Rebuilding the self through valued action and group connections after acquired brain injury: Participant perspectives of the VaLiANT group intervention

ABSTRACT

Effective interventions that facilitate adjustment following acquired brain injury (ABI) are needed to improve long-term outcomes and meaningful reengagement in life. VaLiANT is an 8-week group intervention that combines cognitive rehabilitation with Acceptance and Commitment therapy to improve valued living, wellbeing, and adjustment. This study explored participant experiences of VaLiANT to optimize its ongoing development. This included characterization of individually meaningful treatment outcomes, mechanisms of action, and intervention acceptability. Qualitative interviews and quantitative ratings were collected from 39 ABI survivors (M_age= 52, SD = 15; 54% stroke) following their participation in VaLiANT. Participants reported diverse outcomes which resulted in three themes being generated following reflexive thematic analysis. “A fuller toolkit for life with brain injury” indicated increased strategy usage and better daily functioning; “The value of connection and belonging” captured the importance of social experiences in shaping recovery; and “Finding the me I can be” represented cognitive, behavioural, and emotional aspects of identity reconstruction post-ABI. The content and delivery of the intervention were rated highly but participants desired greater follow-up and tailoring of the intervention. Overall, VaLiANT appears to facilitate adjustment through several mechanisms, but greater intervention individualization and dosage may be required to enhance the treatment impact.

KEYWORDS:

• Acquired brain injury
• adjustment
• self-identity
• valued living
• holistic rehabilitation
• acceptance and commitment therapy

Introduction

Survivors of acquired brain injury (ABI) commonly experience lasting changes in cognitive and emotional functioning which negatively impact daily activities, participation in meaningful life roles, and overall wellbeing and quality of life (Draper et al., 2007; Kutlubaev & Hackett, 2014; Stolwyk et al., 2021; Wood & Rutterford, 2006). This can lead to significant changes in self-identity with an associated loss of direction and meaning in life (Carroll & Coetzer, 2011; Shipley et al., 2018). Many intervention approaches do not adequately address this whole-person impact of ABI and remain focused on addressing specific impairments in isolation. For example, cognitive rehabilitation can improve cognitive functioning following ABI (Velikonja et al., 2023; Withiel et al., 2019) but these interventions typically do not improve meaningful participation, quality of life, or adjustment (Elliott & Parente, 2014; Wang et al., 2018).

In contrast, growing evidence suggests that integrated interventions that simultaneously target cognitive and emotional changes can consistently improve these broader outcomes (Davies et al., 2023). For example, intensive holistic interventions result in ongoing improvements beyond the impairment level up to three years post-treatment, reduce the need for additional therapeutic supports, and appear more effective than standard multidisciplinary rehabilitation (Cicerone et al., 2008; Holleman et al., 2018; Shany-Ur et al., 2020). However, delivery of these interventions requires substantial resources and time due to their intensive nature (e.g., 10 months of treatment, 5 + hours daily; Shany-Ur et al., 2020) which limits their implementation in many healthcare systems.

Therefore, there is a need to develop and evaluate a briefer and more efficiently delivered holistic intervention. VaLiANT (Valued Living After Neurological Trauma) is a novel 8-week group intervention for adult survivors of ABI and other acquired neurological conditions that combines cognitive rehabilitation with Acceptance and Commitment Therapy (ACT) to facilitate adjustment to brain injury, increase engagement in meaningful behaviours (valued living), and improve quality of life and overall wellbeing. Our Phase I single case experimental design supported the feasibility and acceptability of the intervention, with reliable improvements identified across a range of secondary outcome measures (Sathananthan, Dimech-Betancourt, et al., 2022). A Phase II pilot randomized controlled trial (RCT) has recently been completed which further supported the feasibility, acceptability, and preliminary efficacy potential of VaLiANT (Sathananthan et al., under review). Compared to treatment-as-usual, VaLiANT did not improve the primary outcome of wellbeing. However, VaLiANT resulted in medium reductions in anxiety and stress symptoms, small-medium improvements in psychological flexibility, and greater proportions of reliable improvement for valued living and self-identity.

In addition to establishing efficacy through clinical trials, the Medical Research Council guidelines for developing complex interventions highlight the importance of understanding participant experiences with the intervention. This involves identifying individually meaningful treatment outcomes, the mechanisms underpinning these outcomes, contextual factors influencing treatment responses, and the acceptability of intervention content and delivery (Moore et al., 2015; Sekhon et al., 2017; Skivington et al., 2021). Therefore, this mixed-methods study served as an in-depth evaluation of VaLiANT to complement and aid in the interpretation of the main trial results and to assist in the refinement of the intervention for future delivery and evaluation. We aimed to:

1. characterize participants’ experiences and ideas about the value and therapeutic impact of the intervention beyond trial outcome measures.

2. identify potential mechanisms of action within the intervention that contributed towards therapeutic outcomes.

3. explore the acceptability of the intervention components and delivery.

4. identify factors that participants recognized as important for the implementation or success of the intervention.

Method

Research design

This study utilized a mixed methods design that was primarily qualitative with embedded quantitative elements (QUAL + quan; Fetters et al., 2013; Schoonenboom & Johnson, 2017). The data were collected simultaneously and interpreted together, and the study is reported in line with the consolidated criteria for reporting qualitative research (CORE-Q; Tong et al., 2007).

Participants

Participants were community-dwelling adults with ABI. Inclusion criteria required individuals to be at least 3 months post-brain injury with ongoing cognitive and/or emotional difficulties impacting meaningful participation (self- or informant-reported). Individuals with potentially progressive neurological conditions (e.g., multiple sclerosis; MS, brain tumour) were eligible providing they were in a stable period of remission with no new symptoms or disease progression in the last 12-months. Individuals with pre-existing intellectual disability, severe psychiatric disorders, comorbid neurodegenerative disorders, insufficient cognitive and/or language abilities to complete outcome assessments or participate in the group, or who were unable to attend the program in-person (or via telehealth during COVID-19 related restrictions) were excluded. We included participants who had completed the VaLiANT intervention as part of our Phase I single case experimental design (n = 10; Sathananthan, Dimech-Betancourt, et al., 2022) or Phase II randomized controlled trial (n = 29; Sathananthan et al., under review). A sample size of approximately 25 was initially estimated as being sufficient to capture a range of opinions and depth based on similar qualitative studies of rehabilitation interventions (Lawson et al., 2022; Ramirez-Hernandez et al., 2022). However, the onset of the COVID-19 pandemic resulted in methodological changes to the intervention delivery (e.g., shifting to telehealth/blended delivery). As such, data collection was extended to reach information power with 39 interviews sufficiently capturing participant experiences (Braun & Clarke, 2021). Individuals were invited to participate in the interview during a follow-up assessment after completion of the VaLiANT intervention. To capture a range of opinions and identify barriers to treatment engagement, those with low intervention attendance were not excluded providing they had attended at least one VaLiANT session. Participants were not compensated for their time.

