Group-based Emotional Awareness and Expression Therapy to Support Recovery After Acquired Brain Injury: A Clinical Development and Evaluation Study

Surviving an acquired brain injury (ABI) often means having to learn to live with changes in abilities, roles, and relationships. For some, this adaptation itself becomes a barrier to continued recovery. Difficulties in understanding and managing emotions such as grief, fear and anger may affect how a person relates to their altered functional capacity, engages in rehabilitation, and resumes everyday activities and roles. Despite this, rehabilitation after ABI is primarily focused on physical and cognitive consequences, while targeted treatment options addressing emotional adjustment remain limited.

The aim of the study is to investigate whether emotion-focused group therapy can improve this aspect of recovery after ABI. The intervention is based on Emotional Awareness and Expression Therapy (EAET) and helps participants identify, process, and express emotions and needs that have emerged in response to the illness and changes in their life circumstances. The effects of the treatment on emotional functioning, quality of life, activity, and participation will be assessed over time and complemented by interviews exploring participants' experiences of the treatment and of life after stroke.

• TAU + Group Therapy (EAET) (Behavioral): Behavioral: Treatment as usual • Individually tailored multidisciplinary rehabilitation based on an assessment of each participant's rehabilitation needs. An individual rehabilitation plan is developed, and interventions are provided by relevant members of the rehabilitation team according to the participant's identified needs. Rehabilitation may include medical management, occupational therapy, physiotherapy, psychological treatment, and psychosocial support. Behavioral: Group-based Emotional and Expression Therapy (EAET) • 10-session manualized group-based Emotional Awareness and Expression Therapy (EAET) designed to help participants identify, process, and express emotions and needs. Weekly group sessions are complemented by structured homework assignments. A follow-up session is provided three months after completion of the intervention. The intervention is delivered by a clinical psychologist.
• Treatment as Usual (TAU) (Behavioral): Individually tailored multidisciplinary rehabilitation based on an assessment of each participant's rehabilitation needs. An individual rehabilitation plan is developed, and interventions are provided by relevant members of the rehabilitation team according to the participant's identified needs. Rehabilitation may include medical management, occupational therapy, physiotherapy, psychological treatment, and psychosocial support.

Primary outcomes

• Brief Mentalized Affectivity Scale (B-MAS) [Baseline (pre-intervention), post-treatment (10 weeks after baseline), 3-month follow-up (approximately 22 weeks after baseline), 12-month follow-up (approximately 62 weeks after baseline).]: Evalutates three core components of emotion regulation: "Identifying emotions"; "Processing emotions", "Expressing emotions".

Secondary outcomes

• Quality of Life after Brain Injury (QOLIBRI) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: QOLIBRI consists of 37 items in six scales. Health-related quality of life is assessed in the areas of "Cognition," "Self," "Daily Life and Autonomy," and "Social Relationships," and feeling bothered by "Emotions," and "Physical Problems."
• Quality of Life after Brain Injury Overall Scale (QOLIBRI-OS) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Six item scale that ask about health related quality of life in six dimensions: "Physical condition, "Cognition", "Emotions", "Ability to carry out daily activities", "Personal and social life" and "Current situation and future prospects"
• Short Form 36 (SF-36) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: The SF-36 measures eight scales: physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH).
• Rivermead Post-Concussion Symptoms Questionnaire (RPQ) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-64, with a higher score indicates worse symptoms.
• Insomnia Severity Index (ISI) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-28, where higher scores indicate severity of insomnia.
• Generalized Anxiety Disorder 7-Item Scale (GAD-7) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-15, where higher scores indicate severity of anxiety experienced.
• Patient Health Questionnaire-9 (PHQ-9) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-27, where higher scores indicate severity of depression experienced.
• Patient Health Questionnaire-15 (PHQ-15) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-30, where higher scores indicate severity and burden of common physical symptoms.
• Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-48, where higher score indicates higher avoidance.
• Behavioral Responses to Illness Questionnaire (BRIQ) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Evalutates behavioral response to illness on a four factor subscale: "All-or-Nothing Behavior", "Limiting Behavior", "Emotional Support Seeking" and "Practical Support Seeking".
• Alcohol Use Disorders Identification Test (AUDIT) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-40, where higher score indicates greater risk of problematic alcohol use.
• Drug Use Disorders Identification Test (DUDIT) [Pre-intervention, after 10 weeks (following completion of the intervention), after 22 weeks, and after 62 weeks.]: Score of 0-44, where higher score indicates greater risk of problematic drug use.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Person of working age, primarily 18-65 years.
* Acquired brain injury.
* At least three months since the time of injury.
* Signs of significant psychological distress, such as mental health difficulties, vulnerability to mental health problems, or dysfunctional coping.
* Sufficient cognitive functioning and proficiency in Swedish to participate in group-based talk therapy.

Exclusion Criteria:

* Current severe mental illness (e.g., psychosis or severe personality disorder).
* Active substance use disorder.
* Severe cognitive impairment that precludes participation in group-based talk therapy.
* Other medical conditions that, based on clinical assessment, may make participation inappropriate.

• Anna Nordström, M.D., Study chair, Uppsala University
• Peter Nordström, Professor, Study chair, Uppsala University