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Character building through Positive Psychology

Elysium Healthcare assess whether there is a place for Positive Psychology in neuro-rehabilitation

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Positive Psychology aims to improve an individual’s wellbeing and mood by utilising their personal strengths and characteristics*

As a relatively new psychotherapeutic approach, Positive Psychology’s use in clinical settings, in particular complex care and rehabilitation, is not yet commonplace. However, constructs from the field of Positive Psychology have been explored in a range of illness populations and are increasingly gaining attention as factors that may influence recovery from acquired brain injury (ABI)**  

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

In this article we talk with Dr Darren Perry, consultant clinical psychologist with Elysium Healthcare and psychology lead at AGCC.

Darren has worked for 20 years in NHS neuropsychology, physical health and older adult mental health services, and has a particular interest in psychological adjustment to changes in neurological and physical health. Darren led the development of a Positive Psychology group trial at AGCC. He is continuing to explore how Positive Psychology can be used in neurorehabilitation and the impact that improved wellbeing has on individual outcomes.

Hi Darren. Perhaps you could start by explaining a bit about the difference between Positive Psychology and traditional clinical psychology? 

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

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

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

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

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

Darren: Yes, they are. Alongside this, Positive Psychology has also focused on character strengths and their role in wellbeing. Based on an extensive review of literature on philosophy, ethics, education, psychology and theology spanning over 2,500 years, Seligman and his team identified 24 character strengths. These include qualities such as gratitude, kindness, bravery, appreciation of beauty, perseverance and determination.

Research has subsequently established that we all have a unique and dynamic blend of character strengths and engaging these effectively in our daily life is linked to experiences of the five domains of wellbeing.

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

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

Individuals we work with at AGCC are often so focused on regaining abilities that they have lost as a result of their injury or illness that their awareness of preserved character strengths becomes diminished.

We initially help the resident to identify their core or ‘signature’ character strengths. Once their awareness of these intact strengths improves, we help them to spot when they are engaging them during everyday activities. We introduce the notion that strengths can be under-used and can even become a weakness if they are over-relied upon in some contexts. We also focus on developing interventions that encourage them to use their strengths in new ways, during their wider rehabilitation. 

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

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

Darren: The pilot group was a useful exercise. The content of the group sessions was adapted from a ‘Positive Psychology Workbook’ written by Rashid and Seligman (2019).

We found some things that worked really well in the group but it also strengthened, in our mind, the need to develop innovative interventions that are more suited to a neuro-rehab setting; for people with impaired levels of functioning. Our residents engaged well with the themed sessions and benefitted from the social interaction and shared-experiences.

But, we came away with a feeling that it may be more effective to combine group sessions where themes are introduced and discussed with follow-up one-to-one sessions with each resident. The individual work would focus on helping them to increase their awareness of their own character strengths and how to apply them specifically in the context of their rehabilitation.   

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

The first method is the ‘Three Good Things’ journal. Every day the individual keeps their eyes and mind open to three good things that have happened, no matter how small or insignificant they may seem. It might be a friendly smile from someone, or a carer bringing them a cup of tea at just the right time or a family member called for a chat. They literally just record those three things every day in a journal or notebook.

This process operates on two levels; it helps them to have their ‘antenna’ more attuned to noticing small things that they can be more grateful for every day – that may otherwise have passed them by. In addition, the process of writing it down it, reflecting on it and perhaps discussing it with a member of the care team, actively engages and reinforces that sense of gratitude and generates good feelings. 

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

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

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

Are you looking at ways of working with other character strengths too?

Darren: Yes, we’ve used these techniques with people that have identified with gratitude quite a lot, but we’re still in the process of trying to explore the other character strengths and find effective ways of employing them. Bravery and persistence are other strengths that seem to lend themselves readily to intervention in this context.

A resident may acknowledge something that they’re feeling anxious about or tend to avoid or put off and then we encourage them to take a little step towards it on a daily basis. So they’re engaging with bravery or persistence and at the same time hopefully making some behavioural changes, and by doing something that they wouldn’t have been doing previously it can bring about some positive changes for them.