Intervention

VaLiANT is an 8-week group intervention that aims to improve meaningful participation, wellbeing, and adjustment following ABI. It focuses on reconnecting participants to what gives their lives a sense of meaning by integrating cognitive rehabilitation and ACT techniques to target barriers to valued living. Each weekly session runs for two hours and involves values clarification exercises, identification of weekly committed actions or SMART goals in line with personal values, psychoeducation, teaching of cognitive compensatory and emotion regulation strategies, group discussion and sharing, and homework setting. All intervention sessions were facilitated by a senior clinical neuropsychologist (DW) with support from two provisionally registered psychologists. Group sizes ranged from three to eight participants and were delivered in-person at the La Trobe University Psychology Clinic before transitioning to telehealth/blended delivery during the RCT after the onset of the COVID-19 pandemic. Detailed information on the VaLiANT intervention and pandemic-related methodological changes are described in the trial protocol (Sathananthan, Morris, et al., 2022).

Materials

Sample characterization included pre-intervention assessment of mood with the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) and of cognitive functioning with the Rey Auditory Verbal Learning Test (Schmidt, 1996), Trail Making Test with the oral version substituted during telehealth delivery (Ricker & Axelrod, 1994; Tombaugh, 2004), and Controlled Oral Word Association test which was administered to RCT participants only (Lezak, 1995).

Semi-structured interviews with an embedded quantitative survey were used to explore each participant’s individual experience of VaLiANT while also drawing out their feedback on different elements of the intervention and its delivery. The purpose of the interview was explained to participants as gaining feedback to aid in understanding of what was useful from VaLiANT while helping refine the intervention for future delivery. Interviews were opened by asking participants to describe their overall experience of the intervention and whether it was helpful. Subsequent prompts explored which aspects of the intervention were helpful and why, whether participants were integrating strategies from VaLiANT into their daily lives, areas for improvement, and overall satisfaction with the intervention. Following the onset of COVID-19, three interview prompts were added to ask about telehealth delivery. The interviewing style was kept open and could be tailored to allow the interviewer to pursue lines of questioning relevant to each individual or to seek more detail on comments made by each participant. To support those with cognitive and/or communication difficulties, the interview questions and prompts were provided both in written and oral format, repeated and simplified/paraphrased if needed, and examples were used to remind participants of specific aspects of the intervention for which feedback was sought.

Within the interview, participants also completed a quantitative survey to prompt further feedback on the intervention. This included two general questions relating to satisfaction/helpfulness of the intervention rated on a 5-point Likert scale (e.g., please rate how helpful you found the VaLiANT intervention; Not at all helpful 1 – Very helpful 5). Participants also completed a 24-item checklist that listed different components of VaLiANT (e.g., values clarification exercises) and asked participants to tick whether they found that component helpful. Finally, participants completed a 13-item survey relating to the general delivery of the intervention (e.g., too much information was delivered in each session) rated on a 5-point Likert scale (strongly agree to strongly disagree). Quantitative ratings were completed within the interview to allow for elaboration and clarification on the ratings, which were included in the transcripts. Appendix reflects the layout of the interview schedule and quantitative items which could be flexibly adapted to follow the participants’ line of conversation providing all topics were covered. The quantitative items were generally completed once the interview topics had been covered.

Data collection

Ethics approval was obtained from the La Trobe University Human Research Ethics Committee (HEC #18423) for both studies from which participants were recruited, and each participant provided informed consent. Data collection occurred between April 2019 – August 2021. Interviews were conducted individually, either in-person at the La Trobe University Psychology Clinic (n = 12) or in the participant’s home (n = 5), or via videoconferencing following the onset of COVID-19 (n = 22). The time between treatment and collection of the interview varied depending on the original study and treatment condition. Participants from the single case experimental design study and RCT waitlist control condition completed the interview 1–2 weeks following treatment (those in the latter condition received the intervention after their final outcome assessment for the trial). Those in the RCT treatment condition completed the interview 8–9 weeks following treatment to prevent unblinding of the outcome assessor during their post-intervention outcome assessment. All interviews were conducted at the end of an outcome assessment by one male and three female provisionally or generally registered psychologists with postgraduate training in Clinical Neuropsychology (NS = 14 interviews, HM = 16, BDM = 5, KB = 4). Before conducting interviews, they were familiarized with the interview schedule and provided opportunities to observe recordings of previous interviews to facilitate learning. NS was involved with the delivery of some VaLiANT groups but did not conduct interviews for those participants, and participants had no relationships with the interviewers prior to their involvement in the research. Interviews were audio recorded and transcribed verbatim by a professional transcription company before being checked for accuracy.

Data analysis

Analysis of the transcripts was primarily guided by Braun and Clarke's reflexive thematic analysis approach to characterize experiential aspects of the intervention and to gain a deeper understanding of the change processes and individual therapeutic outcomes (Braun & Clarke, 2006, 2022). We adopted a critical realist orientation to the data which is compatible with reflexive thematic methodologies (Fryer, 2022; Wiltshire & Ronkainen, 2021). This allowed for coding to be conducted in a data-driven and reflexive manner to characterize participant experiences while also supporting the development of a deeper understanding of VaLiANT (Fletcher, 2017). In the context of the current study, analysis and interpretation positioned each participant’s experience as true to them while also interpreting these experiences through theoretical assumptions of how the intervention worked (e.g., contextual behavioural theories underpinning ACT; compensatory approaches to cognitive rehabilitation) and prior knowledge of rehabilitation and theory relating to brain injury (e.g., theories of identity reconstruction) to identify underlying causal mechanisms that contributed towards meaningful outcomes. We considered this analytic orientation and approach to be the most pragmatic in answering our research questions.

