An exploratory study of working alliance in traumatic brain injury peer support
Alyssa Turcott
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Abstract
Peer support is recognised as a promising intervention for people with traumatic brain injury (TBI). Peer support increases belonging, mood and self-acceptance after TBI. In peer support, working alliance is associated with rehabilitation engagement and better health-related outcomes. A better understanding of the working alliance formed between those providing and receiving TBI peer support will inform design considerations for creating peer support networks, including specific considerations for matching peer support workers with peer support receivers.
The objectives of this study were to characterise how working alliance is developed through brain injury peer support, and to identify barriers and facilitators of creating peer support networks.
This study used a qualitative interpretive description methodology. Semi-structured interviews were conducted with peer support receivers and peer support workers who were involved in a co-designed TBI peer support program, as well as community partners who were involved in the development or implementation of the program. Responses were analysed using reflexive thematic analysis (Objective 1) and inductive content analysis (Objective 2).
Nine participants participated in the interviews: three peer support receivers, two peer support workers and four community partners. Three themes describe how working alliance is developed. First, ‘feeling understood’ explored the importance of validating experiences after TBI. Second, ‘expanding conversations beyond injury’ highlighted participants’ desire to connect on similar life experiences and personal topics other than TBI, such as navigating milestones and life events. Last, ‘reciprocal growth’ identified how learning occurs between both the peer support receiver and worker. There were four main facilitators of forming a peer support network: characteristics of peer support workers, flexibility in content of sessions, collaboration between researchers and peer support organisations, and formatting of sessions. There were three main barriers to forming a peer support network: irregularity of sessions due to scheduling conflicts, lack of an established peer support program within acute care settings, and lack of resources including space, volunteers and funding.
Findings reveal how working alliances between peer support workers and peer support receivers in TBI peer support are facilitated through validation of individual TBI recovery experiences, and mutual growth in the areas of self-acceptance and hope. Successful peer support networks appear to benefit from flexibility and individualisation of format and content of sessions, as well as the creation of collaborations between acute care and community support networks.
Keywords: collaboration, lived experience, peer support, TBI, working alliance.
References
Ahmed SK (2024) The pillars of trustworthiness in qualitative research. Journal of Medicine, Surgery and Public Health 2, 100051.
| Crossref | Google Scholar |
Andreassen TA, Solvang PK (2021) Returning to work or working on one’s rehabilitation: Social identities invoked by impaired workers and professionals in health care and employment services. Sociology of Health & Illness 43(3), 575-590.
| Crossref | Google Scholar | PubMed |
Aterman S, Ghahari S, Kessler D (2023) Characteristics of peer-based interventions for individuals with neurological conditions: A scoping review. Disability and Rehabilitation 45(2), 344-375.
| Crossref | Google Scholar | PubMed |
Baumgartner-Dupuits M, Sep SJS, Verbunt J, Bosma H, van Eijk J (2021) Peer Support to Enhance Social and Emotional Self-Management Following Acquired Brain Injury Rehabilitation: Design of a Pre-post Study With Process Evaluation. Frontiers in Neurology 12, 647773.
| Crossref | Google Scholar | PubMed |
Bordin ES (1979) The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice 16(3), 252-260.
| Crossref | Google Scholar |
Brain Injury Canada (2023) Traumatic Brain Injury: A lifelong condition: Moderate to severe brain injury as a chronic condition. Available at https://braininjurycanada.ca/wp-content/uploads/2023/07/TBI-Paper-English-July-19-2023.pdf
Braun V, Clarke V (2019) Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health 11(4), 589-597.
| Crossref | Google Scholar |
Brown A, Barth DC, Leslie AR (2024a) “You’re someone different now”: An autoethnography on identity and occupational identity disruption after traumatic brain injury. American Journal of Occupational Therapy 78(2), 7802180110.
| Crossref | Google Scholar | PubMed |
Brown HK, Strauss R, Fung K, Mataruga A, Chan V, Mollayeva T, Urbach N, Colantonio A, Cohen E, Dennis C, Ray JG, Saunders N, Vigod SN (2024b) Mental illness in the 2 years prior to pregnancy in a population with traumatic brain injury: A cross-sectional study. Canadian Journal of Psychiatry 69(8), 607-617.
| Crossref | Google Scholar | PubMed |
Canadian Institute of Health Research (2023) Strategies for Patient Oriented Research. Available at https://www.cihr-irsc.gc.ca/e/41204.html
Cole FL (1988) Content analysis: Process and application. Clinical Nurse Specialist 2(1), 53-57.
