An Evaluation of a Cognitive Rehabilitation Group for

An Evaluation of a Cognitive

Rehabilitation Group for Individuals

with Neurological Conditions

Rachel Crane

Commissioned by Dr Trishna Gandhi

Clinical Health Psychology

Pinderfields Hospital

The Mid Yorkshire Hospitals NHS Trust

Service Evaluation Project: Cognitive Rehabilitation Group – Neurological Conditions

Prepared on the Leeds D.Clin.Psychol. Programme, 2019

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Contents Page

Introduction .................................................................................................................................................. 4

Commission ................................................................................................................................................... 4

Overview of Service ...................................................................................................................................... 4

Overview of Group ....................................................................................................................................... 4

Literature Review ......................................................................................................................................... 5

Aims ............................................................................................................................................................... 7

Methodology.................................................................................................................................................. 7

Ethics ............................................................................................................................................................. 7

Design ............................................................................................................................................................ 8

Qualitative Data ......................................................................................................................................... 8

Quantitative Data ....................................................................................................................................... 9

Participants ................................................................................................................................................... 9

Data Collection ............................................................................................................................................10

Outcome measures ....................................................................................................................................10

Patient Health Questionnaires (PHQ-9) ..............................................................................................10

Generalised Anxiety Disorder (GAD-7) ...............................................................................................10

Procedure .....................................................................................................................................................11

Analysis ........................................................................................................................................................11

Qualitative data analysis ...........................................................................................................................11

Quantitative data analysis .........................................................................................................................12

Reflexivity.....................................................................................................................................................13

Results ..........................................................................................................................................................13

Demographics ..............................................................................................................................................13

Group set-up ................................................................................................................................................14

Location ....................................................................................................................................................14

Parking ......................................................................................................................................................14

Timings .....................................................................................................................................................14

Figure 1. Presentation of the Themes and Sub-themes from the Cognitive Rehabilitation Group

(questions 3-7) ..............................................................................................................................................16

Theme 1: Usefulness of the group ..............................................................................................................17

Subtheme 1a: Sense making .....................................................................................................................17

Subtheme 1b: Learning new skills ............................................................................................................17

Subtheme 1c: Improved knowledge..........................................................................................................18

Subtheme 1d: Mindfulness .......................................................................................................................18

Subtheme 1c: Psychological well-being ...................................................................................................18

Theme 2: Mindfulness .................................................................................................................................18

Subtheme 2a: Thinking skills ...................................................................................................................19

Subtheme 2b: Barriers ..............................................................................................................................19



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Subtheme 2c: Prior experience .................................................................................................................19

Subtheme 2d: Acceptance .........................................................................................................................19

Subtheme 2e: Imagery ..............................................................................................................................20

Subtheme 2f: Well-being ..........................................................................................................................20

Theme 3: Improvements .............................................................................................................................20

Subtheme 3a: Family work .......................................................................................................................21

Subtheme 3b: Identity ...............................................................................................................................21

Subtheme 3c: Sharing personal experiences .............................................................................................21

Subtheme 3d: Resources and questionnaires ............................................................................................22

Subtheme 3e: Physical impact ..................................................................................................................22

Subtheme 3f: Session length .....................................................................................................................22

Quantitative Outcome Measures ................................................................................................................22

Discussion .....................................................................................................................................................23

Conclusions ..................................................................................................................................................25

Recommendations........................................................................................................................................25

Identity and family involvement .....................................................................................................25

Resources ........................................................................................................................................25

Length of sessions ...........................................................................................................................26

Strengths and Limitations ..........................................................................................................................26

Dissemination ...............................................................................................................................................27

References ....................................................................................................................................................28

Appendix A: Neuropsychology Service Pathway ......................................................................................31

Appendix B: Ethics Confirmation Email ..................................................................................................32

Appendix C: SEP Questionnaire ................................................................................................................32

Appendix D: Interview Topic Guide ..........................................................................................................36

Appendix E: Patient Health Questionnaire (PHQ-9) ...............................................................................37

Appendix F: Generalised Anxiety Disorder (GAD-7) ..............................................................................38

Appendix G: Patient Information Sheet ....................................................................................................39

Appendix H: Timings and Location of Group ..........................................................................................41

Appendix I: Consent Form .........................................................................................................................42

Appendix J: Poster Presented at SEP Poster Conference ........................................................................43



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Introduction

Commission

This Service Evaluation Project (SEP) was commissioned by Dr Trishna Gandhi (Clinical

Psychologist) of the Clinical Health Psychology Department at Pinderfields Hospital,

Wakefield. The aim of the SEP was to evaluate the effectiveness of a 6-session cognitive

rehabilitation group for people with neurological conditions. The SEP also explored

feedback regarding the application of mindfulness-based strategies completed in the group.

The information collected from the SEP will be used to inform the content of future groups.

The SEP was approved by the Faculty of Medicine and Health Research Ethics Committee

in December 2018 (DClinREC18-003).

Overview of Service

The Clinical Health Psychology Department provides psychology services to individuals

over the age of 18 who have been diagnosed with a neurological condition, who are under

the care of a Mid Yorkshire NHS Hospitals Trust Consultant in Neurology, Stroke, or

Neurorehabilitation. The department also provides services to individuals within the

Wakefield district who are under the care of a neurologist. The service currently provides

outpatient appointments which are offered across two sites: Pinderfields Hospital and

Dewsbury District Hospital. There are three services for patients within the department.

These include: (1) the neurological assessment service, (2) the neuropsychological therapy

and rehabilitation service and (3) the assessment and formulation service for people with a

Functional Neurological Disorder. The referral pathway can be found in Appendix A.

Overview of Group

The cognitive rehabilitation group aims to provide individuals with strategies to help them

cope better with difficulties (e.g. cognition, mood and daily living skills) often associated

with neurological conditions. The group runs for 6 weeks. Topics covered during the group

are described in Table 1.



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Table 1. Overview of group sessions.

Literature Review

The number of people living with a neurological condition in England is rising and will

continue to increase (The Neurological Alliance, 2018). Neurological conditions such as

motor neurone disease and epilepsy can result from damage to the brain, spinal column or

peripheral nerves. Some neurological conditions are life threatening, with many conditions

affecting an individual’s quality of life (NHS England, 2019). Neurological conditions can

have a range of causes including genetic factors, progressive illness, traumatic injury,

infection or sudden onset injuries to the brain (The Neurological Alliance, 2017).

