REC 5338 Value Added Project

Sarah Walters
REC 5338
27 July 2016
Value Added Project Report
Initially, the extent of my Value Added Project was to be the development of a new
“Stress Management” group. I would develop an outline for the group, curate support
materials for the outlined discussions, and lead the first round of the group with minimum
support from my supervisor, who would in turn be able to use the developed outline and
materials to lead a second (third, fourth, etc.) round of the group with minimum
preparation. I did, in fact, develop said discussion outline and support materials and lead
the initial 8-week group for 12 participants. However, upon being tasked with hosting the
summer’s Research Review sessions – monthly meetings of the management staff and
therapists to review evidence based practice research and discuss implications for ResCare
programming – I saw an opportunity for expanding the scope of the project to increase its
value.
In each of the two Research Review sessions that I hosted, I presented an article
addressing group interventions similar to the one that I had developed; the first article’s
studied intervention was a mindfulness-based stress reduction program, and the second
article’s a program combining social skills training and anxiety management. My
presentations of these articles were, in part, focused on considering how we could adapt
the design of the studied interventions to improve our own Stress Management group. A
secondary focus was on the encouragingly positive results identified by the researchers, as
I sought to engage the team in a discussion of how to bring those results to ResCare

Premier Texas. We keyed in on the idea that the success of the studied interventions
seemed to be linked to the thorough integration of group concepts throughout daily
programming, as the need to expand our participants’ learning and practice of group
concepts beyond 1-hour weekly sessions had become obvious. The team agreed that a
prudent strategy for expanding that learning would be to increase its permeation into daily
programming through a focus on supporting direct care staff in supporting participants.
This support would include educating program staff on group concepts, supporting their
implementation of home practices for participants, and continuing to develop the Stress
Management group to integrate basic social skills training and coping techniques. While
that process will continue beyond my tenure as the Recreation Therapy Intern at ResCare
Premier, I have set it in motion as I have shared the group outline and support materials
with our Program Directors and direct support staff, identified resources for participants’
home practice, and begun to locate the materials necessary to improve the Stress
Management group lesson plan based on the interventions considered in my Research
Review presentations.
I thoroughly enjoyed developing and leading the Stress Management group and feel
I gained a great deal of confidence in my ability to facilitate a discussion-based group,
something I felt would be a significant challenge for me as a Recreation Therapist before I
began my internship. The lesson plan outline and curated support materials would likely
have been a sufficiently valuable contribution. However, I am thrilled that I was pushed to
lead Research Review sessions that led to the improvement of the Stress Management
group and offered me an opportunity to engage in evidence based practice. I am also very
happy that the discussions held in those Research Review sessions led to the initiation of a

process that will increase the impact of the group on participants and lead to lasting change
in the philosophy of group learning provision and the permeation of that learning into daily
programming at ResCare Premier Texas.

The Stress Management Group Outline with support materials, Research Review
presentations, and reviewed articles are presented alongside this report.

Stress Management Group Outline
Weekly Lesson Plans
Week 1: What is Stress? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Week 2: Relaxation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Week 3: Cognitive Restructuring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Week 4: Active Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Week 5: Stress Management in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Week 6: Assertiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Week 7: Receiving Criticism & Dealing with Aggression . . . . . . . . . . . . . . . . . . . . . 8
Week 8: Putting it All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Handouts
Symptoms of Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Relaxation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Progressive Muscle Relaxation Script . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
The Cognitive Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
The Cognitive Model Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cognitive Distortions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Active Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Reflections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Passive, Aggressive, and Assertive Communication . . . . . . . . . . . . . . . . . . . . . . . . 25
“I” Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Responding Assertively to Criticism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Dealing with Aggressive People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Fair Fighting Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Stress Management Group Wrap-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Week 1: What is Stress?
Handouts: “Symptoms of Stress”
Defining Stress
o Ask participants, “What does ‘stress’ mean to you?”, “What is ‘stress?’”, etc.
o Offer dictionary definition of stress, “a state of mental tension and worry
caused by problems in your life, work, etc.” (Merriam-Webster.com, 2016).
Causes of Stress
o Introduce the term “stressor” and offer the dictionary definition, “something
that makes you worried or anxious; a source of stress” (Merriam-
Webster.com, 2016).
o Ask participants, “What causes you stress?”, “What are your stressors?”, etc.
Positive vs. Negative Stress
o Ask participants, “So, is stress always a bad thing?”, “Do you think stress can
ever be a good thing?”, etc.
o Introduce the concept of positive stress and differentiate it from negative
stress; explain that the difference is in the positivity or negativity of the
stressor.
o Ask participants for examples of times they’ve experienced positive stress
and point out that, while positive stress may be motivating or compelling, it
still “adds to your cup” and has the same effects/symptoms as negative stress
when “your cup gets too full.”
Effects of Stress
o Ask participants, “So, what are the effects or symptoms of being under too
much stress?”, “What happens when your cup gets too full?”, etc.
o To facilitate discussion, pass out “Symptoms of Stress” handout
(Therapistaid.com, 2012).
The Stress Cycle(s)
o Introduce the concepts of the negative and positive stress cycles and draw a
simplified version (Stressor  Thought  Feeling Behavior  Stressor) of
each cycle on the board based on the following diagrams:

(UT Counseling & Mental Health Center, 2016)
o Ask participants, “Which cycle do you think is better?”, “Would you rather be
caught in the positive or negative cycle?”, etc.
o Wrap-up day’s discussion by explaining that the goal of this group is to move
ourselves from the negative to the positive stress cycle so that we can keep
our cups from getting too full!
Week 2: Relaxation Techniques
Handouts: “Relaxation Techniques,” “Progressive Muscle Relaxation Script”
Week 1 Review
o Have participants remind you of definition of stress and stressor, differences
between positive and negative stress, and effects of stress.
o Re-draw the positive stress cycle on the board.
What is relaxation?
o Explain that the first step we’ll take towards getting into the positive stress
cycle is to practice some ways we can cope with stress – or “empty our cups”
– when it does happen. Identify relaxation as the method we’ll discuss.

o Ask participants, “What is relaxation?”, “What does it mean to relax?”, etc.
o Offer the dictionary definition of “relax,” “to become less tense, tight, or stiff;
to stop feeling nervous or worried; to spend time resting or doing something
enjoyable” (Merriam-Webster.com, 2016).
How to Relax
o Ask participants, “How do you relax?”, “What do you do to relax?”, etc.
o Emphasize the value of recreation/leisure for relaxation! Try to draw out
examples of relaxation that involve recreation/leisure.
o Explain that, while it’s great to use recreation to relax and empty our cups,
there are some other strategies for relaxation that we might want to add to
our list of coping techniques.
o Pass out the “Relaxation Techniques” handout (Therapistaid.com, 2013) and
discuss each of the techniques outlined.
Practicing Relaxation
o Pass out the “Progressive Muscle Relaxation Script” handout
(Therapistaid.com, 2014) and explain that there are many printed resources
like this one that can help us practice different relaxation techniques on our
own. Express that anyone who needs assistance locating those resources is
welcome to ask CTRS!
o Explain that many people enjoy using things like videos, audio recordings,
phone apps, etc. for guided relaxation. Offer appropriate examples of apps
using phone and, as you prepare to show videos for practice, guide
participants through that process of accessing videos on YouTube.
o Play a 10-minute guided meditation video for the class and suggest that all
participate so that we may practice relaxation together. Next, play a 10-
minute guided progressive muscle relaxation video.
o Wrap-up the day’s class by debriefing the experiences of practicing these two
relaxation techniques and, again, emphasizing that CTRS is more than willing
to share resources with anyone who is interested. Explain that direct care
staff are familiar with what we’re doing and will be able to offer support, too.

Week 3: Cognitive Restructuring
Handouts: “The Cognitive Model,” “The Cognitive Model Practice Exercises,” “Cognitive
Distortions”
Weeks 1-2 Review
o Have participants review terms from Weeks 1-2 and briefly review the
concepts of relaxation learned in Week 2.
o Re-draw the positive stress cycle on the board.
The Cognitive Cycle
o Introduce the concept of the cognitive model and draw the diagram on the
board (Situation  Thoughts  Emotions  Behaviors). Point out that this
model is pretty similar to the stress cycle and emphasize that it seems to be
the order that really matters. Explain that the ideas we’re discussing are
based on this concept illustrated in the model that “how you think determines
how you feel which determines how you behave” (Therapistaid.com, 2016).
o Discuss this concept of the order of the model and consider how a clinically
identified deficit related to impulsivity could complicate it. Emphasize that
everyone has impulsive and irrational thoughts and that the key here is to
practice taking responsibility for those thoughts so that we can control them.
What is cognitive restructuring?
o Pass out packet including “The Cognitive Model,” “The Cognitive Model
Practice Exercises,” and “Cognitive Distortions” handouts (Therapistaid.com,
2016; Therapistaid.com, 2015; Therapistaid.com, 2012).
o Explain that this idea of practicing taking control over our thoughts is called
“Cognitive Restructuring.” Emphasize that the first step is to become aware
of our thoughts in stressful situations and take responsibility for them, rather
than making the excuse that a situation caused our negative behavior or that
a person made us feel (and then act) in a negative way. Acknowledge that it
might feel like these things are happening but that we are going to practice
taking control to change that!
o Work through the example of switching an irrational, negative thought with a
rational, neutral one given on “The Cognitive Model” worksheet
(Therapistaid.com, 2016). Next, work through the scenarios given on “The
Cognitive Model Practice Exercises” worksheet (Therapistaid.com, 2015).