For aims 1 and 2, relating to participants’ reported experiences of the intervention and potential mechanisms of action, data were coded both inductively and deductively using a mixture of semantic and more interpretative/latent codes with the generated themes capturing core meanings shared across transcripts. Analysis shifted between immersion and familiarization with the data, extensive coding, theme generation, and review. For aims 3 and 4, relating to the acceptability of the content and delivery of the intervention, a “codebook” thematic analysis approach was used as we sought to capture predefined information relating to specific components of the intervention (Braun & Clarke, 2022). This second approach was primarily deductive using semantic coding, with themes representing domain summaries of feedback relating to different intervention components. These feedback data were supplemented by the quantitative ratings completed during the interview, which were analysed using descriptive statistics.

Coding was conducted over three successive rounds by the first author (NS) using NVivo12 (QSR international, 2021). After each round, the code labels, descriptions, and codebook structure were discussed and refined with DW to encourage reflexivity. Theme generation occurred between NS, DW, and EM. The initial themes were collapsed, expanded, and/or refined during a subsequent meeting and several follow-up discussions to improve their coherence. The researchers drew on their experiences of designing and delivering VaLiANT and their clinical expertise in ACT and cognitive rehabilitation during this process to develop a richer analysis of the data. The structure and interpretation of these themes were reviewed and discussed by all authors to triangulate perspectives before finalization.

Results

Individual participant demographic and injury-related information is presented in Table 1. Participants were 39 community-dwelling adults (M_age = 51.72, SD = 15.49; 59% male) who were predominately Caucasian. Five spoke English as a second language and none identified as Aboriginal or Torres Strait Islander. Brain injury aetiology mostly included stroke (54%) and traumatic brain injury (23%). Those with MS (8%) were in a stable period of remission at study entry with no change in MS status during the study period. Time since injury was particularly long for some ABI aetiologies (e.g., multiple sclerosis, brain tumour) resulting in high variability (M_years= 6.94, Mdn_years = 4.21, SD = 9.17). Most participants (32/39; 82%) self-reported elevated anxiety and/or depression symptoms (>7) during their baseline assessment and over half the sample (22/39; 56%) displayed cognitive impairment on at least one baseline cognitive measure (1.5SD below the normative mean). Participants attended 7.3/8 intervention sessions on average and delivery modality varied between completely in-person (44%), completely telehealth (28%), and blended delivery that was predominately in-person (28%).

Table 1. Participant demographic and injury information.

Participant^a	Gender	Age	Education (years)^b	Type of ABI	Time since injury^c	Attendance (no. sessions)
SCED
Olivia	F	49	18	Stroke	8 months	4
Liam	M	43	11	TBI	14 years	8
Mary	F	65	17	Stroke	4 years	8
Noah	M	41	13	Refractory epilepsy	34 years	6
Amelia	F	26	16	TBI	11 years	8
Charlotte	F	49	14	Stroke	21 years	8
Oliver	M	62	13	TBI	5 years	8
Elijah	M	51	12	TBI	6 years	8
James	M	80	12	TBI	9 months	6
William	M	53	13	Stroke	3 years	7
RCT
Ben	M	79	16	Stroke	1 year	8
Mia	F	34	17	Stroke	2 years	8
Lucas	M	65	13	Brain tumour	5 years	6
Henry	M	71	17	Stroke	6 years	7
Eleanor	F	55	13	Stroke	2 years	8
Theo	M	72	17	TBI	8 years	8
Jack	M	64	17	Stroke	2 years	8
Alex	M	51	14	Stroke	10 months	8
Emma	F	48	11	Brain tumour	46 years	6
Daniel	M	56	11	Stroke	1 year	8
Anthony	M	24	12	Brain tumour	17 years	6
Ethan	M	63	13	Stroke	2 years	8
Owen	M	37	18	Multiple sclerosis	9 years	8
Penelope	F	19	14	Stroke	3 years	7
Jacob	M	48	16	TBI	1 year	8
Aiden	M	41	18	TBI	5 years	7
Chloe	F	20	15	Stroke	6 years	8
Madison	F	49	19	Stroke	7 years	8
Joseph	M	57	11	Brain tumour	2 years	4
Ellie	F	48	14	Multiple sclerosis	13 years	8
David	M	54	16	Stroke	6 years	8
Grace	F	50	18	Stroke	2 years	8
Zoe	F	35	17	Multiple sclerosis	7 years	6
Leo	M	74	10	Stroke	1 year	8
Eliza	F	60	14	Stroke	1 year	8
Victoria	F	53	13	Meningitis	1 year	3
Luke	M	55	14	TBI	6 years	8
Hannah	F	76	17	Stroke	2 years	8
Matthew	M	40	11	Stroke	4 years	8

Notes: SCED, single case experimental design; RCT, randomized controlled trial.

^a All participant names are using pseudonyms.

^b 13 years indicates completion of high school.

^c Time since injury rounded to the nearest month or year.

No individuals who were invited to participate in the interview refused. Participants expressed a breadth of perspectives and experiences during their interviews, covering direct feedback on the intervention, their personal experience of the intervention, life with brain injury more generally, and the impact of the intervention on aspects of their recovery or functioning. The richness of information and amount of feedback varied between interviews and appeared to be influenced by individual participant characteristics (i.e., memory impairment, treatment engagement). Interviews conducted immediately post-intervention tended to include more granular feedback on intervention components, while interviews at the 8-week follow-up timepoint included more reflections on the broader impact of VaLiANT and experience of integrating the strategies into daily life. Interviews varied from 5–54 min (median length 22 min; 85% of interviews were over 15 min).

Qualitative findings

Reflexive thematic analysis resulted in the generation of three final themes. (1) “A fuller toolkit for life with brain injury” represented increased strategy usage which led to better daily functioning and management of ABI-related difficulties. (2) “The value of connection and belonging” captured how social experiences, particularly within VaLiANT, shaped recovery and self-identity following ABI. (3) “Finding the ‘me’ I can be” represented aspects of identity reconstruction and behavioural adjustment. It was best represented by three subthemes: (i) “Understanding who I am now”, (ii) “Exploring new possibilities”, and (iii) “Noticing a shift in feeling”. Figure 1 depicts the conceptualized relationship between the three main themes as a hierarchical but interacting model whereby changes in functioning and strategy usage (theme 1) and social connection (theme 2) contributed to changes in adjustment (theme 3). This adjustment process then reinforced participant’s new behaviours and their orientation towards social connection. Qualitative themes are discussed in detail below with supporting data extracts (edited for brevity and clarity).

