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Gracey (2009) Y-Shaped-Process-Model
Gracey (2009) Y-Shaped-Process-Model
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Neuropsychological Rehabilitation
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To cite this Article Gracey, Fergus, Evans, Jonathan J. and Malley, Donna(2009)'Capturing process and outcome in complex
rehabilitation interventions: A “Y-shaped” model',Neuropsychological Rehabilitation,19:6,867 — 890
To link to this Article: DOI: 10.1080/09602010903027763
URL: http://dx.doi.org/10.1080/09602010903027763
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NEUROPSYCHOLOGICAL REHABILITATION
2009, 19 (6), 867– 890
Correspondence should be sent to Fergus Gracey, Oliver Zangwill Centre for Neuropsycho-
logical Rehabilitation, Princess of Wales Hospital, Lynn Road, Ely, Cambridgeshire CB6 1DN,
UK. E-mail: fergus.gracey@ozc.nhs.uk
We would like to acknowledge Joanna Colicutt McGrath for discussions about the use of
behavioural experiments in rehabilitation, Siobhan Palmer for developing the interpersonal
part of the model, Joe Deakins for helping with the boring bits, and the Oliver Zangwill
Centre team and clients for their contribution.
We would also like to acknowledge the National Institute for Health Research funded
Collaborations for Leadership in Applied Health Research and Care (CLAHRC) for
Cambridgeshire and Peterborough in providing support to Donna Malley and Fergus Gracey
for the writing of this paper.
# 2009 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab DOI:10.1080/09602010903027763
868 GRACEY, EVANS, AND MALLEY
INTRODUCTION
In this paper we describe a model that we believe is useful in both under-
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the intervention; variable outcomes; and flexibility and adaption of the inter-
vention to the individual situation. This complexity makes specifying the
critical ingredients in complex rehabilitation interventions difficult (Craig
et al., 2008). Nevertheless in order to develop and refine interventions it is
necessary to try to understand the relationship between the process of rehabi-
litation and outcome (Whyte & Hart, 2003). Craig et al. (2008) highlight that
a key task is “to develop a theoretical understanding of the likely process of
change by drawing on existing evidence and theory, supplemented if necess-
ary by new primary research” (p. 981). Whyte and Hart (2003) note too that
“rehabilitation research is in critical need of systematic ways to characterise
and define the content and process of rehabilitation interventions” (p. 640).
The challenge of theoretical modelling of complex change processes is not
a new one but one that has been addressed by clinicians and researchers in
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other areas of healthcare. Whyte and Hart (2003) note that “psychotherapy
outcome research, because it involves a field that is similarly challenged to
prove efficacy in the current healthcare reimbursement climate and because
psychotherapy consists almost entirely of structured interactions, may
provide an especially fruitful set of comparisons for rehabilitation research”
(p. 641). Another reason why psychotherapy research is relevant to this dis-
cussion is because of the importance of psychological factors in relation to the
likelihood of achieving the personally meaningful outcomes reflected in reha-
bilitation goals. Such issues have been addressed in studies of cognitive-
behaviour therapy (CBT) where there is a long tradition of development in
clinical practice based on theory-driven investigation of emotional disorders.
Salkovskis (2002) describes the dynamic relationship between clinical
practice, theory, outcome research and experimental studies in the develop-
ment of CBT. He notes that the result of this dynamic relationship is a set
of empirically grounded clinical interventions that have been shown to be
effective in treating a range of mental health conditions. David Clark and
his collaborators have made substantial contributions both in developing
theoretical models of specific anxiety disorders to inform intervention and
in conducting treatment trials of interventions derived from these theoretical
models (see, for example, Clark, 1999, for a review). Salkovskis also argues
that an approach to clinical practice founded solely on clinical outcome
research (characterised as a narrow version of the evidence-based medicine
approach) may fail adequately to address the issue of the relationship
between interventions and outcomes (i.e., therapy processes), limiting the
further development of therapy. These authors and the guidance from the
Medical Research Council (2006) highlight research designs and method-
ologies that can be helpful in evaluating complex interventions. A key
aspect is clarification of the main outcomes or goals for interventions, in
addition to identification of theoretically derived measures of specific pro-
cesses that can be linked to specific aspects of the intervention to answer
870 GRACEY, EVANS, AND MALLEY
the question how has the intervention worked. The Medical Research Council
guidance notes that: “Only by addressing this kind of question [what are the
specific processes underpinning change outcomes] can we build a cumulative
understanding of causal mechanisms, design more effective interventions and
apply them appropriately across group and setting” (p. 7). The document con-
tinues: “. . . a vitally important task is to develop a theoretical understanding
of the likely process of change, by drawing on existing evidence and
theory . . .” (p. 9). Addressing this task is the essence of the current article.