The direct effect of a neurological condition, as well as the side effects of treatment, may

affect an individual’s quality of life. Difficulties with low mood, identity and adjustment

are often reported and can affect an individual’s psychological well-being (Gupta et al.,

2008). The Neurological Alliance (2017) reported that 52% of neurology patients reported

having one or more co-morbid mental health conditions (anxiety and depression) alongside

their neurological condition and have the highest co-morbidity of mental health conditions

out of all long-term health conditions (NHS England, 2016), demonstrating the high level

of mental health, emotional and cognitive need for individuals living with a neurological

condition. Providing effective psychological support for the treatment of these difficulties

can be challenging for clinicians and requires specialist expertise in which clinical

neuropsychology services can offer (The Neurological Alliance, 2019).

Week Topic

1 Introduction to the brain

2 Attention

3 Memory

4 Executive function

5 Other factors that can affect cognitive functioning

6 Review



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Providing psychoeducation for patients with neurological conditions offers a cost-effective

way of improving health-related quality of life and can reduce costs in other aspects of

healthcare (The Neurological Alliance, 2018). Psychoeducation refers to the process in

providing education and information to individuals with physical and/or mental health

difficulties. The goal of psychoeducation is to help people to better understand their

condition. Research shows that individuals who have a better understanding of their

condition demonstrate better coping abilities and have an increased awareness of their

strengths in being able to manage their condition more effectively (Barley & Lawson,

2016; Donker, Griffiths, Cuijpers, & Christensen, 2009). Forman and Lincoln (2009) found

a significant reduction in depression for individuals who attended group psychotherapy for

multiple sclerosis (MS) compared to individuals on the control waiting-list, suggesting

group interventions can be beneficial for individuals living with a neurological condition.

Mindfulness-based approaches can be used to manage psychological wellbeing and are

frequently used within healthcare settings (Keng, Smoski, & Robins, 2011; Mars & Abbey,

2010). Mindfulness-based strategies are thought to have a positive effect on an individuals’

health and well-being by reducing the impact of the behavioural, emotional and cognitive

patterns often associated with neurological conditions (Kang, Gruber, & Gray, 2013).

Research has also demonstrated that mindfulness interventions can have positive effects

for anxiety and low mood (Evans et al., 2008). Emerging evidence has found a relationship

between mindfulness and certain aspects of attentional functioning (Moore & Malinowski,

2009). Furthermore, mindfulness for neurological conditions has been associated with

improved self-regulation and attentional skills (Immink, 2014). Attentional difficulties are

often associated with neurological conditions which make mindfulness-based strategies

particularly beneficial for this clinical population (Ulrichsen et al., 2016). One group

programme offering support to individuals with MS, which involved lifestyle and

mindfulness training alongside the individual’s conventional medical care, demonstrated

an improvement in patient quality of life (Hadgkiss et al., 2013).



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Aims

The aim of the SEP was to evaluate the effectiveness of the cognitive rehabilitation group.

The SEP looked at whether the group improved participants’ knowledge and understanding

about their cognitive difficulties, and whether they were able to apply strategies outside of

sessions. The SEP also explored feedback regarding what was helpful and unhelpful with

a view to inform future groups. The SEP had a particular focus on exploring the usefulness

of mindfulness-based strategies. In collaboration with the commissioner, the SEP aimed to

answer the following questions:

1. How well was the group attended and were there any barriers to attendance?

2. How can the set-up, timing, facilities and location be maximised to increase

accessibility to the group?

3. What did group members find particularly helpful in attending the group?

4. How did group members find the mindfulness-based exercises and were they able to

practice these strategies outside of the group?

5. Is there anything which can be changed about the group to improve future groups?

6. Did group members feel that their understanding and knowledge of their neurological

condition changed after attending the group?

7. What did group members find unhelpful in attending the group?

8. Did members’ responses on the PHQ-9 and GAD-7 change after attending the group

(although this was not an explicit aim of the group)?

Methodology

Ethics



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The SEP was approved by the Faculty of Medicine and Health Research ethics committee

in December 2018 (DClinREC18-003; Appendix B).

Design

A mixed methods design was chosen for this SEP and is described in further detail below.

Qualitative Data

Part of the SEP involved collecting qualitative data from participants. Both a questionnaire

(Appendix C) and semi-structured telephone interview (Appendix D) were devised in

consultation with the commissioner to answer the SEP aims. A focus group was considered

but it was felt that individual telephone interviews and questionnaires would provide richer

detailed information. Furthermore, focus groups may have been an anxiety-provoking

experience in which participants may have different views and feel uncomfortable

expressing these in the presence of other patients (O.Nyumba, Wilson, Derrick, &

Mukherjee, 2018).

Individuals living with a neurological condition may experience difficulties with cognition.

Although telephone interviews allowed the researcher to ask follow-up questions and for

questions to be explored in more detail, there was a possibility that participants may find

this approach challenging due to difficulties with attention, memory and processing speed;

therefore, a questionnaire was devised which allowed participants to complete this in their

own time, in an environment with fewer distractions and less emotional pressure. The

questionnaire consisted of both open and closed questions.

Although a questionnaire design has many strengths, there are also limitations. Individuals

with a neurological condition may have difficulties understanding written information and

may find completing a questionnaire distressing. Participants were therefore given the

opportunity to complete a telephone-based interview. The interview schedule consisted of

open-ended questions and allowed the researcher to provide prompts to the participants,



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when required, and allowed for personal opinions and feelings to be described which may

not necessarily be offered by other means of data collection (e.g. a questionnaire).

Due to the described difficulties with both methods of data collection it was agreed, in

consultation with the commissioner, to offer participant’s the opportunity to complete both

a telephone interview and questionnaire.

Quantitative Data

Although measuring participant’s psychological well-being was not identified as a SEP

aim, the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) and

the Generalised Anxiety Disorder (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006;

Appendix E and F) were outcome measures routinely collected by the Service.

Pre- and post-group scores were compared; however, there are limitations to this design.

