Accepting and Committing to a values-based life

How psychological flexibility for Brain Injury clients can improve outcomes

We know all too well that having a life-changing injury is a complex adjustment process:

1. Almost half of those who experience a brain injury suffer with major depressive responses, and 38% with anxiety symptoms.

2. We know that depression has significant effects on the health of brain injury clients and their families: there are more in-patient stays in hospital, less social participation, lower return-to-work rates, greater burden on caregivers, and a huge impact on general quality of life.

3. In addition, anxiety and depressive symptoms have a negative influence on rehabilitation and they increase the severity and frequency of reported health problems such as fatigue, memory, headaches and concentration problems.

4. There is often a profound sense of loss and grief after the injury, which contributes to the post-injury difficulties.

Acceptance of disability is considered an important factor in reconstructing the self after a brain injury, as well as engaging with rehabilitation, learning about one’s own deficits and abilities, changing the personal narrative and redefining what the person perceives as ‘success’.

Often, after a brain injury, self-perception can be negative, contributing to increased levels of psychological distress… distress that every Personal Injury Professional reading this would want to minimise as much as possible.

Knowing what strategies and therapies can support these difficult reactions to a significant injury is key to supporting clients and their families. Acceptance and Commitment Therapy (ACT) is a talking therapy that is gaining much credence in the life-changing injury field.

But what is ACT, what problems can it help and, importantly, can it work with brain injury? Read on to learn more…

Acceptance and Commitment Therapy (ACT)

ACT is a spin-off of Cognitive Behavioural Therapy (CBT) and is a mindfulness-based intervention. ACT promotes psychological flexibility by working though and achieving skills in six core processes:

· acceptance

· cognitive defusion

· being in the present moment

· the self–as-context

· values

· committed action

Where CBT might leave clients struggling to implement cognitive restructuring strategies, there is a growing body of evidence supporting the effectiveness of ACT to address a range of issues including with psychological adjustment after a brain injury. There are also promising research outcomes into its effectiveness among those with cognitive impairments.

What client presentations work with ACT?

· Depression: “I’m demotivated by what happened”

· Anxiety: “I’m worried about aspects of life”

· Anger: “I am frustrated by life”

· Sense of hopelessness: “I can’t do anything now”

· Fatigue: “I don’t have the energy to do anything”

· Poor engagement with rehabilitation: “I don’t see the point in doing X therapy”

· Low sense of self-worth: “I’m useless”

· Identity: “What can I do now?”

· Grief and loss: “I can’t do X any more”

· Pain: “The pain dictates actions”

But how does ACT work with brain injury survivors?

The ACT approach reduces the limitations of CBT by focusing on mindfulness-based approaches that do not require the client to engage in reasoning or evaluating their own data. ACT helps the client:

· to make space for difficult experience (in other words, not avoid it!)

· to notice such experience with openness and curiosity

· to become less reactive to such experience

In this way, a thought like “my life is over because of my injury” can be observed, without dominating behaviour.

ACT also uses experiential role plays and visual metaphors so that the strategies are less reliant on verbal expressions and can be made bespoke to the client’s background. This makes the approach much more versatile to a more traditional talking therapy.

When injury strikes, client adjustment requires a redefinition of oneself according to physical and/or cognitive disabilities. Without this, new behaviours and reconnecting with life might not happen. ACT helps clients to let go of limiting senses of self and to develop patterns of adaptive behaviour. This is where ‘acceptance’ may be helpful in facilitating adjustment to unpleasant or unwanted physical changes. If done well, together with analysing one’s ‘values’ and ‘commitment actions’, associated behaviours can be activated in the stable presence of those unwanted changes.

A crucial aspect of ACT is that it aims to promote greater participation in behaviours consistent with one’s values. Interestingly, this is not new to disability work (think: client-centred goals) and ‘values’ create an opportunity to define and personalise goals in order to make them more client focused and relevant to the client.

In summary…

The distressing reactions to brain injury can be minimised by assisting people after a brain injury to move forward with their lives by accepting their cognitive and physical changes. ACT does this by pulling cognitive and behavioural processes together to increase psychological flexibility and the ability to persist with values-consistent behaviour in the face of challenges and obstacles.

Surely this is what we are trying to achieve, at the end of the day, for our clients and their families.

“You cannot stop the waves, but you can learn to surf” 

Kabat-Zinn

If you would like more information on ways ACT can be helpful to your clients and their families, please peruse our website at www.psychworks.org.uk.

PsychWorks Associates launched a series of free podcasts and tips to share psychological ideas that empower us in our work. There will be one on this topic next month.

We also have free online resources via our Case Managers’ LinkedIn group and Personal Injury Professionals Facebook group to help you develop ideas to support your clients and be supported within your role.

Come and join us!