Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

Positive Psychology aims to improve an individual’s wellbeing and mood by utilising their personal strengths and characteristics (Seligman & Csikszentmihalyi, 2014). As a relatively new psychotherapeutic approach, Positive Psychology’s use in clinical settings, in particular complex care and rehabilitation, is not yet commonplace. However, constructs from the field of Positive Psychology have been explored in a range of illness populations and are increasingly gaining attention as factors that may influence recovery from acquired brain injury (ABI) (Rabinowitz and Arnett (2018).

The team at Adderley Green Care Centre (AGCC) in Staffordshire are currently exploring the suitability and impact of Positive Psychology interventions as part of neuro-rehabilitation programmes for ABI survivors. Through both group work and one-to-one sessions, the psychology team are supporting ABI survivors to identify and engage character strengths and are then exploring the impact this has on their wellbeing and progress in rehabilitation.

 

Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

 

In this article we talk with Dr Darren Perry, Consultant Clinical Psychologist and Psychology Lead at AGCC. Darren has worked for 20 years in NHS Neuropsychology, Physical Health and Older Adult Mental Health Services, and has a particular interest in psychological adjustment to changes in neurological and physical health. Darren led the development of a Positive Psychology group trial at AGCC. He is continuing to explore how Positive Psychology can be used in neurorehabilitation and the impact that improved wellbeing has on individual outcomes.

 

Hi Darren, thanks for talking with us today. Perhaps you could start by explaining a bit about the difference between Positive Psychology and traditional Clinical Psychology?

Darren:

“Of course. Clinical Psychology operates on a large and well-established evidence-base which focuses on reducing negative emotional or behavioural states. So, for example, psychological interventions that are effective in helping people to feel less anxious or to overcome depression.

Positive Psychology developed more recently, in the 1990’s in America, and the research that underpins it looks at what makes people feel good, what makes them happy, and what gives them a sense of wellbeing. This understanding of wellbeing and its contributing factors forms the foundation of work to experience more frequent or sustained states of wellbeing. So, whilst the two schools of psychology have different starting positions, they are both pathways to improved functioning.  At the risk of oversimplification, one focuses on reducing suffering and the other focuses on increasing wellbeing.”

Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

 

Martin Seligman and colleagues have researched wellbeing and identified five key components.  They use the acronym PERMA.

  1. P – Positive emotion. Essentially, anything that makes you feel good, gives you pleasure, or hope or optimism and contributes to your overall sense of wellbeing.
  2. E – Engagement. That feeling when you’re really engrossed, when you’re immersed in something. Whether it’s a book, a film, a conversion or a sporting activity and you lose that sense of yourself in time and you become fully engaged. Often referred to as being in a ‘flow state’. That’s an important component of wellbeing.
  3. R – (positive) Relationships. The more quality relationships you have, or the more integrated your social network is, then the more wellbeing you’re likely to feel.
  4. M – Meaning. Having a sense of meaning, either in general or in the activities and day-to-day things that you do that allow you to tap into your sense of purpose. For some, this may have spiritual or religious meaning.
  5. A – Achievement. Doing things that give you a sense of getting somewhere, accomplishing something and making progress is also supportive of wellbeing

So are the PERMA (five key components) researched and proven to underpin wellbeing?

Darren:

“Yes, they are. Alongside this, Positive Psychology has also focused on character strengths and their role in wellbeing. Based on an extensive review of literature on philosophy, ethics, education, psychology and theology spanning over 2500 years, Seligman and his team identified 24 character strengths. These include qualities such as gratitude, kindness, bravery, appreciation of beauty, perseverance and determination. Research has subsequently established that we all have a unique and dynamic blend of character strengths and engaging these effectively in our daily life is linked to experiences of the five domains of wellbeing.”

Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

 

And so how does this help an individual within a neuro-rehab programme?

Darren:

“Wellbeing and quality of life should be a central focus of all good neuro-rehab programmes. Professor Jonathon Evans at the University of Glasgow was one of the early proponents of the potential application of Positive Psychology in Neuro-rehabilitation. He stated back in 2012 that there are areas in which brain injury rehabilitation could draw more on the methods of Positive Psychology. Unfortunately, there has not yet been a lot of work published in this domain.