This includes the internal validity of scores (e.g. self-efficacy and that this may have

changed during the process of the group, as opposed to the effects of the group itself);

history (a pre-post design does not take into account any life events which occur outside of

the group which may have contributed to a chance in participant’s well-being) and the

effect of testing (did the questions increase participant self-awareness causing them to

answer the questions differently at the end of the group). Although there are limitations of

using a pre-post design, it was felt that this would be an appropriate way to collect

quantitative measures. Session-by-session monitoring was considered; however, this

would have required allocating more time at the end of each group session. Due to potential

cognitive difficulties, some participants may have found it difficult to complete

questionnaires at the end of each two-hour group. This then raised concerns relating to the

feasibility of administering outcome measures at the end of each session.

Participants

Participants involved in the SEP were recruited through the Cognitive Rehabilitation Group

held at Pinderfields Hospital, Wakefield. All group attendees were invited to take part in



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the SEP during session 5 by group facilitator, Dr Trishna Gandhi (Clinical Psychologist).

All participants were provided with participant information sheets (PIS; Appendix G). The

timings and location for the group are provided in Appendix H.

Data Collection

Outcome measures

Participants completed the PHQ-9 and the GAD-7 during session 1 and session 6 of the

group. The Clinical Health Psychology Department chose these measures over other mood

and quality of life measures because of their short length. The WSAS and Neuro-QOL are

also routinely collected by the Service but have not been included as part of this SEP.

Patient Health Questionnaires (PHQ-9)

The PHQ-9 (Kroenke et al., 2001) is a 9-item questionnaire which screens for depression.

Scores for each item range from 0 (“not at all”) to 3 “nearly every day” with a total score

ranging from 0 to 27. The PHQ-9 is a reliable (0.89) and valid measure of depression. The

PHQ-9 has an overall sensitivity of 0.84, a specificity of 0.72, and a positive likelihood

ratio of 2.86. A PHQ-9 score more than 10 has a sensitivity of 0.88 and a specificity of

0.88 for depression.

Generalised Anxiety Disorder (GAD-7)

The GAD-7 (Spitzer et al., 2006) is a 7-item scale that is used to measure the severity of

GAD. Each item asks the individual to rate the severity of their symptoms over the past

two weeks. Responses include “not at all”, “several days”, “more than half the days”, and

“nearly every day”, and are scored as 0, 1, 2, 3, respectively. GAD-7 scores range from 0

to 21, with scores of 5, 10, and 15 representing mild, moderate, and severe anxiety

symptom levels.



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A GAD-7 score of 10 has a sensitivity value of 0.89 and a specificity value of 0.82. Internal

consistency was 0.92 and test re-test reliability was 0.83 (Spitzer et al., 2006). The GAD-

7 has been reported to be the most appropriate measure to use within a clinical health

population, with evidence to suggest it is possible to distinguish between depression and

anxiety (Easton, Coventry, Lovell, Carter, & Deaton, 2016).

Procedure

Participants were provided with a PIS during session 5. At the end of session 6, the

researcher gained informed written consent from participants (Appendix I). Participants

were given the opportunity to complete the questionnaire at the end of session 6 or to

complete it at home and return back to the department at their next appointment. Telephone

interviews were arranged for the day after the group finished. This was to ensure that the

group was still familiar to participants in view of any potential cognitive difficulties.

Telephone interviews were originally going to be recorded using a Dictaphone from the

Trust; however, due to technical difficulties, this was not possible. The researcher,

therefore, scribed participant responses as close to verbatim as possible during the

telephone interview.

Analysis

Qualitative data analysis

Thematic analysis (Braun & Clarke, 2006) was used to analyse responses from participant

telephone interviews and open-ended questions from the questionnaire. According to

Braun and Clarke (2006), thematic analysis is a method for identifying, analysing, and

reporting themes within data. This facilitates organisation and allows for the data to be

described in detail. This method was chosen for its simplicity and that it would enable the

main recommendations for improvements to the group, as well as the usefulness of

mindfulness-based strategies, to be clearly identified. Furthermore, this form of data

analysis allowed for personal experiences to be explored in more detail and does not need

to be linked to any pre-existing theoretical framework (Braun & Clarke, 2006).



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Each participant was assigned a participant number to maintain anonymity. The steps taken

in the analysis are shown in Table 2.

Table 2: Stages of analysis (Braun & Clarke, 2006)

Stage Process

1 Responses collected and transcribed. Read and re-read and initial

thoughts noted.

2 Codes are generated through initial reading of the data, collating data relevant

to each code.

3 Codes are organised into potential themes and relevant coded data

extracts gathered within themes and subthemes.

4 Coded extracts for each theme are reviewed and an initial thematic map is

generated. Themes are reviewed ensuring internal homogeneity and external

heterogeneity.

5 Ongoing analysis to refine themes. Themes defined and named.

Validation of themes and subthemes by independent verifier.

6 Themes refined and thematic map created. Themes supported with a selection

of supporting data extracts.

A credibility check was conducted on the themes identified by another trainee clinical

psychologist, independent to the project. This was to check the face validity of the themes

identified by the researcher in order to maximise the reliability of results. A quality check

was also completed with the team commissioning the project.

Quantitative data analysis

The quantitative data pre- and post- were analysed to determine statistical and clinically

statistical significance.



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Reflexivity

I was previously on placement within the Clinical Health Psychology Department and was

based at Dewsbury District Hospital. Although I was no longer on placement at the time

of collecting the SEP data, I was aware that there was a possibility that I may have worked

with potential participants in some capacity prior to data collection (e.g. assessment,

service-user involvement). Whilst this did not appear to be an issue, it was still an important

factor to consider.

Prior to clinical training, I have worked in other NHS neurological rehab units. I was aware

of any pre-existing assumptions I may have had prior to this project and was aware of the

potential barriers in terms of cognitive abilities that may have arisen. Previous experience

helped to manage any difficulties during interviews (e.g. re-wording questions, giving

participants adequate time to answer the questions, providing reassurance) and facilitated

rapport and engagement during the data collection process.

Results

Semi-structured interviews, questionnaires and outcome measures provided both

quantitative and qualitative data. Participant quotes are included to ensure themes are well

represented. Two forms of participant data will be presented: quotes from interviews will

be numbered and quotes from questionnaires will be represented as letters. The results will

be presented based on the 8 study aims. The results from question 1 and 2 of the SEP aims

are reported below.