overall outcomes and processes may be helpful and informative in the evalu-
ation of rehabilitation post-brain injury. Turner-Stokes, Disler, Nair, and
Wade’s (2005) Cochrane Review of ABI rehabilitation outcome studies
concludes that, while a few predictors of outcome have been identified,
areas for further exploration include: “effectiveness of specific interventions
within the rehabilitation programme”, “development of a method to determine
an individual’s ability to engage in and benefit from intensive rehabilitation”,
and “improved measurement techniques for assessment of targeted interven-
tions”, (p. 15). Each of these points suggests the need for a component analysis
of rehabilitation which in turn requires a theoretical model to drive identifi-
cation of key variables and predictions arising from their interactions.
One area that may be informative in this respect is the literature on coping
and emotional adjustment. Work in this field has expanded to the extent that it
now includes reference to literature on self-discrepancy, goal setting, social
and personal identity change, self-awareness and well-being (see Gracey &
Ownsworth, 2008, for a recent review). We have attempted to synthesise
some of this literature into an organising framework we call the “Y-shaped”
model (see Figure 1; Gracey et al., 2008a; Palmer et al., 2009; Wilson et al.,
in press). In addition to providing a theoretical synthesis of existing work
drawn from rehabilitation and psychotherapy studies, we have developed the
model to be of clinical use: to help organise and formulate complex interdisci-
plinary interventions, to engage as well as communicate and collaborate with
clients and their families, and to help track processes we believe may be
related to change and social outcomes.
The Y-shaped model is so-called because it proposes that the process of
adaptation and reintegration into society following brain injury initially
involves the coming to awareness, understanding, and adaptive resolution
of social and psychological discrepancies, this resolution being depicted in
the converging lines of the “V” at the top of the “Y’. Key discrepancies
that may be targeted in rehabilitation include (1) social discrepancies
CAPTURING PROCESS AND OUTCOME 871
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Figure 1. The “Y-Shaped” process model of rehabilitation (adapted from Gracey et al., 2008a, and
Wilson et al, in press, with permission from Cambridge University Press). The converging lines at
the top of the Y indicate reduction of discrepancy. The cycle of behavioural experiments is
mapped out and the ellipses represent the continued use of behavioural experiments or experiential
learning initially to resolve discrepancy, then to support identity development and psychological
growth.
(e.g., fear of stigma resulting in withdrawal from social groups and loss of
relationships), (2) interpersonal discrepancies (e.g., client and relative
holding different views about the nature of difficulties or needs), and (3) per-
sonal discrepancies (e.g., between pre-injury and current self, or current and
hoped-for self). We propose that for a subset of individuals following brain
injury, the threat of feared and actual catastrophic meanings associated
with the post-injury situation leads to the adoption of coping strategies that
may reduce threat in the short term but result in failure to resolve discrepan-
cies, therefore leading to ongoing poor psychosocial outcomes.
Having resolved at least in part the core sense of discrepancy (depicted in
the model as the point of convergence of the branches of the Y), and under
conditions of reduced or absent threat reactions, clients (and family or
carers as appropriate) are supported to consolidate their developing post-
injury sense of self through a process of psychological growth and develop-
ment, as represented in the vertical “trunk” of the “Y”. During this phase,
872 GRACEY, EVANS, AND MALLEY
(1) aspects of continuity with pre-injury self are discovered and developed,
(2) new, adaptive and personally salient meanings arising as a result of the
injury and related experiences are identified, and (3) these meanings are con-
solidated through activity in meaningful contexts. This process may be
initiated during intensive rehabilitation and then continued with appropriate
supports following rehabilitation in keeping with longitudinal models of
psychological growth over the lifespan.
The key theoretical frameworks we have drawn upon in synthesising the
literature and developing the model include contemporary cognitive models
of cognition and affect – especially the Interacting Cognitive Subsystems
model of Teasdale and Barnard (1993) and Conway’s (2005) self-memory
system model; goal process accounts such as that of Carver and Scheier
(1998); and self-discrepancy theory (Higgins, 1987) – and models of psycho-
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logical development (e.g., Vygotsky, 1960/1978) and growth (e.g., Ryff &
Keyes, 1995). Our clinical practice associated with the model is strongly
influenced by intensive holistic rehabilitation models (Ben-Yishay 2000;
Christensen, 2000; Prigatano, 1999), Ylivsaker’s “project based” and “iden-
tity oriented” approaches (e.g., Ylvisaker & Feeney, 2000; Ylvisaker,
McPherson, Kayes, & Pellett, 2008), and CBT (especially the application
of behavioural experiments: Judd & Wilson, 2005; McGrath & King, 2004,
and the use of motivational interviewing: Manchester & Wood, 2001; van
den Broek, 2005). Recently we have also applied systemic thinking to
resolution of interpersonal discrepancies in couples and family work (e.g.,
Palmer et al., 2009).
