Gracey Evans Malley 2009 YShaped Model Rehab Outcomes

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/26689895
Capturing process and outcome in complex rehabilitation interventions: A

“Y-shaped” model
Article in Neuropsychological Rehabilitation · August 2009

DOI: 10.1080/09602010903027763 · Source: PubMed
CITATIONS READS
135 7,953
3 authors:
Fergus Gracey Jonathan Evans

University of East Anglia University of Glasgow
82 PUBLICATIONS 1,426 CITATIONS 240 PUBLICATIONS 13,653 CITATIONS
SEE PROFILE SEE PROFILE
Donna Malley
Cambridgeshire Community Services NHS Trust
12 PUBLICATIONS 199 CITATIONS
SEE PROFILE
All content following this page was uploaded by Fergus Gracey on 05 March 2015.
The user has requested enhancement of the downloaded file.

This article was downloaded by: [Gracey, Fergus]
On: 29 October 2009
Access details: Access Details: [subscription number 916367704]
Publisher Psychology Press
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK
Neuropsychological Rehabilitation
Publication details, including instructions for authors and subscription information:
http://www.informaworld.com/smpp/title~content=t713684225
Capturing process and outcome in complex rehabilitation interventions: A “Y-

shaped” model
Fergus Gracey ab; Jonathan J. Evans c; Donna Malley a
a
Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely, Cambridgeshire, UK b Medical Research
Council Cognition and Brain Sciences Unit, Cambridge, UK c University of Glasgow, Section of Psychological
Medicine, Glasgow, UK
First Published on: 16 July 2009
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
PLEASE SCROLL DOWN FOR ARTICLE
Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
NEUROPSYCHOLOGICAL REHABILITATION
2009, 19 (6), 867– 890
Capturing process and outcome in complex

rehabilitation interventions: A “Y-shaped” model
Fergus Gracey1,2, Jonathan J. Evans3, and Donna Malley1

1
Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely,
Cambridgeshire, UK; 2Medical Research Council Cognition and Brain Sciences
Unit, Cambridge, UK; 3University of Glasgow, Section of Psychological
Medicine, Glasgow, UK
Downloaded By: [Gracey, Fergus] At: 15:18 29 October 2009
A complex and dynamic set of biological, psychological and social factors

interact to determine the consequences of acquired brain injury (ABI). This
has led to recognition of the need for an integrated biopsychosocial approach
to assessment, formulation and rehabilitation after ABI, drawing on multiple
methods and models. This presents a significant challenge for the development
and evaluation of complex rehabilitation programmes that may involve mul-
tiple interventions. In psychotherapy research, such problems are addressed
through an approach which emphasises theoretical modelling of the disorder
from which treatment programmes are developed and then evaluated. The
resulting outcome studies, in which theoretically grounded change processes
are measured, thus provide not only a test of the efficacy of the intervention
but also an empirical evaluation of the underpinning model. In this paper we
advocate such an approach to ABI rehabilitation, and to this end propose a
model of the change process in rehabilitation called the “Y-shaped” model.
This integrates findings from research into psychosocial adjustment, awareness
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
and well-being following brain injury. The notion of discrepant or threatened

identity is central to the model. Specific interventions are identified from the
model, along with processes and interactions that may be central to change
in rehabilitation. In conclusion, we propose that development of integrated
models of change in rehabilitation is required. We also note that outcome
should focus not only on level of activity or social participation, but also on
the personal meaning of this to the person with brain injury.
Keywords: Brain injuries; Rehabilitation; Outcome; Process; Psychosocial.
INTRODUCTION
In this paper we describe a model that we believe is useful in both under-
standing and guiding the process of neuropsychological rehabilitation. The

model also suggests an approach to measurement of outcome and we will
therefore discuss implications for outcome assessment derived from the
model. Before describing the model in detail we will outline the rationale
for its development.
In recent years there has been a clear emphasis on what has been referred to
as the biopsychosocial approach to rehabilitation after brain injury. This is
perhaps most clearly reflected in the World Health Organisation (WHO)
International Classification of Functioning (ICF) framework, which draws
the distinction between body structures, body functions (deficits/impair-
ments), activities and participation (see Wade, 2005). The biopsychosocial
approach emphasises the importance of understanding the consequences of
a health condition in terms of interactions between biological factors (e.g.,
the pathology that causes specific deficits), psychological factors (e.g., cogni-
tion and emotion), and social factors (implications for a person’s ability to
participate in usual activities of daily life, including things, such as work,
leisure, and developing and maintaining social relationships). Adopting a
biopsychosocial approach highlights the importance of defining the goals
for rehabilitation in terms of biological, psychological and social outcomes.
The problem of understanding and evaluating complex

healthcare interventions
Because so many factors interact and contribute to limiting a person’s ability
to participate in valued activities, rehabilitation interventions are necessarily
complex. The UK Medical Research Council (2006) defines complex inter-
ventions as those that may involve: a number of interacting components; a
number of behaviours on the part of those delivering or receiving the inter-
vention; a number of groups or organisational levels that are targeted by
CAPTURING PROCESS AND OUTCOME 869
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
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
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.
MODELLING CHANGE PROCESSES – THE “Y-SHAPED” MODEL

An approach based on a theoretically grounded distinction between specific
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
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,
(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-
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).
LITERATURE REVIEW AND SYNTHESIS

