Introduction

A mild traumatic brain injury (mTBI) occurs when there is a plausible external mechanism of injury (e.g. hitting the head against an object, vehicle accident, fall or assault) and evidence of an altered mental status (such as loss of consciousness, confusion, or disorientation or not being able to remember what happened) [1]. There is now international consensus that a concussion is considered a form of mTBI [2]. The overall incidence of mTBI is estimated to be 302 per 100,000 people and is highest in males and those that are 16–20 years [3]. Following mTBI, individuals may experience physical (i.e., fatigue, headaches), cognitive (i.e., concentration difficulties) and affective (i.e., irritability) symptoms, commonly referred to as post-concussion symptoms (PCS). PCS can be disabling, impacting many facets of an individual’s life [4–6]. This includes difficulties completing everyday tasks, productivity at work/study and participation in the community [7, 8].

For a considerable percentage of individuals (≈30%) symptoms can persist for months or even years following injury [9]. Psychological factors, when considered alongside demographic variables, the severity of acute symptoms, and clinical characteristics of the brain injury, are among the most robust predictors of unfavourable recovery from mTBI [10–14]. As a result, bio-psycho-socio-ecological prognostic models have been proposed to conceptualise mTBI recovery [15]. In short, these models highlight the role of pre-injury vulnerabilities, early physiological effects induced by the mTBI, and over time, an increasing role for other factors, such as psychological reactions, psychosocial stressors, coping strategies, and medicolegal issues [16, 17]. Consequently, mental health treatment, such as psychological therapy, is recommended within clinical practice guidelines for mTBI [18–20].

A common theoretical approach to psychological therapy is Cognitive Behavioural Therapy (CBT). CBT has gone through several different eras, generations, or waves [21]. The first generation is behavioural therapy which focuses on problematic behaviour and emotion based on conditioning and behavioural principles [21, 22]. The second generation, focuses on modifying unhelpful thought patterns impacting emotions and behaviour, training adaptive thinking and engaging in enjoyable activities using various techniques (e.g., activity scheduling) [23, 24]. The third-wave is based on the concept of context and focuses more on the person’s relationship with thoughts and emotions than on the content of cognitions, emphasizing processes such as acceptance, interoceptive exposure, mindfulness, and values [25, 26].

One such third-wave therapy is Acceptance and Commitment Therapy (ACT) [27, 28]. ACT is based on Relational Frame Theory (RFT) with philosophical roots in functional contextualism [29]. RFT posits that human language and cognition are bound into the ability to identify and generate relational links symbolically between stimuli; and are regulated by the relational context and the functional context of the behaviour [28]. The focus of change within ACT is in the context of the distress rather than the content. ACT is a transdiagnostic psychological intervention that aims to target the psychological process of psychological flexibility [30]. Psychological flexibility is defined as remaining in the present moment, staying open to experience whatever thoughts and feelings show up (good or bad), and taking action in service of values [31]. Following a scoping review of the literature, Cherry and colleagues [32] proposed that the essential components of psychological flexibility are: a) handling interference or distress (e.g., receiving new environmental information, experiencing emotional discomfort, facing setbacks); b) taking action to manage interference or distress (e.g., engaging in an emotion regulation strategy, persisting, accepting, tolerating, shifting behaviour); and c) taking action occurs in a manner that fits situational demands and facilitates the pursuit of personal goals or values.

ACT aims to increase psychological flexibility by utilising six core therapeutic processes: acceptance (the active and aware embrace of private events without unnecessary attempts to change their frequency or form), cognitive defusion (changing the way one interacts with or relates to thoughts), self as context (the part of oneself that is able to step back and watch what is happening), being present (ongoing non-judgemental contact with psychological and environmental events as they occur), values (ways of describing the ways in which we want to live) and committed action (patterns of effective action linked to chosen values) [28, 33]. ACT has a well-established evidence base for improving functioning and well-being in a variety of populations with psychological difficulties and/or medical problems [34–37]. Emerging evidence has indicated that this therapeutic approach may be beneficial in individuals following acquired brain injury (any type of brain damage that occurs after birth) [38–41]. For example, Sander and colleagues [38] conducted a randomized control trial where ninety-three participants with complicated mild (a mTBI associated with brain bleeding, swelling or fractures) to severe TBI, were randomly allocated to eight weeks of ACT or a single session of needs assessment, brief counselling/education and referral. The ACT group showed a significantly greater reduction in psychological distress and improvements in psychological flexibility. The authors concluded that this study provided evidence regarding the beneficial effects and feasibility of ACT for the treatment of psychological distress in persons with complicated TBI. However an attention-matched control group would have better supported these conclusions, and it is unclear if those with differing TBI severities responded differently.