Demographics

7 patients originally attended the group; however, only 6 were recruited into the SEP as

one patient dropped out after session 3. This was prior to the researcher attending session

6 to get consent for participants to take part in the study; therefore, participant 7’s data was



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not used. All 6 participants consented to take part in the SEP during the last group session

and completed a telephone interview the day after the group finished. Out of the 6

participants who took part in the SEP, a total of 5 completed and returned the questionnaires

back to the department.

Group set-up

All participants described the set-up of the group as perfectly adequate. They described a

positive group ambiance which was quiet and free from interruptions. Participants felt that

sitting in a circle allowed them to engage effectively in discussions, although some felt that

having access to a table and/or clipboard when completing activities would have been

useful. All participants felt that the group was a good size. Whilst there was a lot of positive

feedback relating to the set-up of the group, participants acknowledged the emotional

impact of attending the group and at times found it hard to control their emotions in a group

setting.

Location

A sense of familiarity from previously attending the department for appointments was

reported; however, some participants found the signage in the hospital confusing and would

have benefited from better directions from reception staff.

Parking

The majority of participants did not drive due to their neurological condition and relied on

public transport or a lift. Participants felt that parking would have been an issue had they

driven due to limited disabled parking at Pinderfields hospital.

Timings

As the group started at 10am, participants using public transport had an early start to their

day. This could have been a potential barrier; however, on balance participants felt that the



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start time was better than a later time. None of the participants felt the group should start

any earlier.

Questions 3-7 from the study aims are described below and relate to the experiences of

participants attending the group and are highlighted in themes. Figure 1 illustrates a

thematic map of the qualitative thematic analysis which answer these questions. Each

theme is described in greater detail.

Subtheme 1a:

Being with peers

Subtheme 1b:

Learning new

skills

Usefulness of

group Subtheme 1c:

Improved

knowledge

Subtheme 1d:

Mindfulness

Subtheme 1e:

Psychological

well-being

Subtheme 3a:

Family work

Subtheme 3b:

Identity

Improvements Subtheme 3c:

Sharing personal

experiences Subtheme 3e:

Physical impact

Subtheme 3d:

Resources and

questionnaires

Subtheme 3f:

Session length

Mindfulness

Subtheme 2b:

Barriers

Subtheme 2d:

Acceptance

Subtheme 2a:

Thinking skills

Subtheme 2e:

Imagery

Subtheme 2f:

Well-being

Subtheme 2c:

Prior experience

Figure 1. Presentation of the Themes and Sub-themes from the Cognitive Rehabilitation Group (questions 3-7)

Theme 1: Usefulness of the group

The cognitive rehabilitation group was consistently referred to as a useful intervention by

participants. Participant responses demonstrated that the group was seen as more than just

a psychoeducational intervention allowing them to learn about their condition, new skills

and strategies. Attending the group allowed participants to ‘share and compare’ their

experiences with one another which facilitated a degree of sense-making and acceptance

in relation to their neurological condition. Participants also described an improved level of

self-awareness and psychological well-being which was supported through the use of

mindfulness exercises.

Subtheme 1a: Being with peers

“The bigger picture for me was hearing experiences from others who had a brain injury-

that was humbling and amazing”

(Participant 1)

“It’s definitely a worthwhile experience. You get more comfort listening to someone else

with a similar problem”

(Participant 5)

Subtheme 1b: Learning new skills

“I found the group useful to understand different strategies”

(Participant 5)

“I never thought of these skills before and I’ve improved when I didn’t think I would”

(Participant E)



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Subtheme 1c: Improved knowledge

“Feeling a bit more knowledgeable about what is going on and what to do to help me”

(Participant C)

Subtheme 1d: Mindfulness

“The mindfulness was really good”

(Participant 2)

“I found the mindfulness very relaxing”

(Participant 3)

Subtheme 1c: Psychological well-being

“I have not been getting as worried as much”

(Participant 3)

“It has helped me manage my stress and mood”

(Participant 5)

Theme 2: Mindfulness

Participants consistently reported that they found the mindfulness exercises useful,

particularly the visual exercises (e.g. leaves on a stream). Participants spoke about the

impact mindfulness had on their psychological wellbeing (e.g. feeling more calm, relaxed

and focused; improved self-awareness; feeling less stressed). Limited changes were

reported with their thinking skills, although one participant felt their concentration had

improved. Many spoke about adapting exercises and practicing these outside of the group;

however, some were unable to practice as much as they would have liked due to

neurological fatigue, limited time and difficulties prioritising and balancing mindfulness



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with family life. Whilst barriers to practicing mindfulness were identified, a common

theme which evolved related to previous experiences of mindfulness and this providing a

foundation for the exercises completed.

Subtheme 2a: Thinking skills

“I have learnt to concentrate on one thing at once without distraction”

(Participant 5)

Subtheme 2b: Barriers

“Limited extent of being able to practice strategies”

(Participant 1)

Subtheme 2c: Prior experience

“Input from Dr Charlotte gave me a foundation and the group sessions added to this”

(Participant 1)

“Mindfulness was really good… I have prior experience of this”

(Participant 2)

Subtheme 2d: Acceptance

“Increased acceptance of my disability. I’m not a failure if I cannot remember things. It’s

not my fault, they are valid reasons”

(Participant D)



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“I have learned to focus more on day to day tasks and not to pass judgement on my

thoughts”

(Participant E)

Subtheme 2e: Imagery

“I use leaves on a stream in the evening – I have a place in mind that I like to go there

with”

(Participant 6)

“I have adapted them as I found leaves on a stream hard, but the visualisation of the

beach was good -writing things in the sand and letting the waves wash them away”

(Participant 2)

“I adapted the strategies to fit with home environment e.g. mowing the lawn”

(Participant 1)

Subtheme 2f: Well-being

“I instantly go calm and relaxed”

(Participant 4)

“I have calm thoughts”

(Participant A)

Theme 3: Improvements

Whilst the group was described as helpful, participants were able to openly discuss what

they would like to see in future groups. Participants shared a sense of diminished identity

compared with before the neurological condition. Participants felt they would have

benefitted from topics which covered a loss in identity and how their brain injury has



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affected them physically. This filtered into participants discussing they would have liked

to have been offered more support in terms of sharing their condition with friends and

family. A startling theme described by the majority of participants related to having the

opportunity to share personal stories. Lastly, although the workbook was described as an

extremely useful resource and provided structure each week, participants spoke about how

they felt the worksheets needed updating as many of the activities were out of date and did

not relate to modern day living.