The model can be divided into three sections dealing with (1) social and
interpersonal discrepancies, (2) threat to self and self-discrepancies, and
(3) psychological growth and lifespan development. Below we present a
summary and synthesis of the relevant literature in relation to these three
domains, which is described with reference to the Y-shaped model.
Social and interpersonal discrepancies

Studies derived from social identity theory emphasise the impact of brain
injury or stroke on social networks, and through this on sense of identity
and well-being (e.g., Haslam et al., 2008). At the start of rehabilitation
(which in our service may be a year or more post-injury), individuals with
ABI have likely had many occasions in which they have experienced discre-
pancy either internally, in their reflections, for example, about lost abilities, or
with others where lack of understanding, arguments and contesting of
accounts of changed abilities, or social stigmatisation may be played out.
Gracey et al. (2008b) conducted a qualitative analysis of the personal

constructs of individuals with ABI pertaining to pre-injury, current and
ideal selves. The themes derived from the analysis highlighted how people
make sense of themselves predominantly in terms of their experience of
themselves in social and activity contexts, for example whether or not they
are “feeling part of things”. The suggestion is that personal emotional adjust-
ment must be considered necessarily connected to context. Nochi’s (1998)
qualitative study found that not only was loss of self experienced through
pre to post-injury self-comparison, but also socially, “in the eyes of
others”. Williams et al. (2008) conducted a survey study of social and per-
sonal identity following brain injury. They found perceived stigma and
broken relationships each mediated the relationship between life satisfaction
and both identity change and fear of discrimination. They conclude that those
who acquire a “stigmatised identity” struggle to maintain social identities and

relationships, thereby having reduced life satisfaction.
Social group membership may not only provide the context in which we
experience, develop, rehearse and consolidate our personal and social identi-
ties, but also may be the source of guidance and advice that can be helpful in
dealing with significant life events (Haslam et al., 2008). Withdrawal from,
disruption to or avoidance of social relationships might impact identity and
well-being through loss of support as well as loss of self-defining contexts.
Discrepancies can often arise between the person with ABI’s account of
their abilities, and the accounts of significant others (carers, family, pro-
fessionals, etc.). Yeates, Evans, Gracey, and Henwood (2007) explored
how people with brain injury judged by rehabilitation staff as having poor
awareness, negotiated their position in interactions with a significant other.
The results suggest that, within close relationships, the identification of
post-injury problems by a significant other may be responded to by the
person with ABI by reframing these problems as enduring traits. This may
serve to maintain continuity of (pre-injury) identity at the cost of both devel-
oping a helpful awareness of difficulties and maintaining satisfactory relation-
ships with significant others. The mental health of the relative may also be a
factor in determining interpersonal outcome; Weddell and Leggett (2006)
suggest this was one of the significant predictors of judgements of “personal-
ity change” in the person with brain injury. As individuals with brain injury
and those around them struggle, in face of significant changes and losses, to
formulate and maintain continuity in the sense of self or identity, they may
unwittingly engage in behaviours that serve to maintain significant social
and interpersonal discrepancies in the longer term. A supportive relationship
that encompasses the qualities of a good therapeutic relationship such as
warmth, acceptance, and a non-judgemental stance may be an important
factor in development of awareness (Schoenberger et al., 2006). While it
may seem like these therapeutic conditions risk reinforcing an inaccurate
sense of self, it is possible that reduction of perceived interpersonal threat, and

fostering positive affect, may enhance metacognitive or self-reflective
capacity.
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-
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.
Threat to self, self-discrepancies and coping style

Moving on from the social level of description to the personal, within the
Y-shaped model we suggest that improved awareness may be accompanied
by an associated increase in negative emotions as individuals engage cogni-
tively with what has happened to them. The literature on adjustment and
coping following brain injury highlights the profound nature of this realis-
ation, and the increased likelihood of poor coping and poor outcomes in
terms of psychological health following brain injury.
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
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 &
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
(even if not currently experienced). Metaphors (often an admired person) are

used to capture a complex identity succinctly, and then goals that would lead
the individual in the direction of the ideal self are identified. Considered
in terms of control-process theory, MIM might be seen as facilitating the
re-establishment of lower level goals that are consistent with the highest
level of representation of ideal self. Doing so may be necessary to begin
the process of reducing the discrepancy between current self and ideal self.
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-
tiveness of a coping skills intervention. Consistent with previous studies,

coping styles associated with negative psychosocial outcomes were avoid-
ance, worry, wishful thinking, self-blame as well as drug and alcohol use.
However, the delivery of a group intervention to improve psychosocial func-
tioning through improvement of coping skills, while effective in changing
the target process (coping style), did not lead to change in the main
outcome, psychosocial functioning (Anson & Ponsford, 2006b). This could
be due to a number of factors such as timescale of change, sensitivity of
measures, or weaknesses in the predictive model regarding relationships
between coping skills and outcomes. It may be that having adaptive coping
skills is necessary but not sufficient for gains to be made in broader psycho-
social functioning. A further analysis of the data (Anson & Ponsford, 2006c)
revealed that participants with higher levels of awareness of deficits had the
best outcomes in terms of reduction in levels of depression, while those with
poor awareness did not benefit from the intervention. Ownsworth et al. (2007)
highlight possible relationships between awareness, adjustment and coping.
Specifically they suggest typologies of awareness whereby neurocognitive
(error detection) and psychological (adjustment) difficulties may be associ-
ated with reduced awareness, while exaggeration of deficits can also occur
because of emotional adjustment issues.
Psychological “threat to self”

What is missing from the coping literature in brain injury at present are
specific hypotheses about what exactly it is that is being coped with or
avoided when individuals engage in frank avoidance and denial, more
subtle processes such as wishful thinking, or attempts to “self-medicate”
through drug and alcohol use. Within the “Y-shaped” model, we draw
upon Goldstein’s (1959) description of difficulties following brain injury
being related to a combination of organic impairment, the “catastrophic
reaction”, and loss of skills due to avoidance of the catastrophic reaction.

