Rehabilitation of Executive Function after Brain Injury – Goal Management Training

by Ciara Brien and Cillian McCormack-Doyle, Assistant Psychologists, Headway.

After a brain injury, people often have difficulty with some higher-level aspects of thinking which are given the term “executive functions”. They include the ability to plan, to monitor and change behaviour as needed, and to make changes to routine when faced with new situations. Difficulties with executive functions can lead to people being easily distracted or failing to follow through activities which need to be done in a particular sequence, such as making a shopping list and following through with a successfully “executed” shopping trip. The research papers described in this article each discuss a technique for helping people with executive function difficulties called Goal Management Training (GMT).

Levine, B., Schweizer, T.A., O’Connor, C., Turner G., Gillingham, S., Stuss, T.D., Manly, T. & Robertson, I.H. (2011) Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5, Feb 17, 2011.

While executive functioning deficits can cause significant real-life disabilities (planning, inhibition, goal-directed behaviour, initiation, insight), evidence for practical interventions is lacking. Goal Management Training (GMT) is a mindful approach to complex real-world tasks, based on theories of sustained attention. When sustained attention is compromised following a brain injury, a person may become distracted from achieving their goals by either habits or environmental influences. The primary focus of GMT is to periodically stop ongoing behaviour, in order to monitor and adjust goals. In this study 14 people with frontal lobe brain damage were randomly assigned to a GMT or Brain Health Workshop group. Training was administered in seven 2 hour sessions. Training included homework involving monitoring absentminded slips and successes and daily mindfulness practice. Results of the study highlight that GMT is associated with reduced attentional lapses, increased behavioural consistency and improved problem solving ability.

McPherson, K.M., Kayes, N. & Weatherall M. (2009). A pilot study of self regulation informed goal setting in people with traumatic brain injury. Clinical Rehabilitation, 23 (4), 296-309.
This study sought to determine the acceptability and real life application of two goal setting interventions, one being Goal Management Training (GMT), in people with traumatic brain injury (TBI). 10 people with TBI met with their keyworker over 6 – 8 weeks, during which they worked on goal setting and goal performance. Once participants identified a goal (e.g. preparing a meal, remembering names, shopping for food within budget), they were supported to follow the goal management pathway of; STOP what I’m doing, DEFINE the task, LIST the steps, LEARN the steps, DO the steps, CHECK that I am doing what I said I would. Feedback from participants and clinicians found the GMT process acceptable and that it led to both goal attainment and improved mood. Additionally some participants felt a sense of increased control, while for others the skills learned could be transferred to improve performance on other activities.

Schweizer, T.A., Levine, B., Rewilak, D., O’Connor, C., Turner, G., Alexander, M.P., Cusimano, M., Manly, T., Robertson, I.H. & Stuss, D.T. (2008). Rehabilitation of Executive Functioning After Focal Damage to the Cerebellum. Neurorehabilitation and Neural Repair, 22 (1), 72-77.

Although primarily associated with damage to the frontal lobes, people with brain injuries to other parts of their brain can have problems with executive function also. One such area is the cerebellum. The above study aimed to examine whether a person with damage to the cerebellum and subsequent problems with executive function benefitted from rehabilitation in the form of Goal Management Training (GMT). Over seven weekly 2-hour sessions, this participant was assisted in developing awareness of lapses in attention, and strategies to overcome these. The efficacy of GMT in this participant was assessed using measures of executive function and attention before commencing the training, immediately following the seven weeks of training, and four months afterwards. This patient made modest gains in the areas specifically targeted by GMT, and maintained these improvements over time. In addition to this, his wife reported significant “real-world” improvements that facilitated the patient returning to work in this instance. It is important to note that this was an uncontrolled single-case study, therefore the results cannot be generalised to a wider population of people with similar brain injuries.

If you would like to learn more about Goal Management Training, or take part in a Goal Management Training group, please contact Suvi Dockree, Headway’s Senior Clinical Neuropsychologist via email dockrees@headway.ie or by telephone 01-8102066.

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