Summary
At the very top of the “Y”, we suggest that, for some attending rehabilita-
tion, the interplay between interpersonal and social factors, sense of identity
and awareness results in social and interpersonal discrepancies through loss
of or withdrawal from relationships and activities, and failure to access appro-
priate and realistic advice. The result of such processes might be maintenance
of poor awareness of difficulties, which may temporarily preserve sense of
identity, but over the longer term lead to loss of social relationships and net-
works with a significant negative impact on psychosocial outcome. It is poss-
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ible that individuals at this level of discrepancy may struggle to engage with
individually targeted interventions aimed at learning compensatory strategies,
and may engage in contesting the nature or presence of difficulties with reha-
bilitation professionals.
Self-discrepancies
Researchers from different methodological orientations have drawn
conclusions that converge with these notions of threat to self and self-
discrepancy. Nochi’s qualitative studies highlight the ways in which individ-
uals experience a “loss of self” (Nochi, 1997, 1998). A number of quantitative
studies suggest people with traumatic brain injury (TBI; Cantor et al.,
2005; Tyerman & Humphrey, 1984) or stroke (Ellis-Hill & Horn, 2000;
Secrest & Zeller, 2006) may experience a sense of self-discrepancy or discon-
tinuity of self in comparing pre- and post-injury selves. In a theory-driven
study of identity change and adjustment following TBI, Cantor et al.
(2005) tested predictions about psychosocial outcome made by Higgins’
(1987) self-discrepancy theory. The study found that higher levels of
pre to post-injury self-discrepancy were positively correlated with levels
of emotional distress. However, specific predictions regarding types of
CAPTURING PROCESS AND OUTCOME 875
self-representation and depression and anxiety were not supported. Arena and
Adams (unpublished) found personal self-discrepancy, as measured by
Tyerman and Humphrey’s Head Injury Semantic Differential Scale, to
mediate the relationship between adjustment and abilities (as measured by
the Mayo-Portland Adaptability Inventory; MPAI-4, Malec, 2005) and
emotional distress (depression and anxiety) in individuals at least one year
post-injury. The study did not include measures of self-awareness (accuracy
of self-appraisal in relation to another’s perspective), so the hypothesis that
poor awareness may be protective of emotional distress specifically
through reducing or avoiding self-discrepancy (preoccupation with, or
sense of, not being oneself) in the presence of deficits in functioning was
not addressed.
Discrepancy is also a central concept in self-regulation theory (Carver &
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Scheier, 1998) and has been discussed in relation to brain injury rehabilitation
(Hart & Evans, 2006; Siegert, McPherson, & Taylor, 2004). Carver and
Scheier’s control-process model of self-regulation suggests that much of
our behaviour is goal-directed and that behaviour is directed towards reducing
the discrepancy between the person’s goal and the current circumstances
(Siegert et al., 2004). Goals are organised hierarchically with broad abstract
goals (e.g., “be successful”) at the top, and more concrete, specific behaviours
or action sequences (get up and go to work each day) at the bottom, with a
large number of other, ever-changing goals in between these two extremes.
A core concept in control-process theory is that affect is associated with
rate of progress towards goal-achievement. Interestingly, it is not the distance
between current situation and goal state that is seen as critical, but the rate at
which progress towards achievement of a goal is being made. A faster than
expected rate of progress leads to positive emotion and slower than expected
rate of progress to negative emotion, while expected progress is affect-neutral
(Carver & Scheier, 1990). Thus, after brain injury, it is possible to identify a
range of possible scenarios in which a person’s goals have stayed the same or
been adapted, and the extent to which the person has the capability to work
towards achieving those goals. In rehabilitation some scenarios will result
in negative affect – a person may have a sense of self which is related to
higher order goals, but as a result of cognitive, emotional or physical deficits
be making little or no progress towards achieving those goals. Conversely,
when the person with ABI has adapted goals and is able to make faster
than expected progress towards achievement of those goals, positive affect
may be experienced. Of course deficits in the ability to monitor progress
(e.g., arising from impairments in attention or memory perhaps) may also
lead to negative affect when progress is not perceived, even if present.