Figure 1. Conceptual model of reflexive thematic themes.

A figure depicting the conceptualized relationship between the three main themes as a hierarchical but interacting model whereby changes in functioning and strategy usage and social connection contribute to changes in adjustment. This adjustment process then reinforces participant’s new behaviours and their orientation towards social connection.

A fuller toolkit for life with brain injury (theme 1)

This theme captured participants’ reflections on how VaLiANT had provided them with a flexible suite of tools that helped them better manage their lives with brain injury. The strategies taught within the program were identified as either being useful in helping improve daily functioning through better management of ABI-related symptoms, or helping improve coping with difficult emotions and thoughts that arose due to ABI-related changes. This included strategies to support the management of cognitive symptoms, sleep and fatigue difficulties, mood symptoms or frustration, and changes in relationships and communication:

I’ve downloaded the mindfulness body scan exercise. I have used that in between meetings at work. I’ve recognised that it’s almost like having a little rest … it helps me keep going. (Charlotte, 49)

There was significant variability between participants on which components of the intervention were identified as useful, which likely reflected each participant’s own needs. This highlighted the importance of having a variety of strategies integrated into the program. Some participants reflected on how the intervention targeted aspects of functioning that had not been covered in previous rehabilitation and delivered content in a way that was specifically tailored to those with ABI, which made it relevant, accessible, and easier to implement into their lives:

It was good having information specifically related to my condition, rather than just general information about sleep and diet. (Zoe, 35)

Participants also noted increased insight into their strengths and limitations following the exploration of these within the program. This helped them identify which strategies were relevant and when to apply them:

It was useful to identify my barriers, because if there are strategies or ways of minimising them it can keep me on my goals. (Madison, 49)

A few participants noted that the repetition each week of identifying their values, generating goals or behaviours in line with these values, identifying barriers, and identifying strategies to overcome those barriers provided a framework that they could integrate into their lives to support ongoing behaviour change following the completion of VaLiANT:

I find I’m doing it each time I set a new goal or want to tweak the direction of things. I use that framework and think, ‘is this something I have control over? Or are there barriers blocking my path? (Mary, 65)

This was often linked to the weekly homework tasks which encouraged participants to implement and practice this framework each week throughout the program. Finally, some participants emphasized that the holistic nature of the intervention was beneficial as it considered the impact of brain injury across different areas of their lives:

I just feel the group has taught us how to deal with different areas of life. It has covered areas such as social or physical or mental, different areas of your personal life, and how you can deal with problems that occur in these areas as well. (Chloe, 20)

These quotes reflect the concept of a toolbox, whereby different participants have come away from VaLiANT with new information, insights and strategies that help them manage their unique symptoms and needs following brain injury.

The value of connection and belonging (theme 2)

This theme captured how social interactions and connections shaped the experience of brain injury and influenced recovery and adjustment. Many participants identified significant changes in their day-to-day social functioning and a reduction in their sense of connection following their brain injury. This was often characterized by loneliness and isolation:

That’s one thing that I’ve missed out on for too long, contact with other people. (Noah, 41)

Others described how their current social interactions frequently made them feel invalidated and misunderstood:

A common thing I hear from family or friends who haven’t got brain injury is ‘oh you’re too hard on yourself.’ It feels like being invalidated. I still feel the deficits and you’re not acknowledging it. (Amelia, 26)

Some participants noted how these interactions harmed their self-identity as they felt devalued and criticized by those around them due to their disability:

I’ve got two adult children who do not allow me the grace of having an ABI and that hurts. They don’t trust me because I’m a bit unpredictable now. (Mary, 65)

These comments reflect a common narrative about the “invisible” nature of brain injury whereby those surrounding the individual are unable to see or empathize with symptoms and limitations that are not directly observable, such as fatigue or cognitive impairment. In contrast, participants described how participating in VaLiANT provided them with an opportunity to feel understood and connected to others when this was often lacking in their day-to-day lives. There were frequent descriptions about how other group members had validated their feelings and helped them make sense of their own experience of brain injury:

In one session someone said ‘I feel quite hard on myself and frustrated because where I am is not where I was before, and it feels like a definite sense of loss’. That was the first time I’ve heard someone say what I’ve been feeling for the last decade. (Amelia, 26)

You learn that you’re not alone and not to blame yourself for the injury because it could happen to the most fit person in the world. It doesn’t discriminate. (Ethan, 63)

Connection to the other group members was frequently singled out as being one of the most important aspects of the program and many participants wanted more emphasis on building deeper connections with other group members:

I feel like it was rushed and we didn't really get to know each other, to feel each other. That connection is important because we don’t have that connection - what we feel as people with strokes is so far away from people that live life normally. Getting to know one another gives us strength. (Grace, 50)

There were also several descriptions of participants connecting outside of the group for social outings, continuing to communicate following the end of the intervention, or feeling a sense of loss once the program had finished:

There’s the chance of actually forming some sort of friendship with the people that were in the group. One of the participants has got everybody’s email. So in time she’ll organise meeting at a coffee shop. (Matthew, 40)

The desire to meet outside of the intervention sessions seemed particularly prevalent in groups where the intervention was delivered via telehealth, which highlighted the value of in-person social interaction:

Telehealth is less pleasant than meeting someone in-person because you feel a deeper connection if you see them face-to-face. (Chloe, 20)

Several participants also highlighted the value of targeting their broader social functioning within VaLiANT by including family and significant others in the program’s seventh session. Some indicated that this helped family members better empathize with their experience of ABI, while others felt better equipped to communicate and advocate for their needs:

That session made me talk to people about what struggles I do have. Helping them understand that sometimes I might forget things. I’m not being ignorant, I just can’t remember. (Luke, 55)

Finally, participants identified different therapeutic group processes that occurred such as feeling more motivated to pursue their goals due to a sense of group identity and accountability, while also highlighting the value of peer-led learning through the sharing of experiences and strategies:

I was impressed with the strategies that she used. Listening to her talk about them week after week, I started using them and they were helpful. (Olivia, 49)

Overall, this theme highlighted how social connection is a strong influential factor and motivator for people with ABI while also demonstrating the unique therapeutic value that group interventions can have as part of the rehabilitation process.