Continue to emphasize the importance of being aware of and taking
responsibility for our initial thoughts in stressful situations and that, with
practice, we can be in control of how we think, feel, and act!
Cognitive Distortions
o Review the “Cognitive Distortions” handout and discuss how these types of
irrational thoughts make us feel badly and result in negative behaviors
(Therapistaid.com, 2012). Emphasize that they put us back into the negative
stress cycle and add to the stress of an already stressful situation.
o Wrap-up the day’s conversation by discussing how changing our thoughts to
make them neutral or positive does the opposite – it puts us into the positive
stress cycle by limiting or eliminating the stress of a stressful situation.
Week 4: Active Listening
Handouts: “Active Listening,” “Reflections”
Weeks 1-3 Review
o Have participants review the terms discussed in Weeks 1-3. Re-draw the
positive stress cycle on the board. Briefly review the two methods of
managing stress that we’ve discussed so far.
o Remind participants that we’re working on making sure our cup doesn’t get
too full. Point out that relaxation helps us empty our cup when it’s getting full
and cognitive restructuring helps us keep stress from filling up our cup in the
first place. Transition to today’s topic by explaining that it’s another method
of keeping stress from filling up our cup in the first place.
What is listening?
o Ask participants, “What does ‘listening’ mean to you?”, “Is there a difference
between hearing and listening?”, etc.
o Discuss difference between hearing and listening. Offer dictionary definitions
– listening is “to pay attention to someone or something in order to hear
what is being said, sung, played, etc.” while hearing is simply “to be aware of
sound through the ear” (Merriam-Webster.com, 2016).
Active Listening
o Ask participants, “What do you think it means to listen actively?”, “What is
active listening?”, etc.

o Pass out the “Active Listening” handout (Mindtools.com, 2016). Work through
the steps of active listening and discuss each.
Reflections
o Explain that we won’t move on to responding today but that a big part of
active listening is giving feedback that helps us listen better by clarifying
what has been said.
o Pass out the “Reflections” handout (Therapistaid.com, 2015). Introduce
reflections as a great way to understand what is being said, discuss the
technique, and work through the practice scenarios.
o Wrap-up the day’s conversation by discussing the importance of
understanding what someone really means before you react/respond.
Emphasize how misunderstanding someone and reacting negatively can
make an already stressful situation that much more stressful, while clarifying
and defusing the situation instead removes or eliminates the stress.
Week 5: Stress Management in Practice
Stressful Games
o Select several board games that are particularly stressful, such as Operation
or Jenga. As you play each game, continue to subtly and appropriately
increase the stress level by introducing or shortening a time limit, adding
distractions, etc.
o Wrap-up the day by debriefing the experience with playing the games.
Connect the experience to “real-world” experiences with stress (While
acknowledging that board games happen in the real world and cause real
stress!) as well as conversations and concepts from Weeks 1-4. Encourage
participants to reflect on what was stressful about playing the games, what
increased the stress level, and how they coped (or didn’t cope) with the
stress.
Week 6: Assertiveness
Handouts: “Passive, Aggressive, and Assertive Communication” and “”I’ Statements”
Weeks 1-5 Review
o Have participants review the terms discussed in Weeks 1-4 and reflect on
their experience in Week 5. Re-draw the positive stress cycle on the board.
Briefly review the two methods of managing stress through communication

that we’ve discussed so far as well as the coping technique, relaxation, and
the concept of cognitive restructuring.
while cognitive restructuring and active listening help us keep stress from
filling up our cup in the first place. Transition to today’s topic by explaining
that it’s another method of making positive changes to our communication
strategies that keep stress from filling up our cup in the first place. Explain
that what we’ll discuss today is one step past the last concept we talked
about – how to respond after we’ve actively listened.
Passive vs. Aggressive vs. Assertive Communication
o Pass out the packet including the handouts “Passive, Aggressive, and
Assertive Communication” and “”I’ Statements” (Therapistaid.com, 2012;
Therapistaid.com, 2014).
o Ask participants, “What does passive mean to you?”, “What does passive
communication look like?”, “How does a passive person communicate?”, etc.
Do the same for aggressive and assertive communication, working through
the “Passive, Aggressive, and Assertive Communication” handout
(Therapistaid.com, 2012).
o Ask participants to choose which kind of communication they think would be
the least stressful/the most positive. Encourage them to land on assertive!
More on Assertive Communication
o Discuss assertive communication in more depth. Emphasize that assertive
communication is respectful and allows both parties to have their needs and
wants acknowledged.
o Point out that, just as in the cognitive model, it’s key that we take
responsibility for what we’re saying so that we can take control.
“I” Statements
o Introduce the “I” Statements technique as one way to take responsibility for
our side of the conversation while respecting the other person and treating
them kindly. Work through the “’I’ Statements” handout to practice the
technique.

o Wrap-up the day’s conversation with a discussion about how being assertive
and using a technique like “I” Statements helps to decrease or eliminate
stress from stressful conversations. Encourage participants to reflect on how
remaining calm, respectful, and kind will help us keep from feeling stressed
and will also make the conversation easier by not riling the other person.
Week 7: Receiving Criticism & Dealing with Aggression
Handouts: “Responding Assertively to Criticism,” “Dealing with Aggressive People,” “Fair
Fighting Rules”
Weeks 1-5 Review
o Have participants review the terms discussed in Weeks 1-6. Re-draw the
positive stress cycle on the board. Briefly review the two methods of
managing stress through communication that we’ve discussed so far as well
as the coping technique, relaxation, and the concept of cognitive
restructuring.
while cognitive restructuring, active listening, and assertiveness help us keep
stress from filling up our cup in the first place. Transition to today’s topic by
explaining that it’s another method of making positive changes to our
communication strategies that keep stress from filling up our cup. Explain
that what we’ll discuss today is an expansion of the last topic we covered –
we’ll go from discussing assertiveness generally to focusing on how to be
assertive when faced with criticism and/or aggression.
Responding to Criticism Assertively
o Pass out the packet that includes the handouts “Responding Assertively to
Criticism,” “Dealing with Aggressive People,” and “Fair Fighting Rules”
(Michel & Fursland, 2008; Brightside.me, 2016; Therapistaid.com, 2012).
o Discuss the differences between constructive and destructive criticism.
Emphasize that constructive criticism is valid and helps us to improve while
destructive criticism tends to be invalid and simply mean.
o Work through “Responding Assertively to Criticism” handout (Michel &
Fursland, 2008). Discuss each strategy for responding to both constructive
and destructive criticism. Consider each example offered and prompt
participants to offer alternative responses. Emphasize the importance of

being calm and assertive, and of acknowledging any valid piece of feedback
while respectfully rejecting or ignoring any exaggerations or untruths.
Turning Destructive Criticism into Constructive Criticism
o Discuss how combining some of the skills we’ve learned – specifically active
listening and assertiveness – can help us turn destructive criticism into
constructive criticism. Emphasize that remaining calm and respectful (and
demanding that same respect in concern) while asking clarifying questions
allows us to get at the true message and benefit from it.
Dealing with Aggressive People
o Work through the “Dealing with Aggressive People” handout (Brightside.me,
2016). Emphasize the idea that it’s much more effective to fight fire with
water than with more fire. Discuss each of the five “steps” and what effect
using this strategy might have on the person you’re communicating with.
Briefly work through the “Fair Fighting Rules” handout to reinforce the
strategies (Therapistaid.com, 2012).
o Wrap-up the day’s session by discussing how using these strategies in a
stressful conversation will not only help us avoid escalating the situation but
will help us defuse it. If appropriate, discuss the concept of mirror neurons to
illustrate that, while assertiveness is difficult and feels a little unnatural, it
can really do the trick in managing a conversation partner’s aggression.
Week 8: Putting it All Together
Handouts: “Stress Management Group Wrap-Up”
Putting it All Together
o Pass out the “Stress Management Group Wrap-Up Handout.” Work through
the handout, discussing each week’s topics in brief detail and allowing
participant’s to take notes. Encourage participants to do most of the talking
and offer reminders as necessary.
o Debrief the group by focusing on processing questions about what we
learned, why we discussed the topics we discussed, how we plan to use the
strategies and techniques we learned, etc.

