Available via license: CC BY 4.0
Content may be subject to copyright.
MAIN
The efficacy of therapist-supported acceptance and
commitment therapy-based bibliotherapy for
psychological distress after stroke: a single-case
multiple-baseline study
Misbah Gladwyn-Khan and Reg Morris*
Cardiff University and Cardiff & Vale UHB, Cardiff, UK
*Corresponding author. Emails: reg.morris@Plymouth.ac.uk,MorrisR8@cardiff.ac.uk
(Received 31 December 2021; revised 11 August 2022; accepted 18 August 2022)
Abstract
Background: Psychological distress is common after stroke, and affects recovery. However, there are few
evidence-based psychological treatments. This study evaluates a bibliotherapy-based approach to its
amelioration.
Aims: To investigate a stroke-specific self-management book, based on acceptance and commitment
therapy (ACT), as a therapist-supported intervention for psychological distress after stroke.
Method: The design was a single case, randomised non-concurrent multiple-baseline design (MBD).
Sixteen stroke survivors, eight males and eight females (mean age 60.6 years), participated in an MBD
with three phases: A (randomised-duration baseline); B (intervention); and follow-up (at 3 weeks).
During the baseline, participants received therapist contact only. In the bibliotherapy intervention,
participants received bi-weekly therapist support. The primary measures of psychological distress
(General Health Questionaire-12; GHQ-12) and quality of life (Satisfaction with Life Scale; SWLS)
were completed weekly. Secondary measures of mood, wellbeing and illness impact were completed
pre- and post-intervention.
Results: Omnibus whole-group TAU-U analysis was statistically significant for each primary measure with
a moderate effect size on both (0.6 and 0.3 for GHQ-12 and SWLS, respectively). Individual TAU-U
analyses demonstrated that the majority of individuals exhibited positive change. All the secondary
measures showed significant pre–post improvements. Eighty-one per cent of participants reported the
book was helpful and 81% also found the ACT-based sections helpful. Relative risk calculations
showed finding the book helpful was associated with improvement in GHQ-12 and SWLS scores.
Conclusions: ACT-based bibliotherapy, with therapist support, is a promising intervention for
psychological difficulties after stroke.
Keywords: acceptance and commitment therapy; bibliotherapy; self-management; stroke
Introduction
Stroke is accompanied by anxiety in about 25% of people (Campbell Burton et al., 2013) and by
depression in 29% (Ayerbe et al., 2013). Psychological distress is associated with impeded
rehabilitation (Ahn et al., 2015), impaired functional outcomes (Ayerbe et al., 2014; Chun
et al., 2018a; Chun et al., 2018b), restricted activities of daily living (Tsuchiya et al., 2016) and
increased mortality (Bartoli et al., 2013). Length of hospital stays (Sugawara et al., 2015) and
© The Author(s), 2022. Published by Cambridge University Press on behalf of British Association for Behavioural and Cognitive
Psychotherapies. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is
properly cited.
Behavioural and Cognitive Psychotherapy, 2022, page 1 of 18
doi:10.1017/S135246582200042X
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
healthcare costs (Naylor et al., 2012) are also greater in the presence of challenges such as impaired
cognition, affective disorders, fatigue and disability that are associated with psychological distress.
Cognitive impairment occurs commonly after stroke (Nys et al., 2007); about 15% of stroke
survivors had cognitive test scores indicative of impaired activities of daily life and the need
for supported living arrangements (Liman et al., 2012). Fatigue is often another barrier to
readjustment after stroke (Acciarresi et al., 2014).
Despite the importance of addressing psychological factors after stroke, several reviews (Allida
et al., 2020; Campbell Burton et al., 2011; Gillespie et al., 2015; Hackett et al., 2008;Wuet al., 2015)
identified few psychological treatment approaches with a sound evidence-base. Consequently,
national guidelines (Intercollegiate Stroke Working Party, ICSWP-UK, The Royal College of
Physicians, 2016; National Institute for Health and Care Excellence, 2013/2018) recommend
few psychological treatments specifically for stroke. For example, the ICSWP recommends
four treatments or preventative approaches for low mood: motivational interviewing based on
one randomised controlled trial (RCT), for which a subsequent pilot RCT failed to find any
benefit (Kerr et al., 2018); behaviour therapy based on one RCT; problem solving therapy
based on two RCTs. While a meta-analysis suggested benefit of cognitive behavioural therapy
(CBT) after stroke for Chinese samples (Wang et al., 2018), the authors urge caution due to
heterogeneity and low quality (61%) of the studies and lack of corroboration in two European
studies. To date, CBT has not been recommended for stroke-specific psychological disorders
in UK stroke guidance.
Cost-effective approaches to psychological disorders after stroke are urgently needed in view of
their high prevalence and impact in the context of limited resources for psychological care (The
Royal College of Physicians, 2015). Transdiagnostic therapeutic approaches such as acceptance
and commitment therapy (ACT) (Hayes, 2004) have the potential to address a wide range of
psychological and behavioural problems without requiring staff training in several diagnosis-
specific therapy protocols. ACT simplifies the treatment of emotional difficulties by targeting
shared aetiological processes underpinning multiple forms of emotional distress (Gros et al.,
2016). Kangas and MacDonald (2011) concluded their review of CBT for acquired brain
injury with a recommendation for research into ACT with this population, stimulating two
RCTs. For people with elevated psychological distress after brain injury, ACT therapy was
beneficial in the short-term compared with a befriending control condition, although other
indices of recovery did not show improvement (Whiting et al., 2020) . Sander et al.(2020)
found that ACT for people exhibiting psychological distress after traumatic brain injury
reduced psychological distress, compared with a counselling/education intervention. However,
the control intervention in this study lacked equivalence to the ACT intervention. There is
now also growing evidence for ACT’s effectiveness in reducing psychological distress and
enhancing psychological wellbeing after stroke (Graham et al., 2016; Majumdar and Morris,
2019). Reviews have concluded that ACT is cost-effective, readily translates to different
settings (Ruiz, 2010) and can be delivered in low-intensity formats (Dindo et al., 2017). In
addition, stroke survivors reported that ACT helped them to adjust to the consequences of
stroke (Large et al., 2019). Consistent with its transdiagnostic foundations, ACT’s focus is not
on a single psychological difficulty or symptom. Instead, it addresses broader psychological
processes encompassed as ‘psychological flexibility’. Psychological flexibility derives from a
capacity to engage positively with six core psychological processes that form the central tenets
of the ACT model (Hayes, 2004). The relevance of psychological flexibility and its constituent
processes to people with psychological distress after a stroke was succinctly summarised by
Majumdar and Morris (2019). They pointed out that the health model underpinning ACT is
conducive to the promotion of wellbeing rather than simply symptom reduction; the emphasis
on acceptance of psychological distress and ‘getting on with life’has application where there
are enduring disabilities following stroke; the focus on mindfulness and ‘being in the present’
encourages a person to make contact with their surroundings and with experiences beyond
2 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
their disability and psychological distress; building ‘self-as-context’, an observing self that is
separate from the experience of psychological distress, counters negative changes in self-
identity after stroke; finally, the discovery of a person’s core values to pursue value-driven
‘committed action’may represent an improvement on current goal setting practice in stroke.
Another advantage of ACT is that it is readily disseminated and administered in different
formats (Assaz et al., 2018; Dindo et al., 2017). Cost-effective delivery of psychological
interventions is vital in the context of restricted healthcare funding (Luchinskaya et al., 2017).
Many of the delivery formats of existing therapies are resource intensive, requiring one-to-one
delivery, coupled with adaptation and specialised training for different conditions (Majumdar
and Morris, 2019). Cost savings can be made by group delivery, delivery by associate grade
staff working under supervision or bibliotherapy (with therapist support or alone).
Bibliotherapy has potential to be cost-effective in stroke. It was shown to be cost-effective for
behavioural disorders in children when compared with therapist-led interventions (Sampaio
et al., 2016), and a review (Latchem and Greenhalgh, 2014) concluded that self-management
is effective in neurological conditions including head injury, dementia and stroke. Several
meta-analyses including bibliotherapy have confirmed that bibliotherapy, alone or with
therapist support, is effective for psychological treatment of emotional disorders (Cuijpers
et al., 2010; Den Boer et al., 2004; Hirai and Clum, 2006).
