Post-stroke interventions Post-stroke interventions

WORKING
WITH STROKE
PATIENTS

The psychological effects of stroke,

including depression, are often overlooked.
Paul Grantham explains how therapy can alleviate
distress for stroke patients and their carers

S
troke is an acute medical condition, caused cause of death in the UK and is the biggest cause
when the blood supply to part of the brain is of adult disability among survivors.1
stopped, either by a blood clot (ischaemic
Psychological effects
stroke), the most common cause of strokes, In addition, the causes of depression are often The figures would suggest that more than 150,000
The psychological consequences of stroke have
or by the bursting of a blood vessel. attributed to the specific neurological effects of people in the UK are currently suffering from anxiety
been well known for more than 100 years. As far
the stroke, such as lack of motivation or mobility as a result of stroke, with agoraphobia and generalised
Speed of identification and treatment plays a key role back as 1911, Bleuler noted: ‘After stroke [there are]
problems, rather than reactions to the trauma anxiety disorder being the most common
in both survival and recovery. Stroke has immediate melancholic moods lasting for months and
or broader neurological effects, such as poor manifestations.5
neurological and physical effects: impaired limb sometimes longer, appearing frequently.’2
emotional regulation.
use, memory losses and communication problems Other psychological effects, which have received even
Not surprisingly, post-stroke depression is the
are the most obvious. Hospital rehabilitation, Depression is not the only psychological problem that less attention, include anger problems, post-traumatic
most commonly reported psychological effect of
not surprisingly, tends to focus on mobility and can arise after stroke. Anxiety problems have also stress disorder, general loss/adaption reactions and
stroke, with between 23% and 61% of people noting
communication, and invariably leads to discharge. been highlighted. The data on anxiety are less clear emotional lability.
symptoms of depression after stroke.3,4 In other
There is typically no regular, ongoing professional and have attracted less interest, mainly because the
words, up to a quarter of a million people in the UK To limit an examination of the psychological effects of
contact following discharge, apart from the provision impact of anxiety on rehabilitation is typically even
are currently suffering from depression as a result stroke to the stroke survivor, however, is to tell only half
of physical aids around the home. less than that of depression. However, to give some
of stroke. However, unless depression is assessed the story. The ongoing impact of stroke on other family
flavour of the size of the problem, Burvill et al’s
The impact of strokes on the population is huge. as an obstacle to physical rehabilitation, it is often members is often overlooked. But the psychological
follow-up study of 294 stroke patients identified that
Currently, 1.2 million people across the UK are not identified in hospital and subsequently impact of being a carer is clear, both from my own
12% of males and 28% of females were clinically
affected. In England, around 85,000 people each becomes ‘invisible’ once the patient has practice experience and the extensive general literature.6
anxious; 50% had not improved after 12 months.5
year suffer stroke. It represents the fourth biggest returned home.

8 July 2023 Healthcare Counselling and Psychotherapy Journal Healthcare Counselling and Psychotherapy Journal July 2023 9
Post-stroke interventions Post-stroke interventions

Carers can also encounter problems with depression, There are, however, resource, logistical and attitudinal The referral was prompted by the fact that Charlie had been found to be effective at lifting depressed mood,
anxiety and anger. Adjustment to a caring role, to a problems to address. First, community planning is not become increasingly verbally abusive towards his usually within relatively short (a month or less)
‘changed personality’ in the stroke survivor, the prioritised, in my experience – a situation that has wife, Priya. The behaviour change appeared to be periods of time. It is a self-monitoring, self-help
financial pressures of disability, as well as ongoing been exacerbated by the pandemic and its aftermath. triggered by his wife’s recent decision to stop her approach that focuses on behaviour rather than
social isolation, are just some of the issues that carers Second, community-based professionals for stroke part-time cleaning work and spend more time at feelings, so it often bypasses initial resistance in some
of post-stroke patients face. patients are thin on the ground. Most clinical home. She felt she could no longer tolerate the stress stroke patients to spending a lot of time focusing on
psychologists do not work with acute physical health of paid work combined with her caring role. They had ‘how I feel’. It also builds therapeutic trust and
Service responses
problems and, if they do, they tend to be hospital- no family nearby and Charlie’s day was typically spent confidence, hence creating a gateway to greater
Acute hospital services typically focus on
based, with a focus on discharge. watching TV. exploration of feelings.
functional, physical rehabilitation, as the route to
discharge. However, following discharge, stroke In my opinion, it is also a mistake to address post- Stroke patients are often highly sensitive to being There are three steps to behavioural activation. First,
survivors’ most common experience is to receive stroke emotional problems in hospital, primarily treated as ‘odd’, ‘mad’ or ‘brain damaged’. So, it is we need to discover what the client already does that
minimal, if any, professional contact beyond six because the interest is typically in their impact on useful before starting any counselling work to explore creates slight improvements in mood – typically,
months after the stroke. rehabilitation. For example, if a patient is depressed, the client’s attitude towards being seen activities that are pleasurable and give a sense of
but not severely enough to stop them complying with a by a counsellor or, in my case, a psychologist. pride. The second step is to help the client to see that
physiotherapist’s rehabilitation programme, their their mood is not constant; it varies with what they do.
‘You know Dr Smith has asked me to see you.
depression might get ignored.
What do you make of that?’ I asked Charlie
‘Depression is the most commonly The depression or anger might also be classified as an when I first saw him for a home visit. It can help

