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Evaluating ‘RE-ID’: An acceptance and commitment therapy group

intervention exploring identity after acquired brain injury

by

Alison Mac Crosain

Submitted in partial fulfillment of the degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyApril 2017

© Alison Mac Crosain 2017

Statement of Originality

This thesis and the work to which it refers are the results of my own efforts. Any

ideas, data, images, or text resulting from the work of others (whether published or

unpublished) are fully identified as such within the work and attributed to their

originator in the text. This thesis has not been submitted in whole or in part for any

other academic degree or professional qualification.

Name: Alison Mac Crosain

1

Overview of Portfolio

The experience of an acquired brain injury (ABI) can fundamentally alter an

individual’s sense of self-concept and identity. This change in identity can impact on

other outcomes following ABI including engagement with rehabilitation, vocational

activity, mood and quality of life. This thesis aimed to explore the effectiveness of

‘RE-ID’, a vocational rehabilitation acceptance and commitment therapy (ACT)

group intervention exploring identity following ABI.

Part one of this portfolio represents a review of qualitative literature

exploring identity after ABI from the perspective of the individual who has

experienced the ABI. The findings suggest that positive and negative changes to

self-concept are experienced following ABI, and that individuals employ a variety of

strategies to adjust and accept these changes including comparison and

consideration of values, goals and meaningful activity. Part two presents an

empirical paper investigating the effectiveness of ‘RE-ID’ using a mixed methods

approach. The findings lend preliminary evidence to support the effectiveness of an

ACT based group intervention for identity following ABI.

Part three is an overview of clinical experience, detailing clinical placements

and the range of clinical experience gained in each. Finally, part four includes a

table of academic assessments completed.

2

Publications/Presentations

An earlier version of the literature review was presented as a poster

presentation at the 13th Conference of the Neuropsychological Rehabilitation

Special Interest Group of the World Federation for Neuropsychological

Rehabilitation (NR-SIG-WFNR) in Glasgow, Scotland on 11th July 2016.

3

Table of contents

Acknowledgements

Research Part 1: The impact of acquired brain injury on identity: A qualitative review

Page 6

Research Part 2: Evaluating ‘RE-ID’: An acceptance and commitment therapy group intervention exploring identity after acquired brain injury

Page 55

Part 3: Summary of Clinical Experience Page 149

Part 4: Table of Assessments Completed During Training Page 152

4

Acknowledgements

Firstly to Dr. Laura Simonds, thank you for your thoughtfulness and guidance

throughout this project. You went above and beyond, and your support and

encouragement helped me to enjoy the experience.

To the staff team and participants from the vocational rehabilitation service, thank

you for your time and enthusiasm.

To mum, dad and Conor, thank you for believing in me for the long haul.

Thank you Grace for being my cheerleader! I’ll be forever grateful for your

thoughtfulness (and all of your cooking) over the past few months.

To Caroline and Hannah, thank you for the Mondays.

Thank you to my friends, family, clinical supervisors and colleagues. Thank you

especially to Gill, Jen, Kirsty, Sophie, Team Organic and Cohort 43, for your listening

and laughter over the past three years.

~

And finally, and most importantly, thank you to Dr. Catherine Doogan.

I would (dare I say obviously) not be on the verge of becoming a clinical

psychologist without you. Go raibh míle maith agat for everything since that first

walk across Waterloo Bridge.

5

Research Part 1:

The impact of acquired brain injury on identity: A qualitative review

Word Count: 10,464 total

6,217 (excluding Abstract, References, Tables & Figures)

6

Abstract

Aim: The current review aimed to appraise and synthesise the qualitative literature

exploring identity after acquired brain injury (ABI), from the perspective of the

individual who has sustained the injury. The literature reviewed explored self-

reported changes to identity and how individuals make sense of these changes.

Method: Three databases were searched (PsycInfo, MEDLINE and SCOPUS) for

articles published prior to February 2016. Twelve articles met criteria for inclusion in

the current review. Thematic analysis was used to extract and synthesise the

findings from the included studies. Results: Two broad themes were identified. The

theme of ‘change’ refers to self-reported positive and negative changes, alongside

some sense of continuity. The theme of ‘adjustment’ refers to how individuals make

sense of these changes including the journey of acceptance, a sense of confusion,

comparison with self and others and the importance of values, goals and

meaningful activity. Discussion: The review suggests the potential utility of identity-

focused interventions. More research is needed to assess efficacy and effectiveness

of such interventions.

7

Introduction

Acquired brain injuries (ABI) include traumatic brain injuries, hypoxic brain

injuries, ischaemic brain injuries and brain injuries from other medical causes e.g.

tumours or encephalopathies (Gurd, Kishka & Marshall, 2010). The consequences of

ABI vary, and can include cognitive, emotional, behavioural and social sequelae, the

magnitude of which depends on the severity of the injury. ABI can result in

difficulties in self-awareness (Ownsworth & Clare, 2006), cognitive deficits (Rohling,

Faust, Beverly, & Demakis, 2009), attentional problems (Park & Ingles, 2001),

fatigue (LaChapelle & Finlayson, 1998), pain (Nampiaparampil, 2008), visual deficits

(Suchoff et al., 2008), sleep problems (Orff, Ayalon & Drummond, 2009) and

emotional difficulties (Anson & Ponsford, 2006) amongst others. Ownsworth (2014)

proposes that fundamentally a brain injury “can alter one’s sense of self or the

unique and persisting qualities that define who we are” (p1), thereby connecting

the experience of brain injury to the concept of self and identity.

The term ‘self’ is used in various ways across the social and behavioural

sciences. It includes reference to the self as an inner psychological entity at the

centre of a person’s experience, beliefs about oneself and, self as the mechanism

that regulates behaviour. Taken together, these three uses represent the self as the

person’s experience of themselves, their perceptions and feelings about

themselves, and their efforts to regulate their behaviour. Ones ‘self’ is influenced by

attentional, cognitive, executive, emotional, and motivational processes (Leary &

Tangney, 2003).

8

The ‘self’ is a broad term understood to include both ones identity and self-

concept. These terms are often used interchangeably throughout the literature, and

both are included in the current review. However, Baumeister (1999) offers a

helpful distinction. Identity is ‘a definition placed on oneself’ (p248), while self-

concept is ‘the individual’s beliefs about himself or herself, including the person’s

attributes and who and what the self is’ (p247). Ownsworth (2014) offers a

schematic representation of the system of identity as relevant to brain injury,

suggesting that sense of self is a global system comprised of “multiple identities

which are tied to specific social roles and relationships and generalised self-

attributes” (p35). Importantly, it is considered that the ‘self’ is comprised of certain

characteristics that remain stable and persist over time (e.g. attributes or traits),

and other characteristics that continue to be constructed and change over time (e.g.

self-efficacy). Markus and Nurius (1986) also emphasise the importance of

considering identity over time, suggesting that a person’s identity reflects their past,

present and future potential selves.

If identity is influenced by attention, cognition, executive processes, emotion

and motivation then, given the profile of deficits arising from ABI, it stands to

reason that a person’s identity can be impacted by the experience of an ABI and its

associated consequences. In one of the first studies exploring self-concept following

ABI, Tyerman and Humphrey (1984) found that the majority of their sample (72%;

N=25) reported changing significantly ‘as a person’ following their ABI, with positive,

negative and neutral changes reported. More recently, both quantitative and

qualitative reviews have supported the notion that ABI impacts identity and self-

9

concept. In a review of quantitative literature exploring changes to identity after

traumatic brain injury (TBI), Beadle, Ownsworth, Fleming and Shum (2015) reported

a negative change in identity following TBI in 11 of the 15 papers reviewed. This

change was measured by at least one reported negative evaluation of post-injury

self compared to pre-injury self, or by a more negative rating of self compared to

healthy matched controls. Interestingly, no significant differences were found for

reported self-esteem or personality between the TBI samples and trauma or

orthopedic control groups. This suggests that identity changes experienced

following TBI may be similar to those experienced following other significant

traumatic life events or as a consequence of living with other chronic health

conditions.

The qualitative literature also evidences identity change following ABI. In a

review exploring the individual’s experience of TBI, conducted to inform the

selection of outcome measures, this change in identity after brain injury was further

evidenced (Levack, Kayes & Fadyl, 2010). Of the eight themes identified to describe

the enduring experience of TBI, two themes directly related to identity: ‘disconnect

with pre-injury identity’ and ‘reconstruction of self-identity’. In a scoping review of

literature exploring occupational identity, Bryson-Campbell, Shaw, O’Brien, Holmes

and Magalgaes (2013) described themes of ‘loss of identity’ and ‘stigmatized

identity’ following ABI.

The literature offers various hypotheses to explain why changes to identity

are experienced following ABI. Identity is essentially social as it is the view of self

that is shared by other people and society broadly (Baumeister, 1999). It involves a

10

sense of continuity (sameness over time) and differentiation (being distinguishable

from other people) and is made up of various components, which reflect the varied

social roles and relationships that people occupy (Baumeister, 1999). Stets and

Burke (2000) describe two processes involved in the development of identity: self-

categorisation and social comparison. Self-categorisation involves classifying oneself

in relation to existing categories (i.e. perceived similarities with the in-group and

differences to the outgroup), while social comparison is the evaluative component,

comparing oneself to others who may be more or less favourable. These processes

can be impacted by the experience of ABI. Klonoff (2010) highlights this potential

impact of ABI on the social aspect of identity, noting that social roles held at family,

community and societal level could be greatly altered as a result of an ABI. Hallett,

Zasler, Maurer and Cash (1994) found that individuals reported a change in 40% of

social roles following a TBI, with 71% of these changes described as losses.

Gracey, Evans and Malley (2009) suggest that successful rehabilitation is the

result of resolving discrepancies between current identity and an aspired-to

identity, which may be the remembered pre-injury identity or an ideal imagined

self. Their ‘Y-shaped’ model proposes that the convergence of these identities (in

the ‘V’ at the top of the ‘Y’) involves awareness and acceptance of changes, and is a

key component of rehabilitation, which then allows for the development of the

post-injury self (in the trunk of the ‘Y’). Therefore, gaining a detailed understanding

of identity changes experienced following ABI can inform the development of

interventions to enhance acceptance, adjustment and the development of a

positive self-concept following ABI. A focus on identity and self-concept is important

11

because they influence wellbeing, contentment, and quality of life (Doering,

Conrad, Rief & Exner, 2011; Tsaousides et al., 2009; Vickery, Gontkovsky, &

Caroselli, 2005) and also behavioural outcomes such as avoidance (Riley, Dennis &

Powell, 2010).

The literature offers various hypotheses to further explain these changes to

self-concept experienced following ABI. Self-concept, defined broadly as beliefs

about oneself, can include both self-esteem and self-efficacy. Self-esteem relates to

perceptions of self-worth and the evaluation of oneself, while self-efficacy relates to

an individual’s perception of their ability to control their own functioning and the

environment around them (Baumeister, 1999; Bandura, 2001; Leary & Tangney,

2003). In a longitudinal study of self-esteem across the lifespan, Orth, Trzesniewski

and Robins (2010) found that the trajectory of self-esteem is a quadratic curve, with

an increase during young and middle adulthood. Income, employment status,

functional health, and chronic health conditions were identified as influential

factors in self-esteem. Given an ABI is likely to impact on all four of these factors, it

not surprising that experiencing an ABI during adulthood could interrupt this self-

esteem trajectory. The negative impact of ABI on self-esteem was supported by an

exploratory study by Cooper-Evans, Alderman, Knight, and Oddy (2008), which

found that individuals reported lower self-esteem following ABI. As performance

experiences are an important influence on self-efficacy beliefs (Bandura, 1977), it is

expected that functional deficits associated with an ABI would also have negative

impact on self-efficacy. Perceived self-efficacy has been found to be the most

important predictor of global life satisfaction following TBI (Cicerone & Azulay,

12

2007). Furthermore, reduced self-efficacy is known to influence the self-regulation

of motivation and, subsequently, a person’s outlook and expectations (e.g. feeling

optimistic or pessimistic about future outcomes), incentive to act, ability to

persevere in the face of adversity, and making choices (Leary & Tangney, 2003).

Thus, reduced self-efficacy beliefs can impact on other outcomes including

engagement with rehabilitation following ABI.

The current review aims to synthesise the qualitative literature exploring

identity after ABI, from the perspective of the individual who has sustained the

injury. A qualitative review was undertaken to complement a recent review of the

quantitative literature (Beadle et al., 2015). It aims to establish what self-reported

changes to identity and self-concept are experienced following ABI and to explore

what the research suggests about how individuals make sense of these changes.

Furthermore, it aims to identify clinical practice and research implications

specifically related to the development of identity-focused interventions following

ABI.

13

Method

Search and inclusion strategy

A search for articles exploring identity and self-concept following ABI was

completed, using the search terms ‘brain injury’, ‘head injury’, ‘traumatic brain

injury’ or ‘acquired brain injury’ AND ‘self-concept’ or ‘identity’. A systematic search

was completed in February 2016 using three electronic databases: PsycInfo,

MEDLINE and SCOPUS. Articles published in peer reviewed journals and written in

English were included. Papers were included only if they were primary qualitative

research and clearly explored the subjective experience of working age adults

following ABI using first-hand accounts. All qualitative methodologies were

considered.

Quality Appraisal

There is little consensus regarding how to assess the quality of qualitative

research, though it is acknowledged that it is important to avoid drawing inaccurate

conclusions (Thomas & Harden, 2008). The current review used the National

Institute for Health and Care Excellence (NICE) quality appraisal checklist for

qualitative studies as a guideline for assessing quality (NICE, 2012). This checklist

considers (i) theoretical approach, (ii) study design, (iii) methods of data collection,

(iv) trustworthiness, (v) methods of analysis and (vi) ethical issues. There is

considerable debate about the utility of calculating exact quality appraisal scores; In

the context of clinical trials, the Cochrane Collaboration advise against using tools

that yield a summary rating score (Higgins et al., 2011). In line with this, the use of a

summary rating score was deemed inappropriate in the current review, as it would

14

be difficult to justify putting a numerical value on subjective qualitative research

and attempts to do so would likely be inconsistent. Consequently, the current

review does not assign quality scores; instead, the quality appraisal tool was used

flexibly to ensure included papers met quality criteria that were considered

essential. These criteria were: specification of a theoretical framework to situate the

study; presence of a clearly specified research question; sufficient detail on the

participant(s) and how they were recruited; and, a clear description of the process

of data collection and analysis.

Data Extraction

Data were extracted using guidance outlined by Thomas and Harden (2008).

Data extracted included all material identified as ‘findings’ or ‘results’ within the

empirical papers, and included quotations from participants.

Synthesis of studies

Data were analysed using thematic analysis (Braun & Clarke, 2006). A three-

stage method of thematic synthesis was used (Thomas & Harden, 2008). An

iterative and inductive analysis was undertaken, similar to the method described by

Wolverson, Clarke and Moniz-Cook (2016). The initial stage involved line-by-line

reading and re-reading of extracted findings to isolate themes related to identity

and self-concept following ABI. These themes, with accompanying direct quotes

from participants, were interpreted and coded into descriptive themes within and

across studies. Further analytical themes were generated based on these

descriptive sub-themes. Direct quotations from participants in the original studies

15

were included to illustrate each theme in order to remain as true to the original

data as possible.

16

Results

Search results

The initial search of three electronic databases (PsycInfo, MEDLINE and

SCOPUS) identified 862 articles (Figure 1). 198 duplicates were excluded. A further

590 articles were excluded based on exclusion criteria following the screening of

titles and abstracts. Reasons for exclusion included non-human population, not

published in English, non-ABI population, non-adult population, exploring other

consequences of ABI including cognitive deficits, agnosia and fatigue, exploring the

perspectives of carers or family members rather than the individuals themselves. 74

full text articles were reviewed for eligibility, with a further 60 excluded, as they did

not use a qualitative methodology or were not specifically exploring identity or self-

concept. Fourteen articles proceeded to quality review, and 12 were selected for

inclusion in the current review.

Characteristics of included studies

Twelve articles were included in the current review (see Table 1). These

articles were published from 1997 – 2015 and were geographically based across

England, Ireland, Netherlands, South Africa, United States, and Australia. The

majority of studies (11 of 12) obtained samples from a community setting, while

one recruited from an inpatient rehabilitation setting (Gracey et al., 2008). Type of

injury varied across studies, with two defining inclusion as any ABI (Gracey et al.,

2008; Lennon et al., 2014), and the remaining 10 reporting specifically on TBI. The

majority of participants included were male, with two studies having all male

17

participants (Freeman et al., 2015 Sabat et al., 2006) and the remaining ten having a

majority of male participants.

Studies were diverse in their methodological approach. One study used

structured facilitated small group discussions (Gracey et al., 2008), while the

remaining 11 studies used individual methods of data collection. All 11 used semi-

structured interviews. Some studies collected additional data through observation

methods (Nochi, 1997, 1998, 2000), clinical records (Douglas, 2013; Freeman et al.,

2015,) and self-report measures (Douglas, 2013; Freeman et al., 2015).

Quality Analysis

Twelve of the initial 14 identified studies were included in the current

review. Methodological strengths and limitations were noted, using the NICE quality

appraisal checklist for qualitative studies as guidance (NICE, 2012). Studies were

included based on the quality assessment inclusion criteria detailed previously. An

independent rater agreed exclusion of two articles based on these criteria.

Overall, based on the quality appraisal checklist, research within the field

was considered to be of high quality. A particular strength noted across the

literature was the high level of detail provided regarding the methodology,

particularly detailing the recruitment processes, methods of data collection and the

analysis. This allowed consideration of the findings in context. Some limitations in

terms of quality included limited information provided regarding the severity of

injury, non-representative samples (particularly gender) and lack of comparison

groups. However, these limitations are common across qualitative literature and

were not deemed to impact on the validity of findings.