Subtheme 3a: Family work

“It would have been nice to cover how to get family to understand your disability”

(Participant 4)

Subtheme 3b: Identity

“Identity- who am I?”

(Participant B)

“We have all been damaged due to our brain injury – but for me, I am changed. I am not

nimble in body or brain compared to 9 months’ ago and I am still coming to terms with

that. I am diminished”

(Participant 1)

Subtheme 3c: Sharing personal experiences

“Maybe a sharing of brain injury if people wanted to share this information, that is”

(Participant C)

“We didn’t have much opportunities to talk about our own stories and came away

yesterday not knowing how other brain injuries happened and how long ago”

(Participant 1)



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Subtheme 3d: Resources and questionnaires

“Sheets could be more structured… found it difficult to read and write”

(Participant 2)

“I think they were helpful… only issue we had was that the worksheets were out of date”

(Participant 6)

Subtheme 3e: Physical impact

“The effect of senses being overwhelmed e.g. too much noise, too much activity…. And

how this affects you physically”

(Participant D)

Subtheme 3f: Session length

“Maybe a bit longer but would need to think about fatigue and tiredness… or spread out

over more sessions”

(Participant 2)

Quantitative Outcome Measures

Participant’s psychological pre- and post- well-being scores (as measured by the PHQ-9

and GAD-7) are presented in Table 3. Although not an explicit aim of the SEP, the results

show that only 1 participant had a statistical and clinically significant change on the PHQ-

9. The pre- and post- scores for all other participants did not demonstrate any change in

well-being scores.



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Table 3. Pre- and post- PHQ-9 and GAD-7 outcomes

*statistically significant **clinically significant change

The PHQ-9 states that if the difference between scores improves by more than 5 points,

this suggests a significant change with depressive symptoms. To achieve clinically

significant change, the client’s score is required to move from a clinical range of more than

10 at pre-treatment to a post-treatment score in the non-clinical range (9 or less).

The GAD-7 states that if the difference between scores was 4 or higher, this suggests a

significant change in anxiety. To achieve clinically significant change, the client’s score is

required to move from a clinical range of more than 8 at pre-treatment to a post-treatment

score in the non-clinical range (7 or less).

Discussion

This SEP provides a unique insight into the experience of individuals attending a 6-week

cognitive rehabilitation group. Despite there being a small number of participants involved

in the SEP, the themes emerging from the data did reach saturation. The major themes

which were identified were the usefulness of the group, mindfulness and improvements.

Other areas described related to the set-up and ambiance of the group.

PHQ-9 GAD-7

Participant Pre- Post- Change Pre- Post- Change

1 5 4 1 3 1 2

2 11 4 7* ** 5 7 -2

3 17 16 1 11 10 1

4 11 10 1 10 12 -2

5 26 21 5 20 21 -1

6 16 15 1 6 7 -1



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A consistent theme identified as part of this SEP related to the mindfulness exercises.

Research has shown that mindfulness-based strategies can have a positive effect on an

individuals’ well-being by reducing emotional patterns associated with neurological

conditions (Mars & Abbey, 2010). Whilst a reduction in anxiety and low mood was not

demonstrated on the GAD-7 and PHQ-9 measures, qualitative feedback provided by

participants demonstrated that the exercises had a positive influence on their psychological

well-being. Positively, most participants reported that they were able to practice, and adapt,

these exercises outside of the group. For a small proportion, however, this was a challenge

and raises the question of how professionals can support individuals to practice

mindfulness once the group has finished.

Whilst this SEP has shown the positive influence that mindfulness can have on participant’s

psychological well-being, contrary to previous research which reports that mindfulness can

improve attention (Norris, Creem, Hendler, & Kober, 2018), limited improvement with

thinking skills (e.g. attention and concentration) was reported. Future research may be

interested in looking at the impact mindfulness has on thinking skills in a more standardised

way, for example, formal cognitive assessment.

Hope has been identified as a key attribute required for neurological rehabilitation (Soundy,

2013). This, alongside a sense of validation, was also an outcome reported by participants.

Barnard (1995) used a paradox to describe that “people with chronic conditions are

impelled at once to defy limitations in order to realise greater life possibilities and to accept

limitations in order to avoid enervating struggles with immutable constraints” (1995, p.

39). It is not surprising that participants from the group not only acknowledged the

importance of accepting their condition through shared experiences of attending the group,

but they also demonstrated an awareness of acceptance of living well with a neurological

condition.

Recommendations from this SEP are detailed below.



25

Conclusions and Recommendations

Conclusions

The SEP was designed to evaluate the effectiveness of a cognitive rehabilitation group for

individuals living with a neurological condition. A mixed-methods design was used to

collect data. Thematic analysis as well as pre- and post-wellbeing scores were analysed.

Three main themes were identified using thematic analysis. The results highlight the

benefits of attending the group with positive feedback provided in a several areas. The

information collected can now be used to inform the content of future groups with

recommendations listed below.

Recommendations

It is important to note that the feedback collected as part of this SEP was positive. The

group facilitators, alongside other members of staff working in Clinical Health Psychology

Department, were acknowledged by participants who were extremely grateful for the

support provided by the department.

Identity and family involvement

Participants frequently spoke about the limited opportunities there were to talk about how

their neurological condition affected their identity and relationship with others. A

recommendation would see the group offer an additional session inviting family members

to learn and understand how their relatives’ condition may impact on them day-to day.

Furthermore, having a section on ‘identity’ would be beneficial.

Resources

Whilst positive feedback was provided in relation to the workbook, participants felt that

the activity worksheets needed updating as they were out of date. It would be helpful if

these worksheets were revised to make them more relatable to clients.



26

Length of sessions

Participants felt they would have benefitted from attending more than 6 sessions. Whilst

offering more group sessions would result in reduced clinic time for clinicians, the group

is a cost-effective way of providing input to individuals with neurological conditions and

provides a safe-space for individuals to share experiences which cannot be offered during

individual therapy. Furthermore, the interviews highlighted that participants would have

preferred not to have had the 2-week gap after session 3.