Ben-Yishay (2000) proposes the catastrophic reaction is a “behavioural mani-
festation of a threat to the person’s very existence . . . due to the failure to
cope” (p. 128). The link proposed within the Y-shaped model between the
coping style literature and the self-discrepancy literature is that a profound
sense of threat to self underpins post-injury adjustment, so threatening in
fact that significant conscious and non-conscious processing efforts are
likely to be drawn upon in reaction to this threat.
The cognitive model of post-traumatic stress disorder (PTSD; Ehlers &
Clark, 2000) also has as a central feature, the notion of psychological
“threat to self” and related attempts to reduce such threats as central to under-
standing development and maintenance of PTSD symptoms. A range of symp-
toms of hyperarousal can arise as a result of chronic activation of the threat
system, including problems common following brain injury such as irritabil-

ity, agitation and poor sleep. Coping styles or behaviours identified in the
brain injury literature (such as, avoidance, denial of difficulties, wishful think-
ing, self-blame and drug or alcohol use) are also associated with negative out-
comes in PTSD. The cognitive model of PTSD also proposes that cognitive
responses to “threat to self” (such as, worry and rumination) and attempts at
internal control of thoughts and feelings (such as suppression) are involved
in the maintenance of PTSD symptoms. More specifically, perseverative pro-
cessing patterns involving cycles of suppression and intrusion, and negative
self-focused attention occur in an attempt at resolution of discrepant person-
ally salient representations. Paradoxically, the cyclical nature of these efforts
results in maintenance or deterioration of emotional disorder (e.g., Teasdale &
Barnard, 1993; Wells & Matthews, 1994).
These responses can all be seen as understandable (albeit classically
neurotic) ways of coping with or reacting to psychological threat. In this way
the general coping style literature is theoretically connected with the literature
on loss of self and self-discrepancy following brain injury. In fact, the inte-
gration of the general coping literature with the more specific literature on
coping after brain injury is of clinical use. In combination, these general and
specific theories highlight, for instance, that attempting to reduce avoidant
coping, or to improve awareness, may result in a profound and possibly cata-
strophic (to sense of identity) threat to some clients (as suggested by Brown,
Lyons, & Rose, 2006, and in a study of awareness in early stages of Alzheimer’s
disease, Naylor & Clare, 2008). Therefore, an attempt to address denial of
problems or more subtle barriers to change by confronting clients with clear evi-
dence of their impairments or the need to change may well result in an increase
in threat-related reactions, such as aggression, denial and avoidance (Langer &
Padrone, 1992; Prigatano, 1999; Toglia & Kirk, 2000).
A specific issue in rehabilitation following brain injury not present in
therapy for PTSD is the presence of significant cognitive impairments and
associated with this, problems in the development of awareness, which

present a significant barrier to engagement in therapy (Judd & Wilson,
2005). The literature on neurocognitive processes (especially memory and
executive functioning, e.g., Ownsworth et al., 2007; and Kopelman, 2002)
in relation to awareness following brain injury and in relation to the neuro-
biology of PTSD (Brewin, Dalgleish, & Joseph, 1996) is relevant to this
discussion. The latter “dual representation theory” model proposes inhibition
of hippocampal and frontal circuits in the context of a chronically activated
threat response (mediated by the amygdalae) which prevents integration of
trauma memories with broader autobiographical memory. Acquired injuries
affecting these systems may cause further disruption to the processes
thought to be necessary for adjustment to trauma.
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.
Psychological growth and adjustment

In contrast to the number of studies concerned with problems and negative
outcomes following brain injury, a relatively small number of studies have
been concerned with positive psychological changes such as personal
growth. This work is informative as it provides a sense of what we might
be aiming for in rehabilitation, where attempts are made at developing and
consolidating a new, adaptive sense of self, along with hope for the future.
A focus on consolidation of new identities is relevant for many people with
ABI. However, where initially the person is resistant to change and in a
state of “threat to self”, we would reserve this type of work until the
person has at least begun to “update” his or her post-injury sense of self,
and is open to considering and exploring alternative perspectives. Nochi
(2000) carried out a qualitative study of the narratives of people who felt
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-
ing on the here-and-now may provide an adaptive way of reducing pre to