18

Figure 1: PRISMA flow chart

Table 1: Characteristics of included studies (continued)



19

Bibliographic Information

LocationCountrySetting

SampleCharacteristics

Sample sizeGender ratio

Age range

ABIType of injury

Time since injury

Aim/Research Question

Cloute, K., Mitchell, A., & Yates, P. (2008)

England

Community

n = 6

5 male:1 female

21 – 60 years

TBI

4 – 20 years

‘1. What kind of IRs (interpretative repertoires) are used by individuals with a TBI and their significant others? 2. How are they used in conversation to construct aspectsof social identity?’ (p654)

Semi-structured interview

Analysis involved cyclical periods of coding, reflecting and writing. References to time since injury were coded and IRs evident in each time frame were distinguished and compared

Douglas, J. M. (2013) Australia

Community

n = 20

16 male: 4 female

21 – 54 years

TBI

5 – 20 years

Understand ‘how adults with severe TBI have constructed a sense of self several years after injury’ (p62)

In-depth interviews, field notes, a personal demographic questionnaire, client files and two rating scales

Grounded theory thematic analysis





Age range

ABIType of injury

Time since injury


Freeman, A., Adams, M., & Ashworth, F. (2015)

England

Community

n = 9

All male

22 – 59 years

TBI

17 months – 21 years

‘Aim to explore the nature of self-identity in the social context for men following TBI. How do survivors of TBI experience changes in the self and identity in relation to their social context following TBI? And what is the nature of the emotional experience of the self in the social world for male survivors of TBI?’ (p193)

Self-report measures, review of clinical notes and semi-structured interviews with an average duration of 58 minutes

Thematic analysis

Gelech, J. M., & Desjardins, M. (2011)

Canada

Community

n = 4

3 male: 1 female

37 – 55 years

TBI (RTA)

4 – 21 years

Exploration of self, considering ‘the roles of both cultural forms and interpersonal processes in the post-injury construction of personhood… revealing nuances in the experience of self, exploring movements and patterns that diverged from those encompassed by the dominant discourse of loss and negative alteration’ (p65)

Life history interview and semi-structured interview 35 – 90 minutes

Thematic analysis





Age range

ABIType of injury

Time since injury


Gracey, F. et al., (2008)

England

Inpatient rehabilitation

n = 32

23 male: 9 female

21 – 59 years

Mixed ABI

1 – 10 years

‘The aim of this study is to find out the salient patterns of self-construing engaged in by individuals when making sense of changes after brain injury’ (p632)

Structured facilitated group discussions of 1 hour (2-5 participants)

Personal constructs elicited (‘in vivo’ data reduction) and thematic analysis

Hoogerdijk, B., Runge, U., & Haugboelle, J. (2011)

Netherlands

Community

n = 4

3 male: 1 female

33 – 61 years

TBI

20 – 27 months

‘How do individuals with traumatic brain injury make sense of their adaptation process and the performance of occupations within this process? This study aimed to understand how individuals valued the performance of everyday life activities within their adaptation process and how those occupational experiences influenced the adaptation process’ (p123)

2 interviews 50mins – 90mins

Polkinghorne’s narrative analysis



20





Age range

ABIType of injury

Time since injury


Lennon, A., et al. (2014)

Ireland

Community

n = 9

8 male: 1 female

28 – 62 years

Mixed ABI

2.5 – 9 years

‘Through exploring and comparing the narratives of individuals with ABI and the narratives of individuals with SCI, the present study will investigate the ways in which individuals with ABI and individuals with SCI rebuild their sense of self following injury. The present study will directly explore the similarities and differences between the self-narratives of individuals with ABI and individuals with SCI, identifying the processes of self-reconstruction unique to each type of injury’ (p29)

Phenomenological life-story approach

Interpretive thematic analysis

Muenchberger, H., Kendall, E., & Neal, R. (2008)

Australia

Community

n = 6

4 male: 2 female

22 – 49 years

TBI (RTA)

> 1 year

‘The current study undertakes an in-depth qualitative analysis of individuals with TBI and explores the perceptions of self, relative to critical life events’ (p980)

Life story interview protocol

Thematic analysis





Age range

ABIType of injury

Time since injury


Nochi, M. (1997) US

Community

n = 4

3 male: 1 female

24 – 40 years

TBI

4 – 12 years

‘This study is concerned with the self-narratives of people with TBI. The intention is to understand what self-images they have when they are aware of their TBI and to reveal how individuals experience psychological distress in their everyday lives’ (p535)

In-depth interviews and participant observation with detailed field notes

Thematic analysis

Nochi, M. (1998) US

Community

n = 10

6 male: 4 female

24 – 49 years

TBI (RTA or sport-related injury)

2 – 12 years

‘This study examines varied experiences of self that people with traumatic brain injuries (TBI) have in their daily lives’ (p869)

2-3 semi-structured interviews 45mins – 60mins and participant observation with detailed field notes

Inductive thematic analysis using grounded theory method





Age range

ABIType of injury

Time since injury


Nochi, M. (2000) US

Community

n = 10

8 male: 2 female

24 – 54 years

TBI

3 – 28 years

‘This study constitutes characteristic ways that individuals with traumatic brain injuries (TBI) describe their current situations when they feel relatively at ease with their lives’ (p1795)

2 or more semi-structured interviews 45mins – 60mins and participant observation with comprehensive field notes

Inductive thematic analysis using grounded theory method

Sabat, A., Moodley, L., & Kathard, H. (2006)

South Africa

Community

n = 1

Male

31 years

TBI

12 years

‘1. To explore the nature and process of self-identity construction pre- and post-TBI2. To consider the implications of the findings for research and clinical practice in the field of SLT’ (p18)

Qualitative life history research methodology3 semi-structured 90minute in-depth interviews

Generating transcripts, narrative analysis, analysis of the narrative.

Thematic synthesis of findings

Nine descriptive sub-themes were developed from the thematic synthesis of

the findings of the papers included in the current review; these were organised

under two broader higher order themes of ‘change’ and ‘adjustment’ (Figure 2). The

theme of ‘change’ describes changes in identity reported following ABI, including

whether individuals experience a change in identity, what they attribute the change

to, the types of positive and negative changes experienced, and the changes

experienced in relation to other people. The theme of ‘adjustment’ describes the

process of making sense of these changes and offers some understanding about

what facilitates and hinders moving forward and making sense of an altered identity

following ABI.

Figure 2: Themes and subthemes

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Change

Continuity versus change

As expected, based on the inclusion criteria, all 12 papers acknowledged

some form of a change in identity following ABI. All papers identified aspects of the

‘self’ that had changed since the injury including changes in functional capacities

and social roles. Changes were identified across various domains including physical,

cognitive, emotional and social; both positive and negative changes were reported.

When describing their identity, many distinguished between the pre-injury and

post-injury self and some acknowledged the ABI as a force that significantly altered

their identity and self-concept. Freeman, Adams and Ashworth (2015) described a

sense of abnormality as central to the identity of participants, compounded by the

issue of a lack of self-awareness, where individuals were often unable to notice

changes in themselves.

However, the ABI was not exclusively seen to cause a change in identity.

Gelech and Desjardins (2011) distinguished between the public and private self.

Participants reported a disruption in continuity to the public self as a result of

losses. However, in contrast, they described their private self as continuous and

stable. This continuity was experienced despite threats to it including the deficits

resulting from their injury and the views of others. In line with this, Lennon et al.

(2014) described a paradoxical finding where individuals with ABI experienced their

sense of self as simultaneously changed and continuous.

22

Table 2: Quotes to illustrate ‘continuity versus change’

Quote Reference‘Things just aren’t the same and I am trying to accept that, more and more’ (p126)

‘[my accident] had a big impact and that’s the date that I was re-born if you like’ (p983)

‘I wasn’t the way I used to [be]... 35 years builds you up dealing with everything to get to that point, then one day this happens, you wake up with a totally different everything’ (p985)

‘I have changed in other people’s eyes for sure… but I still feel like the same person’ (p68)

(Hoogerdijk et al. 2011)

(Muenchberger et al., 2008)


(Gelech & Desjardins, 2011)

Causes of change

A second theme represents the various beliefs individuals hold about the

cause of the changes in identity. Attributing changes to a direct consequence of the

ABI was common with participants expressing a belief that the ABI was a deficit and

the individual who had experienced the ABI was not responsible for their own

actions (Cloute, Mitchell & Yates, 2008). In line with this, participants emphasised

the seriousness of their injury and expressed concern that others would not

recognise their ‘hidden injury’ and incorrectly attribute changes to them ‘as a

person’ (Freeman et al., 2015).

Gelech and Desjardins (2011) described individuals attributing their change

in identity to a combination of practical changes resulting from the injury itself, but

also to the responses of others. Muenchberger, Kendall and Neal (2008) described

changes as resulting from a complex interplay between various factors including

injury-related changes (such as functional deficits and loss of autonomy) as well as

personal responses to these changes (including situational avoidance). Nochi (1997)

23

described some people accepting a causal relationship between ABI and their

current situation, while others discounted the causal relationship and did not

consider the ABI to be an important influence on their self-concept. Douglas (2013)

found that none of their participants identified ‘brain injury’ as a personal attribute.

This suggested that although the ABI was acknowledged to have caused a change,

the participants did not define themselves by the experience of having an ABI.

Table 3: Quotes to illustrate ‘causes of change’

Quote Reference‘Others would not recognise my brain injury’ (p200)

‘Memory loss that I had, from the accident. Loss of people who used to be my friends, because of the accident. Loss of work, because of the accident…’ (p544)

‘My brain is short-circuited’ (p872)

(Freeman et al., 2015)

(Nochi, 1997)

(Nochi, 1998)

Negative changes

In line with the common narrative about identity after ABI, a theme could be

extracted across the literature of negative changes in identity experienced after ABI.

This was seen clearly in papers where the pre-injury identity or ‘old me’ was

acknowledged as highly valued and the ABI was described as resulting in a loss of

identity (Cloute et al., 2008; Freeman et al., 2015; Gelech & Desjardins, 2011;

Lennon et al., 2014; Nochi 1998; Sabat, Moodley & Kathard, 2006). Similarly,

Lennon et al. (2014) described the post-injury identity as defined by inability. Other

negative changes that impacted on identity included physical (Cloute et al., 2008;

Gracey et al., 2008; Nochi, 1997), cognitive (Cloute et al., 2008; Gelech & Desjardins,

2011; Gracey et al., 2008; Nochi, 1997) and functional impairments (Cloute et al.,

24

2008; Muenchberger et al., 2008) and a loss of confidence and autonomy (Douglas,

2013; Freeman et al., 2015; Gelech & Desjardins, 2011; Lennon et al., 2014;

Muenchberger et al., 2008). Furthermore, a sense of abnormality (Freeman et al.,

2015; Gelech & Desjardins, 2011), a change or loss of social roles (Cloute et al.,

2008; Freeman, Gracey et al., 2008; Nochi, 1998) and social withdrawal (Cloute et

al., 2008; Freeman et al., 2015; Muenchberger et al., 2008) resulted in perceived

negative changes in identity.

Table 4: Quotes to illustrate ‘negative changes’

Quote Reference‘It’s too much on my wife to look after me… I wish I could do more to help’ (p69)

‘…but um, it was about me and it’s been all… it was always about me… wanting the old-me I des… desperate to have the old-me back’ (p202)

‘I’m not normal. It will never be like I was before. I think differently and I feel different’ (p125)

‘I have to repeat things and say things out loud and ask my husband for an explanation’ (p127)

‘Somebody with no memory, that’s, that’s it, the nicest way of putting it’ (p34)

‘My whole life changed… I realised that a lot of the skills were gone, and I wasn’t accepted socially as much… I knew there was something different, and the other kids at school knew something was different’ (p985)

(Douglas, 2013)




(Lennon et al., 2014)


Positive changes

A theme of positive changes to identity following ABI could also be

developed from the literature. Some research identified a celebrated survivor role

and associated feelings of pride (Cloute et al., 2008; Freeman et al., 2015; Lennon et

25

al., 2014). Others described framing the ABI as a positive event that had contributed

something positive to their self-concept (Douglas, 2013; Nochi 2000). Positive

changes included acquiring new skills and positive self-attributes (Douglas, 2013;

Lennon et al., 2014; Sabat et al., 2006). Furthermore ABI was described as resulting

in a positive reconstruction of the past (Lennon et al., 2014) and also a

reconstruction of ones life values (Lennon et al., 2014; Nochi, 1997). One case study

also described a ‘moral reawakening’ following the ABI (Sabat et al., 2006).

Table 5: Quotes to illustrate ‘positive changes’

Quote ReferenceI’m glad I had my accident because it’s made me into a better person. It’s made me help people’ (p68)

‘Yeah, I do have a sense of pride about it. Yeah… even though I didn’t achieve nothing, that’s all… I just feel good that I’m still here’ (p206)

‘My family and friends say that I’m more civilized now after the accident’ (p68)

‘I think I am a stronger person’ (p30)

‘The one and only thing I can remember from my coma is saying God, please don’t let me go. I was literally begging God just to let me live, especially for my mother. Since then religion has been so important to me’ (p23)

‘If she [the woman who hit him in the accident] didn’t do what she did, I probably would be dead by now if I lived the same way I was’ (p1798)

(Douglas, 2013)




(Sabat et al., 2006)

(Nochi 2000)

Other people

The influence of other people was identified as an important theme in

identity after ABI. This theme was first evident in changes in the nature of

relationships with others, including an increase in dependence. A loss of autonomy

26

(Lennon et al., 2014), reliance on others (Muenchberger et al., 2008) and

dependence (Cloute et al., 2008) were identified as key components of self-concept

after ABI. Douglas (2013) reported individuals viewing themselves as ‘a burden’

following ABI. Freeman et al. (2015) further described a ‘withdrawal from the social

world’ as a response to changes in identity experienced following ABI.

Following ABI, people perceive that others view and respond to them

differently (Freeman et al., 1998; Gelech & Desjardins, 2011; Nochi, 1998). Some

also reported being treated the same as before (Freeman et al., 2015). Gelech and

Desjardins (2011) suggested that those with ABI perceived others to view them as

having a new social identity of a ‘generic marginalized and dependent person’ (p66).

Changes in relationships with others and devalued social roles were identified as

having a significant impact on self-concept (Freeman et al., 2015; Gelech &

Desjardins, 2011; Gracey et al., 2008). In line with this, other people were identified

as being in powerful positions to influence aspects of identity following ABI (Gelech

& Desjardins, 2011).

27

Table 6: Quotes to illustrate ‘other people’

Quote Reference‘Activities look good and it’s easier going with my wife but it means my wife would have to give up her time to take me there, wait for me and take me home’ (p69)

‘I am dependent on others now, like almost totally. I was pretty independent before. That’s been a change in my identity’ (p66)

‘… I feel that there is something about me th… that there is something that my wife doesn’t feel is right and that is, maybe something about me that is… that I… I need to change…’ (p201)

‘Life isn’t all smooth sailing when you have a disability. People treat you differently’ (p22)

‘Oh yeah, other people see me as having changed. That’s why they’re not my friends anymore. That’s why I had to learn new friends and stuff’ (p68)

‘I am tired of fighting people's perceptions of me as ‘stupid’’ (p874)

‘...that the last year I, I didn’t do anything and um, that would make me question who... who I was and what I could do because it is to hang on to the idea that... that I was the old-me. You... you don’t want to do anything that would make that idea shake so you... err... you... I realized that I had made a prison for myself. I didn’t go out, I didn’t see people I knew I didn’t um, you know, um, I was all very, err, I didn’t want to disturb the idea in my head that I was, err, still exactly the same after the accident’ (p206)

(Douglas, 2013)



(Sabat et al., 2006)


(Nochi, 1998)


Adjustment

The journey of adjustment & acceptance

Some studies describe an initial stage of grief and loss regarding the changes

experienced (Freeman et al., 2015; Nochi, 1997; Sabat et al., 2006). The process of

adjusting to changes was described as long and complex, without necessarily a

direct linear progression (Muenchberger et al., 2008; Nochi, 1997, 1998, 2000).

Acceptance of changes was identified throughout the literature as a key component

of adjustment and ‘moving forward’ following changes to identity experienced after

28

ABI (Freeman et al., 2015; Hoogerdijk, Runge & Haugboelle, 2011; Muenchberger et

al., 2008; Nochi, 1997, 1998, 2000; Sabat et al., 2006). The degree of acceptance a

person has attained was identified as an important self-construct following ABI

(Gracey et al., 2008).

Table 7: Quotes to illustrate ‘the journey of adjustment and acceptance’

Quote Reference‘Bipolar identity constructs associated with self-acceptance:Happy with how I am – Discontent with myselfAccepting of losses or difficulties – Why me?Acceptance, moving on – Denial, hatred of what’s happened’ (p641)

‘not everything needs to change back’ (p126)

‘I have read a story of a woman with brain injury who said that you have to stop trying to be who you were. It’s exactly like that’ (p126)

‘I have to accept that I get tired quickly and do things piece by piece’ (p127)

‘Gradually you can put that accident in perspective. It takes us, takes us a while, about a year. Then say, uhm, `OK, it’ s not the most important thing’ (p542)

(Gracey et al., 2008)




(Nochi, 1997)

Confusion and uncertainty

Following ABI, a sense of confusion or uncertainty about changes is reported

across the literature. Adjustment to injury often involved making sense of a new

identity and filling in gaps in self-knowledge. Muenchberger et al. (2008) described

people continually questioning the foundation of their identity following ABI.

Confusion was often a result of a lack of self-awareness. Participants reported being

unable to recognise changes in themselves and being reliant on feedback from

others or repeated experience in certain situations, e.g. social or occupational, to

29

learn about themselves (Freeman et al., 2015; Gracey et al., 2008; Hoogerdijk et al.

2011). Memory difficulties often contributed to the sense of confusion experienced.

People were often unable to remember their ABI and the circumstances

surrounding it, resulting in confusion about how the changes occurred, often

accompanied by a lack of information about their own life history (Nochi, 1997,

1998). Confusion and uncertainty was associated with despair, distress,

hopelessness and a loss of confidence (Freeman et al., 2015). People described

making efforts to gather information to ‘figure out’ changes and to make their sense

of self more stable (Nochi, 1997, 1998).

Table 8: Quotes to illustrate ‘confusion and uncertainty’

Quote Reference‘I think it’s very important to hear the story about what has happened to you, as it is the only way to piece the puzzle together’ (p127)

‘understanding brain injury and coming to terms with the hospital environment’ (p984)

‘It’s like a void, or a black hole. It’s like, my memory is like a chalkboard, where some parts are erased…’ (p539)



(Nochi, 1997)

Comparison

The theme of comparison represents an important mechanism by which

individuals make sense of and adjust to their identity following ABI. Comparison was

shown to result in both positive and negative outcomes for self-concept.

Comparison was reported as less helpful in situations where individuals reported a

tendency to compare their current self with their past self or ‘old me’ or a potential

future self they had imagined (Freeman et al., 2015; Nochi, 1998). This was usually

30

referring to aspects of their pre-injury identity that they had valued. However,

comparison was also seen as helpful where individuals described comparing their

current identity to usually worse alternatives (Nochi, 2000). Participants described

considering themselves fortunate compared to poorer alternate outcomes, and

strategically comparing themselves to others who had it worse (Douglas, 2013;

Lennon et al., 2014).