Bibliotherapy, which is the provision of psychological therapy through books or other written
materials, may be particularly suited to the stroke population as it can be self-paced and is
accessible by people with mobility restrictions (Jacobs and Mosco, 2008). Moreover, it can be
delivered through existing public library networks (Chamberlain et al., 2008). The aim of the
present study was to investigate the efficacy of a self-management book for stroke (‘Rebuilding
Your Life After Stroke’, Morris et al., 2017), which uses ACT as its core model. The ACT
section of the book was broadly based on material used in a study of group therapy
(Majumdar and Morris, 2019) where it demonstrated efficacy with a group of stroke
survivors. Acceptance of psychological distress is a key goal of ACT and was identified as a
high research priority by a panel of stroke survivors, caregivers and health clinicians (Pollock
et al., 2014). The ACT programme in the book aimed to increase acceptance of the effects of
stroke as a facet of psychological flexibility that promotes positive outcomes (Kashdan, 2010).
It was hypothesised that bibliotherapy, used with therapist support, would reduce psychological
distress and improve satisfaction with life. The bibliotherapy was self-administered and self-paced
and the book consists of two distinct therapy sections with eight chapters. Therefore, in order to
facilitate its effective use over the intervention period, this study used a ‘small-N’replicated single-
case, non-concurrent multiple baseline design (MBD) (Watson and Workman, 1981) with
therapist support, in preference to a group-based RCT. The primary outcome measures were
brief measures chosen to assess changes in distress and satisfaction with life over the course of
the bibliotherapy, while the secondary outcome measures provided a more detailed assessment
of change in common psychological problems after stroke, as well as wellbeing and the impact
of stroke.
Method
Design and analysis
The study employed a small-Nsingle-case non-concurrent MBD. The design was non-concurrent
to improve feasibility (Watson and Workman, 1981). In this design, control for threats to internal
validity are ameliorated through (1) a baseline phase of random duration and (2) frequent
measurement throughout the baseline and intervention phases. Randomisation was achieved
by randomising baseline duration and the start of the intervention. This staggered the
Behavioural and Cognitive Psychotherapy 3
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
intervention across participants and permitted randomised controlled comparisons. To improve
sensitivity to change, outcomes were measured frequently at short time intervals.
Participants all started with a randomised, pre-determined length, baseline phase (see
Supplementary material 1for details) so that entry into the intervention stage was staggered,
and randomised, which allows quasi-control for time and maturation effects (Rhoda et al.,
2011). Staggering the baseline involved some participants remaining in the baseline phase
when intervention for others began. This process permits interpretation through controlling
for whole-sample confounding factors, e.g. alteration in general care practice in stroke and
current events. Primary measures were taken weekly and secondary measures at the start and
end of each phase. The statistical analysis method was designed specifically for MBDs and
partialled out baseline effects from the intervention results (www.singlecase.org; calculators)
(Vannest et al., 2016).
Sample size and phases
The MBD included 32 phases (16 participants, each with a baseline and intervention) and weekly
observations. All the baseline and intervention phases had at least three observations due to
practical issues with starting the intervention for some participants. Initially minimum
baseline points had been set at 2 weeks following advice received by the ethical committee
which advised that the feasibility of the study could be compromised through long baselines
and the likelihood of drop-out due to the complex nature of the participant population (see
Supplementary material 1). The interventions were self-paced and ranged from 3 to 16 weeks.
Based on a quality recommendation for concurrent MBDs –where overlap between phases is
a part of the design (Kratochwill et al., 2013)–the planned design exceeded the quality
standard for the number of phases (6) and met the quality standard for data points per phase
for 11 of the 16 baseline phases and 14 of 16 intervention phases. All the remaining phases
(7) met the quality standard ‘with reservations’.
Recruitment
As the problems of simultaneous recruitment in multiple baseline design are well documented
(Graham et al., 2012), this study recruited participants at point of referral into the study. In
line with guidelines that community interventions should be provided irrespective of time
since stroke (The Royal College of Physicians, 2016), time since stroke was not used as an
exclusion criterion.
Recruitment was from three Health Boards in Wales and one Health Trust in southwest
England, and two stroke charities. Leaflets providing brief information about the study were
provided to staff and passed on to clients. Signed informed consent was obtained by the
researcher. No financial/reward incentives were used.
Inclusion and exclusion criteria were assessed by interview by the first author.
Inclusion:
•a clinical diagnosis of at least one stroke;
•18 years of age or above;
•reporting psychological distress to a referring clinician/key worker;
•ability to read a book.
Exclusion:
•diagnosis of serious psychiatric problems such as psychosis;
•diagnosis of a progressive, degenerative disorder;
4 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
•serious communicative difficulties, such as aphasia;
•traumatic brain injury.
Further details of recruitment and attrition can be found in Supplementary material 2.
Materials
The self-management book, ‘Rebuilding Your Life After Stroke’(Morris et al., 2017) is available
free of charge in the UK through the Reading Agency, ‘Books on Prescription’Scheme (https://
reading-well.org.uk/books/books-on-prescription). The book was written by stroke clinicians and
stroke survivors to address common post-stroke psychological difficulties. The book is divided
into four parts: Part 1, Introduction to the book, its scope, navigation and materials; Part 2,
What is happening to me?, about common psychological distress after stroke; Part 3,
Rebuilding your life after stroke, the ACT-based content; Part 4, Summary, a synthesis and
ideas for the future. There are also lists of stroke-related resources at the end. The book is
designed with spiral binding so it can be read one-handed (see Supplementary material 3for
the Contents page of the book.)
The book provides practical guidance for the management of common psychological and
behavioural problems after stroke in Part 2 and takes ACT as the core model for approaching
more intractable forms of psychological distress in Part 3. The book has linked audio-visual
files on YouTube for practising ACT-based exercises and of interviews with stroke survivors.
Measures
Socio-demographical information
Information was collected about age, gender, date of first and most recent stroke, type of stroke,
and current psychiatric/psychological treatments.
Primary measures
As the primary measures were self-assessment measures, the standard of inter-observer agreement
for MBDs (Kratochwill et al., 2013) was not applicable. Reliability of the measures is instead
attested by the demonstration of test–retest reliability in the validation of the instruments.
The primary measures were collected weekly and were chosen to cover both distress and life
satisfaction.
General Health Questionnaire-12 (GHQ-12). The GHQ-12 is a brief assessment of psychological
difficulties in the general population (Goldberg and Williams, 1988) with scores ranging from
0 to 36. The validity and reliability of the GHQ-12 have been evaluated (Hankins, 2008). In
the general population, Cronbach’s alpha was 0.94 (Lesage et al., 2011). In stroke, the validity
of the General health Questionnaire (GHQ-28, which includes the GHQ-12 questions) has
been reviewed with the conclusion that it has validity as a screening instrument (Burton and
Tyson, 2015). For the GHQ-12, Hilari et al.(2003) reported a correlation of .58 with a stroke
Aphasia Quality of Life Scale. It has been shown to be acceptable as a measure of distress in
over 10 studies of stroke and was recommended as a screening measure for depression after
stroke (Bennett and Lincoln, 2006).
Satisfaction with Life Scale (SWLS). The SWLS (Diener et al., 1985) is a brief, global life-satisfaction
instrument including five questions about level of satisfaction with current life conditions.
Responses are on a 7-point scale from strongly disagree to strongly agree, and the scores
range from 5 to 35. A review of the SWLS (Pavot and Diener, 1993) cited high internal
consistency (alpha .87) and 2-month test–retest reliability of .82. Construct validity has been
Behavioural and Cognitive Psychotherapy 5
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
demonstrated through negative correlations with tests of clinical conditions such as depression
and anxiety and positive correlations with measures of positive affect. A meta-analytic
reliability-generalisation study estimated an average Cronbach’s alpha of 0.78 across 60 studies
(Vassar, 2008). Internal constancy remained high in a neurological sample with Parkinson’s
disease (alpha .92) and Rasch analysis supported its validity (Loveride and Hagell, 2016).