Finding the “me” I can be (theme 3)

This theme captured various aspects of identity reconstruction and adjustment to brain injury that participants described due to participation in VaLiANT. It was best represented by three subthemes which reflected cognitive, behavioural, and affective elements of adjustment.

Understanding who I am now (cognitive)

This subtheme represented cognitive aspects of adjustment including shifts in self-concept and identity reconstruction. Participants discussed how significant changes in their functioning following their ABI had prevented engagement in previously important life roles, negatively impacted their self-concept, and culminated in a loss of meaning, purpose, and direction in life:

In the years since the stroke, having a sense of purpose was missing. I had to give up work and I was going through a divorce at the time. I was feeling lost, like a lot of my identity was tied up in family, in work, and in hobbies. All of those things suddenly stopped, and it felt like a huge vacuum. (David, 54)

In contrast, participants described how VaLiANT provided a space to process how brain injury had impacted them:

I don’t think I mentioned the word ‘stroke’ more than five times prior to the group. It wasn’t talked about in my house. It was a chance to deal emotionally with the fact I had a stroke. (Olivia, 49)

Some participants made references to forming an updated and realistic post-injury identity by beginning to incorporate their injury-related changes and limitations into their self-concept. This assisted them in adjusting their expectations of what was possible while also normalizing the use of strategies to support functioning:

I’m trying to be kinder to myself while going back to work and not taking on too much. On the days that I work, that’s what I do. I go to work and don’t plan anything else for those days. Things take longer now because of the fatigue. (Zoe, 35)

Participants also identified that the focus on personal values within the group had assisted in making sense of what was important to them. Having explicit knowledge of their core values provided participants with a sense of direction and helped them identify whether there had been a change in their priorities following their brain injury:

It showed me what was important in my life, because I was thinking about work being important. I think I’ve realised that family is more important and having fun is more important than work. (Eliza, 60)

Importantly, this represented an orientation towards the future rather than being focused on pre-injury conceptualizations of what was important. Finally, participants also described how other group members served as reference points to make sense of themselves. This occurred through upwards comparisons where some group members were seen as role models with other participants wanting to emulate aspects of their behaviour or their qualities. However, downwards comparisons were more common where participants recognized their own progress and recovery in contrast to those with more severe injuries or disability:

It was good to be in a group with other people, and it was good to see that I was in better shape than a lot of the other people there. I could appreciate my situation wasn’t as bad as some of the other people. (Joseph, 57)

These comments suggest that VaLiANT provided an opportunity for participants to begin making sense of themselves following their ABI by identifying what was important to them now, while also adjusting their self-concept to include sequelae of their injury.

Exploring new possibilities (behavioural)

This subtheme captured behavioural aspects of adjustment including participants adapting their behaviour to accommodate their limitations, engaging in new meaningful behaviours, and having an increased sense of agency and control over the direction of their life. Several participants described new behaviours that they were engaging in which gave them a sense of purpose or that aligned with values that they had identified during VaLiANT:

I’m taking things less seriously and I’m having fun. There was one participant who came in with colourful clothes. Having fun things really stuck so I bought some really colourful leggings that I wouldn’t have normally done. I care less now about what other people think. (Eliza, 60)

Relating to this was the realization that to pursue new valued behaviours, participants needed to accommodate their ABI-related limitations and adjust their expectations around which behaviours were feasible and how they structured their day to manage their limitations:

I’m making sure I take time out for me which I wasn’t really doing. Now I feel all right about going and just having to lie down for half an hour, then coming back to everything. I wasn’t doing that before and everything was getting on top of me. (Victoria, 53)

These statements were often linked to strategies taught within VaLiANT, including practicing self-compassion and thought defusion techniques to manage difficult thoughts that arose while changing their expectations. Other participants noted increased confidence in engaging in new behaviours due to having strategies in place to support their actions or due to behavioural activation tasks within the program, which led to successful completion of goals:

My weakness is cooking, but one of my homework tasks was to cook a vegan meal for my family. It went down well. I had to go and do it because it was part of my homework. Now I’ve got the confidence to go and do it a second time. (Oliver, 62)

Participants also described greater perceptions of control over their lives. This was linked to being more assertive in their relationships and managing other’s expectations, focusing more on their own valued actions, identifying what they could control in their environment, and letting go of what was outside of their control:

During the program I had the epiphany that my children were the negative passengers on my bus. I love them but they are distracting me from my goals. I now make goals that don’t include them. (Mary, 65)

Finally, several participants reflected on how engaging in new “valued” behaviours provided a sense of direction and contributed to an overall feeling of progress in life:

The behaviours I put on my worksheet were things I wanted to achieve. I followed through and did the behaviours. I think that reflects that since my stroke I’ve come a long way and I’m on a path that’s heading in the right direction. (Daniel, 56)

These comments indicate that VaLiANT helped participants identify new meaningful behaviours to engage in that were within their injury limitations, and engagement in these behaviours helped participants envision a different future which they had more control over.

Noticing a shift in feeling (affective)

This final subtheme captured how VaLiANT fostered positive growth and emotions which reinforced the behaviour change that participants were making. Several participants referenced having a deeper sense of enjoyment and fun in their lives following VaLiANT:

When I actually put aside time for leisure, I was just like ‘wow, I enjoy life more.’ I got deeper enjoyment out of my free time. (Amelia, 26)

Similarly, some participants referenced having an increased quality of life or wellbeing:

You just want your life to change for the better. It's definitely improved my life. (Luke, 55)

Participants described increases in intrinsic motivation due to the successful completion of their actions, which reinforced their sense that they were on the right track with their rehabilitation and recovery:

When we were encouraged to pick actions for the week, it’s something I wouldn’t have done before without that encouragement. It just pushes you along. It just makes you want to better yourself. (Oliver, 62)

This may have reflected an increase in the pay-off from new behaviours when the behaviours were aligned with core values. Finally, some participant reflections evoked the idea of increased hope for the future and that ongoing improvement in their lives was possible:

Don’t sign yourself off. You’re in the game. If you feel there is some hope, you work harder towards the goal to be completed. For me, I want to try and fight as hard as I can to try and achieve what is achievable. (William, 53)

Overall, this subtheme highlights how changes in self-concept and behaviour had led to shifts in how some participants were emotionally relating to themselves and the impact of their ABI.

