Theresa Powell

Motivational Interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review

The benefits of rehabilitation following acquired brain injury (ABI) are all too often disrupted by a lack of engagement in the process, variously attributed to cognitive, emotional and neurobehavioural sequelae, and prominently to impaired self-awareness of deficits. Motivational Interviewing (MI) has been widely applied to address treatment adherence in health settings, including a small but emerging evidence base in brain injury contexts. A conceptual review of the literature is offered, examining the interplay of neurological and psychosocial determinants of engagement difficulties after ABI, and discussing the possibilities and limitations of MI as a therapeutic strategy to enhance motivation. The theoretical bases of MI are outlined, focusing particularly on the transtheoretical stages of change model and self-determination theory. The converging evidence suggests that the guiding philosophy and principles of MI – characterised by non-confrontation, collaboration and self-efficacy – might help to foster readiness for participation in rehabilitation. A dynamic motivational model of engagement is presented, identifying MIs potential contribution in three key areas: firstly, to set the stage for therapeutic alliance and case formulation; secondly, to facilitate acceptance of deficits and realistic goal-setting; and thirdly, to promote constructive engagement in the range of clinical interventions that comprise a holistic neurorehabilitation programme.

Threat appraisal and avoidance after traumatic brain injury: why and how often are activities avoided?

Objective: Goldstein emphasized the anxiety-related avoidance of activities after brain injury, but such avoidance has rarely been systematically investigated. This study aimed to compile a list of specific threat appraisals that may lead to avoidance and to obtain data on the frequency with which these appraisals and consequent avoidance occur. Design: Survey. Method: Qualitative methodology was used to obtain an account of threat appraisals. These data were then used to compile two questionnaires that asked about the experience of these appraisals and consequent avoidance. Fifty individuals with a TBI completed the questionnaires. Results: A varied list of threat appraisals was obtained. Appraisals and consequent avoidance were frequent in the sample. Males and those whose TBI resulted from an assault reported more avoidance. Conclusions: A core aim of rehabilitation is to facilitate participation in valued roles and activities. Threat appraisals and avoidance deserve more attention in research and practice because they may constitute a significant obstacle to achieving this.

A single case experimental design comparing two memory notebook formats for a man with memory problems caused by traumatic brain injury

There is extensive literature demonstrating that restoration of memory is not a realistic goal for rehabilitation and that efforts are more effective if focused on developing compensatory strategies. This paper compares two formats of memory notebook using an ABAB single-case experimental design with a 46-year-old man with a history of head injury. Results revealed significantly better performance on a series of prospective memory tasks for the “modified” notebook. The study highlights the importance of tailoring the diary to the patients needs and giving careful consideration to the way in which the diary is introduced.

An exploration of the experience of gaining awareness of deficit in people who have suffered a traumatic brain injury

Gaining awareness of deficits was explored in 10 people with moderate to severe traumatic brain injury (TBI) using a semi-structured interview and interpretative phenomenological analysis. Eight master themes emerged from the transcripts. Knowledge of deficits was acquired through personal discovery and the reactions of others, often outside the rehabilitation environment. Rehabilitation provided explanations and a normalising and supportive environment that facilitated people in acknowledging their deficits. Most participants spontaneously referred to denial and saw this as an active cognitive and behavioural process that both helped and hindered recovery. The emotional reaction to learning about deficits was described largely in terms of fear and loss and resonates with psychological models of grief.

Evaluation of coping resources and self-esteem as moderators of the relationship between threat appraisals and avoidance of activities after traumatic brain injury.

It is not uncommon for people after a traumatic brain injury (TBI) to develop anxieties about possible negative outcomes (i.e., threat appraisals) in relation to participating in valued activities. Some respond to this anxiety by avoiding the activities, but others maintain their participation. The present study investigated two factors that may help explain this variation across individuals in their response to threat appraisals – self-esteem and the evaluation of coping resources. Forty-one individuals with a TBI completed the Avoidance and Threat Appraisals Questionnaire, the Rosenberg Self-Esteem Scale and the Coping Resources Questionnaire. The studys hypotheses were supported: Those low in self-esteem, and those with a negative evaluation of their ability to cope with the TBI, were significantly more likely to respond to threat appraisals with avoidance. Those whose injury was more recent and those whose injury was the result of an assault were also more likely to respond with avoidance. The theoretical and therapeutic implications of these results are discussed.