There are currently no stroke validation studies of the SWLS. However, it has been used
successfully with stroke survivors in several studies (e.g. Mahmoud et al., 2016).
Secondary measures
Secondary measures were collected only pre- and post-intervention.
Beck Depression Inventory –II (BDI-II) Fast-Screen. The BDI-II-FS (Beck et al., 1996) is a 7-item,
self-report measure. Although less thoroughly validated than the longer form of the BDI-II,
the fast-screen version avoids confounding somatic symptoms in physical illnesses (Salter
et al., 2008). The validity of the BDI-II-FS has been established in a review of studies of
mixed medical patients (Wang and Gorenstein, 2013) and it has acceptable sensitivity (0.71),
specificity (0.74) and internal consistency (0.75) in stroke (Healy et al., 2008).
Hospital Anxiety and Depression Screen (HADS). The HADS (Zigmond and Snaith, 1983)isa
14-item mood and anxiety screening tool for patients with physical illnesses. It was included
to allow comparison with other studies due to its widespread use in stroke research. The
HADS has undergone validation for use in stroke and has shown good performance:
AUC=85.9% (Prisnie et al., 2016). Sensitivity and specificity values of 0.92 and 0.65,
respectively, are established in stroke (Burton and Tyson, 2015). Cronbach’s alpha has been
shown to be high at 0.85 in stroke survivors (Aben et al., 2002). Total HADS scores were
used for analyses in this study.
The Beck Anxiety Inventory (BAI). The BAI (Beck and Steer, 1993) is a 21-item self-report measure
of symptoms of anxiety. The BAI has been shown to measure general anxiety (Muntingh et al.,
2011). A comprehensive meta-analysis of 192 studies found the BAI to demonstrate sound
psychometric properties, with good reliability (Cronbach’s alpha) and test–retest reliability
(0.91 and 0.65, respectively). Sensitivity was .83 and specificity 0.89 in a sample of cancer
patients (Bardoshi et al., 2016). There are currently no formal validation studies of the BAI in
stroke, although one small-sample study compared it with a clinical interview, finding it had
good sensitivity but low specificity (Schramke et al., 1998). The BAI has been also been
compared with other indices of anxiety; a study evaluating anxiety in stroke survivors using
the BAI found that the rates of anxiety correlated with published rates and somatic symptoms
were not over-reported in comparison with emotional items (Barker-Collo, 2007).
The Warwick Edinburgh Mental Wellbeing Scale (WEMWS). Wellbeing was assessed separately to
psychological distress (depression and anxiety) as the absence of distress does not necessarily
signify the presence of wellbeing. The WEMWS has 14 items and its validity in non-clinical
populations was evidenced by a negative correlation with the GHQ-12 and high positive
correlations with a range of life-satisfaction scales. It had good internal consistency and test–
retest reliability (0.89 and 0.83, respectively) (Stewart-Brown et al., 2011; Tennant et al., 2007).
The WEMWS has not been validated for stroke populations but has been shown to be
acceptable and accessible by stroke survivors (Majumdar and Morris, 2019).
Stroke Impact Scale (SIS). The SIS is a complete assessment of physical and functional disability
associated with stroke (Duncan et al., 2003). It is an 8-domain measure, consisting of 59 questions.
The SIS gives a composite disability score and the internal consistency of the measure ranges from
0.86 to 0.95 (Jenkinson et al., 2013). Its reliability (internal consistency and test–retest) and
validity against a wide range of cognitive and performance measures have been extensively
6 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
studied and this research is reported at: https://strokengine.ca/en/assessments/stroke-impact-
scale-sis/
Survey. Participants completed a brief, closed-question survey at the completion of the study. The
survey consisted of three enquiries using a Likert Scale of 0 to 10 (where 10 is rated as most
helpful): ‘How helpful was the book?’;‘Which part of the book was found to be particularly
helpful?’;‘What aspect of wellbeing did the book help address?’. Five options were provided for
each area: [Improvements to] anxiety, depression, confidence, self-activation or other.
Study procedure
Participants started baselines as they were recruited over a 10-month period in 2018–19. Baseline
lengths were randomised in advance using a randomisation programme. Planned randomised
baseline lengths ranged from 2 to 8 weeks.
The study consisted of three phases: baseline, intervention, and a 3-week follow-up.
The two primary measures were collected weekly and the five secondary measures were
collected before and after the intervention phase. The survey was completed at the end of the
intervention.
In the baseline phase one-to-one therapist contact occurred every 2 weeks in the patient’s home
to control for this element in the intervention phase. During the ‘no active intervention’, baseline
phase, therapist support consisted of person-centred support, e.g. empathy, positive regard and
congruence (Fazio et al., 2018). The sessions lasted 40–50 minutes. The number of therapist
sessions received by each participant are given in Supplementary material 1.
Individuals continued with any usual treatments, e.g. anti-depressants, GP appointments,
stroke clinic appointments, specialist nurse visits, physiotherapy, etc. None was having
concurrent psychological therapy. The baseline phase allowed assessment of the effects of
these treatments as well as the therapist contact. Some participants were unable to start the
intervention at the end of the planned baseline stage and the baseline was extended until they
could do so (see Supplementary material 1for details).
During the intervention phase, each stroke survivor was given the book and therapist provided
support to use the book and to practise/apply its principles. The therapist was a pre-registration
trainee clinical psychologist with 7 years of NHS experience as a graduate psychologist and basic
(non-accredited) training in a range of therapies including ACT, CBT and general counselling.
The support was provided on an individual basis every 2 weeks by home visits and was based
on the client’s expressed questions and needs in relation to their use of the book. These
sessions also lasted 40–50 minutes. The number of sessions received by each participant is
given in the tabulation of the study phases in Supplementary material 1. The pace of reading/
applying the book material was decided in collaboration with the individuals. The intervention
phase length therefore varied for individual participants (between 6 and 16 weeks). The book
material used was also tailored to individuals. Session structure was as follows:
(1) Set the agenda; ask about current difficulties for which book could be used.
(2) Discuss what the book offers to manage difficulty.
(3) Review psychoeducation from the book by collaboratively considering information in the
book that is potentially helpful in promoting psychological flexibility.
(4) Try out exercises (optional) from the book.
(5) Review session and set homework from the book.
The follow-up used the primary measures (GHQ-12, SWLS). Follow-up was conducted by the
researcher 3 weeks following the completion of the final, intervention phase.
Behavioural and Cognitive Psychotherapy 7
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
All therapist contact and measurements took place face-to-face in the participants’places of
residence (apart from two contacts to the participant’s home by telephone). Home visits
improved recruitment and reduced the burden of travel due to stroke-related mobility
restrictions. Blinding of researcher to the phase for collection of participant self-assessments
and to the intervention was not feasible.
Statistical analysis
Analysis of the MBD was completed using TAU-U. TAU-U is an effect size that combines the
trend from the intervention phase with non-overlap from both baseline and intervention
phases and is a reliable test in multiple-baseline design analysis (Brossart et al., 2018). TAU-U
provides conservative effect sizes (Brossart et al., 2018). The TAU-U tool used is internet-
based (singlecaseresearch.org, calculators; Vannest et al., 2016). Baseline correction was used if
baseline TAU-U exceeded 0.2 (Vannest and Ninci, 2015). This TAU-U calculator yields effect
sizes for the difference in phases (Brossart et al., 2018). Effect sizes were interpreted based on
guidelines (Vannest and Ninci, 2015): <0.20, small change; 0.20–0.60, moderate change; 0.60–
0.80, large change.
SPSS 25 was used to analyse before and after change in the secondary measures. Paired t-tests,
with Bonferroni corrections, were used to evaluate change in the scores of the secondary measures
between the pre- and post-intervention assessment points. A sample of 13 is required to detect a
large effect size (Dz) with a power of 0.9 with a one-tailed test.
Survey analysis
Relative risk can be used to determine associations in cohort studies (Viera, 2008). Here it was
defined as the rate of reported benefit if exposure to the book was found helpful (rated as >6/10)
divided by the rate of reported benefit in those who did not find the book helpful.
