Group Interactive Structured Treatment (GIST): a Social Competence Intervention for Individuals with Brain Injury

Brain Injury, October 2010; 24(11): 1292–1297

ORIGINAL ARTICLE

Group interactive structured treatment (GIST): A social competence intervention for individuals with brain injury

LENORE A. HAWLEY1,2 & JODY K. NEWMAN1,2,3

1Private Practice, Denver, CO, USA, 2Craig Hospital, Englewood, CO, USA, and 3Neurobehavioral Disorders Program, Department of Psychiatry, School of Medicine, University of Colorado, Aurora, CO, USA

(Received 19 May 2010; revised 30 June 2010; accepted 5 July 2010)

Abstract Background: Impairments in social competence are among the most prevalent sequelae of traumatic brain injury and present a major barrier to a person returning to a productive life. The recent increased incidence of TBI among military personnel and the subsequent difficulties these individuals face reintegrating into society accentuates the need for efficacious social competence treatment interventions for the TBI population. Method and results: This paper outlines the theoretical model and clinical application of Group Interactive Structured Treatment (GIST) for Social Competence. GIST- Social Competence is a structured cognitive-behavioural group therapy model addressing the underlying cognitive, communicative and emotional impairments impeding social competence after TBI. A recent randomized control trial (RCT) funded by the National Institute on Disability and Rehabilitation Research demonstrated the efficacy of this programme. GIST integrates the principles of established cognitive-behavioural therapy, group therapy and holistic neuro-rehabilitation in a manualized 13 week intervention combining a structured curriculum For personal use only. with a group therapy format. The structured cognitive-behavioural approach allows even those with significant underlying deficits (including self-awareness, memory, problem-solving, etc.) to benefit from this intervention. Conclusion: The GIST model can be applied to other treatment areas in TBI rehabilitation. Clinical observations from application of GIST with military personnel are reviewed.

Keywords: Social skills, brain injury, group therapy, social communication skills, social competence

Introduction The recent increased incidence of TBI among military personnel and the subsequent difficulties Brain Inj Downloaded from informahealthcare.com by Oregon Health & Science University on 09/20/10 The ability to successfully interact with others and these individuals face reintegrating into society [5] develop social and vocational relationships is critical accentuates the need for efficacious social compe- to being an active member of society. Vocational, tence treatment interventions for the TBI marital and social success depend upon one’s ability population. to communicate his or her needs and thoughts, listen Social competence encompasses the cognitive, and understand others, regulate emotions in social emotional and communication skills (including interactions and interact in a manner which is pragmatics) needed to interact successfully, as well assertive and confident [1–4]. Impairments in as the ability to determine how to apply those skills social competence are among the most prevalent in a variety of social situations [6–8]. Individuals and persistent sequelae of traumatic brain injury with TBI may have difficulty with a wide range of (TBI) and present a major barrier to a person social competence skills such as starting, sustaining returning to a satisfying and productive life [1]. and/or ending conversations; staying focused on a

Correspondence: Lenore A. Hawley, LCSW, CBIST & Jody Newman, MA, CCC, Craig Hospital, Research Department, 3425 S. Clarkson St. Englewood, CO 80113, USA. Tel: 303-789-8570. Fax: 303-789-8441. E-mail: [email protected]; [email protected] ISSN 0269–9052 print/ISSN 1362–301X online ß 2010 Informa UK Ltd. DOI: 10.3109/02699052.2010.506866 Group interactive structured treatment 1293

