NeuroRehabilitation 40 (2017) 259–270 259

DOI:10.3233/NRE-161411
IOS Press

Training in positivity for stroke?

A qualitative study of acceptability of use
of Positive Mental Training (PosMT)
as a tool to assist stroke survivors
with post-stroke psychological problems
and in coping with rehabilitation
Nahal Mavaddata,b,∗ , Sheila Rossc , Alastair Dobbind , Kate Williamsa , Jonathan Graffya
and Jonathan Manta
a Department of Public Health and Primary Care, Primary Care Unit, University of Cambridge, UK
b School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Australia
c Ming Chen Clinics, Edinburgh, Scotland
d School of Clinical Sciences and Community Health, University of Edinburgh, UK

Abstract.
BACKGROUND: Post-stroke psychological problems predict poor recovery, while positive affect enables patients to focus
on rehabilitation and may improve functional outcomes. Positive Mental Training (PosMT), a guided self-help audio shows
promise as a tool in promoting positivity, optimism and resilience.
OBJECTIVE: To assess acceptability of training in positivity with PosMT for prevention and management of post-stroke
psychological problems and to help with coping with rehabilitation.
METHODS: A modified PosMT tool consisted of 12 audio tracks each lasting 18 minutes, one listened to every day for a
week. Survivors and carers were asked to listen for 4 weeks, but could volunteer to listen for more. Interviews took place
about experiences of the tool after 4 and 12 weeks. Subjects: 10 stroke survivors and 5 carers from Stroke Support Groups
in the UK.
RESULTS: Three stroke survivors did not engage with the tool. The remainder reported positive physical and psychological
benefits including improved relaxation, better sleep and reduced anxiety after four weeks. Survivors who completed the
programme gained a positive outlook on the future, increased motivation, confidence and ability to cope with rehabilitation.
No adverse effects were reported.
CONCLUSIONS: The PosMT shows potential as a tool for coping with rehabilitation and overcoming post-stroke psycho-
logical problems including anxiety and depression.

Keywords: Stroke, rehabilitation, rehabilitation interventions, positivity, depression, anxiety, qualitative analysis, semi-
structured interviews

∗ Addressfor correspondence: Nahal Mavaddat, School of Pri- Australia, 35 Stirling Highway, Crawley, WA 6009, Australia. Tel.:
mary, Aboriginal and Rural Health Care, University of Western +61 89346 7504; E-mail: nahal.mavaddat@uwa.edu.au.

1053-8135/17/$35.00 © 2017 – IOS Press and the authors. All rights reserved
260 N. Mavaddat et al. / Training in positivity for stroke?

1. Introduction et al., 2015). Wellbeing approaches such as mindful-

ness training and relaxation therapy show promise in
As the population in developed nations age, the the stroke population (Golding, Kneebone, & Fife-
burden of stroke, already a significant cause of dis- Schaw, 2015; Johansson, Bjuhr, & Ronnback, 2012;
ability, is expected to rise (World Health, 2000). The Lawrence, Booth, Mercer, & Crawford, 2013). Such
presence of psychological problems including psy- approaches, however, often require intense training
chological distress, anxiety or depression frequently for greatest effect. There is a potential role for inter-
interferes with stroke rehabilitation and is an inde- ventions for post-stroke psychological problems to
pendent predictor of recovery, functional outcome help with coping with the stressors of rehabilita-
and quality of life as well as mortality after stroke tion that are evidence-based, simple and not costly
(Ellis, Zhao, & Egede, 2010; Kim, Warren, Madill, & to deliver.
Hadley, 1999). About a third of survivors of stroke Interventions that promote positive affect have
suffer from clinical depression, nearly a quarter with potential for improving the psychological state of
anxiety, and many more with psychological distress people with chronic health conditions and comor-
and problems adjusting to post-stroke life that do not bid psychological problems (Pressman & Cohen,
reach clinical criteria for a mental health disorder 2005). These have however not been extensively eval-
(British Psychological, 2010; Campbell Burton et al., uated in stroke survivors. It is hypothesised that such
2013; Hackett, Yapa, Parag, & Anderson, 2005). approaches counter the effects of negative mood and
Adequate services for post-stroke psychological care increase self-efficacy, coping strategies and sense of
of survivors within rehabilitation care are however control, enabling patients with disability to focus
often lacking (National Audit Office, 2005, 2010). on their rehabilitation needs (Partridge & Johnston,
Limitations in services include access to expertise 1989; Pressman & Cohen, 2005). Indeed positive
and staff, and lack of evidence-based interventions affect in the context of stroke has been associated
(NHS East of England, 2010). Management of post- independently with improved functional status, lower
stroke psychological problems including depression post-stroke pain, increased social participation and
and anxiety that hinder rehabilitation present a unique reduced mortality (Berges, Seale, & Ostir, 2011,
challenge to services since such problems may be 2012; Ostir, Berges, Ottenbacher, Clow, & Otten-
attributed not only to the consequences of physical, bacher, 2008).
social and financial disruption but also to biologi- Positive Mental Training (PosMT) is a guided
cal damage of the brain after stroke (House, Dennis, self-help treatment consisting of a 12 week audio
Warlow, Hawton, & Molyneux, 1990). Studies nev- training in positivity, optimism and resilience that
ertheless suggest that for many survivors it is the has shown promise in improving anxiety and depres-
helplessness, hopelessness and the feeling that there sion in patients in primary care (Dobbin, Maxwell,
is little they can do for themselves that may be & Elton, 2009). It incorporates therapeutic tech-
most associated with poor stroke rehabilitation out- niques from relaxation, mindfulness and positive
comes (Lewis, Dennis, O’Rourke, & Sharpe, 2001; psychology to generate positive feelings, allowing
Morgenstern et al., 2011). Many stroke survivors listeners to overcome negative thinking patterns
prefer self-help and psychological approaches to and become more positive, confident and resilient.
management of their psychological problems after Over 70,000 patients have already received the
stroke and are reluctant to be medicalised and to tool in the NHS in Scotland and other parts of
take antidepressant medication (Stroke Association the UK including those with a range of chronic
Report, 2013). Psychological interventions to reduce co-morbid physical and mental health conditions
post-stroke psychological problems including psy- (www.foundationforpositivementalhealth.com).
chological distress, anxiety and depression, and to PosMT has been reported to produce rapid
help with coping have however, not always been suc- improvements in mental health (observed in some
cessful (Hackett, Anderson, House, & Xia, 2008; after 4 weeks of use) and there have been no
House et al., 1990). Cognitive Behavioural Therapy reported complications or side effects (Dobbin et
(CBT) has shown promise with improving depression al., 2009). Self-help tools such as PosMT may be
but requires mental effort on the part of the survivor particularly important in the context of stroke reha-
during and outside the treatment session and there are bilitation, since stroke survivors often have additional
not always staff qualified to deliver it (Kneebone & challenges to receiving psychological care such as
Dunmore, 2000; Kneebone & Jeffries, 2013; Kootker the ability to attend services. With approximately
 N. Mavaddat et al. / Training in positivity for stroke? 261