Results
The flow of participants from their initial recruitment to the study is depicted in the PRIMA
diagram in Supplementary material 4.
The median number of baseline and intervention weeks were 6.0 (range 3–11) and 11.0 (range
3–16), respectively. The corresponding medians for therapist contacts and therapist time during
baseline and intervention phases were 3.0 sessions (range 1–4) or 2.25 hours and 5.0 sessions
(range 2–8) or 3.75 hours, respectively (see Supplementary material 1).
Demographical analysis
Table 1gives a summary of the sample characteristics. The mean time since stroke was 19 months.
Primary measures’analysis: GHQ-12 and SWLS
Figures S2 to S17 (see Supplementary material 5) illustrate the effects of intervention on the GHQ-
12 and SWLS. Graphs for participants 3 and 8 are given as illustrations in Fig. 1. The GHQ-12
scores were indicative of high levels of psychological distress in this sample, with 14 of 16
participants scoring 20 or over at the start of the baseline. On the SWLS only two participants
scored in the very dissatisfied range at the start of baseline, but all scored below 20, which is
regarded as the ‘neutral’point on the scale.
The whole-sample omnibus analysis of the GHQ-12 results was statistically significant with a
moderate effect size (0.6, p<0.05). TAU-U scores were computed for each participant; all
8 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
demonstrated an effect in the positive direction and seven (43.7%) showed statistically significant
effects. Due to the short baselines of some participants the absence of more individual significant
effects was not unexpected.
The whole-sample omnibus analysis of the SWLS results was also statistically significant
(TAU=0.3; p<0.05) with a moderate effect size. Individual TAU-U analyses showed a positive
effect of the intervention for 12 (75.0%) of the participants and five (31.3%) were statistically
significant. However, two participants showed statistically significant effects in a negative
direction on this measure. See Table 2.
Follow-up
Paired sample t-tests for the 3-week follow-up results of both primary measures compared final
intervention scores and 3-week follow-up scores on GHQ-12 [means 9.0 (5.1) and 10.7 (6.5),
respectively] and SWLS [(means 17.1 (9.2) and 18.8 (8.5), respectively]. Differences were not
statistically significant. This was commensurate with the maintenance of gains.
Secondary measures analysis
Paired samples, t-test, results of the pre–post, whole-group analysis of the BDI, BAI, HADS,
WEMWS and SIS are presented in Table 3. At baseline, mean BDI-II scores were in the
Table 1. Sample characteristics
Participant
Age and
gender Type of stroke
Number of
strokes
Employment status (R: retired, W:
working, U: unemployed) Medication
1 53, F Infarct, lateralisa-
tion unknown
1 U Sertraline
2 59, M Right-sided hae-
morrhage
1Un/a
3 52, M Right-sided
ischaemic
attack
1 U Citalopram
4 84, F Left-sided infarct 1 R NA
5 56, M Left haemorrhage
and TIA
2 U Beta-blockers
6 73, F Right-sided infarct 1 U Carbamazepine
and Lorazepam
7 29, F Left-sided hae-
morrhage
1 U Propanol
8 80, M Cerebellar infarct
and TIA
2 R Sertraline
9 67, M Left-sided Infarct
and TIA
2 R Citalopram
10 82, M Mid-brain infarct
and TIA
2Rn/a
11 56, F Left-sided infarct
and TIA
2 U Citalopram
12 56, M Left-sided infarct 1 W n/a
13 56, F Left-sided infarct
and TIA
2 U Sertraline
14 53, M Right-sided infarct 2 U Sertraline and
Diazepam
15 34, F Left-sided hae-
morrhage
1Wn/a
16 79, F Left-sided infarct 1 R Amitriptyline
Behavioural and Cognitive Psychotherapy 9
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
normal range, while BAI and HADS total scores indicated significant distress. Following
Bonferroni correction (adjusted α=0.01), the results of the pre–post, whole-group analysis
remained statistically significant.
Figure 1. Baseline and intervention scores for GHQ and SW for participants 3 and 8. GHQBn, GHQ-12 baseline; GHQIn,
GHQ-12 intervention; SWBIn, SWLS baseline; SWIn, SWLS intervention; nis the number of the participant.
10 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
Survey results
Survey results are presented in Table 4. Eighty-one per cent of the sample reported the book was
very helpful. It was reported useful for anxiety, low mood, confidence, motivation, acceptance and
understanding carer’s role. Eighty-one per cent of the sample also reported Part 3, which contains
the ACT programme, as helpful.
The relative risk calculation showed that the chance of improvement on the GHQ-12 if the
book was found helpful was 81% and the corresponding figure of the SWLS was 68%. The
chance of improvement on GHQ-12 if the book was found helpful was increased by a factor
of 8, compared with if the book was not found helpful. The corresponding factor for the
SWLS approached 7.
Discussion
The TAU-U whole-sample omnibus results for both primary measures showed moderate effect
sizes of the intervention on both GHQ-12 and the SWLS over a median of 11 weeks of using the
book with six therapist contacts (median 4.5 hours in total). Individual analyses support the
omnibus analysis with the majority of participants showing changes in a positive direction on
both measures. This lends support to the hypothesis that ACT-based bibliotherapy, with
therapist support, was beneficial for the psychological wellbeing and quality of life of stroke
survivors in the short term. The outcome extends the conclusion of meta-analyses of
Table 2. Individual TAU-U statistics for GHQ-12 and SWLS
Participant no.
GHQ-12 SWLS
TAU-U Effect size p-value TAU-U Effect size p-value
1 0.50 Moderate 0.110 0.70 Large 0.021*
2 0.90 Large 0.000* 0.40 Moderate 0.011*
3 0.10 Small 0.717 –0.69** Moderate 0.016*
4 0.71 Moderate 0.011* 0.58 Moderate 0.038*
5 0.70 Large 0.018* 0.66 Moderate 0.027*
6 0.42 Moderate 0.212 0.42 Moderate 0.183
7 0.70 Large 0.031* 0.28 Small 0.395
8 0.98 Large 0.000 * 0.80 Large 0.004*
9 0.50 Moderate 0.121 0.60 Moderate 0.071
10 0.60 Moderate 0.027* 0.30 Moderate 0.239
11 0.10 Very small 0.730 0.43 Moderate 0.174
12 0.07 Very small 0.813 –0.16** Small 0.592
13 0.60 Moderate 0.155 0.60 Large 0.110
14 0.22 Small 0.662 0.33 Moderate 0.512
15 0.14 Small 0.608 –0.94** Large 0.007
16 0.83 Large 0.000* –0.50** Moderate 0.143
*alpha<0.05; **indicates reduced satisfaction with life.
Table 3. Whole-sample pre–post analysis for secondary measures
Measure
Pre-test
mean (SD)
Post-test
mean (SD) Paired t-test
BDI-II 8.4 (4.7) 4.3 (4.2) p<.001
BAI 22.6 (11.4) 9.9 (10.5) p<.0001
HADS 23.1 (8.9) 14.7 (8.6) p<.0001
WEMWS 36.9 (11.5) 48.9 (11.7) p<.0001
SIS 188.9 (36.0) 218.3 (30.2) p<.001
BDI-II, Beck Depression Inventory-II; BAI, Beck Anxiety Inventory; HADS, Hospital Anxiety and Depression Scale; WEMWS, Warwick Edinburgh
Mental Wellbeing Scale; SIS, Stroke Impact Scale.
Behavioural and Cognitive Psychotherapy 11
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
bibliotherapy in the mental health context (Cuijpers et al., 2010; Den Boer et al., 2004; Hirai and
Clum, 2006) to psychological sequelae of a physical health condition. It also supports the
conclusions of Majumdar and Morris (2019) that ACT-based interventions are beneficial for
stroke survivors, at least in the short term. This outcome was achieved with a medium of only
4.5 hours of therapist contact in the intervention phase and is encouraging for the
development of cost-effective, low-intensity interventions for psychological distress (Latchem
and Greenhalgh, 2014; Sampaio et al., 2016), delivered through book prescription schemes
(Chamberlain et al., 2008).
All secondary outcome measures showed large statistically significant change in a positive
direction. Although these pre–post results may be a consequence of temporal change
unconnected to the intervention, they are congruent with those of the controlled MBD and
together these findings support the efficacy of bibliotherapy.