| Crossref | Google Scholar | PubMed |
Kelly C, Cornwell P, Hewetson R, Copley A (2024) “Everyone’s brains are different…you can’t just have one therapy plan to suit everyone” – A qualitative investigation of community-based rehabilitation services following traumatic brain injury. International Journal of Speech Language Pathology 1, 1-13.
| Crossref | Google Scholar |
Damianakis T, Climans R, Marziali E (2008) Social workers’ experiences of virtual psychotherapeutic caregivers groups for Alzheimer’s, Parkinson’s, stroke, frontotemporal dementia, and traumatic brain injury. Social Work with Groups 31(2), 99-116.
| Crossref | Google Scholar |
Dams-O’Connor K, Juengst SB, Bogner J, Chiaravalloti ND, Corrigan JD, Giacino JT, Harrison-Felix CL, Hoffman JM, Ketchum JM, Lequerica AH, Marwitz JH, Miller AC, Nakase-Richardson R, Rabinowitz AR, Sander AM, Zafonte R, Hammond FM (2023) Traumatic brain injury as a chronic disease: Insights from the United States traumatic brain injury model systems research program. Lancet Neurology 22(6), 517-528.
| Crossref | Google Scholar | PubMed |
De Dios Perez B, Morris RPG, Craven K, Radford KA (2024) Peer mentoring for people with acquired brain injury – a systematic review. Brain Injury 38(4), 316-329.
| Crossref | Google Scholar | PubMed |
Douglas J (2020) Loss of friendship following traumatic brain injury: A model grounded in the experience of adults with severe injury. Neuropsychological Rehabilitation 30(7), 1277-1302.
| Crossref | Google Scholar | PubMed |
Gainforth HL, Giroux EE, Shaw RB, Casemore S, Clarke TY, McBride CB, Garnett CV, Sweet SN (2019) Investigating characteristics of quality peer mentors with spinal cord injury. Archives of Physical Medicine and Rehabilitation 100, 1916-1923.
| Crossref | Google Scholar | PubMed |
Grewal J, Kennedy CJ, Mamman R, Breese Biagioni J, Garcia-Barrera MA, Schmidt J (2024a) Understanding the barriers and facilitators of healthcare services for brain injury and concurrent mental health and substance use issues: a qualitative study. BMC Health Services Research 2(24), 881.
| Crossref | Google Scholar |
Grewal J, Nguyen SV, Nonis N, Singh H (2024b) A qualitative study of individuals with acquired brain injury and program facilitators experience in virtual acquired brain injury community support programs. Disability and Rehabilitation 47(7), 1764-1773.
| Crossref | Google Scholar |
Heredia-Callejón A, García-Pérez P, Armenta-Peinado JA, Infantes-Rosales MÁ, Rodríguez-Martínez MC (2023) Influence of the therapeutic alliance on the rehabilitation of stroke: A systematic review of qualitative studies. Journal of Clinical Medicine 12(13), 4266.
| Crossref | Google Scholar | PubMed |
Kent A (2019) Evidence-informed practices and strategies for patient-oriented research (POR): A “menu” for research teams. BC SUPPORT Unit: Vancouver. Available at https://healthresearchbc.ca/bc-support-unit
Kersten P, Cummins C, Kayes N, Babbage D, Elder H, Foster A, Weatherall M, Siegert RJ, Smith G, McPherson K (2018) Making sense of recovery after traumatic brain injury through a peer mentoring intervention: A qualitative exploration. BMJ Open 8, e020672.
| Crossref | Google Scholar | PubMed |
Kessler D, Egan M, Kubina LA (2014) Peer support for stroke survivors: A case study. BMC Health Services Research 14(1), 256.
| Crossref | Google Scholar | PubMed |
Lau SKC, Luong D, Sweet SN, Bayley M, Levy BB, Kastner M, Nelson MLA, Salbach NM, Jaglal SB, Shepherd J, Wilcock R, Thoms C, Munce SEP (2021) Using an integrated knowledge translation approach to inform a pilot feasibility randomized controlled trial on peer support for individuals with traumatic brain injury: A qualitative descriptive study. PLoS One 16(8), e0256650.
| Crossref | Google Scholar | PubMed |
Law M, Cooper BA, Strong S, Stewart D, Rigby P, Letts L (1996) The person-environment-occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy 63, 9-23.
| Crossref | Google Scholar |
Levy BB, Luong D, Bayley MT, Sweet SN, Voth J, Kastner M, Nelson MLA, Jaglal SB, Salbach NM, Wilcock R, Thoms C, Shepherd J, Munce SEP (2021) A Pilot Feasibility Randomized Controlled Trial on the Ontario Brain Injury Association Peer Support Program. Journal of Clinical Medicine 10, 2913.