over 30 years experience treating individuals with TBI. Working with treatment groups through a private practise in the community, the GIST developers have applied this group model over the past 18 years to individuals with mild, moderate, and severe TBI, as well as individuals with acquired brain injury, and with active duty military and veterans from the recent conflicts. A recent randomized control trial (RCT), funded by the National Institute on Disability and Rehabilitation Research and conducted at Craig Hospital, demonstrated the efficacy of this programme [15]. A feasibility study, funded by the Colorado Traumatic Brain Injury Trust Fund, substantiated the efficacy of the programme for individuals with co-morbid psychi- atric diagnoses and alcohol and substance abuse histories. The feasibility study is described in a separate article in this journal issue. GIST integrates the principles of established cognitive behavioural therapy [16–19], group therapy [20–23] and holistic neuro-rehabilitation [24, 25] in a manualized (based on a manual) 13-week intervention combining a structured curriculum with a group therapy format. The structured cognitive behavioural approach allows even those Figure 1. GIST social competence model. with significant underlying deficits (including self-awareness, memory, problem-solving etc.) to social interaction; respecting and setting social benefit from this intervention [15]. boundaries; taking turns; initiating social activities; Within GIST’s structured group therapy sessions, interacting assertively; resolving conflicts; initiating empirically validated active mediators from For personal use only. appropriate topics; and social problem-solving. Cognitive-Behavioural Therapy (CBT) are utilized Being socially competent requires some of the very to promote behavioural change. These include: skills that are frequently impaired after TBI includ- observation, verbal persuasion, feedback, cognitive ing initiation, awareness, sustained attention, social restructuring, cueing, modelling, behavioural rehear- perception, problem-solving, language, speech, and sal, social problem-solving, assertiveness training, emotional regulation. social reinforcement and homework. Specific social Social interactions with individuals with TBI have competence skills are discussed, modelled and prac- been characterized as effortful and unrewarding [9]. tised in small and large interactive groups. Group Without successful social skills, a person may members receive a session-by-session workbook with become isolated, engage in conflicts and be denied weekly homework, providing an opportunity for access to social and vocational opportunities repetition and practise in the real world, as well as Brain Inj Downloaded from informahealthcare.com by Oregon Health & Science University on 09/20/10 [10, 11]. Loneliness and social isolation have con- feedback and reinforcement from available support sistently been cited as a major concern post-TBI [12] persons. Generalization is not only promoted by and marital breakdown is a common consequence family/significant other involvement, but also [13, 14]. through weekly homework, practise across environments and real-life social problem-solving. Family/ significant others are asked to participate in three Group interactive structured treatment (GIST) support person sessions emphasizing their role in for social competence encouraging development and generalization of Group Interactive Structured Treatment (GIST) for social competence skills. Social Competence is a structured cognitive- Commonly accepted group process mediators behavioural group therapy model addressing the [20, 23] are also emphasized within the groups to underlying cognitive, communicative and emotional advance group members through the sequence of impairments impeding social competence after stages of the GIST model. These include: univer- TBI [10]. GIST was developed by a clinical social sality, the realization that one is not alone; altruism, worker and a speech-language pathologist, both with the ability to be helpful to others; and group 1294 L. A. Hawley & J. K. Newman

cohesion, a sense of belonging and group trust. problem-solving and feedback, receiving video Therapists approach the group with an emphasis on feedback and engaging in homework activities group process, encouraging the group to interact, requiring self-reflection and family/significant share insights, give and receive feedback and help other feedback. each other. The group therapists guide the conver- (3) Goal setting – The process of identifying realistic, sation and encourage group interaction, rather than personally relevant and measurable social com- teaching the curriculum. An interactive group petence goals, facilitated through the use of approach offers the opportunity for group members self-assessment, modelling, shaping and feedback. to learn from each other’s successes and failures. The GIST programme emphasizes setting Group members discuss real life problems and hear individual social competence goals that are a variety of potential strategies for handling such personally and contextually relevant, realistic problems. In the GIST programme, group therapists and measureable. The group as a whole follows model the problem-solving process, rather than the manualized curriculum; however each indi- explicitly teaching specific problem-solving steps. vidual’s goals provide a path for that group Group members gradually become more indepen- member’s individualized treatment. Within the dent in solving problems as they practise in the group GIST programme, family/significant others as and are encouraged to try out potential solutions in well as other group members also provide their everyday life. Social self-efficacy is strengthened by observations and feedback regarding the indi- this process, reinforcing the social self-confidence vidual’s potential goal areas. Group therapists and desire to apply new skills to a variety of guide the individual through the goal-setting situations, promoting generalization. process as needed. The stages of the GIST model are based on the (4) Skill mastery – The acquisition of new skills, social principles discussed in holistic neuro-rehabilitation routines and compensatory techniques, facilitated literature. Participants in GIST groups go through a through group interactive practise of new informa- series of stages, both sequentially and repeatedly tion and the use of behavioural learning strategies. as the individual develops new skills and awareness [24, 25]. These stages are: Functional skills are developed and practised (1) Engagement – The attention and motivation through group problem-solving and in struc- necessary to participate in the treatment process, tured interactions completed within the group