reported psychological effect

initial reaction to the stroke, with the assumption that
it will eventually dissipate. Although there might be
the client to engage if you can acknowledge any
scepticism about the value of counselling and explore ‘The ongoing impact of
of stroke’
some truth to this in some instances, it is also an
all-too-easy way of ignoring an ongoing problem for
the issue in a non-judgmental way. ‘I hear there’s been
some changes at home recently and I wondered how stroke on other family members
many. In other words, I believe that a proper
assessment of the problem is best conducted once the
you felt about that.’
Charlie spoke at length about his general sense of
is often overlooked’
patient is at home.
anger and despair. When his wife was at work, it was
The Stroke Association has been vocal in its concerns
I have only occasionally met counsellors working with different. ‘I could forget about being an invalid when
about the limited support. Stroke survivor Stuart says: The realisation can increase hope and confidence
stroke patients – and they were usually working she’s wasn’t here, but these days she keeps trying to
‘After six months, the doctors and nurses decided I did regarding change. The third step is slowly to increase
privately and would see clients in their therapy room. get me to do things around the house.’ His words
not need further support, which left me feeling as if an the frequency of activities that improve mood and to
The former means that access to counselling for most prompted me to go through a more detailed risk
‘‘umbilical cord’’ had been cut.’1 Stuart isn’t an isolated monitor the effects.
is limited; the latter restricts help to those who are assessment of his own and his wife’s physical safety.
case: two thirds of stroke survivors receive no six-
physically mobile. I’m sure there are exceptions but I could find no evidence of either escalation or Charlie discovered that, although he spent a lot of time
month review whatsoever.7
you can see the problem. pressing risk. in front of the TV, he enjoyed weeding his garden
In the Stroke Association’s 2016 survey, 21% of stroke every week and talking to his grandchildren on the
Making home visits, learning how to negotiate My initial formulation was that the conflict between
survivors reported that the ‘emotional impact of phone, usually fortnightly. So, we agreed to try
communication difficulties and liaising with multiple Charlie and Priya was an expression of resistance to
stroke’ was hard to deal with; 59% stated that the increasing the frequency of both.
agencies needs to be an integral part of any work with increased activity, which is common in depression.
therapy they received for emotional impact was ‘poor
stroke clients. However, if there is a willingness to The first step would be to introduce Charlie to By our fourth meeting, Charlie’s behaviour had
or very poor’.1 The Stroke Association’s subsequent
reach out to this largely hidden group, there are some ‘behavioural activation’, increasing his confidence as noticeably changed. He smiled when I entered the
survey of more than 1,000 stroke patients and their
major gains to be made and satisfaction to be achieved a result. I thought this should be combined with some room and appeared more animated. He talked
families listed their top service priority for the future
for both client and counsellor. direct work with his wife on her beliefs about stroke, enthusiastically about his grandchildren and, for the
as the study of the impact of psychological problems
perhaps illustrated by her comment: ‘He needs to do first time, spoke in detail about how his stroke had
and how to reduce them.8 Charlie’s story
more to stop becoming a vegetable.’ I also wanted to affected him.
Charlie, 55, suffered a left-sided stroke two years
Additionally, NHS England has highlighted the think with her about her communication style, as she
before his GP asked me to see him. The stroke had left
importance of professionals in addressing the would often say: ‘He needs to be told. If I just left him
him with a slight weakness on his right side, which
problem, stating that psychological care requires ‘... to it, he wouldn’t do a thing’. If improvement occurred
required the use of a walking stick. His speech was
accessible clinical psychology/ neuropsychology in these areas, I believed there would be a reduction in
slightly slurred but fully understandable. However, his
services with stroke expertise, alongside wider, his depression and that their relationship would
difficulty with comprehension meant that he often had
step-down emotional and psychological support improve.
to ask others to repeat things – and he sometimes
pathways for all patients’. NHS England also
became frustrated. Behavioural activation
stresses the importance of ‘... clinical psychologists/
Behavioural activation is based on the simple idea
neuropsychologists with stroke expertise to train Charlie had been taking anti-depressants since his
that inactivity and depression are co-dependent.
and clinically supervise the relevant wider discharge from hospital, but his GP felt they no longer
When you’re depressed, it’s increasingly easy to do
psychological and emotional support service had any real impact on his mood. However, Charlie
nothing; when you do nothing, it helps to keep you
providers (such as IAPT therapists, counsellors was reluctant to stop taking the medication, so the
depressed. Behavioural activation has repeatedly
and peer support workers in the third sector).’9 prescription continued.