The work that residents do with our physiotherapy and occupational therapy colleagues can often require a degree of bravery or persistence that can be easily overlooked. For instance, the task of re-learning to transfer from sitting to standing or walking or to cooking independently can potentially induce quite a lot of fear. This could be a fear of physical injury but could also be a fear of failing and the psychological injury of facing up to or accepting impairment and loss. This fear sometimes leads to disengagement and reduced progress in rehabilitation.  It is easy to see how engaging bravery and persistence in these activities can be really effective, both for wellbeing and for the wider rehab progress.  

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

Darren: It’s been both. The first time we ran the group, it was more multi-disciplinary, as the psychology assistant, therapy assistant and various other professionals dipped in and out of the group sessions. When we are working on a one-to-one basis with residents it’s more of an endeavor for the psychology team. But as we find more suitable interventions, applicable for a neuro-rehab setting, then the plan would be to share these with the care team and therapy team so they can support engagement with residents in as many rehabilitation activities and interactions as possible.

I also plan to run some multi-disciplinary CPD sessions to increase understanding about wellbeing and character strengths and hopefully to encourage professionals from different perspectives to contribute their expertise to the development of new character strength interventions.  

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

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

“As I’ve hinted so far in our discussion, examples of interventions in most of the published work in this field are designed for people with reduced wellbeing who are otherwise cognitively intact or free of physical impairment or disability. These constraints are almost a defining feature of the population we work with in neuro-rehab.

Some of the concepts of mainstream Positive Psychology are too abstract for our residents and many of the suggested interventions may be too physically or cognitively challenging for our residents. Hence the ongoing need to be innovative in adopting the principles for this area of application. We are still at the stage of forging new ground with this.

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

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

Sadly, not all functions are regain-able following ABI. We try to support individuals to see that we are all changing, all of the time. Our physical functions are changing and none of us can actually be the exact same person we used to be. So the idea that quality of life and wellbeing should be based on the hope that you’re going to get back to something from the past is quite precarious. We try to move away from that.

Positive Psychology principles enable us to help people to look at what’s actually still intact. We focus on what’s still strong, not just what’s wrong…or gone. Usually each person will have some parts of their character that are unaffected by what has happened to them. Aspects of themselves that they value, or they value in other people. However it can take quite a lot of work for some people to see that, which is of course understandable considering everything that they have been through. 

Often individuals are focused on the loss, the things they want but didn’t get back, and they become dissociated from what’s actually still in them, that sense of continuity of self. Positive Psychology can help them reconnect and re-engage with those character strengths, which really has potential benefits in terms of preserving wellbeing and self-acceptance.

Ultimately, the end goal of this type of work is to help our residents to establish a positive, post-ABI, sense of self that incorporates the residual changes but allows them to acknowledge that they are still able to experience fulfillment and wellbeing in life, now and in the future.

References:

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

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

Insight

Dementia care – how to use storyboards

Dementia Carers Count look at how this valuable creative tool can be used at home

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Do you know that people living with dementia often process visual stories and information better than verbal communication?

Misunderstandings, distress, fear and worry all impact heavily on us and can place strain on relationships. Visual aids such as storyboards can help maintain mental wellbeing for both the person with dementia and for the carer.

Sue Hinds, head of services at Dementia Carers Count, takes us through a range of techniques that carers can adopt (or adapt).

When and why visual support might be useful

There may be times when you need to support a person with dementia in attending events which are important to them. This might include appointments with the GP or other services, family events, shopping excursions, planning a trip and opportunities to engage in hobbies and pastimes.

We know that people with dementia often have challenges in both understanding information provided to them and/or retaining the information for long enough for it to be meaningful.

Carers tell us that a range of situations and emotions can arise. This could include the person with dementia refusing to go because they genuinely believe they were never told about it. Anxiety about where they are going, confusion, disorientation, agitation, distress, tearfulness, a sense of unease, and many more emotions can all emerge.

