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R E H A B I L I TAT I O N A RT I C L Egroups and health professionals to supporttransition back to accessible social andpleasure activities if possible, before dischargefrom therapy.Two of the participants experienced severephysical pain during the course of the sessions.It was clear that this influenced their mood andcould be associated with suicidal thoughts. Painmanagement was shown to be crucial for theseparticipants. For client 6, improvements wereharder to see on the DASS and were unchangingon objective outcomes. This participanthowever began to demonstrate positivechanges, and though he rated ‘I felt I hadnothing to look forward to’ highly (3), he haddescribed looking forward to a trip out and hissocialisation was improving. In addition,suicidal comments stopped during the sessions.Most participants were able to completethe outcome measures, though help wasrequired by one participant to be clear aboutthe meaning of elements of the rating scale.This help was by writing out the choices of 0-3in a larger font and by giving reminders foreach question. With the Visual Analog MoodScale, the scales were completed together withthe couple and differences were discussed asthe scales were completed. Sometimes thesedifferences were not anticipated, so this was initself useful to the counselling work.DiscussionImportantly this service development projecthas identified people experiencing moderateto severe stroke associated depression, stressand anxiety. Most of these people werealready on antidepressants and were in needof psychological support after stroke. It seemsto us convincing that there is a need for aservice such as this, especially when some riskof suicide has been shown. More specificallyfor most of these people, support was neededfor their feelings of grief, loss, death anxietyand fear.With the majority of participants, there weremultiple issues as well as a stroke. In somecases, a person’s stroke brought out otherissues that were repressed and that had notbeen spoken about before. In other cases, thestroke had coincided with other life issues,such as the loss of parents and businesses, andwith the poor health of a family member.Examples of issues for participants covered inthis counselling work:• Recent loss of a mother and similarities inmedication and mobility to mother.• Forced retirement, loss of job, loss of business.• Loss of mobility and some participantsalready had losses prior to stroke, such asimpaired vision.• Other medical challenges such as epilepsy,heart attacks, arthritis.• Difficult family relationships e.g. steprelationships,fostered children.• Previously undisclosed abuse.• Losses of siblings at a younger age.• Previous relationship break-ups anddivorce.The trauma of stroke has been central to all thecounselling, but exploration of relevant andrelated issues such as those mentioned abovewere vital for counselling to be beneficial.Accessible services that doctors and healthprofessionals know about and know how torefer to are crucial for those experiencingstrokes. For three participants that did nothave access to psychological support servicesafter their first strokes, we can questionwhether their assessment outcome measureswould have been better at the start of thispilot. A referral pathway for psychologicalsupport needs to be clear to all GP services, assome participants’ needs after their first strokewere not recognised and there were limitedservices to refer to. Some participants said, “Ididn’t know services existed; I didn’t get anyhelp after my first stroke.”We argue that commissioning of Strokespecialistpsychological services is needed forlong-term post-stroke. Without this there willremain poor service provision, such as failingto meet The National Stroke Strategy forEngland (2007) guidelines. 13A harder element to articulate in a servicedevelopment project is the observation thatpsychodynamic counselling ‘felt’ appropriateto the counsellor for the majority of participants,especially participants, 3, 5, 6, and 8. Itwas also felt some participants could havecontinued to benefit from longer termsessions. One reason was because thedynamic of the sessions seemed appropriatein terms of the application of psychodynamictheory and the rapport, transference and interpretationof feelings and emotions thatevolved.This service evaluation has shown the valueof a stroke experienced counsellor. Forexample some of the counselling was aimedat helping the individuals to understand ‘whatis normal’ after stroke. The counsellingprovided included sharing of expert knowledgeabout stroke and gave support andunderstanding of rehabilitation. Tiredness wasa recurring issue with most of the participantsseen. In particular, partners understandingissues such as tiredness was important. ‘TheStroke and Aphasia Handbook’ 14 was a muchappreciated resource and reading about theseissues was reassuring for some people.The DASS was shown to be a good accessibleoutcome measure for these clients as itdirected assessment and understanding of thedegree of stress, anxiety and depression. It isinteresting to note from the results that thecounselling appeared to be more effective atreducing depression than anxiety for participants4, 5 & 10. With a psychodynamicapproach, depression and stress showedgreater improvements. It is indicated thatfurther sessions may be needed to reduceanxiety.At the outset of this project, some groupwork with participants was anticipated, suchas a carers’ group. 1:1 work and couplessessions were however shown to be the mostappropriate for this particular group of participants.This service development project and evaluationhas identified that increased psychologicalsupport is needed for people followingstrokes who have moderate-severe depression,stress and/or anxiety. This small evaluationproject demonstrates that increased clinicalpsychology provision and/or provision ofcounsellors/psychotherapists specialising instroke are needed as part of a permanentlyfunded service. This service has shown that 15participants needed – and benefited from –Individual case study with more details of this counselling service.Case Study, illustrating how losses are discussed in therapy.Participant 4 (from Tables 1-2, female, aged 67) was on antidepressantsand despite this stress, anxiety and depression were rated as extremelysevere initially. There was some risk of self-harm due to low mood andat one point clear suicidal ideation. Losses were multiple, not onlysevere mobility losses due to her stroke, but loss of occupation andgrief for her mother who had recently died.Sessions were focused on the mourning her mother, alongside herown mourning of previous role. In addition, the counselling wassupportive and client-centred and followed her through her rehabilitationwhen the level of recovery was uncertain.There was clear reliance on attachment figures with strong dependencyin the first year post stroke. As the sessions progressed, there wasless dependency. In our final sessions, she stated, “I’m not worried ofsitting alone. Not terrified anymore.”Outcomes improved from extremely severe to lower levels as shownin Table 2. She was later referred back for a further four sessions due toconcern from another health professional that her levels of depressionhad deteriorated again. She was however maintaining improvementwell. Her level of depression had however been extremely severeinitially and some level of enduring depression was likely. This is interestingas it shows different perceptions of depression. Participant 4 feltthat the counselling was very beneficial to her and described it as, “Arelief through a difficult time.” Since these sessions, follow-up appointmentshave indicated that she has maintained the gains that she made.ACNR > VOLUME 12 NUMBER 4 > SEPTEMBER/OCTOBER 2012 > 19