Table 9: Quotes to illustrate ‘comparison’

Quote Reference‘so many people worse off that there is no point feeling sorry for yourself. I’m pretty lucky considering the others who were in rehab and you know, it could be worse – could not be here’ (p69)

‘It wasn’t until I went to college and I start meeting people. And I think that just gave me a good kick up the arse. There are worse people out there than you’ (p31)

‘Ok, (you) did survive. Your injury is not the worst’ (p544)

‘It has been an extremely emotional roller coaster for me in realising that the direction that I wanted to pursue has been snatched away’ (p873)

‘I, I don’t know, there’s no similarities to, of who I am and who I was. I don’t know who I was’ (p873)

‘Things could be worse’ (p1798)

‘I was older. He was a younger man when he got injured. I was thirty. . .seven? Yeah, I was 37 when I was injured. So, I already lived pretty much my. . .you know, not much was going to be changed for me. I didn't miss anything. You know, I have pretty much life experience by 37. . . I feel bad for them [younger people with TBI] because they are never going to have, have girlfriends…’ (p1798)

(Douglas, 2013)


(Nochi, 1997)

(Nochi, 1998)

(Nochi, 1998)

(Nochi, 2000)

(Nochi, 2000)

31

Values, goals and meaningful activity

This theme refers to the importance placed on certain activities and aspects

of personhood following ABI. Many changes were reported following ABI in terms of

an individual’s personal values and chosen valued goals. The contribution of

occupation and meaningful activity to the reconstruction of identity was also

highlighted. An alteration in life values was noted in the narratives of individuals

following ABI. Participants spoke about reconstructing their priorities in life (Lennon

et al., 2014) and changing the focus of their concerns (Nochi, 1997). Similarly,

Gelech and Desjardins (2011) reported participants altering the importance placed

on components of their social identities as they came to accept the changes they

had experienced.

Goals for the future were identified as an important aspect of identity across

the literature. The importance of progression, positive growth and productivity was

highlighted (Cloute et al., 2008; Freeman et al., 2015; Nochi, 1997). Goals and

striving statements across various domains including physical, material, social and

activity were noted as significant in self-narratives (Douglas, 2013). Gracey and

colleagues (2008) described motivation, interest and effort in these goals as a key

aspect of identity. In line with this, meaningful activity was recognised throughout

the literature as essential in the process of adjustment and establishing a new

identity following ABI. Productive and meaningful activity was identified as an

important method of assessing progress, with an increase in activities indicative of

recovery (Cloute et al., 2008; Nochi, 1997). Meaningful activity was identified as a

means through which individuals make sense of themselves (Gracey et al., 2008;

32

Lennon et al., 2014). Engagement with meaningful activities was seen to promote

positive self-reconstruction and facilitate adaptation to the post-injury identity

(Hoogerdijk et al. 2011). There was also reference to ABI as a barrier preventing

individuals returning to previous occupations (Cloute et al., 2008).

Table 10: Quotes to illustrate ‘values, goals, and meaningful activity’

Quote Reference‘I would like to find work, find employment, I volunteer at the moment’ (p65)

‘I’m looking forward to the spring when I can begin working in my garden again’ (p127)

‘Well I do volunteer work you know. I’ve done that for the last two and a half years. And that, the whole thing, you know, the feeling of being useful again you know. A great moral booster you know’ (p31)

‘… the trouble is you know if I get a full-time job I’ll be all right for a couple of days, and then the next two or three days, I might have a pounding headache and. I won’t be going to work so I’ve had that like I’ve had jobs… I’ve had too much time off and all that you know… I told my doctor about it an my doctor just told me to… cease work so’ (p661)

‘And when you go through something like that you realize that the emphasis people put on certain things aren’t really that important. It’s not that important to show people that you are good, . . . there are a lot more important things in life than what other people think’ (p987)

(Douglas, 2013)



(Cloute et al., 2008)


There are dominant themes in the sample of literature, which were identified in all

or nearly all studies (Table 11). Whilst most studies report negative changes, as

might be expected, it is evident that many studies also report positive changes. The

themes of ‘the journey of adjustment and acceptance’ and ‘values, goals and

meaningful activity’ were also dominant.

33

Article

THEME

Cloute et al., 2008

Douglas, 2013

Freeman et al., 2015

Gelech & Desjardin

s, 2011

Gracey et al., 2008

Hoogerdijk et al. 2011

Lennon et al., 2014

Muenchberger et al., 2008

Nochi, 1997

Nochi, 1998

Nochi, 2000

Sabat et al., 2006

CHANGE

Continuity versus change

Causes of changes

Negative changes

Positive changes

Other people

ADJUSTMENT

The journey of adjustment and acceptance

Confusion and uncertainty

Comparison

Values, goals and meaningful activity

Table 11: Representation of identified themes across studies

34

Discussion

The aim of the current review was to explore current understandings of

identity and self-concept after ABI with a view to drawing implications for clinical

practice and research related to identity-focused interventions. All 12 qualitative

studies reviewed reported a change in identity following ABI. However, the impact

of ABI was complex and involved some sense of continuity alongside both negative

and positive changes. The review furthermore revealed how individuals make sense

of changes experienced, including the journey of adjustment and strategies used to

enhance acceptance of the post-ABI self.

Beadle et al. (2015)’s quantitative review proposed that changes in self-

concept experienced following TBI are a result of broad psychosocial consequences

of TBI rather than the direct neurological consequences of TBI. This finding was

somewhat supported in the current review. Memory impairments as a result of

neurological damage contributed to the theme of ‘confusion and uncertainty’, as

participants reported being unable to recall details of the accident or information

about their pre-injury self. However, the theme of ‘other people’ highlights the

complexity of the impact of ABI including it’s influence on social roles and

relationships, while the theme of ‘causes of changes’ points to other factors that

impact on the change including the reactions of others, loss of autonomy and

avoidance. The other three themes related to adjustment (‘the journey of

adjustment and acceptance’, ‘comparison’ and ‘values, goals and meaningful

activity’) all propose that progress can occur in spite of existing neurological deficits,

suggesting that the changed identity is not solely attributable to such deficits.

36

The themes of ‘continuity versus change’ and ‘negative changes’ which both

refer to a difference experienced between the pre-injury and post-injury identity

reflect the theme of ‘discconnect with pre-injury identity’ noted by Levack and

colleagues (2010). The four subthemes under the broader theme of ‘adjustment’ all

describe how an individual makes sense of changes following ABI and strategically

reconstruct their identity on an extended complex journey. These themes are

similar to the theme of ‘reconstruction of identity’ noted by Levack et al. (2010).

The theme of ‘values, goals and meaningful activity’ is consistent with the findings

of Bryson-Campbell and colleagues (2015) who concluded that changes to identity

following ABI could impact on successfully returning to previous occupational

activity. The current review expands on these findings to consider that returning to

employment or other valued meaningful activities can, in turn, positively impact on

identity and self-concept following ABI.

Clinical implications

The findings suggest that identity is an important component in

rehabilitation following ABI. Rehabilitation professionals across disciplines would

benefit from focusing on identity and the meaning of losses for individuals.

Specifically, the findings suggest that clinical interventions would benefit from

engaging individuals in personally valued and meaningful activities, as this was

identified as an important component in adjustment after ABI. Furthermore, as

comparison was identified as another mechanism of adjustment, rehabilitation

efforts would likely benefit from a consideration of systemic factors and systemic

interventions.

37

The results of the current review lend support to the hypothesis that

impairments alone do not account for changes to identity experienced following

ABI, and thus offers a hopeful message that improvements can be made even in the

context of remaining neurological impairments. This reflects current thinking in the

mental health literature, where ‘recovery’ has been redefined from being a ‘cure’ or

‘getting back to normal’ to the concept of ‘living well’ with enduring symptoms and

vulnerabilities (Roberts & Wolfson, 2004, p37). This is an important message for

professionals and individuals who have experienced ABI, particularly as the focus of

early rehabilitation efforts is often on identifying functional deficits and restoring

abilities (Burns, 2008). If this is considered unsuccessful, self-concept can be

impacted and engagement in further rehabilitation efforts later can be problematic.

The current review also lends support to the utility of specific psychological

interventions focusing on identity following ABI. The two broad themes of ‘change’

and ‘adjustment’ suggest that identity change is experienced following ABI. They

suggest that this can impact on other important outcomes and that individuals

strive to make sense of this change in order to move forward. It is also notable that

changes are not exclusively negative and thus an intervention would benefit from a

strengths-based approach utilising resilience and positive consequences of ABI.

An acceptance and commitment therapy (ACT) approach has been proposed

as a potentially suitable intervention for psychological problems following ABI

(Kangas & McDonald, 2011). The current review, and specifically the broad theme

of ‘adjustment’, lends support to the proposition that an ACT intervention could be

beneficial within a neurorehabilitation setting for a number of reasons. The theme

38

of ‘the journey of adjustment and acceptance’ fits with Gracey and colleagues’

description of neurorehabilitation as a ‘Y-shaped’ model (Gracey et al., 2009). It

suggests that rehabilitation should aim to reduce the discrepancy between the

current identity and aspired-to identity and increase acceptance of the post-injury

identity. An ACT intervention is well placed to support this as one of the key

processes of the therapy is acceptance, defined as ‘opening up and making room for

painful feelings, sensations, urges and emotions’ (Harris, 2009, p9). Furthermore

defusion, which is described as ‘learning to step back and separate or detach from

our thoughts, images, and memories’ (Harris, 2009, p9), could facilitate this process

by reducing ties to thoughts associated with the aspired-to identity. This is also

consistent with the theme of ‘comparison’ in which individuals reported making

sense of their identity by comparing themselves to others or their pre-injury self;

defusion from thoughts of the pre-injury self could reduce this negative self-

comparison. Mindfulness, a further process within ACT, would also likely reduce this

comparison as it promotes paying attention to the present moment in a non-

judgemental way without getting absorbed in thoughts about the past and future

(Harris, 2009).

As ACT is based on the premise of moving forward towards valued goals

(Hayes, 2004), the theme of ‘values, goals, and meaningful activity’ provides further

evidence for its potential utility. The ACT mechanisms of values and committed

action, which support individuals to explore what qualities are important to them

and act in accordance with these values, may be beneficial in supporting individuals

to re-engage in meaningful activity. The findings of the current review suggest that

39

this could in turn facilitate acceptance of the post-injury identity. Furthermore, an

opportunity to explore values may reduce the impact of confusion and uncertainty,

which was also noted in the current review as a consequence of identity change

which negatively impacts on moving forward following ABI.

The current review also lends support for the utility of delivering a

neuropsychological rehabilitation intervention in a group format as acceptance and

comparison were identified as key components in the adjustment process. Group

therapy has been shown to promote acceptance through the process of being

accepted by the group (MacKenzie, 1990). Furthermore, as individuals report

making sense of their identity through comparison with others, a group intervention

with others who experience similar difficulties would likely provide a comparison

group more similar to the individual’s current identity, thus reducing the magnitude

of the discrepancy perceived between an individual’s own identity and that of

others.

Research Implications

The review found that most studies used an individual interview

methodology. In future research, there is a need for more diverse methods of data

collection to further understand changes to identity following ABI and also explore

the views of populations not currently represented e.g. those with speech

impairments. One study (Gracey et al., 2008) collected data during group

discussion, and future research would likely benefit from using more focus group

methodologies to further understand the social aspects of identity construction

after ABI. Methodologies including observations and creative work (e.g. art,

40

photography) may allow for exploration of identity for individuals with more severe

impairments who cannot engage with individual interviews. Their understanding of

identity following ABI may differ from those included in the current sample.

As the current review points to the potential utility of an ACT intervention

for identity following ABI, further research is also needed to investigate this. Though

a recent review evaluated rehabilitation interventions measuring self-concept

(Ownsworth & Haslam, 2016), there were no ACT interventions included within this

review. To date, there are no published studies exploring the impact of ACT on

identity or other outcomes following ABI. Research is needed to understand the

potential effectiveness and efficacy of ACT interventions, for example effectiveness

studies to generate practice-based evidence from clinical settings or efficacy studies

using a randomised-control trial methodology.

Limitations

There are some limitations associated with the current review, relating both

to the quality of the included papers and the review methodology itself. Limitations

within the selected sample of papers included a lack of information regarding the

role of the researcher, limited information on the context of data collection, and

lack of information about ethical procedures. The quality assessment tool was used

to delineate those criteria that it was considered essential for selected papers to

meet for inclusion; where information was missing or poorly specified (e.g. in the

areas of limitation listed above), studies were included if their results were deemed

unlikely to alter based on the missing information. It must also be noted that the

generalisability of samples included in the current review may be a further

41

limitation. As participants, by definition, were required to have a certain level of

language and cognitive ability to participate in data collection, their views may not

be representative of all who have experienced an ABI, particularly those who

sustained more severe injuries. Furthermore, the majority of participants in the

included studies were male. Though this partly reflects the high incidence of ABI

amongst males, it is also worth baring in mind that findings may not reflect the

female experience of ABI.

As Wolverson and colleagues (2016) highlight, the synthesis of qualitative

studies with differing methodologies and epistemological positions is challenging.

Conducting a thematic analysis runs the risk of losing important contextual factors

and the original meanings of individuals’ experiences. However, whilst the findings

of the current review should been seen as one interpretation of the studies

included in this review, there was a recurrence of many of the themes across the

sample of included papers, which adds to the trustworthiness of the review

(Estabrook, Field & Morse, 1994). Furthermore, direct quotes from the reviewed

studies were presented to demonstrate that the themes developed in this review

are grounded in the source data.

Conclusion

The current review of qualitative literature supports the notion that ABI

impacts on identity and self-concept. Furthermore, findings suggest that some

continuity of self is experienced by many following ABI, and that both negative and

positive changes are experienced. The review highlights the significance of other

people in how individuals understand their sense of self following ABI. The review

42

suggests that ABI can result in a sense of confusion and uncertainty about ones

identity, and that adjustment is often a result of acceptance of changes

experienced. The review also suggests that individuals use comparison to make

sense of their new identity, resulting in both positive and negative outcomes.

Finally, the review highlights the importance of values, goals and meaningful activity

for self-concept following ABI. Overall, the review lends support for the potential

utility of a clinical intervention targeting identity and self-concept following ABI,

specifically promoting acceptance and engagement in meaningful activity.

43

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50

Research Part 2:

Evaluating ‘RE-ID’: An acceptance and commitment therapy group

intervention exploring identity after acquired brain injury

Word Count: 15,445 total

9,973 (excluding Abstract, References, Tables & Figures)

51

Abstract

Aim: Self-concept and identity are impacted by the experience of an acquired brain

injury (ABI), often negatively. These changes have been shown to impact on other

domains including mood and vocational outcomes. The study aimed to provide

practice-based evidence for the effectiveness and acceptability of ‘RE-ID’, a novel

vocational rehabilitation group intervention exploring identity after an ABI using an

acceptance and commitment therapy (ACT) approach. Method: The study

employed an idiographic case series approach, using a mixed methods single case

design. Reliable change index and clinically significant change analyses were used to

assess changes in self-report measures of self-concept, mood, quality of life, self-

esteem, general self-efficacy, and occupational self-efficacy pre to post intervention

and at one-month follow-up. Semi-structured follow-up interview data were

analysed using deductive thematic analysis. Results: Quantitative outcome

measures showed limited change across the intervention. Qualitative data provided

preliminary evidence for the potential effectiveness of ‘RE-ID’, with participants

reporting change and attributing this change to a combination of ACT therapeutic

factors and group process factors. Discussion: The current study provides initial

data suggesting that ‘RE-ID’ may be an effective vocational rehabilitation

intervention following ABI, and that both the ACT model and the delivery of the

intervention in a group format likely contribute to its effectiveness.

52

Introduction

The impact of an acquired brain injury (ABI), including traumatic brain

injuries, hypoxic brain injuries, ischaemic brain injuries and brain injuries from other

medical causes, such as tumours or encephalopathies (Gurd, Kishka & Marshall,

2010), can be wide-ranging. They include possible physical, cognitive, emotional and

social changes. Experiencing an ABI ‘throws people off the life course they had

anticipated’ (Evans, 2011 p117). The experience of an ABI can also alter ones sense

of self by impacting on the qualities that define who we are i.e. our identity

(Ownsworth, 2014). Ownsworth (2014) summarises identity as consisting of the

collective characteristics we consider to be our own, which are both consistent and

continually under construction, and include biological, psychological and social

factors. Baumeister (1999) offers a helpful distinction between identity and self-

concept, with identity described as ‘a definition placed on oneself’ (p248), while

self-concept is ‘the individual’s beliefs about himself or herself, including the

person’s attributes and who and what the self is’ (p247). Rosenberg (1965)

described self-concept as the thoughts or feelings an individual has about their

identity. Often authors do not differentiate between the terms, and the use of the

terms in what follows reflects this mixed use.

An ABI can cause many changes to functioning and abilities and it is

important to understand the subsequent changes to identity and self-concept.

Tyerman and Humphrey (1984) were some of the first investigators to explore

changes to self-concept following ABI. Their study of self-concept in individuals who

sustained a traumatic brain injury (TBI) found that individuals viewed themselves as

53

having changed substantially across a range of traits, with almost three quarters of

the sample describing themselves as changed significantly ‘as a person’.

Research over the last three decades has led to a complex and nuanced

understanding of the impact of ABI on identity. Many researchers report negative

changes, but positive changes and some continuity of self-concept are also

reported. In a recent quantitative review of the impact of traumatic brain injury

(TBI) on identity, eleven of fifteen studies reported an overall negative impact of TBI

on identity, with individuals rating themselves more negatively on measures of self-

concept or personality than their pre-injury self or matched controls who had not

experienced a TBI (Beadle, Ownsworth, Fleming & Shum, 2015). The qualitative

literature also points to a change in identity following ABI (Mac Crosain,

unpublished). Participants in all twelve qualitative studies reviewed acknowledged

some change in identity following ABI, with some studies also reporting a continuity

of identity. Negative changes that were frequently reported included loss of

confidence, autonomy and physical, cognitive and functional abilities (Cloute et al.,

2008; Freeman et al., 2015; Gelech & Desjardins, 2011; Lennon et al., 2014; Nochi

1998; Sabat, Moodley & Kathard, 2006). However, the review also noted positive

changes to identity following ABI. In some instances, the ABI was viewed as

contributing something positive to a person’s self-concept such as a celebrated

survivor role, a reconstruction of values, or the acquisition of new skills (Cloute et

al., 2008; Douglas, 2013; Freeman et al., 2015; Lennon et al., 2014; Nochi, 1997;

Nochi 2000). Other qualitative reviews have shown similar results, with negative

changes most commonly reported including a loss of valued characteristics and

54

disconnection with the pre-injury identity (Bryson-Campbell, Shaw, O’Brien, Holmes

& Magalhaes, 2013; Levack, Kayes & Fadyl, 2010).