These situations can also provoke a range of emotions for you as a carer including stress, worry, fear, frustration, and anger.

Things we know:

  • Providing information in bitesize chunks can help a person with dementia.
  • Providing visual reminders can help.
  • Visual information is often better understood than verbal information.
  • Visual information can be referred back too, spoken descriptions (unless recorded are fleeting).
  • Step-by-step instructions help.
  • Visual formats can help a person express their concerns more clearly.

What are story boards?

Image of a storyboard example to use with someone with dementia

Storyboards are one way to help support a person to understand, remember and engage fully with a meaningful visit, event or routine either inside or outside the home. They can capture key elements and stages of an event with images which can help the person to understand the event and will help to describe the actions at each stage.

By creating a storyboard, it can help you to identify all the stages and can help you think about what situations might arise, and can support a person with dementia to express areas which give them concerns.

Often storyboards can then be adapted or used again for other events.

Misunderstandings, distress, fear and worry all impact heavily on us and can place strain on relationships, and a storyboard can help maintain mental well being for both the person with dementia and the carer.

They provide a way to cope, help to maintain relationships and provide a new way of coping with challenges – providing a new way of thinking, behaving and interacting together even when things are tough.

How to create a storyboard

Generally, a story board can look how you want it to look, but they should not have too much information on a page as this can be overwhelming.

You may wish to create a storyboard on one page, or a storybook where you flick from one page to the next, or even a storymat where you can add, remove drop things down into a ‘we are here now’ section.

Follow the steps:

Think about the task e.g. Going to the doctors, and then think of all the steps which will happen (this is unique to your own routine):

For example:

  • We need to get up and out of bed at 8am
  • We will go downstairs
  • We will have breakfast
  • We will go to the bathroom and have a wash
  • Clean teeth
  • Get dressed
  • Go to the car
  • Travel to the surgery
  • Wait in the waiting room
  • Go in to see the doctor and talk to the doctor
  • Say goodbye and leave the surgery
  • Get back in the car and drive home
  • Arrive home
  • Sit down in the kitchen for a cup of tea and a cake

Ideas of things you can use to help you

There are lots of symbols and resources which you can purchase to help with this, but a good tip is to also take photos within your own home and when you are out and about with the people and places you visit. This will help you to tell the story with as many familiar pictures as possible.

It’s also often worth taking photos during a familiar event so these can be used in the future.  However, if you need some symbols there are various sites you can purchase them from and I have listed a couple below.

The creative visual aids website also gives a wonderful explanation of how visual aids can be used to support children, but the principles are exactly the same. The video below talks about the use of storyboards with children and I am currently in discussion with Gina regarding storyboards for people with dementia.

Talking Mats is another incredibly useful resource for supporting conversations, with videos and case studies of how visual aids can help a person with dementia in conversation and day to day life.

Good luck creating one, and have fun – we would love to hear from you with photos, descriptions and stories of how and when you use them. Perhaps you could also inform other carers through our forum: Virtual Carers Centre | Dementia Carers Count

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Dementia

Supporting mental and physical needs in complex dementia

St Andrew’s Healthcare look at the importance of meeting the needs of this client group

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Designed to recreate the feel of a village environment with a post office, pillar box, village hall, bandstand and bus stop, Lowther’s outside space helps to maintain familiar routines, encourage activities and provide essential distractions and engagement

In supporting the mental and physical healthcare needs of people living with complex dementia, specialist expert support is vital to achieving the best possible quality of life. 

St Andrew’s Healthcare is renowned for its work in this area and for its support of people and their families. Based within its Northampton site, the St Andrew’s neuropsychiatry service supports people with the most complex neuropsychiatric needs.

The service extends across Kemsley, the hospital’s brain injury unit, which has pioneered specialist neurobehavioural care since it opened over 40 years ago, and Lowther dementia hub, a bespoke environment opened in 2020 that is designed to meet the needs of people living with complex dementia and other progressive neurological conditions.