Individuals we work with at AGCC are often so focused on regaining abilities that they have lost as a result of their injury or illness that their awareness of preserved character strengths becomes diminished. We initially help the resident to identify their core or ‘signature’ character strengths. Once their awareness of these intact strengths improves, we help them to spot when they are engaging them during everyday activities. We introduce the notion that strengths can be under-used and can even become a weakness if they are over-relied upon in some contexts.  We also focus on developing interventions that encourage them to use their strengths in new ways, during their wider rehabilitation.

The simple notion here is that when you’re focusing on something that is effective about yourself, something that is a character strength, this helps you to feel engagement and achievement, boosts your relationships, makes activities feel more meaningful and gives rise to  positive emotions and a sense of wellbeing.”

Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

 

You led the development of a ‘Psychological Wellbeing Group’ and piloted it with the aim of supporting a group of ABI survivors through the rehabilitation process. What were the main learnings from the pilot group?

Darren:

“The pilot group was a useful exercise. The content of the group sessions was adapted from a ‘Positive Psychology Workbook’ written by Rashid and Seligman (2019). We found some things that worked really well in the group but it also strengthened, in our mind, the need to develop innovative interventions that are more suited to a neuro-rehab setting; for people with impaired levels of functioning. Our residents engaged well with the themed sessions and benefitted from the social interaction and shared-experiences. But, we came away with a feeling that it may be more effective to combine group sessions where themes are introduced and discussed with follow-up one-to-one sessions with each resident. The individual work would focus on helping them to increase their awareness of their own character strengths and how to apply them specifically in the context of their rehabilitation.

So we’re now actively looking for ways to modify established interventions or design new ones to help people with cognitive, communication, sensory or motor impairments. There are certain character strengths that lend themselves more readily to character intervention without needing a great deal of adaptation. One of the most powerful ones we have used is for people who identify gratitude as a character strength, and there’s a few ways this can be done.

The first method is the ‘Three Good Things’ journal.  Every day the individual keeps their eyes and mind open to three good things that have happened, no matter how small or insignificant they may seem. It might be a friendly smile from someone, or a carer bringing them a cup of tea at just the right time or a family member called for a chat. They literally just record those three things every day in a journal or notebook. This process operates on two levels; it helps them to have their ‘antenna’ more attuned to noticing small things that they can be more grateful for every day – that may otherwise have passed them by. In addition, the process of writing it down it, reflecting on it and perhaps discussing it with a member of the care team, actively engages and reinforces that sense of gratitude and generates good feelings.”

Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

 

Journaling is a very popular method in mainstream/popular psychology, so it’s really interesting that you’re seeing benefits within a neuro-rehab setting too. Are there any other methods that you’re using?

Darren:

“Another approach we’ve used successfully with some of our residents in relation to gratitude is a ‘Gratitude Letter’. The individual can write a letter to somebody important to them and tell them what they are grateful for. Often the individual will need to receive support to write the letter but they do get something out of the writing process. Plus the person who receives the letter really enjoys it and, in turn, gives them positive feedback about it. This engages gratitude and invokes feelings of achievement which bolsters the sense of the positive relationship with the recipient.

And then the third way we’ve used gratitude is to turn the focus on the character strength internally, which, although really impactful, is something that people struggle with a little bit. This method involves thinking about oneself and what you feel grateful for. This process mostly takes the form of a conversation that we can have with the individual, as we go about daily tasks. It’s another way of integrating gratitude throughout daily life.”

 

That’s fascinating – are you looking at ways of working with other character strengths too?