Overall, research suggests that identity change is common, if not universal,

amongst those who have experienced an ABI and can have a negative impact on

rehabilitation outcomes. This change in identity has been linked to other important

outcomes and, of particular relevance in the current study, psychological difficulties

and vocational outcomes. Self-discrepancy theory provides a useful framework for

understanding the psychological impact of identity change. Self-discrepancy theory

proposes that distress (including anxiety and depression) is experienced when a

person perceives a discrepancy between their current (‘actual’) self and their ‘ideal’

self (Higgins, Bond, Klein & Strauman, 1986; Beadle et al., 2015). In the case of

those who have experienced an ABI, this ‘ideal’ self is often the perceived pre-injury

self, with comparisons to the ‘old me’ resulting in a negative view of the ‘actual’

current self (Cloute et al., 2008; Douglas, 2013; Freeman et al., 2015; Lennon et al.,

2014; Nochi, 1997; Nochi 2000). This common position can act as a barrier to the

person engaging with rehabilitation because they feel hopeless or remain fused

with the idea that that if they cannot do things exactly as before then there is no

point. The aim of neuropsychological rehabilitation is often to reduce this

discrepancy and promote acceptance and compassion towards the new identity

(Gracey, Evans and Malley, 2009).

Research has also found an association between identity change and

vocational outcomes following ABI. As a result, identity is considered an appropriate

target for vocational rehabilitation interventions. Self-continuity, i.e. maintaining

55

pre-injury resources and qualities including self-confidence, has been reported as an

important factor in successfully returning to work (Lundqvist & Samuelsson, 2012).

Consistent with this, identity change has been found to negatively impact on

returning to previous occupations following the experience of an ABI (Bryson-

Campbell et al., 2013). However, the relationship between identity disruption and

return to work has been found to be cyclical; the process of returning to work

facilitates ‘the reconciliation of a new identity’ (Stergiou-Kita, Rappolt & Dawson,

2012, p184) and meaningful activity has been described as a means through which

individuals make sense of their identity (Gracey et al., 2008, Lennon et al., 2014).

Over the past decade, there has been increasing interest in including identity

in neuropsychological rehabilitation interventions (Gracey & Ownsworth, 2008). In

the first review of its kind, Ownsworth and Haslam (2016) reviewed rehabilitation

interventions measuring self-concept. The mixed results emerging from the review

were attributed largely to methodological differences across studies. However, ten

of the seventeen studies reviewed provided positive evidence that such

interventions are associated with improvements in self-concept, suggesting that

self-concept is amenable to change through therapeutic intervention. Interventions

included in the review were Cognitive Behavioural Therapy (CBT) (Anson &

Ponsford, 2006), group psychotherapy (Manchester et al., 2007; Vickery et al.

2006), Compassion Focused Therapy (CFT) (Ashworth, Gracey & Gilbert, 2011),

family based support (Kelly et al., 2013; Sinnakaruppan et al., 2005), cognitive

rehabilitation (Hellfenstein & Wechsler, 1982; McGuire & Greenwood, 1990; Rath et

56

al., 2003) and activity-based interventions (Driver et al., 2006; Fines & Nichols,

1994; Gemmell & Leathem, 2006; Schwandt et al., 2012).

The range of interventions included in the review highlights the complexity

of influencing identity, with interventions targeting both lower and higher level self-

representations (Ownsworth & Haslam, 2016). Lower level self-representations are

self-perceptions of behaviour in specific situations, while higher-level self-

representations refer to broader perceptions of ‘who I am and how I feel about

myself’ (Ownsworth & Haslam, 2016, p29). Some interventions focus on specific

behaviours, abilities and group memberships aiming to exert a ‘bottom-up’

influence on identity. For example, cognitive rehabilitation might be used to

improve performance in a specific context that results in an increased sense of

competence that, in turn, may result in a more positive overall self-concept.

Alternatively, interventions may target a broader global self-concept with a view to

having a ‘top-down’ influence on outcomes. This latter form of intervention is the

focus of the current study.

Acceptance and commitment therapy (ACT) interventions have been

proposed as potentially effective in ameliorating the psychological impact of ABI

(Kangas & McDonald, 2011). Given that ACT aims to facilitate functional change

rather than eliminate symptoms, it may be well placed to support individuals who

have experienced an ABI to re-engage with a meaningful life in spite of physical and

neurological deficits. Though there has been limited research exploring the efficacy

of ACT in ABI populations to date, a meta-analysis has shown its efficacy across a

range of other physical health conditions including diabetes, fibromyalgia, tinnitus,

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chronic pain and cancer (A-Tjak et al., 2009). These findings may apply to an ABI

population as the conditions studied often share characteristics with ABI including

the chronicity of difficulties, pain, physical impairments, sensory impairments,

requirement of medical input and an increased dependence on others.

ACT is hypothesised to be an appropriate intervention to address changes in

self-concept following ABI for various reasons. The main aim of ACT is to increase

psychological flexibility, which is described as consisting of six core processes:

contacting the present moment, defusion, acceptance, self-as-context, values and

committed action (Harris, 2009). Psychological flexibility is proposed to facilitate a

more positive self-concept through acceptance of the ‘actual’ self. Acceptance has

been shown to be a key component in post-traumatic growth and ‘moving forward’

following ABI (Mac Crosain, unpublished; Ownsworth, 2014). Moreover, a focus on

values and committed action is likely to support individuals to engage in productive

and meaningful activity, which has been shown to aid in the reconstruction of

identity following ABI (Cloute et al., 2008; Mac Crosain, unpublished). To date,

there has been no research exploring the efficacy or effectiveness of an intervention

incorporating all six processes of psychological flexibility in ACT with an ABI

population (Kangas & McDonald, 2011).

The ‘RE-ID’ intervention (Doogan, unpublished) uses an ACT approach to

explore identity after ABI, with a specific emphasis on vocational activity. ‘RE-ID’ is

delivered as a group intervention for both theoretical and practical reasons.

Practically, delivering interventions in a group is cost-effective, reducing waiting

times and enabling greater numbers of participants to receive the intervention.

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Theoretically, group-based neuropsychological rehabilitation interventions

following ABI have been found to facilitate acceptance (Klonoff, 2010). There are

other group therapy mechanisms of change that may be particularly relevant in an

intervention aiming to influence self-concept, including universality (i.e. recognising

that you are not alone in your difficulties) and acceptance by the group (Corsini &

Rosenberg, 1955; MacKenzie, 1990; Brabender, Smolar & Fallon, 2004). These are

known as supportive factors and have been shown to increase self-esteem, which in

turn influences overall self-concept. Furthermore, as comparison has been shown to

be a mechanism through which individuals adjust to changes in identity following

ABI (Mac Crosain, unpublished), being in a group with individuals who have a shared

experience of ABI is hypothesised to facilitate a reduction in the discrepancy

between the ‘ideal’ and ‘actual’ self by providing a new comparison group more

similar to the ‘actual’ self.

Aim

The current study aimed to provide practice-based evidence for the

potential effectiveness and acceptability of ‘RE-ID’, a vocational rehabilitation group

intervention exploring identity after an ABI using an ACT approach in a naturalistic

context. It was hypothesised that the intervention would be associated with

positive changes in self-concept, anxiety, depression, quality of life, self-esteem,

self-efficacy, and occupational self-efficacy measures. Furthermore, the study aimed

to assess the utility of these specific outcome measures in the evaluation of the

intervention. The study also aimed to explore hypothesised ACT and group therapy

mechanisms of change using a qualitative methodology.

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Method

Design

The study used an idiographic case series approach, focusing intensively on

individuals over time, allowing for the in depth evaluation of the effects of the

intervention on individual participants (Kazdin, 1982; Barlow & Nock, 2009). Though

Randomised Control Trials (RCTs) are often considered the ‘gold standard’ of

intervention research and may provide greater causal clarity, they are resource-

intensive and may be considered premature in exploring the effectiveness of a

novel treatment (Jarrett & Ollendick, 2012). Furthermore, Elliott (2002) argues that

RCTs do not offer an understanding of causal relationships (i.e. whether therapy

was the source of reported changes) and may offer poor generalisability.

Single case designs are described as particularly well suited for studying the

effectiveness of interventions, allowing for the examination of processes and

outcomes (Smith, 2012). Barnett and colleagues (2012) suggest that single case

designs are also more appropriate in research targeting a limited sample of people

with an aim of understanding changes in their behaviours or functional status. The

use of single case designs in naturalistic settings increases external ecological

validity, although this may be at some sacrifice to internal validity (Shadish, Cook &

Campbell, 2002; Smith, 2012).

A single case design was deemed the most suitable for the current study as

it aimed to study the effectiveness of a novel intervention in a naturalistic setting

with a limited pool of participants. Furthermore, this methodology allowed for the

60

gathering of data related to the tolerability of the intervention and the utility of

specific outcome measures in the evaluation of the intervention.

The current study falls between a quantitative single case experimental

design (SCED) (Smith, 2012) and a hermeneutic single-case efficacy design (HSCED)

(Elliott, 2002). SCED involves the repeated, systematic measurement of treatment

outcome variables. The current study employed a variant of SCED - the multiple

baseline design - with baseline lengths of one, two and three weeks prior to the

intervention (Kazdin, 1982). A multiple baseline design allows for each participant to

act as their own control, with scores during the intervention phase compared to

their baseline scores. Successive participants enrolling in the current study were

randomised to baseline length in an effort to enhance internal validity (Kratochwill

& Levin, 2010). Though the effect of history cannot be eliminated as the

intervention began at the same time for each participant, as necessitated by the

nature of a group intervention, the various lengths of baseline aimed to allow for

increased control of variables including the effect of multiple testing or regression

to the mean (Bevan, Wittkowski & Wells, 2013).

The HSCED approach uses both quantitative and qualitative measures to

evaluate the ‘causal role of therapy in bringing about outcome’ (Elliott, 2002, p3).

This mixed method approach was employed in the current study to enrich the

assessment of intervention effectiveness and tolerability, and to gather information

about the utility of outcome measures. Quantitative data included demographic

information, attrition rates and self-report weekly outcome measures during

baseline, intervention and at one-month follow-up. Qualitative data included a

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semi-structured interview with each participant at one-month follow-up. However,

the current study did not use a complete HSCED, as it was not deemed feasible to

collect and analyse the additional data sources recommended, including records of

therapy sessions (e.g. videotapes and therapist process notes).

Participants

Participants were recruited from a specialist vocational rehabilitation service

within a neurology and neurosurgery hospital. Their profile indicates that they are

endeavoring to return to work or have returned to work and thus have made

positive adaptations following their ABI and are not at an acute stage of

rehabilitation. A clinical psychologist and occupational therapist from the clinical

team identified potential participants during routine practice. Those who met

criteria to participate in the intervention were invited to attend the group and

consent to be contacted by the researcher was requested. Working age adults (age

18-65 years) who had experienced an ABI were eligible to participate. Exclusion

criteria included severe communication difficulties or cognitive deficits that would

impact on ability to participate in a group intervention, or severe mental health

difficulties as assessed by a clinical psychologist.

Intervention

Participants completed a five-week ‘RE-ID’ intervention. ‘RE-ID’ is a novel

vocational rehabilitation group intervention exploring identity after ABI using ACT

principles (Doogan, unpublished) (Appendix 1). The intervention was introduced

within the service as a clinical intervention, and was not occurring as a purely

experimental intervention. Appropriate participants were invited to attend the

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group and subsequently invited to participate in the research. Participation in the

research did not impact on eligibility to participate in the intervention. Participants

attended the group weekly for five weeks. The intervention sessions lasted two

hours, with a brief break in the middle. The intervention was facilitated by a clinical

psychologist who was known to all six participants prior to the group as a result of

previous vocational rehabilitation input. The participants were not known to each

other prior to the group. The researcher was independent of the intervention to

minimise participant response being subject to bias.

Measures

Outcome measures were used to assess self-concept, mood, quality of life,

self-esteem, general self-efficacy, and occupational self-efficacy (Table 1)(Appendix

2). Psychometric data, including Cronbach’s alpha reliability estimates, were taken

from relevant clinical samples where available. In instances where this was not

possible, reliability estimates from general non-clinical samples were used. A semi-

structured interview based on the Change Interview (Elliott, Slatick, & Urman, 2001)

was used to assess participant views on acceptability, tolerability and effectiveness

of the intervention (Appendix 3).

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Table 1: Outcome measures

InstrumentAcronym(Reference)

Construct measured Items and scale Scores and interpretation Psychometrics

Head Injury Semantic Differential Scale - III

HISDS-III

(Tyerman & Humphrey, 1984; Tyerman, personal correspondence)

Developed to explore changes in self-concept arising from severe traumatic brain injury

Consists of 18 adjective pairs, rated on a 7 point scale from ‘1’ negative pole to ‘7’ positive pole

Sum the 18 items to a total score ranging from 18-126, with higher scores indicative of a more positive self-concept

A comparable sample of adults who had experienced a TBI scored a mean of 74.99 (SD = 20.59). A Cronbach’s alpha of 0.92 has been reported for the scale (Carroll & Coetzer, 2011)

Hospital Anxiety and Depression Scale

HADS (HADS-A & HADS-D)

(Zigmond & Snaith, 1983)

Developed to identify possible and probable caseness of anxiety and depression among patients in nonpsychiatric hospital clinics

Each scale consists of seven items rated on a 4 point Likert scale from ‘0’ (e.g. very seldom, not at all) to ‘3’ (e.g. very often, definitely)

Sum to a total score ranging from 0-21 for each subscale. Higher scores are indicative of more symptoms of anxiety or depression. A clinical cut-off score of 8 was used (Dahm, Wong & Ponsford, 2013). As some studies have found that cut-off scores of the HADS have limited utility in predicting ‘caseness’ of anxiety or depression following ABI (Whelan-Goodinson et al., 2009), the current study used both clinical cut-off scores and descriptive categories when analysing results and calculating whether clinically significant change had occurred. The descriptive categories used were ‘normal’ (0–7), ‘mild’ (8–10), ‘moderate’ (11–15) and ‘severe’ (16–21) (Snaith & Zigmond, 1994)

A Cronbach’s alpha of 0.90 has been reported for the anxiety subscale (HADS-A) and 0.86 for the depression subscale (HADS-D) (Dahm et al., 2013)

64

Table 1: Outcome measures (continued)



Quality of Life After Brain Injury

QOLIBRI

(von Steinbuchel et al., 2010).

Developed to assess health related quality of life after traumatic brain injury

Consists of 37 items across six sub-scales, rated on a five point Likert scale from ‘1’ to ‘5’. The first section assesses level of satisfaction across four domains: cognition, self, daily life and autonomy and social relationships. The second section asks respondents how ‘bothered’ they are by items across two domains: emotions and physical problems

The total QOLIBRI score ranges from 37-185. QOLIBRI total scores are converted to a percentage and presented on a 0 (worst possible score on the QOLIBRI) to 100 (best possible score on the QOLIBRI) point scale (Truelle et al., 2010)

A Cronbach’s alpha of 0.97 has been reported for the scale (von Steinbuchel et al., 2010)

Rosenberg Self-Esteem Scale

RSES

(Rosenberg, 1965)

A one-dimensional measure of global self-esteem

Consists of ten items rated on a four point Likert scale from ‘0’ (disagree) to ‘3’ (strongly agree), with five items reverse scored

Sum to a total score ranging from 0-30, with higher scores indicative of a more positive self-esteem.

A Cronbach’s alpha of 0.88 has been reported for the scale (Robins, Hendin & Trzesniewski, 2001)

65

Table 1: Outcome measures (continued)



Global Self-Efficacy Scale

GSES

(Schwarzer & Jerusalem, 1995)

A measure of an individual’s belief in his or her own ability to respond to novel or difficult situations and to deal with any associated obstacles or setbacks

Consists of ten items rated on a four point Likert scale from ‘1’ (not at all true) to ‘4’ (exactly true)

Sum to a total score ranging from 10-40, with higher scores indicative of a more positive sense of general self-efficacy.

A Cronbach’s alpha of 0.89 has been reported for the scale (Luszczynska, Scholz & Schwarzer, 2005)

Occupational Self-Efficacy Scale – Short Form

OCCSEFF-8

(Schyns & Von Collani, 2002)

A shortened version of the OCCSEFF which was designed as a measure of self-efficacy related to the occupational domain

Consists of eight items rated on a six point Likert scale from ‘1’ (completely true) to ‘6’ (not at all true)

Sum to a total score ranging from 8-48, with lower scores indicative of a more positive sense of occupational self-efficacy

The short form was found to be highly correlated with the long form (r=0.947), and has a reported Cronbach’s alpha value of 0.88 (Schyns & Von Collani, 2002)

66

Procedure

The study was reviewed by the University of Surrey Research Integrity and

Governance Office and then granted ethical approval by the NHS Health Research

Authority London - City Road & Hampstead Research Ethics Committee (Appendix

4). Access for research was permitted by the local trust (Appendix 5). All

participants provided informed consent (Appendix 6).

The baseline phase ranged from one to three weeks and the intervention

phase lasted five weeks. Self-concept and mood outcome measures were collected

weekly during the baseline and intervention phases, and again at one-month follow-

up. A larger battery of outcome measures (including quality of life, self-esteem,

global self-efficacy and occupational self-efficacy measures) was completed at pre-

intervention, post-intervention and one-month follow-up points (Figure 1).

All outcome measures were completed online using Qualtrics software, a secure

survey software platform, hosted at the University of Surrey (Qualtrics, 2016).

Participants received prompt emails each week, with a personal link to access the

measures. Outcome measures were sent to participants immediately following the

intervention group, though response times varied, with all participants completing

the measures within seven days. If participants had not completed the measures

within five days, a reminder email was sent. A semi-structured interview ranging

from 25-45 minutes was completed with each participant at one-month follow-up.

67

Figure 1: Data collection timeline

Analysis

Baseline measures

Initially, baseline measures were to be collected weekly for two, three and

four weeks prior to the intervention. However, the recruitment timescale was

shortened due to local service issues and staffing constraints. Furthermore, some

participants did not complete the initial baseline measures after being assigned to

baseline length condition. As a result, the following baseline data was collected: one

participant with three baseline measures, three participants with two, one

participant with one, and one participant with no baseline measures.

One-month follow-upHISDS, HADS-A, HADS-D, QOLIBRI, RSES,

GSES, OCCSEFF-8 Semi-structured interview

Post-interventionHISDS, HADS-A, HADS-D, QOLIBRI, RSES, GSES, OCCSEFF-8

Intervention phase (5 weeks)Weekly: HISDS, HADS-A, HADS-D

Baseline phase (1-3 weeks)Weekly: HISDS, HADS-A, HADS-D Pre-intervention: HISDS, HADS-A, HADS-D,

QOLIBRI, RSES, GSES, OCCSEFF-8

RecruitmentInvite to attend the group Consent to participate in research

68

Given that comparison of baseline and intervention phases requires a

minimum of two and usually uses three or more baseline data points, it was not

possible to utilise this analysis to assess the potential effectiveness of the

intervention (Kazdin, 1982). Instead, the baseline measurement period was used to

establish a more stringent test of the intervention by establishing the score that was

closest to the direction of symptomatic improvement across the baseline for each

baseline measure (HISDS, HADS-A and HADS-D). This ‘baseline’ score was used as

the pre-intervention score for these measures, to compare with the participants’

post-intervention and follow-up scores using the reliable change index (RCI) and

clinically significant change (CSC) methodology outlined by Jacobson and Truax

(1991)(detailed below). This approach was used for the four participants with two

or more baseline measures. One participant had only one baseline measure and

therefore this was the only pre-intervention score that could be used. One

participant had no baseline measures and therefore could not be included in the

quantitative analysis; however, their interview data was included in the qualitative

analysis.