Symptoms of Stress
Provided by TherapistAid.com © 2012
Stress is one way that our bodies respond to the demands of our lives. A little bit of stress can
be healthy—it keeps us alert and productive. However, all too often, we experience too much
stress. Too much stress can result in serious physical, emotional, and behavioral symptoms.
Physical Emotional Behavioral
 Fatigue
 Sleep difficulties
 Stomachache
 Chest pain
 Muscle pain and
tension
 Headaches and
migraines
 Indigestion
 Nausea
 Increased sweating
 Weakened immune
system
 Neck and back pain
 Loss of motivation
 Increased irritability
and anger
 Anxiety
 Depression or
sadness
 Restlessness
 Inability to focus
 Mood instability
 Decreased sex drive
 Unhealthy eating
(over or under
eating)
 Drug or alcohol
use
 Social Withdrawal
 Nail biting
 Constant
thoughts about
stressors

Relaxation Techniques
TherapistAid.com © 2013 | Page 1
When a person is confronted with anxiety, their body undergoes several changes and
enters a special state called the fight-or-flight response. The body prepares to either
fight or flee the perceived danger.
During the fight-or-flight response it’s common to experience a “blank” mind, increased
heart rate, sweating, tense muscles, and more. Unfortunately, these bodily responses do
little good when it comes to protecting us from modern sources of anxiety.
Using a variety of skills, you can end the fight-or-flight response before the symptoms
become too extreme. These skills will require practice to work effectively, so don’t wait
until the last minute to try them out!
Deep Breathing
It’s natural to take long, deep breaths, when relaxed. However, during the fight-or-flight
response, breathing becomes rapid and shallow. Deep breathing reverses that, and sends
messages to the brain to begin calming the body. Practice will make your body respond
more efficiently to deep breathing in the future.
Breathe in slowly. Count in your head and make sure the inward breath lasts at least 5
seconds. Pay attention to the feeling of the air filling your lungs.
Hold your breath for 5 to 10 seconds (again, keep count). You don’t want to feel
uncomfortable, but it should last quite a bit longer than an ordinary breath.
Breathe out very slowly for 5 to 10 seconds (count!). Pretend like you’re breathing
through a straw to slow yourself down. Try using a real straw to practice.
Repeat the breathing process until you feel calm.
Imagery
Think about some of your favorite and least favorite places. If you think about the place
hard enough—if you really try to think about what it’s like—you may begin to have feelings
you associate with that location. Our brain has the ability to create emotional reactions
based entirely off of our thoughts. The imagery technique uses this to its advantage.
Make sure you’re somewhere quiet without too much noise or distraction. You’ll need a
few minutes to just spend quietly, in your mind.
Think of a place that’s calming for you. Some examples are the beach, hiking on a
mountain, relaxing at home with a friend, or playing with a pet.

Relaxation Techniques
Paint a picture of the calming place in your mind. Don’t just think of the place briefly—
imagine every little detail. Go through each of your senses and imagine what you would
experience in your relaxing place. Here’s an example using a beach:
a. Sight: The sun is high in the sky and you’re surrounded by white sand. There’s no
one else around. The water is a greenish-blue and waves are calmly rolling in
from the ocean.
b. Sound: You can hear the deep pounding and splashing of the waves. There are
seagulls somewhere in the background.
c. Touch: The sun is warm on your back, but a breeze cools you down just enough.
You can feel sand moving between my toes.
d. Taste: You have a glass of lemonade that’s sweet, tart, and refreshing.
e. Smell: You can smell the fresh ocean air, full of salt and calming aromas.
Progressive Muscle Relaxation
During the fight-or-flight response, the tension in our muscles increases. This can lead to a
feeling of stiffness, or even back and neck pain. Progressive muscle relaxation teaches us
to become more aware of this tension so we can better identify and address stress.
Find a private and quiet location. You should sit or lie down somewhere comfortable.
The idea of this technique is to intentionally tense each muscle, and then to release the
tension. Let’s practice with your feet.
a. Tense the muscles in your toes by curling them into your foot. Notice how it feels when
your foot is tense. Hold the tension for 5 seconds.
b. Release the tension from your toes. Let them relax. Notice how your fingers feel
differently after you release the tension.
c. Tense the muscles all throughout your calf. Hold it for 5 seconds. Notice how the feeling
of tension in your leg feels.
d. Release the tension from your calf, and notice how the feeling of relaxation differs.
Follow this pattern of tensing and releasing tension all throughout your body. After you
finish with your feet and legs, move up through your torso, arms, hands, neck, and head.

Progressive Muscle Relaxation Script
Progressive muscle relaxation is an exercise that reduces stress and anxiety in your body by having you
slowly tense and then relax each muscle. This exercise can provide an immediate feeling of relaxation,
but it’s best to practice frequently. With experience, you will become more aware of when you are
experiencing tension and you will have the skills to help you relax. During this exercise each muscle
should be tensed, but not to the point of strain. If you have any injuries or pain, you can skip the affected
areas. Pay special attention to the feeling of releasing tension in each muscle and the resulting feeling of
relaxation. Let’s begin.
Sit back or lie down in a comfortable position. Shut your eyes if you’re comfortable doing so.
Begin by taking a deep breath and noticing the feeling of air filling your lungs. Hold your breath for a few
seconds.
(brief pause)
Release the breath slowly and let the tension leave your body.
Take in another deep breath and hold it.
(brief pause)
Again, slowly release the air.
Even slower now, take another breath. Fill your lungs and hold the air.
(brief pause)
Slowly release the breath and imagine the feeling of tension leaving your body.
Now, move your attention to your feet. Begin to tense your feet by curling your toes and the arch of your
foot. Hold onto the tension and notice what it feels like.
(5 second pause)
Release the tension in your foot. Notice the new feeling of relaxation.
Next, begin to focus on your lower leg. Tense the muscles in your calves. Hold them tightly and pay
attention to the feeling of tension
(5 second pause)
Release the tension from your lower legs. Again, notice the feeling of relaxation. Remember to continue
taking deep breaths.
Next, tense the muscles of your upper leg and pelvis. You can do this by tightly squeezing your thighs
together. Make sure you feel tenseness without going to the point of strain.
(5 second pause)

Progressive Muscle Relaxation Script
And release. Feel the tension leave your muscles.
Begin to tense your stomach and chest. You can do this by sucking your stomach in. Squeeze harder and
hold the tension. A little bit longer.
(5 second pause)
Release the tension. Allow your body to go limp. Let yourself notice the feeling of relaxation.
Continue taking deep breaths. Breathe in slowly, noticing the air fill your lungs, and hold it.
(brief pause)
Release the air slowly. Feel it leaving your lungs.
Next, tense the muscles in your back by bringing your shoulders together behind you. Hold them tightly.
Tense them as hard as you can without straining and keep holding
(5 second pause)
Release the tension from your back. Feel the tension slowly leaving your body, and the new feeling of
relaxation. Notice how different your body feels when you allow it to relax.
Tense your arms all the way from your hands to your shoulders. Make a fist and squeeze all the way up
your arm. Hold it.
(5 second pause)
Release the tension from your arms and shoulders. Notice the feeling of relaxation in your fingers, hands,
arms, and shoulders. Notice how your arms feel limp and at ease.
Move up to your neck and your head. Tense your face and your neck by distorting the muscles around
your eyes and mouth.
(5 second pause)
Release the tension. Again, notice the new feeling of relaxation.
Finally, tense your entire body. Tense your feet, legs, stomach, chest, arms, head, and neck. Tense harder,
without straining. Hold the tension.
(5 second pause)
Now release. Allow your whole body to go limp. Pay attention to the feeling of relaxation, and how
different it is from the feeling of tension.
Begin to wake your body up by slowly moving your muscles. Adjust your arms and legs.
Stretch your muscles and open your eyes when you’re ready.

The Cognitive Model
Thoughts  Emotions  Behaviors
© 2016 Therapist Aid LLC Provided by TherapistAid.com
Cognitive behavioral therapy (usually referred to as “CBT”) is based upon the idea that
how you think determines how you feel and how you behave. The diagram and example
below show us this process:
Something happens.
It could be anything.
You have thoughts
about what has just
occurred.
You experience
emotions based upon
your thoughts.
You respond to your
thoughts and feelings
with behaviors.
Example: Pharrell
Situation: A stranger scowls at Pharrell while passing him on the street.
Pharrell’s Thoughts: “I must’ve done something wrong… I’m so awkward.”
Pharrell’s Emotions: Embarrassed and upset with himself.
Pharrell’s Behaviors: Pharrell apologizes to the stranger and replays the situation over and over
in his head, trying to understand what he did wrong.
In this example, you might’ve noticed that Pharrell’s thought wasn’t very rational. The
stranger could’ve been scowling for any number of reasons. Maybe the stranger just got
dumped, or maybe he scowls at everyone. Who knows?
As humans, we all have irrational thoughts like these. Unfortunately, irrational or not,
these thoughts still affect how we feel, and how we behave. Consider how Pharrell
might’ve responded to the same situation if he had a different thought:
Thought Emotion Behavior
“What a jerk!” Angry Pharrell shouts: “What’s your problem?!”
“He must be having a bad day…” Neutral Pharrell walks away and forgets the incident.
Using the cognitive model, you will learn to identify your own patterns of thoughts,
emotions, and behaviors. You’ll come to understand how your thoughts shape how you
feel, and how they impact your life in significant ways.
Once you become aware of your own irrational thoughts, you will learn to change them.
The thoughts that once led to depression, anxiety, and anger will be replaced with new,
healthy alternatives. Finally, you will be in control of how you feel.

The Cognitive Model
Practice Exercises
Examples
See how two people can experience the same situation in different ways based upon
their thoughts. Each example depicts a negative and rational thought, and a typical
outcome of each thinking style.
Situation: Jason and Kurt both receive a negative evaluation at work.
Jason Kurt
Negative Thought: “I can’t do anything right. I
bet I get fired because of this!”
Rational Thought: “I guess I didn’t work hard
enough—I’ll have to come up with a better
plan for next time.”
Emotion: Depressed and nervous. Emotion: Disappointed but motivated.
Behavior: Jason avoids his boss because he
believes he’s in trouble. He feels nervous the
next time he’s confronted with challenging
work, and performs poorly.
Behavior: Kurt seeks out his boss to talk
about how he can improve. He approaches
his next task as a challenge and gradually
improves.
Situation: Gwen and Shirley both have an argument with a close friend.
Gwen Shirley
Negative Thought: “We always argue! Why
can’t she ever see my side? This is so unfair.”
Rational Thought: “That was rough—I should
apologize. We can both be stubborn
sometimes.”
Emotion: Angry and blaming. Emotion: Forgiving and regretful.
Behavior: Gwen stays angry at her friend and
does not reach out to repair the relationship.
Over time, Gwen’s friendship becomes more
and more toxic.
Behavior: Shirley accepts a portion of the
responsibility and apologizes to her friend.
They communicate and continue to
strengthen their relationship.