post-injury discrepancy, or altering expectations about speed of recovery so
as to be less concerned about slow progress. Finally, the strategy of compar-
ing oneself with others who may be worse off may also be helpful in reducing
discrepancies both socially (in terms of degree of difference from non-
disabled others) or personally in terms of pre to post-injury comparison.
The other two themes, relating to being worthwhile because of the injury,
are interesting in that they provide insight into personal growth and develop-
ment. In terms of having “grown” because of the injury, two participants
described how their TBI’s were the catalyst to change unhealthy lifestyles,
giving up alcohol and drug use. One participant said how he felt good
about himself in terms of having survived something so extreme. The
theme of “protesting self” highlighted how some participants found
meaning by getting involved with groups supporting the rights or needs of
people with brain injury. Rather than making sense in terms of reduction of
a negatively oriented self-discrepancy (e.g., reduced sense of loss by using
strategies to manage memory problems), these themes highlight the important
fact that people with brain injury can aspire towards and find new meaning in
life post-injury. This can be conceptualised as a reduction of discrepancy
between current and desired state in relation to goals that represent ideal or
aspired-to values and meanings, or reducing social discrepancy by “feeling
part of things”. While appearing consistent with the Y-shaped model,
however, it is clear that further research is needed to explore these hypotheses
and the relationships between these specific aspects of coping and psychoso-
cial outcomes.
The notion of psychological wellness has been described in the positive
psychology literature in terms of a “trajectory of continued growth across
the life cycle” (Ryff & Keyes, 1995; p. 720). These authors note that research
into the processes leading to increased well-being suggest that life experi-
ences and interpretations of them are key processes. They go on to identify
six dimensions to psychological wellness: autonomy, environmental mastery,

personal growth, positive relations with others, purpose in life and self-
acceptance. Ryff and Keyes present these dimensions as representing the
range of themes covered by prior theoretical models of psychological well-
ness and growth across the lifespan, including, for example, those of
Erikson (1959) and Maslow (1968). Collicutt-McGrath and Linley (2006)
investigated post-traumatic growth following ABI. The study found greater
growth in those who were in the long-term post-injury “late” group (mean:
118 months post-injury) compared to a relatively more acute “early” group
(mean: 7 months post-injury), although the “late” group also had higher
ratings of anxiety. The authors conclude that the process of positive growth
may be quite slow following brain injury, and may also require a degree of
engagement with negative emotions.
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.
IMPLICATIONS FOR THE REHABILITATION PROCESS

We have previously described the approach to rehabilitation based on this
synthesis of the literature (see Wilson et al., in press) and the related
Y-shaped model. We will therefore not go into the detail of explaining
specific rehabilitation interventions that we apply to address the processes
identified in the model. Table 1 sets out the key phases of the process of reha-
bilitation in the far left column. These correspond to (1) the development of
safety, (2) understanding of, engagement with and reduction of social, inter-
personal and intrapersonal discrepancies, and (3) supporting psychological
growth. The key interventions that might be used in relation to the model
and related processes are summarised in the far right column in Table 1.
The central columns detail areas that we consider relevant to the process of
change in rehabilitation in social, emotional, and cognitive domains.
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
CAPTURING PROCESS AND OUTCOME

significant others) address in rehabilitation
Resolving social Social discrepancy Subjective social Social problem solving Gently explore the client and family’s differing and diverse
or interpersonal (loss of social discrepancy Social communication predictions or perspectives using exploratory, survey
discrepancies groups) (experience of isolation skills and activity-based behavioural experiments related to
Interpersonal or withdrawal from the person’s personally salient goals as appropriate
discrepancy social contexts, fear of Provide information about brain injury as alternative
(degree of discrimination) narrative about problems (e.g., as relating to cognitive
difference in self Behavioural markers of impairment or emotional adjustment rather than
versus informant interpersonal “personality change”)
rating on symptom discrepancy (e.g., Identification of points of agreement: Contexts and
measures such as occurrence of anxiety, conversations when discrepancies are reduced, common
EBIQ) aggression, irritability, goals are evident
Behavioural markers low mood in Draw on reflections from behavioural experiments to
of interpersonal interpersonal or social foster a curious, exploratory approach to rehabilitation
discrepancy in contexts) in which even failures can be viewed as helpful learning
relationships (e.g., experiences
881
(Table continued)
882
GRACEY, EVANS, AND MALLEY
TABLE 1 Continued
Social or
Y-shaped model interpersonal
stage variables Emotional variables Cognitive variables Rehabilitation activity
frequency of Present information about, and provide opportunities for

disagreements, practice of strategies for management and
“contesting compensation for cognitive, emotional and social
accounts”; difficulties, and link these opportunities with personal
measures of goals and activities and meanings through the structure
“expressed of behavioural experiments
emotion”) Identify and develop skills and strategies required for
effective affect and behaviour management (e.g.,
arousal reduction, behavioural regulation, inhibition,
attention control, mindfulness meditation, external
alerting, etc.) as required.
Resolving Self-esteem or Cognitive processes that Using appropriately developed skills and strategies,
intrapersonal self-concept may be influenced by engage in collaboratively reframing the catastrophic
discrepancies Symptoms of depression selective attention to meanings associated with post-injury life, including, for
Self-discrepancy threat, suppression of some, reprocessing of traumatic meanings
Perseverative emotional emotions, attempts to Identify pre-injury values and meanings that may not be
processes such as control thoughts, threatened by the injury, or new adaptive post-injury
rumination or worry cognitive avoidance: meanings that the individual or family might begin to
Preoccupation with “How 1. Executive aspects of draw upon in finding adaptive meaning post-injury
I used to be” vs “How I attention (switching, Carry out behavioural experiments designed to develop
am now” focusing) and working and consolidate these new meanings
Coping style and coping memory (switching, Develop a “constructive formulation” using diagrams,
skills filtering, inhibiting) metaphors and other forms of scaffolding for sense
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
CAPTURING PROCESS AND OUTCOME