Reliable change index and clinically significant change

Change from pre-intervention to post-intervention, and pre-intervention to

follow-up were assessed using the reliable change index (RCI) and clinically

significant change (CSC) methodology (Jacobson & Truax, 1991; Jacobson et al.,

1999; Morley, Williams & Hussain, 2008). Initially, the RCI was calculated for all

measures. Then, CSC was calculated if there was evidence of reliable change. The

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rationale for this was that the RCI determines whether any observed change is

greater than that expected due to measurement error. If this is the case, change is

then assessed in terms of clinical significance (i.e. the clinical meaningfulness of

change). Changes that are not reliable do not evidence a potential treatment effect

and, therefore, assessment of clinical significance has little relevance. Jacobson and

Truax’s (1991) approach to calculating the reliable change index (RCI) was used. The

standardised error of the difference (Sdiff) provides an estimate of error in

measurement of change (Elliott, 2002). The following formula was used:

where s1 is the standard deviation of a comparative normative population, and rxx is

a reliability estimate. In line with Morley (2008), a measure of internal consistency

(Cronbach’s alpha) was used as the reliability estimate. This was available for all

measures.

The standardised error of the difference was then multiplied by 1.96 to establish

the minimum threshold at which change is unlikely to be due to measurement error

at the 95% confidence level (Jacobson & Truax, 1991). If the discrepancy between

pre-intervention and post-intervention scores, or pre-intervention and follow-up

scores exceeded this number, it is possible to conclude that change is reliable and

not due to measurement error.

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If change was found to be reliable, the clinical significance of this change

(CSC) was calculated, again using Jacobson and Truax’s (1991) statistical approach.

In line with Morley’s (2008) recommendations for determining which criterion to

use, a normative criterion (n) was used when established cut-off scores were

available for the measure. Criterion (c) was used if distributional data were available

from both a clinical population and a suitable normative control population, while

criterion (a) was used if only a clinical sample was available with no control sample.

Thus, criterion (a) was used for measures specifically designed for an ABI

population. Criterion (b) was used for measures where only normative data from a

non-clinical population was available.

The CSC value is described as a clinically meaningful threshold between a

‘dysfunctional’ (clinical) and ‘functional’ (non-clinical) population (O’Neill, 2010).

Criterion (a) defines this threshold as two standard deviations from the clinical

mean, criterion (b) defines it as within two standard deviations of a non-clinical

mean, while criterion (c) defines clinically significant change as moving across the

midpoint between clinical and non-clinical means, and is calculated using the

following formula

where x1 and x2 are the means, and sd1 and sd2 are the standard deviations of the

non-clinical and clinical normative samples respectively. Table 2 displays the RCI

thresholds and CSC criteria used. For two measures (QOLIBRI and OCCSEFF-8) the

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measure norms did not permit calculation of a viable CSC threshold and therefore

only reliable change could be assessed for these measures.

Table 2: Data used to calculate RCI and CSC

Measure Reliability coefficient

(Cronbach’s α)

RCIp<0.05

Criterion CSC cut point

Scale range

HISDS 0.92 16.15 a 116 18-126HADS-A 0.90 3.88 n 8* 0-21HADS-D 0.86 4.57 n 8* 0-21QOLIBRI 0.97 8.58 a ** 0-100RSE 0.88 1.67 c 16 0-30GSE 0.89 5.00 b 26 10-40OCCSEFF-8 0.88 2.99 b ** 8-48Note: *HADS descriptive categories: normal (0–7), mild (8–10), moderate (11–15) or severe (16–21) (Snaith & Zigmond, 1994), n/a = Calculated CSC cut off points non-attainable. HISDS = Head Injury Semantic Differential Scale III, HADS-A = Hospital Anxiety and Depression Scale Anxiety Subscale, HADS-D = Hospital Anxiety and Depression Scale Depression Subscale, QOLIBRI = Quality of Life After Brain Injury, RSE = Rosenberg Self-Esteem Scale, GSE = General Self-Efficacy Scale, OCCSEFF-8 = Occupational Self-Efficacy Scale Short Form.

Qualitative analysis

The qualitative component of this study was guided by Crabtree & Miller’s

(1999) deductive approach to qualitative data analysis. A template of themes was

developed a priori, based on the core processes of acceptance and commitment

therapy (ACT) and mechanisms of change in group therapy. Six ACT themes were

included based on Harris (2009), Kangas and McDonald (2011) and Miller (2015),

which have been described as the six core processes of psychological flexibility:

contacting the present moment, defusion, acceptance, self-as-context, values, and

committed action (see Appendix 7 for full descriptors and examples). A further four

themes describing mechanisms of change and group processes within group

therapy were included, based on Brabender et al. (2004), Corsini and Rosenberg

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(1955), and MacKenzie (1990): supportive factors, self-revelation, learning from

others and interpersonal factors (see Appendix 8 for full descriptors and examples).

Qualitative data from follow-up interviews were analysed to explore

participants’ perceptions of whether change had occurred and their understanding

of this. The use of a deductive thematic analysis aimed to identify whether

participants’ descriptions of change related to specific ACT techniques, more

general mechanisms of change in group therapy, or a combination of the two.

Harris (2009) describes the technical aim of ACT as increasing psychological

flexibility. Thus, if the six processes of psychological flexibility were expressed in

participants’ accounts of change, this would provide evidence that ACT intervention

processes contributed to changes. Similarly, evidence of the group therapy

mechanisms of change within participants’ accounts would support the idea that

specific aspects of the group process were instrumental in participants’ experience

of change.

Audio recordings were listened to, transcribed verbatim and re-read by the

researcher. Transcription allowed the researcher become familiar with the data

(Riessman, 1993). Initial codes were generated from the transcript. These codes

were arranged into themes based on the a priori framework of ACT and group

process themes. Any additional codes, which did not fit within these themes, were

examined for relevance to the research question. Themes and participant quotes

were checked by a second researcher to ensure credibility and reliability (Appendix

9). A critical realist approach was adopted which relied on the manifest content of

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the data to reduce the impact of researcher bias on the interpretation and a

reflexive account was completed detailing this process (Appendix 10).

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Results

Six participants met inclusion criteria for the intervention and were invited

to attend the group and participate in the research component; all six completed

the intervention and consented to participate in the research. Five participants

attended all of the intervention sessions; one participant attended four of the five

sessions.

To protect the anonymity of participants, demographic information is

presented at a group level. The group consisted of four males and two females. Age

ranged from 44 years to 56 years (mean 50 years). Time since injury ranged from 11

months to 9 years (mean 3 years 7 months). Two participants had experienced a

traumatic brain injury and four had a haemhorragic stroke. Four participants were

employed full time at the time of the intervention: an assistant director of a charity,

a chartered legal executive and an architect. One participant did not report their job

role. Two participants were unemployed: one who worked freelance prior to

experiencing an ABI and one who was on sick leave. Educational attainment

amongst the group varied. One participant had completed school exams, two were

educated to degree level and three had professional qualifications.

Quantitative data is presented individually for each participant, with the

exception of participant 4 who did not complete outcome measures prior to the

intervention or following week two of the intervention. Thus, quantitative analysis

was not possible due to the volume of missing data. Qualitative data is included

individually where it adds explanatory value to interpretation of quantitative

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measures. Qualitative analysis is presented at a group level, including data from all

six participants.

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Participant 1

Figure 2: Participant 1 baseline, intervention and follow-up outcome measure scores on Head Injury Semantic Differential Scale (HISDS) (panel a), HADS-Anxiety (panel b), and HADS-Depression (panel c). The ellipse in each panel denotes the first measurement following the start of the intervention. The square in each panel denotes the baseline measurement closest to symptomatic improvement. The broken line extends this baseline measurement throughout the invention and follow-up series to indicate how many subsequent data points show improvement/deterioration relative to baseline.

Figure 2 indicates that participant 1 demonstrated an initial increase in HISDS score compared to baseline following introduction of the intervention (panel a). However, during the intervention phase there was a decreasing trend in HISDS scores. The final three intervention scores showed worsening self-concept relative to baseline. HISDS score did not change at follow-up. There was no reliable change in HISDS scores (Table 3).

Participant 1 reported lower anxiety relative to baseline following introduction of the intervention (panel b). However, anxiety scores then showed a relatively stable pattern throughout the intervention with all remaining scores falling at or above the baseline. Anxiety reliably increased from pre-intervention to follow-up (Table 3). Although this change was not deemed clinically significant as Participant 1 started the intervention above the cut-score of 8 and was consistently within the clinical range, they did move from the mild to moderate anxiety range.

All depression scores in the intervention phase and follow up were higher than the baseline data point (panel c). There was an upward trend in depression scores throughout the intervention. Follow-up depression score was the same as the final post-intervention score. There was a reliable increase in depression from pre-intervention to post-intervention and follow-up (Table 3). As participant 1 scored within the clinical range throughout, this was not deemed clinically significant, though they moved from the mild to moderate depression range.

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Table 3: Participant 1 raw scores for all measures with reliable change (RCI) and clinical significance (CSC) calculation outcomes

Note: *represents the baseline score closest to symptomatic improvement where there was >1 baseline score available; RCI = reliable change index; CSC = clinically significant change; n/c = not calculated due to there being no evidence of reliable change; n/a = calculated CSC threshold was non-attainable and thus was not used; HISDS = Head Injury Semantic Differential Scale III, HADS-A = Hospital Anxiety and Depression Scale Anxiety Subscale, HADS-D = Hospital Anxiety and Depression Scale Depression Subscale, QOLIBRI = Quality of Life After Brain Injury, RSE = Rosenberg Self-Esteem Scale, GSE = General Self-Efficacy Scale, OCCSEFF-8 = Occupational Self-Efficacy Scale Short Form.

There were no reliable or clinically significant changes found for quality of life, self-esteem or general self-efficacy. There were no

reliable or clinically significant changes found between pre-intervention and post-intervention scores for occupational self-efficacy.

However, there was a reliable change from pre-intervention to follow-up, with scores increasing, indicating a reduced sense of occupational

self-efficacy. No attainable threshold was available to calculate clinical significance.

Measure Pre Post Follow Up Post-Pre RCI CSC Follow up - Pre

RCI CSC

HISDS 61* 52 51 -9 No n/c -10 No n/c

HADS-A 9* 9 14 0 No n/c +5 Yes NoHADS-D 8* 15 15 +7 Yes No +7 Yes NoQOLIBRI (Scale) 43 44 39 +1 No n/c -5 No n/c

RSES 9 9 10 0 No n/c +1 No n/c

GSES 12 16 15 +4 No n/c +3 No n/c

OCCSEFF-8 42 41 47 -1 No n/c +5 Yes n/a

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During the follow-up interview, participant 1 explained that many factors outside of the group were influencing their mood, “It’s also

being affected by the other things… well all things going on in my personal life… I guess I was concerned it wasn’t, when I was filling it out,

that it might not be as representative of the, of the positive sense of the group I had I guess, because there were so many other things sort

of going on that were affecting it… And I guess it was making some of those things easier to deal with”. This may explain the increase in

symptoms of depression observed throughout the intervention.

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Participant 2


Figure 3 indicates that participant 2 demonstrated a stable HISDS score following introduction of the intervention (panel a). Overall, the HISDS showed little variability compared to the baseline score and this was supported by no reliable or clinically significant changes (Table 4).

Participant 2 demonstrated no change in anxiety at the introduction of the intervention (panel b). Throughout the intervention, anxiety scores showed a decrease relative to baseline, until the final week when scores returned to baseline level. Scores reduced again at follow-up. There was no reliable change in anxiety scores from pre-intervention to post-intervention or follow-up (Table 4).

Participant 2 showed an increase in depression relative to baseline upon introduction of the intervention (panel c). Three of the subsequent intervention scores were higher than baseline, with one score indicating reduced depression relative to baseline. Follow-up score was also higher than baseline. No reliable change in depression scores was found (Table 4).

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Note: RCI = reliable change index; CSC = clinically significant change; n/c = not calculated due to there being no evidence of reliable change; n/a = calculated CSC threshold was non-attainable and thus was not used; HISDS = Head Injury Semantic Differential Scale III, HADS-A = Hospital Anxiety and Depression Scale Anxiety Subscale, HADS-D = Hospital Anxiety and Depression Scale Depression Subscale, QOLIBRI = Quality of Life After Brain Injury, RSE = Rosenberg Self-Esteem Scale, GSE = General Self-Efficacy Scale, OCCSEFF-8 = Occupational Self-Efficacy Scale Short Form.

There were no reliable or clinically significant changes found between pre-intervention and post-intervention scores, or pre-

intervention and follow-up scores for quality of life or global self-efficacy. Self-esteem remained stable from pre-intervention to post-

intervention, but showed a reliable and clinically significant deterioration between pre-intervention and follow-up. Occupational self-

efficacy showed reliable increase in scores from pre-intervention to post-intervention indicating a reduced sense of occupational self-


RCI CSC

HISDS 80 78 82 -2 No n/c +2 No n/c

HADS-A 9 9 7 0 No n/c -2 No n/c

HADS-D 7 7 8 0 No n/c +1 No n/c

QOLIBRI (Scale) 65 58 64 -7 No n/c -1 No n/c

RSES 16 16 11 0 No n/c -5 Yes YesGSES 30 27 29 -3 No n/c -1 No n/c

OCCSEFF-8 20 24 15 +4 Yes No -5 Yes n/a

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efficacy. However this was not maintained, with occupational self-efficacy scores reliably decreasing between pre-intervention and follow-

up, indicating an improved self-efficacy. No attainable threshold was available to calculate the clinical significance of these changes.

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Participant 3


Figure 4 indicates that participant 3 showed deterioration in HISDS score relative to baseline following introduction of the intervention (panel a). During the intervention, worsening self-concept relative to baseline was seen for three further data points, with an improvement relative to baseline seen once in the middle of the intervention. The follow-up score also showed deterioration relative to baseline. No reliable changes in HISDS scores were found however (Table 5).

Participant 3 showed an increase in anxiety upon introduction of the intervention, and anxiety scores remained high relative to baseline throughout the intervention phase (panel b). The follow-up score showed a return to baseline. There were no reliable or clinically significant changes in anxiety however (Table 5).

Participant 3 showed a decrease in depression following introduction of the intervention (panel c). Depression scores were at or below baseline throughout the intervention and follow-up for all but one measurement time point. There were no reliable or clinically significant changes in depression however (Table 5).

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Participant 3 showed no reliable or clinically significant change on measures of quality of life, self-esteem or global self-efficacy.

Occupational self-efficacy showed a reliable change from pre-intervention to follow-up with scores increasing, indicating a reduced sense of

occupational self-efficacy. Although, no attainable threshold was available to calculate clinical significance, this reliable change fits with the

participant’s description of approaching work differently, and acknowledging limitations, which may have resulted in reduced occupational

self-efficacy: “it’s accepting the limitations and then ehm trying to re-adapt to that really”. The intervention may have served to increase

insight and acceptance of limitations resulting from ABI.


RCI CSC

HISDS 71* 68 65 -3 No n/c -6 No n/c

HADS-A 11* 14 11 +3 No n/c 0 No n/c

HADS-D 11* 14 11 +3 No n/c 0 No n/c

QOLIBRI (Scale) 40 43 44 +3 No n/c +4 No n/c

RSES 13 13 12 0 No n/c -1 No n/c

GSES 27 27 24 0 No n/c -3 No n/c

OCCSEFF-8 20 22 26 +2 No n/c +6 Yes n/a

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Participant 5


Figure 5 indicates that participant 5 showed an improvement in self-concept relative to baseline following introduction of the intervention (panel a). Scores showed improvement relative to baseline throughout the intervention, but showed deterioration relative to baseline at follow-up. There were no reliable or clinically significant changes in HISDS scores (Table 6).

Participant 5 showed stability in anxiety scores following introduction of the intervention (panel b). Participant 5 showed improvement relative to baseline for two measurements during the intervention phase. The final intervention score and follow-up score showed stability relative to baseline. No reliable or clinically significant changes in anxiety were found (Table 6).

Participant 5 showed an increase in depression relative to baseline following introduction of the intervention and this was maintained, with all but one of the intervention and follow-up scores falling above the baseline, indicating deterioration (panel c). One intervention score was stable relative to baseline. No reliable change in depression scores was found (Table 6).

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Participant 5 showed no reliable or clinically significant change in self-esteem. Quality of life showed a reliable deterioration between

pre-intervention and post-intervention. No attainable threshold was available to calculate clinical significance. No reliable change was found

between pre-intervention and follow-up QOLIBRI scores. Global self-efficacy showed a reliable increase from pre-intervention to post-

intervention and follow-up, though these improvements did not meet criteria for clinical significance because the pre-intervention score was

at the threshold. Occupational self-efficacy showed a reliable change between pre-intervention and post-intervention and follow-up, with


RCI CSC

HISDS 57* 67 51 +10 No n/c -6 No n/c

HADS-A 14* 14 14 0 No n/c 0 No n/c

HADS-D 9* 12 11 +3 No n/c +2 No n/c

QOLIBRI (Scale) 55 45 49 -10 Yes n/a -6 No n/c

RSES 10 9 11 -1 No n/c +1 No n/c

GSES 26 31 34 +5 Yes No +8 Yes NoOCCSEFF-8 20 24 23 +4 Yes No +3 Yes n/a

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scores decreasing indicating deterioration in self-efficacy, although again no attainable threshold was available to calculate clinical

significance.

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Participant 6


Figure 6 indicates that participant 6 showed deterioration in self-concept following introduction of the intervention (panel a). During the intervention phase three scores showed reduced self-concept relative to baseline, one remained stable compared to baseline and one showed an increase. The follow-up score showed an increase. No reliable or clinically significant changes in self-concept scores were found (Table 7).

Participant 6 showed an increase in anxiety relative to baseline following introduction of the intervention (panel b). Participant 6 maintained increased anxiety relative to baseline for two further measurement points. This was followed by a decreasing trend with the two subsequent scores showing decreased anxiety relative to baseline. The follow-up score showed an increase relative to baseline. No reliable change in anxiety scores was found (Table 7).