The Cognitive Model
Practice Exercises
Practice
Write down an alternative rational thought for each situation. What do you think the
resulting emotion and behavior might be?
Situation: Emily is cut off by another driver and has to quickly hit her brakes.
Negative Thought: “What a jerk! They don’t care about anyone but themselves. I could’ve
crashed!”
Emotion: Angry
Behavior: Emily drives aggressively to provoke the driver who cut her off. Emily is still angry
when she gets home, and yells at her family.
Rational Thought:
New Emotion and Behavior:
Situation: Travis notices his wife hasn’t helped around the house for a week.
Negative Thought: “Does she even care? She knows I’ll clean up, so she abuses my kindness!”
Emotion: Angry and sad.
Behavior: Travis lets the dishes pile up and doesn’t say anything to his wife. He doesn’t ask why
she hasn’t helped, and becomes angrier when he assumes she’s just selfish.
Rational Thought:

The Cognitive Model
Practice Exercises
Situation: Regina is invited to a birthday party by an acquaintance.
Negative Thought: “I won’t know anyone at this party and I’ll just seem out of place. She
probably invited me because she felt obligated.”
Emotion: Sad and anxious.
Behavior: Regina lies and tells her friend she already has plans for the night of her party. Regina
and her friend fail to develop their friendship.
Rational Thought:
Situation: Thom notices a girl on the bus who keeps looking his direction.
Negative Thought: “Do I have something on my face? Is my fly down? Maybe I smell bad or
something. I need to get home and take a shower.”
Emotion: Self-conscious and anxious.
Behavior: Thom avoids the girl and rushes off the bus without looking up from his shoes.
Rational Thought:

Cognitive distortions are irrational thoughts that can influence your emotions. Everyone
experiences cognitive distortions to some degree, but in their more extreme forms they
can be harmful.
Magnification and Minimization: Exaggerating or minimizing the importance of
events. One might believe their own achievements are unimportant, or that their
mistakes are excessively important.
Catastrophizing: Seeing only the worst possible outcomes of a situation.
Overgeneralization: Making broad interpretations from a single or few events. “I felt
awkward during my job interview. I am always so awkward.”
Magical Thinking: The belief that acts will influence unrelated situations. “I am a good
person—bad things shouldn’t happen to me.”
Personalization: The belief that one is responsible for events outside of their own
control. “My mom is always upset. She would be fine if I did more to help her.”
Jumping to Conclusions: Interpreting the meaning of a situation with little or no
evidence.
Mind Reading: Interpreting the thought sand beliefs of others without adequate
evidence. “She would not go on a date with me. She probably thinks I’m ugly.”
Fortune Telling: The expectation that a situation will turn out badly without
adequate evidence.
Emotional Reasoning: The assumption that emotions reflect the way things really are.
“I feel like a bad friend, therefor I must be a bad friend.”
Disqualifying the Positive: Recognizing only the negative aspects of a situation while
ignoring the positive. One might receive many compliments on an evaluation, but focus
on the single piece of negative feedback.
“Should” Statements: The belief that things should be a certain way. “I should always
be friendly.”
All-or-Nothing Thinking: Thinking in absolutes such as “always”, “never”, or “every”. “I
never do a good enough job on anything.”

Active Listening
1. Pay Attention
Give the speaker your undivided attention, and acknowledge the message. Recognize that non-
verbal communication also "speaks" loudly.
Look at the speaker directly.
Put aside distracting thoughts.
Don't mentally prepare a rebuttal!
Avoid being distracted by environmental factors. For example, side conversations.
"Listen" to the speaker's body language.
2. Show That You're Listening
Use your own body language and gestures to convey your attention.
Nod occasionally.
Smile and use other facial expressions.
Note your posture and make sure it is open and inviting.
Encourage the speaker to continue with small verbal comments like yes and uh huh.
3. Provide Feedback
Our personal filters, assumptions, judgments, and beliefs can distort what we hear. As a listener,
your role is to understand what is being said. This may require you to reflect what is being said
and ask questions.
Reflect what has been said by paraphrasing. "What I'm hearing is," and "Sounds like you are
saying," are great ways to reflect back.
Ask questions to clarify certain points. "What do you mean when you say…", "Is this what
you mean?"
Summarize the speaker's comments periodically.

4. Defer Judgment
Interrupting is a waste of time. It frustrates the speaker and limits full understanding of the
message.
Allow the speaker to finish each point before asking questions.
Don't interrupt with counter arguments.
5. Respond Appropriately
Active listening is a model for respect and understanding. You are gaining information and
perspective. You add nothing by attacking the speaker or otherwise putting him or her down.
Be candid, open, and honest in your response.
Assert your opinions respectfully.
Treat the other person in a way that you think he or she would want to be treated.
Mind Tools Editorial Team (2016). Active listening: Hear what people are really saying. Retrieved from
https://www.mindtools.com/CommSkll/ActiveListening.htm

Reflections
Communication Skill
Using a technique called reflection can quickly help you become a better listener. When
reflecting, you will repeat back what someone has just said to you, but in your own words. This
shows that you didn’t just hear the other person, but you are trying to understand them.
Reflecting what another person says can feel funny at first. You might think the other person will
be annoyed at you for repeating them. However, when used correctly, reflections receive a
positive reaction and drive a conversation forward. Here’s an example:
Speaker: “I get so angry when you spend so much money without telling me.
We’re trying to save for a house!
Listener: “We’re working hard to save for a house, so it’s really frustrating when it
seems like I don’t care.”
Quick Tips
The tone of voice you use for reflections is important. Use a tone that comes across as a
statement, with a bit of uncertainty. Your goal is to express: “I think this is what you’re telling
me, but correct me if I’m wrong.” Your reflections don’t have to be perfect. If the other person
corrects you, that’s good! Now you have a better understanding of what they’re trying to say.
Try to reflect emotions, even if the person you’re listening to didn’t clearly describe them. You
may be able to pick up on how they feel by their tone of voice or body language.
Switch up your phrasing, or your reflections will start to sound forced. Try some of these:
 “I hear you saying that…”
 “It sounds like you feel…”
 “You’re telling me that…”
Focus on reflecting the main point. Don’t worry too much about all the little details, especially
if the speaker had a lot to say!

Reflections
Communication Skill
Practice
“I was in a bad mood yesterday because work has been so stressful. I just can’t
keep up with everything I have to do.”
Reflection:
“I feel like I’m doing all of the work around the house. I need you to help me clean
and do the dishes more often.”
Reflection:
“I’ve been worried when you don’t answer your phone. I always think something
might’ve happened to you.”
Reflection:
“I don’t understand what she wants from me. First she says she wants one thing,
then another.”
Reflection:

Passive, Aggressive, and Assertive Communication
Passive Communication
When using passive communication, an individual does not express their needs or
feelings. Passive individuals often do not respond to hurtful situations, and instead
allow themselves to be taken advantage of or to be treated unfairly.
Traits of passive communication:
· Poor eye contact
· Allows others to infringe upon their rights
· Softly spoken
· Allows others to take advantage
Aggressive Communication
Aggressive communicators violate the rights of others when expressing their own
feelings and needs. They may be verbally abusive to further their own interests.
Traits of aggressive communication:
· Use of criticism, humiliation, and domination
· Frequent interruptions and failure to listen to others
· Easily frustrated
· Speaking in a loud or overbearing manner
Assertive Communication
With assertive communication, an individual expresses their feelings and needs in a way
that also respects the rights of others. This mode of communication displays respect
for each individual who is engaged in the exchange.
Traits of assertive communication:
· Listens without interrupting
· Clearly states needs and wants
· Stands up for personal rights
· Good eye contact

“I” Statements
Taking responsibility for your feelings will help you improve your communication when
you feel upset or angry. One way to achieve this is by using “I” statements. This
technique will allow you to communicate what is upsetting while minimizing blaming. If
our statements feel too blaming, the person we are trying to speak to will often become
defensive.
“I” Statement format: “I feel ______ when you ______ because ______.”
Examples
Regular “You make me angry because you are always late”
“I” Statement
“I feel frustrated when you come home late because I stay awake
worrying.”
Regular “You never call. You don’t even care.”
“I” Statement
“I feel hurt when you forget to call because it seems like you don’t
care.”
Practice
Scenario
Your friend keeps cancelling plans at the last minute. Last weekend you
were waiting for them at a restaurant when they called to tell you they
would not be able to make it. You left feeling hurt.
“I” Statement
Scenario
You are working on a project with a group and one member is not
completing their tasks on time. You have repeatedly had to finish their
work which has been very frustrating.
“I” Statement
Scenario
A friend who borrows movies from you usually brings them back
damaged. They want to borrow one again but you’re feeling worried.
“I” Statement

Responding Assertively to Criticism
Dealing with Constructive Criticism
We all need to be able to accept constructive criticism. Depending on the way the criticism
is presented to you, you can respond in a number of different ways.
1. Accept the criticism
If the criticism is valid then just accept it without expressing guilt or other negative
emotions. Accept that you are not perfect and that the only way we can learn is to
make mistakes, see what we need to change and move on. Thank the person for the
feedback if appropriate. See the criticism as a gift.
2. Negative assertion
This technique involves not only accepting the criticism but openly agreeing with the
criticism. This is used when a true criticism is made to you. The skill involves calmly
agreeing with the criticism of your negative qualities, and not apologizing or letting
yourself feel demolished. For example, someone may say:
Criticism: “Your desk is very messy. You are very disorganized”.
Response: “Yes, it’s true, I’m not very tidy”.
The key to using negative assertion is self-confidence and a belief that you have the
ability to change yourself if you wish. By agreeing with and accepting criticism, if it is
appropriate, you need not feel totally demolished. This type of response can also
diffuse situations. If someone aggressive is making the criticism they may expect you
to become defensive or aggressive back. By agreeing with them the tension in the
situation is diffused.
3. Negative inquiry
Negative inquiry consists of requesting further, more specific criticism. If someone
criticizes you but you are not sure if the criticism is valid or constructive you ask for
more details. For example:
Criticism: “You’ll find that difficult won’t you, because you are shy?”
Response: “In what ways do you think I’m shy?”
If the criticism is constructive, that information can be used constructively and the
general channel of communication will be improved. If the criticism is manipulative or
destructive then the critic will be put on the spot.