1.1 million stroke survivors living in the UK were also excluded. Carers and caregivers of stroke
alone (British Heart Foundation Health Promotion survivors could listen to the audio alongside the stroke
Research, 2012), training sufficient staff to manage survivor if they chose to do so and participate in the
the psychological needs of all stroke survivors would interview. Stroke survivors and carers were screened
be cost-intensive. If effective, PosMT could be used to exclude severe depression and suicidality.
as an additional self-help tool in rehabilitation for pre-
vention or management of post-stroke psychological 2.2. Questionnaires
problems (Koeser, Dobbin, Ross, & McCrone, 2013).
It may also have a role for those with subthreshold or Psychological scales completed at the point of
no symptoms to improve quality of life and aid cop- consent were the Positive and Negative Affective
ing with the stresses associated with rehabilitation. Scale (PANAS) (Crawford & Henry, 2004), Hospital
Half of carers for stroke survivors themselves experi- Anxiety and Depression Scale (HADS) (Zigmond &
ence mental health problems (National Audit Office, Snaith, 1983) or Depression Intensity Scales Circles
2005) and PosMT could also be offered to carers. (DISCs) (Turner-Stokes, Kalmus, Hirani, & Clegg,
The aim of this qualitative study was to gain insight 2005) in case of dysphasia. Those who were severely
from stroke survivors and their carers regarding their depressed (HADS–D > 15 or DISCs > 4 or who
experience of training in positivity using the audio- responded ‘true’ to the BASDEC suicide question),
based PosMT tool. were excluded and referred to their GP for further
care for the sake of safety. The same measures were
repeated at the time of interview.
2. Methods
2.3. Positive Mental Training (PosMT)
We captured experience of use and acceptability intervention
of the Positive Mental Training (PosMT) tool from
stroke survivors and their carers through qualitative A modified PosMT audio (with instructions re-
feedback and recording of adverse events. recorded to ensure suitability for stroke survivors
Ethical approval was obtained from the Lon- based on feedback by a stroke rehabilitation psychol-
don Bridge NHS Research Ethics Committee ogist SR) was used. The modified tool consisted of
(REC:14/LO/0053) prior to commencement of the 12 audio tracks each lasting 18 minutes, to be lis-
study. tened to everyday for a week with a different track
each week. After obtaining written consent, stroke
2.1. Study population survivors were supplied with either a downloadable
mp3 file or three CDs. Participants were informed
We drew interested members of the community - that this programme was being assessed as a new
stroke survivors and their carers from existing sup- intervention to help stroke recovery. They were asked
port groups (Kings College London Stroke Research to listen for the first four weeks (as effects may be
Patient and Family Group and the local Stroke seen in that time), but could carry on to listen to the
Association Voluntary Support Group Peterborough, whole programme if desired. The first track focuses
Bedford Stroke Association Support Group, and Dif- on physical relaxation, tensing and releasing muscles
ferent Strokes) to assist with the study. Volunteers (Jacobsen Relaxation) and developing slow diaphrag-
were asked if they were willing to listen to the PosMT matic breathing, the second track on a short cut to
tool to provide feedback either on personal benefits relaxation and a body scan (Jacobsen, 1938); the third
or on whether they thought the tool would be useful track visualises a state of calm ‘special place’ and
for other stroke survivors. the fourth track further develops mental visualisa-
Volunteers who had evidence of stroke and who tion of this calm state to help in carrying out goals.
were over 18 were invited to listen to the PosMT tool The remaining tracks address a variety of themes
either online or on a CD. Those who lacked capacity including self-confidence, problem-solving, creative
to provide informed consent, had moderate to severe thinking and visioning the future.
cognitive deficits or who were felt by their GP to Participants received follow-up phone calls in the
be unsuitable on clinical grounds (including patients first 4 weeks to ensure that they were not experiencing
with significant receptive aphasia) were not asked any problems with listening to the audios. Qualitative
to participate. Those who did not speak any English semi-structured interviews were carried out by NM
262 N. Mavaddat et al. / Training in positivity for stroke?