Intervention acceptability and feedback

The overall acceptability of the intervention and its delivery were high, with most participants rating VaLiANT as helpful and indicating that the program had a positive impact on the way they thought, felt, and behaved (see Figure 2). Almost all participants agreed they would recommend VaLiANT to others (95%; n = 37/39):

I feel that for all the others who will have a stroke that there’s now something they can participate in that will be of help to them. (Daniel, 56)

Participants also indicated that clinicians delivered the intervention effectively, that supporting materials were appropriate, and that the balance of information presented in each session was suitable. Participants who rated the program as less helpful or satisfactory noted that they required more tailoring and individualization of the intervention to meet their personal needs or indicated that some aspects of the program had been covered in their personal rehabilitation which reduced the value-add of the intervention:

Figure 2. Distribution of overall intervention acceptability ratings. *Indicates different response scale; please rate how satisfied you were with VaLiANT overall (extremely dissatisfied, a little bit dissatisfied, indifferent, mostly satisfied, extremely satisfied), please rate how helpful you found VaLiANT (not at all helpful, slightly helpful, somewhat helpful, moderately helpful, very helpful).

Bar chart displaying the distribution of participants levels of agreement with statements about VaLiANT’s delivery. The ratings indicate high overall acceptability as the majority agreed with positively worded statements and disagreed with negatively worded statements.

It was stuff that I got taught in the hospital when I first woke up from the coma. I’ve been doing it for years. (Penelope, 19)

Others identified that having competing priorities (e.g., work or parenting responsibilities), significant cognitive impairment, or significant mood disturbance impacted their attendance and treatment engagement:

I had a lot of trouble finding the energy to implement strategies because externally things are really difficult. Maybe if I attended regular therapy in conjunction with VaLiANT, I could have participated better. (Anthony, 24)

Some participants desired individual sessions on top of the group program to further explore their own goals and strategies directly applicable to their needs. Similarly, some participants identified that they were having difficulty maintaining their progress and behaviour change at their follow-up assessments and suggested the program needed to run for longer or include booster sessions to help them consolidate the intervention content:

Initially it was really good, but I’m finding over time that I’m forgetting what I learnt. (Eliza, 60)

This seemed particularly apparent for participants with more significant cognitive difficulties, who struggled to remember many aspects of the intervention. Finally, participants felt that the intervention was delivered effectively via telehealth and that online delivery was more convenient and less confronting. However, there was an overwhelming preference for in-person delivery to allow for deeper connection to other participants and reduce social isolation:

You’re looking at a screen and looking at people. It’s like watching television. It’s not the real thing and it was not personal. (Leo, 74)

When you actually see people you pick up on a lot more than when you’re just watching a screen. There’s a lot of energy that you miss out on. That’s the big downer to telehealth for this particular thing. (Joseph, 57)

Acceptability of individual intervention components was generally high (see Table 2). Consistent with our three reflexive themes, participants identified the most helpful aspects of VaLiANT as being the group nature of the program, the focus on values identification and valued living, and the teaching and practicing of strategies to manage cognitive and emotional changes associated with the ABI. In particular, many participants identified the values work as being novel and a key takeaway from the intervention and appreciated the use of the values card sort task:

I found that the scope of values that were presented on the cards was really comprehensive. There were things that I hadn’t considered that the cards presented. (Aiden, 41)

Mindfulness and self-compassion exercises were also highlighted as key strategies that participants continued to implement. Participants appreciated how VaLiANT linked various mindfulness exercises to a particular situation (e.g., using the body scan exercise to monitor levels of fatigue) which helped make each exercise more accessible and easier to implement into daily practice. In contrast, the passengers on the bus metaphor was polarizing. Some participants found the concept too abstract and difficult to understand or found that physically acting out the metaphor was confronting or uncomfortable. Other participants indicated it helped increase psychological flexibility, awareness of internal barriers, and reduce emotional distress:

The exercise with the bus, I realised ‘oh there aren’t things that are actually holding you back. It’s usually just in your head and you holding yourself back’. (Luke, 55)

Intervention components that were less frequently rated as helpful predominately were the supporting materials of the intervention (e.g., handouts and slides). Bringing a family member or friend to session 7 was the component least frequently rated as helpful despite the overall session being rated as most useful. This may suggest that some individuals did not think family involvement was valuable. However, the low rating may be because many participants were unable to bring someone due to logistical difficulties (e.g., their spouse was working) or due to being socially isolated and not having someone willing to be involved. There was variation amongst participants in whether other sessions of VaLiANT were helpful (see Table 2). The sessions on leisure and work were least frequently rated helpful. The variation in these ratings often reflected previous comments that some areas of the intervention were not applicable or relevant to their personal circumstances. For example, a few participants noted that the session on work didn’t feel relevant as they were either working with no difficulties, or no longer intended to work. Session ratings were similar when calculated using the total sample with some slight differences in the rank order of the sessions.

Discussion

This study served as an in-depth exploration of the VaLiANT intervention. Findings of our thematic analysis indicated that participants experienced VaLiANT as facilitating adjustment to brain injury, with multiple therapeutic components underpinning this process. While intervention content and delivery were acceptable to participants, future delivery of VaLiANT could be improved through increased tailoring of the content to individual participant needs and further follow-up to support ongoing behaviour change and adjustment following completion of the initial 8-week group program.

Table 2. Ratings of intervention components and individual sessions.

	% indicating helpful
Intervention component
Sharing experiences and ideas with other group members	87 (34/39)
Doing the values card sort activity each week	79 (31/39)
Learning about values and how to determine what is most important to me	77 (30/39)
Identifying barriers	74 (29/39)
Learning and practicing coping strategies e.g., mindfulness, self-compassion	74 (29/39)
Learning and practicing doing strategies e.g., cognitive/memory/planning strategies	67 (26/39)
Doing homework tasks	62 (24/39)
Identifying and noticing your passengers on the bus	59 (23/39)
Using SMART goals to identify committed actions	59 (23/39)
Identifying personal strengths that enable valued living	59 (23/39)
Filling out the “way to valued living worksheet” every week	56 (22/39)
Reviewing the notes and handouts	54 (21/39)
The information on the slides	51 (20/39)
Doing the passengers on the bus group activity	49 (19/39)
Getting a recording of the mindfulness exercises	46 (18/39)
Having the opportunity to bring along a family member or friend	41 (16/39)
Individual sessions^a
Session 7: Healthy relationships (family/friend session)	67 (22/33)
Session 2: Sleep and fatigue	59 (22/37)
Session 1: Getting introduced to values and valued living	59 (22/37)
Session 6: Communication strategies	57 (20/35)
Session 3: Diet and exercise	56 (20/36)
Session 8: Revising the program	49 (17/35)
Session 5: Leisure	42 (14/33)
Session 4: Work, study, community involvement	41 (15/37)

^a Session ratings excluded participants who did not attend that particular week of the intervention.