Dealing with Destructive Criticism
Unfortunately we are all going to encounter destructive criticism at some point in our lives.
This can be more difficult to deal with than constructive criticism. If we practice the
techniques below, we can become skilled at dealing with these difficult situations. As with
all skills remember it will take practice and some time to feel confident using these skills.
You will notice that some of the skills are the same as for dealing with constructive
criticism.
1. Disagree with criticism
The first technique for dealing with destructive criticism is simply to disagree with it. It
is important that you remain calm and watch your non-verbal behaviors including tone
of voice as you do this as it is easy to become aggressive or passive when disagreeing.
Keep your voice calm, your eye contact good. For example:
Criticism: “You’re always late”.
Response: “No, I’m not always late. I may be late occasionally, but I’m certainly not
always late”.
2. Negative Enquiry
As described above, if someone makes a comment you may not be sure if it is
constructive or destructive criticism. We need to check what is meant. If the criticism is
destructive then we can either disagree with it as above, or we can use one of the
diffusion techniques described below.
3. Fogging aka Clouding aka Diffusion
The three names above all refer to the same techniques. The idea behind the
techniques is to defuse a potentially aggressive or difficult situation. You can use this
style when a criticism is neither constructive nor accurate. The tendency for most
people when presented with destructive criticism is either to be passive and crumble
or be aggressive and fight back. Neither of these are good solutions. Essentially what
the techniques do is find some way of agreeing with a small part of what an antagonist
is saying. By staying calm and refusing to be provoked or upset by the criticism you
remove its destructive power.
Example 1:
Criticism: “You’re not reliable. You forgot to pick up the kids, you let the bills pile up
until we could lose the roof over our head, and I can’t ever count on you to be there
when I need you.”

Response: “You’re certainly right that I did forget to pick up the kids last week after
their swimming lesson.”
Example 2:
Criticism: “If you don’t floss your teeth, you’ll get gum disease and be sorry for the
rest of your life.”
Response: “You’re right I may get gum disease.”
Additional tips to remember when being criticized:
1. Respond to the words not the tone of the criticism.
It is important when you are being criticized to separate the suggestions in the
criticism from the way that they are being spoken to you. Often when people are giving
criticism they can come across as confrontational, even aggressive. This may mean that
we dismiss what they are saying despite the fact that the criticism may be a useful one.
We need to practice separating the criticism from the style of criticism. Even if people
speak in an angry manner, we should try to detach their emotion from the useful
suggestions which lie underneath.
2. Don’t Respond Immediately.
It is best to wait a little before responding. If we respond with feelings of anger or
injured pride we will soon regret it. If we wait patiently it can enable us to reflect in a
calmer way.
3. When Feeling Criticized:
1. Stop - Don’t react until you are sure what is going on.
2. Question – have you really been criticized? Are you mind-reading?
3. Check if you need to by asking the other person. For example, you can say: “What did
you mean by that?”
4. Once you have worked out if it is really a criticism, decide if it is valid or not and
respond using one of the techniques above.
Michel, F. & Fursland, A. (2008). Assert yourself: How to deal assertively with criticism.
Retrieved from http://www.cci.health.wa.gov.au/docs/Assertmodule%207.pdf

Dealing with Aggressive People
It is almost certain that we will have to deal with aggressive people in our lives. Aggression
arises during a conflict when one person feels the need to protect their interests or fight
to gain something, often at the expense of others. So let’s be clear that aggression
is something at our expense.
First of all, you can recognize an aggressive person if:
They interrupt you or talk loudly to keep you from speaking.
They do not allow your point of view and input.
You often have the sense that your boundaries are being crossed.
Interaction with the person usually leads to tension.
You feel energetically and emotionally exhausted after interacting with them.
Unfortunately, we can’t avoid these people. So we need to find a solid balance between
assertiveness and empathy to deal with them. Follow these 5 steps to master the art
of dealing with aggressiveness.
Keep Your Cool
Fighting fire with fire will only make things worse and spur the other person’s aggression.
A few tips for staying calm, even when you feel like you’re bursting with anger:
Take a deep breath.
Get up to get a glass of water or your phone. Doing something else diffuses the
tension that is building up in the moment.
Think of how much you will regret the things you might say out of anger.
Point Them Out
Call it as you see it. Don’t go along with the conversation as if nothing is bothering you.
However, you need to point out that the other person is being aggressive with
an empathetic statement rather than agitating them even more. Avoid using the words
’you’ or ’your,’ and try something along the lines of:
’There is no need to stress, we will resolve it/find a way/work it out.’
’Could you please lower your voice.’

If you do this early on, it will help knock them out of the place of being unaware
of themselves and be more conscious of what they are doing. As a result, it can help the
person be more open to hearing whatever you say.
Empathize
Put yourself in the other person’s shoes, and try to understand the reasons why he/she
is being aggressive. As we mentioned above, aggression is a natural reaction in order
to protect or claim something. Try to consider:
How would you feel if you were in that situation?
Is there something else going on in the person’s life that makes him/her generally
very easily agitated and quick-tempered?
Be Assertive
It might sound contradictory that you can be empathetic and assertive, but one doesn’t
exclude the other. Understanding the other person’s position does not mean you will allow
them to be aggressive.
Keep your voice low and steady. This will show confidence and will not spur the
other person into trying to talk more loudly than you.
Stand your ground, and don’t allow the person to monopolize the discussion. Speak
out on your opinion.
Remain respectful, and ask for the same respect in return.
If the level of aggression begins to increase, respond with more force and
assertiveness to show that your tolerance is decreasing.
Focus
If someone is overtaken by their emotions, they lose sight of the matter at hand and how
the whole argument even started! By focusing the conversation on the important things
and facts, you are helping the other person revert to thinking and reasoning. For example:
’All that matters is that...’
Try to make the other person laugh as it will completely disarm them.
Brightside.me (2016). 5 Tips for Dealing with Aggressive People. Retrieved from
http://brightside.me/inspiration-psychology/5-steps-for-dealing-with-aggressive-people-
175755/

Fair Fighting Rules
Before you begin, ask yourself why you feel upset.
Are you truly angry because your partner left the mustard on the counter? Or are you upset
because you feel like you’re doing an uneven share of the housework, and this is just one more
piece of evidence? Take time to think about your own feelings before starting an argument.
Discuss one issue at a time.
“You shouldn’t be spending so much money without talking to me” can quickly turn into “You don’t
care about our family”. Now you need to resolve two problems instead of one. Plus, when an
argument starts to get off topic, it can easily become about everything a person has ever done
wrong. We’ve all done a lot wrong, so this can be especially cumbersome.
No degrading language.
Discuss the issue, not the person. No put-downs, swearing, or name-calling. Degrading language is
an attempt to express negative feelings while making sure your partner feels just as bad. This will
just lead to more character attacks while the original issue is forgotten.
Express your feelings with words and take responsibility for them.
“I feel angry.” “I feel hurt when you ignore my phone calls.” “I feel scared when you yell.” These are
good ways to express how you feel. Starting with “I” is a good technique to help you take
responsibility for your feelings (no, you can’t say whatever you want as long as it starts with “I”).
Take turns talking.
This can be tough, but be careful not to interrupt. If this rule is difficult to follow, try setting a timer
allowing 1 minute for each person to speak without interruption. Don’t spend your partner’s
minute thinking about what you want to say. Listen!
No stonewalling.
Sometimes, the easiest way to respond to an argument is to retreat into your shell and refuse to
speak. This refusal to communicate is called stonewalling. You might feel better temporarily, but
the original issue will remain unresolved and your partner will feel more upset. If you absolutely
cannot go on, tell your partner you need to take a time-out. Agree to resume the discussion later.
No yelling.
Sometimes arguments are “won” by being the loudest, but the problem only gets worse.
Take a time-out if things get too heated.
In a perfect world we would all follow these rules 100% of the time, but it just doesn’t work like
that. If an argument starts to become personal or heated, take a time-out. Agree on a time to come
back and discuss the problem after everyone has cooled down.
Attempt to come to a compromise or an understanding.
There isn’t always a perfect answer to an argument. Life is just too messy for that. Do your best to
come to a compromise (this will mean some give and take from both sides). If you can’t come to a
compromise, merely understanding can help soothe negative feelings.