to capture stroke survivor and carer experience of use severe depression or suicidality on the HADS and
of the tool over the intervention period with regards BASDEC questionnaires. The 10 stroke survivors
to: likely benefits and harms of the modified PosMT admitted into the study represented a range of age,
tool to increase positivity and overcome post-stroke gender, physical disability level, time since stroke and
psychological distress; whether the tool is easy to use; level of aphasia, depression or anxiety (see Table 1).
if stroke survivors would adhere to it, how it might Of the four carers who listened to the programme,
be adapted to best suit stroke survivors and whether two had borderline and two severe depression. Three
it may be particularly useful in specific groups of reported severe anxiety on the HADS scale. The mean
survivors. age of stroke survivors was 64.5 (SD13.1) and of car-
ers 70.2 (SD6.6). Most participants chose to receive a
2.4. Interviews and analysis CD rather than an mp3 file to listen to the PosMT tool.
Ten semi-structured interviews with stroke sur-
The interviews lasted on average between 30 to 45 vivors were conducted, five of whom had carers
minutes and were audio recorded and then transcribed present during interview, but only four who had vol-
verbatim by an approved external agency, checked for unteered to listen alongside the survivor. One stroke
accuracy and entered into NVivo (version 10.0) soft- survivor did not wish to have any recording but agreed
ware, which was used to allow for data management to have notes taken of the interview. Five of the
to organise transcripts and codes and for comparative interviews were held approximately one month after
analysis. Two members of the research team (NM being given the PosMT. Five further interviews were
and SR) carried out the analysis. Transcripts were conducted later when the participants had the oppor-
read and reread by NM and SR and themes identi- tunity to listen to more of the recordings. In the
fied using a grounded theory approach. Themes were following quotations I = interviewer, S = stroke sur-
identified until no further data could be described. A vivor, C = carer. Analysis of interviews demonstrated
preliminary assessment of those most likely to benefit the following themes:
was made. All questionnaires were re-administered at
the same time as the interview. 3.1. Willingness to listen

Stroke survivors who participated had all initially

3. Findings expressed a willingness to listen, although in some
cases carers had initiated involvement. Most were
Four stroke survivors and one carer who volun- keen to access and try a self-help and non-drug
teered could not be included in the study due to having approach to psychological intervention:

Table 1
Demographic and other characteristics of study participants

Study ID Age Gender Years since Physical Disability Aphasia Anxiety Depression PANAS Positive‡ PANAS Negative§
stroke (Clinical) (Clinical) (Hads-A)∗ (Hads-D)† (percentile) (percentile)
Survivors
S1 54 M 1 None None None None 21 28
S2 74 F 1.5 Severe Moderate Mild Mild 98 81
S3 81 F 6 Severe Moderate None None 41 18
S4 64 F 1 Mild None Mild Mild 41 94
S5 75 F 3 Mild Mild Mild None 62 63
S6 65 F 1.5 Mild None None None 36 28
S7 35 F 1.5 Mild Mild Moderate Mild 28 91
S8 64 M 5 Severe Mild Mild Mild 13 18
S9 73 F 10 Severe Moderate None Severe 8 47
S10 60 F 7 None None xx xx xx xx
Carers
C2 74 M N/A N/A N/A Mild Mild 98 81
C3 77 M N/A N/A N/A Mild Mild 13 94
C6 68 M N/A N/A N/A None Mild 88 74
C8 62 F N/A N/A N/A Mild None 81 90
∗ HADS-D Hospital and Anxiety Depression Scale - Depression. † HADS-A Hospital and Anxiety Depression Scale – Anxiety. ‡ Positive and

Negative Affective Scale (PANAS) - Positive Score. § Positive and Negative Affective Scale (PANAS) – Negative Score.
 N. Mavaddat et al. / Training in positivity for stroke? 263

S: I’ve always been pretty anti being labelled S: the majority of the time I must confess because
depressed or anything like that . . . I’ve always I find it so relaxing I use it for that purpose when
been very very sceptical of medication . . . . . . . . I need - I’ve gone over the top and I need to
I’m more for other approaches than for medica- relax and unwind. . . . . . I actually found your CD
tion. (S1) very therapeutic and relaxing . . . . I went to sleep
that’s how relaxing it was for me . . . . (S5)
Although, participants originally agreed to listen to
4 weeks of the recordings, an elderly female stroke S: Yeah it does help with that because it’s I have
survivor with significant physical disability and apha- a problem where I can’t slow down sometimes
sia and her carer said that they were too busy with I’m just going like this the whole time and I’ve
family life to carry on and stopped listening after always got to be doing something and it’s like I
a week, although they were happy to participate in find it quite difficult to just sit down. (S1)
interview. Later at interview they reported that the Having the PosMT audio provided a mechanism
audio had done ‘nothing for us at all’, although they to enable relaxation, through structuring relax-
admitted that they felt they had not gone into it ation time including some who preferred to listen
‘wholeheartedly enough’. Later they suggested that at bedtime.
they would have liked to have listened to more of the
‘psychological bits’ of the audio and that timing was S: I mean if I hadn’t had the CD there I wouldn’t,
also a factor for them: I probably wouldn’t have taken a break. It’s like
I know it’s there, I know I can have access to it
S: In six months time we might ring you up and say and I’ve forced myself to listen to it and to spend
‘can we have it because we think now we might half an hour or an hour just chilling. (S1)
be able to appreciate it more’ . . . . (C2)
S: I listen to it at the same time every night before
Another female older stroke survivor with aphasia I go to bed . . . . . . so that helps me into a routine
who was disabled requiring a wheelchair, listened to and I think towards the end of the week I tend to
the recording as her husband played the CD, but said fall asleep before it’s finished because my body’s
she preferred to be doing other activities rather than got used to that relaxation which is really good.
listen. (S7)
One elderly stroke survivor living on her own, par-
I: Why do you think she didn’t listen to it?
ticularly found the PosMT comforting and relaxing,
C: I don’t know because she didn’t like it . . . . . . .
helping her feel less isolated.
S: No time ok, it’s more fun at the Centre! (C3/S3)
S: The voice is comforting for me. Anything that
The 8 remaining participants completed 4 weeks gives a feeling of comfort is then that you’re not
of listening and 5 of these carried on beyond four alone in that respect. (S5)
weeks.
Stroke survivors also reported benefits in handling
stress and anxiety. One young 35 year old female
3.2. Positive benefits
stroke survivor suffered severe anxiety when alone as
a result of her having had a stroke when she had been
(i) Overall. Seven of the ten stroke survivors
on her own during one of her husband’s work trips.
reported positive benefits from listening, generally
This survivor found listening to the PosMT helped
found the programme helpful and would recommend
her anxiety at being on her own while her husband
it to others. Comments included “on the whole it was
was away:
quite good . . . I would recommend it to others” (S4),
“very therapeutic” (S5), “I think it’s potentially a very S: It’s really helpful for me because the post-
useful tool” (S6) “very satisfying CD to listen to . . . .. stroke anxiety, I can listen to it whenever I need to
I do feel better in general, I think ‘oh, I do feel good”’ which has been helpful . . . . the sleep deprivation
. . . (S1) is one thing that I’ve really suffered from. It’s the
(ii) Relaxation, sleep, reduction of anxiety. Relax- anxiety of being in the house by myself. . . . . . . . I
ation, unwinding, and falling asleep were all major know when I squeeze my hand and hold my breath
themes described by those who found benefit from (relaxation technique from CD) I can do that -
the programme. bring in positive feelings - when I’m at work so if
264 N. Mavaddat et al. / Training in positivity for stroke?