Participant 6 showed an increase in depression relative to baseline following introduction of the intervention and this was maintained throughout the intervention with all scores falling above the baseline, and some evidence of an increasing trend (panel c). The follow-up score showed a decrease in depression relative to baseline. No reliable change in depression scores was found (Table 7).

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There were no reliable or clinically significant changes in quality of life or global self-efficacy. Self-esteem showed a reliable increase

from pre-intervention to post-intervention, though this was not clinically significant and scores did not change reliably between pre-

intervention and follow-up. Occupational self-efficacy showed a reliable increase in scores indicating a reduced sense of self-efficacy

between pre-intervention and post-intervention, and showed a reliable decrease in scores from pre-intervention to follow-up indicating

improvement, but neither of these changes met criteria for clinical significance.

Measure Pre Post Follow Up Post-Pre RCI CSC Follow Up - Pre

RCI CSC

HISDS 82* 78 83 -4 No n/c +1 No n/c

HADS-A 9* 8 10 -1 No n/c +1 No n/c

HADS-D 9* 12 8 +3 No n/c -1 No n/c

QOLIBRI (Scale) 56 57 62 +1 No n/c +6 No n/c

RSES 22 25 22 +3 Yes No 0 No n/c

GSES 29 30 31 +1 No n/c +2 No n/c

OCCSEFF-8 21 26 18 +5 Yes No -3 Yes n/a

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During the follow-up interview, participant 6 spoke about the cognitive demand of completing the questionnaires: “It can be difficult

for people when you have values, you ask a question, but sometimes the left side would be increased and the right side increased the other

side, so you’ve got to think about the question” (referring to some questions being reverse coded). This may have impacted on the reliability

of responses and explain the inconsistent pattern of responses.

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Summary of quantitative analysis

The weekly outcome measures generally showed a pattern of stability. This

was supported by the general lack of evidence of reliable change in the outcome

measures pre to post and pre to follow-up. Where participants did evidence reliable

change, this tended to be deterioration although not meeting the criteria for

clinically significant deterioration. Participants 1 and 3 evidenced reliable change

across more of the measures (three) than the other participants. Participant 1

reliably deteriorated in anxiety, depression and occupational self-efficacy although

no changes were clinically meaningful according to the criteria used. Participant 3

reliably deteriorated on quality of life and occupational self-efficacy but reliably

improved in general self-efficacy, thereby evidencing inconsistent change across

measures.

Qualitative analysis

Ten deductive themes were used to analyse the data, with six originating

from acceptance and commitment therapy (ACT) and the remaining four from group

therapy literature. Each is described with a number of selected illustrative quotes.

No additional inductive themes were identified.

ACT themes

Contacting the present moment

This theme describes ‘consciously connecting with and engaging in whatever

is happening in this moment’ (Harris, 2009 p.9). This includes attending to internal

and external experiences as they occur (Miller, 2015) and observing ones own

experiences in a non-judgemental way (Kangas & McDonald, 2011). This theme was

evident throughout the data, with the intervention described as an opportunity to

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learn mindfulness skills while also having protected time to pause and focus.

Participants spoke about the intervention providing a space to explore thoughts and

feelings and:

“pull more of those things to the surface” (participant 1)

It was described as an opportunity to take a break from thinking about the

past and future, from offering explanations for impairments to others, and from

problem solving. Participants described noticing their thoughts and feelings and

reflecting on their current experiences within the group, and being able to take this

forward into other situations. They described an increased ability to focus on their

current self in a non-judgmental way. The process of ‘contacting the present

moment’ was facilitated through the use of meditation and mindfulness exercises

within sessions. These were described as helpful, with some participants reporting

that they continued to practice these techniques when the intervention finished.

Table 8: Participant quotes to illustrate ‘contacting the present moment’Quote Participant‘I suppose just reflecting, I don’t suppose you do take time to reflect on things do you, very often’

‘Every day is a struggle, and that was a bit of a pause’

‘one of the things I did learn to do was meditation… and I think I’ve continued more of it, and being more mindful’

4

5

3

Defusion

This theme describes ‘learning to step back and separate or detach from our

thoughts, images and memories’ (Harris, 2009 p.9). It involves observing thoughts as

words or pictures and viewing them as an experience rather than a literal truth

(Miller, 2015). Harris (2009) describes holding thoughts ‘lightly instead of clutching

them tightly’ (p9). This theme was also evidenced in the participant data. While none

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of the participants made direct reference to defusion, there was clear evidence

throughout that, for many participants, the relationship to their thoughts had

changed during the intervention. One participant described detaching from worries

and ‘stepping back’ from them, making specific reference to an ACT metaphor used

in the intervention to describe defusion. Participants referred to the ability to view

their situation in greater perspective and consider alternative ideas, which likely

reflects an ability to hold thoughts ‘lightly’ as described by Harris (2009). Participants

described an ability to observe their thoughts as simply thoughts rather than facts,

and the positive impact this has had. Defusing from thoughts e.g. from negative

thoughts about limitations resulting from neurological impairments, resulted in

improvements in other domains of psychological flexibility such as acceptance.

Table 9: Participant quotes to illustrate ‘defusion’Quote Participant‘you know problems are problems whether you’ve got them, you know whether you’re worrying about them all the time… very simple example [the facilitator] gave us when you hold the book up in front of you, and if you just put that down, it’s not gone away but it just opens up, and you can deal with that as and when, it doesn’t have to always be there’

‘So it actually helped to understand that, to put that struggle into perspective… you see your situation in a bit more perspective… you know, there were different options and maybe, maybe it’s ok to let go of some expectations or dreams or whatever you call it… just changed the outlook a little bit, you know, opened different perspectives’

‘Yeah I definitely don’t think I’m as… I had a thing where I’d say if I couldn’t do something… ‘why can’t you do it’, now I’m just like ‘whatever’’

2

5

4

Acceptance

This theme describes ‘opening up and making room for painful feelings,

sensations, urges, and emotions’ and giving them space to ‘allow them to be as they

are’ (p9). Miller (2015) describes acceptance as an ‘active and intentional choice to

respond in an open, non-judgemental, and flexible manner, allowing oneself to have

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an experience rather than seeking to avoid or alter private unwanted events’ (p2).

Kangas and McDonald (2011) discuss acceptance in the context of ABI, describing

acceptance as an ability to live ones life while taking into account any limitations

resulting from neurological impairments.

Acceptance was one of the dominant themes identified throughout the

participant interview data. Improvements experienced following the intervention

often did not result from a reduction in impairments or limitations, but rather an

increased acceptance of these limitations. Acceptance appeared to be further

facilitated by the experience of listening to others and having a shared

understanding of one another’s difficulties.

Table 10: Participant quotes to illustrate ‘acceptance’Quote ParticipantBut, you know, I think in the first year I thought, oh this is just temporary, it will go, you know I’ll be back to how I was. And I think to accept that it doesn’t matter if it doesn’t go because you can cope with it differently, you can just do things differently, you know you might not be able to [do a certain activity] anymore or do things like that before, and it’s just accepting well there’s other things you can do’

‘I’ve got more relaxed about the fact that I can’t do certain things, which takes up less angst doesn’t it? And less sort of stress, and that in itself, you know – if you can’t do it, you can’t do it’

‘It’s just when you start getting better that you want to change things as they were… so you want to turn back the clock. And the acceptance therapy at least tells you ok, it’s alright to change, it’s alright to downsize your life for example’

3

4

5

Self as context

This theme describes ‘pure awareness’ or the ‘observing self’, that is ‘the

aspect of us that is aware of whatever we’re thinking, feeling, sensing or doing in any

moment’ (Harris, 2009 p11). Kangas and McDonald (2011) describe this process as

allowing individuals to differentiate between their experiences (including physical

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and psychological) and their sense of self, i.e. viewing their ABI and the associated

consequences as only one aspect of their identity.

This theme was not identified in the data. Participants did not directly refer to the

‘observing self’ (e.g. differentiating between their self and their thoughts and

feelings) or make reference to their ABI as comprising only one aspect of their

overall identity. Though it can be inferred from other themes (including the ability to

defuse from thoughts, identify values and take committed action) that individuals

were able to view themselves as separate to their thoughts, feelings and indeed

their ABI and associated consequences, this was not self-reported during the follow-

up interviews.

Values

This theme refers to knowing what matters and ‘desired qualities for ongoing

action’ (Harris, 2009 p11). Values are described in ACT as ‘chosen life directions’

which give direction and guide the ongoing journey through life, as a compass would

(Harris, 2009). Values are distinct from goals. When considering values in the context

of ABI, therapists guide individuals to think of ways to pursue their ‘valued’ goals

whilst accommodating neurological impairments (Kangas & McDonald, 2011).

This was another dominant theme identified within the participant follow-up

interviews. The work around values within the group sessions was the aspect of the

intervention most commonly reported as helpful. Participants referred to specific

techniques used within the intervention to elicit values, including the ‘birthday party’

question where one is asked to think about what they would like people to say about

them at a milestone birthday, with a view to eliciting their values and what is

important to them.

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Participants reported using their new awareness of their values in everyday

situations. It impacted on how they thought about their neurological impairments

and difficulties that arose, and the importance placed on these. Participants also

reported that awareness of their values supported them in making various decisions

following the intervention.

Table 11: Participant quotes to illustrate ‘values’Quote Participant‘Well the work around values… I think that was the most helpful piece’

‘It makes me think about, more about values’

‘Particularly going back to the thing about the values, having that focus and being able to apply that to some of those difficulties, to think about where that sits on the spectrum, that was helpful’

‘Thinking about what I really want to do. And I think I’m changing my focus of what I want to do. I don’t know that I want to work in the same area.’

1

6

1

4

Committed action

This theme refers to ‘taking effective action, guided by our values’ and means

‘doing what it takes to live by our values even if that brings up pain and discomfort’

(Harris, 2009 p11). Miller (2015) describes ‘committed action’ as choosing small,

achievable goals and working towards valued directions in a concrete way.

Evidence of participants taking ‘committed action’ guided by their values was

seen throughout the follow-up interviews. Participants spoke about a range of

actions taken, from small changes to great achievements, across a variety of

contexts. Participants spoke about making changes within their professional roles

following the intervention, with some focusing on certain valued aspects of their job

while others applied for new jobs. Participants also spoke about making changes

within their personal lives, guided by their values. This was in spite of the challenges

associated with the change, including eliciting feelings of anxiety and being limited

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by impairments resulting from their ABI. Participants spoke about returning to

activities valued before their ABI. Some participants also acknowledged the difficulty

in taking committed action and making changes following the intervention. They

discussed the challenges of implementing change in everyday life. Some suggested

that taking action might be easier if the intervention were longer or further ongoing

support was provided.

Table 12: Participant quotes to illustrate ‘committed action’Quote Participant‘But after the, after the sessions, I approached work differently to a certain extent’

‘Yeah, I mean I think that whole thing about being inspired to get on and do something… Well, I was going to, and I did, I applied for six or seven jobs… I think as part of that whole process, I did, I signed up for job sites and put my name forward for five or six maybe more jobs’

‘I’ve got, not braver, braver’s not the right word, but I’ve been prevaricating whether or not to go back to playing [sport] and I’ve made the excuse, because I’ve got [neurological impairment]… but since that group I’ve thought ‘well, give it a go, what have you got to lose, give it a go’ so I played [sport] for the first time in a year last Sunday… thoroughly enjoyed it thoroughly enjoyed it, the social interaction, just because that’s, because I’ve played [sport], it’s been a major part of my life since I was 8’

‘I think because the five weeks doesn’t really give you enough time, especially during a summer, to go through the sort of gamut of all the experiences you know. So I think for me, I would have thought that eight weeks would have been a much more helpful… But longer so that you can actually think a little bit more about these issues and maybe take an action… In five weeks, you don’t take any actions, you know, it’s just one month of your life’

2

4

2

5

Group process themes

Four mechanisms of change and processes in group therapy were used as

themes to explore whether the experience of completing the intervention in a group

contributed to changes reported by participants.

97

Supportive factors

This theme refers to a range of factors that assist the participant in regaining

a sense of mastery, improving their self-esteem and boosting morale. They include

the installation of hope, acceptance by the group, altruism, universality, and group

cohesion (Brabender et al., 2004; Corsini & Rosenberg, 1955; MacKenzie, 1990;).

Supportive factors were identified throughout the data, and participants spoke

positively about the group and the impact it had on them. Participants described

feeling more hopeful following the group intervention. There was evidence of

altruism and a desire to help others within the group, and the factors of universality

and group acceptance were evidenced. Participants spoke about the benefits of

discovering they were not alone in experiencing their difficulties and described

feeling understood by other group members. However, one participant described

the challenge of still feeling alone despite knowing that others are experiencing

somewhat similar difficulties.

Further evidence of the presence of supportive factors was observed through

the group cohesion reported. It was further observed in the attachment participants

felt towards the group, their attendance (all participants attended all sessions,

except one participant who missed the final session due to prior commitments) and

their desire to continue meeting beyond the five-week intervention.

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Table 13: Participant quotes to illustrate ‘supportive factors’Quote Participant“My [family member] says I’ve, since that I’m more optimistic, brighter. So…Do you feel like you are?Yeah, I do”

“I guess sharing something with other people and I found a lot of those people really inspirational actually… I thought that was nice to have that so, not to aspire to, but to see that people, I mean obviously everybody had their own issues, and a lot of people were finding it really difficult, which I can completely understand and appreciate but I found the whole thing quite inspiring”

“I think just having a commonality, and hearing everyone, that’s it’s normal to feel the way that I felt, or not being able to do things, or how difficult things are, you know just hearing from everyone, that it’s normal”

“As a group setting, with similar people of similar challenges, it was beneficial as… they were in a similar position, so they we all had understanding about each others’ conditions… empathy, shared between us… like a team”

“And I think it’s probably to have a space as well. I mean we... because we sort of had this thing at the end of it, people all felt that they still wanted to meet”

“I think we all missed it when it finished”

2

4

3

6

4

5

Self-revelation

This theme describes the conveyance of personal and private information to

others within the group, and includes both the sharing of factual cognitive

information and expression of emotions (MacKenzie, 1990). This expression of

thoughts and feelings, usually repressed in other non-therapeutic situations, is

thought to be an important mechanism of change in group therapy (Corsini &

Rosenberg, 1990). This theme was also clearly evidenced in the participant follow-up

interviews. Participants described viewing the group as a safe space to express

thoughts and feelings. They spoke about the role of the facilitator in providing this

safe space and supporting them to use it to share some of their thoughts and

feelings with others.

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Table 14: Participant quotes to illustrate ‘self-revelation’Quote Participant“having that space to kind of talk about the changes and explore the feelings”

“It was an environment where you could talk about yourself because you don’t often talk about yourself, you just keep it inside, so you don’t often talk about things that might be bothering you”

“I was very open, I didn’t know what to expect, never been in that situation before, was apprehensive, washing your dirty linen in public sort of thing, but [the facilitator] made everybody feel at ease, comfortable”

1

4

2

Learning from others

This theme refers to learning from others within the group setting and

includes modeling, vicarious learning, guidance and education (MacKenzie, 1990).

This theme refers to learning from both the facilitator and other group members.

This theme was observed in the data, with participants self-reporting a

variety of things they had learnt within the group intervention. Participants

discussed direct learning from the facilitator, particularly regarding the ACT model.

Participants referred to specific aspects of the intervention including exercises

around values and mapping your life back, evidencing learning from the facilitator.

Participants also spoke about learning from others in a variety of ways, including

learning from observing how others coped and acknowledging their own problems

as a result of seeing them in others. There was also evidence of learning from others

though the sharing of information and resources.

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Table 15: Participant quotes to illustrate ‘learning from others’Quote Participant“For me, it was the acceptance theory was the best part of the group. Understanding that you can take these actions, take these strategies”

“I felt that they dealt with it better than me in some ways, and they seemed to be getting back on with, I mean obviously they had issues and things like that, but they got on with their lives and I sometimes feel that I put mine on hold. So I found them really inspirational to be honest”

“And also, we shared a lot of knowledge in terms of coping strategies and resources… And in that sense it was good, it was very good. It was very good to share that experience”

“Good to share information, good ideas from other people, you can share your ideas if you’re more relaxed to share your feelings, ideas, in that situation”

5

4

5

6

Interpersonal factors

This final theme is also known as ‘psychological work factors’ and refers to

the interpersonal learning one does within the group setting, and the resulting

knowledge gleaned about ones own interpersonal style, it’s impact on others and

the internal processes associated with it (Brabender et al., 2004).

This theme was not evident in the data. One participant reported the group as useful

in terms of developing social skills:

‘and social skills with people. Really important. Social skills are the stepping-

stone to recovery in my thinking… ‘(participant 6)

However, generally participants did not discuss the specifics of interactions within

the group or interpersonal styles. Participants did make reference to other group

members in a variety of ways, including developing positive relationships with each

other and having a shared understanding of each other’s difficulties. However, there

were no direct references to the interpersonal factors that influenced these

relationships, and no reference to interpersonal learning occurring within the group.

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Discussion

Findings

Using a mixed methods approach, the current study aimed to provide

practice-based evidence for the potential effectiveness and acceptability of ‘RE-ID’, a

vocational rehabilitation group intervention exploring identity after an ABI using a

group ACT approach in a naturalistic context. Evidence for the acceptability of the

intervention was observed through attendance rates, with only one participant

missing one session, and the positive nature of the experience of the group

intervention gathered in the qualitative follow-up interviews. However, with regard

to the assessment of the potential effectiveness of ‘RE-ID’, the evidence was mixed.

Whilst the weekly and pre and post assessments of outcome measures showed

limited or no change, the qualitative data provided evidence for change including

increased mindfulness and optimism, acceptance of ‘actual’ self, reduced impact of

anxiety, and both vocational and lifestyle changes including practicing meditation,

returning to previously valued activities, applying for new jobs and an altered

approach to workplace demands.

Self-concept, as measured by the HISDS, showed no reliable change from pre-

intervention to post-intervention or follow-up. This was in contrast to the qualitative

data, where participants reported a more positive self-concept as a result of

increased acceptance of their current ‘actual’ self, and defusion with thoughts of

their pre-injury ‘ideal’ self. There are a number of hypotheses regarding why this

change was not captured by the HISDS. In the current study, the HISDS was only used

to assess current self-concept. As ACT does not aim to change current circumstances,

it is perhaps unsurprising that ratings of self across a variety of adjective pairs did not

102

alter significantly. The literature proposes that distress arises from a discrepancy

between the ‘actual’ and ‘ideal’ self. It is possible that the intervention had an effect

on perceptions of the ‘ideal’ self so that it aligned more closely with the ‘actual’ self,

but the resulting change in the magnitude of the gap between the two could not be

captured by the HISDS. A reappraisal of the ‘ideal’ self may have been facilitated

through supportive group processes including the normalising effect of being in a

group with people who share similar difficulties, thus offering a new norm

comparison group. The impact of the gap between the ‘ideal’ and ‘actual’ self may

have also been influenced by defusion from the thought of an ‘ideal’ self. This was

evidenced in the qualitative data, when participants spoke about defusion from

thoughts about their pre-injury self and reducing their tendency to compare current

performance with what they could do before their ABI. It is possible that such

changes cannot be adequately detected by standardised questionnaire measures. It

is also possible that the intervention did not have an impact on self-concept, and

thus no change was reported on the HISDS.