A wide range of individually meaningful outcomes were identified across the interviews. These included positive shifts in self-identity, the incorporation of injury-related limitations into self-concept, engagement in new behaviours that provided a sense of purpose, adaptation of existing behaviour to accommodate injury-related limitations, and increased wellbeing and enjoyment of life. These outcomes are consistent with existing models of adjustment to brain injury. For example, adjustment is thought to include the formation of an updated post-injury self-concept that incorporates injury-related changes (Gracey et al., 2009). This updated identity facilitates subsequent adaptive behaviour change which allows for the pursuit of meaningful goals that are possible within injury-related limitations (Brands et al., 2012). Engagement in these psychological and behavioural aspects of adjustment has been strongly associated with higher wellbeing and quality of life (Carroll & Coetzer, 2011; Schönberger et al., 2014). These outcomes are also consistent with our phase II pilot RCT findings which suggested that VaLiANT may be effective at improving psychological distress, psychological flexibility, barriers to valued living, and self-identity, although improvements in wellbeing or quality of life were not identified (Sathananthan et al., under review). Taken together, these findings suggest that VaLiANT may help some individuals engage in different aspects of the adjustment process.

Valued living appeared to be a key mechanism underpinning these positive outcomes. Participant experiences suggested that exploring values-based action helped them identify new ways of expressing important aspects of their identity within post-injury capabilities (e.g., returning to work in a less demanding role). Results also suggested that values work promoted a reprioritization process as some individuals redefined the important aspects of their identity (e.g., choosing not to return to work to focus on family instead). Linking core values to these new/adapted behaviours may have increased the intrinsic reward of engaging in them, even if they represented a change from pre-injury behavioural expressions of self-identity (Arch & Craske, 2008; Van Bost et al., 2020). From an ACT perspective, this may reflect defusion from self-as-content, whereby connecting to values results in a more flexible sense of self due to the loosening of pre-injury self-conceptualizations. Values work may therefore facilitate adjustment by promoting connection to a deeper and more enduring self-identity that can guide engagement in meaningful behaviour despite the presence of persistent limitations.

Social connection also appeared to be an important treatment mechanism. Participants rated positive social connection with other group members as the most helpful intervention component and described how this connection reduced feelings of isolation, validated their experience of ABI, helped them make sense of their own recovery, and inspired behaviour change. Similar benefits have been reported following other group rehabilitation programs (Large et al., 2020; Tulip et al., 2020; Withiel et al., 2020) and group connection following ABI is linked to psychological growth particularly when there is a strong sense of belonging or identification with other group members (Griffin et al., 2022; Lyon et al., 2021). In contrast, isolation and invalidating social experiences post-ABI have been shown to reduce self-worth and reinforce the discrepancy between an individual’s pre- and post-injury identity (Levack et al., 2014; Villa et al., 2021; William et al., 2014). These findings demonstrate the unique value-add of group-based rehabilitation and highlight the importance of facilitating positive social connections to improve self-identity following ABI.

Finally, positive outcomes were also linked to better management of ABI-related symptoms. Participants reported that VaLiANT increased their awareness of their injury-related limitations which guided usage of cognitive and ACT (e.g., mindfulness, self-compassion) strategies to improve daily functioning. Engagement in more effective coping around cognitive and emotional sequelae has been associated with higher self-efficacy, better acceptance of ABI, and better wellbeing and quality of life (Brands et al., 2014; Brands et al., 2019; Cicerone & Azulay, 2007; Yehene et al., 2020). The inclusion of strategies targeting both cognitive and emotional changes was also rated highly by participants in terms of usefulness. These findings largely support the rationale of incorporating both cognitive and psychological strategies in VaLiANT to promote more positive self-perceptions, management of ABI-related barriers, and to facilitate values-based behaviour change.

The overall acceptability of VaLiANT was high with most participants identifying it as helpful, well-designed, and delivered appropriately. Participant ratings supported several components of the Sekhon et al. (2017) acceptability framework, including “affective attitude” (satisfaction with the intervention), “perceived effectiveness” (perceiving impact from the intervention), and “intervention coherence” (understanding intervention design/rationale), while suggesting that the “self-efficacy” component (confidence in being able to perform intervention related behaviours) could be better supported to improve overall acceptability. Specifically, the dosage and structure of the program did not adequately meet the needs of all participants. Some identified the need for increased individualization of content to their personal circumstances, more treatment sessions, or further follow-up to help consolidate content and maintain perceived progress following the intervention.

Several factors appeared to impact the treatment experience. These included significant mood disturbance which impacted behaviour change outside of sessions; significant memory/cognitive problems which reduced understanding of abstract concepts and retention of information; and telehealth delivery which reduced feelings of connectedness to other group members. This can be understood through the “capability” element of the COM-B model of behaviour change which indicates that an individual must feel physically and psychologically capable of performing a behaviour to engage in behaviour change (Michie et al., 2014). Some participants may need more time and support to engage in meaningful behaviour change, particularly those with characteristics that may have negatively influenced treatment engagement. Inclusion of individual and/or booster sessions alongside the 8-week VaLiANT group could improve acceptability and allow greater intervention tailoring and support over time, which may improve capability to engage in behaviour change.