I’m a bit stressed . . . So the CD for me has been listening made them less fearful of having another
very helpful. . . . I had what I thought was another stroke and how the PosMT made them feel more
stroke and actually it was just a panic attack. I positive and optimistic with life. One stroke survivor
felt like I couldn’t breathe, very restricted, so the described how going to her ‘special place’ where she
CD for me has been very helpful. (S7) was ‘positive’ and ‘strong’ helped her cope at times:
(iii) Confidence and coping. Three stroke survivors I: After you’d been listening did you feel a change
described an increased sense of being able to cope in yourself? S: I think it did have a positive effect
with their daily life after listening to the PosMT. For yes, I think I can say that . . . . . I would say just a
example, the 35 year old female stroke survivor with little more optimistic for the future. Maybe stop-
post-stroke anxiety described how using the relax- ping thinking I could have another stroke at any
ation techniques from the audio gave her confidence minute, which I don’t do but those sort of thoughts
and eased her anxiety regarding and ability to cope are obviously there. Anybody who’s had a stroke
with return to work. Another stroke survivor felt on has got to be slightly afraid of having another.
reflection that the PosMT may have helped her cope I think a little bit more positively . . . . . . . . . . . . .
with traumatic events that had taken place during the and I do still try and go to my ‘place’ to be calm
period of listening: and if I’ve got something coming up which is a bit
challenging I’ll try and go to ‘my space’ and think
S: Some people are quite cynical and don’t believe
of my board (image from CD) with ‘calm’, ‘posi-
in your subconscious but mine’s very stubborn
tive’, ‘strong’ on it so it’s still there. . . . . . . (S6)
and very powerful and once you get through to
it, it does make a big difference for me. It’s (the S: Yeah, so you see more on the positive side of
stroke has) basically stripped away my self con- things rather than the negatives, focusing on the
fidence and I’m slowly getting that back which is negatives all the time which is easy to do really
good.” (S7) when you’ve had a stroke it’s easy to focus on neg-
ative, negative, negative everything’s negative.”
S: Being able to . . . . listen to the CD on the train
(S8)
I worked out if I could . . . listen to it twice on the
train actually by the time I’d listened to it twice S: So the CD for me was able to put things into
I’d already be at work so I could do it that way perspective and actually being able to take me
so actually I’d be relaxed. By the time I’d got to to a place where I was happy in my past, and
work I’d be so relaxed I didn’t want to work. I’d actually remind me that I can actually be that in
be like ‘really, this is a great place’! (S7) my future again as well, so that’s where I am at
the moment with the CD, so it’s being able to
S: Yes, well I’ve had three deaths in a week . . . . .
tie the two together. To go back to positive past
so in fact maybe it’s helped me cope. (S4)
experiences... and actually being able to link the
(iv) Mood, optimism, vitality, motivation and two together and take that forward. So for me it’s
resilience. A couple of stroke survivors reported an quite an exciting place to be. (S7)
improvement in low levels of mood and lethargy and
Positivity and motivation helped to enable one
feeling energised and motivated from listening to the
stroke survivor in particular to carry out a previously
PosMT:
impossible task since the stroke. A wheelchair bound
S: I was quite energised afterwards, I felt 65 year old male stroke survivor who had lived with a
refreshed. (S5) stroke for the past 5 years and who had significantly
physical disability and was suffering from border-
S: Yes and also when you wake up you feel
line anxiety and depression described how listening
refreshed and quite motivated you want to do
to the PosMT audio had increased his motivation and
things . . . . . . It energises your feelings about
resilience and ability to focus on activities, allow-
things, not so much physical that comes later I
ing him to regain the ability to perform a task he
think, but it energises your feelings . . . . (S8)
could no longer do since his stroke. This survivor
Letting go of worries allowed stroke survivors to also expressed how important it was to be able to
be able to focus more positively and imagine a hap- do something for himself, no matter how small, and
pier outcome with their rehabilitation and future in believed that the PosMT had encouraged him towards
general. A couple of stroke survivors described how greater autonomy:
 N. Mavaddat et al. / Training in positivity for stroke? 265

