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R E H A B I L I TAT I O N A RT I C L Enumber of themes including grief, loss,mourning, attachment and fear.A key theme is grief and mourning. After astroke, a person can feel lost. Counselling triesto help a person rediscover parts of his orherself that feel lost. Stroke specific psychodynamiccounselling helps a person to talkabout their sense of loss after their stroke andto encourage a person through their rehabilitation.It also aims to help a person findresilience to cope with the long-term consequencesof a stroke. An added dimension ofstroke experienced counselling is the provisionof information about expected recovery,ability to answer some general medicalconcerns, and to refer on to other professionalssuch as medicines management.Understanding unconscious object relationssuch as the ‘lost object’ is important topsychodynamic counselling. In relation tostroke, the lost object may be a part of theself. 10 Leader proposes ‘Grief is our reaction toloss, but mourning is how we process thisgrief.’ (p.26). He describes how we anticipatehearing a loved ones voice on the phone afterthey have died. This could be compared tosomeone thinking back to their pre-stroke selfand seeing themselves back at work or drivingthe car. One hypothesis that underpins therapeuticinterventions is that the more thesememories are processed, feelings begin toimprove. Through therapeutic conversations,the sense of discrepancy from ‘pre-stroke’ selfmay be reduced. 9 For some, this can be a longand difficult process after a stroke. The challengefor counselling following a stroke is tosupport a person to rediscover parts of theirself and develop an adjusted self-concept.Many people also have loss in their lives wherethere is mourning still to be done. Counsellinghelps to look at the unconscious processes ofgrief and mourning to support people torecover from depression. 10Following a stroke, a person often feels alack of confidence and insecurity in theirsense of self and especially how they feelabout their body. Blando 11 describes theoutcomes of Fortner & Neimeyer’s research(1999, p.90) that found higher death anxiety inolder people with more psychological problemsand a reduced sense of self. Feelinganxious about the prospect of death is knownas death anxiety. Awareness of death can be acause of anxiety particularly after middleage. 11 Near-death experiences such as sufferinga stroke and the memories of the daysfollowing a stroke can evoke high anxiety.Death anxiety can restrict how someoneengages with life, and this could includerestrictions to their recovery and their abilityto socialise.Attachment is also important to anypsychotherapeutic approaches. The trauma ofa stroke can affect attachments, for example,there can be increased dependency on partnersand new strong attachments to healthcare staff. The stroke may amplify previousattachment patterns such as ‘anxious avoidant’and ‘anxious resistant’ attachment types(Blando, 2011, p.111-p.112). If someone feelsvulnerable, they may feel as insecure as theydid as a child. A stroke can cause a person tofeel frightened. The support of others helpsalleviate these feelings, and enables a personto cope better. There may especially be difficultiesif a partner has died or a key attachmentfigure is unavailable. In psychodynamicworking, the type of transference and attachmenttype can be closely associated. 11In light of these themes, this project wasconceived following Speech and LanguageTherapist Alys Mikolajczyk’s post-qualificationtraining in Psychodynamic Counselling atCambridge University Continuing Education.Funding from the local Stroke and HeartNetwork to implement this project was soughtand approved because it was recognised thatthere was a lack of service descriptions andevaluation of work in this field locally, despitethe need for psychological support outlined inThe National Stroke Strategy for England (2007).MethodThis service was initially advertised to the rehabilitationteam to support participants and theirfamilies experiencing low mood since a stroke.As a consequence, referrals mainly came fromthe neurological rehabilitation multidisciplinaryteams, though all GP practices in thecatchment area were sent a letter and leaflets.People could also self-refer. This service aimedto be flexible by seeing both individuals andcouples, and aimed to be participant-led andflexible to circumstances. Domiciliary andoutpatient sessions were offered.The number of sessions offered wasdependent on the outcome of the initialassessment and severity of anxiety, stress anddepression that was shown. Initially up totwelve sessions were offered, though as theresults will show this changed as the projectprogressed.ParticipantsIn total, 15 people have been seen over thetime period of this project, seven people seenindividually and four couples (see Table 1 fordemographics). Due to the high severity ofdepression, anxiety and stress fewer peoplewere seen than anticipated in the originalgrant application. At point of referral, 10 participantshad experienced a stroke in the last twoyears, and one man experienced a stroke fouryears previously. Three participants werereferred after a second stroke. All of thesethree participants reported that they had notreceived any psychological support after theirfirst strokes and did not know that helpexisted.Seven participants were over 65 years and 8participants were under 65 years. Only oneparticipant had severe speech difficulties, andtwo other participants had mild-moderatespeech and language difficulties.Outcome Measures:The Depression, Anxiety and Stress Scales 1were used with the majority of participants.‘The Visual Analog Mood Scales’ 12 were usedwith only one couple. As Table 2 shows, overalloutcome measures are very positive andencouraging. Individualised assessment andinterview also helped to evaluate outcomesfor participants, and for one participant achange questionnaire seemed appropriate.ResultsAs this project developed, the level of anxietyand depression in this caseload was found tobe moderate to severe. Seven of the peopleseen were experiencing at least one severerating on the DASS (The Depression, Anxiety,Stress Scales). Four participants needed to beconsidered for risk issues due to suicidalideation and one attempted suicide near to thestart of therapy. With two participants, otherservices were involved, specifically psychiatryand a community psychiatric nurse in onecase and the crisis team and mental healthcare coordinator in the other. More detailedcognitive assessment was also completed fortwo participants by a clinical psychologistspecialising in stroke. These complex participantsrequired more time investment andliaison with other professionals. As a consequenceof the overall severity, only three participantswere offered the originally-planned sixsessions. All other participants were offeredmore sessions due to need, risk and multiplelife issues. As Table 1 shows, in some cases thiswas substantially more (range 6-27 sessions),demonstrating the need for long-term treatmentfor some participants.One referral was a self-referral from a manand his wife, who were looking for strokerelated counselling due to this man’s severedepression and emotionalism. All other referralswere from the multidisciplinary team anda PhD student. Couples were not always seentogether and sometimes only the participantexperiencing the stroke was seen. This wasflexible to daily circumstances. As Table 1shows, this service was mainly domiciliary,though three participants were seen both attheir homes and as outpatients. Dominantconcerns were losses in their lives such as lossof occupation, mobility, income, self-esteem,self-worth and loss of previous overall lifestyle.It seemed that a psychodynamic approachwas appropriate for most of the people seen.With participants 2, 7 & 11 however (See Tablesabove), the psychodynamic approach was notcentral. Participant 2 required a supportiveclient-centred relationship. She requiredcompanionship and was introduced to asupport group during the duration of oursessions. Participant 7 was one of the laterparticipants in the study and wanted furthersupport to understand his stroke, including thetype of stroke he experienced four years previously.He required factual information abouthis stroke and needed to talk about his difficul-ACNR > VOLUME 12 NUMBER 4 > SEPTEMBER/OCTOBER 2012 > 17