OBJECTIVES. We explored the clinical application of goal-directed therapy in community-based rehabilitation from the perspective of clients with traumatic brain injury (TBI), their significant others, and their treating occupational therapists. METHOD. Twelve people with TBI and their significant others completed an outpatient, goal-directed, 12week occupational therapy program. Semistructured interviews with 12 participants, 10 significant others, and 3 occupational therapists involved in delivering the therapy programs explored their experiences of goal-directed therapy. RESULTS. Participants, their significant others, and therapists described goal-directed therapy positively, expressing satisfaction with progress made. CONCLUSION. Goals provide structure, which facilitates participation in rehabilitation despite the presence of barriers, including reduced motivation and impaired self-awareness. A therapist-facilitated, structured, goalsetting process in which the client, therapist, and significant others work in partnership can enhance the process of goal setting and goal-directed rehabilitation in a community rehabilitation context.

Use of formal goal setting approaches appears more prevalent in research studies compared with routine clinical practice. There is a strong theme in the literature that client-centredness and collaboration are necessary components of effective goal setting.

Outcome after traumatic brain injury (TBI) is characterized by a high degree of variability which has often been difficult to capture in traditional outcome studies. The purpose of this study was to describe patterns of community integration 2-5 years after TBI. Participants were 208 patients admitted to a Brain Injury Rehabilitation Unit between 1991-1995 in Brisbane, Australia. The design comprised retrospective data collection and questionnaire follow-up by mail. Mean follow-up was 3.5 years. Demographic, injury severity and functional status variables were retrieved from hospital records. Community integration was assessed using the Community Integration Questionnaire (CIQ), and vocational status measured by a self administered questionnaire. Data was analysed using cluster analysis which divided the data into meaningful subsets. Based on the CIQ subscale scores of home, social and productive integration, a three cluster solution was selected, with groups labelled as working (n = 78), balanced (n = 46) and poorly integrated (n = 84). Although 38% of the sample returned to a high level of productive activity and 22% achieved a balanced lifestyle, overall community integration was poor for the remainder. This poorly integrated group had more severe injury characterized by longer periods of acute care and post-traumatic amnesia (PTA) and greater functional disability on discharge. These findings have implications for service delivery prior to and during the process of reintegration after brain injury.

Combined use of these tools, although time consuming, resulted in goals that were perceived almost unanimously as client centered, despite most participants' having moderate or severe impairment in self-awareness. The process also enabled subjective and objective demonstration of goal achievement, thereby supporting the clinical utility and treatment validity of the combined use of these tools.

The Environment-focused intervention was useful in improving patient outcomes in terms of better self-reported community integration.

The available studies indicate that outcomes of outpatient rehabilitation programmes delivered at home, of short-term duration (mostly 3 months) for people with stroke recently discharged from hospital, are at least equivalent to day hospital-based outpatient rehabilitation programme outcomes. However, there have been no controlled studies designed to investigate the influence of therapy context (home and clinic settings) on outcomes for people receiving outpatient neurological rehabilitation. Furthermore, investigations of the efficacy of community-based rehabilitation with younger people with brain injuries, caused by mechanisms other than stroke, are required.

The goal setting practice framework may guide clinician's understanding of how to engage in client-centred goal setting in brain injury rehabilitation. There is a predilection towards a client-centred goal setting approach in the community setting, however, contextual factors can inhibit implementation of this approach. Implications for Rehabilitation The theoretical framework describes processes used to develop achievable client-centred goals with people with brain injury. Building rapport is a core strategy to engage clients with brain injury in goal setting. Clients with self-awareness impairment benefit from additional metacognitive strategies to participate in goal setting. Clients with emotional distress may need additional time for new identity development.

It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.