29/02/2016

Academic excellence for business and the professions

Communication Treatment Approaches for

People with ABI
Friday 26th February 2016

Improving communication skills and

quality of life (QOL) for people with ABI
following project-based treatment
Dr Nicholas Behn

Wifi: city-guest
Password: zmgpgjvt
Twitter: #CityLCSTBI

Nicholas.behn.1@city.ac.uk
@NicholasBehn

Please do not remove these signs prior to the date stated.

Acknowledgments

Supervisors

Organisations
Dr Linda Crawford, Dr Camilla Herbert and Dr Andrew James (BIRT).
Claire Benson and Michele Fleming (Headway HP)
Dr Rob Heard (The University of Sydney).

Practising therapists

Dr Madeline Cruice

Prof Jane Marshall

Prof Leanne Togher

Nicole Charles, Bridget Churchill, Bibs Cook, Helen Day, Claire-Farrington

Douglas, Eleanor Gillan, Simon Grobler, Michelle Kennedy and Sarah Raffell.

MSc students from City University London

Alice Charlton, Laura Cheeseman, Samantha Leggett and Sophie McKiernan.

29/02/2016

Cognitive-Communication difficulties
(Sim et al., 2013; Snow et al., 1997)

Behavioural deficiencies
Flat affect, reduced verbal
output, difficulty initiating
conversation

Communication treatments

Behavioural excesses

Verbose, tangential, repetitive,

interrupts others, rude and
impolite, poor social awareness

Communication changes for people with

ABI persist for years post injury
(Bond & Godfrey, 1997; Douglas, 2010; Knox & Douglas, 2009;
Oddy et al., 1985; Olver et al., 1996; Snow et al., 1998)

Affect a persons QOL

Social skills training

Social perception skills training
Communication partner training

Subjective
Well-being
HealthRelated
QOL
Impairment/
Pathology

(Dahlberg et al., 2006; Galski et al., 1998; Knox & Douglas, 2009;
Snow et al., 1998; Struchen et al., 2008)

(Feeney & Capo, 2010)

Requires activities that create roles for participants where they are
considered and expert or helper.

Provides an opportunity for socialising and a context for practising

communication skills.

Treatment should be individualised, client goals, take existing skills into

account and work on communication in a broader context (Togher et al., 2014)

Project-based treatment is an alternative where the person with brain

injury works collaboratively towards a common goal (or project) (Feeney &
Capo., 2010; Ylvisaker et al., 2007).

Education (Blumenfeld et al., 1991)

project-based learning integrates knowing and learning. Students
learn knowledge and elements of the core curriculum, but also apply
what they know to solve authentic problems and produce results that
matter (Markham, 2011)

Ageing
Improved physical health and life satisfaction (Knight et al., 2010)
Increased perceived social support & reduced GP calls (Gleibs et al., 2011)
Gives a sense of purpose and meaning (Allen, 2009; Southcott, 2009)

ABI
Projects are meaningful, important to helping others, a good use of
time and led to other meaningful activities (Ylvisaker et al., 2007)
Improved communication and mood (Cherney et al., 2011), QOL (Thomas,
2004), perceived self-efficacy (Vandiver et al., 2000) and achievement of
personal goals (Walker et al., 2005).

a personally meaningful activity that results in the

accomplishment of a specific and objective personal goal

However, only 6/31 included a measure of QOL and 3 reported

improvement (Braden et al.,2010; Dahlberg et al., 2007; Helffenstein et al., 1982).

Existing research on project-based treatment

Ylvisaker et al., (2007); Feeney & Capo (2010)

Require skills in planning, organising and executive function, which

result in a product that is considered to helpful to others.

Project-based treatment

A literature review of communication-based treatments, identified 31

treatment studies (from 284 identified references).

29/02/2016

Principles of project-based treatment

Account for existing cognitive abilities

Practical suggestions e.g. 2-hour sessions, breaks, repetition of

information, session summaries and visual aids.

Impaired recall of goals and session information

Technology e.g. mobile assistive technologies

Account for existing cognitive abilities

Meaningful activities

(Culley & Evans, 2010;

Gillespie et al., 2012).

Set individualised goals

Impaired executive function

Structured sessions and routine format
Step-by-step procedures o(Kennedy et al., 2008)
Metacognitive skills training

Awareness
Non-confrontational feedback, video-taping, peer feedback,
involvement of communication partners and therapeutic rapport

Treatment delivery
Involvement of the communication partner

(Fleming & Ownsworth, 2006).

Meaningful activities

Set individualised goals

Set goals that are client centred, individualised, collaborative and

meaningful.