Anxiety and depression, as measured by the HADS, also showed stability

throughout the intervention across all participants bar one. One participant showed

a reliable increase in depression, but reported external events impacting on their

mood. Overall, the intervention did not appear to influence mood, though

qualitative data suggested a reduction of the impact of anxiety for some participants.

Again, as ACT does not aim to stop people feeling what they already feel (Hayes,

2004), it is possible that the qualitative data reflects a changed relationship to

feelings of anxiety and depression, rather than an elimination of the feelings. The

lack of reliable change may also be due to the fact that mood difficulties were not

103

severe at pre-intervention, with most participants reporting only mild levels of

anxiety and depression.

Similarly, measures of quality of life, self-esteem or global self-efficacy did

not evidence change following the intervention. The only quantitative measure that

showed any pattern of change was occupational self-efficacy, with four participants

showing deterioration and two showing improvement. It is possible that the

intervention had a negative impact on occupational self-efficacy as an increase in

acceptance of limitations may result in increased insight into difficulties, resulting in

a reduced belief in ones ability to manage all of the demands of work without

assistance. However, this may not result in negative outcomes in the workplace, as

some participants reported altering their job role and expectations of themselves to

fit with their current values and capabilities, resulting in greater satisfaction. It is also

worth noting that the rating of self-report outcome measures may have been

influenced by a variety of factors which were noted by participants in the follow-up

interviews, including the cognitive demands associated with completing a battery of

measures with varied responses (i.e. the positive and negative poles alternating from

left to right), memory difficulties impacting on ability to recall information required,

and other external events which impact on the concepts being measured.

A further aim of the study was to assess the utility of specific measures in the

evaluation of the intervention. It is worth noting that a lack of change observed in

the quantitative outcome measures may reflect a true lack of change as a result of

the intervention. However, the lack of change observed in the quantitative outcome

measures in contrast to the qualitative data raises questions about the

appropriateness of using these standardised measures to evaluate outcomes and

104

assess effectiveness of the intervention. In retrospect, the outcome measures

selected may not have been the most appropriate for assessing changes following

the ‘RE-ID’ intervention. Though the outcome measures showed acceptable

reliability and validity in relevant samples, were shown to be sensitive to change and

were feasible to administer, they may not match the goals of the intervention. ACT

outcome measures such as the ‘Valued Living Questionnaire’ (Wilson, Sandoz,

Kitchens & Roberts, 2010) or the ‘Acceptance and Action Questionnaire’ (Bond et al.,

2011) may have detected specific therapeutic changes such as those evidenced in

the qualitative data.

However, the lack of change observed across most measures may point to a

greater problem with using standardised quantitative measures to evaluate

therapeutic change. Though CSC analyses endeavor to assess the clinical significance

of quantitative changes observed in outcome measure data (Jacobson & Truax,

1991), standardised measures can often fail to capture important ‘real life’ change.

Incorporating individualised client-centred outcome measures may have allowed for

quantitative measurement of behavioural change towards specific relevant goals e.g.

finding a new job. Goal Attainment Scaling (GAS) has been found to be more

responsive than standardised tools in assessing change following

neurorehabilitation, and measures gains across areas not specifically targeted by

standardised tools (Turner-Stokes, Williams & Johnson, 2009). A more general

retrospective measurement of client appraisal of change could also have been

included. Using a retrospective Likert scale measurement of appraisal of change has

been shown to be more sensitive to change and more highly correlated to client

satisfaction than standardised measures taken during a neurorehabilitation

105

intervention (Fischer et al., 2009). The discrepancy between the relative stability in

the quantitative data and the self-reported changes in the qualitative data points to

the utility of employing mixed methods when evaluating rehabilitation interventions.

This is supported by Ownsworth and Haslam (2016) who describe mixed methods as

a ‘promising approach’ to exploring changes in self-concept following rehabilitation

interventions, despite it being relatively uncommon.

Finally, the study aimed to explore hypothesised ACT and group therapy

mechanisms of change using a qualitative methodology. The qualitative data

provides initial evidence to support the proposed mechanisms of change, with clear

evidence of five of the six ACT themes and three of the four group therapy themes.

Data lends support for the utility of an ACT intervention for individuals who have

experienced an ABI, with participants reporting the benefit of the processes of

contacting the present moment, defusion, acceptance, values and committed action.

It is worth noting that the qualitative data may be influenced by a number of

variables including population characteristics (participants all had engaged well with

the service previously and had a pre-existing relationship with the facilitator) and the

demand characteristics (Nichols & Maner, 2008).

Caution must be exercised in drawing conclusions, as without a second

supportive source of data it may be that participants were simply reflecting the

content of the model back to the researcher. However, in this instance, participants

appeared to be reporting real changes based on the model. References to the model

were embedded within real life examples of change. Data also points to the value of

delivering the intervention in a group format, with supportive factors, self-revelation

and learning from others reported as beneficial in bringing about change.

106

It is worth noting that there may be an alternate explanation for the mixed

findings. The quantitative outcome measures may accurately reflect no change as a

result of the intervention, while the qualitative results may reflect other processes.

The participants may have been influenced by demand characteristics and the desire

to be a ‘good participant’ (Orne, 1962), or by social desirability and a desire to

present a favourable version of themselves (Van de Mortel, 2008). Although the

researcher was independent of both the service and the intervention in an effort to

reduce these biases, further research with other participant groups is required to

elucidate the current findings.

Clinical and theoretical implications

The qualitative results of the current study lend some preliminary support for

‘RE-ID’. The findings point to the utility of both the theoretical ACT component and

delivering the intervention in a group format. The ACT model was reported as helpful

and identified as a mechanism of change; current findings support Kangas and

McDonald’s (2011) suggestions that ACT may be helpful in improving functionality

rather than reducing symptoms and supporting individuals to live a valued life which

takes limitations resulting from neurological impairments into account. Baumeister

(1999) defines continuity as one of the defining features of identity. The current

study suggests that the intervention works to support individuals to identify their

values and find ways to live within these values (with committed action) despite the

consequences of their ABI. It may be hypothesised that supporting a sense of

continuity in identity reduces the discrepancy between the current and ideal self.

Furthermore, the qualitative data suggests that the intervention serves to generate

hope, which supports a more positive sense of ‘identity potentiation’ i.e. what you

107

may become, which Baumeister (1999) recognises as a major component of identity.

Evidence for the effectiveness of delivering the intervention in a group format is

consistent with previous research that has pointed to the benefits of delivering

neurorehabilitation interventions in groups, describing the group as ‘vital for the

acceptance process’ (Klonoff, 2010, p114). Further research would benefit from the

use of individualised outcome measures e.g. recording of specific behavioural

outcomes or Goal Attainment Scaling (Turner-Stokes et al., 2009).

Limitations and methodological issues

The results of the current study should be considered in light of its

limitations. The sample of participants in the current study was highly selective, and

this may impact on the generalisability of findings to wider ABI populations. The

facilitator had worked with all six participants individually prior to the group

intervention. All six had a history of engaging well with the vocational rehabilitation

service, and all had previous psychology input. As a result, participants were highly

engaged and motivated to participate in the intervention and attrition was low, with

only one participant missing the final session. Though attrition rates are likely to vary

across interventions, influenced by a complex interplay of personal and service

variables, neurorehabilitation intervention RCTs have reported participant attrition

rates as high as 13% (Franceschini et al., 2012). Though the retention rates in the

current study may suggest acceptability and tolerability of the intervention, they

may also in part reflect characteristics of the selected sample. A lack of non-

treatment control group also limits the conclusions that can be drawn from the

current findings.

108

A further limitation of the current study was a lack of quantitative data as a

consequence of a shortened baseline phase. This restricted the options for analysis

of the quantitative data. As three or more baseline points are required in order to

compare phases statistically (Kazdin, 1982), this was not possible with the current

dataset. If the baseline phase was longer and not impacted by missing data, a Tau U

non-overlap analysis could have been used to compare the baseline and intervention

phases, analysing trend and level while controlling for any baseline trend (Parker,

Vannest, Davis & Sauber, 2011). A larger dataset and appropriate statistical analysis

could have provided a more robust analysis of change on the quantitative outcome

measures as a result of the intervention. Furthermore, the standardised outcome

measures might have shown greater evidence of change if the intervention phase

was longer. The qualitative data supports this, with one participant suggesting that

committed action might not be achieved within five weeks.

Concluding comments

The findings of the current study are mixed and do not offer conclusive evidence for

the acceptability and effectiveness of the ‘RE-ID’ intervention, a vocational

rehabilitation group intervention exploring identity after an ABI using an ACT

approach. The quantitative results show limited or no change. However, the

qualitative findings lend preliminary evidence for the potential effectiveness and

acceptability of the intervention. The findings suggest that a combination of the

mechanisms of change associated with ACT and group therapy are perceived by

participants to influence the changes experienced. However, due to methodological

limitations and no evidence of quantitative change, these results should be

interpreted with caution and further research is required to confirm these

109

preliminary conclusions. The study provides support for the use of mixed methods in

assessing outcomes and evaluating the effectiveness of neurorehabilitation

interventions.

110

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List of Appendices

1. ‘RE-ID’ intervention overview and information from group flipcharts

(excluded)

2. Outcome measure questionnaires (excluded)

3. Interview schedule (excluded)

4. Ethical approval letter from the NHS Health Research Authority London - City

Road & Hampstead Research Ethics Committee

5. Letter of access for research from hospital Research and Development

Department

6. Participant Information Sheet and Participant Consent Form

7. ACT deductive themes, descriptors and examples

8. Group therapy deductive themes, descriptors and examples

9. Coded extracts of interview transcripts

10. Summary of reflexive account

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Appendix 4: Ethical approval letter from the NHS Health Research Authority London

- City Road & Hampstead Research Ethics Committee

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Appendix 5: Anonymised letter of access for research from hospital Research and

Development Department

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Appendix 6: Participant Information Sheet and Participant Consent Form

Hospital logo

128

Hospital logo

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Appendix 7: ACT deductive themes, descriptors and examples

Acceptance and commitment (ACT) therapy themes developed based on six core processes of psychological flexibility in ACT:

Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. New Harbinger Publications.

Kangas, M., & McDonald, S. (2011). Is it time to act? The potential of acceptance and commitment therapy for psychological problems following acquired brain injury. Neuropsychological Rehabilitation, 21(2), 250-276.

Miller, C. K. (2015). Group-Based Acceptance and Commitment Therapy: Outcomes and Cognitive Predictors of Efficacy for the ACT Matrix (Doctoral dissertation, WHEATON COLLEGE).

Factor DescriptionContacting the present moment

Be here now.Contacting the present moment means being psychologically present: consciously connecting with and engaging in whatever is happening in this moment. We may spend a lot of time absorbed in thoughts about the past or the future, or on auto-pilot. Contacting the present moment means flexibly bringing our awareness to either the physical world around us or the psychological world within us, or to both simultaneously (Harris, 2009).Mindfulness. Observing or noticing external and internal experiences. Examples: Attending to internal (thoughts, feelings, memories, urges, and sensations) and external experiences (five senses) as they rise and fall away (e.g., hearing wind in the trees, feeling breath pass through the nose, noticing the thought “I wonder what is for dinner”) (Miller, 2015).The third ACT principle of being present in the here and now is facilitated by learning brief mindfulness exercises which can be efficiently applied in relevant situations. By learning to be focused on being present-in-the moment, individuals are able to interact with their experiences and environment in a non-judgemental manner. In the context of Lundgren et al.’s (2006) study, patients with epilepsy were encouraged not to struggle with, nor resist, their thoughts, feelings and sensations pertaining to their seizures. This enabled individuals to learn experientially that their world and their sense-of-self encompasses more than just being a “person with epilepsy” (Kangas & McDonald, 2011).

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Defusion Watch your thinking.Defusion means learning to step back and separate or detach from our thoughts, images, and memories. Instead of getting caught up in our thoughts or being pushed around by them, we let them come and go as if they were just cars driving past outside our house. We step back and watch our thinking instead of getting tangled up in it. We see our thoughts for what they are – nothing more or less than words or pictures. We hold them lightly instead of clutching them tightly (Harris, 2009).Cognitive defusion is an observing of the thought process wherein thoughts are seen as an experience rather than a literal truth. Focus is given to altering the relationship to or function of the thought or its associated emotions. Examples: repetition of a word until its meaning is lessened, no engaging with the content of thoughts (leaves on a stream) but allowing thoughts to naturally occur and fade away (Miller, 2015).

Acceptance Open up.Acceptance means opening up and making room for painful feelings, sensations, urges, and emotions. We drop the struggle with them, give them some breathing space, and allow them to be as they are. Instead of fighting them, resisting them, running from them, or getting overwhelmed by them, we open up to them and let them be. This doesn’t mean liking them or wanting them, it simply means making room for them (Harris, 2009).An active and intentional choice to respond in an open, nonjudgemental, and flexible manner, allowing oneself to have an experience rather than seeking to avoid or alter private unwanted events. Examples: Allowing oneself to experience uncomfortable bodily sensations that accompany a panic attack, rather than seeking to avoid all triggers of such sensations. Or choosing to feel sadness when it naturally shows up instead of engaging in emotional numbing through abuse of substances (Miller, 2015).In accordance with ACT principles, the focus for distressed individuals with an ABI would be to try to live a valued life, taking into account the limitations imposed by their physical and neurological deficits. The core principle of acceptance entails learning to accept both positive and negative feelings and thoughts, particularly pertaining to events and circumstances one has no control over or cannot change (Kangas & McDonald, 2011).

Self-as-context Pure awareness.We are all very familiar with the thinking self – that part of us which is always thinking – generating thoughts, beliefs,

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memories, judgments, fantasies, plans, and so on. But most people are unfamiliar with the observing self – the aspect of us that is aware of whatever we’re thinking, feeling, sensing or doing in any moment. Another term for it is ‘pure awareness’. In ACT, the technical term is ‘self-as-context’. For example, as you go through life, your body changes, your thoughts change, your feelings change, your roles change, but the ‘you’ that’s able to notice or observe all those things never changes. It’s the same ‘you’ that’s been there your whole life. It is also referred to the ‘observing self’ (Harris, 2009).The self is the context for all experiences rather than a collection of attributes or qualities. An individual experiences events but is not those experiences. Examples: Differentiating between self and one’s thoughts or feelings. For example, viewing oneself as experiencing depressed mood rather than identifying with the thought ‘I am a depressive person’. Or one may have a memory of a joyful family celebration but the memory is not a part of the self – only a memory (Miller, 2015).The fourth component, “self-as-context” is also facilitated by applied mindfulness and experiential exercises. This component teaches individuals how to differentiate between their physical/somatic and psychological experiences relative to the essence of self. Referring to the epilepsy studies, once again, patients learned to view their medical condition as just one aspect of their life among other important and meaningful components (Lundgren et al., 2008). By doing so, individuals were able to view their goals and values more objectively without being attached to the sole identity of “being an epileptic”. This process has particular utility for ABI patient groups as studies have revealed that individuals who have sustained a TBI have reported changes in sense-of-self (Tyerman & Humphrey, 1984), as well as loss of sense-of-self (Meili & Kabat-Zinn, 2004; Nochi, 1998). ACT and mindfulness-based approaches may therefore have utility in facilitating persons recovering from a TBI to regain their sense-of-self (Kangas & McDonald, 2011).

Values Know what matters.Values are the desired qualities of ongoing action. In other words, they describe how we want to behave on an ongoing basis. Clarifying values is an essential step in creating a meaningful life. In ACT, we often refer to values as ‘chosen life directions’. We commonly compare values to a compass because they give us direction and guide our ongoing journey (Harris, 2009).A process of clarifying one’s chosen life directions. Without

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values clarity, one may be out of touch with personal values, goals, and meaningful life directions. Values are distinct from goals. Examples: Identifying salient values to pursue in the creation of a meaningful life (e.g. family, creativity, spirituality, honesty, education) (Miller, 2015).The fifth component of ACT addresses values, defined as “chosen qualities of purposive action” (Hayes et al., 2006, p. 8). This component helps patients to identify valued life goals and implement them in the face of obstacles (Hayes, Bissett, et al., 1999). In the context of neurological and physical impairments, this can be achieved by the therapist guiding individuals to think of ways to pursue their “valued” goals whilst accommodating their deficits. Although values and goals are related, they are also distinct. Whereas goals have an end (e.g., getting a job), values are a lifelong process or part of one’s life journey (e.g., being a caring friend or partner, taking part in social activities, or engaging in work that is stimulating) (Kangas & McDonald, 2011).

Committed action Do what it takes.Committed action means taking effective action, guided by our values. It’s all well and good to know our values, but it’s only via ongoing values-congruent action that life becomes rich, full and meaningful. Values-guided action means doing what it takes to live by our values even if that brings up pain and discomfort. All traditional behavioural interventions (goal setting, exposure, behavioural activation, skills training) can be used in this part of the model (Harris, 2009).Actions that serve to move one towards identified values. Choosing small, achievable goals and taking concrete steps toward valued directions. Examples: Moving toward the value of social relationships by scheduling a monthly lunch with a close friend despite a chaotic and busy schedule (Miller, 2015).

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Appendix 8: Group deductive themes, descriptors and examples

Group therapy mechanisms of change developed based on:

Brabender, V. M., Smolar, A. I., & Fallon, A. E. (2004). Essentials of group therapy (Vol. 29). John Wiley & Sons.

Corsini, R. J., & Rosenberg, B. (1955). Mechanisms of group psychotherapy: Processes and dynamics. The Journal of Abnormal and Social Psychology, 51(3), 406.

MacKenzie, K. R. (1990). Introduction to time-limited group psychotherapy. American Psychiatric Pub.

Category Factor DescriptionSupportive

They are supportive in the sense that they assist the patient to regain a sense of mastery. The supportive factors are a directly targeted at a sense of demoralization and reduced self-esteem (MacKenzie, 1990).

Installation of hope

Positioning goals, recognising pathways to reach the goals, and regarding the self as capable of sustaining effort.The idea that there is some chance of relief or improvement is a positive mechanism for reducing anxiety. The development of hope carries with it motivation to engage in therapy, thus providing exposure to other therapeutic factors (MacKenzie, 1990).