10 July 2023 Healthcare Counselling and Psychotherapy Journal Healthcare Counselling and Psychotherapy Journal July 2023 11
Post-stroke interventions

It became clear that he had always seen himself as the I saw Charlie and Priya for a total of 13 sessions,
family’s main financial provider. He resented the fact including a three-month follow up. Charlie’s
that he could no longer fulfil that role but realised ‘it is improvement showed itself in a number of ways – most
what it is’. He felt guilty that Priya had, until recently, notably his mood improved and the arguments and
been the ‘earner’ in the house. Although he was verbal abuse stopped. Charlie also joined a local
pleased that she no longer worked, he felt guilty. He gardening group, and allowed a neighbour to take him.
said: ‘I’m to blame because we have no money now.’ Within the wider family, both of their children and
grandchildren had plans to visit over the next few
Both Charlie and Priya had beliefs about stroke and
months, even though they both lived more than 100
recovery that had created a rather fraught and toxic
miles away and had previously only visited at
relationship. Interestingly, Charlie’s positive response
Christmas. I also discovered at the three-month follow
to behavioural activation, which he’d engaged in
up that Charlie had slowly stopped taking his anti-
without Priya’s help, had changed her view that ‘he
depressants, with his GP’s help. Priya had also taken
needs to do more’. But she still held onto her belief that
on a couple of cleaning jobs, because she felt that
‘he needs to be told’, which struck me as a useful focus
Charlie was now ‘less of a burden’ at home.
for the next few sessions.
Depression following stroke is a common but
Equally, Charlie’s view that his lack of earning power
underestimated and under-recognised problem within
was ‘a valid reason for feeling angry and guilty’
the community. Counselling and other
became a parallel focus over the same sessions. The
psychotherapeutic approaches have a proven track
sessions were split at this stage between Priya and
record in alleviating the distress this creates and can
Charlie. But I saw Priya in my office, as I thought it
open up a new and flourishing life for such clients.
might provide her with some respite.
I began the sessions with Priya by exploring what she
Paul Grantham is a consultant clinical psychologist
made of the fact that Charlie had done the behavioural
and Director of SDS Seminars Ltd, a psychological skills
activation work without her involvement, and how that
and therapy training company that provides training in
sat with the idea that ‘he needs to be told’. It emerged
stroke survivor work for counsellors. For more
that she had always taken the lead in many areas of
information visit: www.skillsdevelopment.co.uk or you
their relationship, a dynamic that had become
can email Paul at: [email protected]
exaggerated and increasingly imbalanced since
Charlie’s stroke. Or, to put it in Priya’s own words: ‘I’ve
probably gone a bit overboard on nagging him.’ Her References
memory and recounting of how their relationship used 1 Stroke Association. A new era for stroke. [Online.] London: Stroke
to work was helpful in resetting the balance. Association; 2016. www.stroke.org.uk/sites/default/files/anefs_report_
web.pdf (accessed April 2023).
2 Bleuler EP. Textbook of psychiatry. New York: Macmillan; 1951.

‘Behavioural activation
3 Robinson RG. The clinical neuropsychiatry of stroke. Cambridge:
Cambridge University Press; 2006.

has been found to be effective

4 Hackett ML, Anderson CS. Predictors of depression after stroke: a
systematic review of observational studies. Stroke 2005; 36(10):
2296-2301.

at lifting depressed mood’ 5 Burvill PW, Johnson GA, Jamrozik KD et al. Anxiety disorders after
stroke: results from the Perth community stroke study. British Journal of
Psychiatry 1995; 166: 328–332.
6 Henwood M, Larkin M, Milne A. Seeing the wood for the trees:
carer-related research and knowledge. [Online.] London: School for
Charlie’s guilt and anger about the loss of his earning Social Care Research; 2019. http://docs.scie-socialcareonline.org.uk/
capacity led to an exploration of his beliefs about fulltext/062780.pdf (accessed April 2023).
masculinity and, in particular, powerful messages 7 Morris S et al. Impact of centralising acute stroke services In English
from his father about ‘how a good husband should metropolitan areas on mortality and length of hospital stay: difference-
behave’. In exploring parental messages, I have often in-differences analysis. [Online.] BMJ 2014; 349: g4757. https://doi.
org/10.1136/bmj.g4757 (accessed April 2023).
found it useful to discuss other areas where the parent
8 Stroke Association. The stroke priority setting partnership (stroke PSP)
and child have diverged in their beliefs, why that results: rebuilding lives after stroke. [Online.] London: Stroke
occurred and what sense the client (child) made of it. Association; 2021. www.stroke.org.uk/sites/default/files/research/
stroke_priority_setting_partnership_accessible_summary.pdf
In Charlie’s case, we discovered that there were other (accessed April 2023).
areas where Charlie did not agree with his father’s 9 NHS England. National stroke service model: integrated stroke delivery
‘old-fashioned’ beliefs, notably whether women should networks. [Online.] London: NHS England; 2021. www.england.nhs.uk/
go out alone and whether men should carry out ourwork/clinical-policy/stroke/national-stroke-service-model/
(accessed April 2023).
domestic duties. The exploration helped Charlie to
have a more flexible approach to the family’s financial 10 Veale D. Behavioural activation for depression. Advances in Psychiatric
Treatment 2008; 14: 29–36.
provision and whether there were other values that
defined ‘a good marriage’.

12 July 2023 Healthcare Counselling and Psychotherapy Journal