Working with older people within a neuropsychiatric service requires a range of specialisms. Here, we meet two of the multi-disciplinary team at St Andrew’s as they explain the importance of meeting the mental health, but also the physical health, needs of this particular patient cohort. 

 

Muthusamy Natarajan, consultant forensic psychiatrist

My name is Muthusamy Natarajan, I’m a consultant forensic psychiatrist and also clinical director for the neuropsychiatry service at St Andrew’s Healthcare.

How do you approach the care and support of older people in a neuropsychiatric service?

It’s important when working with and supporting older adults with mental health problems to consider how their organic and functional illnesses intertwine and how we progress them in their pathway at St Andrew’s and onward into the community. Connections with the patient’s family are also key so we also need to make sure we work to maintain those links whilst offering support to family members too.                                                                                                                                                                                                                             

We have a lot of our patients who are living with dementia and obviously communication with those who are caring for them is a tricky challenge sometimes and making sure that their voices are heard. We have multiple methods do that including our advocacy services, but also our staff are really experienced and skilled in making sure that the patient’s voice is heard. 

How do we support people living with dementia and complex needs?

In 2020, we opened the Lowther village. The Lowther village was very much a critical part of our ability to deliver the best care for patients who are living with dementia and other complex progressive neurological conditions such as Huntington’s disease. 

The dementia village concept comes from the Netherlands, where the key area of focus is making sure that patients are able to experience familiar activities throughout their journey with dementia and that they are able to link with the community, and that’s what we try to do. Our aim is to make sure that patients have the least possibility of feeling like they are in an inpatient setting and that includes people who are on Mental Health Act sections and Deprivation of Liberty Safeguards (DoLS).

What key interventions do you use when working with people living with dementia?

When somebody comes to us, we carry out a comprehensive multidisciplinary assessment that is the basis of their care and treatment. 

An individual might require specific psychological therapies and that may include things like reminiscence therapy, individual sessions to look at what their actual cognitive impairment is meaning for them on a day to day basis and we will use tools such as life story work. 

One of the key things we will look at when an individual comes to us is what activities and supports are going to help them through their journey, and that will include activities within the unit, but it also may include activities within our grounds and also further afield in the community. 

The third intervention is obviously in terms of our medical support, and we have a full complement of doctors, a responsible clinician, a geriatrician who works alongside us and also our specialty doctors and the medical team who look at the treatments we’re offering and make sure that is the most holistic approach to that individual’s care.

Having worked across a number of organisations what do you think makes St Andrew’s different?

What makes St Andrew’s different is that the culture and the organisation are geared to deliver care to very complex patients who come to us. The challenge to us is that we need to be able to demonstrate we can meet the complex care needs of our patients and ensure their journey is delivered in the best possible way and that we maintain our links with the carers and family for that patient. St Andrew’s does that incredibly well, and it does it holistically and in some ways, effortlessly. So building on that is a key area I think within the neuropsychiatry division and also within the charity as a whole. 

Parul Shah, consultant geriatrician

My name is Parul Shah, I’m a consultant geriatrician, and I joined the St Andrew’s neuropsychiatry multi-disciplinary team in February 2021.

As a consultant geriatrician, what is your role within the neuropsychiatry team at St Andrew’s?

My role as a consultant geriatrician within the team is to pick up on the subtleties of medical issues amongst our older adult cohort of patients and implement proactive management of their conditions so that patients don’t deteriorate any further with their physical health, reducing visits to acute hospitals and improving their safety whilst they are in our care here.  

What are some of the key areas of focus for you with St Andrew’s neuropsychiatric service?

One of my key areas of focus is to improve the overall strategy for older people’s health within the neuropsychiatry service with a particular emphasis on identifying frailty. Older people are often living with multiple conditions, and as they physically decline people become frailer, if we identify this and are aware of increasing frailty we can put approaches into practice such as exercise programmes and lifestyle changes that may prevent people’s physical health deteriorating.

