This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

This study presents preliminary validation data on both the Acceptance and Action Questionnaire-Acquired Brain Injury (AAQ-ABI) and the Acceptance and Action Questionnaire-II (AAQ-II). Data from 150 participants with ABI was subject to exploratory factor analysis on the AAQ-ABI (15 items). A subset of 75 participants with ABI completed a larger battery of measures to test construct validity for the AAQ-ABI and to undertake a confirmatory factor analysis (CFA) on the AAQ-II (7 items). Three meaningful factors were identified on the AAQ-ABI: Reactive Avoidance, Denial, and Active Acceptance. Reactive Avoidance demonstrated good internal and test-retest consistency (α = .89) and correlated in expected directions with other related measures including the AAQ-II. CFA of the AAQ-II did not provide a good fit but did have similar correlations with measures of psychological distress as found in prior non-ABI samples. The results suggest both measures can be used with individuals following an ABI but they index different facets of psychological flexibility. The AAQ-ABI appears to measure psychological flexibility about the thoughts and feelings relating to the brain injury itself while the AAQ-II measures psychological flexibility around general psychological distress. Future research could explore the additional 2 factors of the AAQ-ABI and use these measures in outcome studies that promote psychological flexibility in individuals with an ABI. AbstractThis study presents preliminary validation data on both the Acceptance and Action

This study sought to determine if an Acceptance and Commitment Therapy (ACT) intervention (ACT-Adjust) can facilitate psychological adjustment and reduce psychological distress following a severe traumatic brain injury (TBI). The study design comprised a single centre, two-armed, Phase II pilot randomised controlled trial. Nineteen individuals with a severe TBI (PTA ≥7 days) who met a clinical threshold for psychological distress (Depression Anxiety Stress Scales 21; DASS>9) were randomly allocated to either ACT-Adjust (n =10) or an active control, Befriending Therapy (n = 9), in conjunction with a holistic rehabilitation programme. Primary (psychological flexibility, rehabilitation participation) and secondary (depression, anxiety & stress) outcomes were measured at three-time points (pre, post and follow up). Significant decreases were found for DASS-depression (group by time interaction, F1,17 = 5.35, p = .03) and DASS-stress (group by time interaction, F1,17 = 5.69, p = .03) in comparison to the Befriending group, but not for the primary outcome measures of rehabilitation participation or psychological flexibility. The reduction in stress post-treatment was classed as clinically significant, however the interaction differences for both stress and depression were not maintained at one month follow up. Preliminary investigations indicate some promise for ACT in decreasing psychological distress for individuals with a severe TBI with further sessions being required to maintain treatment gains. The pilot results suggest that further investigation is warranted in a larger scale clinical trial.

This study confirms the structure and construct validity of the DASS-21 and provides support for its use as a screening tool in traumatic brain injury rehabilitation.

These initial studies highlight the potential of employing an integrated multi-tiered intervention based on a Behavioural Consultancy model to manage CBs after PBT.

This three‐part article presents: (1) a review of the construct of participation; (2) an overview of the 12‐item Sydney Psychosocial Reintegration Scale (SPRS) as a measure of participation and as a description of new developments resulting in its revision (SPRS‐2); and (3) as an application in different neurological groups. Psychometrically, the SPRS performs very well. There are no significant floor or ceiling effects, and both Form A (change since injury) and Form B (current status) show excellent inter‐rater and test–retest reliability. There is also substantial evidence for its validity (concurrent, discriminant, and convergent/divergent), and it shows good fit to a Rasch model, providing evidence for its construct validity. Rasch logit scores are used to provide reliable change index values to determine whether an individual patient's scores have improved or deteriorated. In Part 3, three samples were compared: traumatic brain injury (TBI; n = 130), primary brain tumour (PBT; n = 54), and spinal cord injury (SCI; n = 50) on the SPRS‐2 Form B. The TBI sample performed more poorly than the PBT and SCI samples on the interpersonal relationships and occupational activity domains. On the living skills domain, the TBI and SCI groups both performed more poorly than the PBT sample. These data demonstrate the differential levels of participation observed in different neurological groups.

This trial provides initial evidence for the efficacy of a psychological intervention in reducing hopelessness among long-term survivors with severe TBI.

Anger is a common problem in trauma‐exposed individuals. This study investigated factors that contribute to post‐traumatic anger in civilian trauma survivors. Fifty‐one trauma‐exposed individuals were assessed for expressed anger, post‐traumatic stress disorder (PTSD), daily hassles, maladaptive cognitions and blame. PTSD and non‐PTSD participants reported comparable levels of anger. Anger expression was associated with maladaptive appraisals about oneself, daily hassles, and self‐blame. Multiple regression analyses indicated that catastrophic appraisals about oneself and time since trauma were the only significant predictor of anger expression. These findings suggest that the influence of daily hassles on post‐traumatic anger may be mediated by trauma survivors' appraisals.