At present, the efficacy of ACT has been examined in severe TBI or mixed acquired brain injury (ABI) samples and has not been explored in relation to mild TBI symptoms or broader recovery from injury. mTBI presents with its own unique characteristics and prognosis and therefore it is important to investigate this therapeutic approach in this population. In regards to this, evidence is currently limited to case studies [42] or within restricted sub-populations (i.e., veterans, -individuals who have served in the military, naval, or air service) [43]. Although these studies provide initial promising results for the benefits of ACT in mTBI, there is a need to examine the effectiveness of this approach in a broader community sample of individuals who have experienced mTBI including uncomplicated mTBI (a mTBI not associated with brain bleeding, swelling or fractures). This is particularly relevant given the unique challenges this group face in terms of the invisibility of the injury, the pressure to return to work and managing expectations of a quick recovery [44–46]. Additionally, in many mTBI rehabilitation settings, only a limited number of psychological services are funded and available. For example, in New Zealand, only 5 hours of psychological services are funded by the national Accident Compensation Corporation (a no-fault insurance provider). Consequently, to aid in the implementation of an ACT approach into clinical practice, there is also a need for ACT to be fit for context and re-designed and tested within a shorter intervention timeframe. As a result, we developed ACTion mTBI, a 5-session treatment protocol that aims to apply the ACT model to improve recovery after mTBI.

Before establishing the efficacy ACTion mTBI feasibility of delivering this intervention protocol within a multi-disciplinary concussion service needs to be established. A feasibility study is a preliminary study to assess the practicality, viability and potential challenges of a proposed clinical trial. The objective of the current study was to understand participants’ experiences of ACTion mTBI and to identify ways to improve the intervention to further inform a full-scale effectiveness trial. Furthermore, this study provides an opportunity for a more informed and nuanced insight into the therapeutic approach, overall intervention and clinical material from participants. This is particularly pertinent for this population in which post-concussion symptoms (i.e., cognitive difficulties, fatigue, headache) could impact engagement and participation in ACTion mTBI. Furthermore, if ACTion mTBI is found to be effective for mTBI, this approach provides an opportunity to examine what aspects of the intervention enabled this to occur. We are particularly interested in understanding whether participants describe ACT processes as being helpful or whether the benefits are produced by more generic ingredients within psychotherapy (i.e. psychoeducation, therapeutic relationship, and emotional disclosure).

Method

The feasibility trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000594820). This manuscript presents the qualitative data obtained as part of the ACTion mTBI feasibility trial delivered within a multidisciplinary community-based mTBI rehabilitation service.

Qualitative interviews

Following completion of ACTion mTBI and follow-up questionnaires, all participants receiving at least one session of the ACT intervention were invited to engage in a semi-structured interview to explore their experience of the intervention. Semi-structured interviews were conducted by a Research Assistant or a Research Fellow (JC) independent of the research team (see interview guide in Table 1). The interview guide was based on a previously used schedule evaluating a psychological treatment in individuals with TBI [51].

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Table 1. Interview guide.

https://doi.org/10.1371/journal.pone.0312940.t001

Participation in the interview was optional and separate informed consent was obtained. Interviews lasted between 15 and 60 minutes. All interviews were conducted over Zoom or Teams teleconference platforms, audio-recorded and transcribed verbatim. All identifying features were removed from the transcriptions to ensure anonymity before analysis.

Results

Twenty-three of the twenty-seven participants assigned to the ACT intervention completed an interview (85.2%). The participants ranged in age from 20 to 65, with a mean age of 33.83 (SD = 12.99) years. As seen in Table 1, most of the participants were female, were predominately New Zealand European and were generally well educated. Participants were on average about 7 months post-injury; the most common mechanism of injury was a fall, followed by hit by an object. About half of participants had previously experienced a mTBI and many had a pre-injury mental health diagnosis (see Table 2).

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Table 2. Demographic and injury characteristics of participants.

https://doi.org/10.1371/journal.pone.0312940.t002

Participants’ experiences and reactions to ACTion mTBI were reflected by two overarching and two sub-themes, as illustrated in Fig 1. The first theme, Attacking the concussion from a different direction, reflected participants’ overall experience of ACTion mTBI. A positive impact on recovery captured the impacts that this intervention was perceived to have had on their mTBI recovery. Within this, our analysis was able to dissect how attacking the concussion from a different direction had a positive impact on mTBI recovery. This occurred through the two sub-themes helpful aspects of the intervention and enablers of intervention effectiveness.