Strategies:
Goal recall e.g. text-messaging
Video-taping
Involvement of the communication partner
Therapist and peer feedback during sessions
Metacognitive skills training

Formal vs. informal approaches to goal setting (77% of research

studies used formal approaches)(Prescott et al., 2015)

in the absence of meaningful engagement in chosen life activities,

all interventions ultimately fail (Ylvisaker et al., 2007)
Meaning connectedness, coherence and subjectivity.
Meaning can be derived from many contexts

Persons involvement
Goals of the activity
(Levasseur et al., 2010)

29/02/2016

Treatment delivery

Involvement of the communication partner

Group vs. individuaal

Evidence base is strongest for group-based communication
treatments (Cicerone et al., 2011; Struchen, 2014; Togher et al., 2014)
Why?
Learn a broad range of strategies beyond personal goal areas
Provide social support from meeting others in a similar situation
May be curative in themselves (Yalom et al., 2005)
Size of group?
2-3 people personal goals, receive feedback, context to
practice skills

Training a communication partner can help to improve conversations

involving people with ABI (Togher et al., 2004; Behn et al., 2012; Togher et al., 2013;
Sim et al., 2013).

Adjunct to more typical treatments

Why communication partners?

Goal-setting
Giving feedback to the person with ABI
Provide feedback about homework
Practice communication outside of clinical environment

(Struchen, 2014)

Step 1:
Create treatment manual

Research aims of the study

Process of definition
and fidelity

Step 2:
Focus group of consultants
Step 3:
Analyse focus group for themes
and categories

1. To define and establish treatment fidelity for project-based

treatment.
Step 4:
Create coding checklist

1. To evaluate the impact of a group project-based treatment on

communication skills and QOL for people with ABI.
2. To explore the experiences of people with ABI who participate in a
project-based treatment.

You almost need to teach people

how to have a 50-50 approach,
you need to be directive but
facilitative, you need to have
structure but be flexible, you
need to be motivated but stand
back and let them come up with
ideas

Step 5:
Modify treatment manual

Step 6:
Checklist and manual
checked by experts
Step 7:
Checklist and manual checked by
focus group consultants
Step 8:
Raters to conduct fidelity checks
on treatment group sessions

29/02/2016

Project-behaviours (4 items on checklist)

Present

Present to
some
degree

Absent

People make reference to what the end-goal is during the session (i.e. it is
easy to identify what the project is).

The rationale for the session can be identified and a plan for how it will
be organised is clear throughout.

Absent

Therapist behaviours (10 items on checklist)

Present

Present to
some
degree

The therapist facilitates and supports identification of problems and a

range of options/actions to solve them.

The therapist is flexible during the session (i.e. able to listen to different
ideas and opinions and able to modify on-line through negotiation)

Present

Present to
some
degree

Absent

The project appears meaningful and motivating to participants within the

group.

In order to achieve the project, participants initiate communication

interaction with other group members.

Participant behaviours (5 items on checklist)

Participants

Assessed for eligibility

Time 1 (Baseline)
assessment

Study Design

Alternate allocation (n=21)

Allocated to Treatment (n=11)

Allocated to Waitlist (n=10)

Time 2 (Post)

Time 2 (Second Baseline)

assessment

Allocated to Treatment

Time 3 (Post)

Time 3 (6-week follow-up)

Time 4 (6-week follow-up)

Outcome measures - communication

Communication skills

IMMEDIATE
(n = 11)

WAITLIST control
(n = 10)

Age

43.55 14.39

48.30 14.91

Time post-injury (y)

12.27 3.78

11.60 13.52

Trauma/Non-trauma

8/3

5/5

Conversational ability
Measure of Participation in Conversation
Measure of Support in Conversation
Global Impression Scales

Male/Female

6/5

6/4

La Trobe Communication Questionnaire (LCQ) (self and other)

70.63 15.80

71.10 15.51

3.45 1.70

3.80 1.93

RBANS
WCST (Categories)

Goal Attainment Scaling (GAS)

29/02/2016

MPC Interaction Anchors

NONE

Measure of
Participation in
Conversation
(MPC)

BASIC

HIGHLY

No participation at all

Occasional responsibility for sharing the

conversational interaction

Clear attempts to share the

conversational interaction sometimes

Increased responsibility most of the time

Full and appropriate participation

MSC Acknowledge Competence Anchors

Measure of
Support in
Conversation
(MSC)

NONE

BASIC

HIGHLY

MPC Transaction Anchors

NONE

BASIC

No evidence of conveying content or

understanding conversation

Beginning to convey content

Conveying content some of the time

3
HIGHLY

Impression
scales

Not acknowledged (patronising)

Minimal acknowledgement

Some acknowledgement (basic skill)

Mostly acknowledges

Full acknowledgement (outstanding)

MSC Reveal Competence Anchors

NONE

BASIC

Conveying content most of the time

HIGHLY

Consistently conveys content

No techniques. Inhibits participation

Low skill. Minimises participation

Basic skill. Maintains participation

Uses techniques to promote participatn

Uses techniques to maximise participatn

Outcome measures - QOL

(Bond & Godfrey, 1997)

SWB: Satisfaction with Life Scale (SWLS)

7 questions; strongly disagree to strongly agree
Scores range from 7-35
e.g.

in most ways my life is close to my ideal

I am satisfied with my life

HRQOL: Quality of Life in Brain Injury (QOLIBRI)

37 questions; not at all to very satisfied/bothered
6 domains (e.g. cognition, social relationships, feelings)
e.g.