S: It helps you with your thinking...It’s hard to go through a lot of anger and why me, and all
explain really but it helps you to focus more on that sort of thing and you go through a lot of pity
the positive side of . . . sometimes when my carer and stuff and other people do as well they pity you
comes they put the cap on the toothpaste too and all that kind of thing but somewhere along the
tight, well before I would say ‘well they’ve put line you’ve got to stop feeling sorry for yourself
the cap on too tight’, then scream wolf and then really but it’s at that point, say after a couple of
get [carer] to come and take the cap off because years or so, that you need a CD and somebody
I can’t get it off. But now I will . . . Try and try professional to guide you through that so that you
again. Try, try, try to get the cap off. It’s only a sim- can start again. It’s all very well saying ‘it’s no
ple thing to me, to you . . . . . I: And can you?......... good asking me to do that I can’t do that’ and you
S: I can yeah, I can now . . . I don’t get so angry may be not able to do that but you can contribute
with it now I get more as though I’m more moti- maybe in other ways and I think listening to the
vated and I think I’m gonna get the cap off, I’m CD they give you quite a clear direction on which
gonna get the cap off. It’s only a little thing that way to go to be able to tap those resources. The
anybody else would do in a second but it takes me resources of your brain are, well they’re more . . .
a while to do it, but I don’t get frustrated about (S8)
it now whereas before I would do.... it makes you
This same stroke survivor also spoke of the PosMT
somehow persevere more. It makes you, say grip
helping him to focus on his remaining abilities since
a bit harder or turn a bit harder. It gives you that
the stroke and to have greater acceptance of his
kind of . . . energy yeah, a bit more energy. (S8)
present situation:
This stroke survivor also reported that listening to
S: Yes and also when you wake up you feel
the PosMT audio had made him more adaptable and
refreshed and quite motivated you want to do
open minded to trying new things, and encouraged
things but that can be a bit frustrating because
him to think further, more laterally and creatively
you want to do things and you can’t do things
of alternative options in the pursuit of achieving his
and so you think well yes I could if, if, if. All the
goals:
time it’s if I was able to but you have to come to
S: Listening to the CDs . . . . . it gives you more terms with things and . . . . . I think the CD does
of a lateral way to go by saying try this, try this, help you come to terms with what you can do and
try this, try this. It’s like a pendulum, if you can’t what you can’t do. It gives you a message, saying
do something then try this, do a lateral movement well it doesn’t matter what you can do as long you
and I think that all my life really has been set can do this you’ll be on the way to this . . . . . . . . .
order, set order, set order but now I can look both You have to adapt. . . . I think the CD has helped
ways. I can look on a pendulum laterally think- me to adapt more to it. (S8)
ing and say ‘well if that doesn’t work what about
going over here, what about going over here?’ 3.3. Barriers to listening, negative effects
and so you might not reach a decision on any- and suggestions to improve the tool
thing so quickly but at least you’ll get there in the
end by going down the arrow. Go sideways and The biggest challenge to listening was not hav-
down. I: Right, so you see more options in your ing time to fit the PosMT into busy lives, and not all
life in a sense? . . . . . S: You have more balanced volunteers were able to listen to the audio every day.
view of things instead of being all one sided about
I: And what were the reasons that you didn’t listen
things. I think you agree with that [carer] won’t
on those days?
you? C: Yeah it makes you more rounded doesn’t
it? . . . . In what you’re thinking. (S8/C8) S: I was just busy, really busy. I work and I do my
garden so it’s quite, I’m whizzing around all the
S: I think it’s because it shows you that you can
time and if I’m not doing that I’m doing house-
use what you have, what you’ve got left. You can
work or . . . . . So it’s like, I’m full on a lot of the
use that to good effect without worrying because
time. (S1)
you do get a lot of worry, a lot of stress and I think
when you first have a stroke you go through a lot However, commitment to and giving the pro-
of mixed emotions as you no doubt know that you gramme a chance was recognised as important since
266 N. Mavaddat et al. / Training in positivity for stroke?

this would help reinforce the benefits. One stroke sur- PosMT that would harm stroke survivors. One sur-
vivor for example described how at the beginning vivor reflected that if someone didn’t like the tool that
she felt it was not for her, but sticking with the tool it was easy to turn it off (which reflects the experience
found it more helpful. Practicalities such as one cou- of those who disengaged).
ple only having a CD player in their car or another
S: Well people aren’t that sensitive I don’t think
who did not know how to work the CD player prop-
. . . , they’ve got their handicaps and they know
erly were barriers to listening. Conversely one couple
what they are. They’re not going to burst into tears
and another stroke survivor who put the programme
because of the tape . . . .. I don’t think there’s
on their ipod found this very helpful, making listening
anything offensive in the tape. (S1)
easy. Additionally making a routine was helpful.
S: If it’s too much they can just switch the damn
S: I think most people would get into it if they thing off. (S1)
just give it a chance but it’s giving something a
chance isn’t it, to work? (S1) Stroke survivors were specifically asked about
aspects of the programme focussing on the visual-
Physical exhaustion as well as daily activities tak- isation of the future and of rehabilitation goals and
ing longer to complete following a stroke added to whether it may upset them if they were later unable to
the burden of listening. One elderly stroke survivor carry out the task they had visualised. Concerns were
explained how tiredness meant that she had to priori- not generally raised. However, one interviewee felt
tise more essential activities. Another spoke of how this may be a problem. The same survivor, however,
much longer carrying out of activities took in the pres- also reported that the visualisation did make her feel
ence of a stroke, making the simple act of listening peaceful, even though she was unable to physically
to a CD more difficult. carry out the task:
I: What were the reasons that you didn’t listen on S: Just imagine yourself in this situation doing
those days? S: I was just busy, really busy . . . if something that you don’t do very easily . . . . And
you’re paralysed like if your hand’s paralysed or you know keep imagining it . . . . . . . Fine my head
you’re paralysed down one side you’re going to might say I can get on a horse and go for a
have less time because everything’s going to take ride; my body’s not going to let me do it. Not
three times as long to do. (S1) yet . . . . . (S6)

Mental concentration was also a problem for the S: Moments that you think I’m never going to for-
three stroke survivors with the most disabling strokes get this moment, when you’re down if you can go
who also had aphasia and became a barrier to listening to that place and relive it. When I think of myself
and completing the programme. galloping my horse up a hill in the Lake District
and the view opening up . . . . . one of those bril-
S: My brain doesn’t cope with a lot these days liant days, weather perfect on the top of a ridge.
does it? Not a soul in sight, right on top of the world and
who’d want to be anywhere else – well I wouldn’t
I: Do you remember listening to it?
[laughs]. (S6)
S: No, I did, I did listen, they said I weren’t She suggested that more specific instructions
listening properly. (S9) should be given to stroke survivors to carefully select
I: When you tried to put it on did she say turn rehabilitation tasks they feel they could improve on
it off? C: no, no she doesn’t . . . . but she doesn’t with greater confidence rather than to generally visu-
concentrate on it or you know. (C3) alise a task they would like to carry out in the future:
S: Think if you say, if it was more . . . ‘what do
Negative effects of listening to the PosMT tool
you find at the moment you lack confidence in
were minimal, although one carer reported that an
doing’ for example . . . Then find an area where
older stroke survivor with aphasia was at times irri-
I’m lacking in confidence? (S6)
tated when listening to the CD. No one however
stopped listening specifically because it upset them. Other feedback on how the PosMT could be modi-
The interviewees generally expressed the view that fied for stroke survivors included comment regarding
there wasn’t anything unsuitable in the content of the physical relaxation, with mixed views expressed as to
 N. Mavaddat et al. / Training in positivity for stroke? 267