For personal use only. facilitated through the interactive group process, as a whole or in pairs. The sense of skill mastery emphasizing the concepts of universality, altruism appears to lead to improved social confidence and group cohesion. and a willingness to apply these new skills in everyday life. The GIST process begins with engagement. (5) Generalization – The application of knowledge and This begins in the orientation session of GIST, skills learned in the group to the individual’s daily as group members share their histories and life, facilitated through real-life group interactions, discover that they are not alone in the challenges weekly homework, practise across environments, they face. Engagement continues to develop social problem-solving of real-world problems and throughout the GIST sessions, as group mem- involvement of support persons. bers receive feedback and reinforcement from

Brain Inj Downloaded from informahealthcare.com by Oregon Health & Science University on 09/20/10 each other and the group therapists and build a Family/significant others are asked to partici- sense of group cohesion. pate in a support person orientation session (2) Awareness – The knowledge of one’s own strengths which takes place the first week of the group and and challenges and how these may impact current a support person education and social problem- social functioning, facilitated through universality, solving session which takes place mid-group. learning new information about social competence, The family/significant others also participate in self-assessment and feedback from the group and the celebration at the end of session 12, after support person. which the group therapists meet with each group member and his/her support person to Group participants continuously have opportu- review progress and individual recommenda- nities to gain insight and increased awareness tions. Family involvement in the GIST pro- through discussion of the skills of a great gramme is valued in promoting generalization; communicator, completing an individual however, some group members may not have self-assessment of social competence strengths access to a family member/support person and and challenges, exchanging feedback with may need prompting to think of another support others in the group, taking part in social person, such as a case manager or therapist. Group interactive structured treatment 1295

It should be noted that the desire for social strategies and skills are practised interactively and acceptance appears to be an underlying motivator real-life social problems are addressed. Previously driving participation, effort and success of those covered topics are integrated into each session participating in the GIST programme. Baumeister through discussion and problem-solving to provide and Leary [26] describe the need to belong as a repetition and reinforcement of information. The fundamental human motivation, suggesting that 13 session topics are: Orientation Meeting, Skills ‘human beings are fundamentally and pervasively of the Great Communicator, Self-Assessment and motivated by a need to belong, that is, by a strong Goal Setting, Starting Conversations, Keeping desire to form and maintain enduring interpersonal Conversations Going and Using Feedback, attachments’. The desire for social acceptance is Assertiveness and Solving Problems, Practise in the considered to be a factor as group members advance Community, Social Confidence through Positive through the sequence of phases as they progress Self Talk, Social Boundaries, Video Taping, through this model. Video Review, Conflict Resolution, Closure and Celebration. The two follow-up sessions are focused on reinforcing previously learned skills and behaviours, problem-solving any barriers that Criteria for group participants may have developed and setting new goals as The following criteria are regarded as basic require- needed. ments for participation in the GIST group: Treatment sessions take place in a comfortable room, preferably with couches and casual seating, . Medically stable; rather than office chairs. At least one session takes . Functional memory/strategies for recall of basic place in a community setting, such as a restaurant, information from session to session; in which skills can be practised. Each session has a . Emotional regulation for group participation 10–15 minute break, providing participants with an (able to take part in group safely without 1:1 unstructured opportunity to socialize, as well as an supervision); opportunity to take a ‘mental break’. . Adequate receptive and expressive communica- Most sessions follow the following format: tion skills for group interaction; and . 16 years of age and up (GIST could be adapted . Reconnect; for younger population). . Review goals, progress, homework;

For personal use only. . Introduce a new topic; The authors have observed that the following . Break; factors, although not essential, tend to positively . Practise skills; affect a group member’s potential for treatment . Problem solve; and success: . Assign new homework. . At least 12 months post-injury (this allows people Sessions are usually 1.5 hours in length. time to have experienced social successes and Depending on the specific needs of the group failures following the injury, providing greater participants, the length of each session and/or the potential for increased awareness and motivation number of sessions may be increased or decreased to to work on social skills goals); meet the group’s needs. For example, each session . Family/significant other support person available; can be extended over a 2-week period if needed to Brain Inj Downloaded from informahealthcare.com by Oregon Health & Science University on 09/20/10 . Some awareness of social competence challenges; cover a topic in more detail or to allow for more . Motivation to improve; and repetition. Factors such as participants’ age, time Ability to accept feedback. . since injury, severity of the injury and multiple diagnoses may call for adjustments in the curriculum. Group format GIST groups consist of six-to-eight group partici- Application to other areas of treatment pants and two group therapists. Group participants receive the workbook and are asked to bring it to The GIST model was developed to address social each session. There are 13 sessions, with two competence; however, the model can also be applied additional follow-up sessions which generally occur to other areas of treatment for individuals with brain 1 and 3 months post-intervention, depending on the injury using the structured group therapy format. schedules of group members. During each of the For example, the principles and format of the GIST 13 weekly sessions, key concepts from the previous programme have been applied to a health and session are reviewed, a new topic is discussed, wellness intervention and could be applied to other 1296 L. A. Hawley & J. K. Newman