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Fig 1. Schematic representation of the four themes.

https://doi.org/10.1371/journal.pone.0312940.g001

Discussion

This qualitative description study sought to understand the experiences of individuals participating in ACTion mTBI, a time limited ACT intervention for mTBI, within a community-based multidisciplinary rehabilitation service. It aimed to identify possible impacts of the intervention, understand what aspects of the intervention drive these impacts, and identify any required modifications or unexpected outcomes. During the interviews, participants reflected on the psychological difficulties that they experienced after their mTBI. This included heightened distress, mood changes, uncertainty, anxiety, and changes to self-concept. These experiences are consistent with the well-known mental health difficulties that can occur after mTBI [59, 60]. These mental health difficulties can reflect pathological consequences of the injury, environmental and post-injury effects and/or continuation/exacerbation of pre-injury mental health conditions [13, 17]. Our qualitative description analysis revealed that ACTion mTBI was able to identify and address these psychological difficulties as indicated by the overarching theme: attacking the concussion from a different direction. Participants noted that ACTion mTBI went “beyond the physical” and targeted a different aspect of their mTBI recovery, the emotional and cognitive effects of the injury. Interestingly, participants were often aware of the importance of this but felt powerless or overwhelmed in their ability to address or manage these aspects of their well-being prior to the intervention. This illustrates the importance that psychological interventions can have in mTBI recovery and are in accordance with consensus guidelines for mTBI rehabilitation [18–20].

Participants described how ACTion mTBI attacking the concussion from a different direction was beneficial as reflected in Theme 2: a positive impact on recovery. These benefits were diverse. Some participants described ACTion mTBI as contributing to complete recovery, whilst others described alleviation in symptom severity and improved daily functioning. Importantly, no adverse reactions to the intervention were reported by participants. These results are promising and suggest that ACT may be a useful psychotherapeutic modality for supporting recovery after mTBI. This finding is consistent with a limited, but growing evidence to support the use of ACT for more severe TBI and stroke populations [38–43], and with more expansive research on the benefits of ACT for a range of health conditions including cancer, chronic pain, insomnia and fibromyalgia [61–66]. In addition, a promising finding was that even if some participants had not felt fully recovered from mTBI, they expressed confidence and self-efficacy in their recovery journey. This aligns with a key objective of ACTion mTBI. With only five sessions available, ACTion mTBI aims to provide participants with a toolbox of techniques that they can draw on to support their ongoing recovery and well-being journey. Additionally, in accordance with the ethos of ACT, the primary objective of this approach is not to reduce, eliminate or control internal experiences [28, 33]. Instead, in accordance with ACT, ACTion TBI aims to cultivate a more flexible response to thoughts and emotions about mTBI and to clarify values and commit to the pursuit of more meaningful activities [33]. It is reassuring that the experience that participants had of ACTion mTBI on their mTBI recovery, aligns with these objectives.

Under theme 3, Helpful Aspects of the Intervention, we were able to discern what aspects of the intervention resulted in the positive impact that ACTion mTBI had on mTBI recovery. Of significance, this theme consisted of ACT processes which align with the therapeutic components of the ACT model (commonly referred to as the ACT hexaflex). These included: able to be more present (contacting the present moment), acknowledging and accepting (acceptance), being able to step back (defusion) and identifying and living alignment with values (values and committed action) [33]. This provides evidence that some of the effects that were produced by ACTion mTBI are driven by core ACT processes. It is also worth noting that participants described a range of ACT processes and there did not appear to be a dominant favoring of one process over another. This suggests that ACTion mTBI may strike the balance in how the ACT model is embedded and delivered throughout the intervention. One exception is however noteworthy, which is self as context. Commonly referred to as the “observing self”, self-as-context is the stable perspective from which all self-relevant processes can be seen [67]. Self as context is implicit in several of the core concepts of ACT such as defusion, acceptance and contacting the present moment [68]. Thus, even though not explicitly stated by participants, the fact that these concepts were described by participants illustrates that self as context has been harnessed by ACTion mTBI. However, experts in ACT argue for the importance of self as context in ACT and stress the importance of making it explicit within the therapeutic context [67]. This may be particularly important for mTBI recovery where changes in sense of self can often be a salient driver of psychological distress [69]. These findings suggest a need to review and reflect on how self as context is delivered within ACTion mTBI. To aid in this, future research would benefit from understanding participants’ experience of this aspect of the intervention.

The theme, Helpful Aspects of the Intervention also revealed that the positive impact of ACTion mTBI on recovery was also due to the education provided within the intervention. In fact, it was clear from the participants’ experience that this part of the intervention was critical. Participants noted that this enabled them to understand their injury and their recovery experience which reduced feelings of uncertainty, confusion and fear. These feelings were salient for many of our participants. Research illustrates that these factors can significantly contribute to symptom persistence and incomplete recovery after mTBI [44], and as a result, education has been stipulated as being an essential part of mTBI rehabilitation [18]. Given its importance, based on participants’ experience, it is reassuring that the education component within ACTion mTBI is achieving its intended outcome. In addition, participants also described how the education within ACTion mTBI enhanced their engagement and participation in the entire intervention, which likely influenced the benefits produced by the ACT model. Thus, education appears to be an essential ingredient within ACTion mTBI to facilitate participation and enhance the effectiveness of the intervention.

