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 devel- opers 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 ther- apy [20–23] and holistic neuro-rehabilitation [24, 25] in a manualized (based on a manual) 13-week intervention combining a structured curric- ulum 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 environ- ments 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