Stress Management Group Wrap-Up
Putting it All Together
Week 1  What is Stress?
Defining Stress
Causes of Stress
Positive vs. Negative Stress
Effects of Stress
The Stress Cycle(s)
Week 2  Relaxation Techniques
What is relaxation?
How to Relax
Practicing Relaxation

Week 3 Cognitive Restructuring
The Cognitive Model
What is cognitive restructuring?
Week 4  Active Listening
What is listening?
Active Listening
Reflections
Week 5  Practicing Stress Management
What does a playing stressful game teach us about managing our stress?
Week 6  Assertiveness
Passive vs. Aggressive vs. Assertive Communication

More on Assertive Communication
“I” Statements
Week 7  Receiving Criticism & Dealing with Aggression
Responding to Criticism Assertively
Turning Destructive Criticism into Constructive Criticism
Dealing with Aggression
Week 8  Putting it All Together
What did we learn about stress and how to manage it?
What techniques did you gain for emptying your cup?
What strategies did you gain for keeping your cup from filling up?
Why did we spend so much time talking about talking?

MINDFULNESS-BASED STRESS REDUCTION IMPROVES
LONG-TERM MENTAL FATIGUE AFTER STROKE OR TBI
JOHANSSON, B., BJUHR, H., & RONNBACK, L. | DECEMBER 2012 | BRAIN INJURY

PARTICIPANTS
¡ Inclusion criteria included:
¡ Diagnosis ofAcquired Brain Injury (Stroke orTBI)
¡ Aged 30-65
¡ 12 months or more post-injury
¡ Glasgow Outcome Scale (GOS) score of moderate disability or higher
¡ Mental Fatigue Self-Assessment (MFS) score of 10/25 or higher
¡ 29 participants included in study
¡ 15 participants included in MBSR Group 1,14 participants included in Control Group/MBSR Group 2
¡ 22 participants completed MBSR program,12 in Group 1 and 10 in Group 2
¡ 12 females and 11 males completed MBSR program

INTERVENTION
¡ Mindfulness-Based StressReduction
¡ “a structured public health intervention to cultivate mindfulness in medicine, healthcare and society” (p.1623)
¡ Includes gentle mindfulness yoga,progressive relaxation/body scanning,sitting guided meditation, and active meditations
¡ Studied MBSR Program
¡ 8-week program
¡ One 2.5-hour long group session per week
¡ 45-minute home practice 6 days per week with guided instructions and CDs

ASSESSMENT MEASURES
¡ Assessment measures included:
¡ Mental Fatigue Self-Assessment (MFS)
¡ Comprehensive Psychopathological Rating Scale (CPRS) for depression and anxiety
¡ Neuropsychological tests such as theTrail Making Test and tests for digit coding/span and verbal fluency
¡ Participants assessed at baseline and post-intervention
¡ MBSR Group 1 participants assessed at baseline and upon completion of MBSR program
¡ Control Group/MBSR Group 2 participants assessed at baseline, upon Group 1’s completion of MBSR program, and upon
completion MBSR program
¡ Primary end-point measure MFS score
¡ Secondary end-point measures neuropsychological test results, specifically information processing speed and attention

RESULTS
¡ MFS score improvements of about 5 pointsfor both groupspost-intervention
¡ No change in MFS score for Control Group
¡ Significant decreasesin general and mental fatigue,sensitivity to stress,depressed feelings,anxiety,pessimistic
thoughts,irritability,concentration difficulty,and slownessof thinking post-intervention
¡ Significant increasesin sleep quality and processing speed post-intervention
¡ Results independent of time since injury,gender,otherdemographic factors
¡ Researchers acknowledge deficitsrelated toABI a barrier for participation in MBSR programs,but emphasize that
the intervention’s adaptability and repetitive,guided nature make it successful in increasing attention and
decreasing mental fatigue

APPLICATION
¡ MBSR“offers strategies to better handle stressful situations
appropriately and economize with mental energy” (p. 1627)
¡ How can we bring these benefits to ResCare PremierTexas?
¡ Extending group learning by integrating topics throughout groups and
ensuring that they permeate daily programming
¡ Supporting home practice by supporting direct care staff

REFERENCE
Johansson,B.,Bjuhr,H., & Ronnback,L.(2012).Mindfulness-basedstress
seduction improves long-term mental fatigue after stroke orTBI.
Brain Injury,26,1621-1628.

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/229089854
Mindfulness-based stress reduction (MBSR)
improves long-term mental fatigue after stroke
or traumatic brain injury
Article in Brain Injury · July 2012
Impact Factor: 1.81 · DOI: 10.3109/02699052.2012.700082 · Source: PubMed
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Brain Injury, December 2012; 26(13–14): 1621–1628
ORIGINAL ARTICLE
Mindfulness-based stress reduction (MBSR) improves long-term
mental fatigue after stroke or traumatic brain injury
B. JOHANSSON, H. BJUHR, & L. RO¨ NNBA¨ CK
Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska
Academy, University of Gothenburg, Gothenburg, Sweden
(Received 31 August 2011; revised 28 May 2012; accepted 30 May 2012)
Abstract
Objective: Patients who suffer from mental fatigue after a stroke or traumatic brain injury (TBI) have a drastically reduced
capacity for work and for participating in social activities. Since no effective therapy exists, the aim was to implement
a novel, non-pharmacological strategy aimed at improving the condition of these patients.
Methods: This study tested a treatment with mindfulness-based stress reduction (MBSR). The results of the programme
were evaluated using a self-assessment scale for mental fatigue and neuropsychological tests. Eighteen participants with
stroke and 11 with TBI were included. All the subjects were well rehabilitated physically with no gross impairment
to cognitive functions other than the symptom mental fatigue. Fifteen participants were randomized for inclusion in the
MBSR programme for 8 weeks, while the other 14 served as controls and received no active treatment. Those who received
no active treatment were offered MBSR during the next 8 weeks.
Results: Statistically significant improvements were achieved in the primary end-point—the self-assessment for mental
fatigue—and in the secondary end-point—neuropsychological tests; Digit Symbol-Coding and Trail Making Test.
Conclusion: The results from the present study show that MBSR may be a promising non-pharmacological treatment
for mental fatigue after a stroke or TBI.
Keywords: Mental fatigue, TBI, stroke, MBSR, mindfulness, information processing speed, attention
Introduction
Mental fatigue is common and disabling after
a stroke or traumatic brain injury (TBI) [1–3]. The
symptom is included in (and defined within) the
diagnoses Mild cognitive impairment, Neurasthenia
and Post-traumatic brain syndrome. Persistent
mental fatigue is also commonly reported after TBI
and stroke, irrespective of severity [4–8]. The person
who suffers from this mental fatigue is able to
perform activities involving mental effort for short
periods only and, notably, it will take longer than
normal to restore energy levels after being
exhausted. This mental fatigue will make it more
difficult for the person to return to work and
participate in social activities. Accompanying symp-
toms, such as irritability, sensitivity to stress, con-
centration difficulties, emotional instability and
headache may further impair social interactions [2,
9–11]. Many suffer for years in the absence of an
adequate treatment.
It was estimated that 30% of TBI victims suffer
from severe fatigue 6 months after the injury [12].
Improvement was reported during the first year,
after which it was limited [13]. Thus, up to 70%
reported fatigue 5 years after TBI [6] and O’Connor
et al. [14] reported that the fatigue may be present
even 10 years after the trauma. The degree of mental
fatigue after TBI is not related to the severity of the
Correspondence: Birgitta Johansson, Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska
Academy, University of Gothenburg, Per Dubbsgatan 14, 1tr, SE 413 45 Gothenburg, Sweden. Tel: þ46-31-3421000. Fax: þ46-31-3422467.
E-mail: birgitta.johansson2@vgregion.se
ISSN 0269–9052 print/ISSN 1362–301X online ß 2012 Informa UK Ltd.
DOI: 10.3109/02699052.2012.700082
BrainInjDownloadedfrominformahealthcare.combyGoteborgsUniversityon12/05/12
Forpersonaluseonly.