| Crossref | Google Scholar | PubMed |
Liu Q, Jin Y, Wang Y, Feng J, Qiao X, Ji L, Si H, Bian Y, Wang W, Yu J, Wang C (2023) Association between self-efficacy and self-management behaviours among individuals at high risk for stroke: Social support acting as a mediator. Journal of Clinical Nursing 32(1–2), 71-82.
| Crossref | Google Scholar | PubMed |
Lowe N, Crawley L, Wilson C, Waldron B (2021) ‘Lonely in my head’: The experiences of loneliness in individuals with brain injury. British Journal of Health Psychology 26, 444-463.
| Crossref | Google Scholar | PubMed |
MacLellan J, Surey J, Abubakar I, Stagg HR (2015) Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences. PLoS One 10(10), e0141122.
| Crossref | Google Scholar | PubMed |
Mamman R, Mortenson WB, Fleming J, Schmidt J (2022) Living in a reshaped reality: Exploring social participation and self-identity after TBI. Neuropsychological Rehabilitation 32(8), 2102-2124.
| Crossref | Google Scholar | PubMed |
Maru M, Rogers ES, Nicolellis D, Legere L, Placencio-Castro M, Magee C, Harbaugh AG (2021) Vocational peer support for adults with psychiatric disabilities: Results of a randomized trial. Psychiatric Rehabilitation Journal 44(4), 327-336.
| Crossref | Google Scholar | PubMed |
May C, Bieber K, Chow D, Mortenson WB, Schmidt J (2023) Experiences of adults with stroke attending a peer-led peer-support group. Brain Impairment 24, 443-455.
| Crossref | Google Scholar | PubMed |
Miao M, Power E, Rietdijk R, Debono D, Brunner M, Salomon A, Mcculloch B, Wright MR, Welsh M, Tremblay B, Rixon C, Williams L, Morrow R, Evain JC, Togher L (2022) Coproducing Knowledge of the Implementation of Complex Digital Health Interventions for Adults with Acquired Brain Injury and their Communication Partners: Protocol for a Mixed Methods Study. JMIR Research Protocols 11(1), e35080.
| Crossref | Google Scholar | PubMed |
Mikolajczak-Degrauwe K, Slimmen SR, Gillissen D, de Bil P, Bosmans V, Keemink C, Meyvis I, Kuipers YJ (2023) Strengths, weaknesses, opportunities and threats of peer support among disadvantaged groups: A rapid scoping review. International Journal of Nursing Sciences 10(4), 587-601.
| Crossref | Google Scholar | PubMed |
Moncada M (2025) Should we use NVivo or Excel for qualitative data analysis. Bulletin of Sociological Methodology 165-166(1–2), 186-211.
| Crossref | Google Scholar |
Morris RP, Fletcher-Smith JC, Radford KA (2017) A systematic review of peer mentoring interventions for people with traumatic brain injury. Clinical Rehabilitation 31(8), 1030-1038.
| Crossref | Google Scholar | PubMed |
Morrow SL (2005) Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counselling Psychology 52(2), 250-260.
| Crossref | Google Scholar |
Nalder E, Fleming J, Cornwell P, Shields C, Foster M (2013) Reflections on life: experiences of individuals with brain injury during the transition from hospital to home. Brain Injury 27(11), 1294-1303.
| Crossref | Google Scholar | PubMed |
Nicmanis M (2024) Reflexive Content Analysis: An Approach to Qualitative Data Analysis, Reduction, and Description. International Journal of Qualitative Methods 23, 16094069241236603.
| Crossref | Google Scholar |
Northcott S, Behn N, Monnelly K, Moss B, Marshall J, Thomas S, Simpson A, Mcvicker S, Flood C, Goldsmith K, Hilari K (2022) “For them and for me”: a qualitative exploration of peer befrienders’ experiences supporting people with aphasia in the SUPERB feasibility trial. Disability and Rehabilitation 44(18), 5025-5037.
| Crossref | Google Scholar | PubMed |
Norton MJ (2024) More than just a health care assistant: Peer support working within rehabilitation and recovery mental health services. Irish Journal of Psychological Medicine 41, 420-421.
| Crossref | Google Scholar | PubMed |
Pagan E, Ownsworth T, McDonald S, Fleming J, Honan C, Togher L (2016) A survey of multidisciplinary clinicians working in rehabilitation for people with traumatic brain injury. Brain Impairment 16(3), 173-195.