Ylvisaker et al. (2008) describe a technique they call metaphoric identity
mapping (MIM) which is used to help individuals to set personal goals that
are consistent with a sense of identity that is valued by that individual
876 GRACEY, EVANS, AND MALLEY
Coping styles
This promising line of theory and research on self-discrepancy post-injury
may link with the substantial literature on post-injury coping, but such links
have not yet been fully explored. A recent series of studies by Anson and
Ponsford (2006a) focused on coping style, psychosocial outcomes, and effec-
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Summary
Therefore, in our view, there exists across the literature on psychosocial
outcomes following brain injury converging themes, which are echoed in con-
temporary models of emotional disorders, such as PTSD. These are of an
understanding of psychological threat as central to poor adjustment following
a significant traumatic life changing event, with implications for neuro-
cognitive systems, affect and behaviour directly via heightened and chronic
arousal, and indirectly via the interplay between conscious and non-
consciously mediated ineffective coping responses. Clarification of the
interplay between those neurocognitive deficits acquired through injury,
those resulting from emotional distress, and those required for emotional
adjustment awaits further investigation. Furthermore, the social or interperso-
nal factors as described in the previous section, provide a context in which
“threats to self”, personal discrepancies, awareness and coping resources
may interact to influence psychosocial outcome.
they had adjusted well following TBI with such an aim in mind. The study
highlighted five narrative themes which study participants drew upon in
constructing positive or adaptive stories about themselves post-injury. In
three of these themes, participants constructed themselves in narratives of
being okay or worthwhile “despite” the injury by describing being better
off than others with disabilities, by talking about taking one day at a time
and focusing on the “here and now”, and by talking about recovery, within
which return to a hoped-for state more or less like the pre-injury self is
central. This latter theme links with the goal process and self-discrepancy
literature described previously in that setting goals which relate to at least
an aspect of pre-injury self provides a sense of reduction in self-discrepancy.
The theme of coping by focusing on the here-and-now was constructed by
some participants as opposed to focusing on the past and losses. Again, focus-
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Summary
Together, these two studies and the broader notions of psychological well-
ness and growth, serve as a reminder that our focus in rehabilitation may go
beyond compensation for deficits and optimum practical functioning in tasks
and society, and perhaps should more explicitly incorporate a focus on growth
and personal meaning. The findings from Nochi’s (2000) study and the
literature on well-being (Ryff & Keyes, 1995) both point to the importance
of interpretation of (or stories about) life experiences as key to positive
adaptation. The specific strategies embedded within narratives of positive
adaptation identified by Nochi (2000) also appear to achieve a reduction
in experienced self-discrepancy, consistent with the predictions of the
Y-shaped model.
TABLE 1
Summary of stages proposed within the Y-shaped model, key processes in social, emotional and cognitive domains, and examples
of rehabilitation activity
Social or
Y-shaped model interpersonal
stage variables Emotional variables Cognitive variables Rehabilitation activity
Developing safety Quality of close Autonomic arousal Self-awareness Create a safe and compassionate therapeutic context for
and self- relationships Levels of stress, anxiety, Self-monitoring, self- client and family
reflection Working alliance or aggression reflection and error Develop a shared understanding of the nature of social,
quality of Motivation or readiness to detection skills interpersonal and personal discrepancies in the context
therapeutic change of acquired losses and changes in functioning
relationship (with (involving client and relevant significant others)
client and with Identify the personally salient goals the client wishes to
881
(Table continued)
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882
GRACEY, EVANS, AND MALLEY
TABLE 1 Continued
Social or
Y-shaped model interpersonal
stage variables Emotional variables Cognitive variables Rehabilitation activity
Degree of belief in “core 2. Autobiographical making and adjustment to help maintain awareness of
beliefs” and unhelpful retrieval these new meanings, and support the application of
assumptions 3. Problem solving or required strategies towards personally salient goals
divergent thinking Identify and support social and interpersonal resources to
ability help maintain awareness of these new meanings, and
support the application of required strategies towards
personally salient goals
Personal growth Well-being scales Measures of positive
and social Quality of Life affect
participation measures
Social group
memberships
Post-traumatic growth
Specific predictions about change processes also arise from our Y-shaped
model and the synthesis of the literature presented here. The key relationships
are between presence of a trigger for highlighting post-injury changes
(internal, external, personal or social), threat-based response by the person
(with brain injury or others affected) due to the implications of the
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packages can then be tested through randomised controlled trials. Despite its
early stage of development, we believe that the broad framework provided by
the Y-shaped model is a helpful contribution to the integration of current
theory and research towards theoretical modelling of rehabilitation.
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