Through theme 4: Enablers of intervention effectiveness we were able to unpack the contextual factors that facilitated engagement and the effectiveness of ACTion mTBI. Participants all liked how ACTion mTBI equipped them with techniques that they could incorporate into their context to assist with recovery. Experiential exercises are integral to ACT as they offer a practical and hands-on approach to learning and applying ACT principles and increasing psychological flexibility [27, 31]. Participants resonated with this approach and often expressed appreciation for the practical nature of the intervention. Participants also highlighted the significance of the therapeutic relationship. Within the ACT model, the development of a consistent and collaborative therapeutic relationship, often referred to as the ACT therapeutic stance, is of central importance [70]. The ACT therapeutic stance is open, accepting and non-judgmental [50]. Creating this relationship provides the context to facilitate engagement and ensure the ACT model can be implemented in a way to maximise its effect.

Participants also provided valuable feedback on the structure of ACTion mTBI and when it could be delivered. Interestingly, some participants suggested adding in an additional follow-up session to support the maintenance of the intervention effects. The research evidence strongly supports the addition of booster sessions [71] and should be considered when implementing ACTion mTBI in the future. Further regarding its structure, ACTion mTBI is an intervention protocol and it was useful to know that many participants liked the structure of each session. Importantly though, and in accordance with the ACT model [31], participants also appreciated the flexibility of ACTion mTBI and its ability to address the most salient issues for the client. Adopting this flexibility was also suggested by participants in regard to when the intervention should be delivered (i.e., “timing matters”). Interestingly, many participants suggested that they would have liked to have received ACTion mTBI earlier in their recovery, however, other participants highlighted the need to feel ready to enable active engagement in the intervention. This aligns with treatment guidelines that advise early psychological treatment to address and mitigate the influence that psychological factors can have on recovery [18]. Finally, participants also reported that ACTion mTBI was culturally and spiritually responsive and could therefore adhere to the specific individualistic of each client that engaged in the intervention. This is consistent with a body of evidence demonstrating the applicability and usefulness of ACT in a range of different ethnic and cultural groups [72–75]. In summary, being experiential, developing a strong therapeutic connection, cultural and spiritual responsivity and being flexible in intervention delivery and timing must occur when delivering ACTion mTBI.

The results of this study do need to be considered in the context of its limitations. First, our participant sample was predominately female. There is evidence that females may experience more heightened emotional distress (i.e., anxiety) after mTBI [76]. It may therefore be that this group is in greater or is more open for psychological treatment to address these difficulties. However, males are at a heightened risk of experiencing mTBI [3]. In addition, our sample was also relatively small, were more likely to be highly educated and were undergoing treatment for mTBI. This limits our ability to generalise the findings of this study to other demographics, as well as the wider mTBI population and it will be important to obtain the perceptions of ACTion mTBI from a larger and more diverse cohort. Second, our analysis was conducted on interviews with participants—85.2% of whom completed the intervention. Although we had a high retention of participants in the treatment, those who took part in the interviews may have more positive experiences of the intervention than those who declined. Thirdly, we conducted interviews following the completion of the intervention and we therefore did not collect data on the longer-term effects of ACTion mTBI on mTBI recovery. We cannot assume that the benefits described by participants in this study translate to sustained changes in recovery over time. There is also inherent subjectivity when conducting qualitative research that needs to be acknowledged. Finally, this study interviewed participants of one treating psychologist who delivered ACTion mTBI. Attributes such as therapist style, rapport, communication style and experience unique to the treating psychologist should therefore be kept in mind with interpreting the results. Future research should establish experiences of ACTion mTBI from a more diverse cohort of treating psychologists.

In conclusion, this study highlights the perception and experience of individuals who have engaged in an ACT-informed intervention for mTBI; ACTion mTBI. This analysis was able to determine that ACTion mTBI has a positive impact on recovery and therefore provides preliminary support for the utilisation of this psychotherapeutic modality in mTBI rehabilitation. Importantly, this study was able to provide valuable insights into how this intervention produces these effects and the value that attacking the concussion from a different direction can have on mTBI recovery and overall well-being. Based on participant reflections, ACT processes were found to be helpful in addition to generic ingredients within psychotherapy (i.e., psychoeducation, therapeutic relationship, and emotional disclosure).

Supporting information