883
IMPLICATIONS FOR PROCESS AND OUTCOME MEASUREMENT

IN REHABILITATION
The Y-shaped model was initially developed to support organisation of inter-
disciplinary, intensive, holistic rehabilitation, and then to identify and track
factors thought to be significant to rehabilitation outcome (in terms of indi-
cators of social participation, such as goal attainment). We have suggested
that perceived and experienced changes in personal and social identity and
relationships (e.g., in terms of threats and losses) and attempts to maintain
continuity of identity (e.g., through “motivated unawareness”, contesting of
accounts with families, professionals or others, avoidance, and other ineffec-
tive coping styles) may not only impact emotional outcome. These factors
may also play a significant part in broader social adaptation including
indicators of social participation and psychological health or well-being.
The Y-shaped model identifies specific factors relevant to rehabilitation

that may be worth measuring in clinical practice as well as future research,
including:
. Relationship satisfaction and interpersonal relationships outside and

within therapy or rehabilitation (including quality of therapeutic
working alliance; differences in perspective about problems or changes).
. Awareness of strengths and weaknesses (including both denial of
disability as well as over-sensitivity to difficulties).
. Pre-injury history of traumatic or stressful events and coping styles.
. Metacognitive and self-regulatory skills (e.g., self-reflection, error-
detection, inhibition).
. Degree of subjective self-discrepancy (between, for example, current
self and hoped-for self; current self and pre-injury self; status of
current self with regard to salient hoped-for goals) and self-esteem.
. Strength of the individual’s overly negative or overly positive beliefs
about him or herself, others, the world and the future.
. Indicators of activation of the autonomic system in response to
perceived threat (hyperarousal symptoms; subjective ratings and phys-
iological markers of stress).
. Knowledge of, confidence with and application of coping styles, skills,
and compensatory strategies.
. Cognitive-emotional processes (especially those seen as relevant in
contemporary models of emotional disorder where accounts of failed
resolution of self-discrepancies are central) such as rumination, worry,

over-general autobiographical memory, suppression and intrusion.
. Indicators of psychological well-being such as personal growth, auton-
omy, positive affect, environmental mastery.
. Indicators of behavioural change and social participation, such as goal
attainment, social group membership, vocational status.
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
meaning of this change to personally salient meanings or goals, and the

coping responses in reaction to the threat response of both people with
brain injury and those around them. The nature and likelihood of threat
response and further reactions will in part depend on the background and
coping styles of those involved and the nature of their cognitive strengths
and weaknesses. It is predicted that during the process of resolution of discre-
pancies through engagement with hitherto avoided activities, tasks and infor-
mation, there may be increases in distress before these ameliorate alongside
an increase in indicators of psychological well-being. We would also predict a
resolution of self-discrepancy through the course of rehabilitation, and an
associated improvement in self-esteem, and reduction in cognitive-emotional
processes associated with failed processing of discrepancies, such as rumina-
tion. Factors such as the quality of the therapeutic relationship, nature of
cognitive impairments, and presence of supports and strategies to aid
compensation for impairments would also be predicted to have an influence
on outcome. Given the specific cognitive-behavioural or family therapy
approaches that could be applied to address these processes, additional
processes predicted to affect outcome include the skills of the therapist,
clients’ experience of therapy, and the extent to which behavioural exper-
iments or prescribed family rituals are set collaboratively and address predic-
tions, actions, observations and reflections according to intervention
guidelines.
SUMMARY AND CONCLUDING COMMENTS

Multiple models are required to guide effective delivery of rehabilitation
(Wilson, 2002). Here we have argued that the themes within current
outcome literature and other fields, such as CBT process and outcome
research, converge sufficiently to warrant attempts at theoretical integration
regarding change processes in rehabilitation. We believe that this type of

endeavour will help to inform intervention and further research in cycles of
increasing explanatory and predictive power, following the approach taken
in CBT research. A “Y-shaped” model has been proposed that suggests the
experience and the fear of the “catastrophic reaction” underpins maladaptive
threat-based coping responses resulting in poor psychosocial outcomes.
This model links bodies of research relating to coping style, subjective self
and social discrepancies, self-regulation, and awareness. The synthesis of the
literature presented here and the resulting model highlights a range of
process factors that could be tracked in routine clinical practice as well as
quasi-experimental or correlational studies of rehabilitation outcome. In pro-
posing that meaning of life experiences is key to well-being, psychosocial
outcome measures that focus solely on amount or level of activity (e.g.,
scales of level of employment) might not reflect meaningful personal change