In this study, the WEMWS wellbeing scale and the SWLS quality of life measure both showed
significant change over time, whereas Majumdar and Morris (2019) found they did not show
benefit in a controlled trial of group-based ACT. They attributed the lack of benefit to
insufficient intervention time (4 weeks) to develop secondary benefits in overall wellbeing.
The longer study period here may have allowed sufficient time for this. The improvement on
the SWLS may also reflect the individualised approach of the current study in contrast to the
group-based didactic approach taken by Majumdar and Morris (2019), as the stroke survivors
were able to discuss and plan individual values-based activities and social engagement during
the therapist support sessions. Generally, in the absence of psychological intervention, post-
stroke life satisfaction remains low despite extensive rehabilitation (Langhammer et al., 2017).
Improving quality of life is a priority in view of the high prevalence of post-stroke disability
(Carmo et al., 2015) and the bibliotherapy approach is promising in this respect.
The Stroke Impact Scale (SIS) showed positive change in perceptions and experiences of
disability after stroke and includes dimensions of Health Related Quality of Life (Salter et al.,
2008). This finding may attest to the role of acceptance and defusion (Graham et al., 2016)in
amelioration of negative psychological processes stemming from enduring disability and loss
of function which are frequent consequences of stroke (American Heart Association, 2011;
Table 4. Survey results
Participant
Helpfulness rating
0–10
(10 =extremely
helpful) What did the book help with?
Which part of the book was
most helpful?
1 5 Anxiety: understanding burden on carer‡2
2 8 Confidence and low mood 1, 2, 3
3 8 Confidence: learning that I can get through it‡2
4 10 Confidence 3
5 8 Anxiety 3
6 10 Confidence 3
7 10 Anxiety, low mood 2, 3
8 10 Anxiety, low mood 3
9 9 Getting motivated 3
10 10 Low mood, confidence, anxiety 3
11 7 Anxiety thoughts 3
12 9 Anxiety, motivation 3
13 Lost to follow-up* ——
14 10 Anxiety, confidence 2, 3
15 10 Low mood, confidence, anxiety 3
16 7 Confidence: understanding and realising you
are not alone‡
1, 2, 3
*Participant’s view of the book prior to drop-out was favourable: ‘I carry it around with me’
‡reason given for ‘other’response.
12 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
Feigin et al., 2017). ACT’s focus on identifying values to underpin goal setting and value-based
living may be particularly helpful in promoting active engagement in the context of enduring
disabilities (Clarke et al., 2014). Value-based living is associated with psychological wellbeing
and improved function in people after traumatic brain injury (Pais et al., 2019).
Taken together, the results of the SWLS, WEMWS and SIS tentatively support the
bibliotherapy-ACT intervention as an effective intervention for enhanced wellbeing and
quality of life for stroke survivors.
The brief survey showed that the book was perceived favourably by participants, with 81% of
the sample reporting part 3 (ACT intervention) as the most helpful part. ACT fits particularly well
in stroke from a theoretical and practical point of view. Its therapeutic techniques do not aim
primarily to alleviate psychological distress (Guadiano, 2011) but rather to enhance
psychological flexibility to change the relationship between a person, their distress and the
behaviours the distress engenders. This promotes the transdiagnostic nature of ACT by
requiring less specificity for interventions than psychological approaches based on cognitive
processes and reinforcement contingencies (Assaz et al., 2018).
The emphasis of ACT on experiential learning enables it to be used successfully with
generalised cognitive impairments in learning disability settings (Brown and Hooper, 2009).
For example, the ACT process of defusion (distinguishing between thoughts and reality) does
not require cognitive reframing of psychologically distressing thoughts in order to reduce
negative responses to thoughts (Assaz et al., 2018) and has been shown to produce more
rapid change than cognitive restructuring (Deacon et al., 2011). Cognitive factors may also
underpin ACT’s success with complex presentations, i.e. treatment-resistant populations
(Clarke et al., 2014).
Limitations and future research
This MBD study provided a level of experimental control but a concurrent design, where all the
participants start baseline at the same time, would have provided more definitive evidence.
Further research using randomised control conditions, blinding to hypotheses and phases/
conditions, longer baselines and follow-up and larger samples is required to address the
limitations of this study and strengthen evidence for the effectiveness of ACT-based supported
bibliotherapy in stroke. Although all baselines were 3 weeks or longer, it would have added
greater control to ensure planned randomised baseline lengths were set at a minimum of 3
weeks. However, the minimum of 2 weeks was dictated by ethical concerns about attrition
during a non-treatment period for this fragile population. In addition, inclusion of only those
with clinical levels of psychological distress would enhance generalisability to clinical
populations. However, data from the current study may be valuable in establishing aspects of
feasibility of future randomised studies as well as the length of intervention required.
Investigations of bibliotherapy without therapist support are also required to determine if
efficacy is maintained in its absence as this could limit the cost-effectiveness of the approach.
Although three of the measures used had not been fully validated in stroke, all had previously
been used successfully with this population. People with severe aphasia and who could not
read were not included in the study and research using communication aids for this sample
would extend the findings. The current study did not include a measure of ACT processes
related to psychological flexibility as, when the study was designed, none was validated
specifically for stroke or had been demonstrated to be acceptable for this population.
Inclusion of validated ACT-process measures would increase confidence that ACT-specific
factors are responsible for benefits. While the baselines were randomised in advance of the
study, it was not possible for all participants to transfer to the intervention in the identified
week due to unplanned events such as individual or family illness. In these cases, the baseline
and data collection were continued (median 1 week) until the participant could start the
Behavioural and Cognitive Psychotherapy 13
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
intervention. It was considered that such unplanned extensions would not affect the conclusions
as extended baseline phases allow rigorous comparisons.
Service implications
Co-morbidity of stroke and mood-based difficulties is high (Hackett and Pickles, 2014).
Healthcare cost is increased by psychological co-morbidity in long-term conditions (Naylor
et al., 2012). The Royal College of Physicians (2016) suggest that stroke patients should be
offered a choice of interventions for psychological difficulties. The results of the current study
indicate that the novel ACT-based bibliotherapy, with therapist support, is effective in the
short term. The intervention can be tailored to individual needs and requires less therapist
time per week than traditional therapy.
Supplementary material. To view supplementary material for this article, please visit: https://doi.org/10.1017/
S135246582200042X
Data availability statement. The data are available from the first author (TAU-U analyses and relative risk analysis) and the
second author (all other analyses) upon reasonable request.
Acknowledgements. The authors would like to acknowledge the generous assistance received in recruiting participants from
‘Bristol After Stroke’charity, The Stroke Association (Wales) and Dr Irina Lapadatu, clinical psychologist, Bristol.
Author contributions. Misbah Gladwyn-Khan: Data curation (equal), Formal analysis (equal), Investigation (lead),
Methodology (equal), Project administration (lead), Software (lead), Visualization (lead), Writing –original draft (lead),
Writing –review & editing (supporting); Reg Morris: Conceptualization (lead), Data curation (equal), Formal analysis
(equal), Investigation (supporting), Methodology (equal), Supervision (lead), Writing –original draft (supporting),
Writing –review & editing (lead).
Financial support. The study was funded by salary support for the first author from Health Education and Improvement
Wales. The work formed part of a DClinPsy programme.
Conflicts of interest. R. Morris is an author of the book that is the subject of this evaluation. However, royalties from sales of
the book are paid to NHS Wales.
Ethical standards. This study abided by the ethical principles of the BPS and BABCP. This study was approved through the
integrated research applications system (IRAS) for NHS ethics, IRAS ID 232266. Research and Development Department
permission was granted by four Health Boards/Trusts (three in south Wales, one in south-west England). Three stroke
survivors were consulted during the design of the study. They suggested that individual support from a therapist should
be included.