how useful Jacobsen physical relaxation would be to audio after a week. One carer, the husband of an older
survivors and how much this should be included in the stroke survivor reported that the PosMT tool was not
audio, although many did report benefit. A few felt ‘for me’ and expressed how he “just didn’t relate to
that having an earlier taste of the positive psychol- it”, although he was fully encouraging of his wife
ogy aspects of the audio and less physical relaxation listening.
would be more useful to stroke survivors. Comments
were made about the voice by some and others did not C: I think I had an open mind when I started it.
find the music relaxing. Several stroke survivors com- I didn’t find it did anything to me at all . . . . It
mented that it may be difficult to have a programme just didn’t click. . . . . I don’t react particularly to
that everyone likes, due to individual taste in voice, people telling me things [laughs] . . . . . . . . . But
music and pitch and so choice would be helpful. if it helps [wife] it helps, end of story as far as
I’m concerned’. (C6)
3.4. Who might benefit the most from
the PosMT? The other two carers listened and found positive
benefits. One carer described how she was now more
Stroke survivors and their carers offered sugges- patient and understanding with her husband and that
tions as to which survivors they felt the tool may help the PosMT had helped her with negativity regarding
the most. Although not everyone felt the PosMT was her husband’s future with stroke. She also reported
for them, all believed that the tool could be helpful to that the PosMT had helped them to get through a
other survivors, with a couple suggesting that those depressing winter.
with anxiety would be most likely to benefit.
C: I think I would say I’m more understanding of
S: Would recommend if someone has deep anxiety what [stroke survivor] has gone through and also,
and worry as these (meditation/hypnosis) helped I am a patient person anyway, but I did used to get
me with anxiety and worry. (S10) a little bit frustrated at times. You do because it’s
out of your control sometimes when you can’t do
Review of stroke survivor interviews suggests that
something for somebody who’s had a stroke so I
completing the PosMT resulted in the most posi-
have felt more positive and it’s got us through this
tive feedback during interview and that commitment
winter as well, much better, because in the winter
to the entire programme may be important for best
you don’t tend to go out quite so much, do you,
outcomes. Time since stroke and degree of physical
so that’s helped that way . . . . . . . . . You can be
disability did not appear to be a barrier to reporting
very negative, and it can help you to get through
benefit. Those with depression or anxiety did appear
that negative . . . . I think it just helps you just to
to describe greater benefits. A survivor who found
relax and forget the rest of the world, forget your
the programme the most useful had suffered a stroke
worries and concentrate on the future.” (C8)
5 years previously and was wheel-chair bound. In
general, older participants were less willing to listen In another situation where the stroke survivor said
to the tool. However, those who did reported positive she was too busy to listen to the CD herself, she sug-
feedback. The presence of significant aphasia, was gested that it would benefit her husband who was her
however, a barrier to concentrating and listening and carer. He himself felt that the tool helped him to relax
the three participants with more significant aphasia and to have more energy for his daily tasks including
did not continue to the end of the programme, mostly looking after his wife.
due to lack of interest in listening.
S: Yes, but he need it . . . . . . I: why do you say
3.5. Feedback regarding use of the PosMT he needs it?
in carers
S: because he has time to listen to it . . . . You can
Both stroke survivors and their carers felt that go to bed you lie down there asleep with it . . . ..
addressing the mental health of carers was impor- relax him. (S3)
tant and were keen to try any interventions that might
help. Two carers who originally volunteered to listen C: Quite like it yeah . . . . I feel energetic yeah . . . .
to the PosMT and who were not depressed or anx- yeah it makes me fall asleep and then you know
ious, however decided not to continue listening to the fall into a trance yeah . . . . good dreams . . . (C3)
268 N. Mavaddat et al. / Training in positivity for stroke?