Strengths and Limitations

Particular strengths of this SEP include the combination of both quantitative and

qualitative methods to provide context and meaning, as well as the credibility checks which

have enhanced the quality of analysis. Quality checks were not only completed with a

trainee but also with the commissioning team in which all themes were agreed. Lastly, this

SEP not only answers the overall aims to the project, but it has also implemented a feasible

methodological design supported with thorough data analysis.

It is also important to consider the methodological limitations to this study. Whilst the SEP

is not an exploratory qualitative research project, one of the main limitations relates to the

design of the interview schedule. It is likely that the style of questions which formed the

topic guide produced the themes identified. Although a limitation, Clarke and Braun (2013)

acknowledge this as a common pitfall resulting in the data being summarised and organised

rather than analysed.

Although psychological well-being was not an explicit aim of the SEP, the pre-post design

used is a very weak non-experimental design for determining any causal mechanism of

change as no control condition was recorded (Morley, 2018). As previously discussed, the

internal validity of scores, history and the effect of testing limits the interpretation of

results.



27

Lastly, as the questionnaires and interviews were not matched up to participants, it was not

possible to match quotes. It was therefore not possible to keep a headcount of themes. In

hindsight, this may have been helpful to support the saturation of identified themes.

Dissemination

Findings were presented at the annual Leeds DClin Psychology SEP Poster Conference

(October 2019; Appendix J) and at the Clinical Health Psychology Departmental meeting,

Pinderfields Hospital, Wakefield.



28

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long-term conditions. British Journal of Nursing, 25(20), 1102-1107.

Barnard, D. (1995). Chronic illness and the dynamics of hoping. Bloomington, IN, US:

Indiana University Press.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology, 3(2), 77-101.

Clarke, V., & Braun, V. (2013). Teaching thematic analysis: Overcoming challenges and

developing strategies for effective

learning. Retrieved from

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%20Repository%20version.pdf

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depression, anxiety and psychological distress: A meta-analysis. BMC medicine,

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Quality of life and psychological problems in patients undergoing neurological

rehabilitation. Annals of Indian Academy of Neurology, 11(4), 225-230.

Hadgkiss, E. J., Jelinek, G. A., Weiland, T., J.,, Rumbold, G., Mackinlay, C., A., , &

Gutbrod, S. (2013). Health-related quality of life outcomes at 1 and 5 years after a

residential retreat promoting lifestyle modification for people with multiple

sclerosis. Journal of the Neurological Sciences, 34(2), 187-195.

Immink, M. A. (2014). Fatigue in neurological disorders: a review of self-regulation and

mindfulness-based interventions. Fatigue, 2, 202-218.

Kang, Y., Gruber, J., & Gray, J. R. (2013). Mindfulness and de-automatization. Emotion

Review, 5, 192-201.

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psychological health: a review of empirical studies. Clinical Psychology Review,

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Mars, T. S., & Abbey, H. (2010). Mindfulness meditation practise as a healthcare

intervention: a systematic review. . International Journal of Osteopathic

Medicine(13), 56-66.

Moore, A., & Malinowski, P. (2009). Meditation, mindfulness and cognitive flexibility.

Conscious Cognition, 18(176-186).

Morley, S., Masterson, C., & Main, C. J. . (2018). Single-case methods in clinical

psychology: A practical guide. Abingdon, Oxon; New York, NY: Routledge.

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patient.co.uk/SurveysAndReports

NHS England. (2019). Neurological Conditions. Retrieved from

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conditions/neurological/

Norris, C. J., Creem, D., Hendler, R., & Kober, H. (2018). Brief mindfulness meditation

improves Attention in novices: Evidence from ERPs and moderation by

neuroticism. Frontiers in human neuroscience, 12, 315-315.

O.Nyumba, T., Wilson, K., Derrick, C., J., , & Mukherjee, N. (2018). The use of focus

group discussion methodology: Insights from two decades of application in

conservation. Methods in Ecology and Evolution, 9(1), 20-32.

Soundy, A., Smith, B., Dawes, H., Pall, H., Gimbrere, K., & Ramsay, J. (2013). Patient’s

expression of hope and illness narratives in three neurological conditions: a meta-

ethnography. Health Psychology Review, 7(2), 177-201.

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assessing generalized anxiety disorder: The GAD-7. Archives of Internal

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conditions: Meeting the emotional, cognitive and mental health needs of

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07-parity-of-esteem.pdf

The Neurological Alliance. (2018). The long term plan for the NHS: Getting it right for

neurology patients, 1-27. Retrieved from

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Ulrichsen, K. M., Kaufmann, T., Dørum, E. S., Kolskår, K. K., Richard, G., Alnæs, D., . .

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fatigue after stroke, traumatic brain injury and multiple sclerosis: A systematic

literature review and meta-analysis. Frontiers in Psychology, 7(912).

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https://www.england.nhs.uk/ourwork/clinical-policy/ltc/our-work-on-long-term-conditions/neurological/

https://www.england.nhs.uk/ourwork/clinical-policy/ltc/our-work-on-long-term-conditions/neurological/

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https://www.neural.org.uk/assets/pdfs/2018-08-long-term-plan-for-nhs.pdf

https://www.neural.org.uk/our-priorities/



30

APPENDICES



31

Appendix A: Neuropsychology Service Pathway

Referrals

management meeting

Referral letter

received

Letter sent to

referrer to explain

Referral not

accepted

Discharged and letter

sent to referrer and GP

No response within

two weeks or

appointment declined

Client opts-in

Assessment appointment offered

(aim within six weeks)

Following assessment, a brief letter will be

sent to client/referrer/GP outlining outcome

of assessment

Psychological

Therapy

Neuropsychological

Assessment

Attend group

Inappropriate for

service:

Reasons discussed

with client

Where possible

signpost/refer to

appropriate

service

Living with Neurological

conditions (ACT group) Cognitive

rehabilitation group

Referral accepted

Opt-in letter sent



32

Appendix B: Ethics Confirmation Email



33

Appendix C: SEP Questionnaire

Service Evaluation Project

Cognitive Rehabilitation Group

Questionnaire

As part of the Service Evaluation Project, I would like to get your feedback on some

aspects of the group you have recently attended. I would appreciate it if you could

answer the following questions:

Question 1

Have you learnt any practical skills as a result of attending the group? YES NO

If yes, what skills have been most helpful?