References
Aben, I., Verhey, F., Lousberg, R., Lodder, J., & Honig, A. (2002). Validity of the Beck Depression Inventory, Hospital
Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as screening instruments for depression
in stroke patients. Psychosomatics,43, 386–393. https://doi.org/10.1176/appi.psy.43.5.386
Acciarresi, M., Bogousslavsky, J., & Paciaroni, M. (2014). Post-stroke fatigue: epidemiology, clinical characteristics and
treatment. European Neurology,72, 255–261. https://doi.org/10.1159/000363763
Ahn, D.-H., Lee, Y.-J., Jeong, J.-H., Kim, Y.-R., & Park, J.-B. (2015). The effect of post-stroke depression on rehabilitation
outcome and the impact of caregiver type as a factor of post-stroke depression. Annals of Rehabilitation Medicine,39,
74–80. https://doi.org/10.5535%2Farm.2015.39.1.74
Allida, S., Cox, K. L., Hsieh, C. F., Lang, H., House, A., & Hackett, M. L. (2020). Pharmacological, psychological, and non-
invasive brain stimulation interventions for treating depression after stroke. Cochrane Database of Systematic Reviews,1,
CD003437. https://doi.org/10.1002/14651858.CD003437.pub4
American Heart Association (2011). Heart disease and stroke statistics –2011 update: a report from the American Heart
Association. Circulation,123, e18–e209. https://doi.org/10.1161/CIR.0b013e3182009701
Assaz, D. A., Roche, B., Kanter, J., & Oshiro, C. K. B. (2018). Cognitive defusion in acceptance and commitment therapy:
what are the basic processes of change? The Psychological Record,68, 405–418. https://doi.org/10.1007/s40732-017-0254-z
Ayerbe, L., Aysis, S., Crichton, S., Wolfe, C. D., & Rhudd, A. G. (2014). The long-term outcomes of depression up to
10 years after stroke: the south London stroke register. Journal of Neurology, Neurosurgery and Psychiatry,85,
514–521. https://doi.org/10.1136/jnnp-2013-306448
14 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
Ayerbe, L., Aysis, S., Wolfe, C. D., & Rhudd, A. G. (2013). Natural history, predictors and outcomes of depression after
stroke: systematic review and meta-analysis. British Journal of Psychiatry,202,14–21. https://doi.org/10.1192/bjp.bp.
111.10766
Bardoshi, G., Duncan, K. J., & Erford, B. T. (2016). Psychometric meta-analysis of the English version of the Beck Anxiety
Inventory. Journal of Counselling and Development,94, 356–373. https://doi.org/10.1002/jcad.12090
Barker-Collo, S. L. (2007). Depression and anxiety 3-months after stroke: prevalence and correlates. Archives of Clinical
Neuropsychology,22, 519–531. https://doi.org/10.1016/j.acn.2007.03.002
Bartoli, F., Lillia, N., Lax, A., Crocamo, C., Mantero, V., Cara, G., Agostoni, E., & Clerici, M. (2013). Depression after
stroke and risk of mortality: a systematic review and meta-analysis. Stroke Research and Treatment,2013,1–11. https://doi.
org/10.1155%2F2013%2F862978
Beck, A. T., & Steer, R. A. (1993). Beck Anxiety Inventory Manual. San Antonio, TX, USA: Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory. San Antonio, TX, USA:
Psychological Corporation.
Bennett H. E., & Lincoln N. B. (2006). Potential screening measures for depression and anxiety after stroke. International
Journal of Therapy and Rehabilitation,13, 401–406. https://doi.org/10.12968/ijtr.2006.13.9.21784
Brossart, D. F., Laird, V. C., & Armstrong, T. W. (2018). Interpreting Kendall’s TAU and TAU-U for single case
experimental designs. Cogent Psychology,5, 1518687. https://doi.org/10.1080/23311908.2018.1518687
Brown, F. J., & Hopper, S. (2009). Acceptance and commitment therapy (ACT) with a learning-disabled young person
experiencing anxious and obsessive thoughts. Journal of Intellectual Disabilities,13, 195–201. https://doi.org/10.1177/
1744629509346173
Burton, L. J., & Tyson, S. (2015). Screening for mood disorders after stroke: a systematic review of psychometric properties
and clinical utility. Psychological Medicine,45,29–49. https://doi.org/10.1017/S0033291714000336
Campbell Burton, A., Murray, J., Homes, J., Astin, F., Greenwood, D., & Knapp, P. (2013). Frequency of anxiety after
stroke: a systematic review and meta-analysis of observational studies. International Journal of Stroke,8, 545–559.
https://doi.org/10.1111/j.1747-4949.2012.00906.x
Campbell Burton, C. A., Holmes, J., Murray, J., Gillespie, D., Lightbody, C. E., Watkins, C. L., & Knapp, P. (2011).
Interventions for treating anxiety after stroke. Cochrane Database of Systematic Reviews,12, CD008860. https://doi.org/
10.1002/14651858.CD008860.pub2
Carmo, J. F., Morelato, R.-L., Pinto, H.-P., & Araujo de Oliviera, E. R. (2015). Disability after stroke: a systematic review.
Fisioterapa em Movimento,28, 407–418. https://doi.org/10.1590/0103-5150.028.002.AR02
Chamberlain, D., Heaps, D., & Robert, I. (2008). Bibliotherapy and information prescriptions: a summary of the published
evidence-base and recommendations from past and ongoing Books on Prescription projects. Journal of Psychiatric Mental
Health Nursing,15,24–36. https://doi.org/10.1111/j.1365-2850.2007.01201.x
Chun, H.-Y.-Y., Carson, A. J., Dennis, M. S., Mead, G. E., & Whiteley, W. M. (2018b). Treating anxiety after stroke: the
feasibility phase of a novel web enabled RCT. Pilot and Feasibility Studies,4, 139. https://doi.org/10.1186%2Fs40814-018-
0329-x
Chun, H.-Y.-Y., Whiteley, W. M., Dennis, M. S., Mead, G. E., & Carson, A. J. (2018a). Anxiety after stroke: the importance
of subtyping. Stroke,49, 556–564. https://doi.org/10.1161/STROKEAHA.117.020078
Clarke, S., Kingston, J., James, K., Bolderston, H., & Remington, B. (2014). Acceptance and commitment therapy group for
treatment resistant participants: an RCT. Journal of Contextual Behavioural Sciences,3, 179–184. https://doi.org/10.1016/j.
jcbs.2014.04.005
Cuijpers, P., Donker, T., Van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-help as effective as face-to-face
psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome
studies. Psychological Medicine,40, 1943–1957. https://doi.org/10.1017/S0033291710000772
Deacon, B. J., Fawzy, T. I., Lickel, J. J., & Wolitzcky-Taylor, K. B. (2011). Cognitive defusion versus cognitive restructuring
in the treatment of negative self-referential thoughts: an investigation of process and outcome. Journal of Cognitive
Psychotherapy,25, 218–232. https://doi.org/10.1891/0889-8391.25.3.218
Den Boer, P. C., Wiersma, D., & Van den Bosch, R. J. (2004). Why is self-hep neglected in the treatment of emotional
disorders? A meta-analysis. Psychological Medicine,34, 959–971. https://doi.org/10.1017/S003329170300179X
Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The Satisfaction with Life Scale. Journal of Personality
Assessment,49,71–75. https://doi.org/10.1207/s15327752jpa4901_13
Dindo, L., Van Liew, J. R., & Arch, J. J. (2017). Acceptance and commitment therapy: a transdiagnostic behavioural
intervention for mental health and medical concerns. Neurotherapeutics,14, 546–553. https://doi.org/10.1007/s13311-
017-0521-3
Duncan P. W., Bode R. K., Min Lai S., & Perera, S. (2003). Rasch analysis of a new stroke specific outcome scale: the
Stroke Impact Scale. Archives of Physical Medicine and Rehabilitation,84, 950–963. https://doi.org/10.1016/s0003-
9993(03)00035-2
Fazio, S., Pace, D., Flinner, J., & Kalmyer, B. (2018). The fundamentals of person-centred care for individuals with dementia.
Gerontologist,58 (suppl), S10–S19. https://doi.org/10.1093/geront/gnx122
Behavioural and Cognitive Psychotherapy 15
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
Feigin, V. L., Norvving, B., & Mensah, G. A. (2017). Global burden of stroke. Circulation Research,120, 439–448. https://doi.
org/10.1161/CIRCRESAHA.116.308413
Gillespie, D. C., Bowen, A., Chung, C. S., Cockburn, J., Knapp, P., & Pollock, A. (2015). Rehabilitation for post-stroke
cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence. Clinical
Rehabilitation,29, 120–128. https://doi.org/10.1177/0269215514538982.