for the individual. The importance of setting personally meaningful goals in
rehabilitation, and capturing this meaning in rehabilitation outcomes studies
(e.g., through measures of dimensions of well-being), is also highlighted.
The model is not without its weaknesses. Possible neurocognitive factors
pertinent to the change process have been mentioned; however, we recognise
that significant further work is required to improve the power of the model in
this respect. A further limitation is the question of to whom this model
applies. The literature has been drawn upon to understand those with
complex needs presenting to an intensive holistic rehabilitation service, and
to model the rehabilitation process developed to meet the needs of this
group. It is possible that those who do not require such an approach to reha-
bilitation, or those who appear to adjust well with minimal professional
support, also follow their own process of awareness and resolution of
social and self-discrepancies. If this is so, the literature presented here
suggests domains that are of relevance to this population as well. However,
it is also possible that the factors and processes described in the model are
not relevant to post-injury adjustment in general and only apply to a sub-
group of individuals who find it difficult to adjust to changes in cognitive,
emotional or physical abilities or to limitations in participation in previously
valued activities.
Research is required to test specific hypotheses regarding links between the
key issues identified in this model, namely social discrepancy (including
social group membership and quality of interpersonal relationships), self-
discrepancy, psychological threat, coping style, awareness, cognitive func-
tioning, well-being and social participation. By using measures to track
hypothesised change processes while simultaneously measuring broader
outcome, such as, goal attainment or social participation, it may be possible
to develop models with a goal of devising more highly specified, and therefore
potentially more cost-effective, intervention packages. Such well-defined
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.
REFERENCES
Anson, K., & Ponsford, J. (2006a). Coping and emotional adjustment following brain injury.
Journal of Head Trauma Rehabilitation, 21(3), 248 –259.
Anson, K., & Ponsford, J. (2006b). Evaluation of a coping skills group following traumatic
brain injury. Brain Injury, 20(2), 167 –178.
Anson, K., & Ponsford, J. (2006c). Who benefits? Outcome following a coping skills group
intervention for traumatically brain injured individuals. Brain Injury, 20(1), 1 –13.
Arena, K., & Adams, M. (unpublished). Self-discrepancy, emotional distress and functioning in
traumatic brain injury. Thesis submitted in part fulfilment of the degree doctorate in clinical
psychology, University of East Anglia, June 2008.
Ben Yishay, Y. (2000). Postacute neuropsychological rehabilitation: A holistic perspective.
In A. L. Christensen, & B. Uzzell (Eds.), International handbook of neuropsychological
rehabilitation (pp. 127 – 136). New York: Kluwer Academic/Plenium Publishers.
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of PTSD.
Psychological Review, 103, 670 – 686.
Brown, D., Lyons, E., & Rose, D. (2006). Recovery from brain injury: Finding the missing bits
of the puzzle, Brain Injury, 20(9), 937 –946.
Cantor, J. B., Ashman, T. A., Schwartz, M. E., Gordon, W. A., Hibbard, M. R., Brown, M.,
Speilman L., Charatz, H. J., & Cheng, Z. (2005). The role of self-discrepancy theory in
understanding post-traumatic brain injury affective disorders: A pilot study. Journal of
Head Trauma Rehabilitation, 20, 527 – 543.
Carver, C. S., & Scheier, M. F. (1990). Origins and functions of positive and negative affect: A
control process view. Psychological Review, 97(1), 19– 35.
Carver, C. S., & Scheier, M. F. (1998). On the self-regulation of behavior. New York:
Cambridge University Press.
Christensen, A.-L. (2000). Neuropsychological postacute rehabilitation. In A.-L. Christensen &
B.P. Uzzell (Eds.), Critical issues in neuropsychology: International handbook of neurop-
sychological rehabilitation (pp. 151 – 163). Amsterdam: Kluwer Academic Publishers.
Clark, D. M. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour
Research and Therapy, 37, S5– S27.
Collicutt McGrath, J., & Linley, P. A. (2006). Post-traumatic growth and acquired brain injury:
A preliminary small scale study. Brain Injury, 20, 767–773.
Conway, M. A. (2005). Memory and the self. Journal of Memory and Language, 53(4),
594 – 628.
Craig, P., Dieppe, P., Macintyre, S., Mitchie, S., Nazareth, I., & Petticrew, M. (2008). Developing
and evaluating complex interventions: The new Medical Research Council guidance. British
Medical Journal, 337, 979–983.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
Behaviour Research and Therapy, 38, 319 –345.
Ellis-Hill, C. S., & Horn, S. (2000). Change in identity and self-concept: A new theoretical
approach to recovery following a stroke. Clinical Rehabilitation, 14, 279– 287.
Erikson, E. (1959). Identity and the life cycle. New York: International Universities Press.
Goldstein, K. (1959). Notes on the development of my concepts. Journal of Individual Psychology,

15, 5–14.
Gracey, F., & Ownsworth, T. (2008). The self and identity in rehabilitation – editorial.
Neuropsychological Rehabilitation, 18(5), 522 – 526.
Gracey, F., Palmer, S., Malley, D., Keohane, C., Cooper, J., Prince, L., Brentnall, S., Ashworth,
F. et al. (2008a). Cases illustrating a “Y-shaped” model of identity and participation change
processes in holistic rehabilitation of brain injury. Abstracts of the Fifth Satellite
Symposium on Neuropsychological Rehabilitation, Iguaçu Falls, Brazil, 7 –8 July 2008.
Brain Impairment, 9(2), 205 –235.
Gracey, F., Palmer, S., Rous, B., Psaila, K., Shaw, K., O’Dell, J., Cope, J., & Mohamed, S.
(2008b). “Feeling part of things”: Personal construction of self after brain injury. Neuro-
psychological Rehabilitation, 18(5 – 6), 627 – 650.
Hart, T., & Evans, J. J. (2006). Self-regulation and goal theories in brain injury rehabilitation.
Journal of Head Trauma Rehabilitation, 21(2), 142 – 155.
Haslam, C., Holme, A., Haslam, S. A., Iyer, A., Jetten, J., & Williams, W. H. (2008). Maintain-
ing group memberships: social identity continuity predicts well-being after stroke. Neuro-
psychological Rehabilitation, 18(5 – 6), 671 – 691.

