clinical and research staff is crucial.
These challenges rendered recruitment to besufficiently slow that randomisation was not feasi-ble within the study timeframe. Further challengesincluded the appropriateness of certain assessmentand intervention with individuals with significantcognitive impairment (particularly attention, con-centration, information processing, learning/memory, fatigue) including higher-level executiveskills (such as insight, self-monitoring, motiva-tion, planning/organising, reasoning, impulsivity,disinhibition, emotional/behavioural regulation).Therefore, it is unclear whether the use of certainself-report measures in individuals with these dif-ficulties are appropriate and result in valid andmeaningful results. Increased use of self-report
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measures by significant others in addition topatients, such as the LCQ, to which the responserate was low in this study, may help to assess theaccuracy of patients’ self-reporting. Due to thelack of clinical thresholds on some of the outcomemeasures used, it is difficult to determine the exactclinical significance of the changes in some of thescores, which warrants further work.
Despite the small sample size, the participantsvaried in age, gender, the nature of their braininjury (equal representation of ABI and TBI), timesince injury and length of hospital admission. Thisdiversity is likely to be reflective of this type ofinpatient clinical setting. Moreover, a mix of agesand types of injury appeared to facilitate supportamong group members. For example, youngerTBI participants were supported by older ABIindividuals who reported greater sense of satisfac-tion due to helping others, which may alsoincrease their sense of achievement at a time whenthey may be experiencing a loss of roles (e.g.,work). Due to lack of randomisation and thereforea suitable control group, it is not appropriate toattribute the changes in communicative ability andanxiety solely to the group program. Other reha-bilitation therapies and factors such as change insocial situation may confound the results.Likewise, other skills such as the perception/iden-tification of emotion and ability to empathise arelikely to be crucial prerequisites for effectivesocial communication and relevant complemen-tary interventions in the TBI population have beendeveloped (Bornhofen & McDonald, 2008a, b, c).
This pilot feasibility study provides encourag-ing findings that warrant further investigation in alarger randomised study with longer term follow-up. This could allow for tests of statistical andclinical significance and for the exploration of theeffect of such an intervention on long-term healthcare needs associated with physical, psychologi-cal and social wellbeing. In addition, it would beimportant to determine the cost-effectiveness incomparison to existing individual speech pathol-ogy and clinical psychology services.
ConclusionDespite the challenges and limitations of this pilotstudy, the findings are encouraging, and thus sup-port both the value and feasibility of a multidisci-plinary social communication and coping skillsgroup intervention for adult inpatients within one-year post-ABI. The experience of this pilot studyhas highlighted several key issues that warrant fur-ther exploration and modification within an inpa-tient ABI population, including broadening of
recruitment strategies, reduced/condensed dura-tion of the group program in order to maximiserecruitment and completion, and identification ofmore appropriate assessments and outcome mea-sures. Further research addressing these factorsmay facilitate the development of this inpatientintervention into a group program that could beadopted into routine rehabilitation services.
AcknowledgementsWe thank all the patients and their families whoparticipated in this study; Janet Hodgson et al. forsharing their social anxiety management program;Jarred Munro, Trish Ray and Gary Patullo, clini-cal psychologists, for their valuable contributionsto the development and implementation of theprogram in the local ABI setting; and the StateHealth and Research Advisory Council for fund-ing this study.
ReferencesAnson, K., & Ponsford, J. (2006). Evaluation of a coping
skills group following traumatic brain injury. BrainInjury, 20(2), 167–178.
Australian Bureau of Statistics (2011). Disability,ageing and carers, Australia: Summary of findings.Canberra, Australia: Author.
Bedard, M., Felteau, M., Mazmanian, D., Fedyk, K.,Klein, R., Richardson, J., … Minthorn-Biggs, M.B.(2003). Pilot evaluation of a mindfulness-basedintervention to improve quality of life among indi-viduals who sustained traumatic brain injuries.Disability & Rehabilitation, 25(13), 722–731.