Acceptance Experiencing oneself as positively esteemed by the other members of the group.Acceptance by other members is not automatic and to some extent must be earned. Once achieved, however, the feeling of acceptance and belonging is highly self-enhancing (MacKenzie, 1990).Respect for and sympathy with the individual. Acceptance implies belongingness, a warm, friendly, comfortable feeling in the group (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Acceptance (Corsini & Rosenberg, 1955).

Altruism Responding in a helpful way to another member.Altruism refers to an action that benefits another individual. The idea that one can help someone else reinforces self-esteem. It can begin the process of creating a sense of worth and value in one’s thoughts or behaviours. Reciprocal altruism is predicated on the assumption that the two involved will have a chance for further activity so that an opportunity might emerge for the payoff. Altruism is an important mechanism in

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consolidating social system bonds (MacKenzie, 1990).Closely related to acceptance, but in addition involving wanting to do something for others. The essence of this mechanism is the desire to help others (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Altruism (Corsini & Rosenberg, 1955).

Universality Recognising that one is not alone with one’s difficulties.When misfortune arises in our lives, we are drawn to others who are facing or have faced similar circumstances (Forsyth & Coranzzini, 2000 as cited in Brabender et al. 2004).By finding threads of common experience, people are pulled together and have a way of beginning to associate. In addition, some commonality implies that the other is going to be understandable. To hear that others indeed have shared similar experiences is highly therapeutic. It allows the person to rejoin the human race (MacKenzie, 1990).The realization that one is not unique, there are others like oneself with problems either identical with or very similar to ones own (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Universalization (Corsini & Rosenberg, 1955).

Cohesion Experiencing the sense of togetherness in the group.Three elements of group cohesion – group-level phenomena (e.g. cohesion in the sense of togetherness in the group), member-to-member phenomena (e.g. cohesion is the members’ levels of attraction for one another), individual-member phenomena (e.g. cohesion is the individual’s level of felt commitment to the group) (Brabender et al., 2004).Transference: This concept implies the existence of a strong emotional attachment either to the therapist, to separate members of the group, or to the group as a whole (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Transference (Corsini & Rosenberg, 1955).Interaction: Perhaps the most difficult of the mechanisms to understand and classify is the one which relates to relationships of unspecified

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nature within the group. What this process seems to amount to is that any interaction engaged in by a therapeutic group manages to have beneficial results (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Interaction (Corsini & Rosenberg, 1955).

Self-revelation Self-disclosure Conveyance of personal of private information to other members – factual or cognitive information.Revealing oneself to the group in a cognitive way.The process of self-disclosing facilitates the enactment of other therapeutic factors, particularly from the supportive cluster, as well as initiating the process of interpersonal learning. Psychological distress is often associated with an inability to ‘get outside of oneself’ and look at ptoblems with some degree of objectivity. Therefore the process of self-disclosure is an important early step in beginning to address personal problems. The self-disclosing process is also evidence of increasing commitment to therapy – by putting issues into works, there is a tacit acknowledgement that they must be addressed (MacKenzie, 1990).One of the important mechanisms in the group is the release of feelings and the expression of ideas usually repressed in other nontherapeutic situations (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Ventilation (Corsini & Rosenberg, 1955).

Catharsis Conveyance of personal of private information to other members – affective material.Revealing of oneself to the group in an affective way that is accompanied by a sense of relief. Catharsis has not only potential benefits but also possible costs. When group members experience the release of strong feelings for which they are not provided some cognitive frame, disorganization and distress may ensue rather than symptom relief (Brabender at al., 2004).From the standpoint of catharsis as a therapeutic factor, the importance lies in getting the emotion out, not simply revealing information. The research literature supports the idea that a state of heightened emotional arousal promotes change. At the same time, affective discharge without the change for cognitive integration if not as effective and may be harmful. Thus, a middle

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ground can be justified where emotional self-revelation is encouraged by reflection on the material is also expected (MacKenzie, 1990).One of the important mechanisms in the group is the release of feelings and the expression of ideas usually repressed in other nontherapeutic situations (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Ventilation (Corsini & Rosenberg, 1955).

Learning from others Modelling A member’s copying a particular behaviour or set of behaviours exhibited by another member.In many cases, the effect of modeling is simply to convey that it is acceptance to engage in a given behaviour. As noted in the discussion of self-disclosure, once one member breaks the ice, others are likely to follow (Brabender et al., 2004).Copying what others do is a major learning strategy (MacKenzie, 1990).The concept of ‘reality testing’ means that the group situation is one where real and important things happen; it is not only a temporary artificial environment. It assumes reality and in it the patient can test himself in a safe and unthreatening atmosphere (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Reality testing (Corsini & Rosenberg, 1955).

Vicarious learning

A member’s privately applying knowledge gained from the behaviours of one or more members, or interactions between them, to his or her life.For other members, the learning is not so much in establishing the response in one’s range of responses but in recognising that some anticipated outcome does not always occur when a particular response is made (Brabender et al., 2004).Through the mechanism of ‘spectator therapy’, people gain from listening to and observing themselves and others (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Spectator therapy (Corsini & Rosenberg, 1955).

Guidance Advice given to a member by another group member or the therapist.Members will often hear suggestions that they have received from friends, family, and other persons outside the group. Although the content

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of the advice is often not highly useful, the fact of its occurrence is. Members experience the pleasure of showing the care for another that advice often implies even if other motives are present, such as the wish to place oneself above another group member (Brabender et al., 2004).Advice may present the individual with options that had not before been considered. Sometimes, practical advice serves to break through resistance when fancy interpretations are rejected (MacKenzie, 1990).

Education Didactic information presented to the group members.The language of education – learning, new ways of understanding, and homework – can add to the therapeutic experience and frame it in a positive direction of mastery rather than a negative orientation of deficit (MacKenzie, 1990).This is a process of learning, or acquiring knowledge in the group. Intellectualization leads to insight (Corsini & Rosenberg, 1955).SEE LIST OF STATEMENTS – Intellectualization (Corsini & Rosenberg, 1955).

Psychological work factors / interpersonal factors

These two processes are difficult to separate because they represent the internal and external components of the same process (MacKenzie, 1990).

Interpersonal learning

Achieving a cognitive and affective awareness of one’s interpersonal style and the effect it produces on others.Being engaged in the here and now of the group in an affective way and cognitively processing data emerging from this engagement (Brabender et al., 2004).Interpersonal learning results in enduring internal alterations concerning how the individual views the interpersonal world. Interpersonal learning has been divided into input and output categories: input refers to the effects of receiving feedback form others, output concerns attempts to try out new behaviours with others (MacKenzie, 1990)

Self-understanding

Gaining insight into the internal process and psychological elements that give rise to one’s interpersonal style.Self-understanding involves the resurrection of the internal templates of relationships, which influence one’s interactions with others and their correction based upon interpersonal learning experiences (Brabender et al., 2004).Self-understanding can be viewed as the resulting “corrective emotional experience” [of above

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described interpersonal learning input and output] (MacKenzie, 1990).

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Appendix 9: Coded transcript extract examples

Transcript Extract - participant A Theme

And what changes, if any have you noticed in yourself since the group started?So I have definitely started to look at things a little bit more differently, and have accepted that you know that this is a new me and there are things that I can’t do in the same way that I used to do. Ehm, and I do need more rest ehm, I do need more time out to ehm you know think about things differently. It’s not all about well, you know being the old me or getting back to the old me, it’s accepting the limitations and then ehm trying to re-adapt to that really.Ok.So, I think I have begun to accept in you know, from the therapy we have had and the things that [facilitator] discussed, that you know acceptance can be difficult but you know it’s not a failing just because of what we’ve been through, it’s not failing. I think I’ve been quite harsh on myself and you know to try and strive to get back to where I was ehm and when I can’t do the things I used to be able to do and the hours I used to be able to do then or with the ease I used to be able to, I’ve kind of felt inside me I was failing me, but really you know given what has happened I think ehm I’m incredibly lucky still to be able to go back to work especially hearing other people who have not been able to go back to their jobs and things so you know ehm and it doesn’t matter if people look at me differently or think of me differently know you know, those things aren’t important. It’s what I can do. So yeah I think I have taken good things out of that and started to change the way I think.And has anything changed in work? Have you noticed you’re doing anything different or?So in work now, I’ve accepted that people aren’t going to ehm necessarily always ehm view me the way they used to view me. Because I do sit in a different office to the rest of the team and you know they don’t know if I’m around sometimes, although they have been told where I am and what my contact details are and everything like that ehm, you know I’ve just accepted it. I’ve just thought ‘well they know I’m here and if they want to speak to me or want my help, they know where I am’. And, so I think it’s the acceptance part, I’ve accepted it more now than before.And anything else that’s changed that you’ve noticed?Ehm, you know one of the last sessions when we had, [facilitator] did this exercise on ehm, it was a mindfulness thing and we talked about things like, it was a hand thing, we were concentrating on what we saw in our hand and stuff and one of the things it made me realize that ehm I don’t wear nail varnish anymore and I don’t spend the time I used to spend on myself but, so I’ve booked a session for a manicure and pedicure on Friday.Lovely.

Acceptance

DefusionAcceptance

Acceptance

DefusionAcceptance

Values

Acceptance

Acceptance

MindfulnessLearning from others

Committed action

Transcript Extract - participant B Theme

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What was your overall experience of the group?Ehm, I felt it was really positive actually. I got the feeling that everybody felt that actually, that it was an environment where people don’t often get to talk about. It was an environment where you could talk about yourself because you don’t often talk about yourself, you just keep it inside, so you don’t often talk about things that might be bothering you or things with people that you don’t have to explain it to. So it was really positive.Ok, and what about it was helpful?Ehm, I guess sharing something with other people and I found a lot of those people really inspirational actually. Because I felt that they were, I felt that they dealt with it better than me in some ways, ehm and they seemed to be getting back on with, I mean obviously they had issues and things like that, but ehm they got on with their lives and I sometimes feel that I put mine on hold. So I found them really inspirational to be honest.Ok, so the other people in the group?Yeah, yeah, no I thought that was nice to have that so, not to aspire to, but to see that people, I mean obviously everybody had their own issues, and a lot of people were finding it really difficult, which I can completely understand and appreciate but I found the whole thing quite inspiring. And ehm, yeah. And [facilitator]’s a pretty calming influence sometimes. She can be quite calm.And what is it about her that’s calming?She can be quite a calming, I don’t know, that whole meditation thing. I could sit and do that for hours.Ok, so you liked that?Yeah, no, I mean I do do things like that. I do headspace and things, but only when you remember it. It’s like yeah, I know they’ll tell me that I should have a diary and fit it into my diary, all those things, and that’s fine but you sort of do forget about those things sometimes, so that was nice.To have the reminder to?Yeah, to have that reminder and to think about it. And I think it’s probably to have a space as well. I mean we, I volunteered to arrange to meet again and I haven’t done it, which is really bad of me but I’ve been away for three weeks ehm and so I haven’t been thinking about anything. So I might try and do it this week, and see if people are interested, because we sort of had this thing at the end of it, people all felt that they still wanted to meet.Yeah.And have that, and keep in touch with people.Which is a good sign.No, it is a good sign. It is a good sign ehm I guess it’s that whole thing isn’t it, of not feeling like on your own as well.Yeah.‘Cause I haven’t really met anybody else who’s had a brain haemhorrage.

Supportive factors

Self-revelation

Supportive factors

Supportive factors

Supportive factors

Mindfulness

Contacting the present moment

Supportive factors

Supportive factors

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Appendix 10: Summary of reflexive account

This following details the process of completing the deductive thematic analysis, the

method of qualitative data analysis completed for the empirical paper. It aims to

highlight the factors considered throughout the process, specifically personal and

professional factors which may impact on the analysis. Consideration of these factors

is essential in order to maintain a reliable and credible account of the participant

data.

As detailed within the main paper, I adopted a critical realist approach, which

relies on the manifest content of the data to reduce the impact of researcher bias on

the interpretation. As the study aimed to explore specific mechanisms of change

based on the literature (based on both ACT and group process theories), a deductive

approach was used to ensure transparency in this.

However, despite adopting these approaches to minimise bias, the analysis

remains influenced by the researcher. I considered the multiple roles I held within

the project and outside of it while completing the analysis. Notably, I was the main

researcher with an investment in finding something ‘useful’ in the data and was

professionally invested in the intervention being beneficial, in order that I had not

‘wasted people’s time’ by inviting them to participate in this novel intervention.

Furthermore, I had a positive professional relationship with the clinician delivering

the intervention, and thus held assumptions about the likelihood of the intervention

being a helpful experience for the participants.

Additionally, I considered my clinical role as a trainee clinical psychologist and

how this may impact on my interpretation of the findings. With years of previous

experience working with a range of clients who have benefitted from ACT

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interventions, I viewed the model positively. Furthermore, my familiarity of the

model combined with experience of developing hypotheses and formulations with

clients may encourage me to ‘read between the lines’ or fit their anecdotes and

experiences into the model rather than considering whether the model had

impacted on their experience.

I considered the impact of these perspectives throughout the data collection

and analysis, and made efforts to identify when other roles (e.g. colleague, clinician,

student) were being prioritised over the researcher role. In order to maintain the

relative objectivity of the researcher role, I employed a number of strategies. Firstly,

with regards to data collection I used a semi-structured interview based on Elliott’s

Change Interview protocol to ensure each participant was asked broadly the same

questions and to reduce the chance that the interview would be led by my

expectations. However, my professional voice and perspective was also influencing

our interactions as I summarised, reflected and asked follow-up questions.

Throughout the analysis phase I aimed to stay as true to the original data as

possible, keeping direct participant quotes within each of the codes and

subsequently developed themes. Furthermore, I asked a second researcher to code

the transcripts to ensure some inter-rater agreement on the presence and absence

of relevant themes. I also considered whether the participants were simply reflecting

the model back to me in the interviews. In these instances it was important to ask

participants for specific examples of changes they had made or experienced in order

to ensure we did not simply discuss the theoretical merits of ACT, but rather

considered the clinical implications as per the research question.

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Part 3: Summary of Clinical Experience

Throughout the three years, I have completed five clinical placements across a range

of settings including: adult mental health (1 year), older adults (6 months), learning

disabilities (6 months), children and young people (6 months) and a specialist

placement in paediatric oncology (6 months).

I completed an adult mental health placement within an NHS community

mental health recovery service. Responsibilities included assessment, formulation

and delivery of psychological interventions with adults experiencing severe and

enduring mental health difficulties including depression, anxiety, OCD, and those

with personality disorder diagnoses. I co-facilitated weekly CBT 'coping skills' and

STEPPS groups. I jointly completed family work for psychosis. I completed

neuropsychological assessments. While there I also completed a Service Related

Research Project exploring staff perspectives on service user involvement.

I completed my older adult placement within an NHS community mental

health team for older people, including a memory service and challenging behaviour

service. Responsibilities included assessment, formulation and delivery of

psychological interventions for older adults in inpatient, community and residential

settings. Individual interventions included CBT and behavioural activation for

depression and anxiety. I co-facilitated a Cognitive Stimulation Therapy group for

newly diagnosed dementia. I also facilitated 'Fear of Falling' group on an inpatient

physical health ward. I completed neuropsychological dementia assessments using

TOPF, WAIS-IV, WMS-IV, HVLT, Boston Naming Test, BADS, Hayling & Brixton, and

ACE-III screening tool. I delivered a half day training on 'Mindfulness and Wellbeing'

at local day centre.

145

I completed my learning disability placement within an NHS and social

services joint community learning disability team. Responsibilities included

assessment, formulation and intervention with adults with a learning disability

diagnosis. Delivered adapted CBT interventions for anxiety, depression, and anger. I

completed positive behavioural support assessments and systemic interventions

with residential home staff to support individuals demonstrating behaviour that

challenges. I completed autism spectrum disorder and sexual capacity assessments. I

also completed dementia assessments jointly with nursing colleagues. I completed

neuropsychological assessments including WAIS-IV and NAID, used systematic

interview tools including the Life Events Checklist and Functional Assessment

Interview.

My children and young people placement was split between a Youth Support

Team and Looked After Children Team, both were NHS teams based within social

services. Responsibilities included assessment, formulation and delivery of

psychological interventions to children and families within social services YST and

LAC teams. Integrative psychological interventions were informed by CBT, narrative

therapy, dyadic developmental psychotherapy, attachment theory and systemic

theory. Difficulties included emotion regulation difficulties, anxiety, low mood,

anger, behavioural difficulties including soiling and physical aggression and

placement breakdown. I facilitated consultations with social work colleagues,

parents and foster carers. I attended TAC meetings. I also delivered 3 day ‘Skills to

Foster' training with social worker colleagues.

146

My final placement was a specialist placement, which I completed in a

paediatric oncology service within a specialist hospital. Responsibilities include

assessment, formulation and delivery of psychological interventions with children

and families where the child has a diagnosis of cancer and is currently undergoing or

recently completed treatment. I delivered CBT, behavioural, narrative, ACT,

counselling and systemic interventions for difficulties including adjustment and loss,

low mood, anxiety, phobias. I completed neuropsychological assessments including

WISC-IV, WIAT, ChAMP, NEPSY.

147

Part 4: Table of Assessments Completed During Training

Year I Assessments

Assessment TitleWAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity

Assessment and formulation with a 55-year-old man presenting with a diagnosis of Borderline Personality Disorder.

Audio Recording of Clinical Activity with Critical Appraisal

Audio recording and critical appraisal of an individual CBT session using a written thought record with a woman in her early thirties.

Report of Clinical Activity N=1

Cognitive behavioural therapy with a woman in her early thirties presenting with an episode of bipolar depression.

Major Research Project Literature Survey

A review of the ‘self’ after brain injury. Current understandings of self-concept and identity after brain injury and how this relates to vocational rehabilitation.

Major Research Project Proposal

The self after acquired brain injury: A vocational rehabilitation intervention.

Service-Related Project Exploring staff perspectives on service user involvement in a Community Mental Health Recovery Service.

Year II Assessments

Assessment TitleReport of Clinical Activity/Report of Clinical Activity – Formal Assessment

A diagnostic assessment of dementia in an older adult male presenting with word finding difficulties and changes in social behaviour.

PPLD Process Account Personal reflections on the process of participating in a personal and professional development group during the first two years of clinical psychology training.

Presentation of Clinical Activity

A psychological intervention with Daisy - a woman in her early 20s with a learning disability presenting with difficulties managing her emotions.

Year III Assessments

Assessment TitleMajor Research Project Literature Review

The impact of acquired brain injury on identity: A qualitative review.

Major Research Project Empirical Paper

Evaluating ‘RE-ID’: An acceptance and commitment therapy group intervention exploring identity after acquired brain injury.

Final Reflective Account On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of

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trainingReport of Clinical Activity/Report of Clinical Activity – Formal Assessment

An integration of CBT, developmental and systemic approaches to inform work with a young person in care and his wider care system.

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