Higgins, E. T. (1987). Self-discrepancy: A theory relating self and affect. Psychological Review,
94, 319– 340.
Judd, D., & Wilson, S. L. (2005). Psychotherapy with brain injury survivors: An investigation of
the challenges encountered by clinicians and their modifications to therapeutic practice.
Brain Injury, 19(6), 437 – 449.
Kopelman, M. (2002). Disorders of memory, Brain, 125, 2152 – 2190.
Langer, K. G., & Padrone, F. J. (1992). Psychotherapeutic treatment of awareness in acute
rehabilitation of traumatic brain injury. Neuropsychological Rehabilitation, 2, 59– 70.
Malec, J. F. (2005). The Mayo Portland Adaptability Inventory. The Center for Outcome
Measurement in Brain Injury. Retrieved April 16, 2009, from http://www.tbims.org/
combi/mpai
Manchester, D., & Wood, R. L. (2001). Applying cognitive therapy in neurobehavioural
rehabilitation. In R. L. Wood, & T. M. McMillan (Eds.), Neurobehavioural disability and
social handicap following traumatic brain injury. Hove, UK: Psychology Press Ltd.
Maslow, A. H. (1968). Toward a psychology of being (2nd ed). New York: Van Nostrand
Reinhold.
McGrath, J., & King, N. (2004). Acquired brain injury. In J. Bennett-Levy, G. Butler,
M. Fennell, A. Hackman, M. Mueller, & D. Westbrook (Eds.), Oxford guide to behavioural
experiments in cognitive therapy. Oxford: Oxford University Press.
Medical Research Council (2006). Developing and evaluating complex interventions: New
guidance. Retrieved from www.mrc.ac.uk/complexinterventionsguidance.
Naylor, E., &Clare, L. (2008). Awareness of memory functioning, autobiographical memory
and identity in early-stage dementia. Neuropsychological Rehabilitation, 18(5 – 6),
590 – 606.
Nochi, M. (1997). Dealing with the “Void”: Traumatic brain injury as a story. Disability &
Society, 12(4), 533 –555.
Nochi, M. (1998). “Loss of self” in the narratives of people with traumatic brain injuries: A
qualitative analysis. Social Science and Medicine, 7, 869– 878.
Nochi, M. (2000). Reconstructing self-narratives in coping with traumatic brain injury. Social
Science and Medicine, 51, 1795– 1804.
Ownsworth, T., Fleming, J., Strong, J., Radel, M., Chan, W., & Clare, L. (2007). Awareness
typologies, long-term emotional adjustment and psychosocial outcomes following acquired
brain injury. Neuropsychological Rehabilitation, 17(2), 129 –150.
Palmer, S., Cooper, J., Cope, J., Prince, L., Malley, D., Deakins, J., & Gracey, F. (2009). It’s the
small things that matter: Integrating ‘doing’ and ‘meaning’ in rehabilitation. Manuscript
submitted for publication.
Prigatano, G. (1999). Principles of neuropsychological rehabilitation. New York: Oxford
University Press.
Ryff, C.D., & Keyes, C.L.M. (1995). The structure of psychological well-being revisited.
Journal of Personality and Social Psychology, 69, 719– 727.
Salkovskis, P. (2002). Empirically grounded clinical interventions: Cognitive-behavioural
therapy progresses through a multi-dimensional approach to clinical science. Behavioural
and Cognitive Psychotherapy, 30, 3 – 9.
Schoenberger, M., Hulme, F., Zeeman, P., & Teasdale, T. W. (2006). Working alliance and
patient compliance in brain injury rehabilitation, and their relation to psychosocial
outcome. Neuropsychological Rehabilitation, 16(3), 298– 314.
Secrest, J., & Zeller, R. (2006). Replication and extension of the Continuity and Discontinuity
of Self Scale (CDSS). Journal of Nursing Scholarship, 38(2), 154– 158.
Siegert, R. J., McPherson, K. M., & Taylor, W. J. (2004). Toward a cognitive-affective model of
goal-setting in rehabilitation: Is self-regulation theory a key step? Disability and Rehabilita-