Bjelland, I., Dahl, A.A., Haug, T.T., & Neckelmann, D.(2002). The validity of the hospital anxiety anddepression scale: An updated literature review.Journal of Psychosomatic Research, 52, 69–77.
Bornhofen, C., & McDonald, S. (2008a). Comparingstrategies for treating emotion perception deficits intraumatic brain injury. Journal of Head TraumaRehabilitation, 23(2), 103–115.
Bornhofen, C., & McDonald, S. (2008b). Emotion per-ception deficits following traumatic brain injury: Areview of the evidence and rationale for intervention.Journal of the International NeuropsychologicalSociety, 14, 511–525.
Bornhofen, C., & McDonald, S. (2008c). Treatingdeficits in emotion perception following traumaticbrain injury. Neuropsychological Rehabilitation,18(1), 22–44.
Braden, C., Hawley, L., Newman, J., Morey, C., Gerber,D., & Harrison-Felix, C. (2010). Social communica-tion skills group treatment: A feasibility study forpersons with traumatic brain injury and comorbidconditions. Brain Injury, 24(11), 1298–1310.
Cattelani, R., Zettin, M., & Zoccolotti, P. (2010).Rehabilitation treatments for adults with behavioral
221
SOCIAL COMMUNICATION SKILLS INTERVENTION AFTER ABI
and psychological disorders following acquiredbrain injury: a systematic review.Neuropsychological Review, 20, 52–85.
Channon, S., & Crawford, S. (2010). Mentalising andsocial problem-solving after brain injury.Neuropsychological Rehabilitation, 20(5), 739–759.
Chesney, M.A., Neilands, T.B., Chambers, D.B., Taylor,J.M., & Folkman, S. (2006). A validity and reliabil-ity study of the coping self-efficacy scale. BritishJournal of Health Psychology, 11, 421–437.
Chiu, W.T., Huang, S.J., Hwang, H.F., Tsauo, J.Y.,Chen, C.F., Tasi, S.H., & Lin, M.R. (2006). Use ofthe WHOQOL-BREF for evaluating persons withtraumatic brain injury. Journal of Neurotrauma,23(11), 1609–1620.
Dahlberg, C., Hawley, L., Morey, C., Newman, J.,Cusick, C.P., & Harrison-Felix, C. (2006). Socialcommunication skills in persons with post-acutetraumatic brain injury: Three perspectives. BrainInjury, 20(4), 425–435.
Demakis, G.J., Hammond, F.M., & Knotts, A. (2010).Prediction of depression and anxiety 1 year aftermoderate–severe traumatic brain injury. AppliedNeuropsychology, 17(3), 183–189.
Douglas, J.M., Bracy, C.A., & Snow, P.C. (2007).Measuring perceived communicative ability aftertraumatic brain injury: Reliability and validity of theLa Trobe communication questionnaire. Journal ofHealth Trauma Rehabilitation, 22(1), 31–38.
Douglas, J.M., O’Flaherty, C.A., & Snow, P.C. (2000).Measuring perception of communicative ability:The development and evaluation of the La Trobecommunication questionnaire. Aphasiology, 14(3),251–268.
Draper, B., Bowring, G., Thompson, C., Van Heyst, J.V.,Conroy, P., & Thompson, J. (2007). Stress in care-givers of aphasic stroke patients: a randomized con-trolled trial. Clinical Rehabilitation, 21, 122–130.
Eriksson, G., Kottorp, A., Borg, J., & Tham, K. (2009).Relationship between occupational gaps in every-day life, depressive mood and life satisfaction afteracquired brain injury. Journal of RehabilitationMedicine, 41, 187–194.
Fleming, J., Kuipers, P., Foster, M., Smith, S., & Doig,E. (2009). Evaluation of an outpatient, peer groupintervention for people with acquired brain injurybased on the ICF ‘Environment’ dimension.Disability and Rehabilitation, 31(20), 1666–1675.