3.6. Changes in psychological measures positive outcomes by letting go of anxiety related

of stroke survivors to carrying out of tasks, and increasing motivation
to attain goals. In particular, the PosMT has been
Four stroke survivors who participated moved up developed based on sports psychology techniques
the positive scale of the PANAS and down the neg- where visualisation of future performance after posi-
ative scale during the period of listening. One of tive emotional generation, a recognised technique for
these, a 35 year old female also moved from mild improving physical and mental outcomes has been
depression and moderate anxiety to no depression employed. In our study we found that in two par-
and mild anxiety on the HADS scale, while a 64 ticipants who suffered from post-stroke anxiety and
year old male survivor moved from mild anxiety depression, listening to the PosMT while visualising
and depression to no anxiety or depression. On the a future task aided with later successfully carrying
other hand, one elderly stroke survivor who had also out an activity of daily living in one participant, and
listened to all 3 PosMT audios moved from border- in the other a more complex task of returning to
line to severe anxiety and borderline depression. This work.
participant had reported the PosMT to be helpful Based on reports from stroke survivors in our study,
and relaxing, however, during the weeks of listening we found the negative effects of the PosMT to be min-
had several hospital admissions for atrial fibrillation, imal, although those with moderate aphasia found
which she reported to have affected her psychological it difficult to concentrate and did not persist. When
wellbeing. stroke survivors did not feel they received personal
benefit, they nevertheless felt the tool could still be
useful to others especially those with anxiety and
4. Discussion difficulty coping with their stroke. Age, degree of
physical disability or years since stroke did not appear
This exploratory qualitative assessment suggests to influence the kind of feedback received regarding
that training in positivity for stroke survivors may be the PosMT among our small group of stroke sur-
a potentially beneficial intervention to help with cop- vivors, although those with anxiety or depression
ing and the prevention or management of post-stroke did appear to report greater benefits, while those
psychological problems that interfere with rehabilita- with aphasia reported least benefits. Our findings,
tion. Specifically Positive Mental Training (PosMT) however, are limited by the fact that our sample
appears to be an acceptable tool for use in stroke sur- was self-selected and this may have led to more
vivors and suitable for further trial. Our qualitative positive reviews than a random sample of stroke sur-
interviews with 10 stroke survivors and some with vivors. On the other hand, since not all volunteers
their carers suggests that while a few survivors did not had clinical depression or anxiety and those with the
find the PosMT tool to be suitable for them and did most severe depression and anyone who was suici-
not engage with it sufficiently, a majority of survivors dal were excluded, reported benefits may have been
who listened (7 out of 10) reported positive physical minimised. Another short-coming was that stroke
and psychological benefits including improved relax- survivors were only asked to volunteer to listen for 4
ation, better sleep and reduced anxiety after 4 weeks weeks and only to continue if they wished and there-
of listening. Three stroke survivors who completed fore not all went on to complete review of the full
the full 12-week programme appeared to find the tool 12 week programme.
the most helpful and reported improved motivation, Our preliminary qualitative study nevertheless sug-
confidence and coping, and positive outlook with gests that while the PosMT may not be suitable
increased optimism with relation to the future and for all, it may be of benefit for those stroke sur-
towards achieving rehabilitation goals. Interventions vivors who are motivated to listen. Having a stroke
that focus on improving general wellbeing and reduc- presents a number of challenges to accessing and
ing anxiety including cognitive behavioural therapy, engaging with psychological services including prob-
relaxation and mindfulness meditation have shown lems with mobility limiting attendance at therapies,
benefit to stroke survivors (Golding et al., 2015; physical difficulties in engaging with computer-based
Johansson et al., 2012; Lawrence et al., 2013). Train- programs and often difficulties in verbal commu-
ing in positivity, however goes beyond addressing nication. Our study suggests that since the PosMT
negative symptomatology and promoting relaxation requires only daily listening by the survivor at home
and mindfulness, to help survivors to focus on for less than 20 minutes a day, that it is nevertheless
 N. Mavaddat et al. / Training in positivity for stroke? 269

an acceptable and easily accessible tool for many been developed and produced by AD & SR, and the
stroke survivors. After a few hours of initial train- copyright is held by Positive Rewards Ltd (SR is
ing, the PosMT also requires no other expertise to shareholder). AD and SR were not involved in data
deliver and could be offered to stroke survivors by collection.
any health professional including primary care staff.
It is also a very low cost intervention at around £38
($57) for the full audio programme (Koeser et al., References
2013). Further it can be used alongside antidepres-
sant medication and other psychological therapies.
Berges, I. M., Seale, G., & Ostir, G. V. (2011). Positive affect and
For carers, listening with survivors may provide addi- pain ratings in persons with stroke. Rehabil Psychol, 56(1),
tional benefits. Development of the PosMT to benefit 52-57. Retrieved from PM:21401286. http://www.ncbi.nlm.
also those with more significant aphasia is a fur- nih.gov/pmc/articles/PMC3063951/pdf/nihms278541.pdf,
ther important step in development of the tool before http://psycnet.apa.org/journals/rep/56/1/52/
trial. Berges, I. M., Seale, G. S., & Ostir, G. V. (2012). The role of
positive affect on social participation following stroke. Disabil
In short, we believe trials of this and other tools Rehabil, 34(25), 2119-2123. Retrieved from PM:22506691.
that promote positivity, resilience and coping in http://informahealthcare.com/doi/abs/10.3109/09638288.2012.
stroke survivors and counter psychological prob- 673684
lems including anxiety and depression are warranted. British Heart Foundation Health Promotion Research, G. (2012).
Some argue that health services should minimise Coronary heart disease statistics: A compendium of health
statistics. Retrieved from Department of Public Health:
over-optimism and engage with stroke survivors British Psychological, S. (2010). Psychological services for people
regarding possible disappointment with progress in who have had a stroke and their families - Briefing paper 19.
rehabilitation (Wiles, Ashburn, Payne, & Murphy, Retrieved from
2004). Positivity training, however, we believe should Campbell Burton, C. A., Murray, J., Holmes, J., Astin, F., Green-
aim to develop a ‘realistic optimism’ in survivors wood, D., & Knapp, P. (2013). Frequency of anxiety after
stroke: A systematic review and meta-analysis of observa-
(Schneider, 2001). Adapting training in positivity to tional studies. Int J Stroke, 8(7), 545-559. Retrieved from
the specific needs of stroke survivors is crucial. PM:23013268
Crawford, J. R., & Henry, J. D. (2004). The positive and nega-
tive affect schedule (PANAS): Construct validity, measurement
Acknowledgments properties and normative data in a large non-clinical sam-
ple. Br J Clin Psychol, 43(Pt 3), 245-265. Retrieved from
PM:15333231
All authors contributed to the design of the study Dobbin, A., Maxwell, M., & Elton, R. (2009). A benchmarked
and writing of the paper. NM and KW carried out feasibility study of a self-hypnosis treatment for depression in
recruitment and project management. NM carried out primary care. Int J Clin Exp Hypn, 57(3), 293-318. Retrieved
interviews. NM and SR analysed the data. Thank from PM:19459090
Ellis, C., Zhao, Y., & Egede, L. E. (2010). Depression and increased
you to Dr. Stephanie Rossitt for advice on modify- risk of death in adults with stroke. J Psychosom Res, 68(6),
ing the PosMT for use with stroke survivors, and 545-551. Retrieved from PM:20488271
to Professor Chris Mckevitt and Dr Nina Fudge for Golding, K., Kneebone, I., & Fife-Schaw, C. (2015). Self-help
allowing access to stroke survivors and carers through relaxation for post-stroke anxiety: A randomised, controlled
the Stroke Research Patients and Family Group at pilot study. Clin Rehabil, doi:10.1177/0269215515575746
Hackett, M. L., Anderson, C. S., House, A., & Xia, J.
King’s College London. Special thanks to all the vol- (2008). Interventions for treating depression after stroke.
unteers from Stroke Research Patients and Family Cochrane Database Syst Rev, (4), CD003437. Retrieved from
Group at King’s College London and the local Stroke PM:18843644
Association Voluntary Support Group Peterborough, Hackett, M. L., Yapa, C., Parag, V., & Anderson, C. S. (2005).
Bedford Stroke Association Support Group, and Dif- Frequency of depression after stroke: A systematic review
of observational studies. Stroke, 36(6), 1330-1340. Retrieved
ferent Strokes, UK. from PM:15879342
House, A., Dennis, M., Warlow, C., Hawton, K., & Molyneux,
A. (1990). Mood disorders after stroke and their relation to
Conflict of interest lesion location. A CT scan study. Brain, 113(Pt 4), 1113-1129.
Retrieved from PM:2397385
Jacobsen, E. (1938). Progressive relaxation. Chicago: University
This work was supported through the Royal Col- of Chicago Press.
lege of General Practitioners (RCGP), UK Scientific Johansson, B., Bjuhr, H., & Ronnback, L. (2012). Mindfulness-
Foundation Board,UK. Positive Mental Training has based stress reduction (MBSR) improves long-term mental
270 N. Mavaddat et al. / Training in positivity for stroke?