brain injury, age or time since injury [8]. Factors
which could be significant in determining whether
the mental fatigue will be referred to as persistent
include genetic variations [15] as well as previous
psychiatric disease [16]. Furthermore, fatigue after
brain injury was suggested not to be explained as an
effect of depression, pain or sleep disturbance [17].
Persistent mental fatigue is also commonly reported
after stroke, irrespective of severity [4, 5, 7, 18–21].
Mental fatigue is suggested to be a diffuse or
multi-focal brain disorder [22] related to decreased
neuronal efficiency [3], with extreme sensitivity to
mental and concentration activities [23]. The con-
nection to concentration activities is clearly noticed
in the fluctuation in the fatigue over daytime, with
morning most often reported as the best time of the
day and afternoon and evening being the worst [9].
Azouvi et al. [24] proposed that mentally tiring
activities after brain injury are related to reduced
resources and that patients with brain injury also
describe mental activity as more energy-demanding
than healthy persons. After a severe TBI, subjects
showed an increase in reaction time during a dual-
task condition and reported a higher subjective
mental effort. TBI subjects also performed slower
on a complex attention test, made more errors
and reported a higher level of subjective fatigue [25].
These results reflect the recent results from this
group [9].
For some individuals affected by long lasting
mental fatigue, it can take several years to find the
right balance between rest and activity in daily life,
find strategies and to accept the new situation.
Since no effective therapy exists today, the authors
have endeavoured, in this study, to find a suitable
method with the intention of relieving the long-term
burdens of mental fatigue including concentration
problems and helping patients to find a balance
in the performance of ordinary activities and accep-
tance in their daily lives. Therefore, a treatment
with mindfulness-based stress reduction (MBSR)
was tested. MBSR is designed for an heterogeneous
population. It is an educational programme, not
about training to remove something unwanted,
but rather to learn to live life to the fullest. MBSR
is a clinically effective method for a wide range
of conditions as stress, depression, pain and fatigue
and cancer, with the potential of helping individuals
to cope better with their difficulties [26–29].
Mindfulness meditation is also suggested to be
linked to improvement in attention and cognitive
flexibility [30] and changes in brain neuronal con-
nectivity, with indicated improved attention [31].
The effect with MBSR on mental fatigue after
TBI and stroke has not previously been studied.
It is hypothesized that, compared to the waitlist
regime, patients randomly assigned to the MBSR
programme will experience improvement at 8 weeks
in their assessment of mental fatigue (MFS).
This study used the following as end-points: a self-
evaluation questionnaire for mental fatigue (MFS,
mental fatigue scale) [10] and neuropsychological
tests to determine processing speed, attention and
working memory, all cognitive functions connected
to mental fatigue after TBI and stroke [9].
Materials and methods
Subjects
Twenty-nine stroke or TBI victims were included.
They were all healthy and held positions of employ-
ment before falling ill or becoming injured. All
participants had recovered from neurological symp-
toms but had been suffering from pathological
mental fatigue for at least 1 year before inclusion.
In comparison with healthy subjects, the cognitive
level was very similar to the anticipated level indi-
cated in the standardized norms relating to neuro-
psychological tests and also in comparison with the
findings of previous studies of participants with
mild TBI, also suffering from mental fatigue [9].
At the start of the study, each person had attained
a steady-state level concerning social and occupa-
tional performance. The persons included in the
study were recruited from an advertisement in a local
daily newspaper. Both men and women were
included. All participants provided an informed
consent. The study was approved by the Ethical
Review Board, Gothenburg, Sweden, dno. 408-10.
Inclusion criteria
(1) Subjects who, >12 months earlier, suffered a
stroke or TBI.
(2) Aged 30–65.
(3) Glasgow Outcome Scale (extended), moderate
disability ($5) or a score indicating a higher
level of recovery.
(4) Self-assessment questionnaire for mental fati-
gue, with a score of 10 or higher.
Exclusion criteria
(1) Significant co-morbidity including psychiatric
or neurological disorder. No history of alcohol
or drug abuse.
(2) Significant cognitive impairment.
Medication permitted
Stable therapies were allowed. This was defined as
therapies which had started at least 6 months before
1622 B. Johansson et al.
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inclusion and had continued unchanged during
the study period.
Description of study
The participants were randomized, either to the
MBSR group 1 or to the control group who were
placed on a waitlist for the MBSR programme at
a later stage (MBSR group 2, Figure 1). All were
assessed before the start and after 8 weeks. Fifteen
individuals were included in the MBSR group 1
programme. One of the participants decided not to
start. Furthermore, extensive cognitive difficulties
became apparent during the pre-assessment for one
participant and that person would not have been
able to start on the basis of the inclusion criteria.
However, the person wanted to try the MBSR
programme, but stopped after the first session, as it
was not possible to follow the instructions for
the programme. During the MBSR programme,
one dropout was reported after 3 weeks. A total of
12 persons completed the MBSR programme
(group 1). The control group on waitlist for MBSR
consisted of 14 persons. One of the controls declined
the MBSR programme offered at a later stage, due
to a shortage of time. The travel to the sessions was
too taxing for one person who was extremely tired.
Two persons dropped out after one and three
sessions, respectively. Ten persons subsequently
completed the second MBSR group programme
(group 2).
MBSR method
MBSR is a structured public health intervention
to cultivate mindfulness in medicine, healthcare
and society. It includes a range of both formal
and informal practices. The intervention is based on
Kabat Zinn’s [32] MBSR programme. The formal
practices in MBSR are described by Cullen [33] and
include gentle Hatha yoga (with an emphasis
on mindful awareness of the body), the body scan
(designed to systematically, region-by-region, culti-
vate awareness of the body without tensing and
relaxing of muscle groups associated with progres-
sive relaxation) and sitting meditation (awareness
of the breath and systematic widening the field
of awareness to include all four foundations of
mindfulness: awareness of the body, feeling tone,
mental states and mental contents). As such, the
intention of MBSR is much greater than simple
stress reduction. The programme consists of eight
weekly $2.5-hour long group sessions, one day-long
silent led retreat between session six and seven
and home practice of $45 minutes, 6 days a week.
They received guided instructions and CDs for
home practice.
Measures
The assessments included self-assessment of men-
tal fatigue (MFS), the level of depression and
anxiety and neuropsychological tests. The MFS
is a multidimensional questionnaire containing
15 questions [9, 10]. It incorporates affective,
cognitive and sensory symptoms, duration of sleep
and day-time variation, all common symptoms after
brain injury and stroke [11]. The Comprehensive
Psychopathological Rating Scale (CPRS) was used
for depression and anxiety [34]. The neuropsycho-
logical tests measured information processing speed,
attention and working memory. The tests included
were Digit Symbol-Coding and Digit Span from the
WAIS-III scale [35], the FAS verbal fluency test [36]
and the Trail Making Test (TMT) A and B [37].
A series of new Trail Making Tests (C, D) were
constructed to evaluate higher demands such as dual
tasks. The tests were constructed with three and four
factors, respectively [9]. Reading speed was mea-
sured with a test used for dyslexia screening [38].
End-points
The primary end-point was to investigate the ther-
apeutic effects of MBSR as measured by the MFS.
Secondary end-points were the results from neuro-
psychological tests, with specific focus on informa-
tion processing speed and attention.
Statistical analysis
A comparison between the groups was made and
the ANCOVA analysis of covariance was conducted
for this purpose. The paired t-test was used
for repeated measurements within groups. The
Mann-Whitney U-test was used when analysing
separate items included in the self-assessment
scales. The Bonferroni adjustment was used after
multiple comparisons. Pearson’s correlation was
used to find the correlation between mental fatigue
and processing speed. SPSS 16.0 for Windows was
used for data analysis.
Results
Demographic data
No significant differences in age and education were
found between the MBSR group 1 and the control
Figure 1. Schematic presentation of study design.
Mindfulness (MBSR) and mental fatigue 1623
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group on waitlist, but the control group reported
a longer time since brain injury or stroke (Table I).
However, there were no variables which correlated
significantly to time since injury or stroke. As age
has an effect on cognitive function and the time
since injury differed, ANCOVA analysis of covari-
ance was conducted to adjust for differences in
variables relating to age and time since injury/stroke.
Furthermore, no differences were found between
gender and type of disorder in any of the variables
included in the self-assessment and the measure-
ments of cognitive functions.
Self-assessment scales
The MBSR group 1 and the control group
on waitlist did not differ significantly in their
self-assessment of MFS at the start of the pro-
gramme (ANCOVA, F ¼ 1.16, p ¼ 0.29), but there
was a significant difference between the two groups
after 8 weeks (F ¼ 8.47, p ¼ 0.008, Figure 2). The
participants who completed the MBSR programme
(group 1) showed a decline in their self-assessment
of MFS (paired T-test, p ¼ 0.004), while the control
group was unchanged during the 8 weeks (paired
T-test, p ¼ 0.89, Figure 2). The control group
completed the MBSR programme (MBSR group
2) at a later stage and they also showed a similar and
significant decline in the MFS after 8 weeks of
MBSR (p ¼ 0.002, Figure 2). Depression and anx-
iety were not changed when comparing the MBSR
and control group on pre- and post-test. However,
a repeated measure (paired t-test) detected signifi-
cantly decreased scores over time for both MBSR
Figure 2. Mean (Æ SEM) score for reported mental fatigue (MFS). Test 1 (pre-test) before MBSR or controls on waitlist and test
2 (post-test) after 8 weeks with MBSR or controls on waitlist. MBSR group 2 (the former controls on waitlist) before and after MBSR
(tests 2 and 3).
Table I. The distribution of individuals according to the following groups: age, education, sick leave, time since