Hawley, L.A., & Newman, J.K. (2010). Group interac-tive structured treatment (GIST): A social compe-tence intervention for individuals with brain injury.Brain Injury, 24(11), 1292–1297.
Hodgson, J., McDonald, S., Tate, R., & Gertler, P.(2005). A randomised controlled trial of a cogni-tive–behavioural therapy program for managingsocial anxiety after acquired brain injury. BrainImpairment, 6(3), 169–180.
Hofgren, C., Esbjornsson, E., & Sunnerhagen, K.S.(2010). Return to work after acquired brain injury:facilitators and hindrances observed in a sub-acuterehabilitation setting. Work, 36, 431–439.
McDonald, S., Bornhofen, C., Togher, L., Flanagan, S.Gertler, P., & Bowen, R. (2008). Improving firstimpressions: a step-by-step social skills program.Sydney, Australia: School of Psychology,University of New South Wales.
McDonald, S., Tate, R., Togher, L., Bornhofen, C.,Long, E., Gertler, P., & Bowen, R. (2008). Socialskills treatment for people with severe, chronicacquired brain injuries: a multicenter trial. Archivesof Physical Medicine Rehabilitation, 89, 1648–1659.
National Stroke Foundation. (2010). Clinical Guidelinesfor Stroke Management 2010. Melbourne,Australia: Author.
Nicholas, L.E., & Brookshire, R.H. (1993). A system ofquantifying the informativeness and efficiency ofthe connected speech of adults with aphasia.Journal of Speech and Hearing Research, 36, 338–350.
Schonberger, M., & Ponsford, J. (2010). The factorstructure of the Hospital Anxiety and DepressionScale in individuals with traumatic brain injury.Psychiatry Research, 179, 342–349.
Sheehan, D.V., Lecrubier, Y., Sheehan, H., Amorim, P.,Janavs, J., Weiller, E. … Dunbar, G.C. (1998). TheMini International Neuropsychiatric Interview(M.I.N.I.): The development and validation of astructured diagnostic psychiatric interview forDSM-IV and ICD-10. Journal of ClinicalPsychiatry, 59(suppl. 20), 22–33.
Wertheimer, J.C., Roebuck-Spencer, T.M., Constantini-dou, F., Turkstra, L., Pavol, M., & Paul, D. (2008).Collaboration between neuro-psychologists andspeech-language pathologists in rehabilitation set-tings. Journal of Head Trauma Rehabilitation, 23(5),273–285.
West, J.F., Sands, E., & Ross-Swain, D. (1998). Bedsideevaluation screening test (2nd ed.). Austin, TX:Pro-Ed.
Whelan-Goodinson, R., Ponsford, J., Johnston, L., &Grant, F. (2009). Psychiatric disorders followingtraumatic brain injury: Their nature and frequency.Journal of Head Trauma Rehabilitation, 24(5),324–332.
Williams, W.H., & Evans, J.J. (2003). Brain injury andemotion: an overview to a special issue on biopsy-chosocial approaches in neurorehabilitation.Neuropsychological Rehabilitation, 13(1/2), 1–11.
WHOQOL Group (1998). Development of the WorldHealth Organization WHOQOL-BREF quality oflife assessment. Psychological Medicine, 28(3),551–558.
Zigmond, A.S., & Snaith, R.P. (1983). The hospital anx-iety and depression scale. Acta PsychiatricaScandinavica 67, 361–370
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AppendixParticipant Feedback Questionnaire
What did you like most about the program?What did you like least about the program?Did you think that any topics were missing?Did you think that any topics were a waste of time?Would you change anything about the program?Would you prefer to come to the program or your usual individual therapy sessions?Overall, how helpful do you feel the program was for you?
Not at all Helpful A Little Helpful Somewhat Helpful Quite a Bit Helpful Very Helpful
1 2 3 4 5
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