fatigue after stroke or traumatic brain injury. Brain Inj, 26(13- NHS East of England. (2010). Psychological Supprt for stroke: A
14), 1621-1628. doi:10.3109/02699052.2012.700082 guide for commissioners.
Kim, P., Warren, S., Madill, H., & Hadley, M. (1999). Quality of Ostir, G. V., Berges, I. M., Ottenbacher, M. E., Clow, A., & Otten-
life of stroke survivors. Quality of Life Research, 8(4), 293-301. bacher, K. J. (2008). Associations between positive emotion
Kneebone, I. I., & Dunmore, E. (2000). Psychological manage- and recovery of functional status following stroke. Psychosom
ment of post-stroke depression. Br J Clin Psychol, 39(Pt 1), Med, 70(4), 404-409. doi:10.1097/PSY.0b013e31816fd7d0
53-65. Retrieved from PM:10789028 Partridge, C., & Johnston, M. (1989). Perceived control of recovery
Kneebone, I. I., & Jeffries, F. W. (2013). Treating anxiety from physical disability: Measurement and prediction. Br J
after stroke using cognitive-behaviour therapy: Two cases. Clin Psychol, 28(Pt 1), 53-59. Retrieved from PM:2522329
Neuropsychol Rehabil, 23(6), 798-810. doi:10.1080/0960 Pressman, S. D., & Cohen, S. (2005). Does positive affect influ-
2011.2013.820135 ence health? Psychol Bull, 131(6), 925-971. Retrieved from
Koeser, L., Dobbin, A., Ross, S., & McCrone, P. (2013). Economic PM:16351329. http://psycnet.apa.org/journals/bul/131/6/925/
evaluation of audio based resilience training for depression in Schneider, S. L. (2001). In search of realistic optimism. Meaning,
primary care. J Affect Disord, 149(1-3), 307-312. Retrieved knowledge, and warm fuzziness. Am Psychol, 56(3), 250-
from PM:23489394 263. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/
Kootker, J. A., Rasquin, S. M., Smits, P., Geurts, A. C., van 11315251
Heugten, C. M., & Fasotti, L. (2015). An augmented cogni- Stroke Association Report, U. K. (2013). Feeling Overwhelmed:
tive behavioural therapy for treating post-stroke depression: The emotional impact of stroke. Retrieved from
Description of a treatment protocol. Clin Rehabil, 29(9), 833- Turner-Stokes, L., Kalmus, M., Hirani, D., & Clegg, F. (2005). The
843. doi:10.1177/0269215514559987 Depression Intensity Scale Circles (DISCs): A first evaluation
Lawrence, M., Booth, J., Mercer, S., & Crawford, E. (2013). A of a simple assessment tool for depression in the context of
systematic review of the benefits of mindfulness-based inter- brain injury. J Neurol Neurosurg Psychiatry, 76(9), 1273-1278.
ventions following transient ischemic attack and stroke. Int J doi:10.1136/jnnp.2004.050096
Stroke, 8(6), 465-474. doi:10.1111/ijs.12135 Wiles, R., Ashburn, A., Payne, S., & Murphy, C. (2004).
Lewis, S. C., Dennis, M. S., O’Rourke, S. J., & Sharpe, M. (2001). Discharge from physiotherapy following stroke: The man-
Negative attitudes among short-term stroke survivors predict agement of disappointment. Soc Sci Med, 59(6), 1263-1273.
worse long-term survival. Stroke, 32(7), 1640-1645. Retrieved doi:10.1016/j.socscimed.2003.12.022
from http://www.ncbi.nlm.nih.gov/pubmed/11441213 World Health, O. (2000). The world health report 2000.
Morgenstern, L. B., Sanchez, B. N., Skolarus, L. E., Garcia, N., Retrieved from Geneva: http://www.foundationforpositive
Risser, J. M., Wing, J. J., . . . Lisabeth, L. D. (2011). Fatalism, mentalhealth.com. How do we calculate how many patients
optimism, spirituality, depressive symptoms, and stroke out- have used Positive Mental Training?
come: A population-based analysis. Stroke, 42(12), 3518-3523. Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety
doi:10.1161/STROKEAHA.111.625491 and depression scale. Acta Psychiatr Scand, 67(6), 361-
National Audit Office. (2005). Reducing brain damage: Faster 370. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/
access to better stroke care. Retrieved from 6880820
National Audit Office. (2010). Progress in improving stroke care.
Retrieved from
Copyright of NeuroRehabilitation is the property of IOS Press and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.