Goldberg, D., & Williams, P. (1988). A User’s Guide to the General Health Questionnaire. Windsor, UK: NFER-Nelson.
Graham, C. D., Gouick, J., Krahe, C., & Gillanders, D. (2016). A systematic review of the use of acceptance and commitment
therapy (ACT) in chronic disease and long-term health conditions. Clinical Psychology Review,46,46–58. https://doi.org/
10.1016/j.cpr2016.04.009
Graham, J. E., Karmarkar, A. M., & Ottenbacher, K. J. (2012). Small sample research designs for evidence-based
rehabilitation: issues and methods. Archives of Physical and Medical Rehabilitation,93, S111–116. https://doi.org/10.
1016%2Fj.apmr.2011.12.017
Gros, D. F., Allan, N. P., & Szafranski, D. D. (2016). Movements towards transdiagnostic psychotherapeutic practices for
affective disorders. Evidence-Based Mental Health,19, e10–e12. https://doi.org/10.1136/eb-2015-102286
Guadiano, B. A. (2011). A review of acceptance and commitment therapy (ACT) and recommendations for continued
scientific advancement. Scientific Review of Mental Health Practice,8,5–22.
Hackett, M. L., Anderson, C. S., House, A., & Xia, J. (2008). Interventions for treating depression after stroke. Cochrane
Database of Systematic Reviews,4, CD003437. https://doi.org/10.1002/14651858.CD003437.pub3
Hackett, M. L., & Pickles, K. (2014). Part 1: Frequency of depression after stroke: an updated systematic review and meta-
analysis of observational studies. International Journal of Stroke,9, 1017–1025. https://doi.org/10.1111/ijs.12357
Hankins, M. (2008). The reliability of the 12-item General Health Questionnaire (GHQ-12) under realistic assumptions. BMC
Public Health,8, 355. https://doi.org/10.1186/1471-2458-8-355
Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory and the third waves of behavioural and
cognitive therapies. Behaviour Therapy,35, 639–665. https://doi.org/10.1016/S0005-7894(04)80013-3
Healy, A. K., Kneebone, I. I., Carroll, M., & Anderson, S. J. (2008). A preliminary investigation of the reliability and validity
of the brief assessment schedule depression cards and the Beck Depression Inventory –fast screen to screen for depression
in older stroke survivors. International Journal of Geriatric Psychiatry,23, 531–536. https://doi.org/10.1002/gps.1933
Hilari, K., Byng, S., Lamping, D. L., & Smith, S. C. (2003). Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39):
evaluation of acceptability, reliability and validity. Stroke,34, 1944–1950. https://doi.org/10.1161/01.STR.0000081987.
46660.ED
Hirai, M., & Clum, G. A. (2006). A meta-analytic study of self-help interventions for anxiety problems. Behaviour Therapy,
37,99–111. https://doi.org/10.1016/j.beth.2005.05.002
Jacobs, N. N., & Mosco, E. (2008). In O’Donohue, W., & Cummings, N. A. (eds), Evidence-Based Adjunctive Treatments
(1st edn). NY, USA: Academic Press. https://doi.org/10.1016/B978-012088520-6.50003-2
Jenkinson, C., Fitzpatrick, R., Crocker, R., & Peters, M. (2013). The Stroke Impact Scale: validation in UK setting and
development of a SIS short form and SIS index. Stroke,44, 2532–2535. https://doi.org/10.1161/STROKEAHA.113.001847
Kangas, M., & McDonald, S. (2011) Is it time to act? The potential of acceptance and commitment therapy for psychological
problems following acquired brain injury. Neuropsychological Rehabilitation,21, 250–276. https://doi.org/10.1080/
09602011.2010.540920
Kashdan, T.B. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review,30, 865–878.
https://doi.org/10.1016%2Fj.cpr.2010.03.001
Kerr, D., McCann, T., Mackey, E., & Wijeratne, T. (2018). Effects of early motivational interviewing on post-stroke
depressive symptoms: a pilot randomised study of the Good Mood Intervention Programme. International Journal of
Nursing Practice,24, e12657. https://doi.org/10.1111/ijn.12657
Kratochwill, T. R., Hitchcock, H. H., Horner, R. H., Levin, J. R., Odom, S. L., Rindskopf, D. M., & Shadish, W. R. (2013).
Single-case intervention research design standards. Remedial and Special Education,34,26–38. https://doi.org/10.1177/
0741932512452794
Langhammer, B., Sunnerhagen, K. S., Stanghelle, J. K., Salstrom, S., Becker, F., & Fugi-Meyer, K. (2017). Life satisfaction
in persons with severe stroke: a longitudinal report from the Sunnas International Network (SIN) stroke study. European
Stroke Journal,2, 154–162. https://doi.org/10.1177/2396987317695140
Large, R., Samuel, V., & Morris, R. (2019). A changed reality: experience of an acceptance and commitment therapy (ACT)
group after stroke. Neuropsychological Rehabilitation,30, 1477–1496. https://doi.org/10.1080/09602011.2019.1589531
Latchem, J. M., & Greenhalgh, J. (2014). The role of reading on the health and well-being of people with neurological
conditions: a systematic review. Aging & Mental Health,18, 731–744. https://doi.org/10.1080/13607863.2013.875125
Lesage, F. X., Martens-Resende, S., Deschamps, F., & Berjot, S. (2011). Validation of the General Health Questionnaire
(GHQ-12) adapted to a work context. Open Journal of Preventative Medicine,1,44–48. https://doi.org/10.4236/ojpm.
2011.12007
16 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
Liman, T. G., Endres, H. M., Schwab, F. S., & Kolominsky-Rabas, P. L. (2012). Impact of low mini-mental status on health
outcome up to 5-years after stroke: the Erlangen stroke project. Journal of Neurology,259, 1125–1130. https://doi.org/10.
1007/s00415-011-6312-6
Loveride, L., & Hagell, P. (2016). Measuring life satisfaction in Parkinson’s disease and health controls using the Satisfaction
with Life Scale. PLOS One,11, e0163931. https://doi.org/10.1371%2Fjournal.pone.0163931
Luchinskaya, D., Simpson, P., & Stoye, G. (2017). UK health and social care spending. In Emmerson, C., Johnson, P., &
Joyce, R. (eds), The IFS Green Budget 2017, pp. 141–176. London, UK: Institute for Fiscal Studies. https://www.ifs.org.uk/
publications/8879
Mahmoud, S., & Elaziz, N., A. A. (2016). Impact of stroke on life satisfaction and psychological adjustment among stroke
patients during rehabilitation. Life Science Journal,13,7–17. https://doi.org/10.7537/marslsj13031602
Majumdar, S., & Morris, R. (2019). Brief group-based acceptance and commitment therapy for stroke survivors. British
Journal of Clinical Psychology,58,70–90. https://doi.org/10.1111/bjc.12198
Morris, R., Falk, M., Miles, T., Wilcox, J., & Fisher-Hicks, S. (2017). Rebuilding Your Life After Stroke: Positive Steps to
Wellbeing. London, UK: JKP.
Muntingh, A. D. T., van der Feltz-Cornelis, C. M., van Marwik, H. W. J., Spinhoven, P., Pennix, B. W. J. H., & van
Balkom, A. J. L. M. (2011). Is the Beck Anxiety Inventory a good tool to assess the severity of anxiety? A primary
care study in the Netherlands study of depression and anxiety (NESDA). BMC Family Practice,12,1–6. https://doi.
org/10.1186/1471-2296-12-66
National Institute for Health and Care Excellence (2013/2018). Stroke Rehabilitation in Adults. London, UK: NICE. www.
nice.org.uk/guidance/cg162
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M., & Galea, A. (2012). Long-term Conditions and Mental
Health: The Cost of Comorbidities. London, UK: The King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/
field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
Nys, G. M. S.,van Zandvoort, M. J. E., de Kort, P. L. M., Jansen, B. P. W., de Haan, E. H. F., & Kappelle, L. J. (2007).