areas such as anger management, parenting skills or GIST was developed out of a clinical need to address marital relationship skills. The hierarchical structure the pervasive social problems which interfere with and use of behavioural strategies in the GIST successful reintegration to work, family and com- intervention, as well as individual goal-setting, facil- munity. Based on theoretically sound principles, as itate successful learning of new information for well as years of clinical implementation of the individuals with TBI. programme, GIST offers a structured, interactive group intervention, emphasizing real-world interactions and generalization of skills. This model can be Observations of GIST with military personnel applied to other treatment areas such as health post-TBI and wellness, anger management, parenting and The GIST intervention has been used for groups marital/family relationships. GIST can also be of active duty military and veterans post-TBI in applied to specific groups, such as Military TBI Colorado. Participants in these groups have included populations. Although there is evidence to support those with mild, moderate and severe TBI and have the efficacy of this intervention, additional research included blast injuries. These GIST military groups is needed to evaluate the effectiveness of the inter- have been provided through a partnership vention across a variety of settings with additional between the GIST programme developers and therapists trained in the GIST intervention. Denver Options and funded through the Denver Options Operation TBI Freedom programme. Denver Options is a non-profit organization providing service delivery systems and case coordination Acknowledgements for individuals with intellectual and developmental We are grateful to the many clients and families we disabilities in Colorado. have worked with through the years who have given Four treatment groups have been completed and us the knowledge and insight to develop this an additional group is currently running. Data is programme. We would like to thank Craig being collected by the group therapists regarding Hospital, especially Cynthia Harrison-Felix, PhD, participation, social competence self-ratings and Gale Whiteneck, PhD, Cynthia Braden, MA, CCC goal-attainment scaling. Initial clinical observations CPHQ, and the entire research team, for believing in indicate that participation in the GIST programme the GIST programme and for providing the oppor- can improve specific social competence skills in For personal use only. tunity to demonstrate its efficacy. The National active military personnel and veterans with TBI. Institute on Disability and Rehabilitation Research Many of the goals and needs of these groups are supported the treatment efficacy RCT at Craig similar to non-military GIST groups. However, Hospital, as part of a TBI Model Systems grant. there are several areas that seem to consistently The Colorado TBI Trust Fund funded the feasibility stand out for this particular population. Most nota- study, providing further information regarding the bly, military participants frequently describe a lack application of GIST to individuals with TBI and of interest in other individuals. In addition, military co-existing diagnoses. Special acknowledgement is participants describe significant difficulty resolving given to Don Gerber, PhD, for sharing his expertise interpersonal conflicts, especially with family. Sessions may need to be extended, allowing for and encouraging the authors to further develop the additional discussion and social problem-solving, GIST theoretical model, and to Clare Morey, MA, Brain Inj Downloaded from informahealthcare.com by Oregon Health & Science University on 09/20/10 with additional emphasis on social initiation, devel- CCC, for her valuable clinical observations, feed- opment of friendships and conflict resolution. Use of back and review. Denver Options is currently sup- the GIST intervention with military participants porting the GIST intervention for active duty demonstrates the importance of applying GIST as a soldiers and veterans and we would like to acknowl- flexible treatment model, rather than a rigid curric- edge Jennifer Anderson, Christen Mason and John ulum, allowing therapists to use clinical judgement Lenz of Denver Options for their support in that to adapt the programme as needed for a particular effort. group. Declaration of Interest: The authors alone are responsible for the content and writing of this paper. The authors are the programme developers and own Conclusions the copyright for Group Interactive Structured The GIST for Social Competence programme is an Treatment – GIST: Social Competence workbook. evidence-based intervention for individuals with TBI The workbook can be purchased upon request by addressing the emotional, cognitive and communi- other clinicians wishing to implement the GIST cative aspects of social competence after brain injury. programme. Group interactive structured treatment 1297

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