Sometimes our patients exhibit very advanced stages of frailty, and then we need to recognise that they may be approaching end of life and that maintaining their quality of life is of prime importance, rather than necessarily focusing on physical health care interventions.

So I think that’s one of my main aims; to provide comprehensive assessments to older patients and identify why they’re getting frailer. If there are no reversible factors we then need to think about how to make them more comfortable and make the right decisions for them in their best interest by involving them.

To find out more about the St Andrew’s neuropsychiatry service visit: Neuropsychiatry services » St Andrew’s Healthcare (stah.org)

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Insight

The impact of stress on sleep

Dr David Lee at Sleep Unlimited offers advice on how to reduce stress and improve sleep

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In response to acute stress, our body produces adrenaline, to help us with the fight or flight response.

When our body perceives there is an immediate threat to our lives, this activates our Sympathetic Nervous System (SNS) to increase our heart rate, respiratory rate, stop non-essential functions such as digestion and produce stress hormones.

During acute stress you may experience issues falling asleep and entering the restorative sleep stage as your body believes your life is in danger and so prevents you from entering a deep sleep in case you need to fight or flee during the night.

Once the threat has diminished the Parasympathetic Nervous System (PNS) is activated to lower our heart rate, respiratory rate and stop the production of stress hormones.

Evolutionarily this response was useful as we had to fight for survival if, for example, a bear was going to attack us. However, now our stressors tend to be due to relationships, financial stresses, or work-related stress. Things we are unable to run from, which can cause long term stress and SNS dominance.

Long term stress increases our cortisol production. Cortisol is normally at its highest peak in the morning to help us wake up, get out of bed, and have enough energy for the day. Levels of cortisol steadily decrease during the day, reaching its lowest point at around 10pm. This is so we are relaxed and able to fall asleep.

When cortisol levels are low, the PNS is activated during sleep, and we enter the restorative period of sleep. Cortisol levels start to slowly rise again at around 2am. If you are experiencing long-term stress, you may wake up at around 2am/3am as cortisol levels are already high.

To help reduce stress, you need to allow your body to feel safe. Here are some tips to help reduce stress and improve sleep:

  • Stick to a good sleep routine but try to go to bed earlier rather than later. If we are constantly stressed the PNS system may only be dominant during times we are asleep. As PNS is only dominant until around 2am, going to bed around 10pm will provide you enough time to rest and restore. 
  • In times of acute stress, exercise is important, so we move our bodies as if we are acting upon the fight or flight response. However, in terms of long-term stress more restorative exercise, such as yoga, may be helpful as this activates our PNS. High-intensity exercise activates our SNS as it increases our heart rate and respiratory rate, so try to incorporate restorative exercises into your routine as well. Remember exercise outside in the morning is better as it increases melatonin production for release later in the day to help you fall asleep.
  • Try deep belly breathing when you are feeling stressed to helps you to feel relaxed. When we are stressed, we tend to breathe short quick breaths from our chest instead of long deep breaths from our stomach.
  • Allocate time during the day to write down your worries and your to-do list as this will prevent you from worrying about them as you try to fall asleep.
  • Try to reduce caffeine intake. When we do not enter the restorative stage of sleep, we can wake up feeling unrefreshed and groggy, this can cause us to make a cup of coffee to increase our energy. However, caffeine also increases cortisol so try to reduce the amount of caffeine you consume, at least try to stop caffeine intake after lunchtime as this can increase difficulty in falling asleep. If you improve your sleep practices you are likely to feel refreshed in the morning, making it easier to reduce your caffeine intake.
  • Avoiding screens and working in the 2 hours before bed allows us to wind down and help us to switch from SNS to PNS. If we engage in work or see something on social media that causes our stress levels to rise, then this may cause us difficulty falling asleep.

*  Dr David Lee BSc PhD CertEd CPsychol AFBPsS CSci is clinical director at Sleep Unlimited

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