Brain injury beliefs, self-awareness, and coping:A preliminary cluster analytic study based within the self-regulatory model.

The interplay between individuals’ subjective beliefs about traumatic brain injury, their coping style and their self-awareness might provide a more helpful guide to rehabilitation goals than looking at these factors in isolation. We therefore conducted a preliminary study to determine whether the Self-Regulatory Model can identify different clusters of individuals according to belief schemata, and to explore whether clusters differed across measures of coping and self-awareness. The Illness Perception Questionnaire–Revised was administered to 37 participants with severe traumatic brain injury (TBI), along with the Ways of Coping Checklist–Revised and the European Brain Injury Questionnaire. Clinicians also rated clients’ level of difficulties using the latter scale, and the discrepancy between client and clinician scores was used as a measure of self-awareness. Hierarchical cluster analysis distinguished three groups based on profiles of subjective beliefs about TBI, labelled “low control/ambivalent”, “high salience”, and “high optimism”. The high salience group was characterised by beliefs about serious consequences of the injury and greater self-awareness, and reported a greater range of coping strategies. The other two groups showed lower levels of awareness but differed in coping styles, with the low control/ambivalent group showing a trend towards more avoidance coping against a background of lower perceived control.

Errorless learning of novel routes through a virtual town in people with acquired brain injury

Impaired route learning is a common consequence of acquired brain injury (ABI) but has received little attention in the research literature. Errorless learning may be a method of facilitating the learning of routes but this is unclear as previous studies of errorless learning have focused mainly on verbal skills and the only previous study involving route learning was based upon a pencil and paper task. In the present study we therefore use virtual reality to explore the benefits of errorless learning for routes in an ecologically valid task. Twenty people with acquired brain injury learned two routes, of equivalent difficulty, around a virtual town based upon the city of Nice. For one route, full guidance was provided throughout the learning trials in an errorless learning paradigm; the other route was learned using a procedure that allowed for trial and error. Route recall following the errorless learning condition was significantly more accurate than recall after errorful learning. This suggests that the benefits of errorless over errorful learning in acquired brain injury rehabilitation extend beyond verbal learning tasks to the practical task of route memorisation.

Factors influencing the uptake of memory compensations: A qualitative analysis

In 1996, Wilson and Watson stated that it is not always easy to persuade people with memory impairments to use memory strategies, despite the value of using them. To date, there has been no in-depth exploration of what motivates people to use memory compensations from the perspective of the individual with an acquired brain injury. In this study eight people attending an out-patient brain injury rehabilitation service were interviewed. Transcripts were analysed using interpretative phenomenological analysis. Four master themes emerged from the analysis: emotional barriers that need to be overcome before memory compensations are used; factors that may have a reverse effect on motivation, such as the strategy being an unpleasant reminder that one is different; beliefs about memory, such as it is better to use your own memory rather than relying on memory aids otherwise it will become lazy; and the final master theme “Its not in my nature”, i.e., it does not fit with the persons lifestyle. The results show that motivation for strategy use depends on complex processes that include social, emotional and practical factors. This study demonstrates the importance of adhering to a biopsychosocial approach within rehabilitation.

Google Calendar: A single case experimental design study of a man with severe memory problems.

A single case experimental design across behaviours was utilised to explore the effectiveness of Google Calendar text alerts delivered to a mobile phone as a memory aid. The participant was a 43-year-old man (JA) with severe memory problems and executive difficulties caused by a traumatic brain injury (TBI). JA was initially very unwilling to use any memory aid and so a detailed assessment of his beliefs about memory aids, his cognitive difficulties and his social context was performed and a set of specifications for an aid was produced collaboratively. Six weeks of baseline data and six weeks of intervention data were collected for three target memory behaviours and three control memory behaviours. Results were analysed using nonoverlap of all pairs (NAP) analysis which showed a reduction in forgetting in the three target behaviours and no change in two of the three control behaviours. A subjective measure (the revised Everyday Memory Questionnaire) also suggested improvement. This study illustrates that Google Calendar is a highly effective memory aid and emphasises the importance of choosing a memory aid to suit the persons lifestyle and beliefs.