tion, 26(20), 1175 – 1183.
Teasdale, J. D., & Barnard, P. J. (1993). Affect, cognition and change. Hove, UK: Lawrence
Erlbaum Associates.
Toglia, J., & Kirk, U. (2000). Understanding awareness deficits following brain injury. Neuro-
Rehabilitation, 15, 57– 70.
Turner-Stokes, L., Disler, P.B., Nair, A., & Wade, D. T. (2005). Multi-disciplinary rehabilita-
tion for acquired brain injury in adults of working age. Cochrane Database of Systematic
Reviews, Issue 3. Art. No.: CD004170. DOI: 10.1002/14651858.CD004170.pub2
Tyerman, A., & Humphrey, M. (1984). Changes in self-concept following severe head injury.
International Journal of Rehabilitation Research, 7(1), 11– 23.
van den Broek, M. D. (2005). Why does neurorehabilitation fail? Journal of Head Trauma
Rehabilatation, 20(5), 464 – 473.
Vygotsky, L. S. (1960/1978). Internalisation of higher psychological functions. In M. Cole,
V. John-Steiner, S. Scribner, & E. Souberman (Eds.), L. S. Vygotsky mind in society: The
development of higher psychological processes. Cambridge MA: Harvard University Press.
Wade, D. T. (2005). Applying the WHO ICF framework to the rehabilitation of patients with
cognitive deficits. In P. W. Halligan, & D. T. Wade (Eds.), Effectiveness of rehabilitation
for cognitive deficits. Oxford: Oxford University Press.
Weddell, R. A., & Leggett, J. A. (2006). Factors triggering relatives’ judgements of personality
change after traumatic brain injury. Brain Injury, 20, 1221 –1234.
Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Hove, UK:
Lawrence Erlbaum Associates.
Whyte, J., & Hart, T. (2003). It’s more than a black box; it’s a Russian doll: Defining
rehabilitation treatments. American Journal of Physical Medicine and Rehabilitation,
82(8), 639 – 652.
Williams, W. H., Jones, J. M., Haslam, C., Haslam, S. A., Jetten, J., & Morris, R. (2008). Social
experience and well-being after brain injury: Is there a fear of not fitting in? Abstracts of the
Fifth Satellite Symposium on Neuropsychological Rehabilitation, Iguaçu Falls, Brazil, 7 –8
July 2008. Brain Impairment, 9(2),
Wilson, B. A. (2002). Towards a comprehensive model of cognitive rehabilitation. Neuro-
psychological Rehabilitation, 12, 97 –110.
Wilson, B. A., Gracey, F., Malley, D., Bateman, A., Evans, J. J. (in press). The Oliver Zangwill
Centre approach to neuropsychological rehabilitation. In B. A. Wilson, F. Gracey, J. J. Evans,
& A. Bateman, (Eds.), Neuropsychological rehabilitation: Theory, models, therapy and

outcome. Cambridge: Cambridge University Press.
Yeates, G., Henwood, K., Gracey, F., & Evans, J. J. (2007). Awareness of disability after
acquired brain injury and the family context. Neuropsychological Rehabilitation, 17(2),
151–173.
Ylvisaker, M., & Feeney, T. (2000). Reconstruction of identity following brain injury. Brain
impairment, 1(1), 12 –28.
Ylvisaker, M., McPherson, K., Kayes, M., & Pellett, E. (2008). Metaphoric identity mapping:
Facilitating goal management and engagement in rehabilitation after traumatic brain injury.
Neuropsychological Rehabilitation, 18(5/6), 713 – 741.
View publication stats

Gracey Evans Malley 2009 YShaped Model Rehab Outcomes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Gracey Evans Malley 2009 YShaped Model Rehab Outcomes

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Capturing process and outcome in complex rehabilitation interventions: A

Article in Neuropsychological Rehabilitation · August 2009

Fergus Gracey Jonathan Evans

SEE PROFILE SEE PROFILE

The user has requested enhancement of the downloaded file.

Capturing process and outcome in complex rehabilitation interventions: A “Y-

First Published on: 16 July 2009

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf

Capturing process and outcome in complex

Fergus Gracey1,2, Jonathan J. Evans3, and Donna Malley1

A complex and dynamic set of biological, psychological and social factors

and well-being following brain injury. The notion of discrepant or threatened

Keywords: Brain injuries; Rehabilitation; Outcome; Process; Psychosocial.

standing and guiding the process of neuropsychological rehabilitation. The

The problem of understanding and evaluating complex

MODELLING CHANGE PROCESSES – THE “Y-SHAPED” MODEL

LITERATURE REVIEW AND SYNTHESIS

Social and interpersonal discrepancies

Gracey et al. (2008b) conducted a qualitative analysis of the personal

who acquire a “stigmatised identity” struggle to maintain social identities and

sense of self, it is possible that reduction of perceived interpersonal threat, and

Threat to self, self-discrepancies and coping style

(even if not currently experienced). Metaphors (often an admired person) are

tiveness of a coping skills intervention. Consistent with previous studies,

Psychological “threat to self”

reaction”, and loss of skills due to avoidance of the catastrophic reaction.

system, including problems common following brain injury such as irritabil-

associated with this, problems in the development of awareness, which

Psychological growth and adjustment

ing on the here-and-now may provide an adaptive way of reducing pre to

six dimensions to psychological wellness: autonomy, environmental mastery,

IMPLICATIONS FOR THE REHABILITATION PROCESS

CAPTURING PROCESS AND OUTCOME

frequency of Present information about, and provide opportunities for

CAPTURING PROCESS AND OUTCOME

IMPLICATIONS FOR PROCESS AND OUTCOME MEASUREMENT

The Y-shaped model identifies specific factors relevant to rehabilitation

. Relationship satisfaction and interpersonal relationships outside and

resolution of self-discrepancies are central) such as rumination, worry,

meaning of this change to personally salient meanings or goals, and the

SUMMARY AND CONCLUDING COMMENTS

regarding change processes in rehabilitation. We believe that this type of

scales of level of employment) might not reflect meaningful personal change

Goldstein, K. (1959). Notes on the development of my concepts. Journal of Individual Psychology,

psychological Rehabilitation, 18(5 – 6), 671 – 691.

goal-setting in rehabilitation: Is self-regulation theory a key step? Disability and Rehabilita-

& A. Bateman, (Eds.), Neuropsychological rehabilitation: Theory, models, therapy and

View publication stats

You might also like