How satisfied are you with your ability to make decisions?

How bothered are you by feeling bored?

29/02/2016

10 sessions over 6 weeks

Treatment session 1

Example goals

Set individualised communication goals with the CP using videotaped conversation

Talk about communicative strengths and areas for improvement

Give feedback that increases awareness

Talk about positive question asking to help improve conversational

interactions involving the person with ABI and their CP

GAS outcome
level

Goal 1: Ask questions

in conversations

Goal 2: To find a topic of

interest and take control
of the conversation

Goal 3: Try new natter

outlets

Much less than

expected (0)

I will ask questions

10% of the time

I will rate my ability to do

this as a 0 (on a 10-point
scale)

Attend no classes and

dont go out into the
community

Less than
expected (1)

I will ask questions

30% of the time

I will rate my ability to do

this as a 1

Attend no classes but

go out into the
community

Expected level
outcome (2)

I will ask questions

50% of the time

I will rate my ability to do

this as a 4

Make contact with 2

places and visit 1 (e.g.
meditation and church)

Better than
expected (3)

I will ask questions 7080% of the time

I will rate my ability to do

this as a 7

Visit 2 places

Much better
than expected
(4)

I will ask questions 8090% of the time

I will rate my ability to do

this as a 10

Visit 3 places

Show emotion, and tell us what youre thinking

"Let's think about that - do I need to say it?
Say "stop, let me talk" and "can I get a word in" to make the
conversation more 50/50
Ask more questions to start or keep the conversation going and to
make it more interesting
To find a topic of interest to take control of the conversation
Look at the situation, think "how do I deal with it?" and then act. Try
new natter outlets (e.g. meditation, church).

Treatment session 2

Identify goals and goal-rating

Group rules
Talk about hobbies and interests, personalities of group members
Define what a project is, examples of projects, start brainstorming
Take minutes

29/02/2016

Treatment session 3

Treatment session 4-10

Identify goals and goal-rating

Develop project idea
Discuss problem solving (Goal-obstacles-plan-do-review)
Visual planning scaffolds
Equipment needs
Allocation of roles

Flexible according to the project.

Range of tasks
Videotaping
Writing scripts
Taking photographs
Downloading images
Recording voice-overs
Identify goal and goal-rating
Take minutes
Celebration

Follow brain injury projects on YouTube

Follow me @NicholasBehn on twitter

Better future
project

Communication Treatment
Approaches for People with ABI
Friday 26th February 2016

Time for
change

Life-lines
project

Wifi: city-guest
Password: zmgpgjvt
Please do not remove these signs prior to the date stated.

29/02/2016

Between
TREATMENT
and WAITLIST
group analyses

Results over
time

Results over
time

Goal
achievement

Results Communication skills

Results - summary

Between
TREATMENT and
WAITLIST group
analyses

Goal
achievement

Between group analyses

Improved communication skills for the person with ABI, their
communication partner and the overall conversation
No changes in QOL

Immediate
Immediate

Waitlist control
Waitlist control

Results over time

Improved communication skills for the communication partner
Positive improvements in QOL