Darren:

“Yes, we’ve used these techniques with people that have identified with gratitude quite a lot, but we’re still in the process of trying to explore the other character strengths and find effective ways of employing them. Bravery and persistence are other strengths that seem to lend themselves readily to intervention in this context. A resident may acknowledge something that they’re feeling anxious about or tend to avoid or put off and then we encourage them to take a little step towards it on a daily basis. So they’re engaging with bravery or persistence and at the same time hopefully making some behavioural changes, and by doing something that they wouldn’t have been doing previously it can bring about some positive changes for them. The work that residents do with our Physiotherapy and Occupational Therapy colleagues can often require a degree of bravery or persistence that can be easily overlooked. For instance, the task of re-learning to transfer from sitting to standing or walking or to cooking independently can potentially induce quite a lot of fear. This could be a fear of physical injury but could also be a fear of failing and the psychological injury of facing up to or accepting impairment and loss. This fear sometimes leads to disengagement and reduced progress in rehabilitation.  It is easy to see how engaging bravery and persistence in these activities can be really effective, both for wellbeing and for the wider rehab progress.”

 

And has this work been part of a collaborative approach between different therapists or more the focus of the psychology team?

Darren:

“It’s been both. The first time we ran the group, it was more multi-disciplinary, as the psychology assistant, therapy assistant and various other professionals dipped in and out of the group sessions. When we are working on a one-to-one basis with residents it’s more of an endeavor for the psychology team. But as we find more suitable interventions, applicable for a neuro-rehab setting, then the plan would be to share these with the care team and therapy team so they can support engagement with residents in as many rehabilitation activities and interactions as possible. I also plan to run some multi-disciplinary CPD sessions to increase understanding about wellbeing and character strengths and hopefully to encourage professionals from different perspectives to contribute their expertise to the development of new character strength interventions.”

 

And have there been any challenges with this exploration of Positive Psychology in neuro-rehab?

Darren:

“COVID-19, isolation, social distancing and reduced access to the community was a big obstacle when encouraging residents to explore character strengths socially or to go out and try new experiences in the world. Hopefully, we are over the worst of those restrictions now.

As I’ve hinted so far in our discussion, examples of interventions in most of the published work in this field are designed for people with reduced wellbeing who are otherwise cognitively intact or free of physical impairment or disability. These constraints are almost a defining feature of the population we work with in neuro-rehab. Some of the concepts of mainstream Positive Psychology are too abstract for our residents and many of the suggested interventions may be too physically or cognitively challenging for our residents. Hence the ongoing need to be innovative in adopting the principles for this area of application. We are still at the stage of forging new ground with this.”

Character Building: Is There A Place For Positive Psychology In Neuro Rehabilitation?

 

And those developments are really exciting and hold lots of promise. What do you have to be mindful of when being innovative in such a way?

Darren:

“Well, another potential challenge is that rehabilitation is traditionally set up with an underpinning idea that you are aiming to regain lost functions and return to a previous state of being. In extreme cases, individuals may say things along the lines of ‘if I can’t get back to doing ‘X”, life won’t be worth living or rehabilitation is pointless.

Sadly, not all functions are regain-able following ABI. We try to support individuals to see that we are all changing, all of the time. Our physical functions are changing and none of us can actually be the exact same person we used to be. So the idea that quality of life and wellbeing should be based on the hope that you’re going to get back to something from the past is quite precarious. We try to move away from that. Positive Psychology principles enable us to help people to look at what’s actually still intact. We focus on what’s still strong, not just what’s wrong…or gone. Usually each person will have some parts of their character that are unaffected by what has happened to them. Aspects of themselves that they value, or they value in other people. However it can take quite a lot of work for some people to see that, which is of course understandable considering everything that they have been through.

Often individuals are focused on the loss, the things they want but didn’t get back, and they become dissociated from what’s actually still in them, that sense of continuity of self. Positive Psychology can help them reconnect and re-engage with those character strengths, which really has potential benefits in terms of preserving wellbeing and self-acceptance. Ultimately, the end goal of this type of work is to help our residents to establish a positive, post-ABI, sense of self that incorporates the residual changes but allows them to acknowledge that they are still able to experience fulfilment and wellbeing in life, now and in the future.”

 

 

 

References:

 

Seligman, M. E., & Csikszentmihalyi, M. (2014). Positive psychology: An introduction (pp. 279-298). New York, NY: Springer Netherlands.

Amanda R. Rabinowitz & Peter A. Arnett (2018) Positive psychology perspective on traumatic brain injury recovery and rehabilitation, Applied Neuropsychology: Adult, 25:4, 295-303.

 

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