Exploration of community neuropsychological rehabilitation following acquired brain injury: psychosocial outcomes and narratives of identity
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Introduction: High intensity holistic neuropsychological rehabilitation is the most evidenced-based intervention for post-acute ABI rehabilitation. However, the majority of the current evidence has examined inpatient or residential treatment contexts. Little is known about the efficacy of community neuropsychological rehabilitation interventions or the clinical validity of both high and low intensity forms of rehabilitation in a community rehabilitation setting. The systematic review synthesises the existing evidence for community-based holistic neuropsychological rehabilitation and its psycho-social outcomes. Changes in self and group identity have been suggested to underpin evidence-based neuropsychological rehabilitation. However, little is known about how these processes of identity change following ABI and throughout the rehabilitation process. The empirical study explores key turning points in the self-narratives of individuals with ABI in order to better understand the clinical and contextual factors which influence their rehabilitation. Methods: A search was conducted of Embase, Embase classic, Medline and PsycInfo. Studies were assessed for risk of bias and outcomes were synthesised following the PRISMA guidelines for systematic reviews. A ‘holistic-content’ narrative methodology was then employed to explore the post-acute adjustment and rehabilitation narratives of 11 individuals following ABI. Three-dimensional analysis of interaction, continuity and situation was used to examine individuals’ personal reflections of identity changes across their illness experience; and cross-case comparisons identified common transformational themes. Results: 15 studies were included in the review. Two distinct levels of intervention intensity were identified: high intensity interventions delivered multiple days per week, and low intensity interventions delivered only once a week. A synthesis of nine studies examining high intensity neuropsychological rehabilitation found evidence that these interventions can improve psychological wellbeing and enhance community integration following ABI when delivered on an outpatient basis. A synthesis of six low intensity interventions found limited evidence that they can lead to improved psycho-social outcomes when structure to target specific difficulties, and evidence that they can effectively support the achievement of individual patient goals. Following the analysis of ABI survivor narratives, themes of ‘Rehabilitation focus and psychological distress’, ‘Reclaiming efficacy in valued life domains’, and ‘Social comparisons: inclusion and exclusion’ were identified; each representing a continuum of personal and social understanding along which people moved during their rehabilitation. Conclusions: The systematic review suggested that high intensity forms of outpatient neuropsychological rehabilitation are effective at improving psycho-social outcomes. Low intensity forms of outpatient neuropsychological rehabilitation appear to offer a less favourable alternative to supporting psycho-social adjustment in the community at present. Findings from the empirical paper suggest that illness identity may be co-constructed in the context of early treatment experiences, and appears to influence post-acute rehabilitation focus; and that pre-injury values and self-identity guided participant approaches to re-establishing self-efficacy. These processes were supported by clinical, social and group interactions.