Goal achievement
Achievement of communication based goals

Between
TREATMENT and
WAITLIST group
analyses

MPCInteraction; p=0.04

Results over
time

Results Communication skills

MSC-RC; p=0.02

Between
TREATMENT and
WAITLIST group
analyses

Goal
achievement

Results over
time

Goal
achievement

Results - QOL

Waitlist control

Immediate
Immediate

Immediate

Waitlist control
Waitlist control

Impression scales Effort; p=0.03

SWLS; p=0.147

QOLIBRI; p=0.438

29/02/2016

Between
TREATMENT and
WAITLIST group
analyses

Results over
time

Results over time (n=18) - Communication

MSC-AC; p=0.03

Between
TREATMENT and
WAITLIST group
analyses

Goal
achievement

Results over
time

Results over time (n=21) - QOL

Goal
achievement

Results over time (n=21) - Communication

MSC-RC; p=0.002

Between
TREATMENT and
WAITLIST group
analyses

Results over
time

LCQ (other); p=0.04

Between
TREATMENT and
WAITLIST group
analyses

Goal
achievement

Results over
time

Goal
achievement

Results - Goal recall

No. people with ABI

20
15
10
5
0
1

SWLS; p=0.06

QOLIBRI; p=0.05

5
6
7
Treatment session

10

10

29/02/2016

Between
TREATMENT and
WAITLIST group
analyses

Results over
time

Goal
achievement

Qualitative Treatment experience

Achievement of GAS goals

GENERAL EXPERIENCE
well chuffed (P20)
really really good (P21)
when it was first talked about I thought
is it going to be another one of this funny
wonders but as the weeks progressed
and I could feel that we were making
progress and I thought it was all
worthwhile (P17)

GAS (PwABI); p<0.001

GROUP EXPERIENCE:
the right mixture of
people. Without that you
havent got it so if there
was one thing, it was the
right mixture of people,
that was the thing that did
it (P19)
our little group we were
all sharing and talking and
supporting each other
(P10)

GAS (CP); p<0.001

Qualitative Treatment experience

Qualitative Benefit of treatment

WORKING ON GOALS:
COMMUNICATIVE BENEFIT:
PROJECT EXPERIENCE:
rewardablefantastic (P1)
To start with I thought ohhh
I cant do this but actually it
was really good to have
something to get your teeth
into and to actually see
something at the end of it,
the fruits of your work really
(P6)

It was very handy the texts that

you kept sending me to the point
that I was remembering them and
I didnt have to go to the text to
look and see what I have to do
(P10)
having the text reminders has
made the idea of being in control
of the conversation become more
important to me so then I start to
think about different questions to
ask them and stuff to keep the
conversations going (P16)

it helped me firstly to see where

I still had areas of improvement
in my conversational skills and
expressing myself umwhich I
knew there were problems but I
couldnt pinpoint them and noones ever been able to bring
them up before um and I think
part of it would be able to see it
for myself, and that was the big
thing (P6)

OTHER BENEFIT:
Concentration levels a bit
better from the start. Its
given me more positive
outlook which helps me
to concentrate. I can sit
down and read something
and get more out of it
(P12)

11

29/02/2016

Qualitative Benefit of treatment

What do these results mean?

EMOTIONAL EFFECTS:
MEETING OTHERS

High retention rate with representative sample.

Treatment was delivered in 6-weeks as intended with 90%

attendance.

PwABI were overwhelmingly positive and satisfied with the

treatment.

Treatment can produce some modest improvements to

communication skills and QOL.
Person with ABI
Communication partner

confidence (P4)
SOMETHING TO DO
uplifted (P21)
I felt on a high (P2)
stronger (P9)

Participant factors

Treatment factors

Impaired awareness
Better awareness means more positive outcomes

(Braden

et al., 2010; Dahlberg et al., 2007; McDonald et al., 2008; Togher et al., 2013)
(Anson et al., 2006;

Ownsworth & Clare, 2006; Schrijnemaekers et al., 2014).

Emotional state - Experience of emotionally unsettling life events.

Meaning of treatment as some may have been found more meaning

in their lives

More attention to communication and improving conversations

Further targeted input to communication partners

(Behn et al., 2012; Togher

et al., 2004; Togher et al., 2013)

A generalisation participation goal to help with transfer of

communication goal, reflecting what they hope to achieve from the
treatment (Grant et al., 2012)

Increased strategies that develop a more positive sense of self and

perceived self-efficacy (Ownsworth, 2014; Vickery et al., 2006)
Positive psychology (Evans, 2011; Seligman, 2011; Sharp, 2012)

Longer duration of treatment (e.g. additional individual sessions)

Communication partners; Some more actively involved than others

12

29/02/2016

Clinical implications

Positive changes can be made long-term

Treatment engagement
Strong sense of helping others

Use of groups with 2-3 people

Set individual communication-based goals

Video-taping
Text-messaging
Metacognitive skills training
Involvement of communication partners
Use of GAS to evaluate goal achievement

Next steps

Further research will examine changes that can be made to the

treatment (as outlined above).

Consider other outcomes of:

Conclusions

First exploratory study of project-based treatment to improve

communication skills and QOL in people with ABI

Importance of measuring BOTH communication skills and QOL

Treatment is feasible (also in terms of clinician time)

The hypotheses of the study were partially supported, with modest

improvements

Gained further information about treating people with ABI with

cognitive-communication difficulties

Thank-you
nicholas.behn.1@city.ac.uk

QOL (e.g. Psychological well-being, perceived self-efficacy)

Communication (e.g. adapting existing measures,
communicative coping, communication confidence).

Any questions?

Neuropsychological Rehabilitation Newton Fund (British Council)

Brazil

13