| Crossref | Google Scholar |
Patterson F, Fleming J, Doig E (2017) Clinican perceptions about inpatient occupational therapy groups in traumatic brain injury rehabilitation. Brain Injury 31(8), 1077-1087.
| Crossref | Google Scholar | PubMed |
Poritz JMP, Harik LM, Vos L, Ngan E, Leon-Novelo L, Sherer M (2019) Perceived stigma and its association with participation following traumatic brain injury. Stigma and Health 4(1), 107-115.
| Crossref | Google Scholar |
Sherer M, Evans CC, Leverenz J, Stouter J, Irby JW, Jr, Lee JE, Yablon SA (2007) Therapeutic alliance in post-acute brain injury rehabilitation: Predictors of strength of alliance and impact on alliance on outcome. Brain Injury 21(7), 663-672.
| Crossref | Google Scholar | PubMed |
Silva MA, VandenBussche Jantz AB, Klocksieben F, Monden KR, Rabinowitz AR, Cotner BA, Dillahunt-Aspillaga C, Nakase-Richardson R (2021) Unmet rehabilitation needs indirectly influence life satisfaction 5 years after traumatic brain injury: A veterans affairs TBI model systems study. Archives of Physical Medicine and Rehabilitation 102(1), 58-67.
| Crossref | Google Scholar | PubMed |
Sohlberg MM, O’neil-Pirozzi TM, Ness B, Meulenbroek P, Byom L, Lemoncello R (2024) Moving Beyond Rapport: The Importance of Active Facilitation of Therapeutic Alliance in Adult Acquired Brain Injury Rehabilitation. American Journal of Speech-Language Pathology 33(6), 3129-3138.
| Crossref | Google Scholar | PubMed |
Stagg K, Douglas J, Iacono T (2019) A scoping review of the working alliance in acquired brain injury rehabilitation. Disability and Rehabilitation 41(4), 489-497.
| Crossref | Google Scholar | PubMed |
Sveen U, Guldager R, Soberg HL, Andreassen TA, Egerod I, Poulsen I (2022) Rehabilitation interventions after traumatic brain injury: A scoping review. Disability and Rehabilitation 44(4), 653-660.
| Crossref | Google Scholar | PubMed |
Talbot KJ, Kruger E, Pillay BS (2023) Experiences of acquired brain injury one-month post-discharge from acute hospitalisation. African Journal of Disability 12, a1037.
| Crossref | Google Scholar |
Thomas EC, Salzer MS (2018) Associations between the peer support relationship, service satisfaction and recovery-oriented outcomes: A correlational study. Journal of Mental Health 27(4), 352-358.
| Crossref | Google Scholar | PubMed |
Thompson Burdine J, Thorne S, Sandhu G (2021) Interpretive description: A flexible qualitative methodology for medical education research. Medical Education 55(3), 336-343.
| Crossref | Google Scholar | PubMed |
Thorne S, Kirkham SR, MacDonald-Emes J (1997) Interpretive description: A non-categorical qualitative alternative for developing nursing knowledge. Research in Nursing & Health 20(2), 169-177.
| Crossref | Google Scholar | PubMed |
Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal of Qualitative Health Care 19(6), 349-357.
| Crossref | Google Scholar | PubMed |
Tsow R, Pollock C, Mehta S, Turcott A, Kang R, Schmidt J (2024) A Look at Traumatic Brain Injury Community Programs in British Columbia: Barriers and facilitators of implementation. Brain Injury 38(7), 539-549.
| Crossref | Google Scholar | PubMed |
Williams LM, Douglas JM (2022) It takes two to tango: The therapeutic alliance in community brain injury rehabilitation. Brain Impairment 23(1), 24-41.
| Crossref | Google Scholar |
Wobma R, Nijland R, Kwakkel G (2019) Patient characteristics related to the need for peer support in rehabilitation after acquired brain injury: a prospective cohort study in the Netherlands. BMJ Open 9, e025665.
| Crossref | Google Scholar |
Zelencich L, Kazantzis N, Wong D, McKenzie D, Downing M, Ponsford J (2019) Predictors of working alliance in cognitive behaviour therapy adapted for traumatic brain injury. Neuropsychological Rehabilitation 30, 1682-1700.
| Crossref | Google Scholar | PubMed |
Zhou L (2019) Application of self-efficacy focused health education among individuals at high risk for stroke. Electronic Journal of Practical Clinical Nursing Science 4(22), 187-188.
| Google Scholar |