This study provides several theoretical and clinical implications for the way holistic interventions are designed, delivered, and evaluated. Clinically, our findings support the rationale of integrating strategies that target different domains of functioning (e.g., cognitive, emotional, social, health) into a broader person-centred framework (e.g., valued living) to support adjustment following ABI. These findings also support valued living as a viable framework around which to organize person-centred rehabilitation, particularly given that higher valued living is linked to better long-term outcomes (Baseotto et al., 2022; Miller et al., 2023; Pais et al., 2019). Secondly, group connection was important but some participants noted this connection was attenuated online. Therefore, additional support may be required to facilitate group connection if delivered via telehealth. Thirdly, many of the positive outcomes reported by participants were subtle and varied between individuals. These may be difficult to capture on standard outcome questionnaires which are often narrowly defined. Qualitative paradigms can therefore add value and depth by characterizing the nuanced impact of complex holistic interventions. Finally, our themes have similarity with findings from other qualitative studies exploring the adjustment process and adjustment-related interventions following ABI (Domensino et al., 2022; Fadyl et al., 2019; Large et al., 2020; Salas et al., 2018). A qualitative meta-synthesis could be conducted to better understand how positive adjustment is facilitated by mapping themes onto existing models of adjustment and wellbeing (Gracey et al., 2009; Tulip et al., 2020). This could guide future intervention development and better measurement of these outcomes.

Our findings need to be considered in the context of certain methodological limitations. The current sample excluded individuals with moderate-severe language/communication impairments and VaLiANT’s acceptability needs to be explored in this population to identify possible accessibility issues. Exploration of participant acceptability also did not cover all components of the acceptability framework (Sekhon et al., 2017). “Ethicality” (whether the intervention fits with participant’s values systems), “burden” (amount of effort required to participate), and “opportunity costs” (whether benefits outweigh costs of the treatment) could be explored explicitly in the future to evaluate the acceptability of VaLiANT more comprehensively. This could also include exploration of facilitator’s experiences of delivering VaLiANT and the influence of participant ethnicity and socioeconomic status given that these factors impact treatment engagement and outcomes (Proctor et al., 2011; Williams et al., 2016). Additionally, the intervention delivery modality varied across participants resulting in differences in how certain aspects of content were delivered. Nevertheless, acceptability ratings were high regardless of delivery modality, suggesting that the different delivery modalities were all acceptable.

In conclusion, this mixed methods study provides insight into how VaLiANT influenced adjustment for some participants through the targeting of ABI-related barriers, the facilitation of valued living, and by providing the opportunity for positive social connection. Intervention outcomes could be enhanced in the future through the provision of individual and/or booster sessions in addition to the current group delivery to assist participants in maintaining progress over time. These findings add to the growing evidence supporting holistic interventions that integrate cognitive and psychological therapies in influencing outcomes related to adjustment and identity following ABI.

Acknowledgements

The authors would like to thank the participants who participated in the study. Thanks are also given to Hannah Miller, Katharine Baker, and Bleydy Dimech-Betancourt for their assistance in conducting the outcome assessments and collecting the data used for this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by La Trobe University.

Appendix. Qualitative interview schedule and quantitative ratings

I would like to ask you some questions about your experience with the VaLiANT group program that you recently completed. Please feel free to elaborate on any of these questions with relevant thoughts and ideas. The purpose of this interview is to learn how helpful the program is. The investigators of this program hope to use this information to improve the program in the future.

Opening question: Please describe your overall experience of VaLiANT and whether it was helpful.

Planned questions (*ask for telehealth delivery only):

• What were the most helpful aspects of the VaLiANT program for you?

• What were the least helpful aspects of the VaLiANT program for you?

• Which strategies do you find yourself using in your daily life?

• Do you have any particular suggestions to help us improve the VaLiANT program?

• Do you have any other comments about your experiences in the VaLiANT program?

• *How would you describe your experience doing the group via telehealth?

• *Were there any positives or negatives with using telehealth for the VaLiANT program?

• *How did you find the process of accessing worksheets and handouts and completing the value card sort activity online?

Planned prompts (*indicates prompts for quantitative ratings):

• Can you tell me more about that?

• Could you provide an example?

• *Can you tell me why you provided that rating?

Quantitative items:

Please rate how helpful you found VaLiANT.

1. Not at all helpful

2. Slightly helpful

3. Somewhat helpful

4. Moderately helpful

5. Very helpful

Which of the following aspects of the VaLiANT program did you find helpful? (Tick all that apply):

1. Learning about values and how to determine what is most important to me

2. Doing the values card sort activity each week

3. Identifying and noticing your “passengers on the bus”

4. Doing the passengers on the bus group activity

5. Using SMART goals to identify committed actions in line with your values each week

6. Filling out the “way to valued living” worksheet each week

7. Identifying strengths that enable you to carry out your committed actions each week

8. Identifying barriers that might stop you from carrying out your committed actions each week

9. Learning and practising “doing” strategies (i.e., cognitive/memory/planning strategies) to address the barriers for each committed action, e.g., calendars, alarms, lists, name associations, activity schedules

10. Learning and practising “coping” strategies to address the barriers for each committed action, e.g., mindfulness, S.T.O.P., self-compassion

11. Getting a recording of the mindfulness exercise

12. The information on the slides

13. Sharing experiences and ideas with others in the group

14. Doing the homework tasks

15. Reviewing the notes and handouts

16. Having the opportunity to bring along a family member/friend to Session 7

17. Session 1 content: Getting introduced to values and valued living

18. Session 2 content: Learning more about sleep difficulties and fatigue

19. Session 3 content: Learning more about diet and exercise

20. Session 4 content: Learning more about ways to get involved in work, study, and community activities

21. Session 5 content: Learning more about participating in different leisure activities

22. Session 6 content: Learning more about communication strategies

23. Session 7 content: Learning more about how to have healthy relationships with family and friends

24. Session 8 content: Revising all of the values, committed actions, barriers and strategies

Please rate the following questions to indicate your opinion regarding the VaLiANT program (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree):

• The clinicians were well prepared

• The clinicians explained things clearly

• Too much information was presented in each session

• Too little information was presented in each session

• The slides were helpful and clear

• The handouts were helpful and clear

• There were too many handouts

• The handouts were well organized

• I was given enough opportunity to speak and contribute to sessions

• The homework tasks were appropriate and helpful

• The way I think and feel is better as a result of VaLiANT

• I think I can do more of the things I value in life as a result of VaLiANT

• I would recommend this program to other people

In an overall, general sense, how satisfied are you with the VaLIANT group?

1. Extremely dissatisfied

2. A little bit dissatisfied

3. Indifferent

4. Mostly satisfied

5. Extremely satisfied