Cerebrovascular Disorders,23, 408–416. https://doi.org/10.1159/000101464
Pais, C., Ponsford, J. L., Gould, K. R., & Wong, D. (2019). Role of valued living and associations with functional outcome
following traumatic brain injury. Neuropsychological Rehabilitation,29, 625–637. https://doi.org/10.1080/09602011.2017.
1313745
Pavot, W., & Diener, E. (1993). Review of the Satisfaction With Life scale. Psychological Assessment,5, 164–172. https//:doi.
org/10.1207/s15327752jpa4901_13
Pollock, A., St George, B., Fenton, M., & Firkins, L. (2014). Top 10 research priorities relating to life after stroke –consensus
from stroke survivors, caregivers and health professionals. International Journal of Stroke,9, 313–320. https://doi.org/10.
1111/j.1747-4949.2012.00942.x
Prisnie, J. C., Fiest, K. M., Coutts, S. B., Patten, S. B., Atta, C. A., Blaikie, L., Bulloch, A. G., Demchuk, A., Hill, M. D.,
Smith, E. E., & Jette, N. (2016). Validating screening tools for depression in stroke and transient ischaemic attack patients.
International Journal of Psychiatry in Medicine,51, 262–77. https://doi.org/10.1177/0091217416652616
Rhoda, D. A., Murray, D. M., Andridge, R. R., Pennell, M. L., & Hade, E. M. (2011). Studies with staggered starts: multiple
baseline designs and group randomised trials. American Journal of Public Health,101, 2164–2169. https://doi.org/10.2105/
AJPH.2011.300264
Ruiz, F. J. (2010). A review of acceptance and commitment therapy (ACT) empirical evidence: correlational, experimental
psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy,10,
125–162. https://www.redalyc.org/pdf/560/56017066008.pdf
Salter, K. L., Moses, M. B., Foley, N. C., & Teasell, R. W. (2008). Health-related quality of life after stroke: what are we
measuring? International Journal of Rehabilitation Research,31, 111–117. https://doi.org/10.1097/MRR.0b013e3282fc0f33
Sampaio, F., Enebrink, P., Mihalopoulos, C., & Feldman, I. (2016). Cost-effectiveness of four parenting programs and
bibliotherapy for parents of children with conduct problems. Journal of Mental Health Problems and Economics,19,
201–212. PMID:
Sander, A. M., Clark, A. N., Arciniegas, D. B., Tran, K., Leon-Novelo, L. N., Ngan, E., Bogaards, J., Mark Sherer, M., &
Walser, R. (2020). A randomized controlled trial of acceptance and commitment therapy for psychological distress among
persons with traumatic brain injury. Neuropsychological Rehabilitation,31, 1105–1129. https://doi.org/10.1080/09602011.
2020.1762670
Schramke, C. J., Stowe, R. M., & Ratcliff, G., Goldstein, G., & Condray, R. (1998). Poststroke depression and anxiety:
different assessment methods result in variations in incidence and severity estimates. Journal of Clinical and
Experimental Neuropsychology,20, 723–737. https://doi.org/10.1076/jcen.20.5.723.1117
Stewart-Brown, S., Platt, S., Tennant, A., Maheswaran, H., Parkinson, J., Weich, S., Tennant, R., Taggart, F., & Clarke, A.
(2011). The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS): a reliable tool for measuring mental wellbeing in
diverse populations and projects. Journal of Epidemiology and Community Health,65 (suppl II), A38–A39. https://doi.org/
10.1136/jech.2011.143586.86
Behavioural and Cognitive Psychotherapy 17
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
Sugawara, N., Metoki, N., Hagii, J., Saito, S., Shiroto, H., Tomita, T., Yasujima, M., Okumura, K., & Yasui-Furukori, N.
(2015). Effects of depressive symptoms on the lengths of hospital stays among patients hospitalised for acute stroke in
Japan. Neuropsychiatric Disease and Treatment,11, 2551–2556. https://doi.org/10.2147%2FNDT.S91303
Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., Parkinson, J., Secker, J., & Stewart-Brown, S. (2007).
The Warwick Edinburgh Mental Wellbeing Scale: UK development and validation. Health and Quality of Life Outcomes,5,
1–13. https://doi.org/10.1186/1477-7525-5-63
The Royal College of Physicians (2015). Sentinel Stroke Audit Programme (SSNAP). Post-Acute Organisational Audit. Phase
2: Organisational Audit of Post-Acute Stroke Service Providers. London, UK: RCP. https://www.strokeaudit.org/Documents/
National/PostAcuteOrg/2015/2015-PAOrgPublicReportPhase2.aspx
The Royal College of Physicians (2016). National Clinical Guideline for Stroke (5th edn) London, UK: RCP. https://www.
strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx
Tsuchiya, K., Fujita, T., Sato, D., Midorikawa, M., Makiyami, Y., Shimoda, K., & Tozato, F. (2016). Post-stroke depression
inhibits improvement in activities of daily living in patients in a convalescent ward. Journal of Physical Therapy Science,28,
2253–2259. https://doi.org/10.1589%2Fjpts.28.2253
Vannest, K. J., & Ninci, J. (2015). Evaluating intervention effects in single-case research designs. Journal of Counselling &
Development,93, 403–411. https://doi.org/10.1002/jcad.12038
Vannest, K. J., Parker, R. I., Gonen, O., & Adiguzel, T. (2016). Single Case Research: Web-Based Calculators for SCR
Analysis (version 2.0) [web-based application]. College Station, TX, USA: Texas A&M University. singlecaseresearch.org
Vassar, M. (2008). A note on the score reliability for the satisfaction with life scale: an RG study. Social Indicators Research,86,
47–57. https://doi.org/10.1007/s11205-007-9113-7
Viera, A. J. (2008). Odds ratios and risk ratios: what’s the difference and why does it matter? Southern Medical Journal,101,
730–734. https://doi.org/10.1097/SMJ.0b013e31817a7ee4
Wang, S.-B., Wang, Y.-Y., Zhang, Q. E., Wu, S.-L., Ng, C. H. ::: & Xiang, Y.-T. (2018). Cognitive behavioral therapy for
post-stroke depression: a meta-analysis. Journal of Affective Disorders,235, 589–596. https://doi.org/10.1016/j.jad.2018.04.
011
Wang, Y. P., & Gorenstein, C. (2013). Assessment of depression in medical patients: a systematic review of the utility of the
Beck Depression Inventory-II. Clinics (Sao Paulo),68, 1274–1287. https://doi.org/10.6061/clinics/2013(09)15
Watson, P. J., & Workman, E. A. (1981). The non-concurrent multiple baseline across-individuals design: an extension of the
traditional multiple baseline design. Journal of Behavior Therapy and Experimental Psychiatry,12, 257–259. https://doi.org/
10.1016/0005-7916(81)90055-0
Whiting, D., Deane, F., McLeod, H., Ciarrochi, J., & Simpson, G. (2020) Can acceptance and commitment therapy facilitate
psychological adjustment after a severe traumatic brain injury? A pilot randomized controlled trial. Neuropsychological
Rehabilitation,30, 1348–1371. https://doi.org/ 10.1080/09602011.2019.1583582
Wu, S., Kutlubaev, M. A., Chun, H.-Y.Y., Cowey, E., Pollock, A., Macleod, M. R., Dennis, M., Keane, E., Sharpe, M., &
Mead, G. E. (2015). Interventions for post-stroke fatigue. Cochrane Database of Systematic Reviews,7, CD007030. https://
doi.org/10.1002/14651858.CD007030.pub3
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica,67,
361–70. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
Cite this article: Gladwyn-Khan M and Morris R. The efficacy of therapist-supported acceptance and commitment therapy-
based bibliotherapy for psychological distress after stroke: a single-case multiple-baseline study. Behavioural and Cognitive
Psychotherapy.https://doi.org/10.1017/S135246582200042X
18 Misbah Gladwyn-Khan and Reg Morris
https://doi.org/10.1017/S135246582200042X Published online by Cambridge University Press