injury or stroke and also the distribution and numbers of males and females.
MBSR
group 1
Control group
on waitlist
MBSR
group 2
Number of persons who completed the programme 12 14 10
Age (M Æ SD) 53.7 Æ 6.11 57.1 Æ 7.26 59.1 Æ 6.3
Years since TBI/stroke (M Æ SD) 3.3 Æ 3.84 9.8 Æ 7.54 10.5 Æ 8.42
Education (years, M Æ SD) 15.9 Æ 2.2 15.5 Æ 3.2 15.5 Æ 3.3
Females/males 5/7 10/4 7/3
TBI/stroke 5/7 5/9 5/5
Numbers on sick leave (0, 25, 50 or 100%) 3–0% 2–0% 2–0%
1–25% 2–25% 1–25%
2–50% 0–50% 0–50%
1–75% 1–75% 1–75%
5–100% 9–100% 6–100%
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groups for depression (MBRS group 1, p ¼ 0.006;
MBSR group 2, p ¼ 0.002) and anxiety (MBRS
group 1, p ¼ 0.004; MBSR group 2, p ¼ 0.02).
No such changes were found for the control group
on waitlist (depression, p ¼ 0.84; anxiety, p ¼ 0.79).
The anxiety and depression scores were low
(Figure 3).
Separate questions included in the
self-assessment scales
As both groups who received MBSR changed in a
very similar pattern for MFS and CPRS, the two
groups were grouped together for the statistical
analysis of separate items (24-hour variation not
included here, Figure 3). The items from the MFS,
tiredness, mental fatigue, mental recovery, slowness
of thinking and sensitivity to stress were significantly
decreased after MBSR. The over-lapping items were
on an intermediate level and the items which were
significantly decreased were irritability and lack
of initiative, while none of the specific items for
depression and anxiety from CPRS were signifi-
cantly decreased (Mann-Whitney, corrected for
multiple comparison using the Bonferroni-Holm
approach). In total, there were higher scores for
the items included in the mental fatigue scale
compared with the items depression and anxiety in
the present study.
The report showing a distinct difference in
24-hour variation was not included in the above
analysis as it only measures yes or no. Eight of the
participants in the MBSR group 1 were reported as
having a clear 24-hour variation during the day and,
of these, seven participants reported morning to be
the best time of day, both at pre- and post-test.
From the waitlist group, 13 participants reported
a distinct 24-hour variation and, for 10 of these,
morning was the best time of day and, at the post-
test, 11 reported a 24-hour variation.
Cognitive tests
Between-group analysis. The MBSR group 1 and
the control group on waitlist did not differ signifi-
cantly on the cognitive tests at the pre-test, except
that MBSR group 1 was faster than controls on
TMT A (p ¼ 0.049). This effect was similar at
the post-test (p ¼ 0.032). This may reflect a slight
difference between the groups from the outset.
However, the between-group analysis detected a
significant effect after 8 weeks. The MBSR group 1
performed TMT B and TMT C faster than controls
on waitlist (ANCOVA, TMT B; F ¼ 7.39, p ¼ 0.013,
TMT C; F ¼ 4.84, p ¼ 0.039, Figure 4). TMT B
is considered as a divided attention test. However,
after adjustment for processing speed in this study
(TMT A was used as a covariate; TMT A is mainly
focused on visual scanning and motor speed), the
Figure 3. The figure shows the median values for each self-assessed item for the mental fatigue (MFS) and depression and anxiety (CPRS)
scales before and after the MBSR programme. Items occurring in both scales are encircled. Both groups who received MBSR are grouped
together in the figure, since there was a very similar pattern in the changes in these groups for mental fatigue and depression and anxiety.
In the figure, higher scores reflect a more severe symptom. A rating of 0 corresponds to normal function, 1 indicates a problem, 2 indicates
a pronounced symptom and 3 indicates a maximal symptom.
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effect disappeared, for TMT B and TMT C, indi-
cating a limitation in processing speed. The same
effect for TMT B was reported by Felmingham
et al. [39].
Within-group analysis. Repeated measures (paired
t-test) within the separate groups revealed a signif-
icant improvement on TMT C as well as Digit
Symbol-Coding for both groups after MBSR
(TMT C; group 1: p ¼ 0.001, group 2: p ¼ 0.007,
digit coding; group 1: p ¼ 0.026, group 2: p ¼ 0.028,
Figure 4). A significantly improved result was
also found for the MBSR group 1 on TMT B
(p ¼ 0.017). No significant changes over time were
detected for the control group on waitlist. A signif-
icant increase in word fluency over time was also
reported for the MBSR group 1 (p ¼ 0.050) and
group 2 (p ¼ 0.044), but not for the control group
(p ¼ 0.081). No significant changes were found for
working memory, TMT A, D and reading speed.
Correlation between changes in mental fatigue and
information processing speed
The participants from the two MBSR groups
improved in a similar way, both in MFS (less total
score) and increased processing speed (more cods/
2 minutes, Digit Symbol-Coding). The difference in
improvement between pre- and post-test were used
in a correlation analysis and a significant correlation
for improvement in mental fatigue and information
processing speed was detected (r ¼ À0.48, p ¼ 0.023,
Figure 5).
Discussion
According to this study, MBSR appears promising
for the treatment of persons suffering from mental
fatigue after stroke or TBI, as statistically significant
results were obtained from both primary and
secondary end-points (MFS and tests quantifying
information processing speed, respectively).
Improvement was independent of gender, type
of injury, as well as time since injury or stroke
and age.
No other studies have been performed to deter-
mine the effect of MBSR on mental fatigue.
However, a small study of 10 subjects who were
included in the MBSR programme for 12 weeks after
mild TBI showed significantly improved quality-
of-life and decreased depression [40]. However,
a randomized study with a short MBSR programme,
over a 4-week period, did not detect any subjective
or cognitive changes [41].
Mental fatigue theories suggest that cognitive
activities require more resources than normal [24]
and result in a greater neural activity compared
Figure 4. Cognitive tests (mean Æ SEM). Trail Making Test B and C and Digit Symbol-Coding shown for MBSR group 1 before and after
MBSR, controls on waitlist before and after the 8 weeks and also the effect of MBSR for group 2.
Figure 5. There was a significant correlation (r ¼ À0.48,
p ¼ 0.023, post- minus pre- test value was used) between
decreased mental fatigue (MFS) and improved processing speed
(Digit Symbol-Coding) after MBSR for both groups.
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to controls during a given mental activity [42]. This
indicates an increased cerebral effort after brain
injury. One reason why MBSR was effective may
be that this treatment offers strategies to better
handle stressful situations appropriately and econo-
mize with mental energy.
Mindfulness intervention is fundamentally based
on a disciplined practice which involves cultivating
awareness for the present moment in order to
become wise and compassionate, awake and aware.
For people suffering from mental fatigue this causes
a dilemma, since tiredness, which is named as one of
the classical hindrances to cultivating mindfulness
in the Buddhist scriptures, is more or less constantly
present. Interestingly, after three or four MBSR
sessions together with the teacher, the participants
attended the sessions more awake and the introduc-
tion of new techniques with more physical involve-
ment as yoga and walking meditation facilitated
focused attention. Through the programme new
techniques for everyday use were practiced in
the struggle to find a good balance between activity
and rest.
Difficulties remembering newly-introduced prac-
tices were common among the participants, as well
as difficulties remembering themes from group dis-
cussions and learning dialogues with the teacher.
Considerations were taken to this and also to the
participants needs for more time to pause and reflect.
The main themes and content of the programme was
securely kept and repeated. Overall, adaptation
of the programme were required to find a tempo of
teaching and enable learning and insights without
leaving the participants more tired by the full agenda
and rich content of the programme.
Meditation techniques in healthy subjects were
suggested to improve attention performances,
processing speed and cognitive flexibility [30].
Mindfulness meditation (MBSR) is also associated
with changes in brain activity involved in attention
[31, 43]. Subjects with mental fatigue have difficul-
ties within these domains and will easily become
even more fatigued if the activity is not adapted to
their capabilities. It is, therefore, interesting to see
that MBSR seems to increase attention and also
processing speed. Mental fatigue may be caused by a
dysfunction or imbalance in the signalling system(s)
in the brain and that the brain works with less
precision [42]. Improvements in the neural network
may have been achieved during the course of this
study.
Limitations
A limitation of this study is that the numbers of
participants were relatively small. More participants
are warranted to be included in future studies and it
is anticipated that the study effects over time of such
studies will be extremely valuable.
Conclusion
Patients suffering from mental fatigue after a stroke
or TBI are an extremely important group to identify
and treat, from healthcare and socio-economic
points of view, due to their impaired capacity to
work. There is currently no therapy available to treat
this symptom. Therefore, novel therapies, both
pharmacological and non-pharmacological, would
be of the utmost importance. The results from this
study are extremely promising.
Acknowledgement
The authors express their gratitude to Ingrid
Grunde´n for bringing up the idea of mindfulness
and taking part in the early planning of the study.
Declaration of Interest: The authors report
no conflicts of interest. This work was supported
by grants from AFA Insurance and The Health &
Medical Care Committee of the Region Va¨stra
Go¨taland.
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Forpersonaluseonly.

A MULTI-DISCIPLINARY SOCIAL COMMUNICATIONAND COPING
SKILLS GROUP INTERVENTION FOR ADULTSWITHACQUIRED BRAIN
INJURY: A PILOT FEASIBILITY STUDY IN AN INPATIENT SETTING
APPLETON, S., BROWNE,A.,CICCONE, N., FONG,K., HANKEY, G., LUND, M., . . .YEE,Y. | JANUARY 2011 | BRAIN IMPAIRMENT

SETTING & PARTICIPANTS
¡ Study conducted in partnership with Australian state-supportedAcquired Brain Injury (ABI) rehabilitation and
neurorehabilitation services
¡ ABI rehabilitation service a 29 bed unit with 48.6 day average LOS
¡ Neurorehabilitation service a 27 bed unit with similar LOS
¡ Inclusion criteria included:
¡ ABI rehabilitation and neurorehabilitation inpatients
¡ English-speaking
¡ Aged 18 to 59
¡ Mid-to-moderate high level language difficulties
¡ Severe-chronic ABI diagnosis
¡ No minimum or maximum time post-injury but most within 1 year
¡ 15 participants completed baseline assessment,9 completed a majority of the intervention,and 7 completed the
3-months post-intervention assessment

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