Question 2

Do you remember learning anything about thinking skills? YES NO

(The term ‘thinking skills’ refers to things such as being able to remember things,

communication, attention and concentration, planning and organisation)

If yes, what did you find helpful?

Question 3

Has the group helped you to learn about your feelings? YES NO

Has anything in particular changed with your feelings?

Question 4

Are there any group sessions which you have found particularly helpful? (please tick)

The Brain

Attention



34

Memory

Executive Functioning

Other Factors

Why was this?

Question 5

Are there any group sessions which you have found particularly unhelpful? (please tick)

The Brain

Attention

Memory

Executive Functioning

Other Factors

Why was this?

Question 6

Are there any topics or areas that you wish had been covered?

Question 7

What was the most helpful strategy learnt in the group?

Question 8

What was the least helpful strategy?

Question 9

Have you been able to practice these strategies outside of sessions?

Question 10

Did anything get in the way of being able to use or practice these strategies?



35

Question 11

Did you find the mindfulness exercises helpful? YES NO

What did you like about them?

Do you feel it made any difference? YES NO

If yes, what has changed?

Thank you for your time.

XXXX | Psychologist in Clinical Training | XXXX

Dr XXXX | SEP Academic Tutor | XXXX

Clinical Psychology Training Programme | Leeds Institute of Health Sciences

Level 10 Worsley Building | Clarendon Way

University of Leeds | Leeds | LS2 9NL



36

Appendix D: Interview Topic Guide

Topic Guide

General introduction to the project

How did they find the set-up of the group

Prompts: Location, parking, timings, likes/dislikes, any improvements?

Experience of taking part in the group

Anything particularly helpful covered in the group?

Prompts: Have they been able to use/practice any strategies?

Anything particularly unhelpful?

Mindfulness exercises (e.g. body scan, leaved on stream, brushing teeth)

Prompts: gave they been able to practice these? What they liked/ disliked about

them? Have they helped in anyway? (e.g. changes emotionally, thinking skills,

concentration, attention)

Materials/ supported information provided during the group

Anything which would be improved in the group?

Any other comments/ suggestions



37

Appendix E: Patient Health Questionnaire (PHQ-9)



38

Appendix F: Generalised Anxiety Disorder (GAD-7)



39

Appendix G: Patient Information Sheet


Cognitive Rehabilitation Group

Participant Information Sheet

You are invited to take part in a Service Evaluation Project. This project aims to evaluate

the Cognitive Rehabilitation Group. Please read and consider the following information,

and discuss it with others if you wish, before deciding whether to take part.

What is the purpose of the project and why have I been chosen?

You are being asked to take part because you have attended the Cognitive Rehabilitation

Group. I am interested in hearing about people's experiences at the group, including what

you found helpful and how the group could be improved.

What will I have to do if I take part?

If you decide to take part, I would like you to complete a short questionnaire at the end of

the final session. This should take no longer than 20 minutes to complete. I would also

like to contact you via telephone at an agreed time which is convenient for you. The

telephone discussion would involve talking about your experience of attending the group

and would last approximately 30 minutes. Routine questionnaires will also be collected at

the end of each session and will be included in the write-up of the project.

Do I have to take part?

No. Taking part is entirely voluntary. If you do not want to take part, you do not have to

give a reason. If you decide to take part but change your mind after the interview, your

information can be withdrawn from the study one week after the interview has been



40

completed. This can be done by contacting Dr Trishna Gandhi, Clinical Psychologist,

Clinical Psychology Department, Pinderfields Hospital on 01924 541510.

What will happen with my information?

The telephone interview will be recorded using a Dictaphone. I will also note down what

is said during the telephone conversation. I will look at the interviews afterwards to see if

there are any themes with what was said. A report will be written and findings will be

presented to the commissioning service. This report may use quotes directly taken from

the interviews. Any patient details will be anonymised.

What are the benefits of taking part?

There is no direct benefit to you for taking part. However, your input will help us think

about how the service can be improved for the future.

Who do I speak to if I have any concerns?

If you have any questions about this project, or would like further information, please

contact either XXXX, Psychologist in Clinical Training XXXX or Dr Trishna Gandhi,

Clinical Psychologist, Clinical Psychology Department, Pinderfields Hospital on 01924

541510. If you have any concerns, or wish to make a complaint, please contact Dr XXXX,

Academic Supervisor, Clinical Psychology Training Programme XXXX.

Ethical approval has been sought from the School of Medicine Research Ethics

Committee (SoMREC/SHREC project number DClinREC18-003)






41

Appendix H: Timings and Location of Group

Session Date Topic Location

1

08.01.19

Introduction to the

brain

SEP introduced to

participants

Pinderfields Hospital,

Wakefield

2

15.01.19

Attention

3

22.01.19

Memory

TWO WEEK BREAK

4

12.02.19

Executive function

5

19.02.19

Other factors that

can affect cognitive

functioning

PIS handed out to

group attendees by SEP

commissioner

6

26.02.19

Review

Consent gained;

telephone interviews

booked



42

Appendix I: Consent Form


Cognitive Rehabilitation Group Consent Form

I confirm that I have read and understand the information sheet for the above project. I have had

the opportunity to ask questions about the study.

I understand that my participation is voluntary and that I am free to withdraw up until the

interview has been transcribed (within one week), without giving reason and with no

repercussions.

I agree that all completed questionnaires can be used for the write-up of the project.

I agree to the interview being recorded and transcribed for the write-up of the project.

If quotations are used from my interview, I understand that my anonymity will be preserved.

I agree to the researcher contacting me by telephone regarding participating in this Service

Evaluation Project.

I agree to take part in the above project.

Please tick here if you would like to receive a written summary of the findings

Print name: Signature: Date:

XXXX | Psychologist in Clinical Training | XXXX

XXXX | SEP Academic Tutor | XXXX






43

Appendix J: Poster Presented at SEP Poster Conference

vAll 6 participants who attended the group consented to take part in the SEP.

v 6 out of 6 participants completed a telephone interview.

v 5 out of the 6 participants completed and returned the questionnaires back to

the Clinical Health Psychology Department.

vThree major themes were identified: (1) usefulness of the group, (2)

mindfulness and (3) improvements for future groups (see Figure 1 for themes

and subthemes).

v Pre and post-wellbeing measures are shown in Table 1. No significant decline

in participant well-being was found.

Rachel Crane, Trainee Clinical PsychologistClinical Health Psychology, Pinderfields Hospital, Wakefield

v The number of people living with a neurological condition in England is rising

and will continue to increase (The Neurological Alliance, 2018).

v The direct effects of living with a neurological condition may affect the quality

of life for individuals and can result in psychological difficulties.

v A loss of identify, difficulties with body image, low mood and adjustment

difficulties can affect an individual’s overall psychological well-being (Gupta

et al., 2008).

v Mindfulness-based strategies are thought to have a positive effect on an

individuals’ health and well-being by reducing the impact of the behavioural,

emotional and cognitive patterns often seen in neurological conditions (Kang,

Gruber, & Gray, 2013; Mars & Abbey, 2010).

v The Clinical Health Psychology Department at Pinderfields Hospital provides

psychology services to individuals over the age of 18 who have been

diagnosed with a neurological condition.

v This Service Evaluation Project (SEP) evaluated the effectiveness of the

cognitive rehabilitation group for people living with a neurological condition.

The SEP had a particular focus exploring the mindfulness exercises

completed during the group.

Theme 1

Usefulness of group

Subtheme 1a:

Sense making

Subtheme 1b:

Learning new

skills

Subtheme 1c:

Improved

knowledge

Subtheme 1d:

Mindfulness

Subtheme 1e:

Psychological

well-being

Theme 2

Mindfulness

Subtheme 2a:

Thinking

skills

Subtheme 2b:

Barriers

Subtheme 2c:

Prior

experience

Subtheme 2d:

Acceptance

Subtheme 2e:

Imagery

Subtheme 2f:

Well-being

Theme 3

Improvements

Subtheme 3a:

Family work Subtheme 3b:

Identity

Subtheme 3c:

Sharing

personal

experiences

Subtheme 3d:

Resources and

questionnaires

Subtheme 3e:

Physical

impact

Subtheme 3f:

Session length

PHQ-9 GAD-7

Participant Pre- Post- Change Pre- Post- Change

1 5 4 1 3 1 2

2 11 4 7* ** 5 7 -2

3 17 16 1 11 10 1

4 11 10 1 10 12 -2

5 26 21 5 20 21 -1

6 16 15 1 6 7 -1

*statistically significant **clinically significant change

Table 1. Pre- and post- PHQ-9 and GAD-7 outcomes

Figure 1. Qualitative Analysis: Thematic map

1. INTRODUCTION

An Evaluation of a Cognitive Rehabilitation Group for Individuals

with Neurological Conditions

2. METHODParticipants involved in the SEP were recruited through the Cognitive

Rehabilitation Group held at Pinderfields Hospital, Wakefield. This was a mixed

methods design using semi-structured interviews, questionnaires and outcome

measures.

Quantitative Data: Participants completed pre-post PHQ-9 and GAD-7 measures

(during session 1 and session 6). This was analysed to determine statistical and

clinically statistical significance.

Qualitative Data: Participants either completed the questionnaire at the end of

session 6 or returned the questionnaire back to the department at their next

appointment. Telephone interviews were arranged for the day after the group

finished. Thematic analysis was used to analyse the qualitative data.

3. RESULTS

4. DISCUSSION

vThe findings offer a unique insight into the experience of individuals attending

a 6-week cognitive rehabilitation group.

vDespite well-being measures reaching significance for only one participant,

qualitative feedback provided by participants demonstrated that the

mindfulness exercises had a positive effect on psychological well-being.

vParticipant responses demonstrated an improved awareness and acceptance of

living with a neurological condition by attending the group (Barnard, 1995).

vContrary to previous research, participants reported limited improvements with

their thinking skills (Norris, Creem, Hendler, & Kober, 2018).

vFuture research may be interested in looking at the impact mindfulness has on

thinking skills in a more standardised way, for example, formal cognitive

assessment.

6. CONCLUSIONSThe results from the SEP are positive. The SEP has shown that the cognitive rehabilitation group is useful and beneficial for individuals with a neurological condition. Most

participants were able to practice, and adapt, the mindfulness exercises outside of group sessions. Participants were also supportive of the workbook which was used during

the group.

5. RECOMMENDATIONSv Family involvement and identity

It is recommended that the group offers an additional session involving family

members, so that they can learn and understand how their relatives condition

may impact on them day-to day. Furthermore, having a section on ‘identity’ may

be useful for future groups.

v Resources

Participants felt that the activity worksheets were out of date. It would be helpful

if these worksheets were reviewed to make them more relatable to client’s

accessing the service.

vLength of sessions

Many participants spoke about how they would have liked to have been offered

more sessions as they felt 6 was not enough. This may offer a cost-effective and

beneficial intervention for individuals living with a neurological condition.

7. REFERENCESBarnard, D. (1995). Chronic illness and the dynamics of hoping. Bloomington, IN, US: Indiana University Press.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.

Gupta, A., Deepika, S., Taly, A. B., Srivastava, A., Surender, V., & Thyloth, M. (2008). Quality of life and psychological problems in patients undergoing neurological rehabilitation. Annals of Indian Academy of Neurology, 11(4), 225-230.

Kang, Y., Gruber, J., & Gray, J. R. (2013). Mindfulness and de-automatization. Emotion Review, 5, 192-201.

Mars, T. S., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. . International Journal of Osteopathic Medicine(13), 56-66.Norris, C. J., Creem, D., Hendler, R., & Kober, H. (2018). Brief mindfulness meditation improves Attention in novices: Evidence from ERPs and moderation by neuroticism. Frontiers in Human Neuroscience, 12, 315-315.

The Neurological Alliance. (2018). The long term plan for the NHS: Getting it right for neurology patients. Retrieved from www.neural.org.uk/assets/pdfs/2018-08-long-term-plan-for-nhs.pdf

Documents

An Evaluation of a Cognitive Rehabilitation Group for